Volume 47 Issue 1, February 2020, pp. 18-26

Communication skills are paramount for a successful veterinary curriculum. Technological advances have improved communication processes, and the way instruction is delivered. Yet, with these advances come challenges such as email overload, increased interruptions, and miscommunications. Time is a valuable commodity at any high caseload veterinary teaching hospital. When increasingly more time is spent sending and receiving emails, text messages, pages, and calls in lieu of more focused clinical teaching, then the modes of communication and traditional learning theories need to be evaluated. An effective mode of communication is needed to reduce information overload and miscommunication. This article describes lessons learned from a pilot study to determine if a team-based messaging application could improve a surgical team’s communication by having all forms of transmitted media directly related to their scope of work accessible to everyone on the team in one real-time digital platform (Slack). Fifteen members of a university-based surgical team were enrolled into the study and provided with surveys at specific time points to evaluate the efficacy of an internet-based team communication tool during a 3-month period. Results of our study showed an overall perception of improved communication among team members when using a team-based communication platform. Recommendations are provided to address team member’s underutilization of the platform, which resulted in duplicate messages and miscommunication. We conclude an initial adoption by staff members is essential when implementing significant shifts in communication platforms.

Efficient and effective communication between veterinarians and their staff is paramount in providing optimal care to patients. Communication is considered a core clinical skill within veterinary medicine curriculums.1,2 Veterinarians typically work in teams, especially in university settings, making communication an essential part of clinics. Electronic communication such as electronic mail (email), pagers, and smartphones play a prominent role in the delivery of veterinary care. However, electronic communication can have unintended consequences such as inefficient communications, unnecessary interruptions or miscommunication. When surgical teams are not communicating effectively, there can be confusion, delays, dissatisfaction, and ultimately compromised patient care.3 The most prevalent form of communication is email and over the past decade, email archives have grown tenfold, and inboxes continue to increase, resulting in “email overload” consisting of work emails, personal emails, and junk/spam emails.4,5 With advancements in technology, smartphones have moved beyond personal lives and into the realm of healthcare. Smartphones bring a host of other unintended communication consequences: unsecured messaging increased interruptions due to direct calls, and the frustration of being contacted for unrelated items.6 With so many modes of digital communication with different issues, it would be prudent to provide a veterinary surgical team a way to streamline communication with fewer interruptions.

The busy nature of a university-level surgery service provides an ideal environment to pilot test emerging internet-based team communication tools that allow team members easier access to information, quicker responses, and greater overall transparency.7 The Association of American Veterinary Medical Colleges (AAVMC) recommends that veterinary medical professionals need to be adaptive and responsive to rapidly changing technology.8 Educators are beginning to adopt different pedagogical principles and theories to understand the network phenomenon of communication. Connectivism is a learning theory used by some medical educators to help guide their use and innovation of emerging technologies.9 The connectivism theory seeks to explain learning in the rapidly changing digital world where knowledge is distributed across networks and learning takes place within networked learning communities.10

Two connectivism principles that are integral to the learning process are (1) seeking out accurate, current information while (2) filtering out secondary or extraneous information. Extraneous information or interruptions are a problem in the healthcare industry. According to Dr. Mohseni, an emergency physician in Washington, DC, emergency physicians are interrupted on average 10 times per hour, which increases the risk of medical error. He welcomes the idea of using internet-based team communication tools (e.g., Slacka, HipChatb) to reduce interruptions and medical errors.11 A 2014 study of 400 hospitals found that inefficient communication costs each of the hospitals approximately $1 million per year during patient admissions, emergency care coordination, and patient transfers.12

Traditional methods of communication are also being reevaluated. According to The New York Times and Time magazine, email is being challenged by internet-based team communication tools (Flowdock, HipChat, Slack, and Ryver) that allow individuals to collaborate in large groups, provide greater information transparency, ease of setup and are extremely customizable.13,14

These applications bring different modes of communication together that can allow for ongoing conversation streams, provide additional transparency for team members not directly involved in a conversation stream (they can still view a team conversation), and categorize conversations. Filtering communication centrally can result in fewer overall messages and more time for veterinary faculty to train students and residents, perform research, practice medicine and engage with the veterinary college and the outside community.

