Table 3.

Characteristics of the included studies that explored clinical decision-making.

Reference	Theme (subtheme)	Study setting	Type of intervention	Outcome measure	Study type	Participant, n	Results
Bakken et al [28], 2014	Quality of clinical decision-making (assessment or care decisions)	Various health settings	Decision support (aide-mémoire for structured clinical judgment): handheld decision support tool for the assessment and management of obesity, tobacco use, and depression using screening prompts, standardized screens, selection of patient goals, clinical practice guidelines, and recording treatment plans	Number of encounters with a clinical practice guideline–related diagnosis Number of care plan items in encounters with a clinical practice guideline–related diagnosis.	Randomized controlled trial	363 registered nurses undergoing nurse practitioner education	Significant effect of the intervention on diagnostic rates
Cato et al [41], 2014	Usability, uptake, and acceptance (predictors of HCDa use)	Acute and ambulatory care settings in the New York City metropolitan area	Decision support (aide-mémoire to initiate screening and select treatment): tobacco cessation screening and treatment prompt housed on mobile device or devices	Number of encounters resulting in nurse screening for tobacco use, provision of smoking cessation advice, and patient referrals for smoking cessation treatments	Observational study of the intervention arm of a randomized controlled trial	14,115 patient encounters involving 185 registered nurses	Screening was more likely in patient encounters involving women (ORb 1.14, 95% CI 1.03-1.25) or African American patients (OR 1.18, 95% CI 1.01-1.38) Screening was higher in patients cared for by specialty nurses (OR 4.43, 95% CI 3.20-6.13) or in sites where the predominant payer was Medicare, Medicaid, or SCHIPc (OR 1.88, 95% CI 1.57-2.24). In these sites, nurses were more likely to provide tobacco cessation teaching and counseling (OR 1.74, 95% CI 1.03-2.94) and less likely to provide treatment referrals for tobacco cessation (OR 0.439, 95% CI 0.252-0.764). Patient encounters by nurses in FNPd (OR 0.381, 95% CI 0.209-0.693) or PNPe (OR 0.314, 95% CI 0.109-0.906) specialties were less likely to provide treatment referrals
Cleaver et al [31], 2021	Quality of clinical decision-making (assessment or care decisions)	2 metropolitan hospital EDsf, London, United Kingdom	Decision support (aide-mémoire for structured clinical judgment): tablet-based decision support app to assist ED nurses to select investigations and treatments at initial patient assessment	Speed and accuracy of clinical decisions (including patient acuity score rating) compared with control. Nurse assessment and subsequent expert panel evaluation.	Retrieval and analysis of the stored device data on the type and time of requests made by nurses compared with control nurse decisions and independent postevent review by expert panel	Number of nurse participants was not specified; 529 patient assessments performed via app	Demonstrated time improvements in the identification and actioning of appropriate patient investigations, treatments, and procedures Need to improve some user design features identified
Doran et al [39], 2010	Usability, uptake, and acceptance (patterns of use)	29 acute, long-term, home care, and correctional organizations, Ontario, Canada	No specific intervention—survey of staff perceptions of technology use: mobile devices, including PDAs and tablet computers	Perceived impact of the mobile technologies on the barriers to research use, quality of care, and job satisfaction	Prestudy and poststudy questionnaires	488 frontline nurses	Over 44.5% of the nurses used mobile device at least once every few days
Farrell [6], 2016	Enhancing efficiency, safety, and quality of care (clinical or interdisciplinary communication) Usability, uptake, acceptance (assess usability or identify heuristics or human factors or ergonomic considerations)	Acute gynecological ward, Melbourne, Australia	Electronic clinical reference guide: iPhone with clinical resource and medication information apps—use by nurses in the acute care setting	To explore nurses’ perspectives on iPhone use within an acute care unit	Not available	20 registered nurses	iPhones were accessible and portable and enhanced workplace communication Negative findings: small screen size inhibited use, especially for patient teaching, and device use was perceived to be unprofessional in direct patient care setting
Godwin et al [32], 2015	Quality of clinical decision-making (assessment or care decisions)	Laboratory study	Computerized measurement tool: a software app for Apple devices that facilitates the calculation of total BSAg of patients with burns. App also includes a fluid replacement formula ready reckoner and serial wound photography platform.	Accuracy of app versus traditional “longhand” calculation tools	Repeat measure observation, with 1 week washout between method testing by participants	11 health clinicians, including ED nurses	App allowed faster calculation of BSA and fluid requirements and wound type evaluation compared with traditional methods, with no loss of accuracy
