Communication within the healthcare system is vital, is complex, and has a significant impact on patient outcomes.1,2 Communication errors have been identified as the leading cause of in-hospital mortality, far exceeding mortality due to inadequate clinical skill.1 The National Patient Safety Goals of the hospital accrediting organization in the United States (The Joint Commission) and the report by the Canada Health Council entitled "Health Care Renewal in Canada: Clearing the Road to Quality" both identify the need to improve the effectiveness and coordination of communication among service providers.3,4 Incorporated in this goal is the implementation and standardization of the approach to the process of "hand-off" communications, where accurate and timely patient information is provided in an interactive format, allowing caregivers the opportunity to ask and respond to questions.3
The Institute of Medicine has identified the critical role that nurses play in patient safety.5 The nursing work environment constitutes inefficiencies and distractions, with a potential impact on patient care and patient outcomes. Creating a safe and supportive work environment for nurses can reduce threats to patient safety.5 Work environments and care processes should be designed to reduce errors. The Institute of Medicine specifically identified the development of a robust and consistent means of sharing patient information when transferring patients between services and caregivers and the need to reduce non-value-added activities currently performed by nurses, such as locating and obtaining supplies, looking for personnel, and compensating for poor communication systems. Improvement in nursing work environment has also been identified as a significant recruitment and retention strategy to address the international nursing shortage.6
Advancements in technology have resulted in the availability of new tools to improve communication and decrease inefficiencies related to non-value-added activities performed by nurses. Wireless technologies, combined with portable computing and communication devices, have evolved to the point where they are now secure, efficient, and conveniently compact enough to be of real use in healthcare. Tools that digitize speech and transmit it to voice over Internet protocol have the potential to streamline communication, improve the quality of nursing work life, and ultimately improve patient outcomes. However, the introduction of electronic and wireless tools into complex healthcare settings is challenging. The barriers to adoption of innovative technologies include resistance to change and lack of user input into their selection and implementation. The purpose of this study was to evaluate the implementation and adoption of an innovative communication solution in an acute care setting. The objectives were to (1) document the perceptions and attitudes of clinical staff (users) toward the use of a new communication device (Vocera) prior to and after its implementation, (2) compare communication patterns between unit staff before and after Vocera implementation, and (3) document distance traveled before and after Vocera implementation.
This study has been reviewed for ethical compliance by the Queen's University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board. The study was conducted between April and June 2007 on a 38-bed general surgical unit in a 456-bed acute care facility. The structural design of this unit (H-pattern) does not facilitate communication between staff members. The results from the center's workload measurement tool indicated that staff without portable communication devices (this includes all frontline staff) were spending a significant amount of time on non-direct care communication while staff (charge nurses) with the portable communication devices currently in use found them heavy, bulky, and awkward.
This study incorporated a mixed-method design using a focus group and a pretest-posttest quasi-experimental study. The latter included a paper-based survey and a time and motion study to assess the Vocera Communication System (Vocera Communications, Inc., San Jose, CA).
VOCERA COMMUNICATION SYSTEM
Vocera is a personal communication tool that uses voice over Internet protocol. The system consists of the Vocera System Software and the Vocera Communication Badge. The system software houses the centralized system intelligence, which includes call manager, user manager, and connection manager programs, as well as speech recognition software and various databases. The communication badge, which is approximately the size of a small cellular phone, is compact and light (<54 g) and can be clipped to a shirt or worn on a lanyard. The system functions in a manner similar to that of a walkie-talkie but uses voice recognition. It allows communication with other individual badge wearers, groups of badge wearers, or landline communications. With the exception of the call sender (who presses a button on the badge to initiate a call), all voice communications are hands-free. The system allows the ability to designate the party to be called by name, title, function, or group, eliminating the need to know telephone numbers or who is on duty. Group announcements can be conducted using conference calling, broadcast messaging, and voice mail messaging. Vocera also has the ability to call to and from the badge to other telephones inside and outside the hospital.
THEORY OF PLANNED BEHAVIOR
The Theory of Planned Behavior has been used to identify factors that influence individuals' intention to use new technology.7,8 The Theory of Planned Behavior proposes that a behavior intent is influenced by the attitude toward that behavior (Attitude), the influence of social pressure that is perceived by the person (Subjective Norm), and the person's perception of how easy or difficult performing the behavior will be (Perceived Behavioral Control).7 The goal is to identify and potentially modify factors that influence behavior intent and, ultimately, to influence behavior. The questionnaire was used to assess factors that may influence unit staff to adopt the new communication software.
