Imagine a woman lying unconscious in an intensive care unit with multiple IVs, on a breathing machine, and attached to monitors. Beside her sits another woman, perhaps her wife or sister, her brow crumpled with worry. On the other side of the bed is a table with a computer. A nurse is stationed there, studying his cellphone. What is he doing? Looking at a message from the patient’s doctor? Calculating her medication dosage? Reading a reminder from home to pick up diapers?
Smartphones have become our shopping cart, our bank machine, and our direct line to the people we love. They are also a major source of diversion, whether for watching movies, checking the news or scrolling through pictures on Facebook. We check our phones constantly—on average, we spend three hours a day on them. Most of us have both interrupted and been interrupted, or even ignored, on account of a cellphone alert. And yet, expecting people to put their phones away at the dinner table seems almost Victorian. They’re practically part of the place setting.
But what is it like for patients and families to see doctors and nurses on their phones? Should the rules be different in health care?
Staff on cellphones: A family’s perspective
Carrie Blais* describes the experience as “wounding.” Recently, her father was in intensive care in a Toronto hospital following a triple bypass operation. Blais, her mother and her sister were upset to see a few nurses assigned to his care use their phones to text or scroll through social media. When one of the nurses noticed that the family had seen her on her phone, she showed them pictures of her dog. “I was sitting there thinking, ‘Is my dad going to survive the next hour?’” says Blais. “And she’s looking at puppies on Facebook.”
Beyond wounding, she says, the experience was worrisome. “There were times when my father would be choking on his ventilator, and he suffered if someone wasn’t paying attention,” says Blais. “The machines would eventually alert the nurses to the problem, but it was very disconcerting for us to feel that the nurse who was stationed at the bedside, while she was in her working hours—not on her break—was not paying attention.”
Blais works in health care herself and says she understands that while families and patients in the ICU need a lot of reassurance, the staff have needs as well. “I recognize that every day cannot be the end of the world for the staff that work in the ICU,” she says. “[But] everyone [there] is in critical condition, and so there’s something about bedside phone use—text messaging and social media—that feels really inappropriate.”
Orla Smith agrees. She and her fellow clinical managers in the critical care department of St. Michael’s Hospital in Toronto have received complaints about staff using cellphones for personal reasons. Not only does this behaviour convey disrespect to patients and families, says Smith, it’s also antithetical to the purpose of intensive care. “In the ICU, things can change very subtly,” says Smith. “A subtle trending down in blood pressure, or oxygenation status, or heart rate, or a subtle change in neurological status. You’re expected to pick up on subtleties, to be able to apply critical thinking to understanding, ‘OK, what is happening here?’” This ability might be compromised, she says, “if you’re on your device, or pulled toward that device.”
It’s happened before: In December 2011, John Halamka, chief information officer at Harvard Medical School, wrote about an incident in which a resident responded to a text message just before discontinuing a patient’s anticoagulant. The resident forgot to order the change, and the patient wound up needing open-heart surgery.
A staff perspective
Smartphones have become integral to medical practice. There are apps that provide health care workers with access to information about diseases and treatments, as well as information about their patients’ drugs and lab tests. “Pieces of the job are being transferred to mobile devices,” says Mandy Tanner*, a nurse who works in the intensive care unit in a Toronto hospital. “[Cellphones are] important for communication purposes, especially in the ICU, [where] you can’t leave the patient’s bedside.”
But Tanner says she also uses her phone for personal reasons while on the unit, and so do many of her colleagues. “It definitely comes out in downtime or at four in the morning, when you’re trying to stay awake,” she says. She doesn’t look at her phone while at a patient’s bedside, but will take it out when she goes back to her desk (ICU nurses typically work one-to-one with patients and have individual stations beside or at the end of their beds) “if it’s quiet and no one else needs help,” she says.
Tanner understands the concerns about cellphone use on the unit. “I can definitely see how it could come across as unprofessional seeing a nurse look at their phone,” she says. “Or how, if someone was very engrossed by their phone, that could take their attention away from the room and that would definitely be very bad.”
She describes a specific moment, about a year-and-a-half ago, when she was on her phone “and things started happening,” she says. “The room started to get a bit busier, machines started beeping, patients needed things. So that was my cue to put my phone away. I remember having the thought, ‘Oh, phones can be really distracting.’”
