Abstract
Patient experience is increasingly recognized as a key performance indicator in healthcare. A tertiary hospital in Singapore introduced bedside tablets to enhance patient engagement and informed care. The tablets provide patients with access to health information and communication with healthcare teams. The study team hypothesized that patient experience would improve over time from pre-implementation of the initiative to post-implementation and with each addition of functionality. This prospective observational study, conducted at Singapore General Hospital, used sequential cross-sectional samples collected across different phases of bedside tablet implementation. Patient experience was evaluated using four specific domains of the validated Picker Patient Experience Questionnaire related to nurse communication, patient involvement, addressing patient concerns, and family information provision. Positive scores were calculated following the questionnaire guidelines, based on the proportion of patients reporting the most favourable responses. Data were collected from June 2019 to July 2024 and analyzed using descriptive statistics and Kruskal–Wallis tests. Nurse communication clarity and patient involvement positive scores increased overall, consistently receiving high positive scores across all stages. Patient involvement scores peaked in stage 3, coinciding with added functionalities like self-charting and electronic medical records synchronization. In contrast, addressing patients’ concerns received the lowest positive scores, and family information provision demonstrated a steady decline across all stages. Kruskal–Wallis tests indicated significant differences for patient involvement and family information provision. However, post-hoc tests revealed no significant pairwise differences. The implementation of bedside tablets improved nurse communication clarity and patient involvement in care decisions, although areas for improvement remain, particularly in addressing patient concerns and family information provision. However, the calculation of positive scores, which only account for the most favourable responses, may obscure nuanced patient experiences. Future research would benefit from combining quantitative data with qualitative insights to gain a more comprehensive understanding of patient and family needs.
Keywords
Introduction
Patient experience has gained increasing attention as a performance indicator among healthcare leaders, with it being a requirement for public reporting in some countries (Wolf, 2017). However, there is no fixed definition for the use of this term. The 2009 Health Leaders Media Patient Experience Leadership Survey asked its participants how they would define patient experience (Healthcare Leaders Media, 2014). The following options were provided: “patient-centred care,” “an orchestrated set of activities that is meaningfully customized for each patient,” “providing excellent customer service,” “creating a healing environment,” “consistent with what’s measured by HCAHPS,” or “other” options not available in the survey (Healthcare Leaders Media, 2014). There was no option where the majority of the participants agreed on the definition of patient experience (Healthcare Leaders Media, 2014), showing that this term may carry different meanings to different people.
Wolf (2017) reviewed the literature to identify key elements central to the term “patient experience.” It was found that patient experience is more than patient satisfaction as it reflects occurrences and events that take place independently and collectively through the journey of care; it is strongly tied to patients’ expectations and whether they were positively realized; and closely related to the idea of individualized care, patient engagement, and family-centred care (Wolf, 2017).
A tertiary hospital in Singapore undertook an initiative where each patient in the general wards was equipped with a tablet where they can access their health information (e.g. trend of vital signs, trend of laboratory results, medication list, upcoming laboratory and radiology orders, dietary restrictions, schedule and more), patient education materials and communicate with their healthcare team (Fan et al., 2024).
Prior to this initiative, the patients did not have such health information readily on hand. They had to request such information from healthcare professionals during their regular rounding or monitoring of patients, which may lead to unnecessary anxiety from waiting, or to approach healthcare staff for the information, which may potentially interrupt the healthcare professionals.
This initiative aimed to promote patient engagement and to provide more information in our patients’ hands to keep them updated and well-informed throughout their hospitalization. As these aims match the key elements of “patient experience” presented in the review by Wolf (2017), the team evaluated the effectiveness of this initiative in improving patient experience over time. The study team hypothesized that patient experience would improve over time from pre-implementation of the initiative to post-implementation and with each addition of functionality.
Methods
Study Design
This was a prospective observational study using sequential cross-sectional samples collected across different phases of bedside tablet implementation. Although data were gathered prospectively over time, each stage consisted of different patient samples rather than repeated measures of the same cohort.
