Nurses’ Use of Personal Smartphone Technology in the Workplace: Scoping Review

Background There has been an increase in the technological infrastructures of many health care organizations to support the practice of health care providers. However, many nurses are using their personal digital devices, such as smartphones, while at work for personal and professional purposes. Despite the proliferation of smartphone use in the health care setting, there is limited research on the clinical use of these devices by nurses. It is unclear as to what extent and for what reasons nurses are using their personal smartphones to support their practice. Objective This review aimed to understand the current breadth of research on nurses’ personal smartphone use in the workplace and to identify implications for research, practice, and education. Methods A scoping review using Arksey and O’Malley’s methodological framework was conducted, and the following databases were used in the literature search: CINAHL, PubMed, ProQuest Dissertations and Theses, Embase, MEDLINE, Nursing and Allied Health Database, Scopus, Web of Science, and Cochrane Reviews. Search terms used were Nurs* AND (personal digital technology OR smartphone OR cellphone OR mobile phone OR cellular phone). Inclusion criteria included research focused on nurses’ use of their own digital technologies, reported in English, and published between January 2010 and January 2020. Exclusion criteria were if the device or app was implemented for research purposes, if it was provided by the organization, if it focused on infection control, and if it was focused on nursing students or nursing education. Results A total of 22 out of 2606 articles met the inclusion criteria. Two main themes from the thematic analyses included personal smartphone use for patient care and implications of personal smartphone use. Nurses used their smartphones to locate information about medications, procedures, diagnoses, and laboratory tests. Downloaded apps were used by nurses to locate patient care–related information. Nurses reported improved communication among health team members and used their personal devices to communicate patient information via text messaging, calling, and picture and video functions. Nurses expressed insight into personal smartphone use and challenges related to distraction, information privacy, organizational policies, and patient perception. Conclusions Nurses view personal smartphones as an efficient method to gather patient care information and to communicate with the health care team. This review highlights knowledge gaps regarding nurses’ personal device use and information safety, patient care outcomes, and communication practices. This scoping review facilitates critical reflection on patient care practices within the digital context. We infer that nurses’ use of their personal devices to communicate among the health care team may demonstrate a technological “work-around” meant to reconcile health system demands for cost-efficiency with efforts to provide quality patient care. The current breadth of research is focused on acute care, with little research focus in other practices settings. Research initiatives are needed to explore personal device use across the continuum of health care settings.


Introduction
Smartphone use is increasing globally, with an estimated 3.3 billion users in 2019 and an anticipated 3.8 billion users by 2021 [1]. Countries with the greatest number of smartphone users include China, India, and the United States [1]. A smartphone is a device that has both computing abilities and mobile communication technology [2]. Mobile communication technology has undergone rapid development [3], and smartphone production is one of the fastest growing technological industries [4]. Coupled with the proliferation of smartphones is the high demand for downloadable apps that a smartphone user can add to their device. In 2018, over 4 million Android and Apple apps were available either free or for a cost [5]. These apps provide the user with additional services and features on their smartphone device.
Within the health care context, there has been an increase in the use of smartphones by health care providers in the last several years [2], including an increase in the use of health professional apps [6]. Fölster [7] reported over 200,000 health-related apps available for purchase or free of charge. The increased use of smartphones and selected apps by health care professionals mirrors the increased use of information technology within health care. There has been a significant increase in the implementation and use of electronic documentation systems, with billions of dollars being utilized to support the provision and coordination of health care to patients using information technology [8]. However, despite the increased use of apps in health care, health care professionals have expressed concerns relating to the trustworthiness of apps and a knowledge gap on the effectiveness of apps [9].
Electronic documentation systems have been integrated within health care systems to provide a centralized repository and accessible source of clinical information for health care providers [10]. These same systems are intended to support clinical care practices among all health care providers while providing access to information, decision-support tools, and improved workflow [10,11]. Given their extended contact with patients and families, nurses tend to have the greatest interaction with electronic documentation systems relative to other health care providers [12].
Despite the increase in technological infrastructures of many health care organizations to support the practice of health care providers, many nurses are using their personal digital devices (eg, smartphones) while at work for both professional and personal purposes [13,14]. Yet, there is limited research available on the clinical use of personal smartphone devices by nurses. In addition, there is limited research available that focuses on nurses' use of commercially available health-related apps in the workplace [15]. These gaps in research are especially important to understand given the most recent global pandemic caused by COVID-19 [16]. The COVID-19 pandemic lead to rapidly evolving public health measures with frequent changes in practice guidelines in all health care settings. Health care organizations had to respond and adapt quickly. With smartphones being a convenient and accessible way to locate information, the use of these devices in practice by nurses needs to be an area of focus, especially when facing a global pandemic.
It is unclear as to what extent and for what reasons nurses are using their personal smartphones to support their practice. Similarly, there is a lack of clarity regarding the quality and credibility of the resources accessed by nurses via their personal devices. However, the expectation of evidence-informed patient care practices highlights the importance of access to health-related resources for nurses and other health care providers [17]. In essence, evidence-informed practice necessitates nurses to critically evaluate information collected regarding patients' needs and to integrate it with the available clinical and research evidence to enable evidence-informed patient care [18]. A valued feature of mobile smartphones is the pro re nata, or PRN, access to vast amounts of online health-related information. In this scoping review, we are interested in how nurses are leveraging their personal smartphones for personal and patient care-related purposes across a variety of health care settings.
This research aims to explore and synthesize the current literature regarding nurses' use of their personal digital devices in the workplace. The purpose of this review is to understand the current breadth of research to identify knowledge gaps, practice and policy implications, and future research opportunities. More specifically, this review seeks to gain an understanding of nurses' use of their personal digital technology within the workplace.