The objectives of the focus group were to (1) identify key communication activities and patterns among unit staff; (2) introduce the Vocera tool and obtain feedback regarding who would carry the tool, as well as the anticipated challenges of trialing and using it; and (3) provide input into the development of the survey questionnaire. The focus group was conducted by one of the investigators and included five unit staff. Participants were provided with a draft of the paper-based questionnaire 1 week prior to meeting as a focus group. They were asked to review the questionnaire and come to the meeting prepared to discuss its clarity, readability, and comprehensiveness. The questionnaire consisted of open-ended and Likert scale (1-7) questions. The results of the focus group were used to develop the questionnaire to be used in the survey of all unit staff.
The purpose of the survey was to gather information about the perceptions and attitudes of staff toward the use of a new communication device. The questionnaire was adapted according to template guidelines and using results from the focus group. The purpose of the questionnaire was to capture information about what and how human action is influenced. Four psychological constructs were measured: attitudes, subjective norms, perceived control, and behavioral intention. A series of information sessions about Vocera was provided to all staff, and supporting documentation was made available on the unit. All unit staff (frontline and charge RNs, patient care assistants [PCAs], and unit clerks) were asked to complete the questionnaire. Four weeks after Vocera implementation, staff were again asked to complete the questionnaire. To maximize participation, various follow-up and reward strategies were used; however, participation was voluntary and questionnaires did not include identifying information.
TIME AND MOTION
The purpose of the time and motion study was to document the patterns of communication and the amount of time required for key communication activities before and 4 weeks after the Vocera implementation. A process flow chart was developed depicting communication patterns between nursing unit staff and external departments, with and without Vocera (Figure 1). The communication events were timed and documented by two research assistants who shadowed staff on a one-to-one basis. Before Vocera implementation, RNs (three charge and eight direct care) were shadowed for a total of 120 hours. Sixteen RNs (two charge and 14 direct care) were shadowed for a total of 150 hours after Vocera implementation. Because of the complexity of scheduling, only three of the RNs (all direct care) shadowed before the implementation were available to be shadowed after the implementation.
The research assistants used stopwatches to time six types of communication events that were identified as key activities by focus group participants: (1) walking to the telephone to respond to calls or pages, (2) walking from the telephone to resume work, (3) looking for an individual to respond to a call, (4) looking for assistance, (5) looking for a specific individual (eg, to give report to go to coffee), and (6) looking for the narcotic cupboard medication keys.
The distance traveled was also captured before and after the Vocera implementation. All unit staff (RN, PCA, and unit clerk) were invited to wear pedometers over an 8-hour day shift (7:00 am-3:00 pm) to measure the number of steps and the distance traveled. Each pedometer was calibrated to the stride of the individual.
The nurse-in-charge also completed environmental assessments each day to help assess unit activity and to track any unusual contextual factors. Items such as number of admissions, discharges, and transfers to and from the floor, as well as sick calls, staffing shortages, and overtime, were documented.
Following a 1-hour orientation and practice with the Vocera device, each staff member was provided with a badge and a pocket guide. Seventy percent of the staff were oriented and using the tool within the first 48 hours. All the staff members were oriented within 2 weeks. Three weeks after implementation, a poster campaign was initiated to remind staff of all the options for using the tool. The "off-unit" teams, such as the pain management service and respiratory therapy, were identified on the posters as groups who could be contacted directly by using Vocera.
The data gathered during the focus group was catalogued and examined for similarities and differences. Using an inductive analysis, the data were categorized and then subcategorized into classes and then used to design the larger questionnaire and to identify key communication activities to be captured in the time and motion study. In the survey of the larger study population, a content analysis was conducted on factors identified in the open-ended questions. Common themes were ranked and tabulated. The scores for the four psychological domains were calculated using the Theory of Planned Behavior algorithm.8 In bivariable analysis, correlation between the predictor variables and behavioral intent was assessed using Spearman ρ. In multivariable analysis, the general linear model was used to test the combined effects of the three predictor variables on behavioral intent while controlling for age (<40, ≥40 years). Because of the low frequency of some communication activities, the six communication activities were collapsed into three groups for the purpose of analyses-telephone-related activities, looking for people or supplies, and looking for the medication keys. The differences in median time spent on the key communication activities and median kilometers traveled during an 8-hour shift before versus after implementation were assessed using the Mann-Whitney U test. Unpaired analysis was used because of several staff participating in only the preimplementation or postimplementation period (related to scheduling).
