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© ACM, 2009. This is the author's version of the work. It is posted here by
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version was published in Proceedings of the 27th international conference on Human
factors in computing systems http://doi.acm.org/10.1145/1518701.1519012
A Mobile Voice Communication System
in Medical Setting: Love it or Hate it?
Charlotte Tang
Department of Computer Science
University of Calgary
char.tang@ucalgary.ca
Sheelagh Carpendale
Department of Computer Science
University of Calgary
sheelagh@ucalgary.ca
ABSTRACT
Hospital work coordination and collaboration often requires
mobility for acquiring proper information and resources. In
turn, the spatial distribution and the mobility of clinicians
can curtail the opportunities for effective communications
making collaboration difficult. In this situation, a mobile
hands-free voice communication system, Vocera, was
introduced to enhance communication. It supports quick
and impromptu conversations among coworkers for work
coordination and collaboration anytime and anywhere. We
study this deployment and present our findings concerning
the impact of this communication system on
the information flow. Our information flow framework’s
communication strategies help contrast the information
processes before and after the deployment of Vocera.
Author Keywords
Mobile, voice communication, Vocera, information flow,
healthcare, observational study, communication strategy.
ACM Classification Keywords
H.m. Information Systems: Miscellaneous.
INTRODUCTION
A wealth of research has found that face-to-face
communication facilitates collaborative work, e.g., [4,9,18].
However, given the increasing complexity of most
hospitals, clinicians are often spatially separated, curtailing
the opportunities for face-to-face communication. In fact,
medical work is characterized by local mobility [3,4,10].
Clinicians often have to move around to access people and
obtain information in order to have the resources necessary
to carry out their work [3]. Gathering resources through
clinician mobility entails substantial time cost, which can
impact patient care delivery. Quick and frequent
communication among clinicians is often needed for work
coordination and collaboration in the time-critical hospital
environment, motivating the adoption of mobile technology
such as a PDA [11]. However, most handheld computers
require two-hand manipulation such that the clinicians have
to pause their task-at-hand during communications. Thus, a
mobile communication device that allows clinicians to
communicate with their collaborators while still being able
to continue with their current task could greatly improve the
quality of patient care.
This paper reports a study on the information flow in a local
hospital ward as a result of the deployment of Vocera [17],
which is a mobile voice communication system. This study
is part of a longer-term research project aiming to
investigate and to improve the communication and
information flow as a means to facilitate patient care
delivery. We start by motivating our study and outlining our
framework for nurses’ information flow as derived from our
previous study [15]. Then, we describe our current study’s
findings in terms of our framework’s communication
strategies, and discuss some highlights and design
implications.
BACKGROUND
The increasing specialization of modern medicine often
entails multi-disciplinary collaboration when making a
diagnosis and deciding on a treatment plan for a patient.
This is because each specialty carries specific and often
unique information relevant to a patient’s illness. Therefore,
healthcare practitioners must work together to seek,
synthesize and disseminate information [13]. However, the
distributed nature of medical setting makes the coordination
necessary for collaborative work complex and difficult.
Collaborators often have to locally move around to execute
specific actions in order to accomplish work [3,4]. Thus,
medical practitioners must deal with the continual challenge
of achieving the right configuration of people, resources,
knowledge for collaborative work. To achieve this,
clinicians often have to spatially move in order to get in
touch with their collaborators [3]. Thus mobile technology
that provides a low-cost communication medium that
dispersed collaborators can use to communicate frequently
and spontaneously would be beneficial to support
collaboration and coordination, and to reduce unnecessary
mobility in medical work [3,9,10,11].
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Previously, we conducted two field studies to investigate
nursing communication on an acute medical teaching unit
in a local hospital, paying particular attention to the time
period during shift changes [15,16]. While shift change
communication may occur in different formats, e.g., bed-
side handover, much of the shift change communications in
our study ward exhibited a high degree of active
information seeking by incoming nurses. On arrival,
incoming nurses had to move around to access a variety of
distributed information sources to gather important medical
information. They made use of and added to this
information throughout their shift in preparation for the
information dissemination at the end of their shift.
Meanwhile, outgoing nurses continued providing patient
care, interwoven with various communicative activities
until the actual transfer of responsibility. Although our
previous studies focused mainly on shift change
communications, our observation sessions spanned across
both regular shift work periods and shift changes. As such,
we have become increasingly aware that nurses’ shift
change is only one crucial part of the continual information
flow. We also found the communication strategies used for
the information flow during shift changes and the totality of
shift work highly similar. This motivated us to study how
the deployment of Vocera impacted the communication and
information flow. We expected nurses to take advantage of
the hands-free system to receive updates from their
outgoing coworkers without physically moving into face-to-
face reporting as previously observed [15,16].