Overview
A scoping review was the chosen method to review the literature as it is well suited for burgeoning areas of research. In addition, scoping reviews aim to identify gaps in research while mapping key concepts and types of evidence [19]. Arksey and O'Malley's [20] methodological framework outlines five stages for conducting a scoping review, including identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarizing, and reporting the results. A critical step in this final stage involves identifying the research and evidence gaps that need to be addressed [20]. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist was used to ensure that the scoping review is robust and includes all essential reporting items [21].

Step 1: Identify the Research Question
The research question we identified for this review is "How are nurses using their personal smartphones within the clinical workplace?"

Step 2: Identifying Relevant Studies
The following databases were used in the literature search process: CINAHL, PubMed, ProQuest Dissertations and Theses, Embase, MEDLINE, Nursing and Allied Health Database, Scopus, Web of Science, and Cochrane Reviews. Search terms used were: Nurs* AND (personal digital technology OR smartphone OR cellphone OR mobile phone OR cellular phone). Different search terms were trialed during the initial literature search process. The search terms selected were broad and were determined to capture all relevant studies that relate to the research question. See Multimedia Appendix 1 for the full syntax of search terms.
Articles included in the review had to meet the following inclusion criteria: a research focus on nurses' use of their own digital technology, research reported in English, and research published between January 2010 and January 2020 in order to capture data that aligned with the proliferation of mobile phone ownership. Studies focusing on a specific device or online app use were included only if the motivation for use was nurse driven. Studies were excluded from this review if the workplace organization provided the technology or if the technology was implemented for research purposes. Studies that focused on infection control of personal digital technology were excluded. Studies were also excluded if they focused on personal digital technology use and nursing students or nursing education, as this review was aimed at understanding practicing nurses' use of digital health technologies within clinical settings.

Step 3: Study Selection
A total of 2606 studies were identified using the search criteria above. Through consensus agreement between two reviewers, 22 studies met the inclusion and exclusion criteria and were included for the scoping review. See Figure 1 for a flow diagram of the article selection process. Step 4: Charting the Data Two databases were set up in Step 4. One database, Mendeley, was used for sharing of articles between authors, including sharing to achieve consensus review. The other database was a matrix where all the data were collected. A spreadsheet was created to organize relevant information from the included articles. Data collected from each article included author names, year of publication, study design, data collection method, target population, study location, and research question.

