In the following, the specific technologies that are included in this review and the general direction of the results are presented in more detail by technology categories. This will be introduced by a short definition of each category. A detailed overview of all results of the single studies is presented in Additional File 1.
If there are relevant systematic reviews for the specific technological area in questions, these are mentioned in the corresponding parts of the text. Many of the systematic reviews comprise a wide range of technologies, some of them are focussed on specific care problems and include only very few studies on digital technologies. It is therefore not possible to provide a focussed summary of all systematic reviews within the scope of this paper. All systematic reviews or meta-analyses that are included in this scoping review are listed in Additional File 1. Most systematic reviews conclude or state that the quality of the studies included is only moderate or poor, and that high-quality evidence is missing. Many of them state that the studies are highly heterogeneous and hardly comparable. Nevertheless, these studies help to show the breadth of analysed technologies. High-quality results are only available for very few specific technologies.
Information and Communication Technologies (ICT)
Information and communication technologies comprise a wide set of technologies. In general, they can be defined as technologies that collect, store, provide, manage and/or improve interpersonal communication. We differentiate the included technologies according to the following subcategories:
1. Hospital (or care institution) information systems (HIS)
2. Electronic health/electronic medical records (EHR/EMR)
3. Computerised decision support systems (CDSS)
5. General communication support
6. Systems to support process planning and/or data exchange
8. Target group specific interfaces
The category “Specific Apps” comprises applications that do not fit in any of the other categories; it includes software solutions that support professionals, informal caregivers or care-dependents in diverse ways. HIS and EHR/EMR are mostly highly integrated systems that often comprise some of the technologies included in the other subcategories.
1. Hospital / Care Institution Information Systems (HIS)
HIS are systems that collect, store, manage and transmit data in hospitals or other care institutions that focus on operational management systems, specific organisational systems or comprise patients’ electronic medical records (EMR) and/or other organisational systems.
This category comprises nine studies. Four of these are rather large cross-sectional or cohort studies on HIS in hospitals. Three of them identify positive effects on patient safety indicators [11], or mortality rates [12, 13]. Especially interesting are the ambivalent results of a study by Angst et al. [14]. This study demonstrates in a large cross-sectional analysis of US hospitals that positive effects of cardiology IT on mortality, and negative effects of administrative IT on interpersonal care depend on the extent of IT implementation. Mortality rates were especially low in hospitals with very high and very low levels of cardiology IT. Results on interpersonal care were low if hospitals had very much or very little administrative IT. This indicates, according to the authors, that an over- or underinvestment in IT can potentially have negative effects on hospitals outcomes, and they conclude that relevant mediating processes and interaction effects have to be analysed carefully when IT is implemented [14].
Effects of HIS implementation in nursing homes are analysed in three rather small case or mixed method studies only. Two of them focussed on effects on communication intensity and communication patterns, one with rather ambivalent [15] results and the other one with positive results [16]. The third study analysed the efficiency of electronic documentation and found ambivalent results. Time spent on documentation increased temporarily because the electronic documentation was not sufficiently aligned with caregivers’ documentation practices [17]. Two single studies focussed on HIS in ICU [18] and a HIS subsystem aiming at patient engagement [19] with positive results. One systematic review on the implementation of computer-based nursing records in residential aged care facilities synthesized the evidence of seven qualitative studies – and concludes that the implementation of electronic documentation systems does not automatically lead to a perceived benefit for the staff, but may often be perceived as an additional burden that complicates daily routines [20]. With the exception of two studies all studies on HIS were carried out in the United States.
Overall, study results on HIS are predominantly positive, but based on rather low evidence-level studies. Three studies with ambivalent results indicate that the implementation of complex systems has to be done with care and under consideration of specific work processes so as to avoid unwanted negative effects.
2. Electronic Health Records/Electronic Medical Records (EHR/EMR)
Electronic health records (EHR) and electronic medical records (EMR) are digital records of patient-related health information. The EMR refers to patient data that is stored and exchanged within an institution, mostly a hospital. An EMR system may include quite a range of different functions. These are often, but not always patient information administration, medication administration, computerised physician order entry (CPOE), decision support or data results management systems, care documentation and sometimes nurse reminder systems. The main focus of the EHR is its capability to exchange information between two systems. Thus, the main applications are electronic patient handover tools and the exchange of health information between different institutions or physicians. While we differentiate between both terms, some publications use both terms synonymously [21].