A FRAMEWORK FOR NURSES’ INFORMATION FLOW
In this section, we outline our framework for nurses’
information flow as developed from a previous study on
shift change communications [15]. Its structure proved
useful in analyzing the communication data from our
current study. The framework consists of six components:
information, personnel, artifacts, spatiality, temporality, and
communication mode. These components are not stand-
alone elements independently contributing to the
information flow but are highly interrelated, exhibiting
complex relationships. For example, the kind of
information artifact used influences the timeliness with
which information is communicated among clinicians.
The information is typically patient-specific and thus
uniquely defined for each patient’s illness trajectory. This
information is important for planning nursing care for
individual patients and for coordinating care plans for
multiple patients. The personnel involved are particularly
important when medical diagnosis and care information has
not (yet) been fully documented, a common occurrence due
to time pressure. Thus, clinicians are required to access
different people in order to bring together the intellects and
expertise that reside with individual clinicians. The artifacts
are the physical devices that are used to communicate
information for delivering nursing care. We study the roles
of these artifacts in the information flow and how they
hinder or facilitate their intended usage. The spatiality
considers where communication takes place and how the
locations hinder or facilitate information flow such as the
mobility needed. We also look into the equipment setup in
specific information centers for supporting information
flow in similar ways described by Harrison and Dourish
(1996). The temporality of information flow is the order
and timeliness for accessing specific information sources
and how this impacts the outcome of information flow, as
well as the temporal patterns that may help locate
collaborators [12]. Lastly, the communication mode is the
style and media through which specific kinds of
information are communicated. We also study if specific
communication modes hinder or facilitate information flow.
These six factors are useful in characterizing
communication processes, but they are not exhaustive.
Other factors like organizational mandate and social
structure may also impact the communication process and
should be considered. However, the six factors of our
framework were particularly instrumental in our studies.
STUDYING THE DEPLOYMENT OF VOCERA
The research site is a 40-bed acute medical teaching unit in
a local hospital. Patients admitted to this ward generally
still require acute care as they are often transferred directly
from ICU. However, the nurse-to-patient ratio ranges from
1:4 to 1:8 depending on work shifts as opposed to that in
the ICU of 1:1 or 1:2. Thus, nurses working in this ward
constantly face high stress and time pressure. Innovative
research activities frequently take place on this ward so the
nurses are generally open-minded towards technology. The
ward consists of a centrally located nursing station and four
radiating wings of patient rooms (Fig. 1, Left). Its layout
makes it convenient to access information at the central
information hub but difficult for nurses working in different
wings to communicate and to maintain awareness.
Technology
The technology discussed in this paper is Vocera
communication system [17]. It uses voice recognition and
wearable communication badges running on a wifi network
for making two-way conversations with coworkers using
natural spoken commands. Vocera are compact, lightweight
single button badges. They can be worn with a lanyard or
clipped on a shirt collar. One must log on to the system. To
place a call, one has to press the button and give a verbal
Figure 1. (Left) Ward layout, central nursing station as circled
(Right) Pressing Vocera button to make a call
command to the automated operator (a.k.a. the genie) (Fig.
1, Right). The genie has to recognize the voice command,
e.g., “Call Mary”, it then searches the database before
connection is made for a two-way voice communication.
No other physical manipulation is needed. Thus, once the
voice link is established, the conversing parties can
continue their task-at-hand. To terminate the connection,
one party has to press the button. Vocera allows callers to
leave a message, to broadcast to a specific group and to
forward all the calls to a specific person. Also, built-in fun
tunes will be played in response to specific commands, e.g.,
star-trek tunes played to “Beam me up!”
Method
Our study was conducted in the first week (first stage) and
the fifth month (second stage) of Vocera’s deployment. The
first author conducted 8 and 12 observational sessions
respectively, each lasted 2 to 4 hours. The observations
took place during regular shift periods, shift changes, and
meal breaks. Participants in the two stages were
respectively 3/3 unit clerks, 9/7 nursing aids, 36/37 nurses,
and 1/2 patient care managers (1 unit clerk, 4 nursing aids,
17 nurses, and 1 manager participated in both stages).
Observations and interviews were used to find out how the
participants used the system. Field notes were taken. The
fact that this mobile voice communication system required
minimal and subtle physical interactions from the
participants made the field study complex and challenging
as it was often unclear when they were communicating over
Vocera. The distributed layout of the ward also made it
difficult to observe two-way conversations. The first author
primarily stayed around the central nursing station as many
Vocera communications were initiated in response to
incoming phone calls. With its central location, the
researcher was then able to more easily locate the
respondents who were often distributed in the ward wings.
Because most conversations were brief, the contextual
information was usually missing and could only be
recollected from follow-up interviews with the participants.
