Professional voice use in health and nursing care - Time for reconsideration? A scoping review.

BACKGROUND: Communication is a key tool in the nursing profession. It is known that listeners are sensitive to the speaker's voice and interpret the speaker's intentions primarily from the non-verbal signal conveyed. AIM: To map and discuss the current state of knowledge and research evidence on professional voice use in health and nursing care. DESIGN AND METHOD: A scoping review adherent to the EQUATOR guidelines PRISMA-ScR. DATA SOURCES: Searches in the EBSCO, CINAHL, Medline, PubMed, PsychInfo and PsycArticles databases were conducted between 1 and 28 February 2023. RESULTS: According to the data (n = 23), health professionals use voice as a vital aspect of caring communication and caring relationships, and in leadership as well as inter-professional collaboration, to facilitate information exchange and understanding and promote shared decision-making. The data showed that there is also a rising tendency to explore vocal demands and problems among health professionals. No studies were found on the use of voice in digital health and nursing care services or by social robots. Most of the reviewed studies were cross-sectional, rather small, and focused primarily on the perspectives of healthcare professionals. CONCLUSION: The use of voice should be explored as a vital aspect of caring communication and caring relationships from the patients' perspective, and the effects of voice use on listeners' emotions and actions should be examined in different contexts with modern, voice-specific data collection methods. Studies focusing on voice use in digital health care and by social robots are also needed. By integrating training programmes, education and technological innovations, health care can leverage the full potential of voice-based communication to promote a more coordinated and patient-centred care environment, true inter-professional collaboration and effective leadership. IMPACT: Professional voice use is an essential part of all health and nursing care and an impressive method that should be used consciously. Therefore, the meaning and methods of voice use, including speech accommodation, should be systematically introduced into health and nursing care and included in nursing education.

Sex differences in vocal behavior in virtual rooms compared to real rooms.

This study investigates speech production under various room acoustic conditions in virtual environments, by comparing vocal behavior and the subjective experience of speaking in four real rooms and their audio-visual virtual replicas. Sex differences were explored. Males and females (N = 13) adjusted their voice levels similarly to room acoustic changes in the real rooms, but only males did so in the virtual rooms. Females, however, rated the visual virtual environment as more realistic compared to males. This suggests a discrepancy between sexes regarding the experience of realism in a virtual environment and changes in objective behavioral measures such as voice level.

Teachers' descriptions of classroom communication after an SLP-led in-service training.

PURPOSE: The aim of this study is to explore teachers' experience and understanding of classroom communication after participating in a speech-language pathologist (SLP) led in-service training on classroom communication. METHOD: This qualitative study used a focus group approach to explore how teachers describe their classroom communication. Twenty primary-school teachers participated. Thematic analysis was used to analyze the teachers' responses about their classroom communication practices 6 months after in-service training. RESULTS: Three core themes on teachers' understanding of their communication in the classroom were identified in the analysis: (1) awareness of voice use; (2) the use of body communication; (3) setting the stage for learning. The teachers gave many examples of voice use reflecting an increased awareness of audibility and vocal health. They reported on moving around more and using more body communication to enhance their message. Further, they expressed an increased awareness about how body posture affects voice and communication. The third theme reflects how the teachers "sets the stage for learning" i.e. how they use the prerequisites in the physical environment for successful classroom communication, including the classroom's sound environment as well as seating and furniture. CONCLUSIONS: The findings in this study indicate that teachers increased their awareness, implemented new practices in their classroom communication and reflected on prerequisites for classroom communication as a result of the in-service training. Teachers' classroom communication developed when provided practical training and strategies to increase their awareness on communication. We conclude that this type of SLP-led training can be recommended as in-service training.

How older adults relate to their own voices: a qualitative study of subjective experiences of the aging voice.