Fifty-five (80%) staff completed the questionnaire before and 53 (74%) completed it after Vocera was implemented. Twenty-one percent of the respondents were younger than 25 years, and 43% were 40 years or older. Participating staff had a median of 42 months of experience on the nursing unit and 84 months of total nursing experience. Seventy-one percent of the respondents rated their computer skills as average or above average. There were no statistically significant demographic differences between staff who participated in the preimplementation and the postimplementation questionnaire.
Perceptions and Attitudes Toward Vocera Using the Theory of Planned Behavior
Forty-four staff provided responses to the open-ended questions before implementation, and 39 provided responses after implementation. The top three themes identified for each component of the questionnaire are presented in Table 1. Respondents identified saving time looking for people or things as the primary advantage for adopting Vocera. The proportion reporting this advantage increased from 57% (25/44) of respondents before implementation to 97% (38/39) after implementation. Issues related to patient safety were also identified, in particular, the ability to respond promptly to emergency situations. The perceived disadvantages were related to work flow, confidentiality, and training to use the device before implementation, while confidentiality, technical issues, and privacy concerns were reported after implementation. Respondents identified groups that they believed would approve or disapprove of the device (subjective norms), as well as enabling and interfering factors (perceived control) affecting the adoption of Vocera (Table 1). A complete list of responses to the open-ended questions is available upon request.
RELATIONSHIP BETWEEN PSYCHOLOGICAL DOMAINS
Before implementation: In bivariable analysis, behavioral intent was not correlated with the three predictor variables; however, in multivariable analysis attitude was associated with behavioral intent after controlling for subjective norms and perceived control (F = 12, P < .01; model adjusted r2 = 0.25) (Table 2).
After implementation: During the postimplementation period, all three predictor variables were correlated with behavioral intent in bivariable analysis (r range, 0.37-0.61, P < .05). In multivariable analysis only perceived control was associated with behavioral intent (F = 22, P < .01; model adjusted r2 = 0.45).
Before versus after implementation: The preimplementation predictor variables were not correlated with behavioral intent after implementation in the bivariable or multivariable analysis (model adjusted r2 = 0.03) (Table 2).
Communication Patterns Before and After Vocera Implementation
The time spent on key communication activities, such as walking to and from the telephone, looking for others, or looking for the medication keys, was reduced by 25% overall after Vocera implementation. On average, each nurse engaged in these activities 16.2 times per day before Vocera and 11.6 times per day with Vocera.
There was a statistically significant reduction in the number of times nurses walked to and from the telephone after Vocera (6.8 to 2.9 times per day; P < .05) (Figure 2). There was no change in the amount of time spent per event (Figure 3); however, the reduced frequency of telephone-related activity with Vocera resulted in a 57% reduction in the time spent walking to and from the telephone.
LOOKING FOR OTHERS
The most significant time savings were related to looking for other staff. There was a 45% (30 to 17 seconds per event) reduction in the time spent looking for others (P ≤ .01) (Figure 3). Looking for an individual to respond to a telephone call was reduced by 61% (30 to 12 seconds per call), while looking for assistance was reduced by 54% (32 to 15 seconds per event). There was no significant change in the number of times nurses looked for others before and after Vocera implementation (Figure 2). On average, each nurse engaged in these activities seven times per day. However, the time spent on these activities was reduced from 28 to 17 seconds per event, or 3.4 to 2 minutes per nurse per 8-hour shift. This finding remained significant after controlling for observer (ie, it takes into account differences in recording events by research assistants).
SEARCHING FOR MEDICATION KEYS
The amount of time spent searching for medication keys was reduced by 32% (12 to 7.8 seconds) (Figure 3), and the number of times nurses looked for medication keys was reduced by 29% (2.1 to 1.0) (Figure 2); however, because of the relatively infrequent nature of this event, the results were not statistically significant and should be considered with caution.