Thus, the data collection was based on observable events
and subsequent informal interviews with the participants for
the communication motives and details. The findings of the
two stages are highly similar, with a few differences which
are highlighted in the findings section.
We organized our findings using a fish-bone diagram [8]
(Fig. 2), with the six factors of our framework contributing
the structure. The fish-bone representation provided an
overview visualization of Vocera deployment and helped to
focus the analysis of the phenomena impacted by the
framework factors (see the next section for more
information). Color is used to facilitate reading, with
negative or unexpected phenomena shown in darker
backgrounds. The displayed data includes observed events
and series of events showing causal relationships that are
directly a result of Vocera deployment.
FINDINGS
From our observations, we identified many communication
strategies, which resonate with some aspects of our
framework. The six framework factors were all associated
with a primary strategy for coordinating the communication
on the ward as follows:
Choosing appropriate artifacts for information flow;
Choosing an appropriate communication medium;
Identifying and locating personnel to communicate;
Off-loading information to the intended recipient;
Minimizing spatial movements;
Prioritizing and scheduling activities.
Because of this association between our Vocera
observations and the framework’s communication
strategies, we use the structure of the framework to report
our findings. While our framework allows a thorough
analysis by understanding the inter-relationship between the
six factors, one drawback is that these inter-relations
contain overlaps. However this helps ensure relevant
phenomena were properly considered. To establish previous
communication practices, we first describe the
communications as occurring before deploying Vocera
using the framework’s communication strategies as the
structure, and then we report the impact of Vocera
technology on the information flow and communication
strategies. This helps define the changes that arose with the
use of Vocera.
Pre-Vocera Communication
Choosing appropriate artifacts for information flow
Communication artifacts available before Vocera was
deployed were telephones and computers at the nursing
station and along the ward wings, an intercom at the
nursing station, and portable paper notes. Cell phone use
was not allowed while on duty. Telephones in the ward
could be used to make internal calls within the hospital and
to the outside. Internal calls required only an extension code
while all external calls required a prefix “9” followed by the
phone number. The intercom allowed overhead broadcast of
messages from the nursing station over the entire ward with
the exception of patient rooms. This design was deliberate
so as not to interfere with patients’ rest. Patients could also
communicate with the nursing station via the intercom from
their room. An online text paging system was also available
for contacting physicians.
Most communication from outside the ward came through
telephones at the nursing station. When a phone call came
in, a unit clerk would most likely use the intercom to
broadcast for the attention of a specific clinician, if known,
followed by the targeted clinician either calling the nursing
station from his/her ward wing or spatially moving into
face-to-face interaction at the nursing station. Personal
paper notes were also pervasively used as an intermediary
notepad by all the nurses and unit clerks in the course of
their work for recording information (e.g., a patient’s pain
level) that needed to be relayed to specific clinicians or to
Figure 2: A fish bone diagram used for visualizing and analyzing the findings of the Vocera deployment (Negative or unexpected phenomena in darker backgrounds)
be documented later, and required communicative events,
e.g., appointment scheduling.
Choosing an appropriate communication medium
Face-to face interactions, point-to-point closed telephone
links, one-way broadcast over the intercom, and digital
paging through texts for physicians were available in the
ward. Unfortunately, the most effective face-to-face
communication is not always possible due to the distributed
nature of medical work. But telephone communication still
allows collaborators to synchronously clarify, elaborate,
and confirm information. With its point-to-point closed
connection, a telephone is considered an appropriate
medium to communicate private patient information.
However, as nurses were always on their feet, they were
mostly unavailable to converse over the phone. Therefore,
broadcasting through the intercom provided convenience to
initiate connection with clinicians. However, because of its
lack of a feedback channel, clinicians could only respond
through another medium, typically through telephone or by
spatially moving into face-to-face communication. The
effectiveness of this broadcast medium was also limited by
the presence of “dead zones” inside patient rooms.
Therefore the only way to ascertain proper receipt of the
broadcast communication was to receive feedback from the
intended recipient via another medium. Broadcasts were
also interruptive to clinicians who were not the intended
recipients as they would naturally slow down their task-at-
hand to pay attention to the broadcast and only resume to
normal pace after they realized that they were not the
intended recipient. Such an interruptive work environment
could impede one’s work flow. The public nature of
intercom broadcast also limits the kind of information that
can be communicated. If the information would jeopardize
a patient’s privacy, the broadcast can only be an invitation
for relevant clinician, leaving communication of the content
for a more appropriate medium.
Nevertheless, the value of overhead broadcast was evident
in emergency situations to coordinate rescue operations.
