Usability and feasibility of multimedia interventions for engaging patients in their care in the context of acute recovery: A narrative review

Abstract Purpose The purpose of this narrative review was to examine the usability and feasibility of multimedia intervention as a platform to enable patient participation in the context of acute recovery and to discover what outcomes have been measured. Data sources A narrative review of primary research articles identified through a search of four electronic databases (MEDLINE, CINAHL, EMBASE and PsycInfo) identified peer‐reviewed research evidence published in English language with no limitation placed on time period or publication type. Two authors independently assessed articles for inclusion. From the 277 articles identified through the search, 10 papers reporting the outcomes of seven studies were included in this review. Review methods Articles were independently assessed for quality and relevance by two authors. The most appropriate method for data synthesis for this review was a narrative synthesis. Results From the narrative synthesis of study outcomes, two findings emerged as follows: (a) multimedia interventions are feasible and usable in the context of acute care, and (b) multimedia interventions can improve patients’ perception of care‐related knowledge. Identified gaps included a lack of evidence in relation to the effect of interventions on enhancing patients’ ability to participate in their care and the impact on patients’ health‐related outcomes. Conclusions In conclusion, there is some evidence of the feasibility and usability of multimedia interventions in acute care. That is, patients can use these types of platforms in this context and are satisfied with doing so. Multimedia platforms have a role in the delivery of information for patients during acute recovery; however, the effectiveness of these platforms to engage and enhance patients’ capability to participate in their recovery and the impact on outcomes needs to be rigorously evaluated.

lated knowledge. Identified gaps included a lack of evidence in relation to the effect of interventions on enhancing patients' ability to participate in their care and the impact on patients' health-related outcomes.

| INTRODUC TI ON
It is well established that engaging patients in their care produces better health outcomes for patients with chronic illness. [1][2][3] Emerging evidence suggests participation can enhance patient outcomes in acute care environments, particularly in relation to patient safety 4,5 and satisfaction. [6][7][8] Despite the perceived and emerging benefits of promoting patient participation in their health care, there is a notable lack of studies evaluating the effectiveness and sustainability of interventions to promote patient participation in acute health-care environments. Challenges associated with achieving patient participation in acute care include the higher acuity of illness, [8][9][10][11] greater complexity in medical treatment regimens, 12,13 and shorter length of stay compared to other non-acute environments. 14,15 These factors may all influence patients' ability to participate in their care to the level they would prefer, and in a way that may affect their outcomes.
To date, patient participation research in acute care has foci across five areas: (a) preference for participation in care, 16-18 (b) experience of participation, [19][20][21] (c) participation in decision making, 22-24 (d) participation in safety initiatives to minimize adverse events, 5,[25][26][27] and (e) participation in patient-clinician communication during transitions of care and discharge planning. 23,[28][29][30] Outcomes of research examining patients' preferences for participation suggest patients want to be involved in their care, but often feel they do not have the capability or opportunity to do so. 19,21,[31][32][33] The majority of this research has been descriptive aimed to elicit patients' preferences for participation in acute care. For example, McMurray 32 interviewed patients to gain their perspectives of participation in shift-to-shift, bedside nursing handover. Patients were asked their views about bedside handover including the benefits and limitations, their existing and potential role in handover, the role of family members, and issues related to confidentiality. Findings revealed four major themes. 32 First, patients valued being recognized as "partners". Second, patients viewed bedside handover as a chance to correct any mistakes communicated during the interaction. Third, some patients preferred to be passive rather than full engagement in the handover process, and fourth, most patients appreciated the inclusive approach as it facilitated nurse-patient interactions. 32 When patients' actual experience of participation in nursing care was examined, Tobiano et al 19 found that patients described a power imbalance and expressed feelings that their opportunities for participation were restricted. These findings suggest the opportunity for participation in their care needs to be explicit to patients, and facilitated by clinicians so that it is clear that their participation is welcomed and expected, to support patients' confidence and motivation to engage in the process. 19 The question therefore is how do we as nurses engage patients in their care at the level that is desired by individual patients.
Patient participation specifically in decision making has been explored in a descriptive study by Kolovos 22 that found that although patients were involved in planning and implementation of nursing care their level of participation was moderate. In addition, the results provided evidence that patient education correlated with the degree of participation, highlighting the importance of patients understanding exactly where and how they can participate in their care and recovery. Therefore, how patients receive this information to enable participation, in the context of acute recovery, is an important consideration.
Outcomes of a cluster randomized controlled trial testing a complex, multiple component intervention to reduce falls and adverse events (pressure injury, urinary tract infections) showed a reduction in falls and adverse events. 34 The intervention was designed to involve patients and families by providing written and verbal information related specifically to each patient's identified risks.
Although successful, the intervention was detailed and complex to apply, resource-intensive and dependent on several health disciplines working together, raising questions about its sustainability over time. Further, it was difficult to disentangle the role that patient participation versus staff engagement in risk-reduction strategies played in achieving the reported outcomes. This raises the question of sustainability of interventions over time. If we are to introduce interventions to enable patients to engage, they must be sustainable without the control conditions of a study.
O'Leary et al 7 tested a 'patient-centred bedside rounds' intervention in a cluster randomized controlled trial. The intervention involved a multidisciplinary team, using a structured communication tool designed to be used at the bedside. The tool was based on a communication framework where clinicians were given direct instructions, for example, introduce yourself to the patient, update patients' care team on the white board, review report from previous Conclusions: In conclusion, there is some evidence of the feasibility and usability of multimedia interventions in acute care. That is, patients can use these types of platforms in this context and are satisfied with doing so. Multimedia platforms have a role in the delivery of information for patients during acute recovery; however, the effectiveness of these platforms to engage and enhance patients' capability to participate in their recovery and the impact on outcomes needs to be rigorously evaluated.