Study Site and Initiative
This study took place in the largest acute tertiary hospital in Singapore (Singapore General Hospital, 2021). The first trial of the patient’s bedside tablet took place in November 2018. In that trial, the tablet only contained the first version of the MyCare mobile Application (app), MyCare App v1.0. Further enhancements were made, and MyCare App v2.0, MyEdu App v1.0, and NurseHub App v1.0, together with some commercial Apps were rolled out hospital-wide over a year (November 2021–2022) in a step-wedge manner (Table 1; Fan et al., 2024). Functionalities of the patient bedside tablet over time are detailed in Table 1, and enhancement works continued even after the full rollout.
Progressive Functionalities of the Patient Bedside Tablet.
Indicates functionalities introduced in the current stage.
Data Collection
Data collection occurred from June 2019 to July 2024. A convenience sampling method was used, whereby study team members made regular rounds to recruit all eligible patients from the general wards. The sample size for each implementation stage was therefore determined by the number of patients available for recruitment between application updates. Patients were eligible for inclusion if they were 21 years of age or older and had been admitted to a general ward at the study site.
Instrument
The Picker Patient Experience Questionnaire (PPE-15) is a validated 15-item tool measuring hospital patient experience. Developed and tested among 62,925 participants across five countries (UK, Germany, Sweden, Switzerland, USA), it demonstrates high face validity, construct validity, and internal reliability consistency (Jenkinson et al., 2002). It has also been applied in large-scale studies in China, demonstrating its relevance in an Asian healthcare context like Singapore (Min et al., 2019).
Data Analysis
Patients hospitalized in wards that do not have bedside tablets at the time of data collection will be grouped in the pre-intervention group. Patients in wards where bedside tablets had been implemented were further categorized into three groups (Stages 1, 2, and 3), corresponding to the sequential increases in tablet functionalities (Table 1; Fan et al., 2024).
Four PPE-15 questions, relevant to bedside tablet functionalities and inpatient experience, were selected for analysis (Jenkinson et al., 2002):
“When you had important questions to ask a nurse, did you get answers that you could understand?” (Nurse communication clarity)
“Were you involved as much as you wanted to be in decisions about your care and treatment?” (Patient involvement in care decisions)
“ If you had anxieties or fears about your condition or treatment, did a nurse discuss them with you?” (Addressing patient concerns and communication)
“Did the doctors or nurses give your family or someone close to you all the information they needed to help care for you?” (Family information provision)
Positive scores were calculated following the guidelines provided in the Picker Institute’s data analysis toolkit, which recommends using these scores as a summary measure to monitor trends and facilitate organizational comparisons (Jenkinson et al., 2002). These scores represent the percentage of participants who selected the most favourable response for each question, as indicated by asterisks in the toolkit.
Descriptive statistics were used to analyze demographic distributions and trends in positive scores across intervention groups.
Non-parametric Kruskal–Wallis tests compared these scores across groups. To account for missing data, we adopted a question-specific exclusion approach. For each question, participants with missing responses were excluded from the analysis of that question, while their responses to other questions were retained. This method allowed for maximal use of available data.
Where the Kruskal–Wallis test indicated a significant difference, post-hoc pairwise Wilcoxon rank-sum (Mann–Whitney U) tests were carried out. A Bonferroni correction was applied to account for multiple comparisons, enabling examination of whether observed differences were driven by specific stage-to-stage contrasts. All statistical analyses were conducted using Stata Statistical Software: Release 19 (StataCorp, 2025).
Ethical Considerations
This study was classified as a service evaluation and was determined not to require ethical review from the institution’s centralized Institutional Review Board (Singhealth Centralised Institutional Review Board, 2025). The project did not impact patient care or treatment, and all data was collected and analyzed anonymously.
Results
A total of 1,482 patients participated in this study. The distribution across stages was as follows: pre-intervention (n = 386), stage 1 (n = 161), stage 2 (n = 808), and stage 3 (n = 127; Table 2).
Demographic Table.
