Applied Nursing Research 30 (2016) 228–236Contents lists a.docx

Applied Nursing Research 30 (2016) 228–236
Contents lists available at ScienceDirect
Applied Nursing Research
j ourna l homepage: www.e lsev ie r .com/ locate /apnr
Improving nurse–patient communication with patients with
communication impairments: hospital nurses' views on the
feasibility of
using mobile communication technologies
Bridget Sharpe, BSp Path (Class I Hons), Bronwyn Hemsley,
PhD ⁎
The University of Newcastle, Callaghan, NSW, Australia
a b s t r a c ta r t i c l e i n f o
Conflict of Interest: The authors declare no conflicts o
Funding statement: This research was supported in p
thor from the National Health and Medical Research Coun
safety incidents involving people with communication dis
⁎ Corresponding author at: Level 2 McMullin Building,
University Drive, Callaghan, NSW, 2308, Australia. Tel.: +
E-mail address: [email protected] (
http://twitter.com/bronwynhemsley (B. Hemsley).
http://dx.doi.org/10.1016/j.apnr.2015.11.012
0897-1897/© 2015 Elsevier Inc. All rights reserved.

Article history:
Received 30 July 2015
Revised 13 November 2015
Accepted 18 November 2015
Keywords:
Communication impairment
Mobile technology
Communication aids
Hospital communication
Nurse-patient communication
Nursing
Background:Nurses communicatingwith patientswho are unable
to speak often lack access to tools and technol-
ogies to support communication. Although mobile
communication technologies are ubiquitous, it is not known
whether their use to support communication is feasible on a
busy hospital ward.
Purpose: The aim of this study was to determine the views of
hospital nurses on the feasibility of using mobile
communication technologies to support nurse–patient
communication with individuals who have communica-
tion impairments.
Method: This study involved an online survey followed by a
focus group, with findings analyzed across the two
data sources.
Findings: Nurses expected that mobile communication devices
could benefit patient care but lacked access to
these devices, encountered policies against use, and held
concerns over privacy and confidentiality.
Conclusion: The use ofmobile communication technologieswith
patients who have communication difficulties is

feasible and may lead to improvements in communication and
care, provided environmental barriers are
removed and facilitators enhanced.
© 2015 Elsevier Inc. All rights reserved.
1. Introduction
Communication in hospital is a fundamental human right
(UNCRPD,
2006) and is essential to safe hospital care (Bartlett, Blais,
Tamblyn,
Clermont, &MacGibbon, 2008). Recent reviews have revealed
that com-
munication in hospital is problematic for patients with
communication
impairments (e.g. see Hemsley & Balandin, 2014; Hemsley et
al., 2015)
and that research evaluating strategies to improve
communication and
safety for these patients is lacking. Effective communication
with
patients who have communication impairments in hospital relies
on
many factors in the patient, including skilled nurses who take
time to
communicate (Hemsley, Balandin, & Worrall, 2012), prepared
patients
(Costello, Patak, & Pritchard, 2010), the availability of
communication
aids (e.g., Hemsley & Balandin, 2004), and the support of
family
f interest.
art by a grant to the first au-
cil, on investigating patient
abilities.

The University of Newcastle,
61 2 4921 7352.
B. Hemsley). URL:
caregivers and paid carers in hospital (Hemsley, Balandin, &
Togher,
2008; Hemsley et al., 2012). Not only does effective
communication in
hospital allow individuals with communication disabilities to
assert
control over their environment (Hemsley, Balandin, & Worrall,
2011),
it also helps them to communicate andmanage pain, exchange
informa-
tion, reflect on emotions, demonstrate politeness, and develop
relation-
ships for social closeness (Happ, Tuite, Dobbin, DiVirgilio-
Thomas, &
Kitutu, 2004; Hemsley et al., 2011).
Awide range of conditionsmay impede a patient's ability to
commu-
nicate basic care needs and exchange information about their
health.
People with lifelong disabilities (e.g. cerebral palsy, intellectual
disabil-
ity, autism), acquired disabilities (e.g. stroke, traumatic brain
injury,
cancer, neurodegenerative disease), physical trauma, or
mechanical
ventilation (Beukelman & Mirenda, 2013) might require
communica-
tion supports to convey their message to unfamiliar nursing
staff. Diffi-
culty communicating in hospital is associated with an increased
risk of
patient safety incidents (Bartlett et al., 2008; Hemsley et al.,

2015;
Wassenaar, Schouten, & Schoonhoven, 2014). Also, patients
report
experiencing negative emotional consequences when unable to
speak
in hospital, including fear, anger, worry, depersonalisation,
frustration,
and loss of control (Happ et al., 2004; Hemsley et al., 2008). In
light of
this evidence, the development and use of Augmentative and
Alterna-
tive Communication (AAC) solutions (e.g. communication
boards,
books, electronic devices with speech output such as speech
generating
devices, mobile communication technologies) are vital for these
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Table 1
Demographic information of survey respondents.
Survey question Categories in responses Number of
responses in
that category
Nursing role Registered nurses 24

Nursing administrators 5
Clinical nurse specialists 5
Enrolled nurses 4
Nurse educators 3
Hospital setting Metropolitan setting 30
Rural 10
Country of residence Australia 37
United States of America 2
United Kingdom 2
Frequency caring for patients with
severe communication impairments
Daily 10
Weekly 14
Monthly 13
Experience with types of health
conditions in patients with
communication impairments
Stroke 33
Anaesthesia 33
Cancer 30
Developmental disability 29
Lack of consciousness 25
Intellectual disability 24
Traumatic brain injury 23
Ventilation/intubation 20
Oral/laryngeal structures 17
Cerebral palsy 14
Motor neuron disease 14
Autism 12
Locked-in syndrome 7

Other 4
229B. Sharpe, B. Hemsley / Applied Nursing Research 30
(2016) 228–236
patientswith communication impairments and arewidely
recommend-
ed (Costello et al., 2010; Hemsley & Balandin, 2014).
Despite the known benefits of using AAC in hospital, the
literature is
replete with barriers to using communication aids in hospital.
Patients
rarely have access to their communication aids in hospital, due
to this
being discouraged and fears that systems will be lost, damaged,
or
stolen (Hemsley et al., 2008). Also, nurses report lacking time
and access
to professionals with appropriate expertise to support their use
of
complex speech generating devices (Balandin, Hemsley,
Sigafoos, &
Green, 2007; Finke, Light, & Kitko, 2008; Hemsley et al.,
2008). Unfortu-
nately, human factors also affect the implementation of AAC in
hospital,
with many reports of negative staff attitudes towards patients
with
communication disabilities (e.g. presuming patients who cannot
talk
have an intellectual disability) (Balandin et al., 2007; Hemsley
et al.,
2008; Hemsley et al., 2011), and patients' reduced physical and
cognitive
status while ill in hospital (Costello et al., 2010). These barriers
empha-

size the need for readily available, cost-effective
communication solu-
tions that can be easily used by nurses, and by patients who are
unwell, to improve nurse–patient communication.
Mobile communication technologies, which include portable
elec-
tronic devices that have software installed for communication
(e.g.
mobile phones, tablets, portable laptops, gaming consoles), are
accessi-
ble, engaging communication options for individuals with
severe com-
munication impairments (McNaughton & Light, 2013; Van der
meer
et al., 2011). Mobile communication AAC applications (‘apps’),
such as
‘Proloquo2go’ (Assistive Ware, 2013), and ‘Predictable’
(Therapy Box,
2013), provide text-to-speech and/or symbol or picture-to-
speech
options that can be personalized to suit the individual's
communication
needs. Such software is relatively easy to use, enabling words
and
pictures to be inserted into a ‘grid’ pattern for selection by
pointing or
scanning with a switch, or typing for speech output. Unlike
traditional
high technology AAC systems, mobile technologies are
ubiquitous
(Shane et al., 2011), and are therefore likely to be owned by
both
nurse and patient populations. Mobile technologies are also
compact
and relatively inexpensive, potentially increasing motivation for

pa-
tients to keep their devices with them by less costs being
incurred if
the device is lost, stolen, or damaged. In addition, mobile
technologies
have many universal features (e.g. camera, photo gallery, zoom
func-
tion, Internet access), whichmay facilitatemulti-modal
communication
(Shane et al., 2011) and social networking.
It is not known whether the attitude and knowledge barriers
outlined in previous research on using AAC systems in hospital
also
apply to the new generation of readily accessible mobile
communica-
tion technologies with AAC apps. Examining the feasibility of
using
mobile technologies for communication in hospital could inform
both
the design of ecologically appropriate hospital communication
apps,
and hospital policies and procedures regarding the use of mobile
technologies for nurse–patient communication. Nurses, who are
primary communication partners of all hospital patients, may
provide
unique insight into potential use ofmobile communication
technologies
in hospitals, and any barriers to or facilitators for successful use
to
improve patient communication. The aim of this study was to
deter-
mine the feasibility of nurses usingmobile communication
technologies
to support patients who have communication impairments in
hospital,

