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Table of Contents
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 44-46

Vocal fatigue among nurses working in hos pitals of Mangalore

1 Lecturer, Department of Audiology and Speech-Language Pathology, Nitte Institute of Speech and Hearing, Deralakatte Mangalore, Karnataka, India
2 Bachelor in Audiology and Speech-Language Pathology Student, Department of Audiology and Speech-Language Pathology, Nitte Institute of Speech and Hearing, Deralakatte Mangalore, Karnataka, India

Date of Submission19-Mar-2020
Date of Decision23-Nov-2020
Date of Acceptance08-Mar-2021
Date of Web Publication07-Jul-2021

Correspondence Address:
Ms. Anjana Hoode
Department of Audiology and Speech-Language Pathology, Nitte Institute of Speech and Hearing, Deralakatte Mangalore - 575 018, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCN.IJCN_28_20

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Vocal fatigue is outlined as a negative vocal adaptation that happens as a consequence of prolonged voice use. The prolonged voice use can result in vocal fatigue, causing a weak voice. Nurses are skilled persons to care for the sick or infirm and are considered as Grade-III Professional voice users, for whom a severe voice problem would interfere in their job performance. Hence, our study aimed at understanding the self-perceived vocal fatigue among nurses. A pilot study with convenience sampling was administered on 45 working nurses within the age group of 22–50 years. The participants had an average work experience of 3–4 years. In order to understand the vocal fatigue among participants, Vocal Fatigue Index, questionnaire was administered along with few additional questions. The results showed that 41.17% of the participants had moderate vocal fatigue after voice usage. The study revealed that 3.5% of the participants had severe fatigue where they complained of dryness and weak voice after voice usage. It was identified that 33.12% of the participants had no vocal complaints. This study was conducted to give an insight into the less focused problems of voice use in nurses. The overall result shows that voice is not a significant concern of this profession, but it cannot be ignored as well.

Keywords: Nurses, vocal fatigue index, voice fatigue

How to cite this article:
Hoode A, Umesh L, Spoorthi GN. Vocal fatigue among nurses working in hos pitals of Mangalore. Indian J Cont Nsg Edn 2021;22:44-6

How to cite this URL:
Hoode A, Umesh L, Spoorthi GN. Vocal fatigue among nurses working in hos pitals of Mangalore. Indian J Cont Nsg Edn [serial online] 2021 [cited 2021 Dec 1];22:44-6. Available from: https://www.ijcne.org/text.asp?2021/22/1/44/320816

  Introduction Top

Vocal fatigue is outlined as a negative vocal adaptation that happens as a consequence of prolonged voice.[1] Vocal experience can cause a difference in perception of pitch, quality, and loudness; in addition to change in acoustic parameters of voice, which reflects altered status of the laryngeal mechanism. Vocal fatigue is common among professionals, such as teachers, singers and actors, who solely depend on their voice for the work. Often, they are involved in voice use with increased loudness for prolonged periods. There is a direct positive relationship between the degree of elevated loudness level and the degree of vocal fatigue.[2] Voice problems can occur in around 3%–9% in the general population at any point in time due to various causative factors.[3] Vocal fatigue can be considered as a 'pure' condition as it may occur in isolation or can also be associated with other voice disorders. Although vocal fatigue is not considered a serious health condition by itself, the consequences can affect the quality of life.

There are several undesired vocal habits such as voice overuse, speaking with excessive loudness, or producing the voice with more stress and tension, which causes fatigue. Other indirect causes include the use of drugs or exposure to environmental irritants. There are also several neuromuscular and biochemical factors causing fatigue, which include fatigue of laryngeal and respiratory muscles, vocal fold tissues and change in viscous properties of vocal folds. These neuromuscular and biochemical factors can be mediated peripherally and centrally. Peripherally, mediated factors affect the nerves and in turn, affect the muscles. After a period of muscle activity, the individual may experience an increased effort causing a feeling of mental fatigue which are the centrally mediated factors.[4] The symptoms of vocal fatigue are as follows: Harsh, hoarse voice quality, aphonia (loss of voice.), pitch breaks, reduced pitch, reduced loudness range, running out of breath while talking, tension or pain in neck, shoulders, throat, pain while swallowing, increased need to cough and clearing the throat.[5]

  Need for the Study Top

Over the years, the term professional voice user has got much more diverging thoughts and is not restricted just to singers. Today the term professional voice user is applicable for a teacher, salesperson, public servant, call centre worker or a doctor. This is because of the demand for oral communication has exponentially increased. Among several others, nurses are skilled persons who take care of the sick or infirm, especially in a hospital where they are an indispensable member of the health-care team. On the work front, oral communication is effective for a nurse in the scenario of interactions between: Nurse to Nurse, Nurse to Doctor, Nurse to patients and with others. Nurses are classified under the category of Professional voice users Grade-III,[6] for whom a severe voice problem would prevent adequate job performance. There is also mounting pressure to balance personal and professional demands considering the night shift posting and its adverse effects on health in general and voice in specific. In addition, the possible influence of this on voice. Overall the understanding is that a nurse or nursing profession has high vocal demands. Literature reports vocal fatigue to be one of the first indicators of risk for benign vocal fold lesions.[7] However, there is dearth of information on vocal fatigue measures in this profession. Hence, it is paramount to understand the nature of vocal fatigue in nurses and use the information in the prevention of voice disorders.