When a patient became critically ill, the primary care nurse
would immediately press the “Coding” button available in
every patient room. In response, the hospital would issue a
hospital-wide broadcast, “Code Blue, Unit 38.” The Code
Blue [Resuscitation] Team would then hear the broadcast
and rush to the specific ward immediately.
Identifying and locating personnel to communicate
Multi-disciplinary collaboration is prevalent in modern
medicine. Thus, the nursing station plays a crucial role as
all incoming communications are first received there. The
following vignette illustrates how incoming calls are
typically handled.
Jane, the unit clerk on duty, received a phone call from the
radiology department looking for the primary care nurse
for the patient in room 3840. Jane looked up the large
assignment board across the nursing station and identified
that it was Carrie. She then put the phone call on hold,
picked up the intercom receiver and made a broadcast with
a directed message, “Carrie, radiology is on the phone for
40 [room 3840]”. Carrie was in her ward wing so she
picked up the phone there to call Jane, “Can you transfer it
to B [ward wing B]? She then hung up. The phone in the
ward wing then rang. Carrie picked it up and talked to the
radiologist. [However if Carrie was inside a patient room
at the time, she would have missed the broadcast. Without
getting a response from Carrie, Jane would either make
another broadcast (same broadcast or to ask other people
to relay the message) or to find Carrie herself.]
Sometimes, the unit clerk might not know right away who
the phone call was for. For instance, a physician called,
“Someone paged me?” Jane would then simply make an
undirected broadcast to identify the concerned clinician,
“Who paged Dr. Smith? She’s on the phone.”
As medical work is highly collaborative, nurses often
require assistance from their colleagues in the ward. This
type of connecting with colleagues is frequent. “Carrie
needed help, but she did not see any colleagues nearby. So
she would either call or go to the nursing station to ask
Jane to broadcast for assistance on her behalf.
Alternatively Carrie could go to find her colleagues in
person. But this usually took longer time and more effort.”
Thus, to identify and to locate collaborators often required
the use of multiple communication channels or spatial
movements with the existing technologies.
Off-loading information to intended recipient
The centrally located nursing station serves as the reception
desk and the information hub of the ward. The “gatekeeper”
function, discharged by unit clerks, plays an important role
to ensure communication is properly received and routed so
that patient care is carried out efficiently. For example, the
unit clerk receiving a phone call from the pharmacy
regarding a patient’s newly prescribed medication may take
the message and then relay it to the primary care nurse, or
broadcast for the primary care nurse to ask for routing
directions. Such information off-loading is a common and
frequent practice in the flow of information.
Although each nurse was assigned with a specific number
of patients in each shift, nurses at the ward are highly
collaborative. We observed many instances where a nurse
noticed another nurse’s patient needing assistance or
attention. S/he would then go to find the colleague to relay
the information. In situations where the nurse was too busy
at the time, she would make use of technologies, e.g., to
phone the nursing station to off-load the information.
Minimizing spatial movements
Technology-mediated communications are widely used to
connect distributed collaborators without spatial movement.
Broadcasts on the intercom allow simultaneous
communication to a large audience, thus reducing the need
to spatially move to look for intended recipient(s) of
information. Responses could also be made through
telephone although sometimes face-to-face communication
was necessary. However, when no response was received
for the broadcast, mobility was likely required to physically
look for the intended recipient, which would be more costly
in time and effort.
Though nurses often need to move around to look for
information and resources, when possible they found work-
arounds to reduce their mobility. When the situation was
not time critical, they would postpone their information
seeking and dissemination activities until several demands
made the trip worthwhile. Such poly-motivated mobility
practice [1] can considerably save nurses’ time. The use of
paper notes as a reminder helped facilitate this practice of
grouping tasks which is indeed an integral part of organized
and efficient nursing practice.
Prioritizing and scheduling activities
Nursing care involves many planned as well as spontaneous
activities relevant to multiple patients’ diagnosis, treatment,
and nursing. These activities include actual care procedures
and communication events that must be temporally
coordinated, synchronized, and prioritized. Fluctuations in a
patient’s illness require nurses to dynamically change their
care plan activities, which in turn must also be
communicated to relevant clinicians who would then have
to adjust their work plan. Intercom broadcasts and face-to-
face communication were frequently used to coordinate
clinicians working on the ward whereas off-ward clinicians
were typically contacted through telephones.
Communication with Vocera system
Vocera system was deployed among unit clerks, nursing
staff, and a small number of off-site clinicians. For brevity,
we use members to refer to the people in this Vocera
community. As the majority of communications within the
ward occurred between the nurses, unit clerks, and nursing
aids, our study focused on their communication practices.
In fact, we found communications on Vocera system only
took place between members working on the ward as they
were unaware which off-site clinicians were also members.
