A London trust has piloted the use of an electronic handheld device to record patients’ whereabouts and arousal levels on its inpatient unit for adults with autism
On inpatient mental health wards, recording accurate and up-to-date patient observations is crucial. This is traditionally done using paper records, but the use of mobile and virtual technologies has the potential to significantly improve the system. South London and Maudsley Foundation Trust piloted the use of an electronic handheld device to record patients’ whereabouts and arousal levels on its inpatient unit for adults with autism. An audit and focus group interviews with nursing staff were conducted to assess feasibility. This article describes the nurse-led initiative, highlighting key recommendations with the aim of encouraging others to develop similar improvement projects using new technologies.
Citation: Killikelly C, Quist H (2017) Development of a mobile device to record mental health inpatient data. Nursing Times [online]; 113: 8, 53-56.
Authors: Clare Killikelly is trainee clinical psychologist, Institute of Psychiatry, Psychology and Neuroscience, King’s College London; Haddy Quist is nurse manager, South London and Maudsley Foundation Trust.
- This article has been double-blind peer reviewed
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Mobile technology – including smartphones, handheld devices and tablets – is fast, easy-to-use and accessible, with great potential to improve services and care for patients in mental health care. However, when new technologies are introduced on busy wards, uptake by staff and adherence to protocols can be low (De Veer et al, 2011). Staff often express reservations about how useful the devices will be and whether they will actually improve existing practices.
In 2012-13, we piloted the use of eObs, a portable electronic device for recording patient observations, on a 15-bed inpatient unit for adults with autism at South London and Maudsley Foundation Trust (SLaM). The device, which is the size of a mobile phone, was developed by the nursing team, and it was produced under contract by an independent software developer.
We conducted a small audit to assess whether using this handheld device on our busy inpatient ward was feasible. We also used focus groups to determine staff views on whether the device was meeting nursing practice needs.
Three key factors contributed to the success of the project:
- It was developed from the ground up, so it was clear from the outset that there was a critical service need and that the new technology would directly improve patient care;
- It was the right technology for the job, with a device that could be tailored to fit staff’s needs and had been designed to reduce, not increase, their workload;
- It was developed for nursing staff by nursing staff and led by the nurse team manager.
Using examples from the project and feasibility audit, this article explores these three key factors with the aim of encouraging other nurses and nurse managers to design and conduct improvement initiatives using new technology on their ward.
From the ground up
When introducing a new technology, the aim should be derived directly from front-line clinical practice. It should be clear how the technology will fill an important gap in service delivery or patient care, and the benefit of using the technology over existing practice should be evident.
In our case, there was no question that developing new ways to provide accurate and up-to-date information on patients was paramount. In environments such as inpatient mental health units – where there is an increased risk of suicide, self-harm, aggression, violence and absconding (James et al, 2012) – it is vital for nursing staff to have accurate and timely information on patients’ mental state and whereabouts.
In mental health settings, the monitoring of patient safety typically involves making direct hourly observations and paper recording of patients’ whereabouts and sleep – at SLaM this standard procedure is known as ‘general observations’. One of the main problems with this system is that paper recording is neither an efficient nor effective way to monitor patients. Paper charts have disadvantages such as poor legibility, inaccuracy and risk of duplication. Another critical limitation of the paper-based system is the fact that very little data is used clinically – with the exception of data on sleep, which may be discussed in clinical meetings.
Searching through paper-based data is a time-consuming process, so a wealth of information that is routinely collated and recorded on paper remains untapped, when it could be used to inform personalised patient care and improve clinical practice. Accurate and good-quality documentation is crucial in healthcare for storing legal information, building a knowledge base, conducting research, showcasing nursing work and, most importantly, preserving patient safety (Bates and Gawande, 2003).
With this in mind, the eObs device was specifically designed for use in psychiatric inpatient settings to respond to three important nursing practice needs:
- To improve patient safety through up-to-date patient monitoring;
- To reduce the number of clinical errors through accurate recording;
- To provide data for developing person-centred and evidence-based interventions.
The right technology for the job
New technology has little use on a ward if it does not meet the needs of staff or if it is inefficient or too complicated. For example, use of a desktop computer for recording patient notes will not improve practice if access to this computer is limited due to high demand (Guy, 2015).
We assessed the feasibility of implementing the eObs device by recording two types of patient data:
- Level of arousal, from sleeping to aggressive/violent behaviour;
- Engagement in therapeutic activities and location.
The following feasibility outcomes were measured:
- Number of nursing staff willing to take part in the study;
- Proportion of each patient’s data recorded over the duration of their admission;
- Number of patients with more than 33% of all possible entries completed (Palmier-Claus et al, 2012) – to measure staff’s compliance with using the device;
- Mean percentage of data collected per day.
The feasibility audit took place over a one-year period from March 2012 to March 2013. Data was recorded from the point of admission for every patient as part of normal nursing practice. The eObs device was designed to record levels of activity, location and also the state of arousal for each patient.
In this article, we focus on feasibility data for sleep. Data on how much a patient sleeps can inform medication prescription and behavioural interventions. It can also alert staff to the fact that patients may be entering a period where they may become unwell – for example if their sleep pattern changes.
Data was collected every hour, with one member of staff tasked with completing the records for each shift. The data captured was stored in a virtual cloud database and emailed to users on request. Users could, for example, generate a spreadsheet with hours of sleep recorded for each 24-hour period. Fig 1 shows, as an example of the information that can be generated from data collected with the eObs device, the hours of sleep per day recorded for one patient over a 30-day period.
