BMJ No 7132 Volume 316
Information in practice Saturday 28 Febuary 1998
Communication behaviours in a hospital setting: an observational study
Enrico Coiera, Vanessa Tombs
Abstract
Objective: An exploratory study to identify patterns of communication behaviour among hospital based healthcare workers.Design: Non-participatory, qualitative observational study.
Setting: British district general hospital.
Subjects: Eight doctors and two nurses.
Results: Communication behaviours resulted in an interruptive workplace, which seemed to contribute to inefficiency in work practice. Medical staff generated twice as many interruptions via telephone and paging systems as they received. Hypothesised causes for this level of interruption include a bias by staff to interruptive communication methods, a tendency to seek information from colleagues in preference to printed materials, and poor provision of information in support of contacting individuals in specific roles. Staff were observed to infer the intention of messages based on insufficient information, and clinical teams demonstrated complex communication patterns, which could lead to inefficiency.
Conclusion: The results suggest a number of improvements to processes or technologies. Staff may need instruction in appropriate use of communication facilities. Further, excessive emphasis on information technology may be misguided since much may be gained by supporting information exchange through communication technology. Voicemail and email with acknowledgment, mobile communication, improved support for role based contact, and message screening may be beneficial in the hospital environment.
| No of call events (No of successful connections) categorised by subject and call type among 10 hospital staff | ||||||
| Page call | Telephone call | Length of observation (hours: minutes) | Total No of events | |||
|---|---|---|---|---|---|---|
| Subject and role | Sent | Received | Made | Received | ||
| 7 (consultant) | 0 | 0 | 0 | 0 | 2:55 | 0 |
| 2 (house officer) | 0 | 0 | 0 | 0 | 2:59 | 0 |
| 1 (consultant) | 0 | 0 | 1 (1) | 0 | 3:15 | 1 (1) |
| 6 (senior registrar) | 0 | 0 | 2 (2) | 0 | 2:05 | 2 (2) |
| 9 (house officer) | 3 (0) | 3 (3) | 6 (6) | 0 | 2:41 | 12 (9) |
| 8 (nurse) | 4 (2) | 0 | 4 (4) | 5 (5) | 2:09 | 13 (11) |
| 10 (house officer) | 0 | 2 (2) | 11 (10) | 0 | 2:55 | 13 (12) |
| 5 (senior registrar) | 0 | 4 (4) | 10 (7) | 0 | 3:39 | 14 (11) |
| 3 (nurse) | 1 (0) | 2 (2) | 13 (4) | 1 (1) | 3:23 | 17 (7) |
| 4 (senior house officer) | 1 (1) | 10 (10) | 9 (3) | 4 (4) | 3:39 | 24 (18) |
| Total | 9 (3) | 21 (21) | 56 (37) | 10 (10) | 29:40 | 96 (71) |
Introduction
The healthcare system seems to suffer enormous inefficiencies because of poor communication infrastructure and practices. One estimate suggested that the American health system could save $30bn a year with improved telecommunications.(1) A retrospective Australian survey of hospital admissions found that communication problems were the most common cause of preventable disability or death, and were nearly twice as common as those due to inadequate medical skill.(2)
Yet despite this evidence, there has been little examination of the communication systems within health care. What recent work has been done, mainly in the promotion of telemedicine, is driven largely by technology rather than an understanding of clinical needs.(3) Given the paucity of existing information, we report an exploratory study of communication patterns in a hospital setting.
Subjects and methods
Our study was conducted between 3 March and 22 June 1995 at Frenchay Trust Hospital, Bristol, a 500 bed teaching hospital. Medical staff were equipped with radio pagers, and several telephones were available in wards. Staff did not routinely carry mobile telephones.
We studied eight physicians from the general medicine department, ranging in grade from junior house officer to senior consultant, and two nurses from the medical wards while they carried out their routine duties. The subjects volunteered to participate in the study after we had circulated a description of the study method.