The deployment of this wireless mobile communication
system was adopted with mixed responses, ranging from “I
love it!” to “This is the crappiest thing!”
Choosing appropriate communication artifacts
Vocera provided additional communication resource that is
portable and can be used anytime and anywhere while the
old technologies continued to be in use. However, the voice
recognition was found to be suboptimal and presented a
non-trivial problem that all members had to deal with at
varying difficulties. The genie frequently did not
understand the spoken command. This voice recognition
problem was not limited to non-native members speaking
with an accent. Native English speakers also found this
problem occurred too frequently and caused much mental
stress and frustration. When the genie misinterpreted the
spoken command, the caller could repeat the command but
most members would just terminate the call and restart
another one. They said it was faster than waiting for genie’s
instructions to repeat the command. Most members would
try 2 to 3 times before they gave up and looked for
alternatives to communicate, as illustrated in the following.
Jenny used her Vocera to call Patrick. “Call Patrick.” “I’m
sorry, I don’t understand.” Jenny terminated the call and
restarted another one. “Call Patrick, Unit 38.” “You want
to call dietitian in Unit 38?” She then stopped the call and
told us, “How can Patrick be even close to dietitian?” She
then decided to find another way to reach Patrick. She did
not know where Patrick was so she used the intercom at the
nursing station. “Pat, can you please call Jenny?” Patrick
got the message so he called Jenny on his Vocera. The
connection was uneventful so the two talked on the voice
link. [In situations where if Jenny knew where Patrick was,
she typically just went to find him to talk face-to-face].
We received a wide range of affective responses towards
the system, from loving it to hating it. The dramatic
differences in the feedback largely hinged on their
experiences with the voice recognition at connection. A few
members found this connection experience so frustrating
that they opted against using it for calling. But they still
wore it so that other members could reach them. They also
preferred the old technologies and would personally go to
find their coworkers. But several said they felt coerced to
have to visibly use Vocera and to express positive
experience with it when it was not in reality.
Although Vocera could be used to broadcast to all the
members or a designated subgroup, e.g., the nursing aids,
the intercom was still preferred because it was easy to use.
Moreover, as Vocera was not truly hands-free, members
often had to first take off their gloves which are necessary
in many clinical procedures before pressing the button on
their badge to start a connection. Thus, some nurses found it
tedious and complicated to call on Vocera while they were
working.
The ambient noise was also relevant when deciding which
communication artifact to use. Voice recognition got worse
in noisy areas and the volume of Vocera voice link was
generally low. Thus members always had to either lean
their head towards the badge or hold the badge up close to
their mouth to speak or their ear to listen (Fig. 3). A nurse
stated, “The volume is too low! When I’m working with a
patient, I can’t hear it and I can’t hold it up to listen…”
In the early stage, we found members appreciated the
playful moments when built-in fun tunes were played. They
Figure 3: Holding Vocera badge for better reception
found the tunes helped ease their stress. But we did not see
any members play these fun tunes in the fifth month of its
deployment. We were not too surprised as this is quite
typical when the novelty of a technology faded away.
Choosing an appropriate communication medium
Vocera offered several communication media to the
members in addition to those available through the old
technologies. Communications conducted via Vocera were
open such that people around could also hear the
conversations. It allows open point-to-point
communications between distributed members and
broadcasting to the entire group or to a designated sub-
group. It can be used to leave messages for a member who
could then retrieve the messages through their Vocera
badge. It can also be used to call to regular landlines and
cell phones, with voice commands. At meal breaks,
members can forward their calls to the relief’s Vocera.
Calls made on Vocera are not instantaneous as the genie
must first understand the voice command before making the
connection. But members generally perceived it as a more
efficient way to reach their coworkers than having to
physically moving into conversations. Therefore members
frequently used Vocera to connect with their colleagues.
However, observable latency impeded the actual voice
communications so they had to talk slower than normal,
making it difficult to communicate detailed information.
This is likely why we did not see any reporting activities
taken place using Vocera during shift changes. A nurse
said, “It’s too slow... Unless you’re sick and can’t get up,
then you’ll use a Vocera to do that [shift reporting]!” Also,
although nurses could continue with their current task while
using the technology, they had to somewhat slow it down.
The open voice link that can be overheard by people around
was also detrimental for communicating private
information. Thus, when detailed or private information
was needed, members only used Vocera to coordinate
switching to another medium to continue the conversation.
We frequently saw nurses use Vocera to negotiate when
and where to meet for face-to-face shift reporting.
Members preferred broadcasting on the intercom rather
than using Vocera as the former was easy to use. But
Vocera would be used when the intercom was not an option
such as during night shifts. Intercom use was forbidden at
nights so as not to wake patients up because doors might be
open even though intercom broadcast basically could not be
heard inside the rooms. With its broadcasting utility,
Vocera was used in a real situation making a life-and-death
difference, as told by the nurse who initiated the operation.