The use of internet-based team communication tools is underexplored in the veterinary medical literature. These new software platforms could benefit university-level surgical teams that must be able to communicate effectively about various aspects of surgery including, but not limited to, hospitalized patients, patients awaiting diagnostic results, future patients, resident training, student teaching, and availability. Effective communication will save time, decrease unnecessary redundancy, and allow for more teaching and training. An effective communication improvement strategy should evaluate alternatives and enhancements to electronic communication that can improve the delivery of information, enhance teamwork and collaboration and ultimately improve patient care. This blinded survey-based pilot study evaluated if a popular team-based messaging application (Slack), which embodies the principles of connectivism, would improve a surgical team’s communication. Our main hypothesis was that communication and time management would improve by having all emails, pages, text messages, and attachments segmented by topics (channels) within one searchable platform. We also hypothesized the younger residents would most readily adopt and use the tool as compared to faculty and technicians. Finally, we sought to see if there was a difference in adoption of the tool between faculty, residents, and technicians, to determine the feasibility of a full-scale implementation.

To evaluate the effectiveness of communication and productivity, researchers from the University of Florida (UF) Department of Health Services Research, Management and Policy and the College of Veterinary Medicine’s Department of Small Animal Clinical Sciences disseminated surveys before the implementation of Slack on day 0 (pre-Slack), day 30 (mid-Slack) and within a final follow-up survey on day 72 (final-Slack). Survey announcements were made and participants were given 5 days to complete each survey. Before the implementation of the pilot study, presentations and training were conducted to acclimate the surgical team to the team-based messaging application. The presentation provided an overview of our current communication issues and the consequences well as a video provided by Slack detailing their product features (https://www.youtube.com/watch?v=B6zVzWU95Sw). The presentation also introduced the concept of communication channels and the designated channels for communication within the surgical team along with example scenarios for using Slack. In addition, 1:1 training was provided on a volunteer basis for those participants wanting to be more familiar and comfortable with Slack before the rollout.

Study Sample

The Small Animal Clinical Sciences Surgical Department at the University of Florida was chosen to pilot test Slack. The entire surgical department was grouped into one team. The surgery team consisted of 17 employees: 6 surgeons, 6 residents and 5 technicians who were surveyed on 3 different occasions. One surgeon (author) was excluded from the study to avoid any study bias, for a total of 16 subjects in the study. There were 9 males and 7 females in the study group (median age 32 years, range 24–70 years). The surgery service performs orthopedic, soft tissue, and occasional neurosurgery Monday through Friday. The surgery service also covers any surgical emergencies 365 days per year. The service is further subdivided into three parts, which are referred to as the orthopedic, soft tissue, and priority services. There is one faculty member and 1–2 residents assigned for each of the soft tissue and orthopedic services. For the priority service, which serves as an overflow service for both soft tissue and orthopedic services, there is one faculty member and no residents assigned to the service. The orthopedic and soft tissue services usually comprise of 6–8 senior or junior students. Faculty and residents not actively on clinics are usually performing research, teaching in the classroom or surgical lab, working on various committee projects, studying, or attending conferences.

Slack Environment

The surgery team was provided a conditioning period of 2 weeks. The senior author had over 1.5 years of experience using Slack and provided in-person tutorials to all participants on the use of Slack as well as explained the overarching goal of improving the communication of the surgery team. As mentioned above, tutorials were conducted using PowerPoint tutorials and live demonstrations. Users were also encouraged to help define and create channels for the team. For example, channels created in the study included “ortho callbacks,” “soft tissue scheduling,” and “ortho Dr-To-Tech-Talk.”

