The adoption of instant messaging apps to supplement official communication channels is, in many ways, a sign that NHS staff themselves are being driven to innovate faster than the Trusts they represent.
An important, if ominous, finding of this report is that the issue of NHS staff communicating via consumer-oriented instant messaging services (such as WhatsApp and Facebook Messenger) is much wider than has been previously reported. Further, attempts to stem the tide through education, the provision of alternatives and enforcement of policy are doing little to discourage staff - with 1 in 50 receiving disciplinary actions for IM related incidents.
There is also evidence to suggest that using instant messaging apps to communicate with HCPs (healthcare professionals) for benign purposes such as shift handovers or rota management increases the likelihood that an individual will start to use the same technologies in more fractious ways. Examples identified include communicating directly with patients, storing patient content on mobile devices and sharing medical documents.
A key driving factor of this is a marked dissatisfaction with provided channels of communication when compared to the efficiency that consumer IM apps offer. In fact, their usage has become so culturally engrained, that over 30% of NHS staff believe patient care would suffer if HCPs did not have access to WhatsApp or other consumer messaging tools. This leaves decision makers in a quandary - characterised by a strained status quo, in which the dangers to data security are ignored in favour of the significant benefits that IM provides.
However, as adoption of such apps grows year-on-year (driven primarily by new entrants to the workforce), so too does the risk from accidental or malicious misuse. Participants were able to recall a number of incidents that suggest consumer IM is a space for inappropriate communication and behaviours that are a detriment to confidentiality. Examples include accidentally sending patient information to non-clinical staff , sharing ‘pertinent’ patient details on social media and sending patient photos to others for ‘entertainment purposes’.
This leaves NHS Trusts with a stark, uncomfortable choice; maintain this fragile norm until a catalyst for widespread adoption or rejection is found, or provide staff with the technologies they need in order to deliver the high standards of care expected of them.
Instant Messaging Usage Habits
More than half a million NHS staff use consumer messaging applications, such as WhatsApp, to communicate with colleagues at work. Though policy is adapting, it is imperative to find more permanent solutions that address the rising need for streamlined communication channels & effectively protect sensitive data.
Out of all NHS organisations which provide services directly to the public, IM app usage is lowest within Acute Trusts; where 38.1% of sta use such services. Staff at Community Trusts are most likely to use messaging apps, with 49.7% using at least one. This is followed by Ambulance (42.1%) and Mental Health Trusts (41.3%).
This paints a stark picture in which Acute Trusts are not rogue actors, but actually the least likely to use consumer messaging applications. In turn, it can be suggested that these communication channels have penetrated all NHS structures and are now vital to the provision of not just inpatient care, but also outpatient and community services.
The growing prevalence of consumer IM applications within the NHS, why their use is growing at such a substantial rate
Most consumer-oriented instant messaging applications share a similar suite of features. Designed for personal use, it is safe to hypothesise that some of these features are used more widely in a healthcare context than others.
The results of this survey indicate that the most popular feature is Group Messaging. As many as 73% of frontline clinicians are actively involved in group conversations as part of their day-to-day routine, and actively use this as part of the patient care process. But it is not just appealing to those on the frontline. In fact, Group Messaging featured as the most popular functionality across all staff categories.
It is highly possible that the popularity of Group Messaging features correlates to the number of staff using instant messaging for the purpose of rota management. Such communication channels would provide the best environment in which to organise multiple staff at once. Outside of this, group conversations also allow staff to come together & discuss topics such as individual patients, wards or departments.
This means that while patient care may be delivered more efficiently, it is done without evidence that supports the chain of actions taken; something that any Impact Assessment should take into account. At scale, this has the potential to lead to treatment history dark spots and have serious repercussions to the integrity and historical accuracy of a patient record.
Across all groups, staff most commonly reported using the following features; group messaging (67%), photo sharing (50%), voice or video calling (37%), document sharing (30%) and video sharing (28%). Out of the respondents who use at least one commercial instant messaging applications, only 18% use none of the features listed above. This suggests that four out of every five users take advantage of at least one advanced feature, with a minority using only the basic messaging capabilities.
It is easy to conclude that consumer messaging apps pose a risk to NHS governance teams, however it is also important to understand how patients would be impacted if such channels were not available.
Staff are not turning to WhatsApp and Facebook Messenger without good reason. A number of survey participants reported discontent and short- falls in pager devices typically supplied. For some, instant messaging is regarded as a last resort, used only when paging does not yield results.