by investigating nurses' views and experiences on barriers and
facilita-
tors to using these technologies on the hospital ward to support
patient
communication in hospital.
2. Method
This mixed method research involved two connected stages: an
on-
line survey and a focus group. The online survey was used
initially to
capture a broad range of views (Leeuw, Hox, & Dillman, 2008),
and
the focus group expanded upon and clarified the findings of the
survey
(Krueger & Casey, 2003). This design was selected to
strengthen the re-
sults of each data source in line with the principles of
triangulation,
convergence and corroboration of results, complementarity, and
the
elaboration and expansion of findings across studies.
2.1. Participants
FromMay to July, 2014, nurseswho hadworked in a hospital
setting
in the past 12 months were recruited through a global network
of
nurses in Twitter (e.g., @WeNurses, #WeNurses) to take part in
an
online survey. Online recruitment and data collection were used
to
obtain a large convenience sample of respondents (Leeuw et al.,
2008). In total, 43 nurses attempted the survey. Of these, 31

responded
to all survey questions, and 11 answered only some of the
questions.
Two respondents were excluded from the survey: one accessed
the
survey, but did not answer any questions, and another
respondent
only provided responses that both authors deemed to be non-
genuine
‘troll’ or mischevious acts. Nurses were aged between 23 and 65
years
(average 42 years), most were in Australia (n = 37) and had
worked
on children's and adults' wards (n = 29), and were female (n =
34).
Focus group participants were recruited purposively and
through
snowballing sampling technique through community advertising
to
locate nurses who had worked with patients with communication
impairments. This method of recruitment yielded four nurses
who had
had broad experiences in a range of hospital settings, and who
were
therefore more likely to represent the range of viewpoints.
Details on
the survey and focus group participants are presented in Tables
1 and 2.
2.2. Data collection
2.2.1. Survey
An online survey, based on literature on the use of
communication
technologies in hospital, was developed by the first two authors

to
determine the barriers and facilitators to mobile technology use
by
nurses working with people with communication impairments.
The
surveywas piloted with a colleague of the second author, and
following
feedback and subsequent revision, was published online in
Survey
Monkey™. Survey items included multiple choice, free-
response ques-
tions, and Likert rating scales (Leeuw et al., 2008). The survey
questions
230 B. Sharpe, B. Hemsley / Applied Nursing Research 30
(2016) 228–236
were divided into three sections, which sought information
about
respondents' views on their: (a) experiences and training related
to
communicating with patients who cannot speak, (b) access to
commu-
nication aids and support, and (c) experiences and perspectives
regard-
ing the use of mobile technology for patient communication,
including
confidence. A copy of the survey is available from the second
author.
2.2.2. Focus group
The face-to-face focus group was moderated by the first author
according to methodology described by Krueger and Casey
(2009). Six
key questions derived from themes identified in the survey

responses,
were used to allow for the generation of diverse perspectives.
(1) “What is your understanding of communication aids and
mobile
technologies that could be used to help with patient
communication?”
(2) “What experiences have you had communicating with
patients
who were unable to speak?” (3) “Is mobile communication
technology
something that you see often in your setting for any purpose?”
(4) “The
survey respondents raised a number of barriers to usingmobile
technol-
ogy for patient communication (show figures). Do you agree?
Why do
you think this might be the case? Are there any other barriers
that
you can think of?”(5) “The survey respondents also listed a
number of
features that could make it easier to use mobile technology for
patient
communication. (Show figures). Do you agree? Are there any
other
facilitators that you can think of?” (6) “Would you be willing to
use
mobile technology as a tool for patient communication in your
hospital
setting? At the focus group, two printed communication boards
were
shown as examples of communication aids designed for use in
hospital
settings (Widgit Health BedsideMessages™, 2010) to support
common
communication needs (Hemsley et al., 2011). The focus group
was

audio recorded and transcribed by the first author with all
identifying
information removed prior to analysis.
2.3. Ethical considerations
The survey was anonymous and participants were not
approached
directly to take part in the study. Participation was voluntary
and
confidential, and the study was ethically approved at the
University of
Newcastle, Australia. Focus group participants received a
summary of
the results of the study, and survey respondents were given
access to
a report on the findings of the study on a public Website, and
details
of the Website were provided in the landing page of the survey
at the
point of data collection.
2.4. Data analysis
Survey questions yielded both quantitative data for descriptive
anal-
ysis (e.g. frequencies, percentages) and qualitative results in
written
comments. Quantitative data were represented graphically and
analyzed using descriptive, univariate statistics (e.g. frequency
distribu-
tion, median) (Berg & Lune, 2011). Qualitative data (i.e.
respondents'
comments) were analyzed for content themes. The focus group
tran-
script was read and re-read by both authors, who identified and
discussed the content categories emerging from the discussion
using

the same steps as for the online survey. Key concepts were
identified
Table 2
Demographic information on focus group participants.
Participant Number Age Qualification
1 58 Registered nurse
to first form categories of meaning, and then these were
grouped to
form the content themes.
2.5. Rigor
Findings from the first stage of the research were discussed
with
focus group participants. The first author's coding was reviewed
and
verified by the second author to ensure the trustworthiness,
credibility
and reliability of findings (Patton, 2002). After the first two
authors an-
alyzed the key focus group content themes, a written summary
encap-
sulating these themes was emailed to all focus group
participants to
check whether the researcher's interpretations of the data
adequately
reflected their views and the discussion. Two of the participants
con-
firmed by email that the summary of content themes represented
the
focus group discussion, and none of the participants requested
any

changes to the summary.
3. Findings
Forty-one participants commenced the online survey. As all
survey
questions were optional, and not all survey respondents
answered all
questions, the number of responses for the questions are
provided
when reporting the results. Experiences and views on the
feasibility of
using mobile communication technologies are reported first for
the
survey and then the focus group to provide contextual factors
potential-
ly affecting the use of mobile communication technologies in
hospital.
To reduce repetition across the paper, and to reflect the analysis
across
studies, barriers and facilitators to the use of mobile
communication
technologies for communication in hospital across both studies
are
reported together (Patton, 2002). Participant comments are
labelled to
show study group as R1 (e.g., survey respondent 1) or as P1
(e.g.,
focus group participant 1).
3.1. Survey findings related to experiences and expectations
3.1.1. Use of communication aids with patients who have
communication
impairments
Thirty-six survey respondents reported lacking access to
communi-

cation technologies of all types, including mobile devices. The
frequen-
cies for respondent reports of experiencewith different
communication
aid types in hospital are presented in Fig. 1.
As Fig. 1 shows, themost common communication aid accessed
at all
times by almost two thirds (n = 21) of the 36 survey
respondents was
the ubiquitous ‘notepad and paper’. Most respondents indicated
that
they never had access to speech generating devices (n=29).
However,
despite being ubiquitous in general society, few survey
respondents
always had access to laptops (n = 3) or tablets, such as iPads (n
= 2).
The most common use of mobile communication technologies
by
respondentswas for Internet searches (n=11). Nonetheless,
amajority
(two thirds) listed multiple potential uses for tablet or smart
phone
technologies at the bedside that they would be likely to access
in the
future, including use of nursing, health and education apps, as a
music
player, for communication, and for socialmedia use. One third
of survey
respondents (n = 9) reported that they would not be likely to use
Clinical responsibilities
Critical care, recovery
Medical, surgical, palliative care
General medical, surgical, palliative care, pre-admission clinic,

management
General surgical, oncology, palliative care, orthopaedic
0
5
10
15
20
25
30
35
40
N
u
m
n
b
er
o
f
n
u
rs
es
(
N

=
36
)
Type of communication aid used (ascending in chart)
Never Rarely Sometimes Most of the time Always
Note: Tablets = mobile technology devices without phone
capability
Fig. 1. Frequency for types of communication aids used by the
survey respondents. Note: 'Never' is at the bottom of each
column, working upwards for other categories in increasing fre-
quency of use.
(2016) 228–236
mobile technologies at all to aid patients' communication, now
or in
the future.
3.1.2. Support for using communication aids of any type
Despite having had clinical experience caring for patients with
communication impairments (n = 30, or 73%), and with
communica-
tion aids or technologies (n = 21, or 51%), few survey
respondents
had received any training related to caring for or
communicating with
patients with communication impairments (n = 6, or 15%) or
using
communication technologies (n = 8, or 20%). Where nurses had
received any training, it had been completed over 2 years ago,

and for
many, prior to the introduction of the iPad in 2010. A reported
lack of
support from speech language pathologists and occupational
therapists
for using aids for communicating with patients who have little
or no
speech was common. Just over half reported having access at
least
sometimes to a speech language pathologist (n = 23, or 56%) or
an
occupational therapist (n = 21, or 51%) for communication
support,
but a considerable number of nurses never or rarely had access
to
speech language pathologists (n = 13, or 32%) or occupational
thera-
pists (n=15, or 37%) for communication support on the ward.
Overall,
survey respondents received little support in the use of mobile
technol-
ogies. The most frequent sources of support for nurses were
speech
language pathologists (n = 13, or 32%), other staff members
who
knew about the technology (n = 10, or 24%), and patients'
family/
caregivers (n = 9, or 22%). Few nurses had completed relevant
work-
shops (n=5, or 12%), in-services (n=4, or 10%), or
certificates/degrees
(n = 4, or 10%), while two thirds of respondents (n = 22, or
54%) had
received no support related to the use of mobile communication
tech-
nologies in hospital.

