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
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18).13-15,26-31 Risk of bias was greatest for measures of external validity (mean 2.88, range 2-3, SD 0.34), internal validity (mean 4.06, range 3-6, SD 1.00), and confounding (mean 2.69, range 1-6, SD 1.35). Two of 3 randomized controlled trials had a low risk of bias.14,27 Interrater reliability for study quality adjudication was 0.90, suggesting excellent agreement (see supplementary Appendix B).
DISCUSSION
In this systematic review, the effects of visual tools on outcomes, such as provider identification, understanding of roles, patient–provider communication, and satisfaction with care, were variable. The majority of included studies were conducted on adult patients (n = 11).12-14,22-24,26,27,29,30,33 Pictures were the most frequently used tool (n = 7)13-15,23,27,31,33 and consequently had the greatest sample size across the review (n = 1297). While pictures had a positive influence on provider identification in all studies, comprehension of provider roles and satisfaction were variable. Although the content of whiteboards varied between studies, they showed favorable effects on provider identification (3 of 4 studies)12,22,30 and satisfaction (2 of 2 studies).22,30 While electronic medical record-based tools had a positive influence on outcomes,26,28 only 1 accounted for language preferences.28 Formatted notepads positively influenced patient–provider communication, but their use was limited by literacy.24 Collectively, these data suggest that visual tools have varying effects on patient-reported outcomes, likely owing to differences in study design, interventions, and evaluation methods.
Theoretically, visual tools should facilitate easier identification of providers and engender collaborative relationships. However, such tools do not replace face-to-face patient–provider and family discussions. Rather, these enhancements best serve as a medium to asynchronously display information to patients and family members. Indeed, within the included studies, we found that the use of visual tools was effective in improving satisfaction (6/8 studies), identification (13/13 studies), and understanding of provider roles (8/10 studies). Thus, it is reasonable to say that, in conjunction with excellent clinical care, these tools have an important role in improving care delivery in the hospital.
Despite this promise, we noted that the effectiveness of individual tools varied, a fact that may relate to differences across studies. First, inconsistencies in the format and/or content of the tools were noted. For example, within studies using pictures, tools varied from individual photographs of each team member13,23 to 1-page handouts with pictures of all team members.14,15,31 Such differences in presentation could affect spatial recognition in identifying providers, as single photos are known to be easier to process than multiple images at the same time.34 Second, no study evaluated patient preference of a visual tool. Thus, personal preferences for pictures versus whiteboards versus electronic modalities or a combination of tools might affect outcomes. Additionally, the utility of visual tools in visually impaired, confused, or non-English-speaking patients may limit effectiveness. Future studies that address these aspects and account for patient preferences may better elucidate the role of visual tools in hospitals.
Our results should be considered in the context of several limitations. First, only 3 studies used randomized trial designs; thus, confounding from unmeasured variables inherent to observational designs is possible. Second, none of the interventions tested were blinded to providers, raising the possibility of a Hawthorne effect (ie, alteration of provider behavior in response to awareness of being observed).35 Third, all studies were conducted at single centers, and only 9 of 16 studies were rated at a low risk of bias; thus, caution in broad extrapolations of this literature is necessary.
However, our study has several strengths, including a thorough search of heterogeneous literature, inclusion of both adult and pediatric populations, and a focus on myriad patient-reported outcomes. Second, by contrasting outcomes and measurement strategies across studies, our review helps explicate differences in results related to variation in outcome measurement or presentation of visual data. Third, because we frame results by outcome and type of visual tool used, we are able to identify strengths and weaknesses of individual tools in novel ways. Finally, our data suggest that the use of picture-based techniques and whiteboards are among the most promising visual interventions. Future studies that pair graphic designers with patients to improve the layout of these tools might prove valuable. Additionally, because the measurement of outcomes is confounded by aspects such as lack of controls, severity of illness, and language barriers, a randomized design would help provide greater clarity regarding effectiveness.
In conclusion, we found that visual tools appear to foster recognition of providers and understanding of their roles. However, variability of format, content, and measurement of outcomes hinders the identification of a single optimal approach. Future work using randomized controlled trial designs and standardized tools and measurements would be welcomed.