This review includes nineteen studies on EHR or EMR systems. With the exception of three studies, all of them yield positive results, although the evidence level of most of the studies is rather low. Most studies are situated in hospital settings, and positive effects of EMR systems in general relate to improvements in patient safety [22–24], reduced documentation or data access time [24, 25] and improved workflows [25]. Studies specifically focussing on medication administration observe reduced medication errors and positive effects on guideline adherence [26–30]. All four studies covering aspects of health information exchange or patient handovers yield positive results in terms of reduced workload or treatment times for caregivers and reduced incomplete documentations or error rates [31–33]. Only one of these studies analysed patient-related outcomes and identifies lower 30-days readmission rates and fewer emergency return visits [34]. Two quasi-experimental studies on patient information systems – a nurse reminder tool [35] and a pain notification system [36] – could not identify any statistically significant positive effects. Only three studies analyse the implementation of EMR systems in long-term care facilities. One of them identifies neutral effects on quality indicators, but small measurable increases in productivity and efficiency [37]. Another one finds positive effects on quality of care and improved accessibility of information [38]. The third one is ambivalent in its results: there are positive effects on communication between caregivers and doctors, accessibility of information and safety of care delivery, but the nurses in this study claim that the time spent with the patients is reduced as time spent on documentation has increased, often due to double documentation [39].
These findings are broadly confirmed by an overview of systematic reviews on EMR/EHR by Reis et al. [21] and an extensive systematic review by McKibbon et al. on the impact of health information technologies on medication management processes results in general (including CDSS and CPOE) [40, 41]. Reis et al. conclude that it is possible to identify preliminary benefits of EMR and EHR on quality of care and clinical process outcomes, but that there was no evidence so far of a measurable impact on patient-related outcomes such as mortality, length of stay or cost-effectiveness for the implementing institutions [21]. McKibbon et al. found many studies reporting on improved results for prescribing, ordering and monitoring phases of medication management. Clinical outcomes were sometimes improved, mostly in observational studies, more seldom in controlled trials. Studies on costs or full economic evaluations were especially rare – so they conclude that proof of clinical improvements and economic effectiveness is lacking [40, 41].
Altogether, there are positive results that may be promising for further inquiry, but no strong evidence on clinical outcomes or improved organisational effectiveness. For some neutral and ambivalent results, it is reported that the technology has to be well adapted to the needs of caregivers. Negative results tend to occur when EMR-based documentation is not well integrated into work processes and leads to additional documentation work [35, 39].
3. Computerised Decision Support Systems
Computerised decision support systems (CDSS) are software solutions in which “individual patient data (input) are linked with treatment guidelines and a recommendation (output) for the specific patient is generated” [42] and delivered to a person in charge of care. These systems are sometimes directly integrated in EMR; this review includes four studies that analysed stand-alone CDSS. Many CDSS focus on medical decisions and primary care, and hence are mainly used by physicians. This scoping review focusses on CDSS that are used specifically by nurses.
All four studies yield positive results, two of them relate to risk assessment for complex medication regimes [43] and specific fall risks [44]. The other two studies evaluated systems for supporting care decisions or guideline compliance by nurses for urinary catheter changes [45], and fluid resuscitation in severely burned patients [46]. There are several systematic reviews on CDSS that identify predominantly positive effects, but the main focus of these reviews is on decision support for physicians [42, 47, 48]. An interesting meta-analysis on 162 RCTs, that sought to identify factors that differentiate between effective and ineffective clinical CDSS, concluded that such systems are more likely to succeed if they provide advice for patients as well as practitioners, if they require practitioners to supply a reason for overriding advice or if they were evaluated by their developers [49].
While there is sound evidence on positive effects of CDSSs in the medical context, the number of studies focussing on nurses or long-term care is still rather scarce; however, there are promising positive results in this field.
4. Telecare
For the purpose of this study, telecare is defined as an intervention that involves regular care support from a professional caregiver delivered via digital technologies from a distance. This comprises regular care support that is provided by video, telephone, text-messaging or web-based applications, as well as more complex tele-homecare-systems that are enhanced by wearable or ambient sensors, e.g. for emergency detection.
Study results in this category are much less positive than in other technology categories. Only three of the ten studies yielded positive results, all of which are situated in outpatient long-term care [50–52]. In contrast to these, there are three studies without any significant positive effects [53–55], and four studies with ambivalent results [56–59]. The outcomes analysed in these studies are quite diverse.