K E Y W O R D S
acute care, interventions, multimedia, patient participation shift, perform safety checklist and plan discharge. The hypothesis was that patients who were more informed of their care plan and engaged with the members of their health-care team would be more activated. The authors reported that patient-centred bedside rounds were only partially implemented (54% of patient handovers) and that there was no difference between groups in patient preference for participation, patient activation or satisfaction with care. Due to the poor uptake of the intervention, the authors questioned whether clinicians valued the inclusion of patients in the transition process. 7 Gonzalo et al 35  Resources to support patient participation in their care following surgery need to be procedure-specific but also provide patients with clear guidance about how and when they can participate in their recovery. To enable participation in acute care, patients need to be provided with timely information, relevant to their stage of recovery that can be used to support and encourage their participation.
Rapid advances in information technology and multimedia techniques in the past decade provide novel and unique opportunities for innovative approaches to overcome barriers to patient participation in their care in acute care settings. For example, use of multimedia platforms to provide patient information and education has increased significantly over the past decade. Multimedia tools have being successfully used in a wide range of health situations including preparing patients for specific procedures or surgery by providing education pre-operatively or to gain pre-operative consent [41][42][43][44][45][46][47] ; providing health information for patients to assist them to make informed decisions regarding treatment 48,49 ; presenting information to enable self-management in chronic illness 50 ; increasing knowledge about post-operative care, for example how to use a patient-controlled analgesic pump after surgery 51 ; and improving patient satisfaction overall. 52 Two systematic reviews examining the use of multimedia technologies to facilitate the patient education process 53,54 concluded that these technologies are beneficial in delivering patient education, and value added to the patient education process in terms of increased knowledge, increased confidence in self-care and ability to participate in decision making. 53,54 However, evidence for the use of these types of interventions drawn from the chronic illness and ambulatory care settings may not translate to acute care where the barriers and constraints differ. What is less clear is the usability for patients of multimedia interventions during acute recovery from illness or surgery. Further, evidence that multimedia interventions provide patients with the capability to participate and improve patient outcomes is not available.
The purpose of this narrative review was to examine the usability and feasibility of multimedia intervention as a platform to enable patient participation in the context of acute recovery, and to discover what outcomes have been measured as a result of using multimedia.
For the purpose of this review, multimedia was defined as a tool that uses animation, sound and text, 55 usability was defined as the degree to which a multimedia intervention is easy to use for patients in the acute care context, 55 and feasibility was defined as the ease or convenience of applying a multimedia intervention. 55 Acute care was defined as a pattern of health care in which patients are treated for brief but severe episode of illness, for example recovery following accident or trauma or during recovery from surgery. 56

| Review questions
A specific mnemonic for qualitative systematic reviews (PICO) was used to develop the question for this review. 57 Table 2). This criterion was quite specific and was used to limit the scope of the review.