3.1.3. Confidence in using communication aids
Survey results reflected a lack of confidence in using all types
of com-
munication aids and technologies. On average across the group,
nurses
ranked their confidence on a Likert scale at 2.7, where a score
of 1 rep-
resented not confident at all, and a score of 5 represented
extremely
confident. Only 1 of 31 survey respondents rating their
confidence on
the survey felt extremely confident in her ability to use
communication
technologies. In contrast, 5 of the 31 respondents did not feel
confident
at all in their ability to use communication aids with patients.
3.2. Focus group findings related to experiences and
expectations
Like survey respondents, focus group participants had some
famil-
iarity with a small range of low technology communication aids
(e.g.
pen and paper, alphabet boards), but limited experience with or
access
to any type of high technology communication aids in the
hospital
setting. When shown the AAC systems in the group, one nurse
(P1)
said that while such picture boards were a standard option in the
ICU,
therewere not enough of these on theward. Three nurses had
previous-
ly used a patient's own communication aid (P1-3) and one had
cared for

a patient who used a speech-generating device (P2). As with
survey
results, the focus group results reflected that ‘pen and paper’
was the
most commonly used and preferred method for aided patient
commu-
nication. Even so, focus group participants acknowledged
several
barriers to using a pen and paper, including patient fatigue, poor
fine
motor skills, expressive language impairment, and poor literacy
skills.
Focus group participants reported they did not have ready
access to
mobile communication technologies owned by the hospital. This
suggests that, like speech generating devices, low cost and
relatively
common communication technologies might still be guarded—
and
secured—as highly valued items on a hospital ward. No focus
group
participants reported using technologies of any type for
communicating
with patients. Indeed, they agreed that they had learned how to
“get by”
using unaided communication strategies (e.g. lip-reading, facial
expres-
sion) and striving to understand the patient.
Focus group participants had little access to their
ownpersonalmobile
communication technologies, due to hospital policies banning or
limiting
staff use of mobile phones, with only one participant having
access to her

personal phone at all times. Despite this, nurses described
instances in
which they felt obliged to work outside the policy and use their
ownmo-
bile devices to aid patient care. P4 illustrated this in the
following account:
If someone comes in and they're supposed to be photographed, I
don't have access to the camera, doctors have asked me before
to
take a photo on my iPhone, with the patient's verbal permission.
They didn't say that, but obviously I had to gain it. So, I take a
photo
onmy iPhone and then send it to them (thedoctor) and then go
back
to the patient and say, “I'm deleting that photo from my phone.”
In relation to access to the Internet on the ward, patients used
their
ownmobile phones andwireless connection was not available for
staff:
(2016) 228–236
“Wedon't havewireless at the bedside anyway.We do for our
computer
at the desk, and it's just so slow” (P2).
3.2.1. Perceived advantages of communication technologies
As they had limited personal experiences using communication
technologies, focus group participants hypothesized on potential
ad-
vantages of using traditional and mobile communication

technologies
in their settings. All considered that low-technology
communication
boards—particularly if laminated and kept at the patient's
bedside—would be useful for communicating with patients
about
basic needs, increasing patients' independence, and decreasing
patients'
feelings of frustration. The group viewed that low technology
communi-
cation optionsmay be useful for basic needs communication
more than
other communication purposes (e.g. social communication) and
that in
contrast mobile communication technology might facilitate
more social
communication with patients and enhance the provision of
personal-
ized care. Focus group participants suggested that the multi-
functional
nature of mobile technologies would be advantageous for
improving
communication, as the devices servemultiple purposes,
including com-
munication, leisure, distraction, education, and social
participation (e.g.
via social media). Finally, participants viewed mobile
communication
technologies as having the potential to save time by enhancing
the
‘flow’ of patient care. The focus group discussion reflected
nurses' ex-
pectations of a future where mobile communication
technologies
were bothnecessary anduseful for communication in hospital. As
stated

by P1:
When you see how simple it is out there, and everybody's got
some
sort of device with apps and they use it every day, all day…you
would have to think that it…shouldn't be that hard to, sort of,
imple-
ment. (P1)
However, the groupmembers agreed that usingmobile
technologies
might be more difficult with patients with severe behavioral,
cognitive
or physical impairments. The group considered that the need for
com-
munication support might be greater for patients with more
severe dis-
abilities, due to the long-term nature of their communication
impairments, than for that patients with short-term
communication
impairments, whomight need to “wing it” (P2) without access to
com-
munication aids in hospital.
3.2.2. Training and professional support for using
communication
technologies
Aligning with the results of the survey, the focus group
participants
explained that nurses did not currently receive training in how
to use
communication aids with patients. P4 said she had been shown
how
to use a communication board 10 years previously at university
and

reflected that “since then I have never really had to use it, and
I've
never really thought about it until this study”. All but one of the
focus
group members were readily able to call upon a speech language
pa-
thologist during office hours. However, the nurses rarely sought
the
speech language pathologist's support regarding communication
for pa-
tients with little or no speech. Rather, speech language
pathologists
were consulted primarily for dysphagia referrals:
On our ward, [communication's] not our, not a focus, is it?…It,
it
could be, it should be…probably more, more so…But we, we
tend
to use our speech pathologists to assess swallowing problems…
rather than communication. (P3)
3.3. Both studies' findings related to barriers and facilitators to
mobile tech-
nologies for communication
All 31 of the survey participants who responded on the
questions re-
lating to barriers and facilitators, and the focus group members
identified barriers (see Fig. 2) and facilitators (see Fig. 3) to the
use of
mobile communication technologies in hospitals.
Content themes relating to barriers and facilitators for nurses'
use of
mobile technology were identified in the survey respondents'
com-

ments and focus group discussion. These are presented in Table
3,
with example quotes for each theme.
3.3.1. Access to mobile technologies for communication
Results across both the survey and the focus group reflected
nurses
being inhibited from accessing mobile devices for patient
communica-
tion at the bedside for a range of reasons which will be outlined
in
this section. The limited availability of mobile communication
aids on
hospital wards was considered a significant barrier to their use,
with
75% of 36 survey respondents never having access to hospital-
owned
mobile communication technologies.
3.3.2. Policies affecting access to mobile technologies
Policies preventing nurses fromusing their ownmobile
technologies
were noted as barriers to use for just under a third (n = 10) of
survey
respondents, and the focus group discussion reflected that
personal
use of mobile technologies could be considered a potential
distraction
from attention to patient care. However, one focus group
member
(P4) who did have personal access to mobile technologies on
her
ward disputed this, noting that use of her ownmobile phone
facilitated

patient care by allowing her to conduct Internet searches more
readily.
Almost three quarters of survey respondents (n = 23) considered
that
simply having more mobile technologies available on hospital
wards
might facilitate use for patient communication. The focus group
further
emphasized the need for more ward-owned devices to be made
avail-
able for the sole purpose of supporting communication.
While only one survey respondent cited patient confidentiality
is-
sues as a potential barrier to the use of mobile communication
technol-
ogies in hospital, the focus group reflected that theremight be
potential
threats posed to patient confidentiality by patients or nurses
using the
multi-purpose devices to take or share photos inappropriately.
Thus,
while access to technologies might be helpful, participant's held
some
concerns about patient confidentiality and privacy.
3.3.3. Security
Concerns regarding the theft, damage, and loss of mobile
communi-
cation devices were expressed across both studies. The focus
group
nurses reported that concerns associated with the high personal
value
and subsequent scarcity of these devices in hospital led to
restrictions

on their use on the ward.
3.3.4. Time using mobile technology
Almost half (n=13) of the 31 survey respondents noted lack of
time
for using communication technologies as a barrier to their use
in
supporting patient communication. Focus group discussion
verified
this finding, with participants agreeing that they were “time
poor”
(P2) in completing basic care tasks on the ward. Participants
agreed
that the relative priority of basic care tasks over communication
would further limit the use of mobile communication
technologies at
the bedside. However, more than a third (n=12) of the survey
respon-
dents, and all focus group members, considered that having
more time
to use mobile communication technologies would facilitate
communi-
cation at the bedside and improve work flow.
3.3.5. Attitudes towards communication technologies
A small number of survey respondents considered that negative
staff
attitudes (n = 2) and reluctance to use the technologies (n = 3)
were
potential barriers to the future use ofmobile technologies to
support pa-
tient communication. Focus groupmembers concurred, and
considered
thatmobile communication technologiesmay be perceived as

unneces-
sary, (e.g. “I don't have a need inmy area of work”, R22),
unwanted (e.g.
“People are resistive to change”, P3), or unrecognized (e.g. “It
sort of
0
5
10
15
20
25
30
35
N
u
m
b
er
o
f
n

u
rs
es
w
h
o
id
en
ti
fi
ed
b
ar
ri
er
(N
=
31
)
Barrier
Fig. 2. Barriers to the use of mobile communication
technologies (survey respondents).