Step 5: Collating, Summarizing, and Reporting the Results
During the final stage of collating, summarizing, and reporting the results, the framework approach described by Ritchie and Spencer [22] and used by Arksey and O'Malley [20] was used in this review. This technique involves synthesizing and interpreting the data by sifting, sorting, and charting the information based on the key themes and issues presented in the literature [22]. The data were charted and thematically analyzed. Data analysis was conducted by two researchers and analytical discrepancies were resolved through discussion until consensus was achieved.
Out of 22 studies, 2 (9%) targeted nurses working in community-based health care settings [29,41]. Grabowsky [29] focused on advanced practice nurses who worked in an array of settings, including a variety of outpatient clinics. Chiang and Wang [41] investigated personal digital technology use among community nurses who worked for home care organizations. Out of 22 studies, 1 (5%) included nurses from a range of settings, both acute and nonacute, including hospital, primary care, social health care, prehospital care, management, education, and private practice settings [31].
Two main themes with associated subthemes were generated from the analyses. The first theme was personal smartphone use for patient care. This theme was divided into three subthemes: information seeking, communication, and mobile device functions. The second theme was implications of personal smartphone use, which was refined into five subthemes: smartphone use for personal reasons, distraction, patient perception, privacy and confidentiality, and organizational support and policy confusion. The details of the themes and subthemes are described narratively in the following sections.

Information Seeking
Nurses used their smartphones to access information directed at patient care. The most common information sought was related to medications, including drug guides and drug references, in 14 of the 22 (64%) studies reviewed [23,[26][27][28][29][30][31][33][34][35]37,38,40,43]. Nurses reported efficiency of access to medication information; it was easier to search medications by either the generic name or brand name using their smartphones, despite having access to a drug reference book [40]. By using a mobile device, nurses were able to quickly look up new medications in drug guides [43]. Out of 22 studies, 8 (36%) identified that nurses used apps downloaded to their devices to find information on medications; 4 (18%) did not report the name of the apps used [23,27,34,35]. Whether nurses located medication information though a general search engine app (eg, Google) or by a specific app was not disclosed. The other 4 (18%) studies identified the specific apps used by nurses as Epocrates, Micromedex, Drug Index and Dosage, and Vademecum International [28,29,31,43].
Other than Park and Lee [42], researchers did not specify if nurses located this information specifically through online search engines or by specific apps they downloaded to their smartphone devices.
Nurses identified the need for information access regarding procedures and use of instruments within surgical settings [42].
The greatest barrier to information access included the inconvenience created by a lack of dedicated computers within surgical suites, thereby limiting nurses' ability to access information [42]. Surgical nurses used the app, BAND, on their personal devices in order to consult with each other and to share information, including pictures, videos of themselves describing instruments and procedures, YouTube videos, and other pertinent information [42]. Using the app, information was easy to access and readily available and was positively reviewed by the operating room nurses [42].
Nurses used their smartphones for information seeking for both patient education purposes and for their own educational needs. Out of 22 studies, 4 (18%) reported that nurses used their smartphones for patient education [27,29,33,40]. Flynn et al [27] found that more than 75% of the nurses preferred the use of their smartphones to access information for patient education, and this was more commonly noted among nurses between the ages of 18 and 30 years compared to nurses older than 50 years of age. Furthermore, Flynn et al [27] discussed how nurses used their own smartphones to respond to patients' and families' requests for information on a variety of topics, such as medical procedures, medications, contact information for providers, and directions to local venues.
Personal smartphone use provided nurses with ease of access to information. For example, when asked by a patient about lab values, the nurse used their phone to search Google for the answer in the moment [40]. McBride and Levasseur [33] reported that nurses also used their personal smartphones to access patient handouts and teaching materials. Nurses accessed continuing education and professional development opportunities through their smartphones [30,33], and Mobasheri et al [34] reported that nurses used medical apps to enhance their clinical knowledge and skills.
Other uses of smartphones by nurses included the use of online evidenced-based guidelines to support patient care [26,30], to access information related to patients' prognoses [29], to support nurses' understanding of disease pathophysiology and physiology [30], and to access clinical decision support tools [35]. Multiple smartphone apps that were reported being used by nurses for information seeking included WebMD [28,40], Medscape [23,28,40], Google [28,40,43], UpToDate [23], Infermera virtual [31], and 061 CatSalut Respon [31]. Garner et al [28] reported nurses' use of PubMed, YouTube, Medical in Nursing and Oncology App, Google Scholar, Q Calc, Doc Plus, Praco, Radiopedia, and Wikipedia as apps and programs on their smartphones. Giles-Smith et al [43] identified Lexicomp, Medscape, and iTriage as additional health-related apps on nurses' smartphones for information seeking and patient care purposes. Nurses, particularly those with less than 5 years of clinical experience, used e-books on their personal smartphones for information seeking [24].