Survey

To evaluate the effectiveness of communication and productivity, researchers from the UF Department of Health Services Research, Management and Policy and the Department of Small Animal Clinical Sciences developed a pre-Slack (day 0), mid-Slack (day 30), and final-Slack (day 72) survey (see Appendix 1). The pre- and mid-Slack surveys were identical. Respondents were asked to choose their current position (surgeon, resident or technician), followed by a series of questions designed to evaluate the effectiveness and difficulty in communicating with other coworkers. Aside from knowing their position, the evaluators did not know the respondents’ identifications. The final-Slack survey was additionally designed to evaluate the overall effectiveness of Slack. Questionnaire items were compiled from a review of the literature from communication surveys related to timeliness, efficiency, and collaboration through the use of emails.1518

Surveys were administered to all participants in the study and were kept anonymous. Response to the surveys was not mandatory and not all participants responded to the distributed surveys. On average there was an approximate 28% response rate by all participants. Results of Slack usage are summarized by user and role (resident vs. technician vs. faculty) in Table 1.

Table

Table 1: Slack message delivery by role and individual

Table 1: Slack message delivery by role and individual

Slack users Messages sent Files uploaded
Tech 1 382 69
Tech 2 240 17
Tech 3 123 8
Tech 4 37 6
Tech 5 5 2
Total (%) 787 (54%) 102 (68%)
Surgical Fellow 78 6
Resident Year 1 84 6
Resident Year 2 319 21
Resident Year 3 0 0
Resident Year 4 7 0
Resident Year 4 52 2
Total (%) 540 (37%) 35 (23%)
Doctor 1 72 2
Doctor 2 24 8
Doctor 3 13 0
Doctor 4 13 2
Doctor 5 1 0
Total (%) 123 (8%) 12 (8%)
Overall total 1450 149

When evaluating residents alone, three of five of the respondents found that Slack saved time. However, there was no obvious increase seen in the perceived amount of time spent on patient care, as estimated by the percentage of time devoted to patient care by respondents. Four of five respondents did not feel more connected or involved with the team at the time of final follow-up. Two of five thought Slack helped them stay on task and organized. Finally, three of five thought Slack contributed to the better use of time. Of the responding residents, three residents wrote they would recommend Slack if the whole team was willing to use it. The last respondent would not recommend Slack to others and felt it did not improve communication.

When evaluating technicians, three of four of the respondents found that Slack saved time, however, similar to the residents’ responses, we saw no obvious increase in the perceived amount of time spent on patient care. Three of four respondents felt more connected or involved with the team at the time of final follow-up. Three of four thought Slack helped them stay on task and organized. Finally, three of four thought Slack contributed to a better use of time. Similar to residents, technicians tended to verbally express that in order for Slack to be effective, all members need to be onboard and willing to be engaged. Of four responding, three of them wrote they would recommend Slack as long as the entire team was willing to use Slack.

None of the surgeons in the study found that Slack saved time. Three of four surgeons felt more connected or involved with the team at the time of final follow-up. None of the surgeons felt that Slack helped them stay more on task or organized. Finally, only two of the responding surgeons thought Slack contributed to a better use of overall time. Of the four responding surgeons, two of them wrote that they would not recommend Slack while two of them wrote that to recommend Slack, it is important for everyone to be engaged. Communication and perception of time use and savings results among faculty surgeons, residents, and technicians are summarized in Table 2.

Table

Table 2: Communication and time outcomes during final-Slack* survey, by role

Table 2: Communication and time outcomes during final-Slack* survey, by role

Surgeon (%) Resident (%) Technician (%) Mean Total (%)
Overall, do you think Slack has improved your ability to communicate effectively with people in the surgery team? Yes 2 (50%) 3 (60%) 3 (75%) 2.13 8 (62%)
No 2 (50%) 2 (40%) 1 (25%) 1.80 5 (38%)
Overall, do you think Slack has saved you time? Yes 0 (0%) 3 (60%) 3 (75%) 2.50 6 (46%)
No 4 (100%) 2 (40%) 1 (25%) 1.57 7 (54%)
Do you think the use of Slack may contribute to better use of your time? Yes 2 (50%) 3 (60%) 3 (75%) 2.13 8 (62%)
No 2 (50%) 2 (40%) 1 (25%) 1.80 5 (38%)

* final-Slack survey (day 72)