“The incident occurred during night shift, a time when the
staff is busy and scattered throughout the floor. A seriously
ill and confused patient disconnected himself from his IV
and searched for an exit. Security was called, as he was a
risk to himself and others. The patient went out an exit and
down to the next floor, where the door was locked, and
proceeded to collapse. Vocera was used to communicate
with and coordinate the staff, to bring oxygen and an O2
saturation monitor to the patient, obtain supplies for the IV
site which was bleeding, obtain a wheelchair to take the
patient from the second floor to the third floor and keep the
Code 66 [an emergency code] team, who had been called
when the patient collapsed, apprised of the movements.
Vocera offered communication and coordination that would
not have been possible without the Vocera.”
Despite such encouraging usefulness of the system, some
members were still entirely disappointed with it. For
example, “It [Vocera] is the worst thing ever happened. It
[the genie] just doesn’t understand. The noises here are too
loud that they never work properly.”
Vocera supports asynchronous communication through
voice messages but only unit clerks were seen to leave
messages for other members. This is understandable as unit
clerks had to handle continual incoming calls among
clerical duties, and leaving a message is an easy and direct
way to off-load information to intended recipient(s).
However, we saw a nurse leaving messages for herself
regarding patients’ medical conditions. She said it was too
time-consuming to write the details down but it was easy to
press a button and leave a message. For example, she could
just talk to Vocera about the size, color, shape and amount
of fluid coming out of the wound while she was changing
the dressing for a patient. Another nurse also said that
“leaving messages for oneself” would be very useful when
they were inside isolated rooms where they had to be
gowned up and could not write anything down. But she
could still press the button to record a message.
Vocera was rarely used to make phone calls as spoken
commands must be first recognized by the genie to make
the connection. Thus it is much easier to call on a phone.
We only saw a few nurses calling their families on Vocera
to briefly exchange affections.
We were also told an interesting phenomenon as a result of
the members being used to Vocera communications. Many
members now treated the intercom medium as ambient
noises. Many times when unit clerks used the intercom to
broadcast a message, the members disregarded it. The unit
clerk then had to sound panicked over the intercom for
urgent matters in order to draw their attention.
Identifying and locating personnel to communicate
With Vocera, a member did not need to know where the
other members were when establishing a voice link. The
following vignette illustrates how the unit clerk handled
incoming phone calls differently with Vocera.
Jane received a phone call from the radiology department
looking for the primary care nurse for the patient in room
3840. Jane then looked up the board across the nursing
station and found that it was Carrie. She put the phone call
on hold, used her Vocera to call Carrie and asked how she
would like to take the phone call. Carrie then asked her to
transfer it to the phone in her ward wing. When the phone
rang, Carrie picked it up and talked to the radiologist.
As opposed to broadcasting over the intercom and waiting
for Carrie’s response via another medium, Jane was able to
connect with Carrie directly and negotiate in the same
communication medium. Even if Carrie was inside a patient
room at the time, she would not have missed the call on her
Vocera. Thus, Vocera offered clear benefits in locating
people. However, when communication via Vocera broke
down, members would have to use the old communication
technologies. Vocera breakdown would delay the
communication process as people would usually have tried
it several times before they gave up and reverted. Incoming
phone calls can also be transferred to a member’s Vocera.
However, we did not see anyone using this feature in our
study. Most nurses were not aware of this feature; those
who knew did not use it as they found it too complicated.
Nevertheless, many nurses considered the benefit of using
Vocera to connect with their coworkers without physically
finding them outweighed the frustrations experienced with
the voice recognition at connection. Thus using Vocera to
locate and check the availability of members represented a
large fraction of Vocera use.
Off-loading information to intended recipient
The poly-motivated mobility pattern exhibited before the
deployment of Vocera has transformed into many frequent
and instantaneous off-loading of brief information through
the synchronous voice link. Most conversations conducted
over Vocera were short and dyadic. These conversations
typically involved quick work-related questions,
clarifications and notifications, location and availability
information of a coworker so that further actions could be
arranged. For example:
“Mary, can you go to 23 [Room 3823] to help Sara?”
“Ok, I’ll be there in 5 minutes.”
“Where are you, Joe?” “I’m in [ward wing] A” “Can I
come to give you a verbal [report]?” “Yeah!”
Members used Vocera to spontaneously seek information
when necessary and they could also be certain that the
information has been properly relayed and received through
the synchronous communication. However, we did not see
people using the system to converse over rich information
content. Rather, for longer and complex information
exchange, they used Vocera to obtain location and
availability information to determine if, when and where a
more detailed conversation (e.g., face-to-face) could occur.
