Do Bedside Visual Tools Improve Patient and Caregiver Satisfaction? A Systematic Review of the Literature
BACKGROUND: Although common, the impact of low-cost bedside visual tools, such as whiteboards, on patient care is unclear.
PURPOSE: To systematically review the literature and assess the influence of bedside visual tools on patient satisfaction.
DATA SOURCES: Medline, Embase, SCOPUS, Web of Science, CINAHL, and CENTRAL.
DATA EXTRACTION: Studies of adult or pediatric hospitalized patients reporting physician identification, understanding of provider roles, patient–provider communication, and satisfaction with care from the use of visual tools were included. Outcomes were categorized as positive, negative, or neutral based on survey responses for identification, communication, and satisfaction. Two reviewers screened studies, extracted data, and assessed the risk of study bias.
DATA SYNTHESIS: Sixteen studies met the inclusion criteria. Visual tools included whiteboards (n = 4), physician pictures (n = 7), whiteboard and picture (n = 1), electronic medical record-based patient portals (n = 3), and formatted notepads (n = 1). Tools improved patients’ identification of providers (13/13 studies). The impact on understanding the providers’ roles was largely positive (8/10 studies). Visual tools improved patient–provider communication (4/5 studies) and satisfaction (6/8 studies). In adults, satisfaction varied between positive with the use of whiteboards (2/5 studies) and neutral with pictures (1/5 studies). Satisfaction related to pictures in pediatric patients was either positive (1/3 studies) or neutral (1/3 studies). Differences in tool format (individual pictures vs handouts with pictures of all providers) and study design (randomized vs cohort) may explain variable outcomes.
CONCLUSION: The use of bedside visual tools appears to improve patient recognition of providers and patient–provider communication. Future studies that include better design and outcome assessment are necessary before widespread use can be recommended.
© 2017 Society of Hospital Medicine
Results by Type of Visual Tool Pictures
Five studies that used pictures reported a positive effect on provider identification.13,14,23,27,33 Two27,33 of 4 studies13,14,27,33 that assessed patients’ understanding of team member roles reported a positive influence, while 1 reported no difference.14 A fourth study demonstrated a negative association, perhaps due to differences in the description of providers’ roles listed on the tool.13 Only 1 study examined the influence of pictures on patient–provider communication, and this study found no difference.14 Satisfaction with care via the use of pictures varied between positive (2 studies)23,33 and neutral (1 study).27
Whiteboards
Four studies tested the use of whiteboards; of these, 3 reported a positive influence on provider identification.12,22,30 One study reported a positive impact on patient–provider communication.29 Two studies noted a positive effect on patient satisfaction.22,30 Notably, the responsibility for updating whiteboards differed between the studies (ie, nurses only22 vs residents, medical students, and nurses).30
Patient Portal
In 1 study, an electronic portal that included names with pictures of providers, descriptions of their roles, lists of medications, and scheduled tests and/or procedures was used as a visual tool. The portal improved patients’ identification of physicians and patients’ understanding of roles. However, improvements in the knowledge of medication changes and planned tests and/or procedures during hospitalization were not observed.26 This finding would suggest limitations in the hospitalized patient’s knowledge of the plan of care, which could potentially weaken patient–provider communication.
Notepads
Only 1 study assessed the use of formatted notepads on patient–provider communication and noted a positive association. Notepads used prompts for different categories (eg, diagnosis/treatment, medications, etc) to encourage patient questions for providers.24
STUDIES OF PEDIATRIC HOSPITALIZED PATIENTS
Five studies were conducted on hospitalized pediatric units.15,25,28,31,32 All studies surveyed the parents, guardians, or caregivers of pediatric patients. One study excluded patients ≥12 years of age because of legal differences in access to adolescent health information,32 while another interviewed parents and/or guardians of teenagers.15
Results by Outcomes Provider Identification and Understanding of Physicians’ Roles
Four studies that assessed the influence of visual tools on provider identification and understanding of roles reported a positive association.15,25,28,31 Visual tools varied between pictures (n = 2),15,31 patient portal (n = 1),28 and whiteboards and pictures combined (n = 1).25 The measurement of outcomes varied between surveys with free text responses,28 multiple choice questions,25 and 1-5 Likert scales.15,31
Patient–Provider Communication
Two studies assessed the impact of patient portal use on communication and reported a positive association.28,32 The 2 portals autopopulated names, pictures, and roles of providers from electronic medical records. Singh et al.28 used a portal that was also available in Spanish and accommodated for non-English speakers. Kelly et al.32 reported that 90% of parents perceived that portal use was associated with reduced errors in care, with 8% finding errors in their child’s medication list.
Patient Satisfaction
Three studies assessed patient satisfaction via the use of visual tools.15,28,31 Singh et al.28 noted a positive influence on satisfaction via a patient portal. Dudas et al.15 used a single-page handout with names and pictures of each provider, along with information regarding the training and roles of each provider. Distribution of these handouts to patients by investigators led to a positive influence on satisfaction. While Unaka et al.31 used a similar handout, they asked residents to distribute them and found no significant difference in satisfaction scores between the intervention (66%) and control group (62%).
Results by Type of Visual Tool Pictures
Two studies reported a positive impact on provider identification and understanding of roles with the use of pictures.15,31 Dudas et al.15 demonstrated a 4.8-fold increase in the odds of parents identifying a medical student, as compared with the control. Similarly, after adjusting for length of stay and prior hospitalization, Unaka et al.31 reported that a higher percentage of patients correctly identified providers using this approach.
Whiteboard and Picture
One study evaluated the simultaneous use of whiteboards and pictures to improve the identification of providers. The study noted improved identification of supervising doctors and increased recognition of roles for supervising doctors, residents, and medical students.25
Patient Portal
Two studies used patient portals as visual tools. Singh et al.28 assessed the use of a patient portal with names, roles, and pictures of treatment team members. Use of this tool was positively associated with provider identification, understanding of roles, communication, and satisfaction. Kelly et al.32 noted that 60% of parents felt that portal use improved healthcare team communication.
RISK OF STUDY BIAS
The risk of bias was assessed for both adult and pediatric studies in aggregate. The average risk of bias using the Downs and Black Scale was 17.81 (range 14-22, standard deviation [SD] 2.20). Of the 16 included studies, 9 were rated at a low risk of bias (score