Demographic characteristics were relatively consistent across all stages. Participants were predominantly aged 51 to 70 years, female, and of Chinese ethnicity (Table 2). The ethnic distribution followed a consistent pattern across groups: Chinese predominated, followed by Malay, Indian, and others, with Eurasian being the least represented (Table 2).
Nurse communication clarity and patient involvement in care decisions both showed overall improvement (Figure 1 and Table 3). Nurse communication clarity increased from 72.1% pre-intervention to 78.7% in Stage 3, consistently scoring highest among the questions (Figure 1 and Table 3). Similarly, patient involvement rose from 66.6% pre-intervention to 69.3% in Stage 3 (Figure 1 and Table 3).
Trends in patient experience positive scores across tablet implementation stages.
Positive Scores for Selected PPE-15 Questions Across Implementation Stages.
Note. PPE-15 = Picker Patient Experience Questionnaire
Positive scores calculated as percentages of valid responses, excluding missing data.
Despite their overall improvements, patient involvement in care decisions and addressing patient concerns both declined in Stage 1 before recovering in subsequent stages (Figure 1 and Table 3). Patient involvement dropped to 53.1% in Stage 1 before rising in later stages, while addressing patient concerns decreased from 41.9% pre-intervention to 31.8% in Stage 1, before partially recovering to 38.6% in Stage 3 (Figure 1 and Table 3). Addressing patient concerns consistently scored the lowest across all stages (Figure 1 and Table 3).
Family information provision showed a steady decline across all stages, decreasing from 61.9% pre-intervention to 42.5% in Stage 3 (Figure 1 and Table 3).
Kruskal–Wallis tests revealed no significant differences across stages for nurse communication clarity (χ²(3) = 6.61, p = .085) or addressing patient concerns (χ²(3) = 1.31, p = .726). Significant differences were observed for patient involvement in care decisions (χ²(3) = 12.14, p = .007) and family information provision (χ²(3) = 15.75, p = .001; Table 4). However, post-hoc Wilcoxon rank-sum tests with Bonferroni correction revealed no significant pairwise differences between individual stages (all adjusted p = 1.000). This suggests that observed differences may reflect distributed changes across stages rather than clear pairwise contrasts (Table 5).
Kruskal–Wallis Test Results for Patient Experience Domains Across Implementation Stages.
Post-Hoc Pairwise Wilcoxon Rank-Sum Tests with Bonferroni Correction.
Discussion
This study evaluated the impact of implementing a bedside tablet on patient experience, focusing on domains central to patient-centred care: nurse communication clarity, patient involvement in care decisions, addressing patient concerns, and family information provision (Figure 1). The results demonstrate potential improvements in certain areas while highlighting significant challenges that require further investigation.
Nurse Communication and Patient Involvement
Overall, nurse communication and patient involvement scores increased, with nurse communication receiving consistently high positive ratings across all stages (Figure 1). This suggests that bedside tablets may have facilitated access to critical information, such as lab results, medication lists, and patient requests (Table 1), fostering engagement and bridging information gaps. The peak in patient involvement scores during Stage 3 (Figure 1) coincided with added functionalities such as self-charting intake and output, daily fluid intake reminders, and electronic medical records synchronization, which empowered patients to actively participate in their care (Table 1).
These findings align with studies by Greysen et al. (2014) and Zhao et al. (2019), which demonstrated increased patient engagement and satisfaction with tablet-based tools, even among older adults with limited technological proficiency. Similarly, Alruwaili et al. (2023) reported that older adults are increasingly adopting digital health technologies when perceived as easy to use and beneficial. This aligns with McAlearney et al. (2020) and Winstanley et al. (2017), whose study on MyChart Bedside revealed positive patient experiences and improved understanding of medications and nurse communication.
However, the initial decline in patient involvement and addressing patients’ concerns during Stage 1 may reflect adaptation challenges (Figure 1). Limited access to educational materials in Stage 1 may not have aligned with patients’ immediate concerns (Table 1). The subsequent recovery in later stages coincides with expanded resource availability, which allowed patients to independently seek relevant information (Table 1).