(2016) 228–236
slips through the cracks”, P2). They agreed that a lack of
confidence
might contribute to nurses' unwillingness to usemobile
communication
technologies with patients. Indeed, survey results revealed that
positive
staff attitudes (n = 15) and increased confidence in nurses'
ability to
use the devices (n=13)were seen as facilitators for usingmobile
com-
munication technologies. Some survey respondents identified a
need
for attitudes towards technology to change, for example: “Their
use
(mobile devices) would require a cultural shift” (R39). Focus
group par-
ticipants agreed that a shift in culture to a positive attitude
towards
using communication technologies would enhance the feasibility
of
using these aids in hospital settings.
3.3.6. Training and support regarding use of mobile technology
All focus group participants and almost half (n = 14) of the
survey
respondents viewed insufficient training as forming a
considerable bar-
rier to the use of mobile technologies for communication. Focus
group
participants also suggested that a lack of training or experience
was
0
5

10
15
20
25
N
u
m
b
er
o
f
n
u
rs
es
w
h
o
id
en
ti
fi

ed
f
ac
ili
ta
to
r
(N
=
3
1)
Fa
Fig. 3. Facilitators to the use of mobile commun
associated with decreased confidence and therefore reduced
willing-
ness to use the technologies among nurses. However, results
also sug-
gested a link between ‘training’ and the potential for this to
influence
nurse attitudes towards the use of mobile technologies.
Approximately
two thirds of the survey respondents reported that an increase in
pro-
fessional support (n=18), staff knowledge (n=18), and staff
compe-
tence (n = 17) would be necessary for successful
implementation of
mobile devices in their settings.

The focus group participants agreed that nurses having training
in
the use of mobile communication technologies might facilitate
their
use in hospitals, but only if certain conditions were met in the
training.
They suggested that relevant trainingmust incorporate not only
educa-
tion (i.e. information provision, including awritten information
pack for
the ward), but also hands-on demonstration (i.e. showing nurses
how
to use the technology), and repeated practice or coaching (i.e.
nurses
being supported to gain increased experience with implementing
the
technology in real-life situations). The focus group members
viewed
cilitator
ication technologies (survey respondents).
Table 3
Content themes with quotes illustrating barriers and/or
facilitators in the content theme.
Content theme Example quote illustrating the
barrier
Example quote illustrating
the facilitator
Access There are no devices available in
my workplace. (R39)

The lack of these…and you
know, nurses having to be that
empathetic and just spend their
time trying to do things like
drawing pictures to
communicate better with the
patient. (P4)
Just to have one available
for assistance would be
beneficial to any ward.
(R35)
If you had the availability of
iPads and that specific for
your working area and not
your own personal ones
that would be a better idea.
(P1)
Policies affecting
access to
mobile
technologies
No carrying mobile phones.
(R9)
Restrictive and ill-informed
smart phone use policies in
NSW health. (R23)
Infection control may be an
issue if the ward had some
available as it’s harder to clean
an electronic device. (R17)
Policy/guideline
encouraging use would be

useful. (R30)
I believe keeping them
clean would be relatively
easy. (R22)
Security Management would be
concerned regarding theft of
such devices.(R37)
If they go missing, who is
responsible? (R22)
It's (the ward iPad) under lock
and key so you can’t get access
to it. (P2)
(Not raised as a facilitator)
Time We are so time poor to get
through the basic stuff. (P2)
If…they've finally explained
what they were trying to
tell us…it'd definitely save
time. (P4)
Attitudes
towards
communication
technologies
People are resistive to change.
(P3)
I don't have a need in my area of
work. (R22)
On our ward, it's not our, not a
focus, is it? (P3)
It might be out of fear of not

being able to do it. (P4)
Their use would require a
cultural shift.(R39)
Those that are willing and
can do it will find it really,
really helpful. (P1)
Training More training, more
awareness throughout
staff.(R6)
General information pack
on objectives of using the
device with patients. (R38)
If people are shown how
easy it is to use, people are
happy to try it. (P3)
The more you use it, the
more used to it you will get.
(P2)
Technical issues We don't have wireless at the
bedside. (P2)
The thing with the laptop is that
you… don't have to hang onto it.
(P1)
Patient factors Degree of illness has got a lot to
do with it too. (P1)
Sometimes people can't even,
you know, open their eyes to
read. (P4)
(2016) 228–236
that the ideal mode of training would be hands-on and

‘workshop’ in
style, however, they also agreed that online learning modules
may be
useful, particularly for the education component, and for
demonstration
videos.
3.3.7. Logistical or technical issues
While 10 out of 31 survey respondents noted that a lack of
storage
space would reduce the feasibility of mobile technologies in
hospitals,
the focus group did not share this concern. Other logistical and
technical
barriers to the use of mobile communication technologies,
identified by
less than a third of survey respondents, included threats to
hygiene
(n= 7) or occupational health and safety (n= 7), insufficient
wireless
Internet connection for online functions (n=1), and any known
or po-
tential interference with medical equipment (n=1). Conversely,
tech-
nical issues identified as facilitators by many survey
respondents
included: the messages or images on the devices being helpful
(n =
10), social marketing for promotion and increased popularity of
the
technologies (n = 3), relative affordability of personal mobile
commu-
nication technologies (n = 2), and having adequate wireless
Internet
connection for full use of all functions (n = 2). Focus group

members
agreed that the items identified as facilitators in the survey
would be
important for enhancing the feasibility of mobile
communication tech-
nologies in hospital. They also noted that (a) additional
technological
features, such as larger screens and secure mounting systems,
might
further enhance ease of use of mobile communication
technologies in
hospital; and (b) consistent introduction of mobile technologies
across
hospital wards might facilitate their use for supporting nurse–
patient
communication.
3.3.8. Patient factors affecting use of communication
technologies
Although patient-related factors were not identified in the
survey as
being barriers to the use of mobile communication technologies,
the
focus group perceived that the skills or capacity of the patient
(e.g. de-
gree of illness, cognitive ability, behaviors of aggression)
would affect
implementation on some hospital wards.
4. Discussion and recommendations
The present research identified a number of barriers and
facilitators
to nurses' use of mobile communication technologies for
communicat-

ing with patients with communication impairments in hospital.
Even
though some nurses might optimistically view the use of mobile
com-
munication technologies as being feasible, nurses' perception of
the
barriers listed above could considerably reduce feasibility of the
devices
for supporting patient communication. These barriers are also
similar to
those noted in the use of speech generating devices in hospital
(e.g.
Balandin et al., 2007; Finke et al., 2008; Hemsley et al., 2008).
Nurses in this study viewed that the most common barriers to
the
implementation of mobile communication technologies in
hospital
were the limited availability of devices on the ward, security
concerns
(of theft, damage, or loss), a lack of staff training/support, and
a lack of
time to use the devices. The results suggest that—like speech
generating
devices—low cost and relatively common communication
technologies
might still be ‘locked away’ as highly valued items on a
hospital ward
(Hemsley & Balandin, 2004). The results of this study support
the find-
ings of previous research that nurses are not well supported and
are
insufficiently trained in communicating with patients who have
com-
munication impairments (Balandin et al., 2007; Hemsley &
Balandin,

2014; Radtke, Tate, & Happ, 2012). Therefore, speech language
patholo-
gists may need to play a more active role in advocating for
communica-
tion support in the hospital setting and providing education and
coaching in hospital if mobile technologies are to be used at the
bedside
to improve nurse–patient communication. The increased
availability of
devices, role clarification, and increased staff knowledge were
most fre-
quently perceived by nurses as facilitators to the use of mobile
commu-
nication technologies. Therefore, increasing nursing staff access
to
mobile technologies needs to be matched by providing safe
storage for
these devices and education to staff on ways to use the
equipment.
The finding that nurses might be concerned about
confidentiality
and privacy issues with patients with communication
impairments
usingmobile technologies to communicate has not been
reportedprevi-
ously. The concerns raised in this study related to themobile
technology
camera and Internet functions. Nurses having access to patients'
own
mobile devices, or using the nurse's own personal mobile device
to cap-
ture patient health data to send by email or short message to
medical
staff, also reflects some ‘looseness’ in implementation of
hospital

