“Unnecessary noise is the most cruel abuse of care which can be inflicted on either the sick or the well.”
Florence Nightingale, Notes on Nursing (1860)
In an effort to improve the quality and efficiency of our nursing care delivery and our communication, we recently introduced a wearable hands-free voice communications system. We did this first as a trial on just a few patient care units and now it is being used on all in-patient units throughout the hospital. Our new communications system has proven to be very useful. As with most technological innovations, however, we encountered a number of “glitches” and decided to take a closer look at our organization’s healthcare providers’ perceptions and satisfaction with this new technology. To do this, we designed and carried out a research study that yielded some interesting findings that revealed both pros and cons of our new communications system.
The purpose of this prospective observational and survey research study was to measure the perceptions and satisfaction of healthcare providers regarding voice communications technology.
Inpatient healthcare delivery involves frequent communication as well as inter- and interdisciplinary communication. This “transactional” communication process involves a communicator “A” encoding a message into language and conveying it through some medium, which for the purposes of our study was the voice communications technology, and a communicator “B” receiving and interpreting the message sent through the medium.
The “Message in the Medium,” which in this study is a voice communications badge, is a central component of the communication process. Recent improvements in voice-recognition, wireless technology, connectivity, and identity management now make intelligent communications in healthcare using voice communications technology a practical reality. In fact, researchers have identified electronic communication technology as having an important role in the efficient operations of healthcare organizations.
Recognizing the power of applying this technology in our 642-bed acute care hospital, leadership selected a voice communications system for trial implementation. Our medical center is a Level I Regional Trauma Center that has been designated and redesignated as a Magnet hospital by the American Nurses Credentialing Center. The voice communications system now being used on all in-patient units throughout the hospital is a wearable, hands-free communication system that uses the existing wireless network to support instant mobile voice communications and messaging among healthcare staff.
The voice communications system consists of two main components: the server software and the badge, which is a small, wearable device that weighs less than two ounces and permits one-button voice access to other users on the system or connects to outside telephones through Private Branch eXchange (PBX) integration. PBX is a telephone exchange that serves a particular business, as opposed to one that a telephone company operates for businesses or for the general public. Badge features include voice controls, which provide hands-free ability to answer incoming calls; the ability to designate the individual to be called by name, title, function, or group, thus eliminating the need to know telephone numbers or who is on duty; conference calling, broadcast messages, and voice mail messaging, thus facilitating group announcements; and the ability to call to and from the badge through the PBX to other telephones inside or outside the hospital.
Though the potential benefits and the impact of voice communications technology have been studied previously, early research has focused primarily on workflow, communications, and caregiver satisfaction. Comparing our voice communications technology and other voice communications units, data gathered by Breslin and others at St. Agnes Healthcare in Baltimore, MD, revealed:
- improved quality and effectiveness of communications among staff
- time savings for nurses and unit secretaries to be more than 3,400 hours annually, or the equivalent of 1.7 full time equivalents
- our voice communications technology devices were more than five times faster than other communication methods
- a decrease in overhead paging of more than 94%
- Eighty percent of nurses believed voice communications technology improved workflow and their ability to deliver quality patient care.
Kuruzovich and others reported strong, statistically significant evidence that the use of voice communications technology reduces the overall time for completing patient requests and reductions of up to 51% in care healthcare provider response time. No published studies were found that focused expressly on the satisfaction of physicians, nurses, other healthcare providers, patients, and their families with voice communication technology.
Institutional Review Board (IRB) approval was obtained from all of the investigators’ institutions prior to the collection of any study data. Table 1 depicts sample characteristics of staff recruited from the initial three nursing units selected to pilot the use of the voice communications devices. In addition, 38 (89%) of the participants were women; 5 (11%) were men. Their ages ranged as follows: 20-29 (20%), 30-39 (12%), 40-49 (9%;), 50-59 (5%), and 60 plus (7%). Experience using voice communications technology varied from less than a month to 7 months with an average of 5 months.
