We used a qualitative approach to explore patients’ and nurses’ experiences with the digital EYEpad checklist. The definition of semistructured interviews by Green and Thorogood is “In a semistructured interview, the researcher sets the agenda in terms of the topics covered but the interviewee’s responses determine the kinds of information produced about those topics, and the relative importance of them” [24]. At appointments, we conducted semistructured interviews with patients and their companions, and a focus group with nurses.

Participants were recruited at the Rotterdam Eye Hospital, the only eye hospital in the Netherlands providing secondary and tertiary eye care. The hospital has a specialized ambulatory cataract pathway where about 6500 cataract surgeries are performed annually.

Patients often had questions about how to care for their treated eyes after discharge from the hospital. To prevent this, initially a paper card was designed to relay information to patients before their discharges. The card served as a memory aid for nurses to inform patients about these points, but was rarely used. Subsequently, a checklist for patients was designed. A multidisciplinary team, including cataract surgeons, nurses, pharmacists, and administrative representatives developed a 19-item patient-led checklist for cataract patients who underwent surgery in an ambulatory setting. The items were based on a review of nurses’ current, often inconsistent, and not formally acknowledged, check moments. An initial gross-list of more than 30 items was reduced to 19, all of which were agreed upon by the multidisciplinary team. The checklist was first tested on paper by patients and later modernized into an application for the tablet called EYEpad. This checklist was distributed to patients and their companions via the application EYEpad, on a tablet, during their hospital visits. It contained 3 lists with necessary information the patient should have received during three contact moments with medical professionals on the day of their surgery: before or during surgical preparation (8 items), before anesthesia (2 items), and before discharge (9 items; see Figure 1 for the screenshot of the subchecklist and Textbox 1 for all 19 items).

The EYEpad is handed to the patient on the day of the surgery. The patient is supposed to indicate whether the predefined information on the checklist was discussed with the nurse. Based on this checklist, the patient is expected to address the nurse regarding the missing items. The checklist is also used by the nurse, to confirm whether all information has been addressed in a consistent manner. While the nurse checks the list, he or she can provide missing information for the patient and perform a formal acknowledgment (“check”). Finally, the patient can add his or her own questions to ensure that these questions are addressed during the dismissal conversation. Patients could also use the tablet for other general, educational, or entertainment functions, such as news services and games.

The audiotaped data from the interviews was transcribed verbatim. Transcripts were deductively coded into one of the three main categories: utilization, appreciation, and perceived impact. Next, the fragments in each category were further divided into subcategories, using inductive analysis, meaning the categories were inferred from the data, rather than from the existing literature. Coding was conducted by 2 coders (JVDS, AS). Differences were discussed until a consensus was achieved [24].

From the 32 selected patients, 19 patients met the inclusion criteria. Seventeen patients accepted the invitation to participate in the study. Two patients refused to participate because they did not feel well enough to be interviewed after their surgeries. Eleven out of 17 (65%) patients were female. The average age was 69 years, ranging from 58 to 88. Almost all patients were accompanied by their partner (n=12) and others by their daughter (n=2), son (n=1), or another relative (n=1). One patient was not accompanied by a companion.

Six of the 18 registered nurses participated in the focus group. All nurses were female (n=6). The average age of the nurses was 46 years, ranging from 20 to 57. Most nurses (n=4) worked at the ASC for at least 5 years.

This study showed that the use of the EYEpad as a digital patient-led checklist in cataract surgery is feasible. Feasibility has been demonstrated in three ways. First, the EYEpad was well appreciated by patients. Patients were positive about the additional checks and felt more involved in their care processes. Second, we found the EYEpad, beside some practical difficulties, was easy for patients and nurses to use. Third, we found that the EYEpad helped patients feel empowered.

However, there remains room for improvement. The EYEpad, with its current instructions, can increase nursing workload. Furthermore, an improved introduction on the rationale and use of the digital checklist is needed because the purpose of the EYEpad was not always clear to the participants. Improved instructions are likely to further enhance patient experience, increasing patients’ abilities to understand and influence their own care. This was suboptimal in this study because some patients participated just because the EYEpad was handed to them and not because they were motivated to use it.

