A few years ago, the United Nations approved 17 “Sustainable Development Goals” in which decreased mortality from non-communicable diseases was an example concerning the objective of enhancing health and wellbeing [1]. Nevertheless, health care systems are struggling to provide quality care for an increasing burden of patients with chronic diseases, while simultaneously facing a global shortage of nurses [2-4]. The emergence of new methods of communication providing multidirectional participation can offer new opportunities that could significantly change the landscape of medical care [2]. The implementation of information and communication technologies (ICTs) among healthcare professionals, defined as digital technologies that support the capture, processing, storage, and exchange of information, offers easy access to updated information, simplifies communication between colleagues and patients, and creates new opportunities for clinical education [5-9].

Despite the aforementioned benefits, many ICTs resources have been observed to be insufficient, particularly among developing countries [10]. There are other barriers commonly identified for the implementation of ICTs in the healthcare practice, such as concerns about privacy and patient confidentiality, and lack of time to train or use ICTs in the professional practice [7, 8, 11, 12]. These barriers could lead to the misuse of technology and potentially impact communication at the workplace. For instance, a recent study found that nurses often felt that physicians ignored their emails, feeling belittled and frustrated during working hours, while some nurses even considered ICTs as a distraction instead of a work tool [13, 14].

Nurses represent an important target for ICT implementation, not only because they constitute the largest health provider group of the healthcare workforce, but also due to the significant input they provide to patient safety, recovery and healthcare quality [15-17]. However, only a few studies have explored the ownership and use of these technologies among nurses in developing countries, presenting limited but highly interesting findings [18]. For instance, one study found that more than one-third of nurses are considered novices in their understanding of ICTs, with another study suggesting that many nurses and nursing support staff may not have the minimum computer competencies to effectively and efficiently perform their work [19, 20]. With this in mind, our study aims to achieve a better understanding of how Ecuadorian nurses perceive the theoretical advantages and limitations of ICTs, as well as to explore the current use and interest of these technologies in the setting of the professional nursing practice.

Although computer and information systems have been used in healthcare since the 1980s, mobile technologies in the nursing practice are relatively new but necessary for communication and educational purposes [25]. Currently, it is estimated that approximately 77% of adults in the U.S general population own a smartphone [26]. In our study, we found a higher proportion of smartphone ownership among nurses (97.9%); a finding that agrees with a recent study on the ownership and clinical use of smartphones by healthcare professionals in the U.K [18]. In the same study by Mohammed and colleagues, despite the proportion of smartphone ownership among physicians and nurses being roughly the same, physicians were more likely than their counterparts to use their phones for communication with colleagues [18].

In our study, 96.3% of the nurses used ICTs to communicate with their peers. On the other hand, there was less use of these technologies for communicating with patients (80.1%). A possible explanation to such observation could be the risks associated with their use such as: privacy violation, unmoderated content, unprofessional behavior and organizational risk [27]. Furthermore, of the demographic variables analyzed, working in a rural area was the only factor that was found to be responsible for increasing the likelihood of using ICTs to communicate with patients (OR 4.87). Given the fact that in remote areas, nurses are usually limited in resources and support, ICTs represent a viable channel to increase access and equity to health care information and services [28]. For instance, a pilot study found that the quality of life for older, rural adults and family members living at homes with advancing chronic illness, improved with early palliative support of a nurse navigator, not only through visits but also through cellphone consultations [29]. Telehealth technologies then, through the use of a wide array of ICTs, can provide a platform for remote patient monitoring, videoconferencing, and computer-mediated communications [30].

Despite the theoretical benefits that ICTs can offer, the development and integration of health information technology create significant changes in the nursing practices that have been associated with a low intention to use ICTs by nurses [31, 32]. In this regard, a recent integrative literature review found that i) offering adequate education and training, ii) having an adequate representation of nurses during the design phase of ICTs to be implemented, and iii) having sufficient technological support in the practice, are factors that could foster an organizational culture that supports the use of ICTs in a day-to-day practice [33]. In another study, Lavin and colleagues identified several common issues among nurses and electronic health records, that included issues with medication safety, documentation, standards of practice, and efficiency; while also identifying barriers with technology related to interoperability, vendors, innovation, nursing voice, education, and collaboration [34].

Discussing specific ICTs, we found the instant messaging application WhatsApp to be rated with the highest frequency of use among nurses (82.4%). In the setting of healthcare, a study by Ganasegeran and colleagues exploring the perceived benefits of WhatsApp in the clinical practice found that almost 70% of surveyed health professionals perceived this application as beneficial during clinical practice [35]. This ICT has the potential to enhance and improve the efficiency in communication between health professionals, relaying quick information that could, in turn, reduce medical errors [35]. Additionally, the potential for using WhatsApp is particularly relevant in resource-poor contexts, due to the widespread use and affordability, which in turn could be used for learning purposes in the nursing practice [36]. For instance, one study undertaken in Nigerian student nurses found that participants reported the WhatsApp enabled learning space as valuable, in particular, for the transfer of knowledge in day-to-day teaching practices, and for their professional development [37]. This interesting finding indicates a feasible opportunity for the use of this platform to provide supervision and learning in situations where there are limited face-to-face interactions [37].

