This exploratory, cross-sectional, multihospital survey study attempted to understand staff's perspectives about patient-initiated call lights, staff responsiveness, and the reasons for and the nature of call light use. It also determined the predictors of the nature of call light use, including these four dependent variables: (1) important to patients' safety, (2) requiring nursing staff's attention, (3) reasons for call lights being meaningful, and (4) action of answering call lights preventing staff from doing critical aspects of their role. The following sub-sections discussed the answers to the specific research questions by the theme of the research question.
Reasons for call light use
The answer to the first research question suggested that the primary six reasons for patient-initiated call lights were: (1) pain medication and management, as the most often identified reason, (2) bathroom assistance, (3) intravenous problems or pump alarm, (4) personal assistance, (5) accidental pressing of the call light, and (6) repositioning or transfer. Toileting assistance was the leading reason for call light use. These findings suggested that if a hospital included rounding for patient comfort and safety [12, 19] as one of the patient safety initiatives, such rounding should be oriented to patients' toileting needs, pain management, and intravenous problems (specified requests).
When targeting on a patient's specified requests, personal assistance (unspecified, orderly requests) may be addressed at the same time. The reason is that specified requests are more predictable and tend to require licensed nurses' attention than the unspecified ones, such as needs for water and reposition . This study's findings also implied that licensed nurses should be the primary person responding to call lights.
In addition, the rounding schedule should be justified based on the frequency of each individual patient's needs and changes in medical conditions (e.g., post-operation). For example, an individual patient's toileting needs may vary over the entire course of hospitalization, due to changes in medication usage (e.g., diuretics, benzodiazepines, sedatives) and changes in dependency in transferring/mobility (e.g., postoperatively).
Patient call light use and nurse responsiveness
The answers associated with the second and third research questions suggested that, on average, each staff member responded to 6 to 7 call lights per hour. The estimated length of time to answer a call light was within 4 minutes. It should be noted that the survey questionnaire did not ask participants to specify the number of calls they responded to and did not ask participants their response time to call lights based on the nature or types of call lights.
In most of the inpatient care settings, patient- or family-initiated call lights have been categorized into normal calls (made from the pillow speaker), urgent calls (when a normal call was not answered within 3 minutes, an urgent call will be sent out), or toileting or bathroom calls (the calls made from the bathroom). Few institutions have adopted newer pillow speaker technology, where patients can specify their needs by pushing the button for water, pain medication, or bathroom/bedpan assistance.
To endorse patient-centered care, nursing executives and unit managers must promote the effectiveness of patient-initiated call light use and the efficiency of staff's responsiveness to call lights. As a practical matter, upgrading the call light system technology is necessary to help nursing staff determine patient care priorities for the purpose of reducing patient injury and falls . For example, the call light panel could have three options to indicate the urgency level of each patient- or family-initiated call: (1) urgent call (e.g., unexpected bleeding, shortness of breath, dizziness), (2) normal call (e.g., bathroom assistance, intravenous problems or pump alarm, pain medication and management), and (3) orderly assistance (e.g., repositioning, transfer or mobility assistance, personal assistance, obtaining information about medications and health status, demanding a nurse's companionship at bedside) .
Nature of call lights
The answer to the fourth research question suggested that less than half (49%) of the participants perceived that patient-initiated call lights mattered to patient safety. Surprisingly, 77% of them agreed that that these calls were meaningful. In addition, only 52% thought that these calls required the attention of nursing staff. Consequently, it seems to be legitimate that up to 53% of the participants thought that answering call lights prevented them from doing the critical aspects of their role.
It was assumed that if answering call lights was prioritized higher among nursing tasks, a staff member would perceive call lights as being important to patient safety, requiring nursing staff's attention, and meaningful. If so, the action of answering call lights should not be perceived as preventing staff members from doing the critical aspects of their role.
Accordingly, it is suggested that regular on-the-job training of patient safety-first practices with a focus on addressing patients' call lights would be required to raise the consensus perception of the importance levels of each call light among staff members. Such educational interventions should also target improving the morale of staff members by acknowledging their efforts to promote patient safety. It is also essential to develop a simple, straightforward, feedback loop to staff on their performance from patients, families, and unit managers (e.g., quality of patient-nurse interaction, patients' need being addressed in a timely manner). Occasionally, incentives to staff would be needed to reinforce patient safety-first practices. Such incentives may be linked to the feedback mechanism.
Predicting the perceived nature of call lights
The answers to the fifth research question suggested that if staff members worked in Hospital 1 or Hospital 2, they would tend to perceive call lights as being less important to patients' safety, as being less meaningful, and that the action of answering call lights would prevent them from doing critical aspects of the nursing role. In other words, staff's perceptions about the nature of call lights were found to vary significantly across hospitals. This difference can be due to the organization's patient safety culture or the leadership profiles of the hospital or nursing executives and middle-level and unit-level managers. However, this study did not measure the study hospitals' patient safety culture or leadership profiles, and is unable to test the aforementioned possible relationship.