Hsiao and Chen [43], 2012	Usability, uptake, and acceptance (quality of data entered or retrieved)	Regional Hospital, Taiwan	No specific intervention—survey of staff perceptions of technology use: “m-NIS” available on PDA, notebook, or “panel” computer	Factors affecting fit between mobile nursing system and nursing tasks, task-technology fit, and nursing performance	Prestudy and poststudy questionnaires	310 clinical nurses recruited, with 210 questionnaires returned	Positive effect on information acquisition, integration, and interpretation in nursing
Johansson et al [34], 2012	Enhancing the efficiency, safety, and quality of care (impact on activity flow and perceived safety) Usability, uptake, and acceptance (quality of data entered or retrieved)	Orthopedic ward, palliative care unit, and rural district hospital in Norway	Electronic clinical reference guide: use of mobile phones in clinical nursing practice for 15 weeks	To explore the mobile device’s usefulness in terms of information retrieval, ability to save time, patient safety, quality of care, and work confidence	Descriptive prestudy and poststudy written surveys	Registered nurses (n=14) and nursing students (n=7)	Mobile device perceived as useful and time saving. It also contributed to improved patient safety and quality of care by improving access to information
Johansson et al [44], 2014	Enhancing the efficiency, safety, and quality of care (impact on activity flow) Usability, uptake, acceptance (quality of data entered or retrieved)	Multiple health care agencies, Sweden	No specific intervention—survey of staff perceptions of technology use: the use of mobile devices	Views regarding the use of advanced mobile devices in nursing practice	Cross-sectional survey	62 graduate nurses working in acute care settings (of a larger sample of 107 nurses)	Participants regarded an advanced mobile device to be useful for accessing resources, making notes, planning their work, and saving time
Kartika et al [52], 2021	Quality of clinical decision-making (assessment or care decisions)	Infectious pediatric ward of a major referral hospital, Indonesia	Computerized risk assessment tool: mobile computing application to assess the risk of clinical deterioration, mPEWSh-InPro	AUCi or ROCj Sensitivity and specificity of cut points	Test of diagnostic accuracy	108 pediatric patients	Analyses indicated that the mPEWS-InPro had a strong predictive ability: AUC=0.942 (95% CI 0.865-1.000; P=.001) Using a cut point of 4, the mPEWS-InPro had a sensitivity of 92.3% and a specificity of 80%
Kerns et al [42], 2021	Quality of clinical decision-making (assessment or care decisions)	Emergency and inpatient departments in 75 freestanding Children’s or community Hospitals in the United States	Decision support (algorithmic clinical pathways): mobile “mECDS tool” that provided evidence-based clinical support for the management of pediatric asthma	Determine the impact of the tool on pediatric asthma care quality	Observational study (digital review of screen use by practitioners)	Tool used on 286 devices and 355 times for 4.191 digital events (approximately 50:50 access events in ED versus inpatient settings)	Significantly reduced odds of hospital admission through the use of the mECDSk tool Higher rates of referrals to smoking cessation programs in caregivers through the use of the tool Shortened hospital length of stay
Lin [45], 2014	Enhancing the efficiency, safety, and quality of care (clinical or interdisciplinary communication)	Major regional medical center, Taiwan	Electronic clinical reference guides: a mobile nursing “Cart,” PDA, and tablet device providing access to an m-NISl program (details of this program were not provided)	Factors affecting the fit between nursing tasks and mobile nursing information systems and nurse performance from the perspective of task-technology fit	Postimplementation questionnaire	219 surveys returned	m-NIS improved message exchange between health care professionals and communication with patients, increased the efficiency of patient care duties, improved the quality of care, increased the professional image of nursing, and im- proved the overall performance in nursing practices
McCulloh et al [46], 2018	Usability, uptake, and acceptance (patterns of use)	Inpatient pediatric settings, United States	Decision support (algorithm for structured clinical judgment): smartphone-based evidence-based “PaedsGuide” electronic decision support tool	Tool development, distribution, and use patterns	Descriptive analysis (data analytics and web-based user feedback survey)	3805 multidisciplinary health care practitioner users (number of nurses was not specified)	Of the total user screen time, 61% was spent viewing clinical practice benchmarks, including hospital admission appropriateness, length of hospitalization, and diagnostic testing recommendations Positive feedback on tool’s usability
Momtahan et al [53], 2007	Usability, uptake, and acceptance (assess usability or identify heuristics or human factors or ergonomic considerations)	Canadian acute heart center	Decision support (algorithmic clinical pathways): PDA cardiac patient symptom decision support tool	Viability and value of the digital handheld decision support tool compared with standard paper-based survey approach (retrospective cardiologist opinion on nurse evaluation)	“Cognitive work analysis” and semistructured interviews following 3-month trial	9 cardiac nurse coordinators	Data collection was more complete and clearer with PDA assessment Nurses found the PDA tool more helpful than the paper-based tool Cardiologists concurred with nurse assessment outcomes in 97% of cases