(2016) 228–236
policies on the use of mobile phone technologies on hospital
wards.
However, the camera, Internet, and social media functions of
mobile
technologies may be used to enhance communication, by
visually
supporting written or spoken information and facilitating the
mainte-
nance of social relationships (McNaughton & Light, 2013).
Furthermore,
such devices can also be used without the Internet function, as
commu-
nication aids. These findings highlight the need for further
research into
the protocols associatedwith the use ofmobile technologies on
hospital
wards, and development of policies and guidelines for both
patients and
hospital staff on the risks and benefits, along with rights and
responsi-
bilities associated with the use of mobile communication
technologies
in hospital.
The results of this study further support the notion that time can
be
both a facilitator and a barrier to the use of communication
technologies
in hospital (see Hemsley et al., 2012). Therefore, the speed and
ease of
use of mobile communication technologies may be critical in

determin-
ing whether nurses will use these technologies to communicate
with
patients with communication impairments in hospital. As with
using
other technologies, nurses may need to invest time—putting
efforts to-
wards the use of unfamiliar mobile communication technologies
for
which they receive little training or support—in order to create
time ef-
ficiencies through improved communicationwithpatientswho
struggle
to communicate their care needs.
4.1. Limitations
This study was an initial investigation of the views of nurses on
use
of mobile communication technologies in hospital. It involved a
small,
convenience sample of nurses recruited through Twitter to an
online
survey, where it was not possible to verify identities of
respondents,
and only one face-to-face focus group of four participants. The
research
was time limited by the student's research training enrolment
and it is
possible that further data could have been captured through a
longer re-
cruitment period. Therefore, thefindings of this researchmaynot
reflect
the views of other nurses and caution is needed in interpreting
its re-
sults. However, there was a close alignment of results across the
data

sources, increasing confidence in the results. An additional
limitation
of this study was the participants' limited experience with
traditional
and mobile communication technologies in hospital settings. As
such,
their suggestions of barriers and facilitators to the use of these
devices
were largely hypothetical. Nonetheless, their views closely
align with
previous research relating to barriers to the use ofmore complex
speech
generating devices in hospital.
The finding in this study that nurses perceived mobile
communica-
tion technologies to be feasible for supporting nurse–patient
communi-
cation in hospital is important given the gap between the
substantial
evidence highlighting the need for AAC strategies to support
communi-
cation in hospital (e.g. Balandin et al., 2001; Happ et al., 2004;
Hemsley
& Balandin, 2004; Hemsley et al., 2008), and the growing body
of evi-
dence that nurses lack access to communication technologies of
any
type on hospital wards (Hemsley & Balandin, 2014).
Implementation
research is needed to determine the outcomes of using a range
of com-
munication aids, including mobile communication technologies,
on
hospital care and safety for patients with communication
impairments

(Hemsley & Balandin, 2014; Hemsley et al., 2015). Future
research
could include observational studies to inform the development
of a
valid and reliable tool to measure the communication-related
self-
efficacy and mastery of hospital staff in using these
technologies. In ad-
dition, the ethical concerns raised by nurses in this study
regarding pri-
vacy and patient confidentiality using mobile communication
technologies in hospitalwarrants further attention in the
literature. Fur-
ther research is needed to fully understand the nature and extent
of
these concerns of nurses, and to identify not only potential
benefits,
but also any potential harms associated with enabling use of
mobile
communication technologies in hospital.
5. Conclusions
Nurses in this study, from a wide range of different hospital
wards,
identified many potential benefits to the use of mobile
communication
technologies to communicate with patients who have
communication
impairments, including that such use might (a) enhance a
patient's
sense of independence, while being used for a range of purposes
(e.g.
leisure, distraction, education, social participation), and (b)
create effi-
ciencies in communication that improve work flow and save
time in

care. However, these expected benefits were largely
hypothetical and
based on very limited experiences of using communication
technologies
on theward. Nurses identified several barriers and facilitators to
the use
ofmobile communication technologies on hospital wards, and
these are
similar to reported barriers and facilitators encountered in the
use of
speech generating devices in hospital settings. This suggests
that envi-
ronmental barriers will have to be addressed in order to enable
use of
any communication technology at the bedside. As nurses
expressed
positive attitudes towards mobile communication technologies,
in-
creased access to these—accompanied by training,
demonstration, and
policies guiding use—might increase the feasibility of adopting
mobile
communication technologies in the care of patients with
communica-
tion impairments. Implementation research is now needed to
deter-
mine the impact of providing access to and training for nurses
to use
mobile communication technologies on hospital wards and
optimal
and safe use of the multiple functions of mobile technologies
including
the use of multimedia and social media functions.
Acknowledgment
This researchwas undertaken as part of the Honours Research of

the
first author under the supervision of the second author. The
authors
would like to thank and acknowledge Mr John Costello of
Boston
Children's Hospital, Boston USA for his advice to the first
author on
the survey design and comments on the results of the study. The
authors
would also like to acknowledge the generous contributions of
Paul Mc-
Namara (@Meta4RN) in assisting to disseminating information
about
the study, and all of the nurses who took part and gave
generously of
their views and experiences in this research. Also, thank you to
Dr
Joanne Steel of The University of Newcastle for her assistance
in final
production edits on this manuscript.
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http://widgit-health.com/downloads/bedside-
messages.htmImproving nurse–patient communication with
patients with communication impairments: hospital nurses'
views on the feasibili...1. Introduction2. Method2.1.
Participants2.2. Data collection2.2.1. Survey2.2.2. Focus
group2.3. Ethical considerations2.4. Data analysis2.5. Rigor3.
Findings3.1. Survey findings related to experiences and
expectations3.1.1. Use of communication aids with patients who
have communication impairments3.1.2. Support for using
communication aids of any type3.1.3. Confidence in using
communication aids3.2. Focus group findings related to

experiences and expectations3.2.1. Perceived advantages of
communication technologies3.2.2. Training and professional
support for using communication technologies3.3. Both studies'
findings related to barriers and facilitators to mobile
technologies for communication3.3.1. Access to mobile
technologies for communication3.3.2. Policies affecting access
to mobile technologies3.3.3. Security3.3.4. Time using mobile
technology3.3.5. Attitudes towards communication
technologies3.3.6. Training and support regarding use of mobile
technology3.3.7. Logistical or technical issues3.3.8. Patient
factors affecting use of communication technologies4.
Discussion and recommendations4.1. Limitations5.
ConclusionsAcknowledgmentReferences
Assignment
Assignment : Normalization
Due Week 6 and worth 100 points
Suppose that you are the database developer for a local college.
The Chief Information Officer (CIO) has asked you to provide a
summary of normalizing database tables that the IT staff will
use in the upcoming training session.
Write a two to three (2-3) page paper in which you:
1. Describe the steps that you would use in order to convert
database tables to the First Normal Form, the Second Normal
Form, and the Third Normal Form.
2. Provide one (1) example that is relevant to a college
environment that illustrates reasons for converting database
tables to the First, Second, and Third Normal Forms.
3. Explain typical situations when denormalizing a table is
acceptable. Provide one (1) example of denormalizing a
database table to justify your response.
4. Explain the significant manner in which business rules
impact both database normalization and the decision to
denormalize database tables.
5. Use at least three (3) quality resources in this
assignment. Note: Wikipedia and similar Websites do not

qualify as quality resources.
Your assignment must follow these formatting requirements:
· Be typed, double spaced, using Times New Roman font (size
12), with one-inch margins on all sides; citations and references
must follow APA or school-specific format. Check with your
professor for any additional instructions.
· Include a cover page containing the title of the assignment, the
student’s name, the professor’s name, the course title, and the
date. The cover page and the reference page are not included in
the required assignment page length.
The specific course learning outcomes associated with this
assignment are:
· Recognize the purpose and principles of normalizing a
relational database structure.
· Design a relational database so that it is at least in 3NF.
· Use technology and information resources to research issues in
database systems.
· Write clearly and concisely about relational database
management systems using proper writing mechanics and
technical style conventions.
View grading rubric for this assignment below
Criteria
Fair
70-79% C
Proficient
80-89% B
Exemplary
90-100% A
1. Describe the steps that you would use in order to convert
database tables to the First Normal Form, the Second Normal
Form, and the Third Normal Form.
Weight: 21%