A non-participatory and qualitative observational study was conducted.(4-6) Subjects were shadowed for 2-4 hours by EC or VT during the morning or afternoon of a normal weekday. A total of 29 hours and 40 minutes of activity was observed. Researchers kept a log of events and descriptions of the events. The subjects carried a small radio microphone that recorded their speech and were able to suspend recording or retrospectively exclude recorded material. Two subjects suspended recording - one to permit a confidential discussion with a patient and the other for a private telephone call. Observations were followed by interviews with subjects to obtain clarification of observed events.
Results
Call events
We identified a total of 96 call events involving the attempted
use of the telephone or paging system, giving a frequency of one event
every 18.5 minutes, with a range among subjects from no events to one
event every 9.1 minutes (see table). The frequency among the five
"busiest" subjects was one event every 11.6 minutes. Sequences of
face to face conversation were harder to identify uniquely and were not
recorded with the call events but captured within the qualitative
data.
A person was successfully contacted in 71 (74%) of the call events. A third of 56 observed attempts to make a telephone call failed, usually because the line was busy. There is reason to suspect that the observers influenced staff behaviour and that the usual connection rate was lower. For example, while all of the observed staff answered their pagers (21 events), only three of the nine pages they sent were answered.
In 91 of the 96 call events we were able to identify the role of
both the caller and receiver, including non-observed
participants. Pooling these data produced a wider picture of the
communication traffic between different groups in the hospital (see
figure). However, since only two nurses were studied, the tr Consultants were involved in almost no call events (one of the
96). While junior medical staff bore the brunt of calls received, the
nurses sent a similar number of calls. There is a well recognised flow
of communication events from nursing to medical staff,(7,8)
and we also observed this, with 16 of the 20 events between
nursing and medical staff initiated by nurses.
While it is recognised that medical staff receive many paging
interruptions,(7,8) we found that medical subjects
generated about twice as many outgoing events (43) as they received
(23). Overall, subjects g
Qualitative data All six calls to the switchboard, and most of the 19 calls to
secretaries and administrative staff, were seeking contact information
for individuals in specific roles (such as the cardiac surgeon on
call). Some subjects were unsure about which role could assist them
with a task (for example, "Who do I call to arrange a venogram?").
One specialist nurse who dealt exclusively with elderly patients was
repeatedly paged in error to see patients outside her responsibility.
The hospital's telephone directory was partly structured around roles
but gave no indication of what tasks or responsibilities were
associated with a role.
When interviewed some of the doctors indicated that they assessed the
urgency of a page by the number of times they were called and the
origin of the call. For example, a page from their home ward suggested
to some that nursing staff were calling with minor tasks, and they
would not reply unless paged twice in succession, which would indicate
urgency. Similarly, failure to get a reply to a page within a short
period was often taken to mean that no answer was coming, with the
caller moving on to another ward.
We also found examples of inefficiencies with team communication. For
example, a senior consultant tried to transfer a patient to another's
team by delegating the request, involving at least two intermediaries.
By the time the second consultant received the message it was
substantially distorted and had the potential to endanger the patient.
We also observed problems with cooperative tasks when team members were
geographically separated. In one example, a house officer and senior
house officer were separated and duplicated an order for a portable
x ray because they were unaware of each other's
actions. The radiographer consolidated the two requests after calling
for clarification. Our results should be understood within the limitations of the
methodology adopted. Firstly, the study was observational, so the
resulting qualitative descriptions may not have statistical
significance. Further, only a small cross section of hospital workers
was studied, and different results might come from another population.
Finally, it is likely that subjects altered their behaviour because of
the presence of observers.
High use of synchronous communication methods Interruption is related to the type of communication method chosen.
Synchronous communication occurs when two individuals participate in a
conversation at the same time, such as using the telephone.
Asynchronous communication occurs when the exchange does not require
both to be active participants at the same time, such as exchanging
letters. It is a characteristic of synchronous communication that a
request to speak creates an interruption, but with an asynchronous
message the receiver chooses the moment to check or reply to the
message. Why did subjects not use less interruptive asynchronous
methods whenever possible? Several explanations for a bias to
synchronous communication seem plausible (see below).