Moore and Jayewardene [48], 2014	Usability, uptake, and acceptance (patterns of use)	161 acute NHSm trusts	No specific intervention—survey of staff perceptions of technology use	Questionnaire measuring the patterns of app use, factors affecting app use, and perceived effects on patient care	Cross-sectional survey	82 nurses and 334 doctors	Participant responses indicated a large number of users of textbooks, formularies, clinical decision tools, and calculators.
O’Donnell et al [51], 2019	Quality of clinical decision-making (assessment or care decisions) Usability, uptake, and acceptance (assess usability or identify heuristics or human factors or ergonomic considerations)	Hospital emergency department, Dublin, Ireland	Decision support (algorithmic clinical pathways): Android tablet tool (AcSAPn) determining the probability of patients with suspected coronary syndrome, prompting ECGo performance on patients within 10 minutes	Efficacy of the app in identifying patients requiring an ECG Time until performance of ECG	Patient history audit of time of presentation, triage action, and first ECG and diagnosis and postuse questionnaire on app usability	AcSAP app was activated 379 times by triage nurses (exact number of nurses unstated). 18 triage nurses returned the postuse questionnaire	App successfully identified patients who required an ECG within 10 minutes of presentation App assessed as easy to use by the participants
Reynolds et al [54], 2019	Enhancing the efficiency, safety, and quality of care (perceived safety) Usability, uptake, and acceptance (assess usability or identify heuristics or human factors or ergonomic considerations)	Neonatal and pediatric intensive care units across 2 hospitals in California, United States	Medication dosing support: nurse use of stand-alone customized handheld drug and IVp infusion calculation aid	User acceptance and effect of the device	Mixed methods: ethnographic observation, prestudy and poststudy interviews, and surveys	64 nurses	Device was perceived to be worthwhile; risk perceptions and device usability limited device use No significant difference in cognitive load or administration errors
Ricks et al [50], 2015	Enhancing the efficiency, safety, and quality of care (nurses’ perceptions of care quality)	Public hospital in Port Elizabeth, South Africa	Electronic clinical reference guide and medical calculator: nurses’ use of a smart phone device at the point of care to access electronic resources, namely a disease directory, drug list treatment guidelines, and a medical calculator	To explore the experiences of registered nurses in using the device	Qualitative descriptive study	A total of 50 nurses; purposive sampling of 10 nurses for in-depth interview	The device improved computer literacy, was useful for patient and in-service education, improved the accuracy of diagnosis, increased practice delivery and, improved the quality of care
Ruland [35], 2002	Quality of clinical decision-making (assessment or care decisions)	Acute medical care unit in Oslo, Norway	Decision support (aide-mémoire for structured clinical judgment): “Palm-pilot” handheld computerized support system (“CHOICE”) that assists nurses to determine patient preferences to incorporate into the care plan	Effects of the system on nurses’ care priorities and preferences and patient satisfaction	3 group sequential survey design	28 nurses	Use of the system resulted in improved consistency between patients’ and nurses’ care preferences
Sedgwick et al [37], 2017	Quality of clinical decision-making (capacity for clinical decision-making)	Rural hospital, Lethbridge, Canada	Electronic clinical reference guide: Tepidq app (containing multiple nurse resources) on personal mobile device	Impact of mobile technologies on graduate nurses’ perceived decision-making abilities and self-efficacy	Quasi-experimental pretest and posttest design	A total of 25 graduate student nurses (on clinical placement) were recruited and 12 completed the full questionnaire	Use of app did not enhance self-perceived efficacy or decision-making ability
Sedgwick et al [38], 2019	Quality of clinical decision-making (capacity for clinical decision-making) Enhancing the efficiency, safety, and quality of care (impact on activity flow)	Rural hospital, Lethbridge, Canada	Electronic clinical reference guide: personal smartphone app “PEPID professional Nursing Suite App” (providing access to multiple clinical nursing resources)	Effect on nurses’ walking distance and clinical decision-making ability	Prestudy and poststudy surveys	20 clinical nurses	No significant reduction in nurses’ clinical walking distance No self-perceived effect on nurses’ decision-making ability Increased confidence in using app over time