Four systematic reviews on telecare were identified in this scoping review [60–63]. None of them included any RCTs. Two of them focus on outpatient palliative care. One of these reports studies with positive effects on quality of care, documentation effort, cost, and communications, but none of the studies included described any patient-relevant clinical outcomes [60]. The other one identifies three studies with clinical outcomes, but none of them was large enough to find significant effects [61]. The most recent systematic review on telecare in outpatient long-term care settings concludes, on the basis of an analysis of qualitative studies, that experiences with the use of telecare are diverse. The authors stress that the findings indicate that telecare systems can promote safety and security to age in place, but that “one size does not fit all” – they have to suit individual needs and be supported by service providers [63].
5. General Communication Support
There are nine studies included in this scoping review that focus on ICT technologies for supporting communication. Nearly all of them are situated in hospital settings, and the majority supports communication between professionals. The applications are quite diverse; they comprise nurse-call or task management systems, hands-free communication systems, a tele-conferencing application for remote support and training of health care providers, and collaboration between hospital and home care by text messaging [64–69]. Two studies analyse effects of application that support communication between formal caregivers and non-professionals. One of them analyses a system to support suddenly speechless critical care patients [70], the other one establishes text messages to keep relatives updated during operations [71]. With one exception, all these studies report positive results, but target groups and effect dimensions are quite diverse.
One main outcome that is often improved is communication efficiency and reduction of response times, and one study reports reduced walking distances for nurses. Two studies identify a reduced length of stay for patients [66, 68]. There is only one study reporting ambivalent results: next to an improvement in efficiency, negative effects of the analysed smartphone use in clinical communication refer to more frequent interruptions during face-to-face communication by smart-phone calls and a worsening of interprofessional relationships between physicians and nurses perceived by the latter [72].
The reviews included are quite diverse in scope as well. Five systematic reviews focus on different communication technologies. They review literature on computer-generated reminders [73], digital technologies for pain management in older people [74], internet-based interventions to decrease caregiver stress [75], the use of personal digital assistants in clinical settings [76] or the use of ICT in general in nursing practice in Sweden [77]. There is mostly positive evidence that digital technology may improve care or communication processes. Patient-relevant clinical outcomes are often not researched or no statistically significant effects are proven. The systematic review on strategies to reduce caregiver stress reports ambivalent results: nine of the included studies reported positive benefits, nine yielded only partly positive results and six reported no change on any outcome measure [75]. Thus, results may differ widely depending on the intervention in question.
6. Systems to support process planning and/or data exchange
There are only two studies that explore software solutions that support the planning of work processes in care and are not integrated in a HIS or EHR/EMR-system. These are both situated in outpatient long-term care. The level of evidence of these studies is rather low, but they both identify positive results such as positive effects on patient education, quality of care and patient satisfaction [78, 79].
7. Specific Software/Apps
This category comprises software-based applications that support caregivers or persons in need of care, whose main focus is not communication and which are not integrated in more complex data management systems as EMR/EHR or HIS.
Most of the studies in this category provide therapeutic support for people with dementia. Four studies, including two RCTs, focus on cognitive stimulation with predominantly positive results [80–83]. Two studies tested serious games with a quasi-experimental design aiming mainly at physical improvements in inpatient long-term care settings. While one of the studies reported positive results [84], the other one found positive results on physical functioning, but reported negative effects on emotional performance as a study result [85].There is only one study – an RCT – that targets the support of informal caregivers by evaluating a personalised tool to support carers of people with dementias. The study does not report any positive effects on care receivers, but documents an increased sense of competence in caregivers after 12 months of using the tool [86]. A qualitative study on a personal assistant for dementia identifies positive effects on patients, but no effects on the burden on the family [87]. Four studies in this category provide care support for professionals by providing information about residents, point-of-care documentation or wound monitoring. They all yield positive results, but the level of evidence is low [88–91].
8. Target Group Specific Interfaces
The accessibility of a technology or a technological device is pivotal for its usability. Sometimes technologies cannot fulfil their potential, or produce negative outcomes because their interfaces are not user-friendly enough. Studies on the usability of interfaces are often incorporated into the early stages of technological development, so study results are often not reported. This review includes three studies on the effects of target group-specific interfaces. One of them included about 900 participants in a pre/post-design and identified positive results on overall and ICU mortality, length of stay and hospitalisation cost for a specific EMR-interface for ICU use [92]. The other two studies report rather preliminary, but nonetheless positive results: an early user study on dashboard design for an EHR shows the potential of interface designs to improve efficiency and task accuracy [93], and a qualitative study on a specific interface for people with memory impairment or dementia demonstrates that interfaces aligned for people with dementia enable a beneficial use of internet resources for this target group [94].