To our knowledge, our pilot study is one of the first reported attempts to introduce a team-based messaging application into veterinary medical education. We did not expect the level of difficulty experienced by some of the members of the surgical team to adapt to Slack. Before initiating the study, multiple meetings to demonstrate and discuss the methodology of Slack were attended but there may have been some misunderstanding or comfortability about using a new software which limited participation by some members. Perhaps additional time and more concerted training using Slack would have helped those who were not as engaged in piloting Slack. Of interest, younger residents and technicians were substantially more engaged in the platform than their older counterparts. It was anticipated that once team members understood how a team-based messaging application could improve their work environment, they would participate fully to properly evaluate the software. Some of the responses on the final survey were negative toward Slack and we suspect, but cannot prove, that those comments were generally from those who did not attempt to utilize Slack fully. A response that epitomized the concern to recommending the implementation of Slack in other departments was “if everyone is on board it is a good tool; if everyone isn’t, then you may end up sending two of everything, both in Slack and an email.” Therefore, it is important to emphasize that Slack is not separate from email but an enhancement that combines email with the strengths and features of current social media technology.

Slack may be considered a form of Enterprise Social Media (ESM) which was defined by Leonardi as a: web-based platform that allows workers to (1) communicate messages with specific coworkers or broadcast messages to everyone in the organization; (2) explicitly indicate or implicitly reveal particular coworkers as communication partners; (3) post, edit, and sort text and files linked to themselves or others; and (4) view the messages, connections, text, and files communicated, posted, edited, and sorted by anyone else in the organization at any time of their choosing.19

Studies attempting to understand the acceptance of ESM in the workplace have suggested that not all workers using the technology see the benefits of ESM because of their own pre-existing “frames” of what type of communication is appropriate in the workplace.20 The principles of communication in Slack are based on tools that were first available outside the workplace. Given the open, expressive perception of social media, individuals’ existing frames for technology may be incongruent with expectations for appropriate or effective work behaviors.20 This in turn, may result in a preexisting frame for ESM, leading to a negative effect on the desire to use the newly introduced technology in the workplace. In other words, our participants’ existing familiarity with technology may have resulted in frames formed outside of the workplace, making it difficult for participants to shift frames to an organizational context.20 It is possible these preexisting frames regarding ESM contributed to our lack of Slack utilization.

Theories such as connectivism or the diffusion of innovation can help guide decisions about changing technology. Diffusion of innovation provides insight on individual’s propensity to adopt new technology.21 With more evaluation and studies on team-based messaging applications, veterinary medicine has an opportunity to be an early innovation adopter and potentially reap the benefits early on to improve patient care, teaching, and communication rather than wait until the innovation reaches critical mass and is universally adopted.

Limitations

As with many pilot studies, the small sample size hampers the generalizability of the findings. Another limitation is the incomplete survey participation as well as lack of Slack utilization and embracement from a few members of the team. It is our perception that we failed to achieve initial individual acceptance of Slack in some of the participants despite the surgical team’s firm commitment to pilot Slack during the introduction phase. As a result of not having complete participation, there were data sets that we were not able to readily compare, such as differences in email usage versus the number of Slack messages generated. Participants being out of town, ill, or off clinics during certain parts of the pilot period may explain participation and Slack usage. Another limitation was the effect on employees caused by the radical change from sending email to using an entirely new team-based messaging application. Employees reluctant to change are all too familiar in both small and large organizations. For example, success rates for radical corporate reengineering for Fortune 1,000 companies are well below 50%.22 Some of this resistance may be contributed to the comfort level with technology, which may limit some of the surgical team from fully embracing the new team-based messaging application.