Addressing Patient Concerns
Paradoxically, despite the tablets’ information-rich features, addressing patient concerns consistently received the lowest positive scores. This may stem from factors such as technological familiarity, physical limitations, or struggles with processing increased information (Bertolazzi et al., 2024). Patients may have faced challenges determining which content was most relevant to them. In Stage 1, limited access to selected educational materials may have misaligned with patients’ specific concerns, but broader access in Stage 2 allowed them to find relevant information independently, contributing to a recovery in subsequent stages (Table 1). Addressing such usability barriers requires a deeper understanding of user interface design tailored to specific patient demographics, including older patients, to enhance accessibility and relevance (Fan et al., 2024).
The “send and receive non-urgent messages to/from the care team” function also requires further evaluation (Table 1). While patients could send messages, the responsiveness of the care team remains unclear. McAlearney et al. (2021) and Winstanley et al. (2017) observed significant limitations with this feature, noting that requests often went unanswered due to the absence of real-time alerts, which led nurses to discourage its use.
Family Information Provision
Family information provision demonstrated a steady decline across all stages. Limited functionalities tailored to family engagement and privacy considerations restricting shared access may have hindered family involvement (Hart et al., 2020). Additionally, low staff adoption rates likely compounded this issue, as staff were often responsible for introducing the tablets to patients and families (Fan et al., 2024). McAlearney et al. (2021) noted that integrating tablet tasks into an already busy workflow requires time, as does training patients on tablet technology. Similarly, Walker et al. (2019) noted that staff unfamiliarity with new technology led to rushed introductions of tablets, with some staff perceiving this task as a low priority amidst their busy workloads. Without adequate staff engagement, awareness, and usage of the tablets remained low (Fan et al., 2024).
Kelly et al. (2020) highlighted contrasting results in a paediatric context, where family members actively utilized tablet functions to seek information and clarify care details. This contrast underscores the role of patient demographics and family dynamics in influencing adoption rates. In the present study, cultural expectations may also have played a role, with patients and families potentially viewing healthcare as a service to be provided rather than a collaborative effort (Fan et al., 2024).
Although these trends are observable, the Kruskal-Wallis H test revealed no statistically significant differences across stages, indicating that contextual factors such as staff training and patient readiness likely play a critical role. Barriers such as the manual resetting of tablets post-discharge may have impeded seamless integration, further affecting adoption rates (Fan et al., 2024).
When interpreting quantitative findings, it is critical to account for underlying qualitative nuances. For instance, while the Picker Institute’s methodology only considered definite positive responses, this approach may overlook the complexity of patient and family experiences. In family information provision, increased “No” responses did not necessarily reflect dissatisfaction. Many participants indicated that their families did not require information or were partially satisfied, choosing options like “My family/friends didn’t want or need information” or “Yes, to some extent” (Table 3). This highlights the importance of situating quantitative results within a broader qualitative context to accurately capture the diversity of patient and family needs and experiences.
Conclusion
In conclusion, this study suggests that the implementation of bedside tablets has the potential to improve certain aspects of patient experience, particularly in nurse communication clarity and patient involvement in care decisions. While improvements were observed in later stages, challenges such as initial declines in patient involvement and addressing concerns, along with a steady decrease in family information provision, highlight the need for better system integration, staff training, and user interface design. Although no statistically significant differences were found, the findings emphasize the importance of considering contextual factors and the broader qualitative nuances behind patient and family experiences.
Limitations
Limitations of this study include the uneven distribution of participants across stages, with smaller samples in Stages 1 and 3, potentially affecting statistical power. While the demographic was reflective of the local population, the findings may not be generalizable to other contexts. Future research should aim for more balanced sample sizes and diverse populations. Additionally, the absence of qualitative data restricts a deeper understanding of patient and family experiences. Future studies should incorporate qualitative methods to capture nuanced perspectives and explore strategies to enhance patient and family engagement.
Footnotes
Author Contributions
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.