| Data synthesis
Narrative synthesis was deemed most appropriate approach to use as it allows the combination of qualitative, quantitative and multiple design methodologies. Narrative reviews can be performed in different ways and is determined by the research question and types/ characteristics of articles included. 58

| Study characteristics
The initial search identified 281 manuscripts. A further 13 articles were found through other sources. After removing duplicates, and screening titles and abstracts, 53 full-text papers were identified; 43 of these papers were excluded based on the exclusion criteria (see Figure 1). Two members of the research team reviewed papers independently for inclusion in the final analysis.
The final review consisted of 10 papers reporting the outcomes of seven individual studies of multimedia interventions for patients specifically in the acute in-hospital context. Table 3 summarizes the studies included in the review. Two researchers independently extracted and reviewed the studies and then met to compare and discuss findings. The seven studies all tested multimedia interventions predominately for the purpose of evaluating usability and feasibility in acute care settings; the outcome measures were typically satisfaction ratings.

| Usability, feasibility and patient-related outcomes of using multimedia interventions in acute care
All of the seven studies reviewed reported the usability and feasibility of their interventions in the context of acute care delivery. Table 4 outlines the usability of multimedia in acute care. The degree to which a multimedia intervention is easy to use for patients in the acute care context. These findings suggest that multimedia interventions are both useable and feasible for patient use in the context of acute recovery. Table 5 describes reported outcomes of multimedia interventions in acute care settings, in particular patientreported satisfaction, experience and length of stay.
One of the barriers that has been identified in previous research from patients in understanding their care goals and enactment of participation was receiving conflicting or inconsistent information. [59][60][61][62] To overcome this barrier, Dykes 63 and Dalal 64 and colleagues implemented an intervention delivered via interactive web-based multimedia design, specifically intended to engage hospitalized patients in their plan of care. Outcomes reported included a system usability and satisfaction survey that indicated patients found the system easy to use and were very satisfied (74% satisfied). 63,64 The most frequently accessed pages via the portal included patient goals, test results, care team members, messages and education regarding tests results and medications. 63 However, no measure of patients' ability to understand their plan of care was reported.
Vardoulakis 65 also confirmed that a multimedia intervention was an acceptable and useable way to deliver consistent and reliable information to patients in acute care. Vardoulakis 65 utilized a mobile phone application in the emergency department to present information related to patients' care plan and care team. Patient satisfaction (acceptability) and usability were high amongst the patients and families who engaged with the intervention. 65 In addition, Greysen 66 and colleagues found that patients were satisfied with using tablet computers for discharge planning and were able to show that patients engaged with the intervention supporting the notion that TA B L E 5 Reported outcomes of multimedia interventions in acute care settings: Satisfaction and Experience and Length of stay To assess the effect of tablet computers with a mobile patient portal application on hospitalized patients' knowledge and activation 76% satisfied usability was possible in this context. This is an important finding that in the fast paced context of an emergency department, patients can utilize these types of platforms to receive information; however, what is not clear is if this information delivered actually leads to improved outcomes or a more engaged patient.