Recommendations

The pilot study revealed several areas that need improvement before attempting a full-scale rollout. First, when introducing any new software or technology, investing an adequate time upfront in staff development may be essential to adoption. We learned that the initial workshops may have misled the presenters about the willingness to adopt the new software. The presenters had previously used Slack and knew the potential benefits and mistakenly assumed the entire surgical team staff could also see the positive benefits, but in reality, some the participants were still apprehensive. In academic settings staff who attend workshops to improve their use of technologies often will complain after the training that they do not know where to begin and that is was not a good use of their time.23 Therefore, the process of engaging staff in the preparedness phase is critical, consensus building needs to be more than simply agreement and head nodding during the introduction but requires prescribed follow-up. For example, using a survey after the introduction with questions to gauge organizational fit and resistance is a strategy used by large corporations to improve the success of implementing new software applications.24 Further research after the initial pilot study suggests future questions should be developed using a technology readiness index (TRI) that measures the individual’s propensity to embrace and use cutting-edge technologies and the Technology Readiness and Acceptance Model (TRAM) to predict an individual’s technology-adopting behavior.25,26

Another area we learned from the pilot study results is that when making a case for a new technology, it is important to try and frame the usage toward the future. The recommendation is to place more emphasis contrasting team-based messaging application against what already exists. From a sociological perspective, individuals often interpret new technology in terms of old technology, the first automobile was called a horseless carriage, the point being it takes time to let go of an old technology’s meaning and usage.27,28 We found this particularly true based on the comments about sending an email as a backup or to reach individuals that were reluctant to completely embrace the use of Slack.

Finally, we recommend a continuous process be in place to monitor the usage patterns. Each month when the survey results are downloaded, they should be evaluated. If lower usage of the team-based messaging application is identified, then follow-up meetings should be considered to remind the team members of their original commitment as well as re-emphasize the potential benefits. The original survey questions are provided in the appendix for reuse and modification with the caveat that future IT readiness questions should be added for future rollouts of team-based messaging software. Despite our experience, we feel that there is a place for cloud-based communication tools such as Slack in the veterinary profession as other groups in the medical profession have been able to successfully integrate Slack with 100% agreement on improved communication.29

Results of this pilot study suggest that buy-in is an essential factor in successful implementation of a team-based messaging software, such as Slack. Additional studies on larger adoptions of team-based messaging applications are needed. We see the strong potential for changing the status quo and improve the communication process in veterinary medical education; we also appreciate the many challenges to bring new software technology into wider use, and in evaluating its use. We think that the field would benefit from more discussion and beta testing of emerging technology that mirrors the AAVMC recommendation that veterinary medical professionals need to be adaptive and responsive to rapidly changing technology. Often change is not easy, and it is resisted, but as educators, it is our responsibility to step out of our comfort zone and strive for improvement. We hope that our experience will be helpful for others seeking to implement similar changes.

Notes

a Slack Technologies, San Francisco, USA, https://slack.com/

b HipChat, Atlassian, https://www.atlassian.com

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A-1. Surgery Team Pre- and Mid-Slack Evaluation
  1. Please state your current position at the University of Florida Animal Hospital

    • Surgeon

    • Resident

    • Technician

  2. How would you rate your communication with technicians?

    • Excellent

    • Very good

    • Good

    • Fair

    • Poor

  3. How would you rate your communication with surgeons?

    • Excellent

    • Very good

    • Good

    • Fair

    • Poor

  4. How would you rate your communication with residents?

    • Excellent

    • Very good

    • Good

    • Fair

    • Poor

  5. How would you rate your communication with other technicians in the surgery service?

    • Excellent

    • Very good

    • Good

    • Fair

    • Poor

  6. How hard is it to communicate with people when they are off clinics (and get a timely response)?

    • Very difficult

    • Difficult

    • Somewhat difficult

    • Neutral

    • Somewhat easy

    • Easy

    • Very easy

  7. How hard is it to relay important messages to a surgeon/resident when they are in the OR?

    • Very difficult

    • Difficult

    • Somewhat difficult

    • Neutral

    • Somewhat easy

    • Easy

    • Very easy

  8. How do you feel about emails?

    • I can handle more

    • I receive too many

    • I have just the right amount

  9. How do you feel about phone calls/voicemails?

    • I receive too many

    • I can easily take more

    • I have just the right amount

  10. Which do you wish you were better informed about? [Please Check All That Apply]

    • Waiting Clients

    • Consults to be performed

    • Completed diagnostics

    • rDVM phone call that needs to be made

    • Patient ready in OR

    • Completed lab results

    • General schedule for the week

    • Add on cases

    • Other; please list below

  11. Do you feel our service can communicate better?

    • Yes

    • Maybe

    • No

  12. Please list the total number of items AND unread messages that are currently in your work email.

    • Total Number of Items

    • Unread Messages

  13. Please list the total number of folders that are currently in your work email.

  14. On average, what percent of your time per day is spent doing the following (Total percent of all tasks must be equal to 100)

    • Desk work

    • Phone (receiving/making calls and answering voicemails)

    • Email

    • Scheduled meetings

    • Unscheduled meetings

    • Patient Care

    • Other

  15. On average, please state the percent of unproductive time spent searching for emails, documents, and other correspondence.