Should cellphones be “banned”?
Seventy-eight percent of U.S. hospital nurses surveyed for a study published in 2015 reported using their cellphones for non-work-related purposes while working (excluding breaks). The most common reason was personal emails and texts (39 percent), but some said they used their phones to shop (almost 10 percent) and play games (almost seven percent). Another study, published in 2017, looked at both work-related and non-work-related usage of cellphones, and found lower numbers: 19 percent checked or sent personal messages, five percent shopped, and three percent played games. About 30 percent believed cellphone use helped reduce stress, but almost 70 percent said cellphone use was more negative than positive when it came to doing their jobs, and nearly 40 percent believed that phones were “always or often a distraction while working.”
Of course, this does not apply to nurses alone. In a survey of American physicians published in 2012, 37 percent of residents and 12 percent of faculty reported using their phones during inpatient rounds to read or respond to personal texts or emails. Nineteen percent of residents and 12 percent of faculty believed they missed important information as a result of being distracted by their devices.
So should cellphones be banned on patient wards? “I don’t think there’s any way that we would be able to tell staff, ‘You have to lock up your cellphone when you come to work and you can’t look at it.’ It’s just not reasonable,” says Cathy O’Neill, senior director of patient experience and community engagement for Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital. The policy there is that “accessing the Internet on a cellphone or computer should not in any way distract a staff member from patient care and their duties and responsibilities” and it applies to “everyone—from employees and learners to managers and physicians,” according to communications adviser Michael Oliveira.
“It really is a collective responsibility, and I think people recognize that,” says Mandy Tanner. “I think you would need rules if people didn’t take responsibility to know when it’s appropriate or not. Maybe Facebook in the room right at the patient’s bed—maybe that could be a rule. But I really have seen that so rarely.”
O’Neill thinks it’s easy to make assumptions that staff are using their phones for personal reasons when in fact they may be using them for work. At the same time, she thinks health care providers need to be aware that using a cellphone in front of a patient or family may suggest that they are not fully present. It would be good to let patients know otherwise, O’Neill says. “I should be saying, ‘Hold on a second, maybe I can get an answer quickly, I’m just going to use my phone…’”
“We are going to continue to leverage technology and some of this is going to be through cellphones,” says O’Neill. “How do we educate patients and families about how we use technology to provide care? If we’re going to tackle this, we have to tackle it from both sides.”
But what about when staff really are using their phones inappropriately?
Orla Smith, the critical care manager at St. Michael’s Hospital, agrees that banning cellphones is not the solution. “We have to be pragmatic in 2018,” she says.“Devices are everywhere and we are using computers more and more for care purposes.” The first priority must always be the patient, says Smith, but all staff need breaks and time away from their assignments. “We need to make sure that we take these breaks to refuel. This is when we can check in on our personal lives and social media, or play a few rounds of Candy Crush.” Smith thinks device overuse is a widespread issue, hardly unique to hospital staff, and recently made a pledge for Change Day to reduce her own screen time “in order to be more present and engaged at work (with colleagues, patients, and families) and at home (with family and friends).”
For Andrew Baker, chief of the department of critical care at St. Michael’s, it’s helpful to think of cellphone use as being like an addiction. “The brain sort of gets into this mental pathway where it actually gets used to this rapid type of feeding,” he says. “I’ve witnessed it in myself. If I let myself not be mindful, I can find myself picking up my cellphone and looking at it just because, almost like a fix, to see what’s new, what’s a piece of information.”
On the other hand, he also knows what it can be like trying to talk to someone who’s distracted with their phone. “I feel it in my stomach,” he says. It’s a feeling of: “I wanted you to hear this and I know you’re not listening.”
Baker wonders about finding ways to help providers become more “self-aware and mindful,” to help them recognize that they’re driven to look at their phones, and at the same time to understand how patients feel when they do. “I don’t come at this from a blame thing,” he says. “I think we need facilitated ways to get to a new normal, to understand that something tenacious has come into our social, cultural, neurologic environment that we need to be aware of and control in ourselves.”
*Names have been changed to protect privacy