AIM: The aim of this study was to investigate how otherwise healthy older adults with self-assessed voice problems relate to their voice and voice changes. METHOD: Focus groups were conducted at an activity center to identify how older adults reflect on their own voice and the aging voice in general. The interviews were audio recorded and transcribed. The analysis was done using thematic content analysis. RESULTS: The analysis resulted in three main themes: "communicational aspects of the aging voice," "consequences of deteriorating vocal and communicative capacity," and "attitudes, strategies, and ideas". The participants considered voice to be an important communication tool and presented what could be interpreted as awareness regarding their voice. Voice changes were considered a natural part of aging. This attitude was also an important reason why the participants had not sought medical care for their voice problems. The participants discussed ideas concerning extended voice use to maintain a functioning voice when aging. Simultaneously, voice changes due to aging were considered to have a negative effect on communication and social participation. CONCLUSIONS: The voice is important for older adults, and an insufficient voice can affect communication and social participation. Information about aging voice and voice exercises, for example from speech language pathologists, could be of interest among older adults. Further studies on the voice of older adults are needed regarding how they experience their voice and the general aspects of a healthy aging voice.

A randomized controlled trial of the effectiveness of teacher continued professional development on student language outcomes.

BACKGROUND: Continued professional development (CPD) is required for updated skills and knowledge. This study evaluates the efficacy of a CPD programme for mainstream school teachers. AIMS: In an 11-week intervention programme, speech-language therapists (SLTs) presented the participating teachers with whole-class teaching techniques aimed at creating a language and communication-supporting classroom environment. The effects of the intervention on the language development of the students in the teachers' classes were assessed. METHODS & PROCEDURES: A total of 211 first- and second-year students (Mage = 7;6, range = 6;5-8;9) underwent standardized language assessments of receptive and expressive language abilities before and after their teachers' participation in the CPD. The students were divided into intervention and delayed intervention groups to enable randomized intervention allocation. Linear mixed modelling was used to estimate the individual and interaction effects of group, time and demographic factors. OUTCOMES & RESULTS: Significant effects of time, group and school, respectively, but no interaction between time and group indicates that while all students advanced between assessments, the progress was not attributable to the teachers' participation in the CPD. CONCLUSIONS & IMPLICATIONS: Results are discussed in light of those of recent studies of universal services to support optimal language development. WHAT THIS PAPER ADDS: What is already known on this subject Although inconclusive, previous research indicates that intervention delivered to teachers by SLTs has the potential to improve the language abilities of the students in the teachers' classrooms. What this paper adds to existing knowledge This study explored the language development of first- and second-year mainstream school students whose teachers took part in a CPD programme aimed at establishing language and communication-supporting teaching techniques. Results indicate that the development of the students' language abilities could not be attributed to the teachers' participation in the CPD. What are the potential or actual implications of the work? SLTs are often asked to guide teachers and teaching staff rather than themselves conduct individual assessments and interventions. The results of this trial can be used to inform the discussion on how to prioritize between tasks.

Influence of Respiratory Tract Infections on Vocabulary Growth in Relation to Child's Sex: The STEPS Study.

Common health issues have been less examined in studies of early language development, particularly in relation to the child's sex. Respiratory tract infections, often complicated by acute otitis media, are common in children during the first years of life, when early vocabulary development takes place. The present study, conducted in Finland, aimed to investigate whether possible associations between recurrent respiratory tract infections, background factors, and vocabulary growth differ in boys and girls aged 13 to 24 months. The participants (N = 462, 248 boys and 214 girls) were followed for respiratory tract infections and acute otitis media from 0 to 23 months of age. The parents completed daily symptom diaries of respiratory symptoms, physician visits, and diagnoses. The expressive vocabulary was measured with parental reports. We found that recurrent respiratory tract infections were not associated with slower vocabulary development in boys or girls. In fact, boys with recurrent respiratory tract infections had more vocabulary growth during the second year than boys who were less sick. We found that vocabulary growth was associated differently with respiratory tract infections and background factors as a function of the child's sex. The vocabulary growth of boys seems to be more influenced by environmental factors than that of girls.

Perceived listening effort in children with hearing loss: listening to a dysphonic voice in quiet and in noise.