As well as the speed of communication, many staff also indicated increased levels of responsiveness when using IM alerts compared to traditional channels. In fact, 42% of staff indicated that this was a key benefit that currently improves patient care, highlighting another potential risk associated with removing the technology. The third most reported benefit of IM was that more time can be spent with patients as a direct result of the time saved using this channel.
28% of staff stated this is a key benefit of consumer messaging apps. Overall, 29% of users believe the presence of IM is vital to improving care, with approximately one in ten staff stating individuals who use it are less distracted. Comparatively, less than a quarter (24%) of NHS staff felt that there was no benefit to using IM technology at all – a clear suggestion that demand for the technology is present. In fact, over half of survey participants listed at least two or more benefits to instant messaging that are having a direct, positive impact on the delivery of patient care services. Of those who reported multiple bene ts, 80% stated that the speed of communication was key.
Another commonly cited issue is the lack of controls placed on data sent across non-Trust approved servers. 26.7% of staff suggested that this was a significant security risk, raising concerns such as the storage of patient data by a third party, on an unknown physical server location and the potential for information to be accessed by members of the public.
Finally, the risk of losing data through accident or theft was mentioned by a quarter of participants, suggesting that the issue is a pressing topic for many NHS staff . And, as many are aware, when data is sent through consumer IM apps, Trusts can do little to prevent or minimise risk.
The role of NHS England and Trust level IT policy is to enforce and encourage standard practice. So why is instant messaging policy, in particular, ignored on such a wide scale?
As most Trust policies do not permit any form of instant messaging usage, it could be reasonably argued that simply using such applications constitutes a breach of policy. However, this research aimed to uncover whether there are degrees to which policy is breached, and how this is affected by cultural acceptance. To that end, participants were asked whether they were aware of colleagues using instant messaging in ways that are expressly against policy, and specifically whether they were aware of colleagues with patient content on a mobile device.
The main deterrent for such behaviour is the threat of disciplinary action that can range from cautions to dismissal. As such, it is important to determine how often disciplinary action is taken against staff that misuse instant messaging channels.
Conclusion : there is strong evidence that the lack of streamlined communication channels is driving healthcare professionals towards consumer IM. Now, the NHS must innovate faster than its own staff.
Every day, healthcare professionals across the NHS are knowingly putting sensitive patient data at risk, not out of malice but necessity. These actions are the result of a system that is failing to support those it relies upon most and is in desperate need of change.
As explored in this report, the growing use of WhatsApp, Facebook Messenger and iMessage
is borne out of the pressure HCPs are under to do more with limited time and a lack of sufficient technology. That is not to say, however, that there is no hope for change.
15% of staff use only Trust provided channels of communication already. It is the 43% of staff that use consumer IM (to varying degrees) who must be persuaded that the reasons to use approved channels outweigh those provided by the systems currently in use.
Clearly, methods employed to date - education and the threat of disciplinary action - have
had little impact, with the number of NHS staff using consumer IM continuing to grow by every year. This has led to a strained relationship of reluctant acceptance which is, by its very nature, unsustainable. Eventually, if this continues, there will be a pivotal event that thrusts an unenviable choice upon the NHS; lay blame at the feet of individuals and take action against nearly half of the workforce, or bear the institutional responsibility for allowing such actions to persist. Before such an event happens, the use of consumer IM apps in healthcare environments must be stopped. But, as evidenced by this report, this will not be easy and will require a radically di erent approach.
HCP feedback and needs must be considered so that IT vendors can design, develop and deploy solutions which not only match the capabilities of consumer messaging applications but provide additional benefit that encourages adoption. By ensuring that a robust replacement is in place, enforcement of policy becomes easier and a clear distinction can be made between what is & is not acceptable behaviour. There will be challenges in realising this vision, such as integrating staff databases between Trusts and providing a uid user interface that can compete with WhatsApp.
But government led initiatives such as the creation of STPs and ACOs are encouraging the collaborative mindset required, and beginning to break down barriers that have traditionally hampered such ideas. A number of healthcare technology vendors - including CommonTime - are already developing systems designed to combat the issues raised in this report. However, in order to fully address the now culturally embedded reliance on consumer messaging applications, a co-ordinated approach will be required. IT suppliers, healthcare professionals and NHS policymakers must have an open, honest dialogue to find a way of moving forward that breaks out of a well-established stalemate. It is the hope of this report’s authors that the data presented here may begin to stimulate such a conversation.
Based in Derby, CommonTime has helped organisations deploy mobile communication technology for over 20 years. We have worked with a number of public sector organisations to deliver transformational messaging solutions in complex working environments.
Clients use our secure communication tools every day to make informed decisions in response to critical events. Our systems improve e ciency and deliver vital intelligence to end users, while minimising administrative tasks.
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