Do Bedside Visual Tools Improve Patient and Caregiver Satisfaction? A Systematic Review of the Literature

Quality Assessment

As recommended by the Cochrane Collaboration, 2 reviewers (AG, KT) assessed the risk of study bias by using the Downs and Black Scale.^17,19 Discrepancies in assessment were resolved by a third reviewer (VC). This instrument uses a point-based system to estimate the quality of a study by rating domains such as internal and external validity, bias, and confounding. In keeping with prior systematic reviews,^18,20,21 studies with a score of ≥18 were considered high quality. Interrater agreement for the adjudication of study quality was calculated using the Cohen κ statistic.

RESULTS

After the removal of duplicates, 2646 articles were retrieved and 2572 were excluded at the title and/or abstract level. Following a full-text review of 74 articles, 16 studies met the inclusion criteria (Figure 1). Fifteen studies reported quantitative outcomes,^12-14,22-33 and 1 was a mixed-methods study, of which only the quantitative outcomes were included.¹⁵ Study designs included prospective cohort (n = 7),^{12,13,23,25,28,30,31} randomized controlled trials (n = 3),^14,27,33 pre-post (n = 2),^22,29 cross-sectional survey (n = 2),^24,32 and mixed methods (n = 1).¹⁵ Interventions studied included pictures (n = 7),^{13-15,23,27,31,33} whiteboards (n = 4),^12,22,29,30 electronic medical record-based patient portals (n = 3),^26,28,32 whiteboards and pictures (n = 1),²⁵ and formatted notepads (n = 1 ).²⁴ Eleven studies were conducted on adult units^{12-14,22-24,26,27,29,30,33} and 5 on pediatric units.^{15,25,28,31,32} (Table). Outcomes reported within studies included (a) provider identification (9 adult, 4 pediatric); (b) understanding of roles (6 adult, 4 pediatric); (c) communication (3 adult, 2 pediatric); and (d) patient satisfaction (5 adult, 3 pediatric). Studies were organized by type of intervention and outcomes reported and stratified by adult versus pediatric patients (Figure 2). Interrater reliability for study abstraction was excellent (Cohen κ = 0.91).

Measurement of outcomes related to visual tools varied across studies. Patient satisfaction and patient–provider communication were measured using questions from validated instruments, such as the Patient Satisfaction Questionnaire,^15,31 ad hoc surveys,^22,23,30 free text responses,^27,32 or Likert scales,^13,24,26,32 created by authors. Similarly, measurement of provider identification varied and included picture-matching exercises^15,23,31,33 and bedside interviews.^23,26 Understanding of provider roles was assessed using multiple choice question surveys²⁵ or Likert scales.¹³

The influence of visual tools on provider identification was measured in 13 of 16 studies. In all of these studies, a positive impact of the tool on provider identification was reported.^{12-15,22,23,25-28,30,31,33} Patient understanding of providers’ roles was positive in 8 of 10 studies that measured the outcome.^{15,22,25-28,31,33} The impact of visual tools on patient–provider communication was positive in 4 of 5 studies. ^24,28,29,32 The influence of visual tools on patient satisfaction with care was measured in 8 studies; of these, 6 studies reported a positive impact.^{15,22,23,28,30,33}

STUDIES OF ADULT HOSPITALIZED PATIENTS

Eleven studies were conducted on adult hospitalized pa­tients ^{12-14,22-24,26,27,29,30,33} and included 3 randomized controlled studies.^14,27,33

Results by Outcomes Provider Identification Nine studies measured patients’ ability to identify providers with the use of visual aids, and all 9 reported improvements in this outcome. Visual tools used to measure provider identification included pictures (n = 5),^{13,14,23,27,33} whiteboards (n = 3),^12,22,30 and patient portals (n = 1).²⁶ Within studies that used pictures, individual pictures (n = 2)^13,23 and handouts with pictures of multiple providers (n = 3) were used.^14,27,33 In 2 studies, care team members such as a dietitian, physiotherapist or pharmacist, were included when measuring identification.^14,33

Understanding Providers’ RolesSix studies assessed the effect of visual tools on patients’ understanding of provider roles.^{13,14,22,26,27,33} Four studies reported a positive effect with the use of pictures,^27,33 whiteboards,²² and patient portals.²⁶ However, 2 studies reported either no difference or negative impressions. Appel et al.¹⁴ reported no difference in the understanding of physician roles using a handout of providers’ pictures and titles. Arora et al.¹³ used individual pictures of physicians with descriptions of roles and found a negative association, as demonstrated by fewer patients rating their understanding of physicians’ roles as excellent or very good in the intervention period (45.6%) compared with the baseline (55.3%).

 

Patient–Provider Communication

Three studies evaluated the influence of visual tools on communication.^14,24,29 Using pictures, Appel et al.¹⁴ found no difference in the perceived quality of communication. Singh et al.²⁹ used whiteboards and reported improved communication scores for physicians and nurses. With notepads, patients surveyed by Farberg et al.²⁴ stated that the tool improved provider communication.

Patient Satisfaction

Five studies assessed patient satisfaction related to the use of visual tools. ^{22,23,27,30,33} One study reported satisfaction as positive with the use of individual pictures.²³ Two studies that used handouts with pictures of all team members reported either a positive³³ or neutral²⁷ impact on satisfaction. Studies that used whiteboards reported a positive association with satisfaction^22,30 despite differences in content, such as the inclusion of prewritten prompts for writing goals of care and scheduled tests³⁰ versus the name of the nurse and their education level.²²