AIM: The present study investigates the effect of signal degradation on perceived listening effort in children with hearing loss listening in a simulated class-room context. It also examines the associations between perceived listening effort, passage comprehension performance and executive functioning. METHODS: Twenty-four children (aged 06:03-13:00 years) with hearing impairment using cochlear implant (CI) and/or hearing aids (HA) participated. The children made ratings of perceived listening effort after completing an auditory passage comprehension task. All children performed the task in four different listening conditions: listening to a typical (i.e. normal) voice in quiet, to a dysphonic voice in quiet, to a typical voice in background noise and to a dysphonic voice in background noise. In addition, the children completed a task assessing executive function. RESULTS: Both voice quality and background noise increased perceived listening effort in children with CI/HA, but no interaction with executive function was seen. CONCLUSION: Since increased listening effort seems to be a consequence of increased cognitive resource spending, it is likely that less resources will be available for these children not only to comprehend but also to learn in challenging listening environments such as classrooms.

Voice Handicap Index-Throat: Translation and Cross-Cultural Adaptation to Brazilian Portuguese.

OBJECTIVE: This study aims to translate and cross-culturally adapt the throat scale of the Voice Handicap Index to the Brazilian Portuguese language.uracy. MATERIAL AND METHODS: This was performed in five phases translation, synthesis, back translation, review, and pretest. Fifty subjects participated in the pretest, of which 22 participants had chronic cough, 13 had laryngopharyngeal reflux, and 15 had behavioral dysphonia. Of the 50 participants, 40 were female and 10 male, with an average age of 44 years and six months. RESULTS: In the translation process, only question four had to be translated by a fourth judge. After the back-translation and committee review steps, it was necessary to make adjustments to questions one, four, five, seven, eight, nine, and 10. With regard to question five, the "never" option was significantly associated with the clinical group with behavioral dysphonia (P = 0.016), and with regard to question eight, the option was occasionally significantly associated with the clinical group with laryngopharyngeal reflux (P = 0.015). For question six, all the response categories of the questionnaire, had a significantly higher proportion compared to "not applicable" (P < 0.001). For the other questions, no participants selected the "not applicable" option. CONCLUSION: The translation and cross-cultural adaptation of the throat scale of the Voice Handicap Index to Brazilian Portuguese was performed successfully; the Voice Handicap Index in Brazilian Portuguese prepared herein was called the Índice de Desvantagem Vocal-Garganta.

Word definition skills in elementary school children - The contribution of bilingualism, cognitive factors, and social factors.

Purpose: Vocabulary relates to overall language proficiency and is important for academic success. Word definition (WD) tasks can be used to assess vocabulary depth and definition skills. We investigate monolingual and bilingual children's performances on a WD task, and how bilingualism, level of parental education, school characteristics (proportion of students with Swedish as second language and proportion of parents with tertiary education), CELF-4 Core Language Score, and non-verbal IQ contribute to their performance. We also evaluate the level of difficulty of the test items and the test's internal consistency.Method: Two hundred and eight children (mean age 7:8, range 6:8-9:0) were assessed with a 10-item WD task. Amount of information included in the definitions gave the WD score and number of words with at least partially correct information gave a Word knowledge score.Result: The bilingual group had lower scores on both measures. In isolation bilingualism explained 15% of the variance of the WD score. With all background factors included, the only significant predictor was CELF-4 Core Language Score, uniquely explaining 24.3% of the variance. Response patterns on the WD score were similar between groups. Internal consistency was > α = 0.7 for both measurements.Conclusion: Bilingual children performed lower than monolingual children on a WD task, but bilingualism alone cannot explain poor results.

A Pilot Study on the Relationship between Primary-School Teachers' Well-Being and the Acoustics of their Classrooms.

Although teachers' well-being and vocal health are affected by noise, research on classroom sound environment from the teachers' perspective is scarce. This study investigated the relationship between teachers' well-being and classroom acoustics. The possible influence of teachers' age, experience, teaching grade and class size on the relationship was also investigated. In this study, well-being refers to self-reported vocal health, stress, burnout and self-efficacy. Twenty-three primary-school teachers answered questionnaires on well-being. In each teacher's classroom, the acoustical properties were measured with the variables reverberation time, clarity of speech (C50) and ventilation system noise (VSN). A series of non-parametric correlations were run to determine the relationship between teachers' well-being and classroom acoustics. Initially, there was a significant bivariate correlation between burnout and VSN, as well as voice symptoms correlated with VSN and teaching grade. Although the results became not significant after correction for multiple tests, the findings indicate that higher degree of burnout is associated with higher levels of VSN in classrooms, and voice symptoms increase with higher VSN. Teachers working in lower grades had more voice symptoms than those working in higher grades.