Communication
Nurses used their personal smartphones to communicate with members of the health care team. Out of 22 studies, 11 (50%) found that nurses used their smartphones while at work to connect with health care team members by calling and/or text messaging for patient care purposes [24][25][26][27][28]30,33,34,37,39,40]. Nurses reported improved communication between team members, including physicians, and other allied health care providers and claimed that their personal device use improved efficiency in communication and facilitated immediate contact with colleagues [27,39,40]. Voice calling and text messaging with nurses and physicians was the most commonly cited reason for personal smartphone use at work [24].
Bautista and Lin [40] reported that nurses were able to contact doctors immediately using the Viber app and also received patient care orders via their smartphones. Nurses reported an enhanced efficiency in their workflow because they did not need to "track down" the attending physician; instead, they used their smartphones to contact them immediately [39]. Another efficiency-related technique was the development of a directory of personal contacts, whereby nurses saved the contact information (eg, phone numbers) of physicians, supervisors, and colleagues across diverse organizational departments to their smartphones so they were readily available when required [27]. Specific apps used for communication among the health care team included Viber, Facebook Messenger, iMessage, WhatsApp, and Line [25,28,37,39]. Group chats were also mentioned, but a particular app was not reported for group chat purposes [39].
Nurses also used their smartphones to communicate with patients [41]. Chiang and Wang [41] assessed nurses' experiences using the Line app to communicate with home care patients and families. Home care patients or their family members would contact the nurse regarding their health care via the text option on the Line app [41]. Chiang and Wang [41] found that the picture and video function on the app was used as an assessment tool; home care patients would take pictures and videos of signs and symptoms related to their health condition and send them to the nurse using the app. Nurses found the Line app beneficial because of the asynchronous nature of communication patterns, which afforded them time to problem solve patient care issues, and the unlimited texting function increased opportunities for patient-provider communication [41]. However, nurses also reported a situation of being chronically "on call," where patient text messages were perceived as intrusive outside of their working hours [41]. In another study, which investigated the use of WhatsApp, researchers found that nurses rarely communicated with patients, whereas in the same study, physicians were more likely to communicate with patients using WhatsApp [25].

Mobile Device Functions
Three smartphone functions were identified as useful: the photo and video function [24,27,34,39,40], the calculator [26,27,31,[33][34][35]37,38], and the flashlight function [27,44]. Nurses used the photo and video function on their smartphones to support communication with their colleagues. For example, nurses took pictures of radiology images, patient wound sites, electrocardiograms, procedural equipment, skin test results, and biological samples, such as sputum [27,40], to facilitate communication with other care providers who requested greater details of the patient condition beyond verbal reports [27].
Flynn et al [27] reported that over 75% of the nurses in their study valued the calculator function on their smartphones. The calculator was used to compute nursing and medical formulas and to calculate dose and scale [26,31,37]. Other than reported use, no further details were provided regarding the flashlight function.

Distraction
Distraction from patient care was identified by nurses as a concern regarding smartphone use within the workplace [23,[25][26][27]30,33,37,40,43]. Nurses self-reported instances of their own distraction from patient care activities resulting from the use of their smartphones but also reported observed instances of inattentiveness among their nursing colleagues [23,26,30,33,37]. Pucciarelli et al [37] reported that 42% of nurses felt that smartphones were a distraction. For example, a nurse was distracted from inserting an intravenous line by the ringing sound of an incoming call on their smartphones [40], and 12.5% of nurses had witnessed a coworker make a medical error that they attributed to perceived distraction related to their smartphone use [33]. Alameddine et al [23] similarly found that 55% of nurses had witnessed distraction they attributed to smartphone use. Di Muzio et al [26] found that almost 62% of nurses thought that the use of personal devices could increase the risk of errors.