This study had several limitations. One limitation was that we held just one focus group with nurses. More focus groups could have yielded more information about the nurses’ viewpoints. Moreover, participation in the focus groups was voluntary and in the end, only 6 of the 18 nurses participated. The nurses who participated likely held viewpoints that differed from nurses who did not participate.

Another limitation was that the purpose of the EYEpad was not clear to all patients and nurses at the start of the study. Only 4 patients indicated they understood the purpose of the EYEpad. This may be due to the limited explanation the nurses gave about the checklist. Apparently, a more elaborate explanation is needed to better understand the purpose of the EYEpad, both for patients and nurses. Previous work has suggested the success of checklist implementation largely depends on a clear explanation of the “why” and “how” [22]. A better understanding of the “why” in this study could further improve the feasibility.

Further, although we inquired as to patients’ general experiences with the EYEpad; we did not explicitly address electronic health (eHealth) or health literacy during this study. Therefore we cannot be sure that needs related to EYEpad use were specifically addressed.

In our study, the checklist was patient-led instead of team-led. We found this helped to empower the patients in their own care pathways. We suggested two possible explanations for why patients felt more empowered by using the EYEpad. First, patients may feel more engaged in their own care process. Using health technology makes patients feel more involved in their own care [25]. As indicated by Horwitz and Greysen et al, knowledge alone is not sufficient for proper self-care after surgery [26,27]. Hospitals need to facilitate a good transition, and recovery at home will improve, if patients and caregivers jointly explore patient-centered strategies.

Aujoulat et al described the success factors for patient empowerment. They found that the basics of patient empowerment were to provide reassurance and opportunities for self-exploration on how to manage illness [14]. Second, patients may experience a smaller gap between care professional and patient, which could help them discuss personal questions or issues that may interfere with their treatment.

Besides empowerment, we also found that the EYEpad increased patient participation. Checklists are supplementary tools that encourage critical thinking and conversation [22]. The EYEpad may help patients engage in their own care. It can ease barriers to preventing harm—for example, not speaking up in the case of suspected errors. A study has shown that communication problems are the root causes of wrong IOL implants in cataract surgery [28]. In New York State, wrong implant-related errors account for 63% of the total number of malpractice claims, and data from Veterans Health Administration showed that approximately half of surgical errors were attributed to the use of the wrong implant [29]. Increased patient empowerment and participation using the checklist can prevent IOL-related errors and thereby improve patient safety.

A surprising finding was that nurses experienced the checklist as “extra work” instead of as a supportive tool for their daily tasks. This may be because the goal of the checklist was not clearly explained. Furthermore, not all nurses were involved in the development of the checklist, which may have made them feel less engaged.

Before further development of the EYEpad, some hurdles should be addressed. These include providing clear instruction on the rationale for the professionals involved and an improved introduction and explanation of the purpose of the checklist for patients. Communication about the objective of the new digital technology, both with health care staff and patients, is a vital element for successful implementation. It is important to include nurses and other health care professionals from the early idea generation stage, into development and iteration, to generate support and interest. Communication about the objective of the EYEpad must be clear, both to nurses and to patients. Further, our study showed that the practical implication involved listening closely to the care pathway: Which moments are best for the digital EYEpad checklist to be distributed given the planning of the surgical treatment flow? In the current process the use of the EYEpad sometimes disrupted the existing flow, when it should have contributed to a smoother and high-quality care process.

After these hurdles have been considered, the EYEpad can be further developed and implemented. We found that the EYEpad could encourage learning, for example by conscious information acquisition by patients. We did not give specific attention to eHealth and health literacy of participants. More attention to eHealth and health literacy may improve the level of learning.

Further, the checklist should relate to the various steps of the current care process. The better the checklist is implemented, the more structural value it will add toward patient participation in enhancing safe care. It would be useful to make a connection between the checklist and the patients’ records to give the professionals insight into the data in a more accessible way. In addition, future studies should make a connection between the checklist and other patient tools to give patients a more complete overview of their care process.

In conclusion, we showed that a digital patient-led checklist during surgery was a feasible instrument in cataract care. Our findings suggest that a digital checklist could increase health literacy and provide enhanced guidance on the day of surgery. Our results also demonstrated the crucial role nurses play in the logistics of technological innovations. Increased patient participation will only improve safety as both health professionals and patients feel empowered to share responsibility and balance power.