Partially described the steps that you would use in order to
convert database tables to the First Normal Form, the Second
Normal Form, and the Third Normal Form.
Satisfactorily described the steps that you would use in order to
Thoroughly described the steps that you would use in order to
2. Provide one (1) example that is relevant to a college
Weight: 21%
Partiallyprovided one (1) example that is relevant to a college
Satisfactorilyprovided one (1) example that is relevant to a
college environment that illustrates reasons for converting
database tables to the First, Second, and Third Normal Forms.
Thoroughlyprovided one (1) example that is relevant to a
college environment that illustrates reasons for converting
database tables to the First, Second, and Third Normal Forms.
3. Explain typical situations when denormalizing a table is
acceptable. Provide one (1) example of denormalizing a
database table to justify your response.
Weight: 21%
Partially explained typical situations when denormalizing a
table is acceptable. Partially provided one (1) example of
denormalizing a database table to justify your response.
Satisfactorily explained typical situations when denormalizing a
table is acceptable. Satisfactorily provided one (1) example of
Thoroughly explained typical situations when denormalizing a
table is acceptable. Thoroughly provided one (1) example of
4. Explain the significant manner in which business rules

impact both database normalization and the decision to
Weight: 21%
Partially explained the significant manner in which business
rules impact both database normalization and the decision to
Satisfactorily explained the significant manner in which
business rules impact both database normalization and the
decision to denormalize database tables.
Thoroughly explained the significant manner in which business
rules impact both database normalization and the decision to
5. 3 references
Weight: 6%
Does not meet the required number of references; some
references poor quality choices.
Meets number of required references; all references high quality
choices.
Exceeds number of required references; all references high
quality choices.
6. Clarity, writing mechanics, and formatting requirements
Weight: 10%
5-6 errors present
3-4 errors present
0-2 errors present
© Schattauer 2012
448Applied Clinical Informatics
S.H. Fenton; E. Joost; M.J. Gongora-Ferraez. HIT Knowledge
and Skills Needed by

HIT Employers
Research Article
Health Information Technology
Knowledge and Skills Needed by HIT
Employers
S.H. Fenton1; E. Joost1; M.J. Gongora-Ferraez1
1Health Information Management, Texas State University
Keywords
Health information technology, workforce, biomedical and
health informatics, clinical informatics
Summary
Objective: To evaluate the health information technology (HIT)
workforce knowledge and skills
needed by HIT employers.
Methods: Statewide face-to-face and online focus groups of
identified HIT employer groups in
Austin, Brownsville, College Station, Dallas, El Paso, Houston,
Lubbock, San Antonio, and webinars
for rural health and nursing informatics.
Results: HIT employers reported needing an HIT workforce
with diverse knowledge and skills rang-
ing from basic to advanced, while covering information
technology, privacy and security, clinical
practice, needs assessment, contract negotiation, and many
other areas. Consistent themes were
that employees needed to be able to learn on the job and must
possess the ability to think critically
and problem solve. Many employers wanted persons with
technical skills, yet also the knowledge
and understanding of healthcare operations.
Conclusion: The HIT employer focus groups provided valuable
insight into employee skills needed

in this fast-growing field. Additionally, this information will be
utilized to develop a statewide HIT
workforce needs assessment survey.
Correspondence to:
Susan H. Fenton, PhD, RHIA
Health Information Management
Texas State University
601 University Drive
Health Professions Building, 302
San Marcos, TX 78666
United States
E-mail: [email protected]
Appl Clin Inf 2012; 3: 448–461
doi:10.4338/ACI-2012-09-RA-0035
recieved: September 15, 2012
accepted: November 16, 2012
published: December 5, 2012
Citation: S.H. Fenton; E. Joost; M.J. Gongora-Ferraez.
Health Information Technology knowledge and skills
needed by HIT employers. Appl Clin Inf 2012; 3:
448–461
http://dx.doi.org/10.4338/ACI-2012-09-RA-0035
For personal or educational use only. No other uses without
permission. All rights reserved.
Downloaded from www.aci-journal.org on 2017-02-07 | IP:
73.200.187.94
© Schattauer 2012 S.H. Fenton; E. Joost; M.J. Gongora-Ferraez.
HIT Knowledge and Skills Needed by
HIT Employers
Research Article 449Applied Clinical Informatics

1. Introduction
There is an increasing worldwide need to understand how health
information technology (HIT) can
be most effectively used in today’s healthcare delivery systems
[1–9]. A competent workforce is
required in order for HIT to be effective in a healthcare
organization. According to a recent report by
the Institute of Medicine (IOM), “We are at a unique time in
health care. Technology – which has the
potential to improve quality and safety of care as well as reduce
costs – is rapidly evolving, changing
the way we deliver health care. At the same time, health care
reform is reshaping the healthcare land-
scape [10]. “Meaningful Use” of the electronic health record
(EHR), which is funded by the Health
Information Technology for Economic and Clinical Health
(HITECH) Act of the American Re-
covery and Reinvestment Act (ARRA), includes investment in
workforce development [11]. Due to
this act the demand for health information technology
professionals is growing, with the U.S. Office
of the National Coordinator (ONC) estimating an additional
50,000 workers will be needed [12].
These professionals will help to support the implementation and
effective use of EHRs in hospital
and provider settings.
Texas has one of the largest physician populations in the nation
[13], approximately 600 licensed
hospitals [14], four of the nation’s largest metropolitan areas
for attracting venture capital [15], thir-
teen state-supported local health information initiatives [15],
and a number of private payors and as-
sociations offering support to physicians and others who are
interested in adopting HIT [15]. The

strong healthcare industry, accounting for more than $100
billion in economic activity for this state,
requires a well qualified HIT workforce to support the large and
growing Texas population [15].
In response to the HITECH-ARRA legislation the current HIT
workforce will need to evolve. HIT
workers must possess a wide variety of skills to quickly react
and adapt to their current practices to
future work surrounding industry and regulatory changes. The
Texas HIT Workforce Development
project, funded by a Wagner-Peyser grant and supported by the
Texas Workforce Commission, was
initiated as a direct result of this growing need in the Texas
healthcare industry. One of the initial pro-
ject goals was to conduct a state-wide HIT workforce needs
assessment from all industry stake-
holders in order to understand the HIT workforce knowledge
and skills needed by HIT employers,
as well as the numbers of workers needed now and in the future.
Many organizations, such as the American Health Information
Management Association, the
Health Information Management and Systems Society, the
American Medical Informatics Associ-
ation, and the International Medical Informatics Association,
among others, have developed docu-
ments describing the skills and knowledge needed by HIT (or
health informatics) workers. The re-
search team was able to identify different lists of competencies
which had been published for health
information managers or health information technicians [16–
20]. Several of the competency lists
were compiled or created by professional organizations [16,17,
20]. The Huang (2007) framework
surveyed the literature and extracted data from journal articles

while other researchers included rec-
ommendations for defining competencies [19, 21, 22]. These
efforts are to be lauded. However, the
Texas research team identified a significant gap, a lack of
feedback from employers – those who hire
health information technology workers. The Texas-based project
wished to “start anew” gathering
knowledge and skills information from HIT without bias from
one group or another or any previous
skills or knowledge compilations. This article describes the
findings from the HIT employer focus
groups.
2. Methods
A qualitative research method, or inquiry method, for the initial
phase of this project was chosen as
no data-based evidence of employer needs was available. That is
to say, the previous skills and know-
ledge documents were compiled by expert consensus; however
validation of the content and/or sur-
veys determining actual numbers of employees needed with the
different knowledge and skills could
not be found. The methods used were approved through Texas
State University’s Institutional Re-
view Board (IRB) according to federal guidelines.
Prior to setting up the focus group meetings, a professional
focus group facilitator was hired to
eliminate any bias from the researches who work in the HIT
field. Conference calls were conducted
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HIT Employers
to establish the ideal responder characteristics, desired number
of participants, and the type of ques-
tions that would be utilized in the focus groups. A prepared
topic guide, which is shown in �Table
1, provided the framework for each focus group meeting. The
session began with an introduction by
the facilitator describing the purpose of the focus groups and a
brief explanation regarding the meet-
ing process.
At the beginning of each focus group the facilitator would
introduce the purpose and rules of the
session informing the participants that her role as an
independent moderator was to discover their
attitudes, needs, desires, perceptions and interests related to the
HIT industry. She explained that
their anonymous qualitative responses would provide the
background information to build a
quantitative survey to distribute across the state. The
participants were asked to concentrate on their
workforce needs related to employees who were managing or
participating in EHR design, imple-
mentation, connectivity, security, and data analysis as opposed
to doctors, nurses and staff who were
using computers as a tool to complete a work function, such as
data entry of patient information.
HIT workers are employed in a number of settings ranging from

providers to public health to EHR
vendors to consulting companies. The different types of HIT
employers targeted for participation in
the focus groups are listed in �Table 2.
Recruitment of the focus group participants consisted of e-
mailed flyers and forms sent to poten-
tial respondents who fit the stakeholder requirements. The
stakeholders were grouped by HIT em-
ployer type, but the stakeholders who responded to the
recruitment materials ranged from the Chief
Information Officer (CIO), to the Office Manager, to the Nurse
Informaticist, or other organization-
identified appropriate responsible person. Persons interested in
participating in a focus group com-
pleted a brief registration form (�Fig. 1) and returned it to the
Texas HIT Workforce Development
Team via email. Focus group sites were found with assistance
from local workforce development
boards and universities in the selected cities. They also
provided assistance with outreach to qualified
responders from the targeted HIT employer organizations.
Before the focus group sessions, participants were asked to
complete a form (�Fig. 2) gathering
demographic data such as the healthcare market or location, the
organization type and size, the size
of the community, the types of issues HIT employers are facing
currently and/or expect to face in the
future, and the status of their organization’s EHR
implementation. An additional question invited
initial feedback on the competencies needed for current and
future HIT workforce.
The focus group invitation process was a collaborative effort
involving many regional stake-