Sefton et al [33], 2017	Quality of clinical decision-making (assessment or care decisions) Usability, uptake, and acceptance (quality of data entered or retrieved)	Pediatric hospital, United Kingdom	Computerized measurement tool with pathway decision support: handheld digital “Paediatric Warning System” tool to identify the development of serious illnesses (iPod Touch 4th generation [Apple Inc])	Accuracy of vital sign readings and time taken to document compared with paper-based method	Prospective mixed methods	A total of 23 RNsq, student nurses, health service attendants, and medical students	Improved documentation speed, accuracy, and clarity with the use of the digital device
Shen et al [47], 2018	Usability, uptake acceptance (quality of data entered or retrieved)	Various (nonspecified) clinical departments of a major tertiary hospital in Beijing, China	No specific intervention—survey of staff perceptions of technology use: PDA providing access to mobile nursing information system	Clinical nurses’ satisfaction with the use of PDA	Cross-sectional descriptive survey	383 nurses	Nurses were more satisfied with the delivery of medical orders and documentation facility of the device Utility was dependent on the stability of network, and higher satisfaction positively correlated with nurse education level
Siebert et al [29], 2017	Enhancing the efficiency, safety, and quality of care (impact on activity flow)	Pediatric emergency department, Switzerland	Medication dosing support: tablet-based app to support decision-making for the continuous infusion of medications	Drug preparation time, time of drug delivery, and number of medication errors	Randomized controlled crossover trial	20 nurses	Intervention significantly reduced drug preparation time, time to drug delivery, medication errors.
Siebert et al [30], 2019	Enhancing the efficiency, safety, and quality of care (impact on activity flow)	3 regional pediatric emergency departments in Switzerland	Medication dosing support: tablet-based app to support decision-making for continuous infusion of medications	Drug preparation time, time to drug delivery, number of medication errors	Randomized controlled crossover trial	128 nurses	Intervention significantly reduced drug preparation time, time to drug delivery, and medication errors
Singh et al [36], 2017	Quality of clinical decision-making (assessment or care decisions)	Emergency department, Connecticut, United States	Decision support (algorithmic clinical pathways): use of a bedside tablet computer app to assess patients and guide decisions on the performance of a CTr scan in patients with concussion	Effects of the tool on patient experience, clinician experience, health care use, and patient safety	Pilot study with prestudy and poststudy surveys of patient and clinician experiences	A total of 2 advanced practice nurses, 16 physicians, 11 physician assistants (41 patients enrolled)	The trust of the patients in their physicians increased when they were satisfied with the use of the tool and the clarity of information it provided; most clinicians perceived the app to be helpful for patients and to be usable No clinically important brain injury was missed through the use of the device
Spat et al [40], 2017	Quality of clinical decision-making (assessment or care decisions)	General hospital ward, Graz, Austria	Medication dosing support: customized Samsung Galaxy tablet (Samsung Group) computer designed to assist nurses and medical officers in determining the appropriate insulin dose for patients with type 2 diabetes	Safety, efficacy, and user acceptance of device or system	Feasibility study using field notes on use and prestudy and poststudy written questionnaires	At time point one, 14 nurses and 12 physicians had participated; at time point 2, 12 nurses and 3 physicians had participated and at time point 3, 12 nurses and 6 physicians had participated	High use of device, high confidence in the use of tool over time, and high level of device decisions agreement by health care providers (97%) Perceptions that treatment errors reduced through the use of the device
Yuan et al [49], 2013	Usability, uptake, and acceptance (assess usability or identify heuristics or human factors or ergonomic considerations)	Hospital setting, Texas, United States	Decision support (algorithmic clinical pathways): bedside clinical decision support system housed on tablet devices	Number of heuristic violations Number of successful case simulations Duration of the simulated task NASAs Task Load Index	Heuristic evaluation	A panel of evaluators comprising 3 licensed vocational nurses and 7 registered nurses	Simulation sessions resulted in the following: 83 heuristic violations 100% of successful completions (n=30 sessions) An average of 111 (SD 30) seconds to complete the simulated task NASA Task Load Index results indicated low cognitive and physical burden

^aHCD: handheld computer device.

^bOR: odds ratio.

^cSCHIP: State Children’s Health Insurance Program.

^dFNP: family nurse practitioner.

^ePNP: pediatric nurse practitioner.

^fED: emergency department.

^gBSA: body surface area.

^hmPEWS: Modified Pediatric Early Warning System.

ⁱAUC: area under the receiver operating characteristic curve.

^jROC: receiver operating characteristic.

^kmECDS: mobile electronic clinical decision support tool.

^lm-NIS: mobile nursing information system.

^mNHS: National Health Service.

ⁿAcSAP: acute coronary syndrome application.

^oECG: electrocardiogram.

^pIV: intravenous.

^qRN: registered nurse.

^rCT: computed tomography.

^sNASA: National Aeronautics and Space Administration.