Patient Perception
Similarly, nurses expressed their lack of knowledge about patients' perceptions of their smartphone use and the potential for patient complaints [27,28,35,40,43]. Nurses were concerned about patients' possible negative feelings and thoughts about mobile devices being used at the beside [23,43].

Privacy and Confidentiality
Nurses identified privacy and confidentiality of patient health information as a concern associated with the use of their personal devices within the workplace [25,28,34,40,41]. Mobasheri et al [34] found that 3.6% of nurses believed there was patient-related clinical information retained on their personal smartphones. Similarly, home care nurses discussed their concerns regarding their use of the Line app, reporting that "others could easily see patients' recent whereabouts or sensitive personal information on the software platform" [41].

Lack of Organizational Support and Policy Confusion
Lack of organizational support and policy confusion was expressed by nurses [30,40,41,43]. Despite organizational policy that prohibited personal smartphone use within their clinical setting, most nurses considered their smartphones as helpful technology in their workplace. Some nurses were aware of policies restricting personal smartphone use, while others stated they did not know what the existing policies for personal smartphone use entailed. Hranchook et al [30] reported that 47.2% of the nurse participants in their study knew that their organization had a personal device use policy, 22.6% said their institution did not, while 30.2% were unsure. When asked if medical administrators should develop a code of conduct for smartphone use to minimize unnecessary distraction, 44% of participants agreed, while 51% disagreed [23]. Nurses also reported barriers to Wi-Fi and internet access issues within their organizations that impeded their access to online resources [28,29,38,43].

Principal Findings
A scoping review of 22 studies was conducted to examine the current breadth and range of research on nurses' use of personal smartphones in the workplace; to our knowledge, this is the first review of its kind. Based on the studies included in this review, nurses have reportedly been using their personal smartphones within their workplace for personal and patient care purposes since 2013.
From the existing evidence, we know that nurses used their personal smartphone devices to gather patient care information and to communicate within the health care team. In support of evidence-informed patient care, nurses used online apps and programs to locate information relating to patient-prescribed medications, clinical procedures, diagnoses, laboratory tests, and more. The information-seeking and consultation behaviors align with evidence-informed nursing practice [18,45]. Nurses require access to specialized knowledge and comprehensive clinical information to inform their clinical decision making. However, the significant demands on nurses' time impedes their ability to engage with research and health care resources required for evidence-informed practice [46]. The use of their personal smartphone devices provided nurses with rapid and easy access to online health information. It is possible that nurses are using their personal smartphones as a way to efficiently access needed resources and support their patient care information needs.
Despite the high level of smartphone and app use, there was minimal reporting on nurses' attention to the quality and accuracy of the information garnered from the apps used. The commercial profitability of health-related apps tend to take priority over ensuring that apps are critically appraised for information accuracy [47]. However, when asked, nurses expressed that they want health apps to be certified by a health or professional institution, exemplifying their concern about information quality [31]. Nurses who conducted a risk assessment on the apps that they used assessed the trustworthiness of the source, sought guidance from professional bodies on technology and app use, and were vigilant about patient information privacy [35].
Similarly, nurses may be resorting to their own personal digital devices to compensate for the lack of support provided by their organizations [42]. As reported elsewhere, nurses who have access to resources from a medical library, have internet access at work, and have the opportunity to work with computer technologies are more likely to engage in evidence-informed nursing practice [48]. Organizations that strive to provide the highest-quality patient care are also accountable to providing the resources that make this achievable. The presupposition of health information technology within the clinical setting highlights the need for organizations to provide continuing education to all health care providers regarding risk assessments of health information technologies (eg, devices and apps) for responsible use and to support evidence-informed practices.
Effective communication among the health care team is essential for quality patient care and effective teamwork [49]. In fact, the most common reason for errors resulting in patient harm result from communication failures [50]. In our review, nurses used text messaging, telephone, and picture and video functions on their smartphones to communicate with other members of the health care team. Furthermore, nurses preferred the use of their own smartphones for efficient and immediate communication among health care team members. Medical students have also reported using personal smartphones as an efficient means of communication and for coordination of the clinical team [51]. It may be that organizationally based communication systems do not provide satisfactory options to meet the precipitous communication needs of health care teams working within a digital health context [52]. Similarly, nurses' use of their personal devices to communicate among members of the health care team may demonstrate a technological "work-around" meant to reconcile health system demands for cost-efficiency with efforts to provide quality patient care [53].
Despite nurses' desires to use their personal smartphones in the workplace, they were also mindful of concerns that included personal and/or colleague distraction, and they acknowledged challenges to information privacy and information security related to possible retention of patient data on their smartphones. Nurses' use of their personal devices to share practice-related information among health care teams may characterize their "work-around" of organizational health information systems that have not effectively considered nurses' workflows, their need for accessible and up-to-date health care information, nor communication practices among multidisciplinary health care teams [52,54]. Nurses are not the only health professionals experiencing these tensions. Physicians report that barriers to using their smartphones in practice include organizational policies against smartphone use and concerns about using them during patient consultations [9]. The tension between quality health practices and pressure to find system efficiencies may have also contributed to nurses' use of their personal smartphones within the workplace [54]. The reported lack of awareness of organizational policies related to personal smartphone use and nurses' lack of knowledge regarding patient perception of their smartphone use for patient care constitute two important areas for future research and health professional education [55].