Vawdrey 67 tested patients' perceived usefulness and satisfaction
with iPad TM technology following cardiac surgery. Participation with the intervention was measured as the number of times the program was accessed by patients. 67 Whilst the iPad TM was found to be useable and a useful way to deliver information in the acute context, the study outcomes measured did not provide any evidence that patients were more engaged in their care as a function of using the multimedia program. These findings are consistent with previous research where just providing information to patients did not necessarily lead to an increase in participation or have an effect on patient outcomes. 53,54 Cook et al 68  groups, but despite there being a trend towards higher activation in the intervention group, no significant difference between groups was revealed. However, it is possible that the study was not sufficiently powered to detect a statically significant difference between groups, as patient activation was not the primary outcome. These findings support that patients' desire to participate in their care is an important consideration when evaluating interventions designed to improve outcomes. 19,24 In addition, the power imbalance that exists between clinicians and patient may impact on their capability to participate and this should be taken into consideration when designing and implementing multimedia patient resources.
One indirect measure of patient participation in care and recovery is improvements in clinical outcomes and acute care length of stay. 70 In one study of an e-health platform intervention by Cook et al, 68 patients whose self-reported mobility scale scores were higher also had a shorter length of stay in hospital compared to standard practice (Table 5). However, it is important to note that there was no objective measure of patient mobility and no concurrent comparison group; nor do Cook et al 68 claim that the multimedia intervention mediated a change in patient behaviour and subsequently higher self-reported mobility scores.
In another related study in 2014, Cook et al 6 tested an e-health platform as a way to deliver information to older patients after cardiac surgery and found that the majority (98%) indicated they understood the information provided. These responses were however collected using a self-reported checklist using a dichotomous outcome scale, where patients marked if they did or did not understand the information provided, and no measure of patients' actual knowledge or understanding of their recovery goals was obtained.

| Summary of key findings
All of the studies reviewed reported high patient satisfaction as an outcome of the use of multimedia interventions. 6,67,68 This is an important finding in terms of ensuring patients are comfortable using this type of intervention in the context of acute care and recovery.
Further work is needed using sound methodologies such as randomized controlled trials or quasi-experimental studies to determine whether multimedia interventions increase patients' ability to receive and retain information in acute care contexts. In addition, to evaluate if patient participation following the use of these interventions actually lead to better health-related outcomes. Patients showed moderate engagement with the tools; however, the effectiveness of multimedia interventions in increasing patient participation in their care or in improving patient outcomes has not been investigated. In addition, research needs to take into account previous work around patients' preference for participation, [16][17][18] just delivering information to patients in a way that is acceptable may not lead to better health outcomes.

| D ISCUSS I ON
A major limitation of the studies reviewed was the quasi-experimental, post-test design and lack of a comparative or control group.
One exception was O'Leary 7 who had a control group with similar patient characteristics in both groups that allowed comparisons between those who did and did not receive the intervention. However, the two groups (intervention and control) were allocated to two separate wards in the same hospital 7 and the structural, process and ward culture characteristics may have differed between wards.
Only one of the studies reviewed attempted to investigate whether the interventions had an effect on patient activation, participation or outcomes of care. In addition, the lack of studies provides evidence that patient participation using multimedia interventions is an under-researched area in acute care. As the studies included in this review were heterogeneous in both the interventions trialled and the outcomes measures, it was not possible to aggregate results or perform meta-analyses. Another limitation of this narrative systematic review is that 'grey literature' was not included. As the use of digital technology and multimedia interventions in health-care context is a dynamic area of practice innovation, it is acknowledged that evaluations of more recent innovations may not yet be published in the peer-reviewed literature.
The evidence from this narrative review adds to the growing body of work around the need to engage patients in their own care 4,5 and the necessity for clinicians to find novel ways to do this in the context of acute care. 51 The emerging evidence for using multimedia as a platform to do this is encouraging 6,62,63,65,67-69 ; however, further robust studies are needed to ensure that information delivered in this format to patients leads to better outcomes and improved quality care.

| CON CLUS IONS
There is a worldwide movement to include patients as participants in their own care in the recognition that participation will enhance the quality and safety of the care that patients receive. [71][72][73] The enactment of patient participation involves a complex interplay between patients' capability, opportunity and activation. 8,36,[74][75][76] Evidence-based guidance for facilitating participation in acute care, the implications of patient participation for nursing and health-care practices and what patient outcomes are likely to be impacted upon is emerging but ill-defined. 77 The acute care context presents unique challenges to participation, and it is not clear how patient participation is enacted in this environment, or indeed, if it is possible to implement sustainable interventions to support patient participation. The outcomes of this narrative review demonstrate that using multimedia platforms to deliver information and facilitate patient participation in their care is feasible, and that the useability of these devices by patients is high.
As the use of multimedia interventions to improve patient engagement and participation becomes more ubiquitous in health-care settings, the effectiveness of these interventions needs to be rigorously evaluated.

CO N FLI C T O F I NTE R E S T
All authors declare there is no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analysed in this study.