  16. Please take a moment to answer the following question. If the number of electronic communications you receive daily could be reduced and centrally located in one location, how and why could this improve patient care as well as facilitate additional learning opportunities?

A-2. Surgery Team Final-Slack Evaluation
  1. Please state your current position at the University of Florida Animal Hospital

    • Surgeon

    • Resident

    • Technician

  2. How would you rate your communication with technicians?

    • Excellent

    • Very good

    • Good

    • Fair

    • Poor

  3. How would you rate your communication with surgeons?

    • Excellent

    • Very good

    • Good

    • Fair

    • Poor

  4. How would you rate your communication with residents?

    • Excellent

    • Very good

    • Good

    • Fair

    • Poor

  5. How would you rate your communication with other technicians in the surgery service?

    • Excellent

    • Very good

    • Good

    • Fair

    • Poor

  6. How hard is it to communicate with people when they are off clinics (and get a timely response)?

    • Very difficult

    • Difficult

    • Somewhat difficult

    • Neutral

    • Somewhat easy

    • Easy

    • Very easy

  7. How hard is it to relay important messages to a surgeon/resident when they are in the OR?

    • Very difficult

    • Difficult

    • Somewhat difficult

    • Neutral

    • Somewhat easy

    • Easy

    • Very easy

  8. How do you feel about emails?

    • I can handle more

    • I receive too many

    • I have just the right amount

  9. How do you feel about phone calls/voicemails?

    • I receive too many

    • I can easily take more

    • I have just the right amount

  10. Which do you wish you were better informed about? (Please check all that apply)

    • Waiting clients

    • Consults to be performed

    • Completed diagnostics

    • rDVM phone call that needs to be made

    • Patient ready in OR

    • Completed lab results

    • General schedule for the week

    • Add on cases

    • Other; please list below

  11. Do you feel our service can communicate better?

    • Yes

    • Maybe

    • No

  12. Please list the total number of items AND unread messages that are currently in your work email.

    • Total number of items

    • Unread messages

  13. Please list the total number of folders that are currently in your work email.

  14. On average, what percent of your time per day is spent doing the following? (Total percentage of all tasks must equal 100.)

    • Desk work

    • Phone (receiving/making calls and answering voicemails)

    • Email

    • Scheduled meetings

    • Unscheduled meetings

    • Patient care

    • Other

  15. On average, please state the percent of unproductive time spent searching for emails, documents, and other correspondence.

  16. Please take a moment to answer the following question. If the number of electronic communications you receive daily could be reduced and centrally located in one location, how and why could this improve patient care as well as facilitate additional learning opportunities?

  17. Overall, do you think Slack has improved your ability to communicate rapidly and effectively with people in the surgery team?

    • Yes

    • No

  18. Overall, do you think Slack has saved you time?

    • Yes

    • No

  19. Even if you didn’t write messages frequently on Slack did you feel more connected or involved with the team by being able to see communication streams?

    • Yes

    • No

  20. Do you feel that Slack communication helped you stay more on task or organized?

    • Yes

    • No

  21. On a scale of 1–10:

    • How open are you to change?

  22. Do you think the use of Slack may contribute to better use of your time?

    • Yes

    • No

  23. Did you have enough time to adapt and really try to test the functionality of Slack? Please take a moment to reflect and honestly answer this question because your response is very important.

  24. If a coworker in another department/service asked for your advice and recommendation about implementing Slack, what would you tell them?

  25. Please explain in two sentences reasons why you would like to continue using Slack.