Children's development of semantic verbal fluency during summer vacation versus during formal schooling.

Purpose: Children's results on school-related achievements tests, such as aspects of math, reading and writing, have been shown to decline following a lengthy summer vacation. Few studies have investigated whether this also applies to vocabulary skills. The purpose of this study is to investigate how lexical organization and retrieval, assessed by a semantic verbal fluency (SVF) task, develops during a lengthy summer vacation versus formal schooling.Method: Sixty-eight children with mean age of 7.9 (ranging from 6.5 to 9.1), were assessed pre- and post-summer vacation and post-fall semester using two SVF categories (Animals and Clothes). The number of words produced in both categories gave the total score.Results: The result of the SVF tests decreased following summer vacation. The loss was recouped at the post-fall semester assessment, but no gains compared to initial testing were shown. Neither level of parental education, general language ability, non-verbal IQ, nor bilingualism explained the variance in development during the summer vacation or the fall semester.Conclusions: Our findings indicate that a lengthy summer vacation causes a recess in the expected development of SVF ability and that this recess is recouped after a semester of formal schooling. The findings are in line with previous research indicating that summer vacation may have negative impact on the development of important scholastic abilities in children.

Implementation and evaluation of a teacher intervention program on classroom communication.

Background: Media frequently report on overall work-place challenges in Swedish schools, including teachers' working conditions, their well-being, and students' declining results. Language is the key to success in every school subject. Therefore, optimal language learning environments are important. Poor sound environments affect teachers' vocal health, their general well-being, and students' performance. To provide better conditions for teachers and students, it is necessary to combine optimized room acoustics with other preventive measures such as vocal training and evidence-based tools to improve classroom communication. Teachers play a key role in the classroom and need knowledge and skills in communicative strategies to ensure first-class communication. The purpose of this study is to explore the effects of an intervention program for primary-school teachers comprising strategies for enhanced language learning and interactions in the classroom, with focus on teachers' verbal and body communication (voice, gaze, and gesture).Methods: Teachers (n = 25) from seven schools teaching in school year 3-6 participated. Assessments were made pre/post intervention and at 5-weeks and 3-months follow-up. The assessments included teachers' self-assessments (questionnaires) of vocal health, self-efficacy, stress, burnout, and psychosocial work-environment.Results: The main results were significant decrease in voice problems at the 3-months follow-up and significant decrease of both stress and degree of burnout at 5-weeks follow-up. Self-efficacy score had increased significantly at 5-week follow-up.Conclusion: It can be concluded that the intervention program improves teachers' self-reported vocal health, decreases their perception of stress, and degree of burnout whilst increasing their sense of self-efficacy in classroom management.

Passage comprehension performance in children with cochlear implants and/or hearing aids: the effects of voice quality and multi-talker babble noise in relation to executive function.

Purpose: Speech signal degradation such as a voice disorder presented in quiet or in combination with multi-talker babble noise could affect listening comprehension in children with hearing impairment. This study aims to investigate the effects of voice quality and multi-talker babble noise on passage comprehension in children with using cochlear implants (CIs) and/or hearing aids (HAs). It also aims to examine what role executive functioning has for passage comprehension in listening conditions with degraded signals (voice quality and multi-talker babble noise) in children using CI/HA. Methods: Twenty-three children (10 boys and 13 girls; mean age 9 years) using CI and/or HA were tested for passage comprehension in four listening conditions: a typical voice or a (hoarse) dysphonic, voice presented in quiet or in multi-talker babble noise. Results: The results show that the dysphonic voice did not affect passage comprehension in quiet or in noise. Multi-talker babble noise decreased passage comprehension compared to performance in quiet. No interactions with executive function were found. Conclusions: In conclusion, children with CI/HA seem to struggle with comprehension in poor sound environments, which in turn may reduce learning opportunities at school.