Implications for Research
This scoping review highlights significant gaps in research regarding nurses' use of personal smartphones in the workplace. To date, research has focused on acute care nurses, with little investigation of nurses' device use within other practice settings.
Research is needed to understand personal smartphone use across a more diverse range of health care settings, such as home care, long-term care, and public health. A greater understanding of other health care settings, such as long-term care, will provide invaluable information, especially due to the aging population in Canada and the growing demand on care providers for the elderly. COVID-19 exposed profound gaps in long-term care in Canada, including access to practice standards and education. The importance of public health care workers was also emphasized during the COVID-19 pandemic. Research can help to inform how smartphones can be leveraged to support nurses, especially during resource and staffing shortages. This will also help to generate a greater understanding of the online resources (eg, online information sites and apps) that support nurses' practices. Research is also needed to inform smartphone practice strategies and policies that support efficient team communication and that are accountable to information, privacy, and security concerns.

Implications for Practice
Nurses are using their personal devices to access clinical information and to contribute to clinical decision making. If apps are being used and patient information is entered, it is important to know where the information is being stored, who has access to it, and who owns the data. Nurses' use of their personal digital devices for sharing patient-related information within the health care team carries a potential risk for inappropriate disclosure of personal health information. While unapologetic about using their personal devices, nurses instead advocated for information-secure messaging apps that would ensure the safety and security of people's personal health information [34].

Implications for Policy
Evidence that over 75% of nurses and physicians within acute care settings use their personal smartphones to support their patient care practices is indicative of a clear gap between policy and practice [27,38]. If nurses, as well as other health care professionals, use their smartphones as an efficient way to retrieve and share information, it would be incumbent on organizations to reassess their policies regarding personal phone use and to work with technology developers and care providers to nurture their innovative thinking and insight into effective, responsive, and responsible technology-enabled solutions.

Limitations
There were several limitations when completing this scoping review. As 16 of the 22 studies were quantitative and used cross-sectional surveys to gather data, there were limited descriptions and examples available to provide an in-depth understanding of smartphone and mobile phone use. In addition, due to the lack of diversity in the target population, there is limited evidence across the nursing continuum. Lastly, studies included were only in English; studies in other languages were not included in these findings.

Conclusions
This scoping review provides insight into nurses' use of their personal smartphones within the workplace setting. The review highlights knowledge gaps regarding nurses' personal device use and the safety and privacy of personal health information, patient care outcomes, communication practices among health care teams, and insight into app and information accuracy and reliability, thus creating significant opportunities for future research regarding nurses' use of personal digital technology in the workplace. Organizational policies that limit or prohibit smartphone use may be shortsighted; insightful leadership would leverage the knowledge of nurses with other health care providers to collaboratively develop strategies that enable efficient, respectful, and ethical use of communication technology for effective patient care practices [56].

Conflicts of Interest
None declared.