holders from multiple organizations. Initially, grant staff
contacted each potential collaborator by
email or telephone explaining the purpose of the study and
describing the ideal responder. After sup-
port was garnered, some collaborators shared their email list for
invitations while others preferred to
keep their contact lists confidential, sending the invitation and
registration form to their internal
mailing lists. Because of this, an exact number of those invited
to participate is unknown, however,
we feel confident that a minimum of 20 stakeholders were
invited to each focus group. There were
106 total participants in the focus group population. �Table 3
provides a detailed breakdown of the
participants by their profession. The desired number of
participants for the 12 focus groups was 144,
or an average of 12 people per focus group. A minimum of 20
people per focus group were invited to
participate, for an estimated total of 240 invited. The rate of
participation in the focus groups was
106/144 = 74%.
Focus group methods used included face-to-face and online HIT
employer meetings. The face-
to-face focus group sessions were held in Brownsville, College
Station, Dallas, El Paso, Houston, Lub-
bock, and San Antonio. Additional focus groups were conducted
with rural providers and nursing
informatics professionals using the web conferencing software
Adobe Connect. The focus groups
were conducted in relaxed settings in the afternoon and early
evening. Participants were notified that
the sessions were being recorded and reassured that the
recordings would remain confidential, there
were no right or wrong answers. Participants were asked to
speak one at a time. The recordings were

downloaded into a secure online collaborative tool and
transcribed. The data was manually analyzed
by the Texas HIT Workforce Development Project team using
grounded theory.
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HIT Employers
3. Results
An average of five people attended each face-to-face focus
group; while the online focus groups had
an average attendance of eight people per session. Trends,
themes, and patterns emerged from the
data gathered. Initially, it was noted that health care providers
(clinics and hospitals) and non-pro-
viders (public health, insurance, and so on) had similar, but not
identical knowledge and skill needs.
Within each of these categories the skills were further divided
into basic/entry level skills, intermedi-
ate skills, and advanced skills. HIT employers often used these
words: basic, intermediate, and ad-
vanced; to describe different skills or knowledge needed for
their HIT workforce.
The basic skills were those one might expect of clerks or other
entry-level positions, including

understanding medical terminology, basic computer and
interpersonal communication skills. Inter-
mediate skills ranged from an understand of EHR “meaningful
use” to knowledge of privacy and se-
curity regulations to knowledge of HIT vendor products to data
report writing to project manage-
ment skills. Advanced skills were very broad and included
standard management and strategic plan-
ning skills, with contract negotiation, the ability to use data
analytics and the interpersonal skills
necessary for interactions with senior administration. HIT
employer respondents specified that each
level subsumed the lower levels. For example, an advanced HIT
worker creating a strategic plan
would need to have an understanding of privacy and security
regulations to ensure the practicality of
the plans. The entire breakout of skills resulting from the focus
groups can be found in �Table 4.
4. Discussion
The results outlined in �Table 4 were the main trends found
consistently across the focus groups.
The breakout of skills was illuminating, especially in the areas
of data management and contract ne-
gotiation, areas which might not usually be considered HIT-
related. This list of knowledge and skills
will serve as the foundation of follow-on work, specifically an
HIT employer workforce needs assess-
ment survey to quantify the full-time HIT workforce needed by
Texas HIT employers. The need is
anticipated to be high. One participant stated “today we have 21
or 22 but we have 5 or 6 open posi-
tions out of that, and would like to actually probably hire a
couple more, I say a couple more, but
probably 4 or 5 more to get us over the meaningful use hump.

But there is no point you know, we
can’t fill the open positions.”
The focus groups were revealing of the differences and
similarities, as well as the challenges in
health information technology workforce across the state.
Overall, HIT employers are interested in
people who can think and learn. As one participant stated, “[The
HIT Workforce doesn’t] under-
stand the bigger picture in the interface with the doctor’s office
and getting the medication reconcili-
ation for the doctor’s office to the ER, they don’t have that
picture.” Yet another said, “The most im-
portant thing is their ability to learn. I know that sounds stupid,
but honestly that is what I look for
when I am hiring anybody, is somebody that can come in and
pick up and I can teach them.”
As a rule, HIT employers struggle with the mixed nature of
health information technology. One
stated, “One of the things you need is a survey of career options
split between clinical, or within tech-
nology, because there is a lot of gray areas in there, a lot of
hybrid,” while others said, “Trying to find
the right mix of clinicians versus informatics or IT slanted folks
as well because you need both in a
perfect world. It is just hard to know what the right balance is.”
The clinicians themselves had this
feedback “...of not taking that time to actually to truly sit down
and understand what the needs are
so that you are not hurrying up and throwing in a system and
then have a major impact on us doing
direct patient care.” Yet another, “So, business process analysis
background, process improvement
background, and then just understanding how a clinic functions
or how an inpatient nursing unit

functions enough to say that is a good workflow process or that
it is not.” Getting the clinical/tech-
nical mix will be very important as the country continues to
implement health information technol-
ogy.
Rural HIT employers shared their unique struggles attracting
and retaining qualified HIT staff.
One participant said, “Within our IT/ HIT Department
specifically we have a lot of trouble just at-
tracting IT talent to a rural area and I see that as becoming a
more acute need for rural facilities in
particular, just attracting IT talent.” Another rural provider in a
different focus group shared this
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HIT Employers
sentiment saying “For us in the rural area, the problem is there
is no HIT workforce. I have my own,
but that is strictly by virtue of my husband having the
background that he does. But as far as the other
locations around here being able to hire someone to do their
HIT, there isn’t.”
One of the focus group participants seemed to sum it up best

with this, “We have a need for some-
body who is probably like a unicorn. I could really use
somebody who understands the physician
practice and the workflow there, I need somebody who
understands the politics, policies and tech-
nologies of large healthcare systems and then somebody who
can understand when a vendor is feed-
ing us a line or is actually telling us something that could
happen.”
Study Limitations
A major limitation of this study is the restriction of the data
collection to a single state within the U.S.
Additionally, focus groups were chosen to enable the collection
of free-form input from HIT em-
ployers; however, the focus group participants were volunteers.
It is acknowledged that those who
volunteered are probably those who are experiencing the most
difficulty with HIT workforce recruit-
ment and retention or those who possess an innate interest in the
topic. Participant representation
is also a limitation as it is not possible to determine whether the
roles and titles of those who did par-
ticipate are in proportion to or include the full breadth of HIT
employers in Texas. Finally, the find-
ings of this work are focused on a particular geographical area
at a time of great upheaval in HIT and
EHR implementation in the healthcare industry. The findings
are valid for a limited time as the field
and needs of employers continue to evolve as the technology
and government regulations change
over time.
5. Conclusions

The HIT employer focus groups confirmed that they require a
skilled and diverse workforce to effec-
tively implement health information technology across the
different provider and related organiz-
ations, including public health. They also provided the
information needed to build a statewide
workforce needs assessment. Apparently, the entire healthcare
industry is looking for well-trained
employees, sometimes in two fields, who can demonstrate
critical thinking. The challenge for edu-
cational institutions is now to work with employers to meet
those needs in a constantly changing,
evolutionary field.
Clinical Relevance
Providers need to recruit and retain skilled HIT workers to
support their use of HIT. These find-
ings will assist them in fully describing the skills and
knowledge needed in their organizations.
Conflicts of Interest
The authors declare that they have no conflicts of interest in the
research.
Protection of Human Subjects
The study was performed in compliance with the World Medical
Association Declaration of Hel-
sinki on Ethical Principles for Medical Research Involving
Human Subjects, and was reviewed by
Texas State University’s Institutional Review Board according
to Federal guidelines.
Acknowledgements
The Texas HIT Workforce Development Project wishes to thank
the Office of the Texas Governor, the
Texas e-Health Alliance, and the University of Washington

Workforce Research Center for their sup-
port during this project. Additionally, the authors wish to thank
Cheryl T. Perez for her invaluable as-
sistance with manuscript preparation.
73.200.187.94
©
Schattauer 2012
S.H
. Fenton; E. Joost; M
.J. G
ongora-Ferraez. H
IT Know
ledge and Skills N
eeded by
H
IT Em
ployers
R
esearch A
rticle
453

A
p
p
lie
d
C
lin
ica
l In
fo
rm
a
tics
Fig. 1 Focus Group Registration Form
Sponsored by a Wagner-Peyser Grant
Supported by the Workforce Commission
Academic Medical Center
Major Urban-metro area w/population 750,000+
73.200.187.94