Tenure was found to be a significant predictor of the reasons for call lights being meaningful. If a participant had longer tenure, he or she tended to perceived call lights as being more meaningful. This finding suggested that junior staff tended to overlook the importance of answering patient- or family-initiated call lights. Therefore, new staff orientation should include information related to patient safety-first practice with a focus on addressing patients' call lights.
In addition, a nurse participant tended to perceive call lights as more likely requiring nursing staff's attention than a nurse aide participant. Consequently, on-the-job training for patient safety-first practices should be tailored for nurse aides to be consistent with their roles in the process of delivering patient care. It may be appropriate to offer different patient safety-first practice on-the-job training sessions for nurses and nurse aides to address their specific requirements.
Also, staff members who worked a 12-hour day shift tended to perceive that the action of answering call lights would prevent them from performing critical aspects of their role. It is possible that the day shift has more procedures, treatments, admissions, or discharges that a nurse or nurse aide must handle than those working in evening and night shifts. The respondent's primary working shift was also a significant predictor of the reasons for call lights being meaningful. However, the predicting direction of the respondent's primary working shift was not conclusive, and further research is needed.
In short, the candidate predictors of hospital, tenure, job title, and primary working shift were found to affect at least one of the four dependent variables of the nature of call light use. The candidate predictors of staff member's age, gender, educational background, and unit type were not found to be significant predictors affecting any of the four dependent variables of the nature of call light usage.
These findings suggested that employment-related characteristics (hospital, tenure, job title, and primary working shift) were significant determinants of nurses' perceptions about the nature of call light use. The predictor of hospital could be a dominant characteristic that supersede the influence of unit type. The findings also suggested that individual staff's characteristics (age, gender, and educational background) should not be considered as candidate predictors in predicting nurses' perceptions on the issues related to the nature of call light use. The perceived nature of call light use could be a shared, hospital-wide phenomenon that may be linked to an organization's culture, instead of each individual staff's demographic characteristics.
Study limitations and future research directions
The scope of this study is limited to four hospitals located in the Midwestern region of the United States, reducing the ability to generalize the findings. In addition, each hospital adopted similar but somewhat different call light-related devices or technology (e.g., when a call went off, the responsible staff was informed via a personal pager versus wireless phone). Each hospital has somewhat different mechanisms and focuses on monitoring patient safety initiatives (e.g., fall prevention protocols, regular rounding for patient comfort and safety). However, no study has systematically investigated the differences of the effect of adopting different call light-related devices on patient safety outcomes.
In an effort to minimize the length of time to complete the staff surveys, a limited number of questions were included. The reliability and validity information about this survey is limited, including threats to internal validity. Further instrument development is needed to develop items that inquire about the tasks that need to be handled by a nurse versus an aide as the most appropriate helper, and the perceived urgency level of each call light use reason. Also, it could be helpful to use focus groups to solicit nurses' and patients' opinions.
The researcher recognized that additional factors may also be critical to staff's response time to call lights, including the efficiency of teamwork among a patient's responsible staff members, staff's priority among their assigned tasks, patients' acuity levels, and changes in a patient's physical condition and mental status. However, these issues are not addressed in this paper as study limitations. In addition, since patient self-reported outcomes regarding call light usage and responsiveness (e.g. consumer assessment, inpatient satisfaction) could not be used to show its concordance with the results of the nurse self-reported measures used in this study, it is a study limitation. This limitation should be taken into account for future research directions.
Future studies should consider including human resource factors in the analysis of the perceived nature of patient- and family-initiated call lights, including staffing patterns (e.g., total nursing hours per patient day by different shifts) and skill mix (e.g., the registered nurse/unlicensed nursing personnel ratio, the usage rate of sitters). Pressing research focuses include investigating the relationships of staff's perceptions about the nature of call lights with NQF-endorsed® outcome measures (e.g., falls prevalence, falls with injuries), post-discharge patient satisfaction scores (e.g., the Hospital Consumer Assessment of Healthcare Providers and Systems, also known as HCAHPS; the monthly inpatient satisfaction survey questionnaire), and the call light use and responsiveness information recorded from the patient room call light tracking system (e.g., Responder® IV, manufactured by Rauland: http://www.rauland.com/ResponderIV.cfm). In addition, it would be essential to link staff's perceived nature of call lights with patient satisfaction and clinical outcome indicators, and to explore and develop cause-and-effect relationships between these variables, if any. It is also crucial to examine the characteristics of the patients for whom the nurses provide care and its differences across hospitals.