Preference for information through conversation The reliance of the subjects on discussion to resolve information needs
has suggested to others that this is in response to poor printed or
computer based information sources.(13) Another hypothesis
is that communication is actually the preferred mechanism for gathering
information. Clinical problems are often poorly defined, and
clarification can be obtained through conversation. Thus, medical staff
may opportunistically interrupt each other because face to face
discussion is highly valued but difficult to schedule, and any
opportunity is avidly seized.
Role based contact
Communication policies often unsound
Further research Our study also suggests that much could be gained by supporting
information exchange through communication. While informatics almost
exclusively emphasises computer information systems, the telephone is a
part of a human information system and may often be preferred because
it is better suited to many clinical tasks and settings than computer
based solutions. The implications of this change in emphasis for the
form and role of the electronic medical record are considerable.
Some of the communication problems we identified suggest ways of
improving existing processes or introducing technological solutions to
support the process of care (see below).
This study would not have been possible without the cooperation
of Frenchay Hospital. In particular, we are indebted to the willing
subjects who allowed us to scrutinise their activities and to Dr Ian
Mackintosh who afforded us the authorisation and backup we needed.
Julie Parker provided much useful guidance with the psychological
aspects of this paper, and Jo Reid and Siani Pearson assisted us in the
data collection.
Contributors: EC initiated the study, codesigned the study
protocol, participated in data collection, analysed five subjects in
depth, collated and analysed the quantitative data on call events,
formulated the hypotheses for synchronous bias and information seeking,
analysed communication policy and role based contact, and wrote the
paper. VT codesigned the study protocol, participated in data
collection, analysed five subjects in depth, analysed team
communication patterns, participated extensively in the overall
qualitative data analysis, and contributed to the paper. EC is
guarantor for the paper.
Funding: This study was funded by Hewlett Packard.
Conflict of interest: Hewlett-Packard is a manufacturer of
computer equipment and medical devices.
(Accepted 13 January 1998)
Hewlett-Packard Laboratories, Enrico Coiera,
senior project manager
Vanessa Tombs,
senior member of technical staff
Correspondence to:
Dr Coiera,
email: ewc@pobox.com
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In: Proc AMIA Annu Fall Symp 1996:17-21.
Communication traffic based on call events between different
groups in the study hospital, including non-observed participants in
calls.
It often required a series of calls to book an investigation. For
example, subject 5, a senior medical registrar, made eight telephone
calls (three failed to connect) and one page over 54 minutes to arrange
one computed tomographic scan. Subject 8, a nurse, made two pages (both
unanswered) to medical staff and two telephone calls to a clinic over
12 minutes in an unsuccessful attempt to organise an endoscopy. Such
sequences usually involved the caller following a trail of telephone
numbers, reflecting in part the decentralised organisation of some
departments. Subject 5 had to speak to a variety of radiology
administrative staff, radiographers, and radiologists before he could
complete the scan booking.
Most subjects generated and received multiple interruptions,
either face to face or through call events. In the interviews after
observation the subjects rarely considered the effect that a telephone
call or page would have on the other party. Their actions could thus be
characterised as habitual and selfish in that they vDiscussion
During the study, staff seemed almost to favour interruptive
communication mechanisms - face to face discussion, paging, or
telephone - over less interruptive methods. Some nursing staff did write
down tasks for doctors at the ward desk in preference to paging them,
but this was uncommon. There are well known psychological costs
associated with interruption, leading to diversion of attention,
forgetfulness, and errors.(9-11) Further, interruption
often requires rescheduling of work plans. The interrupt driven nature
of the hospital work environment thus has the potential to generate
extra costs in staff time and efficiency, although there was no
evidence in this study that patient outcomes were adversely affected.