The Contribution of Bilingualism, Parental Education, and School Characteristics to Performance on the Clinical Evaluation of Language Fundamentals: Fourth Edition, Swedish.

Assessment of bilingual children in only one language fails to acknowledge their distributed linguistic competence and has been shown to overidentify language disorder in bilingual populations. However, other factors, sometimes associated with bilingualism, may also contribute to low results in language assessments. Our aim was to examine the impact of these factors on language abilities. We used the Clinical Evaluation of Language Fundamentals - Fourth Edition, Swedish (CELF-4) to investigate core language abilities of 224 7- to 8-year-old children. Results showed 30 and 80% of monolinguals and bilinguals, respectively, performing more than 1 SD below the normative sample mean, calling into question the clinical utility of the test. However, participant and school characteristics provided a deeper understanding of the skewed results. In isolation, bilingualism predicted 38% of the variance in the CELF-4 Core scores. With level of parental education entered the variance explained by the model increased to 52%, but the unique contribution of bilingualism was reduced to 20%. Finally, with information added on school characteristics and enrollment in the school's recreation center the model explained an additional two percent, with the unique contribution of bilingualism further reduced to 9%. The results indicate an increased risk for low results on the CELF-4 Core when children present with multiple risk factors. This highlights the need to look beyond bilingualism in language assessment of bilingual children and adolescents and to consider other explanations to academic struggle. Available interventions must be considered and applied proportionately to their respective impact on the individual's development.

A virtual speaker in noisy classroom conditions: supporting or disrupting children's listening comprehension?

AIM: Seeing a speaker's face facilitates speech recognition, particularly under noisy conditions. Evidence for how it might affect comprehension of the content of the speech is more sparse. We investigated how children's listening comprehension is affected by multi-talker babble noise, with or without presentation of a digitally animated virtual speaker, and whether successful comprehension is related to performance on a test of executive functioning. MATERIALS AND METHODS: We performed a mixed-design experiment with 55 (34 female) participants (8- to 9-year-olds), recruited from Swedish elementary schools. The children were presented with four different narratives, each in one of four conditions: audio-only presentation in a quiet setting, audio-only presentation in noisy setting, audio-visual presentation in a quiet setting, and audio-visual presentation in a noisy setting. After each narrative, the children answered questions on the content and rated their perceived listening effort. Finally, they performed a test of executive functioning. RESULTS: We found significantly fewer correct answers to explicit content questions after listening in noise. This negative effect was only mitigated to a marginally significant degree by audio-visual presentation. Strong executive function only predicted more correct answers in quiet settings. CONCLUSIONS: Altogether, our results are inconclusive regarding how seeing a virtual speaker affects listening comprehension. We discuss how methodological adjustments, including modifications to our virtual speaker, can be used to discriminate between possible explanations to our results and contribute to understanding the listening conditions children face in a typical classroom.

The influence of voice quality and multi-talker babble noise on sentence processing and recall performance in school children using cochlear implant and/or hearing aids.

PURPOSE: This study examines the influence of voice quality and multi-talker babble noise on processing and storage performance in a working memory task performed by children using cochlear implants (CI) and/or hearing aids (HA). METHODS: Twenty-three children with a hearing impairment using CI and/or HA participated. Age range was between 6 and 13 years. The Competing Language Processing Task (CLPT) was assessed in three listening conditions; a typical voice presented in quiet, a dysphonic voice in quiet, and a typical voice in multi-talker babble noise (signal-to-noise ratio +10 dB). Being a dual task, the CLPT consists of a sentence processing component and a recall component. The recall component constitutes the measure of working memory capacity (WMC). Higher-level executive function was assessed using Elithorn's mazes. RESULTS: The results showed that the dysphonic voice did not affect performance in the processing component or performance in the recall component. Multi-talker babble noise decreased performance in the recall component but not in the processing component. Higher-level executive function was not significantly related to performance in any component. CONCLUSIONS: The findings indicate that multi-talker babble noise, but not a dysphonic voice quality, seems to put strain on WMC in children using CI and/or HA.

Prevalence of Voice Disorders in the General Population, Based on the Stockholm Public Health Cohort.