Distance Traveled Before and After Implementation
Distance traveled was reduced from 5.1 km (interquartile range, 3.5-6.7) before Vocera implementation to 4.8 km (interquartile range, 3.3-6.7) after Vocera implementation (Figure 4). The greatest reduction in distance traveled was found with the unit clerks (4.7 to 3.8), followed by the RNs (4.9 to 4.7). The distance traveled increased slightly for the PCAs (6.7 to 7.8). None of the results were statistically significant; however, the study was not powered to test for these differences.
The number of admissions, transfers, and postoperative admissions were lower after than before Vocera implementation, while the patient census was similar during the two periods. The major difference between the two periods was the number of isolation cases present during the postimplementation period. This was due to a vancomycin-resistant enterococcus outbreak in the hospital. Anecdotal responses from nursing unit staff were supportive of the positive impact that the communication device had for nurses working in the isolation rooms (Table 1).
In this study, we found that attitudes predicted the intention to use a new communication device before implementation of the device, but perceived control predicted the adoption of the new device after implementation. A similar study in this institution examined the adoption of electronic documentation before implementation and also found a correlation between attitudes and intention to use electronic documentation.9 Institutions intending to adopt innovative technology such as portable communication devices must account for attitudes of potential users when developing an implementation plan. While not directly measured, it is believed that ongoing involvement of staff throughout all aspects of the study, the implementation, and onsite technical support contributed to the successful adoption of Vocera. This is supported by the comments made by nurses to open-ended questions.
Our findings suggest that improved efficiencies related to common communication-related activities, such as using the telephone, paging, and looking for others, contributed to the successful adoption of Vocera. These findings are consistent with a study conducted in the United States, where the difference in internal nursing communication was 2.67 minutes without Vocera and 0.47 minutes with Vocera.10 In this same report, 79% of nursing unit staff believed that Vocera improved workflow, which is lower than the 97% of participants in our study who believed that Vocera eased communication and provided valuable assistance in searching for people or supplies.
By allowing direct communication between staff, use of this portable device reduced inefficiencies and distractions that have the potential to impact on patient care. This contributes to the goals of national and international patient safety organizations and accrediting bodies to increase patient safety and improve nursing work environments.3-5 One-third of respondents cited the benefits of Vocera in assisting in emergency situations. Vocera reduced non-value-added activities currently performed by nurses, such as locating and obtaining supplies or looking for personnel, and compensated for poor communication systems that result in "phone tag" with off-unit clinicians. This was a particular benefit expressed by the staff during the vancomycin-resistant enterococcus outbreak, where Vocera facilitated communication with staff providing care to patients in isolation. Immediate and direct communication with the appropriate colleague, whether during an emergency or during routine care, is a significant step toward the goal identified by the Joint Commission and the Canada Health Council of improving hand-off communication among healthcare providers.3,4
Future studies are necessary to examine the impact of this communication technology and improved hand-off communication on patient outcomes, healthcare resources, and the work environment. Research is also necessary to examine the effect of this type of instant communication technology on the quality of communication, whether it has an impact on privacy, and how it affects the nature of decisions.
Strengths of this study include the use of mixed-methods design to capture comprehensive information about the adoption of novel communication technology. The involvement of staff in the process of research and implementation of the communication system leads to high response rates and rich narrative material from the focus group and open-ended questions. Limitations of the study include the lack of individuals participating consistently in the pretest and the posttest phase, leading to the use of unpaired analysis techniques for the time and motion analysis. This conservative approach could result in a reduced likelihood of obtaining statistical significance for some of the analyses. The consistent nature of some of the findings between the preimplementation and postimplementation periods, such as the time it took to walk to and from the telephone or the number of times staff looked for one another, led us to believe that observer bias had limited impact on our findings.
Nursing implications of adopting this new communication technology are related to improved efficiency in communication-related activities. Staff had the ability to communicate immediately and directly with their colleagues both on and off the unit appropriate staff member. This study found that Vocera improved communication, was perceived to be of benefit, and has the potential to improve patient safety and work environments. This may also translate to reducing the use of healthcare resources.
We would like to acknowledge the clinical nursing staff of the participating surgical unit, the Information Management team, administration, and management of Kingston General Hospital and the research assistants Jaymie Lim and Sarah Kolumbus.
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