St. Jacques et al
demonstrated faster call response times via HCDs than via pagers.7
Importantly, we found subjects themselves perceived faster response times than with pagers thereby improving the chances that users appreciate the HCD system.16–18
Like St. Jacques et al
, the subjects we interviewed and observed expressed concerns about personal health information being broadcasted as well as frustration with the inconsistent command recognition within the OR's noisy environment. Unlike St. Jacques et al
, we discovered that anesthesiology staff did not uniformly prefer pagers to the HCD system; rather, preference for pagers and HCDs depended on the perceived availability of message recipients and perceived urgency of a communication.
Some results from this study parallel Richardson's and Ash's findings. Users in this study felt that interconnectedness increased the number of unwanted interruptions. To manage interruptions, subjects desired ways to control how they received calls, either by having the HCD system automatically prioritize calls or by assuring that users are knowledgeable about when and where not to make HCD calls. The desire to be interconnected with staff but not be interrupted by staff reflects the communication access-control balancing act.5
That this phenomenon arose in the OR environment, as it has in other clinical settings, leads us to believe that it is a common challenge associated with HCD systems. Further technical sophistication may address this concern. In the mean time, organizations would do well to address the issue with training.
Effective HCD training would go beyond individual use to group use of HCD systems. The additional focus requires explicit acknowledgment that an HCD system supports group processes, group decision-making, and collaboration.19
We therefore encourage organizations to consider group aspects of communication such as interruptions, patient confidentiality protocols, and agreed upon HCD communication etiquette. In addition, address-book updates such as new nicknames and new HCD functions could be systematically communicated to staff rather than leaving knowledge diffusion to social grapevines. Finally, training could give group-based feedback that conveys how well a group is using the system or how well the system is performing.
Subjects were uncomfortable relying on the HCD system for urgent or emergent situations. The recurring phrase, ‘when it worked’ revealed a degree of mistrust. This issue highlights how the HCD system itself heavily relies on the proper functioning of a wireless network system; that is, the HCD system and the wireless network system are not one and the same. This is a critical distinction for assessing the HCD system's reliability. To the subjects in this study, however, the distinction was of little concern. What was of concern to the users was that HCD calls were either successful or not. Further research is required to determine a reasonable level of reliability for OR and other clinical settings.
Anesthesiology staff described having to choose one or more communication channels through which to contact one another. They described traversing mental checklists that took into account a message's urgency as well as users' perceived availability and before sending a communication asking themselves: ‘How available is the person or persons to receive a call?’ and, ‘On which device would it be best to call?’ Traversing these mental checklists was described as tiring as a workday progressed. Therefore, it appeared the mental processes were adding cognitive effort to communication.
Given the ‘multilayered approach to communication’2
in many hospitals, it is reasonable to expect that HCD users in clinical settings outside of surgical suites experience a similar cognitive challenge. We feel it would be valuable to learn if the effort or stress associated with choosing communication channels extends to other clinical settings, and if the phenomenon is associated with HCD systems alone or if it is associated with the number of communication ‘layers’ a hospital utilizes. The answers to these questions could have profound implications for how hospital communication networks are designed and supported, as well as how users communicate through the variety of ICTs that are increasingly available to them. We believe that further research on how layers of ICTs impact clinician cognitive load is warranted.
We conclude that the HCD system caused changes in communication whereby users appreciated communication access that provided situational information and workflow support. This result corroborates previous findings that HCD users perceive fewer communication delays. However, communication access costs users in terms of interruptions and concerns about revealing protected health information. Communication changes brought about by HCD systems require effective user training and organizational strategies that address user communication overload, team-based communication, patient privacy protocols, and address-book updates.