A focus on both quality and efficiency in health care has led to the implementation of innovations such as patient flow teams, bed managers and various support tools.1,2 The traditional whiteboard is a low-technology, low-cost, low-maintenance tool that can be an efficient medium for documenting patient status and progress.3,4 It can assist in timely completion of patient care activities and improve communication and teamwork, both within and across disciplines.4,5 It allows the sharing of information without the need for face-to-face meetings.6 However, it can also be used in a manipulative way, controlling access to information and workflow.4,7 Little attention has been paid to what influences successful integration of whiteboards into unit routines.
We used a case study method8 with four nested cases in one Queensland health service district. To conceptualise the study we used Donabedian’s framework (comprised of three elements: structure, process and outcome)9 to frame the quality evaluation of health service performance. Quality is assessed by appraising structures and processes and linking these to outcomes, on the assumption that structures influence processes, which in turn influence outcomes.9,10 Structures include physical and organisational properties; processes are what is actually done; and outcomes are what is accomplished.10 To evaluate an aspect of quality, we looked at causal relationships between the three elements.
Data were analysed using the case analysis technique.8 This involves an iterative explanation-building process. The objective is to refine a set of ideas and link these to the data. First, data were categorised into the domains of structures, processes and perceived outcomes. Structures were defined, and then propositions about differences in engagement or use of the whiteboard were generated. Processes and outcomes were identified from comparisons of use across cases. Data analysis continued until a final set of explanations was generated.
With each iteration, there was constant reference to the original purpose of the enquiry, and attempts were made to consider alternative, plausible explanations.8 One researcher led the analysis, with other researchers meeting to scrutinise, discuss and question the preliminary findings to refine the quality of the analysis.
The interviewees were five registered nurses, four allied health professionals, one assistant in nursing, and one other person who declined to be identified (Box 1). All doctors who were approached to be interviewed declined, citing work pressures as the reason, but all others who were approached agreed to be interviewed. The structures, processes and outcomes identified are summarised in Box 2 and described in more detail below.
Four structural elements of whiteboard communication were identified: their physical properties, their physical location, concurrent permanent documentation, and the staff who used them. All whiteboards were the same dimensions (280 cm [width] × 200 cm [height]). They were divided into columns for bed numbers, consultant doctors, common allied health referrals, diagnostic tests, discharge medications, and expected date of discharge. Two different coding systems were used to indicate referrals (Box 3).
The patient-centred nature of whiteboard use is aligned with current trends in information transfer. Having health professionals document information in a way that is readily visible can facilitate accurate and appropriate clinical judgements. In the context of information sharing, whiteboard use also has the capacity to promote teamwork and accountability,6 particularly with timely scrutiny of one another’s plans and reports.4 Three key issues surrounding the use of whiteboards emerged from out study: staff buy-in, discharge planning and patient privacy.
For whiteboards to be effective communication tools, the active and willing support and participation of staff is imperative. There needs to be a powerful, guiding coalition to effect change, and this is best achieved with joint, multidisciplinary, systematic planning on the basis of shared goals and a shared vision.11 Our study showed that, when staff perceived they did not have a part in the planning and implementation of a new resource, they did not develop ownership of it and did not see it as a useful tool. Rather, it was seen as a burden, an imposition of extra work, and a source of conflict. This finding highlights the importance of a planned approach to change. Establishing a sense of urgency for change on the basis of patient safety and ensuring that this is communicated widely at the ward and institutional levels can be persuasive for staff members who may initially be resistant to change.11
The notion that the whiteboard facilitated patient flow and discharge planning was a consistent finding and has been recognised previously.7,12 Our observations are consistent with the findings of Xiao and colleagues that whiteboards supported collaborative work in the emergency department.5 Whiteboards allow tasks to be articulated, managed and tracked. They assist in resource planning, such as bed availability, and facilitate both synchronous communication (in which the message is sent and received at the same time) and asynchronous communication (in which the receiver decides when to receive the message).13,14 Others have noted that whiteboards and other communication tools, such as electronic dashboards, can actually be used to control practice.4,7,13 However, our study did not highlight the “game playing” that others have noted.4,6
Joint medical and nursing rounds (which may shorten hospital length of stay15,16) did not occur in the three inpatient wards we studied. In such instances, where medical and nursing rounds are not conducted jointly, the potential for the whiteboard to act as synchronous or asynchronous communication channel is unlikely to be realised unless short updates between doctors and nurses occur at the whiteboard or doctors record their plans on it. Given their workloads, it is no wonder that doctors, nurses and allied health professionals find this difficult. In previous studies, health professionals have argued that, because of time restraints, the need for efficient and relevant information sources is imperative to support collaboration and information needs in patient care.3 It seems self-evident that the information must also be accurate. Thus, if whiteboards are used, there must be a clear line of responsibility for updating the information on them. Further, making reviews of the whiteboard part of ward rounds formalises its integration into ward routines.
Somewhat surprisingly, the issue of patient privacy and confidentiality of information did not feature in our findings. However, the state’s confidentiality guidelines17 and the hospital’s legal department were consulted in the planning phase to address issues related to patient privacy. Unlike other hospitals, where patients’ names are recorded,7 the nurse unit managers in the hospital we studied made the decision to use bed numbers as the only reference. It is self-evident that the physical location of whiteboards may be a significant factor in ensuring patient privacy, but finding appropriate locations for them may be difficult.
- Wendy Chaboyer1
- Karen Wallen1
- Marianne Wallis1
- Anne M McMurray2
- 1 Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, QLD.
- 2 Murdoch University, Mandurah, WA.
Our study was funded by the Australian Commission on Safety and Quality in Health Care.
The Australian Commission on Safety and Quality in Health Care provided funding but was not involved in the study design, data collection, analysis, interpretation or writing of this article.
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Abstract
Objective: To describe the integration of whiteboards into ward routines in one Queensland health service district (HSD).
Design and setting: Case study involving placement of whiteboards in three inpatient wards (two medical, one surgical) in a university-affiliated regional teaching hospital and in a day clinic in the same health service district. Data collection methods included 45 hours of observation of four whiteboards and 62 staff over 2 months, 11 in-depth interviews with nursing and allied health staff, and photographs of the whiteboards taken at intervals. The study was conducted from March to August 2008.
Main outcome measures: Structures, processes and perceived outcomes of the use of whiteboards.
Results: The physical configuration of the whiteboards did not vary, but their content and usage by various professional groups fluctuated. Whiteboards were most successfully integrated in the clinic, where they became an integral part of multidisciplinary rounds, and were updated and referred to several times each day. They were partially integrated into the two medical wards, with various health professionals updating and referring to the whiteboard. In the surgical ward, a nursing assistant updated the whiteboard, but it was not referred to by others. Staff in the clinic and on the medical wards perceived that whiteboards facilitated timely referrals, improved patient flow and enabled timely and better discharge planning, but surgical nursing staff described them as an imposition and a cause of conflict among clinical team members.
Conclusions: Whiteboards have the potential to improve patient flow, but a planned approach to their use is required. Issues relating to the use of whiteboards, including staff buy-in, discharge planning and patient privacy, need to be addressed.