The study hospital, like many at present, did not provide
asynchronous channels such as voicemail or email,(12) thus
biasing choice towards synchronous mechanisms. There seemed to be a need in such an event driven environment to deal
with tasks as they arose. For a communication task to be "ticked off
the list," subjects seemed to want an immediate acknowledgment of
receipt of a message. Acknowledgment was possible with synchronous
channels but not with the available asynchronous channels. Most subjects did not seem to reason about the consequences of their
communication actions, their use of resources, or alternative
approaches.
The high call traffic observed between medical staff (42%) is in
accordance with a study of office based c
A quarter of call events were associated with
id
Some subjects had clear policies about the way they managed
their communication - for example, to decide whether a page would be
answered. Such inferences about the intention of caller or receiver
were unsound on a number of grounds. Firstly, the assessment of urgency
by doctors and nurses is likely to be different. Situations judged to
be non-urgent by nurses have been shown to require medical assessment
as much as ones deemed urgent.(16) Secondly, these paging
policies were based on minimal information that could not support
robust conclusions about the originators or receivers of calls, their
level of busyness, or their intention. Since the paging system was the
main channel for calls between medical and nursing staff, this is
likely to be a problem area for communication.
Our results are based on a small study, and there is an immediate
need to characterise accurately the size and form of different
communication flows, including face to face conversations. For example,
while past analyses of paging behaviour focused on the incoming burden
created for doctors,(7,8) our data suggest that doctors and
nurses are net generators of traffic. Secondly, we have suggested that
communication traffic is apparently higher than necessary, resulting in
an interrupt driven work environment. Our hypotheses about the causes
of these interruptions need to be tested, and in particular we need
quantitative analyses to find out whether the suspected negative
consequences are actually having a substantial impact either on
clinical workers or on patient care.
There seems to be a need for individual workers to consider
carefully the effects of their communication behaviour on their own
efficiency and effectiveness as well as on that of others. Our subjects were highly mobile during their working day. The mobility
of staff and the difficulty contacting these "moving targets"
suggest that support for mobility through the use of wireless
technology (such as cellular telephones) might be
beneficial.(17) Early attempts to introduce message boards in order to reduce paging
traffic have failed.(18) They required medical staff to
travel to central boards, and nursing staff did not have any feedback
about when messages were likely to be read or acted on. Providing
messaging facilities such as voicemail and email might succeed in
decreasing the reliance on synchronous channels, partly because they
can be accessed wherever staff are working.(19) However, our
study suggests that such messaging services may need to provide
acknowledgment to reassure staff that messages have been acted on. Many of the communications observed were to occupants of specific roles
rather than named individuals. A role based database akin to
Yellow Pages could dynamically associate roles with
people as assignments change and could be accessed easily on a computer
network to reduce the effort and error of seeking such
information.(20) Recipients of calls in our study had no information to screen calls
meaningfully. However, information such as the caller's identity,
perceived urgency of task, and nature of task can be attached to email
and voicemail, and these features may provide an added incentive to
their routine adoption. Currently, there is no means by which the
recipient of a call can "pre-publish" their availability to help
prospective callers, but such systems are technologically
feasible.(20) Supporting collaboration among geographically separated team members to
communicate the state of individual tasks may reduce duplication of
effort and communication costs. For example, mobile computers could
allow teams to work from a common task list. Key Messages
We observed communication behaviour among 10 hospital based
healthcare workers Communication behaviours resulted in an interruptive work
place, which seemed to contribute to inefficiency in work practice Medical staff generated twice as many interruptions via
telephone and paging systems as they received, and possible causes for
this included a bias by staff to interruptive communication methods, a
tendency to seek information from colleagues in preference to printed
materials, and poor provision of information in support of contacting
individuals in specific roles Staff were observed to infer the intention of messages based
on insufficient information, and clinical teams showed complex
communication patterns, which could lead to inefficiency We conclude that hospital staff may need instruction in
appropriate use of communication facilities and that some communication
technology - voicemail and email with acknowledgment, cellular
telephones for mobile communication, improved support for role based
contact, and message screening - may be beneficial
Bristol BS12 6QZ
School of Computer Science and Engineering,
University
of New South Wales
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