Dunphy, Heather BA; Finlay, Juli L. MA; Lemaire, Jane MD; MacNairn, Ian BHSc; Wallace, Jean E. PhD
Interdisciplinary teams with excellent communication are essential to healthcare delivery.1 Benefits of a multidisciplinary team include varying sources of expertise, skills, and perspectives to ensure the provision of quality patient care.1,2 As the coordinators of care, nurses are integral in linking the various healthcare providers together.3 The introduction of mobile communication devices (MCDs) has dramatically altered the patterns of communication. Typically, nurses walk room-to-room in search of assistance or contact the unit clerk to page someone for help.4 In contrast, MCDs offer nurses hands-free direct communication that immediately connects the nurse with other providers. Mobile communication devices have been suggested to improve the efficiency of essential communication and the effectiveness of patient care.5,6
In addition, the introduction of new technologies should include an assessment of the impact to nursing, workday stress, and complexity. Healthcare providers are less likely to use new technologies if they believe the systems are less effective, cumbersome, or difficult to use.7
Multiple studies have assessed the impact of wireless communications technology on nursing workflow and the effectiveness of communication. Savings in the process of delivering information (communication) including locating people and decreasing use of overhead paging have been cited as key job stressors in support of the use of MCDs. Mobile communication devices have also been noted to decrease disruptions in patient care and support prompt responses to emergency situations.8-11 Reported disadvantages include negative impact on nursing workflow, confidentiality and privacy concerns, and technical issues with the use of the voice recognition device.8-11
Description of the Study
A plan was developed to implement an MCD, Vocera, a wireless mobile voice device, on a 36-bed medical unit in a university hospital in Western Canada. The selected MCD allows instant voice communication among staff through a wireless network. The system consists of software and a communication badge. The software manages the flow of communication within the wireless network, and the badge acts as a conduit for communication. The voice-controlled badge is worn on a lanyard or clipped to one's clothing, allowing for hands-free, instantaneous 2-way communication without a pager or phone. By saying a name, function, or group name, nurses are immediately connected to each other. Also, the unit under study for this project has mostly private rooms so overhead pages cannot be easily heard by the nurse when the patient room door is closed. The wireless MCD offered a solution to this issue because nursing staff could receive pages to the badges in all areas and request assistance without exiting the room.
The wireless MCD was introduced to the unit over time. A year before the system was introduced to staff, a working group was formed that represented various healthcare providers, administrators, management, information technology staff (IT), and researchers. This group created numerous communication strategies to promote the device before it arrived, organized training schedules, and served as a problem-solving resource team after the device was introduced. Members of the group received additional training about the system and were "super users" available to help staff experiencing difficulties with the device. Nurses could submit problems that they encountered in writing, and a representative from IT would respond. Training for staff was provided for several weeks before the device was brought online. The day that the device was launched, everyone on the unit immediately began using it as part of their regular work routine.
After implementing the MCD, we used a case exemplar approach to elicit the perceptions and stories of nurses on the unit regarding the advantages and disadvantages of the technology. The MCD was initially introduced to 1 unit in the hospital as a pilot site for the local health region. By limiting the study to a single unit, we hoped to control for several potentially confounding factors that may vary across units and/or hospitals, including timing of the initiative, exposure and adoption of the technology, access and training for the MCD system, and the role of management and support. Approval for the study was obtained from the Conjoint Ethics Review Board of the University of Calgary. Written consent was obtained from all participants.
Examination of the introduction of the MCD is part of a larger ongoing study assessing the impact of a variety of healthcare innovations on healthcare providers' well-being. Seven nurses were selected and interviewed by the 3 coinvestigators of this study. These 7 nurses were part of a nonrandom sample, selected because of the unit where they worked, their primary shift, and willingness to participate. On average, the nurses worked 33½ hours per week (range, 24-45 hours per week) for 4 to 5 days a week, and 71% (5 of the 7) worked part-time. Mean years of nursing experience was 7 years (range, 1-20 years).
The wireless MCD was introduced to the unit in March 2008. Semistructured, face-to-face interviews were conducted 1 month after implementation. The interviews were conducted using open-ended questions asking staff to describe their experiences and provide exemplars related to their experiences with the MCDs. Participants were asked to relate how the introduction of this communication system affected their work. The interviews ranged from 12 to 38 minutes and were recorded and transcribed by a research assistant.
A thematic approach was used to analyze the interview transcripts.12 Themes were identified based on frequency, pervasiveness, and deviations from established patterns.13 Researchers incorporated observational (word or phrase repetition and metaphor analysis) and process techniques (cutting and sorting, word frequency, and word co-occurrence) in analyzing the interview transcripts. For example, "doors" emerged as a metaphor in several of the transcripts, both as a physical object on the unit and as a perceived obstacle to communication and teamwork.
In this section, we describe the 4 major themes identified in the interview transcripts in regard to nurses' experiences using the MCD. These major themes and their subthemes are summarized in Table 1.
Frequency of Use of MCD
The frequency of nurses' use of the MCD varied dramatically, depending on a variety of factors. Some estimated they used the device 3 times a day, others as many as 30 times as day (mean, 18 times as day). Frequency varied by the day of the week and patient load. As a nurse noted, "I think use depends on the shift and the patient assignment." The frequency of use appeared to depend on how the device is used. One nurse said, "I used it only when I was going on my break, maybe 3 times during the day." Another nurse reported the device was used when she was in charge. "If I am in charge and there is a high-acuity patient on the unit, I'm going to frequently check in with their [his/her] nurse to assist with support as necessary," reported this participant.