HIT Employers
Market:________________________ Date: _____________
Time:_____________
HEALTH INFORMATION TECHNOLOGY WORKFORCE
PARTICIPANT
PRE-FOCUS GROUP INFORMATION SHEET
1. Name:_________________________________(will only be
used to ensure
comments during focus group are associated with correct
organization type,
community size, etc.)
2. Below, please find a table adapted from the Health
Information Management
Systems Society EMR Adoption Model. Please indicate which
stage most closely
represents your organization in regards to EMR
adoption:_________________
EMR
Adoption
Stage
Major
ancillaries

(lab, Rx,
radiology)
installed
Clinical
data
repository;
with basic
conflict
checking
Clinical
document-
tation
installed
with some
level of
clinical
decision
support;
some
medical
imaging
installed
Computer-
ized
physician
order entry
(CPOE);
clinical
decision
support
with
evidence-
based

medicine
protocols
Electronic
medication
administra-
tion with bar
coding or
radio
frequency
ID
integrated
with CPOE
and
pharmacy
Full MD
document-
ation
installed;
radiology
PACS
available
via network
Clinical
information
can be
readily
shared
electronic-
ally with all
entities
within a
regional
health

network
0 No No No No No No No
1 Yes No No No No No No
2 Yes Yes No No No No No
3 Yes Yes Yes No No No No
4 Yes Yes Yes Yes No No No
5 Yes Yes Yes Yes Yes No No
6 Yes Yes Yes Yes Yes Yes No
7 Yes Yes Yes Yes Yes Yes Yes
3. Issues facing your organization s HIT Workforce:
Today:
_____________________________________________________
_
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
Fig. 2 Pre-Focus Group Data Collection Form

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HIT Employers
Future:
_____________________________________________________
_
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
4. Competencies needed for your organization s HIT workforce:
_____________________________________________________
_____________
_____________________________________________________

_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
_____________________________________________________
_____________
Fig. 2 Pre-Focus Group Data Collection Form (Continued)
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HIT Employers
Table 1 Focus group topic guide; Prost Marketing, Inc., May
2011; Health Information Technology (HIT) Focus Groups
Introduction Background

notes
● HIT is where the internet was in the 90’s (wild, wild west)
● Overall want to understand what Texas employer needs are
related to
HIT workforce
● Likely doing a lot within the HIT industry; working your way
through
● Want to have the right type of workforce (skills) – now and
for the fu-
ture
● Want to have the Right type of training so that employers
have em-
ployees with the right competencies Foundational work – to
make all
the computer technology work
Purpose of Group ● The purpose of this discussion is to learn
about your attitudes, needs
and desires, perceptions and interests relating to Health IT
● Main focus on people whose job is totally concerned with the
HIT
(example would be network security, systems analyst, data
analyst, CIO,
health information manager, etc.)
● Rather than clinical or other staff (such as front-line
physicians, nurses
and other therapists) who use health IT as a tool.
● End Goal: We Will Be Building A Survey From The Focus
Group Information.

Ground Rules ● One at a time, all participate, no cell
phones/pagers
● Audio-taping, confidentiality, no right or wrong answers
● Independent of group sponsor
Introduction
of Partici-
pants
Overview of
HIT Industry
Name and Organ-
ization
Interest in HIT
Current Trends
you see in HIT
Workforce within
your Organiz-
ation.
Frustrations/Bar-
riers
How important is
Needs for the fu-
ture for the HIT
Workforce – gen-
eral Overview;
ask open ended
First and then
Probe

Current Trends/
Comply with
● Job title/function
● Length of time in this job
● Years working in the field
● How you got into field
● Brief overview of organization/city/size
Where Organization is on Adoption Model
● Role of Information Technology within healthcare delivery
organizations
● How large of a priority within organizations (extremely high
to not a
priority at all)
● Why a priority/not a priority?
● A well-trained workforce capable of developing,
implementing, and
evaluating health information technology (HIT) in your
healthcare re-
lated facility. (Description from 2010 Hersh article)
– Extremely important (5)
– Somewhat Important (4)
– Neutral (3)
– Not too important (2)
– Not important at all (1)
● Is your workforce ready?
● How will you get ready?
● What do you need?

● Immediate
● 3–5 years
● Long term
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HIT Employers
HIT Work-
force
Target Seg-
ments of
the Work-
force using
EHRS – Who
are primary
Users?
Description of
current Work
Force
Do you currently
have HIT Work-
force?

Compensation
Model
Clinically fo-
cused: Phys-
icians,. Nurses,
Therapists, Phar-
macy, etc.
● What types?
● How many?
● What is their level of competency?
● How well have they been trained?
● What type of background do they have?
● What type of training have they received?
– Training Source:
Higher Education in HIT
Migrate to position within organization
Continuing Education
On the Job training?
● What types of HIT workforce (roles or general skill sets) do
you need
now?
– For each type, how many would you need?
– What type of background, either experiential or educational
would
you expect them to have?
– What would be the ideal type of worker instead of a set of
skills that
would normally require a lot of different workers?
● What can you afford?

● Are you experiencing challenges with paying and retaining
your HIT
workforce?
● What types of HIT workforce (roles or general skill sets) do
you antici-
pate needing in 3–5 years?
– For each type, how many would you anticipate needing?
● What type of background, either experiential or educational
would you
expect them to have?
● How is the compensation model changing?
● What is the impact on the use of health information?
● Anticipate organizations electronically reporting quality
measures or try-
ing to implement population health monitoring would have new
HIT
workforce needs. From the perspective of their organization.
– Pay for Performance
– Use of incentives to be able to perform more (tasks)
– Other the Windows
Basic Computer Literacy Skills
● What types of job titles require these skills?
● What are the core competencies needed here?
– Demonstrate basic computer operating procedures such as
login the
computer and logoff, opening, closure and saving files.
– Demonstrate proficiency in operating environment.
– Resolve minor technical problems associated with use of

computers.
– Demonstrate Internet/intranet communication skills.
– Access and use a Web browsing application.
– Demonstrate use of email, addressing, forwarding,
attachments, and
netiquette.
– Identify and use icons, windows, and menus.
Table 1 Continued
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HIT Employers
Target Seg-
ments of
the Work-
force using
EHRS – Who
are primary
Users?
Adminis-
trative Per-
sonnel,
Human Re-

sources,
Clerical
Staff,
Data Ana-
lysts,
Public
Health
Workers,
Emergency
Medical Per-
sonnel,
Medical As-
sistants,
Dietary
Workers,
Lab or Radi-
ology Techs,
Nurse
Aids….
Clinically fo-
cused: Phys-
icians,. Nurses,
Therapists, Phar-
macy, etc.
Health Informatics skills using EHRs
– Create and update documents within the electronic health
record
(EHR) and the personal health record (PHR).
– Locate and retrieve information in the electronic health record

for vari-
ous purposes.
– Perform data entry of narrative information.
– Locate and retrieve information from a variety of electronic
sources.
– Know the policies and procedures related to populating and
using the
health data content within primary and secondary health data
sources
and databases.
– Apply appropriate documentation management principles to
ensure
data quality and integrity.
– Use software applications to generate reports.
– Know and apply appropriate methods to ensure the
authenticity of
health data entries in electronic information systems.
– Use electronic tools and applications for scheduling patients.
Basic Computer Literacy Sills
– Demonstrate basic computer operating procedures such as
login the
computer and logoff, opening, closure and saving files.
– Demonstrate proficiency in the Windows operating
environment.
– Resolve minor technical problems associated with use of
computers.

– Demonstrate Internet/intranet communication skills.
– Access and use a Web browsing application.
– Demonstrate use of email, addressing, forwarding,
attachments, and
netiquette.
– Identify and use icons, windows, and menus.
Health Informatics Skills Using EHRs
– Create and update documents within the electronic health
record
(EHR) and the personal health record (PHR).
– Locate and retrieve information in the electronic health record
for vari-
ous purposes.
– Perform data entry of narrative information.
– Locate and retrieve information from a variety of electronic
sources.
– Know the policies and procedures related to populating and
using the
health data content within primary and secondary health data
sources
and databases.
– Apply appropriate documentation management principles to
ensure
data quality and integrity.
– Use software applications to generate reports.
– Know and apply appropriate methods to ensure the

authenticity of
health data entries in electronic information systems.
– Use electronic tools and applications for scheduling patients.
Table 1 Continued
73.200.187.94
HIT Employers
Final Com-
ments
HIT Resources:
EHR Meaningful Use (NEJM article:
http://healthpolicyandreform.nejm.org/?p=3732;
Accountable Care Organizations:
http://www.aha.org/aha/content/2010/pdf/09–26–2010-Res-
Synth-Rep.pdf;
Implementation of ICD-10:
http://www.cms.gov/apps/media/press/factsheet.asp?Counter=34
07&intNumPerPage=10&checkDate=&check
Key=2&srchType=2&numDays=0&srchOpt=0&srchData=icd%2
D10&keywordType=
All&chkNewsType=6&intPage=&showAll=1&pYear=&year=0&
desc=&cboOrder=date

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