Robotic technologies
There are numerous different types of robots developed for and tested in care facilities or homes of persons in need of care. This review distinguishes between assistive social robots and assistive robots that do not perform social interaction with their users. The main function of these non-social assistive robots is physical assistance. They include simple service robots like robotic vacuum cleaners, but also robots for mobility enhancement such as robotic arms, robotic walkers or exoskeletons and autonomous transportation robots or robotic beds. Social assistive robots are differentiated according to the main function of the robot into therapeutic robots, telepresence robots, service robots and socially interactive robots.
This review includes twenty-four studies on robots. Most of them focus on therapeutic robots, predominantly on Paro, the robotic seal, which is the main focus in 16 out of the 18 studies on therapeutic robots. There is one study on a therapeutic robot cat (JustoCat) [95] and one on the humanoid robot NAO [96]. Two studies compare Paro to other robots, namely NAO [97] and the robot dinosaur PLEO [98]. Paro is thus the best investigated technology included in this review. Five of these studies are RCTs, but most of them are relatively small [99–102]. There is only one RCT that included 138 participants [103]. While all these studies yield positive results in social and psychological dimensions, they differ in detail. Some of them report positive results on depression scales, others cannot verify such effects but report positive results on agitation in people with dementia, loneliness, and well-being, especially in patients with severe dementia.
There are only very few studies on other types of social assistive robots. In one quasi-experimental study a social service robot (Cafero) provided assistance by measuring patients’ vital signs prior to personal consultations in a hospital, leading to significant reductions in consultation length, but effects on the patients were not assessed. [104]. A quasi-experiment on a telepresence robot accompanying nurses on night-rounds in ICUs found only small positive effects on satisfaction about care decisions of caregivers (not statistically significant) [105]. In another quasi-experiment on socially interactive robots that employed a guide robot and Cafero to provide entertainment, communication and health monitoring no significant effects either in patients or in caregivers were found, but a clear limitation of this study was that the robots were seldom used by patients [106].
Three (low-level) studies focus on non-social assistive robots used for transport, physical assistance or mobility enhancement. One case study demonstrated positive time effects with pharmacy delivery robots in a hospital/intensive care unit setting [107]. A user study on a robotic patient lifter showed that the force needed to handle the lifter could be significantly reduced compared to a standard hoist [108]. Another user study explored an electronic wheelchair that was equipped with an anti-collision sensor skirt [109]. Though positive effects on independent mobility of long-term care residents with cognitive limitations were observed, the device did not provide the sensor reliability that would be necessary to navigate safely around other inhabitants.
This review also includes three systematic reviews on robots in nursing care. Two of them report results on studies on socially assistive robots in elderly care [1, 110]. Especially the study by Kachouie et al. [110] – covering the years from 2002 to 2012 – comprises a broader set of robots than is included in this study. Both of these systematic reviews conclude that the evidence reported in the studies is predominantly positive, but their methodological quality is mostly low, and the sample sizes small, so the generalizability of the results is very limited. A review by Pearce et al. [111] focuses on robotic devices to enable older people to live at home. They identified four studies that present some kind of effectiveness results, but these are all user studies, predominantly situated in laboratory settings.
Though the field of robotic technology that is researched with respect to possible use in nursing care is extensive, research – with the exception of Paro – is still at a very early stage and no conclusive results in terms of effectiveness are available yet.
Monitoring/Sensors
Technical solutions that use different types of sensors to monitor patients and support caregiving have evolved into an important research area in recent years. Besides complex solutions with many different types of sensors – as in ambient assisted living settings – many applications have been developed that provide less complex solutions, using mostly only one kind of sensor – or have a very specific scope of application. Seventeen studies dealing with this specific kind of sensor application are included in this review, and twelve of them report positive results. Most of the studies aim at some kind of behaviour analysis – mostly to detect or prevent specific risks [112–118] or to analyse behaviour patterns to support care decisions [119–121]. Other application fields are vital sign monitoring [122–125], external risk detection [126] and tracking or identification of persons [127, 128].
The most common application of sensors in this review is the analysis of behaviour for the prevention of falls. Two RCTs in hospital settings could not identify any reductions in fall rate per patient days [114, 117], two quasi-experimental studies yield positive results, but one of them had to acknowledge study limitations that might question the results [115, 116]. These results are in general confirmed by a systematic review on fall prevention technologies, which also identified positive results in quasi-experimental studies and no significant reductions in fall rates in RCTs [129].