Sleep data was recorded for all 26 patients admitted to the ward during the study period. The duration of inpatient stay varied, the mean being 100 days. All 25 nurses employed on the unit participated in the study; Table 1 gives an overview of the quantity and type of data recorded.
The mean number of data points entered for all 26 patients was 1,658.96 (range 27-3,461). The number of entries completed per day for each patient ranged from two to 18, with a mean of 13.52. Out of the 26 patients, 21 (80.7%) had more than 33% of possible entries completed, so the minimum threshold required to achieve feasibility had been reached (Palmier-Claus et al, 2012). Finally, the mean percentage of entries completed for each patient was 56.33% (range 13-77%), which shows that staff had completed more than half of all possible entries in total.
The feasibility data shows that a small portable device can be used frequently and effectively to record an adequate amount of patient data, and that the eObs is fit for purpose. Although the data gives an idea of how nursing staff used the technology, we wanted to capture the insights and experiences of front-line staff so they could be directly involved in the development of the device.
Developed for nurses by nurses
We conducted three focus groups to assess whether staff found the device acceptable, and also determine areas for improvement. The focus groups each lasted 10-20 minutes, and were led by a member of the nursing team. The groups ranged in size, from five to 10 participants, who included band 5, 6 and 7 nurses as well as care support workers. All 25 nurses in the unit participated in the focus groups.
Brief structured qualitative interviews on staff experiences of eObs were conducted, with topics that comprised recording general observations and sleep data on the eObs; ease of use, data display; data inputting; retrieving and downloading data from the virtual cloud; and use in clinical work.
The focus groups provided helpful feedback on the structure, content and technicalities of the device. Participants recommended that the device shows how long it takes to record observations and has a larger screen and longer battery life.
The groups also provided useful feedback in terms of clinical practice; for example, participants recommended explaining the device and its use to patients and visitors. They also suggested that the device could allow users to add information about specific interventions for a patient – for example, recommended hours of sleep.
Table 2 presents an overview of the outcomes and the recommendations of the focus groups.
Physical health observations
In the feasibility study, we found that nursing staff had used the device to record more than 33% of possible entries (the minimum required for feasibility) for over 80% of patients and that, on average, more than half of all possible entries had been completed for each patient. Most staff reported a number of benefits, including ease of use and usefulness for clinical discussions. Staff also provided several helpful recommendations for improving the device and how it is used. Based on the results of the audit, the trust applied for, and was awarded, £1 million from NHS England’s Nursing Technology Fund to further develop and roll out digital technology for recording patient observations on all inpatient wards. The Nursing Technology Fund was launched in 2012 to promote the use of digital technology in nursing and midwifery.
The trust is currently piloting the use of handheld devices for recording physical health observations. While this practice is now commonplace in some acute trusts in the UK, the use of digital technology to record physical health data is fairly new in mental health settings. We believe it could have a positive impact on the care of patients with mental health problems whose physical health is deteriorating. The preliminary results of this pilot show that staff record more physical health observations than they do using paper-based systems and that the response to a deterioration in physical health is improved. There are also anecdotal reports of time saved on scanning and uploading paper records, and of easier access to full patient observation reports.
This small audit provides three key recommendations for those wishing to conduct a similar improvement project using mobile technology (Box 1). Mobile devices can be useful and beneficial on inpatient mental health wards as long as they address a crucial issue in service delivery; have a clear benefit compared with current practice; and are developed in direct collaboration with front-line staff.
In the future, mobile technologies will be further developed throughout the trust to include behaviour and mood monitoring; for example, the recording of instances of challenging behaviour and ratings of mood. This could help clinicians to better understand the triggers for certain behaviours and gauge the effectiveness of pharmacological, behavioural and psychological interventions provided to patients. Finally, it helps to ensure that staff work in a safe environment.
Box 1. Introducing mobile technologies: key recommendations
- Aim to address an essential and significant service need
- Ensure that the technology is appropriate for the job
- Develop the project in partnership with those who will be the main users of the technology – nurses and other front-line staff
- The authors would like to thank Jim Clark, nurse therapist, and Vaughan Bell, clinical psychologist, both at South London and Maudsley Foundation Trust, for their contribution to the success of the eObs pilot.
- Patient observations can be recorded more efficiently on electronic devices than with paper charts
- Mobile technology can improve service delivery and patient care, but uptake can be low if staff are not persuaded of the benefits
- A portable electronic device was developed for use in a psychiatric inpatient setting to record patients’ whereabouts and arousal levels
- When introducing a n ew technology on a busy ward, its benefits over existing practice should be evident
- New technology must be tailored to the needs of staff and developed in collaboration with front-line users
Bates DW, Gawande AA (2003) Improving safety with information technology. New England Journal of Medicine; 348: 25, 2526-2534.
De Veer AJ et al (2011) Successful implementation of new technologies in nursing care: a questionnaire survey of nurse-users. BMC Medical Informatics and Decision Making; 11: 67.
James K et al (2012) Self-harm and attempted suicide within inpatient psychiatric services: a review of the literature. International Journal of Mental Health Nursing; 21: 4, 301-309.
Palmier-Claus JE et al (2012) Affective variability predicts suicidal ideation in individuals at ultra-high risk of developing psychosis: an experience sampling study. British Journal of Clinical Psychology; 51: 1, 72-83.