Prospective subjects were those healthcare providers practicing in the first three units of our hospital that went “live” with voice communications technology. A letter with a brief description of the voluntary study participation was distributed to their interoffice mailboxes. They were asked to respond to the survey independently and informed in writing that their responses would be confidential. Subjects agreeing to participate in our study were instructed to return completed surveys in sealed envelopes to the hospital’s office of research. Completion of the survey was deemed to be implied consent to voluntarily participate in our study of healthcare providers’ perceptions and satisfaction with voice communications technology.
All subjects were asked to complete a simple, 14-item paper and pencil survey. Items were generated from informal interviews with staff members and a review of the literature. Participants were asked to respond to items using a Likert scale across a continuum of agreement/disagreement with 1 being strongly agree, 2 moderately agree, 3 somewhat agree, 4 undecided, 5 somewhat disagree, 6 moderately disagree, and 7 strongly disagree. To determine the survey’s completeness and readability, the instrument was reviewed and approved by all members of our hospital’s Nursing Research Council. Additionally, the investigators made personal, unstructured observations of hospital staff members’ use of the voice communications technology on a random basis. Approximately 30 direct observations were made of the actual use of voice communications technology in the clinical setting.
Table 2 summarizes the findings of this investigation. Choices indicating agreement (strongly, moderately, and somewhat) were collapsed into one category as were those choices indicating disagreement (somewhat, moderately, and strongly).
Of those surveyed, 75% (N =33) reported they were comfortable using voice communications technology, and 43% (N =19) said they were satisfied with their experience in the overall use of voice communications technology. Fifty-nine percent (N =26) said they liked using the technology. Less than 16% (N =7) of our participants reported that it took a long time to learn to use the voice communications technology, and 52% (N =23) thought that using the technology had significantly reduced the noise level in their patient care environment by decreasing the number of overhead pages.
About 64% (N =28) reported that voice communications technology saved them significant time in responding to patient requests/needs and therefore reduced patients’ waiting time. Some 50% (N =22) reported that the quality of their communication with patients had improved with the use of voice communications technology, attributing this to the immediacy with which they were able to respond to patients’ requests combined with fewer interruptions in direct care activities, and 71% (N =31) said that using this technology allowed them to communicate faster with their coworkers. Fifty-nine percent (N =26) thought voice communications technology increased patient safety. More than 57% (N =25) thought this technology had increased the overall quality of care they were providing to patients. Again, this perceived improvement was attributed to more efficient and timely care delivery with fewer interruptions. Because nurses can be contacted whether on the unit or elsewhere in the hospital, these nurses reported that they felt they were more “available” to patients and families in that they could be made aware of their presence and requests at any time.
Thirty-six percent (N =16) of those surveyed disagreed that noise levels had decreased on their units. The same number said that they either didn’t know or didn’t think the voice communications technology had reduced their length of time in responding to patients’ requests. Only 41% (N =18) of those surveyed said that voice communications technology provided a direct line of communication between them and their patients, and 34% (N =15) indicated that use of this technology sometimes violates the privacy of their communication with patients. Thirty-four percent (N =15) of our sample thought voice communications equipment was physically cumbersome to use and got in the way when providing patient care.
We made a series of 5, 15-minute, unstructured observations of voice communications technology usage on the test units over a 2-day period. Advanced practice nurses, nurses, nursing assistants, unit secretaries, and nurse managers used the technology. In most instances, it was used to communicate with staff from the nurses’ station. Most of these exchanges resulted in a quick response (< 20 minutes) to a patient/staff member’s need. We only observed one instance in which the technology was used to communicate a personal message.
In all of our observations, the voice communications badge was worn a third of the time. Staff reported that they were either carrying the badges in their pockets, owing to a broken or missing clip, or that a working badge was not available to them. On one unit, we observed that 8 of the 27 badges were broken and had been for more than a week. On all three patient care units, staff complained about the poor quality of voice recognition. We heard comments: “When it works, it’s great … the system does not work properly”; and “This way of communicating is a waste of time … the system was a waste of money.” One nurse said, “It doesn’t understand my accent.” Overall, in contrast to the survey responses we received at the end of the trial period, there seemed to be a high degree of frustration among those using or attempting to use voice communications technology — particularly regarding high rates of breakage and poor voice recognition.