Benefits of the MCD
Two subthemes reflect the perceived benefits of the MCD to nursing care through improved efficiency and fewer disruptions and interruptions to patient care. The most positive aspect reported about the use of the MCD was increased efficiency on the part of the nurse through multitasking. One nurse said, "I'm not running around trying to communicate with different people; thus, it is easier to get my assessments completed." Others said, "I can communicate right away; however, I wouldn't say it makes the actual job easier, just more time efficient."
Nurses explained that using the MCD meant they did not need to stop what they were doing to receive a message, which improved their ability to provide quality patient care. One nurse said, "The MCD is a minor disruption, just the push of a button, talk, and send a message quickly." Another said, "I feel like before the MCD, I was constantly stopping my work and diverting my attention to the overhead pager." Another reported, "Most of the time the MCD facilitated [patient care] because I didn't have to run back and forth to get messages and calls." One key theme was an increased ability to continue performing nursing tasks and provide patient care with fewer interruptions to the workflow process.
Limitations of the Technology
The nurses identified 2 primary sources of frustration with the MCD: technological limitations and patient confidentiality concerns. In terms of technological limitations, the nurses expressed dissatisfaction with the voice recognition capabilities of the software. For example, "It's frustrating… when the system doesn't catch the name I said and I have to constantly repeat it… that's a hassle." The software had difficulty recognizing commands if staff had an accent or if there were noise in the background. "I think the MCD has a negative impact in that… if you are in a loud environment… it takes several times to call somebody." Another nurse explained: "…There are so many limitations in terms of what it (MCD) can and cannot do in terms of… recognizing your voice or certain people…. Trying to talk slowly and clearly or moving to a space without exterior sounds can significantly limit the ease of use and utility of the device." However, although irritated by the occasional flaws in the voice recognition capabilities, another nurse said, "by no means has it happened enough for me to be discouraged with the device altogether."
A second technological limitation was the MCD's limited range. One nurse said, "…There are dead spots on the unit, and then you break up a little, and you have to keep repeating yourself to make sure that that person heard all of the words you said and not just some of the message. This can be a little bit annoying." An example of a specific dead spot for the system was the employee break room. One nurse said the MCD "won't forward calls in the break room half the time so we miss the message."
The MCD inherently creates a potential for reduced confidentiality. It is designed so that all communication can be heard from a built-in speaker by anyone nearby, including others in the same patient room. Many nurses were apprehensive about what information should be communicated via the device without the sender being aware of the location of the receiver. One nurse cautioned vigilance in discussing other patients, which might limit the usefulness: "You cannot converse back and forth because you have other people around."
Nurses' Feelings of Stress
Over the period of this study, nurses began to adapt to the limitations of the MCD and find other benefits for their work. The study participants spoke about the relationship of the device to their day-to-day stress and the impact of the device on casual socialization during the workday. Casual socializing was improved through the increased ease of coordinating breaks; however, nurses would occasionally be paged for personal, non-work-related communication.
The nurses in the study identified the acuity of patients and staff shortages as their main sources of stress. The nurses reported that although the MCD did not reduce these stressors, it did alleviate feelings of isolation and improve communication, both relieving some job-related stress. The MCD made it easier to call for help and get a confirmed response that help was coming. One nurse said, "Feeling stressed relates to having a lot on my plate at a particular time. Pushing the button to ask for help is easier than having to stop what I'm doing and go and find somebody."
On the converse, the ease of access to others was also a cause of stress. As a nurse stated: "When I'm in the middle of doing a complicated assessment, and people are constantly calling and saying, can you tell me if this is okay…, I feel obligated to stop what I am doing and help them." Some nurses felt that the MCD reduced their stress level and enabled them to cope with other issues related to patient acuity such as accessing expertise. Another nurse, in response to the question: "Has your stress level changed with the MCD?" answered "No, I don't think it's changed, I don't think that it's affected it at all. The sources of my stress are not helped by a communication device."
Private rooms decrease the accessibility to the nurse and other peers to support communication. The benefits of an MCD from this study are consistent with prior reports regarding wireless communication technology usage among nurses.2,8-11 In this study using exemplars, nurses described how the MCD provided efficiencies in communication with colleagues and the ability to locate other members of the team for consultation or assistance. Nurses reported an appreciation in the reduction of distractions from overhead pages, thus decreasing work stress. Prior to the introduction of the device, response to intercom and beepers required that the nurse leave the patient's bedside, also decreasing productivity and continuity.
As with other reports, the nurses in our study encountered frustration with the voice recognition capabilities and were concerned with potential breaches to patient confidentiality.8-11 During implementation of similar technologies including MCDs, consideration should be given to the provision of guidelines for appropriate and inappropriate use. This study describes how a new communication device positively impacted the healthcare providers on 1 medical unit; however, further study and evaluation are indicated to determine appropriate future applications and the effect on nursing.
The authors thank the healthcare providers on unit 36 at Foothills Hospital as well as Deborah White, Steven Friesen, and Janet Gilmour for their contributions to this study.
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