Vocera is operated over an open voice link making it
inappropriate for communicating private or confidential
information. Before, unit clerks always relayed private
patient information to other clinicians through telephone or
face-to-face interactions. But Vocera conversations were
also perceived as similar to the telephony. The fact that
callers were usually unaware of their colleague’s location
would sometimes have unknowingly compromised the
patients’ privacy by sharing private information over the
open voice link when other people were around the other
end of the link. We were told of an incidence where a
member used Vocera to inform a nurse that her patient’s
critical lab results had come back, not knowing that the
nurse was in conversation with the patient’s family. The
nurse immediately saw an increased anxiety of the family.
Thus she would prefer that such information not be
communicated through the open voice link. Many nurses
also reported situations when they were talking on Vocera
with a colleague, the patient and their family mistook that
the nurse was talking to them, thus causing confusion.
Minimizing spatial movements
Before using Vocera, one way to minimize spatial
movements was by making poly-motivated communication
trips. But the convenience offered by Vocera to reach their
coworkers without spatially moving to find them allowed
members to frequently and spontaneously connect with
their coworkers while they were on their feet, accessing
information or providing care. For instance, a nurse used it
to call her outgoing colleague for clarifying a patient’s
treatment progress while reading the patient’s chart at the
nursing station. Thus, members perceived a substantial
decrease of distances they had to cover. One member
stated: “This device is so useful! It saves me a lot of
walking and searching. Once I heard a beeping sound from
an IV [infusion pump] in a patient room and the nurse was
not around. I just used it [Vocera] to let the nurse know
right away!” In fact, preliminary measurements showed
that Vocera reduced a nurse’s mobility in an 8-hour shift
from about 6680 to 3360 steps. Vocera was also useful
when it was not safe to leave a patient while seeking help.
With Vocera, not only could members make and receive
calls inside patient rooms, the reception was also reportedly
better as patient rooms are generally quieter. With less
overhead broadcast on the intercom, the ward has also
become quieter in general. More importantly, the
synchronous voice link provided instantaneous
confirmation of receipt of information without making extra
effort, e.g., going in person, to find out.
Vocera also reduced the trouble of “people hunt” that often
occurred before when a person did not find the intended
collaborator in the location where he/she was expected to
be. The hunt would then continue on to the next expected
location until the collaborator was correctly located.
Instead, Vocera allowed members to first locate the
intended collaborator before making any spatial movement
for further communication.
“Before, I sometimes would go to a wing to find a nurse
who was actually somewhere else, so I would have to
keep searching…wasting so much time!”
“A lot of times, we walk all the way over to the other side of
the ward to just see if somebody can come to help…”
However, a number of locations in the ward have been
reported to be dead zones for Vocera. Members working
there would then have to communicate in the old ways and
use the old technologies. This also caused frustrations to
other members who tried to use Vocera to reach the
members working in these areas.
We also observed an undesirable phenomenon as a result of
the convenience of using Vocera to connect with another
member. Many members have become less alert towards
their physical surroundings. We found that members have
become less watchful about their close proximity for the
presence of coworkers they wanted to communicate with.
They seemed to have subconsciously regarded Vocera as
the first choice for communication. We observed many
incidences where the intended collaborator was just nearby,
e.g., a few steps away, but the member made a Vocera call
without first checking the surrounding for the presence of
their colleague. This made the communication
unnecessarily dependent and worse still, the more effective
face-to-face interaction has become secondary to the
technology-mediated communication.
Prioritizing and scheduling activities
Vocera allows impromptu conversation while members
were working on a task or moving around the ward.
Although the connection on Vocera was not truly
instantaneous, due to the need for voice command
recognition, information could basically be communicated
as soon as it was acquired. Thus members no longer had to
postpone their information seeking or dissemination
activities. Such ubiquitous communications also appeared
to improve the timeliness of information flow for meeting
the dynamic needs of patient care.
Despite the frequent trouble of voice recognition, many
members concurred that the time saved by using Vocera to
locate and negotiate with people outweighed the slight
connection latency. As a result, participants had more time
to spend with their patients. “It makes a huge difference! I
can spend more time getting my work done now coz I don’t
need to go find people anymore…”
DISCUSSION
Our findings indicated mixed responses, although in general
the Vocera technology was well-received.