Comfort with the use of technology is a personal experience, but it can be facilitated through adequate orientation and follow-up. Although comfort was not explicated, the ease of use of voice communications technology was implicated: its ability to designate the party to be called by name and the hands-free feature to answer in-coming calls.
Satisfaction focuses on the operational aspects of technology. If the device works, nurses are often satisfied. When the device malfunctions, nurses are dissatisfied.
How well a nurse likes voice communications technology is personal. Some nurses enjoy using technology in both their personal and professional lives. For those who find technology challenging, administration needs to provide avenues to ease the transition to increased technology in the healthcare arena.
A multitude of factors contribute to noise on any given nursing unit. People, equipment, and the processes of patient care, such as transporting patients, all play a role in the noise level on a unit. It is not simply the voices of a variety of people on a unit, but the number of people, their tone of voice, and the distance between them when they are engaged in verbal dialogue.
Technology can save staff time, in terms of patient care and communication associated with it. Time is inherent in patient satisfaction and perceptions of quality of care. Voice communications technology has the potential to positively impact patient satisfaction. How communication is facilitated is just as important as who is involved, when it is provided, where it takes place, and why is it needed. Voice communications technology only focuses on the how, and it still up to staff to be cognizant of the other key components of communication.
Implications for practice
The most important positive implications for practice are voice communications technology’s contribution to saving communication time and increasing the safety we provide for our patients. Our study provides evidence that voice communications technology may reduce noise levels in the acute care setting and the overall time for completing patient requests, and it may increase the speed and quality of communication between patients and healthcare providers with the possible end result being increased satisfaction for both the healthcare consumer and provider. One negative implication of our findings is the potential impact on privacy of healthcare providers’ communication with patients.
Based on our findings, we recommend that healthcare providers be included in the process of choosing the voice communications system that will be used in their practice environment, as this may increase initial comfort and buy-in with this technology. Also, we found that “staging-in” the implementation of a new voice communications system may have contributed to our success in both processes and outcomes. For example, advancing the use of voice communications technology in stages throughout our hospital allowed us to address such issues as dead zones where the devices did not function owing to gaps in wireless connectivity.
Regarding performance and durability of voice communications technology, our findings suggest that the physical use of voice communications technology is similar to the use of any other piece of equipment in healthcare practice. Just as healthcare practitioners are concerned with and takes responsibility for the working order (e.g., accuracy, sensitivity, etc.) of a stethoscope or sphygmomanometer, the practitioner should give similar consideration to ensuring that voice communications technology is in good working order. Thus, practitioners should be schooled in proper use and maintenance of the system components.
It appears that when voice communications technology is viable and in good working order, the system can improve communication on patient care units. The limitations of the device are the lack of reliability in both the logging-on and voice recognition aspects of the system. Voice recognition devices remain unreliable for the most part, and voice communications technology is no exception.
The capability of voice communications technology in such a high-volume environment as our hospital is questionable. Our experience with breakage and the substantial down time required for repairs are serious limitations for practical usage. Through just our few limited observations, we concluded that future research is needed to verify the actual durability and dependability of the device. Finally, caution should be used in generalizing our findings due to our small size and the fact that our data was obtained from a single institution. We recommend that healthcare provider satisfaction with voice communication technology be studied further, using larger samples obtained from multiple sites.
David Anthony (Tony) Forrester is professor, school of nursing, University of Medicine and Dentistry of New Jersey (UMDNJ), and professor in residence: interdisciplinary health research consultant, Morristown Memorial Hospital/Atlantic Health (MMH/AH). Susan Fowler was clinical nurse researcher, MMH/AH, and Harriet Gaidemak was volunteer nurse researcher, MMH/AH, at the time this article was written. Fatima Alves is manager, customer satisfaction, MMH/AH.
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