Recent evidence suggests that nurses’ attitudes and behaviors are determinants for accessing internet-related health information [11]. For instance, Koivunen and colleagues found that nurses who had positive attitudes toward the internet presented with less stress and more job satisfaction than their counterparts [38]. In another study, most of the surveyed healthcare professionals perceived the clinical use of smartphones and medical apps as positive [18]. We found that the implementation of ICTs in the healthcare practice was perceived by most nurses from our study as useful for promoting professional services, searching for new job opportunities, participating in research projects, promoting health, and working with colleagues as a group. Although most nurses in our study acknowledge some of the benefits related to ICTs, around half of the participants preferred traditional channels of communication, while approximately one-third disliked interaction with colleagues through ICTs. Regarding the latter, one study notes that nurses perceived a negative impact on interprofessional relationships due to the decrease in verbal conversations among healthcare professionals related to the use of technology [13]. It is estimated that in the forthcoming years, web-based consultations will increasingly replace traditional face to face interactions in patient-provider communications [39]. ICTs might not entirely replace face-to-face interactions, but can be considered a compliment for improving patient care [7].

Many developing countries have embraced the use of e-Health and m-Health applications as a means to improve public health, and primary healthcare delivery [40]. However, its worldwide implementation has faced several challenges along the way. According to the WHO, the absence of legal guidelines on privacy and patient confidentiality is regarded as the most important significant barrier to m-Health implementation in regions such as Europe and America [41]. Furthermore, in a recent overview of systematic reviews assessing the impact of ICTs in nursing care, the most frequently reported themes were related to documentation time; assessment, care planning, and evaluation; nurses’ perspective of the quality of care provided; information quality and access; and time spent on patient care [42]. In our study, 78.6% of the participants perceived these privacy and security concerns as a major barrier, even though Ecuador has laws addressing patient’s confidentiality and management of medical records. Furthermore, in a study conducted by Tuckett and Turner, almost thirty percent of registered Australian nurses were not aware of existing policies and standard regarding the use of social media in their practice scope, which could potentially lead to breaches in professional regulations and producing harm to patients [8, 43, 44]. It might be possible that most nurses are not familiar enough with these laws, leading to uncertainty and reluctance to implement ICTs in the healthcare practice.

Developing countries are experiencing an unprecedented increase in the number of users for cellphones and internet-related technologies, as well as a decline in the prices for devices and services [45]. Despite this observation, we found a considerable proportion of participants reporting lack of mobile internet as well as unavailability of the internet at work as barriers (38.2% and 44.4% respectively); findings that were compared with a recent study among Greek nurses [46]. In a recent literature review on nurse’s use and access to internet for health-related information, busy schedules, not having enough time to search the web, difficulties in searching procedures due to skill deficiency, and lack of access were identified as the main barriers reported by nurses [11]. We found that roughly two-thirds of surveyed nurses reported lack of time to learn or use ICTs in their practice. Training and competency are socio-technical factors that influence health information technology adaptation [47]. As such, nurses may improve their competency and technological proficiency through practice, in particular, through a structured educational program [48]. These findings should be considered when designing strategies that require internet availability, as well as time to train and learn them, as a considerable proportion of nurses could miss the potential benefits these programs offer.

There are some limitations to our study. First, even though our survey was conducted based on previous publications and reviewed by an expert panel of professionals, the constructs based on upon it have not been assessed for reliability and validity, for what we leave under the discretion of the reader, the interpretation of the presented results. Secondly, to the best of our knowledge, there are no studies on this subject conducted on ordinary Ecuadorians, thus we are unable to draw conclusions or compare results with the general population. Third, the lack of standardization in data collection may have caused data bias. Finally, there was missing data that lead to heterogeneous sample sizes for the statistical analyses and might have produced type II errors or biased results. However, some strengths of our study are the significant sample size and the inclusion of participants with varying demographical characteristics. To the best of our knowledge, this is the first study to assess the use, and preferences for ICTs among Ecuadorian nurses.

Information and communication technologies have the potential to shape how healthcare is delivered around the world. Low-cost and wide availability allow for a faster transfer of health-related information, as well as scientific knowledge between healthcare professionals. In our study, we found extensive use of ICTs among Ecuadorian nurses for communicating with both colleagues and patients. Most participants had a positive perception of ICTs in healthcare practice, particularly younger nurses. Finally, the major barriers perceived were related to privacy and patient confidentiality, and lack of time to learn how to use, or use ICTs.