Positive results were achieved by an RCT using wearable patient sensors in an ICU setting to prevent pressure ulcers [112]. Positive effects of monitoring devices for preventing pressure injuries are also supported by a systematic review that included nine studies (no RCTs) that all identified positive effects of sensor applications. These include studies on pressure sensing mats, pressure sensors built into mattresses, piezoelectric sensors placed under the mattress, and a portable skin monitor [130].
Another RCT in the field of behaviour analysis yielded positive results for an intervention that used ambient sensors for older people living in assisted living communities to analyse behaviour patterns for early illness detection [120]. A small quasi-experiment that used behaviour analysis for decision support in an outpatient long-term care setting observed no statistically significant changes in the clients, but did identify positive effects on the informal caregivers (decrease in subjective burden and decrease in time spent on the client) [119].
Three studies used sensors for vital sign monitoring with positive results. One study worth highlighting is a large controlled clinical trial situated in an ICU that reported a positive effect on the average length of stay in the ICU and, as a secondary outcome, a lower number of cardiac arrest alarms [122].
Monitoring/Sensors are one of the largest categories in this review. While positive results on fall prevention could not be substantiated by the RCTs, a large RCT on pressure ulcer prevention showed positive results. Nevertheless, there is a substantial number of quasi-experimental studies with positive results, on which future research can build.
Assistive Devices
In this review, assistive devices are defined as physical devices made to assist or support a caregiver or a person in need of care in performing a particular task and enhanced with digital technology, especially devices that are digitally networked/connected or equipped with sensor technology. Particularly in hospital settings, the distinction between assistive devices and (primarily) medical technologies is challenging. The goal of this review was to focus on technologies or technological aspects that facilitate nursing care activities.
Empirical evidence in this technological area is still scarce. There are only seven studies on assistive devices included in this review. Three of the studies focus on electronic medication dispensing devices. An RCT that compared the effects of nurse-coordinated medication self-management in an outpatient setting, either supported by a simple box with different compartments or by a medication dispensing machine, was unable to identify an additional benefit to be gained from the device [131], while two case, resp. user studies at least found positive or ambivalent effects [132, 133]. Two studies report positive effects of smart pump technologies in hospital settings [134, 135], a small RCT finds positive effects of a multimodal distraction device during acute burn care [136]. The only device tested in an inpatient long-term care setting is a smart drink monitor device. The user study yielded positive results on drinking amount and frequency during a one week intervention phase [137].
In the systematic reviews included in this review, evidence on assistive devices is also scant. Most of the reviews identified either no or only low-quality evidence on a small range of assistive devices. A study by van der Roest et al. [138] searched for studies on assistive technologies for memory support in dementia and was unable to identify a single high-level study. Fleming and Sum [2] searched for assistive technology in the care of people with dementia and identified only few studies with very small samples focusing on memory support and alarm systems.
Overall, therefore, positive evidence in this research area is very limited, and mostly only supported by rather small or low evidence-level studies.
Ambient Assisted Living Systems
Ambient Assisted Living (AAL) systems are integrated multifunctional, often modular systems that support a person in his or her living environment. The application generally comprises a set of different technologies, often sensors and communication technologies, which intend to support the well-being, security and independent living of an elderly person.
Our search resulted in only three studies that tried to assess effects on persons in need of care or caregivers. The largest study – a quasi-experimental study on 59 inhabitants of an AAL supported assisted living facility in the intervention group – identified small positive effects on feelings of personal safety, but no effects on QoL or feelings of independence [139]. A quasi-experimental study with 11 older people with dementia in the intervention group could not identify any significant differences in perceived autonomy, care needs, QoL or performance of daily activities [140]. A qualitative study on 14 persons with dementia and their informal caregivers, however, reported positive effects on the sense of safety and security of the person with dementia perceived by the caregiver as well as positive effects on the caregiver with respect to anxieties, concerns and an increased time for restorative activities [141].
Virtual Reality
All three studies on virtual reality devices included in this review focus on distraction and/or pain reduction during wound care in hospital settings. All three studies are rather small (with about 20 patients testing the intervention). One RCT [142] and a quasi-experimental study [143] report positive results with respect to medication needed, the RCT reports positive effects on pain (rated by nurses). The third study, a three-armed RCT, does not identify any differences in pain reduction for all three groups [144].