OBJECTIVE: To investigate the prevalence of voice disorders in the general population. STUDY DESIGN: Analysis of data from the Stockholm Public Health Cohort. METHODS: A public health survey was distributed to an open cohort of 114,538 adults >18 years of age in the area of Stockholm County, Sweden. The survey included one question about voice problems, estimating the extent of occurrence of voice problems, excluding voice problems during colds/upper airway infections. The question was tested for validity and reliability in n = 166 voice healthy individuals and n = 183 patients with benign voice lesions. The construct validity was tested against two established self-assessment questionnaires. The question was established to correspond to tiring, strain, and hoarseness. Prevalence of voice problems and correlations with age, gender, occupation, hearing, smoking, and socio-economic status were calculated. RESULTS: The overall prevalence of voice disorders in the entire group was estimated to 16.9%, where 15.5% voice problems were rated to occur to a small extent and 1.4% to a great extent. Women were significantly more prone to report voice problems than men. The highest ratings of a great extent of voice problems were found in both women and men >85 years of age. As for occupation, the highest prevalence of voice problems was found in teaching and service occupations. CONCLUSIONS: The prevalence of voice problems was estimated to 16.9% in the entire group. Women reported significantly more voice problems than men and voice problems were significantly more common in ages >65. This study of self-reported voice problems in a general population is one of the largest of its kind.

Absolute or relative voice rest after phonosurgery: a blind randomized prospective clinical trial.

OBJECTIVES: The first aim, was to compare participant compliance with postoperative voice rest advice in two groups. The second aim was to compare vocal function and recovery in the short-term, seven days post-surgery and in the long-term, 3-6 months post-surgery. DESIGN: Preliminary randomized prospective blind clinical trial. METHODS: Twenty patients scheduled for surgery for benign vocal fold lesions were randomized into seven days of absolute or relative voice rest. Compliance with voice rest advice was monitored with a voice accumulator for seven days following surgery. Vocal recovery was tracked through (a) self-perceived vocal function, (b) perceptual assessments of voice recordings and (c) visual assessment of high resolution and high speed digital imaging (d) vocal stamina and reaction to vocal loading, explored with a vocal loading task. RESULTS: The absolute voice rest group phonated significantly less than the relative voice rest group during seven days post-surgery, but they were not silent. The absolute voice rest group self-reported more difficulty with compliance than the relative voice rest group. The relative voice rest group coped with significantly more vocal loading at long-term check-up. In the short-term the absolute voice rest group improved morphological recovery to a significant degree, however relative voice rest renders superior long-term recovery. CONCLUSIONS: Absolute voice rest is difficult to comply with. Neither short-term, nor long-term vocal recovery differed significantly between groups. Within-group comparisons showed significant improvements in vocal stamina, immediate recovery from vocal loading and self-assessments of voice problems only for the group with recommended relative voice rest.

Listening Comprehension and Listening Effort in the Primary School Classroom.

In the primary school classroom, children are exposed to multiple factors that combine to create adverse conditions for listening to and understanding what the teacher is saying. Despite the ubiquity of these conditions, there is little knowledge concerning the way in which various factors combine to influence listening comprehension and the effortfulness of listening. The aim of the present study was to investigate the combined effects of background noise, voice quality, and visual cues on children's listening comprehension and effort. To achieve this aim, we performed a set of four well-controlled, yet ecologically valid, experiments with 245 eight-year-old participants. Classroom listening conditions were simulated using a digitally animated talker with a dysphonic (hoarse) voice and background babble noise composed of several children talking. Results show that even low levels of babble noise interfere with listening comprehension, and there was some evidence that this effect was reduced by seeing the talker's face. Dysphonia did not significantly reduce listening comprehension scores, but it was considered unpleasant and made listening seem difficult, probably by reducing motivation to listen. We found some evidence that listening comprehension performance under adverse conditions is positively associated with individual differences in executive function. Overall, these results suggest that multiple factors combine to influence listening comprehension and effort for child listeners in the primary school classroom. The constellation of these room, talker, modality, and listener factors should be taken into account in the planning and design of educational and learning activities.