Technology and technological device use has proliferated. Globally we are connected, often more to devices than each other (Rosen, 2012; Turkle, 2011). This reliance on technology in daily life has also led to an imperative to incorporate technology and device use in healthcare (Weitz, 2013).
Historically, a key component of nursing practice is the holistic, humanistic relationship between the nurse and the patient. More recently, there has been a movement to embrace patient and family centered care in healthcare delivery (Kitson, Marshall, Bassett, & Zeitz, 2013). Yet technology has an allure and presence, which may influence the interactions between patients and care providers (Barnard & Sandelowski, 2001). Qualitative studies provide perspectives from patients and nurses and describe technology and device use paradoxically – providing a sense of security and reassurance but also an awareness of dependency and distraction (Kongsuwan & Locsin, 2011; Locsin & Kongsuwan, 2013; Price, 2013; Stayt, Seers, & Tutton, 2015; Tunlind, Granström, & Engström, 2015).
The purpose of the research study was to examine how patient care technology mediates the interpersonal relationship between the patient and the nurse during care delivery in the acute care setting. The conceptual framework for the study was derived from three mid-range theories: Locsin’s Technological Competency as Caring in Nursing (2005); Swanson’s The Structure of Caring (1993); and Kostovich’s Model of Nursing Presence (2012). Study aims were to quantitatively describe the levels of nurse technological competency as caring, patient perceptions of caring and nurse presence, and to examine the relationships among demographic variables and the study variables. Secondly, the study qualitatively explored nurses’ and patients’ perceptions of technological device use in care delivery.
Methods:
Following Institutional Review Board approval, a non-experimental, concurrent, mixed-methods design was used to address the research aims. The setting was a community adult acute care hospital in the southwestern United States. Participant recruitment occurred in early 2014. Quantitative convenience sampling resulted in 112 nurse and 115 patient participants, and qualitative purposive sampling recruited a subset of 23 nurses and 15 patients. Quantitative data was obtained from three instruments. Nurse technological competency as caring was measured using the Technological Competency as Caring in Nursing Instrument (TCCNI; Locsin, 1999; Parcells & Locsin, 2011). The TCCNI is comprised of 25 items on a 0-100 mm dichotomous visual analogue scale (strongly disagree = 0; strongly agree = 100). The TCCNI has a Cronbach’s alpha of 0.81 (Locsin, 1999) and a S-CVI/Ave of 0.96 (Parcells & Locsin, 2011). Patient perceptions of caring were measured using the Caring Behaviors Inventory (CBI), a 24-item, 6-point Likert scale (1 = never to 6 = always). The CBI produces an overall score and four subscale scores (assurance of human presence, professional knowledge and skill, respectful deference to others, and positive connectedness). The CBI has a reported Cronbach’s alpha of 0.96 (Wu, Larrabee, & Putman, 2006). Patient perceptions of nurse presence were measured with the Presence of Nursing Scale, a 25-item, 5-point Likert scale (1 = never, 5 = always) instrument with a Cronbach’s alpha of 0.95 (Kostovich, 2012). Qualitative data was derived from semi-structured interviews using a consistent set of six exploratory patient questions and four exploratory nurse questions. Data was analyzed using SPSS, Version 22 and by first and second cycle thematic coding.
Results:
Nurse participants were predominantly female (83.9%), white (56.3%) with a mean age of 34.88 years, and with a Bachelor’s Degree in Nursing (80.2%) and 9.42 mean years of nursing experience. Overall nurses rated their technological competency as caring high (M=87.72, SD = 7.56). There were no significant differences related to demographic variables and TCCNI scores except for the variable of race. Asian nurses (29.5% of participants) scored themselves higher than whites (p = .002).
Although 115 patients were initially recruited, a notable amount of missing data resulted in analysis of only patients who had complete data on both instruments (n=87). Final sample patient participants had a mean age of 58.9 years, were male (54.0%), white (66.7%), and had a college (47.1%) or post-graduate education level (18.4%). Patient subjects were admitted for medical (55.2%) rather than surgical reasons, and had a 9.92 day mean length of stay when the data was collected. Patients’ rated perceptions of caring behaviors (M = 5.44, SD = .58) on a 6-point scale. Examining relationships based on demographic variables, patient perceptions of caring differed significantly by gender and pain. Male patients rated overall caring behaviors significantly higher (M = 5.56, SD = .47, p = .040) than females (M = 5.29, SD = .66). Patients in pain rated positive connectedness (M = 4.94, SD = .92, p = .047) lower than those without pain (M = 5.30, SD = .74). Patients’ perceptions of nurse presence were high (M = 115.82, SD = 10.55), and there was a positive relationship between age and presence scores (r[85] = .295, p = .006).
Qualitatively three themes were associated with device use for both patients and nurses: safety, learning, and balance. Both groups felt technological devices provided a safety net. Learning associated with the device varied by group. Patients learned about devices by observation or provider explanations, whereas nurses described learning in operational terms -- to achieve competency in device use and skill in troubleshooting. Balance in technological use was described as achieving an equilibrium between patient and device focus and was dependent on the care context and viewpoint of the operator or receiver. For patients (receivers), technological device use provided a sense of safety and expedited the process of care delivery. However, patients viewed devices negatively when the devices were used brusquely or without explanation. Nurses also appreciated the inherent safety measures provided by devices but were frustrated by the time required for both initial learning and subsequent troubleshooting when devices malfunctioned. Both nurses and patients felt operationalization of devices signified a measure of skill, not only in machine use, but also in how devices were integrated into the care delivery process.
Conclusion:
Globally, technology and technological device use is pervasive in general society and healthcare. The goal of nursing is to provide humanistic and holistic care, but interpersonal interactions can be influenced by device use. In this study, technological device use in care delivery created a presence, which was perceived as positive or negative depending on the care context and how the device was operationalized. Nurses, and all healthcare providers, should be aware of how patients perceive device use and then integrate these new methodologies and devices as adjuncts to patient centered care.
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