Positive Impact. With Vocera, members could
communicate with each other anytime and anywhere,
supporting the time-critical and mobile nature of medical
work. It basically allowed the members to continue their
task-at-hand and reduce unnecessary mobility to locate and
connect with their collaborators who were always on their
feet [3]. Our study revealed more time for patient care with
the savings in time searching for collaborators; previous
literature indicated that such time saving led to improved
medical safety [6]. Members also used Vocera to manage
the conversational progress and negotiate availability for
deciding when to switch media, typically to face-to-face
communication [4]. The synchronous voice channel was
frequently used for spontaneous quick questions,
clarifications, and coordinating work, replacing the poly-
motivated mobility practices [2]. Thus, information was
made available in a timely manner. Meanwhile, the
instantaneous off-loading of information helped reduce
memory load, which will likely decrease medical errors.
Vocera also largely replaced the use of overhead broadcast
which was interruptive and noisy. Thus Vocera brought
about a more pleasant work environment which has been
found to help improve work quality and workload [6].
Life-and-death difference. Vocera’s role in making a life-
and-death difference as demonstrated in the paper showed
that this communication technology has great value in
medical work. Currently, Vocera is only deployed among
the nursing staff in a single ward. The technology will
likely benefit the prevalent multidisciplinary collaborations
once it is widely adopted.
Unintended consequences. Vocera was perceived by most
members as the primary communication mode between
distributed collaborators. Thus they became less alert to
overhead broadcast and the presence of collaborators
nearby. These unintended consequences may have negative
impact on the information flow [1]. Thus, the intercom
system may be designed to integrate with Vocera so that
they compliment with each other and at the same time serve
as a backup should the other fails. Besides, contextual
information of coworkers would be valuable for estimating
their availability as well as their proximity before initiating
communications. On the other hand, the unanticipated use
of Vocera to leave messages for oneself indicated its
potential to include an easy-to-use and retrievable recording
feature that effectively supports dynamic work.
Unrealized expectations. Members did not use Vocera for
casual interactions with their coworkers in the first week of
its deployment. But we expected that social interaction
would more frequently take place through Vocera when
they became more familiar with the technology. We also
predicted that the informal interaction would help improve
the social awareness among the distributed members.
However, social communications on Vocera did not occur
as we had expected in its fifth month of use because the
nurses were usually busy and did not have time for social
interactions at work. They only caught up with their
colleagues during shift changes and meal breaks. The
nurses also did not conduct their shift reporting on Vocera
because of the inferior reception quality. Instead, nurses
mostly used Vocera to negotiate availability and to switch
to another communication medium for the reporting.
Primary technology problem. Communications on Vocera
helped improve information flow in our study ward. Yet,
the biggest hurdle was to make the connection. This led to
some members’ hostility towards its adoption and their
opting to only use the technology as a receiver. To them,
the technology was more a hindrance than a benefit [10].
Since Vocera offers clear benefits and has great potential in
supporting the time-critical and dynamic medical work, we
propose several design guidelines to influence the
(re)design process for this type of technology to better
support information flow among the members.
Design for easy connection. Vocera was designed for
ubiquitous communication across distance. Therefore, it is
vital that connection can be made with ease and confidence.
Since the current state of voice recognition technology is
still limited, we suggest providing an alternative command
input to ensure reliable connection. Examples include
providing an address book of all members and speed dials
for frequently called members such as the nursing station.
Design for heterogeneous adopters. The current Vocera
system provides a homogeneous product to a group of
heterogeneous members whose job nature and mobility
patterns are quite different. Knowing and designing
technologies for the differences in their interactions,
activities and use is important so that everyone benefits
directly [5]. A communication device is ideally compact
and simple to use for mobile workers. But working
primarily at the stationary information hub mainly to
properly route incoming communications to intended
recipients, unit clerks could use a different device which
allow them to easily connect with other member’s Vocera
without facing the voice recognition problem. Being able to
connect reliably would greatly facilitate the information
flow through the central hub while maintaining the benefits
of Vocera use. This is particularly important when Vocera
is to be deployed among other groups of clinicians whose
job and mobility characteristics may be different.
Design for contextual awareness. An up-to-the-moment
awareness of coworkers’ activities and locations would help
coordinate communication and be valuable when
interruptions could be detrimental or unwelcome, e.g.,
when providing comfort to a terminally-ill patient [11].
CONCLUSIONS
The motivation behind this study was to evaluate how the
novel technology impacts communication and information
flow. We found that the technology was adopted with
varied responses, from loving it to hating it. The negative
responses were mainly a result of their dissatisfaction
towards the connection experience whereas the positive
adoption was due to the convenience of connecting with
other coworkers without having to resort physically moving
to locate them. The findings from this study will inform the
overall technology design to support the nurses’
information flow in the study ward, as well as serving as a
guide to Vocera deployment in other wards.
ACKNOWLEDGEMENTS
We thank the nursing staff, unit clerks and ancillary
clinicians on the Ward of the 21st Century in the Foothills
Hospital, and our sponsors AIF, SMART, iCore and
NSERC. We also thank the reviewers for their valuable
comments.
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