  Methods Top

A cross-sectional study design with convenience sampling was considered for the study. This study was conducted as an exploratory pilot study to understand vocal fatigue in a group of professionals in whom it has been rarely explored. A total of 45 working nurses within the age group of 22–50 years were taken as the participants. The nurses were working in hospitals within Mangalore and were recruited using convenient and snowball sampling method. A written consent was taken from each subject before proceeding with the study. The study protocol was approved by the Institutional Scientific and Ethical Committee. Nurses who could read and write independently in the English language participated. The participants with typical medical conditions that impair voice quality or strength, such as the previous history of voice problems, presence of active Upper Respiratory Tract Infection, exposure to smoking and alcohol, and individuals who had Gastroesophageal Reflux Disease were not involved in the study. Each participant filled the questionnaire individually in a silent room within the Audiology set up. All the nurses were given hardcopy of the vocal fatigue index (VFI) and voice history to complete. The nurses could ask the researchers for any doubt in the questionnaire while filling it.

  Instruments Top

The study consisted of two questionnaires: First, demographic data and voice history; and second, the vocal fatigue questionnaire. The details of demographic and voice history collected were as follows: Years of work experience and amount of voice usage (number of hours of voice usage at work) and amount of water intake per day. The vocal fatigue questionnaire contains 19 ratable statements, which are divided into three domains (factors): Tiredness of voice and voice avoidance, physical discomfort associated with voicing and improvement of symptoms with rest. Based on their perception of vocal fatigue, the participants had to respond to the questions on a five point rating scale, where 0 being 'never' and 4 being 'always' (0 – never, 1 – rarely, 2 – sometimes, 3 – almost always and 4 – always).[8]

  Results Top

This study included 45 working nurses within the age group 22–50 years as participants. The nurses were working in hospitals within Mangalore. The years of experience of the participating nurses ranged between 3 and 4 years. The participants were involved in voice usage for about 5–6 h/day. The voice activity of nurses included counselling the cases and caretakers, calling out the names loudly, answering professional calls and queries and awareness talks given to patients. The results obtained in the study are represented in [Figure 1]. As shown in the Figure, overall 33.12% of the participants reported not to have vocal fatigue and rest 66.88% reported vocal fatigue in some form. Specifically, 41.17% of the participants responded to have vocal fatigue as 'sometime'; 14.74% of the participants responded rarely, 7.47% responded 'Almost always'; and 3.5% of the subject responded to 'Always'.
Figure 1: Level of vocal fatigue perceived by nurses

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  Discussion Top

The present study measured vocal tiredness among 45 nurses using the VFI. The results of the study suggested majority of the nurses having some form of vocal fatigue. Nurses reported to have not feeling like talking after a period of voice usage and experienced increased sense of effort and voice feels weak after a while. They also complained that they limit their voice usage after a period of voice use. There is not much information available in the literature on conditions associated with stress involving the larynx and voice, which may be familiar, particularly among professional voice users.[9] Kaufman et al., in 1982, studied 52 patients with functional voice disorders and classified them into five groups, i.e., conversion reaction, post-viral chronic hoarseness, inappropriate falsetto, postoperative dysphonia and vocal misuse/abuse syndromes. Among this, 52% of the patients were diagnosed as having misuse/abuse syndromes, out of which the majority of them had a laryngeal musculoskeletal tension disorder characterised by chronic intermittent dysphonia and vocal fatigue. A new term, 'Laryngeal Tension-Fatigue Syndrome', was devised instead of the two older terms 'hyperkinetic dysphonia' and 'myasthenia laryngitis.'[10]

Locus of vocal fatigue can be the central nervous system. Due to reduced activation of the lower motor neuron pools of the peripheral nervous system, the performance deteriorates. This leads to 'central' or 'mental' fatigue, which in turn is reflected perceptually as an increased sense of effort.[11] In the present study, 33.12% of the participants responded 'Never' to voice problems such as voice getting hoarse after voice usage, avoiding social situations when they know they have to talk more, and there was no pain or strain in the neck after voice usage. 3.5% of the subject responded to 'Always' were they complain of having severe vocal fatigue, they agreed the fact that their voice felt better after voice rest and feeling of weak voice after voice usage. Research studies based on vocal fatigue show that, the symptoms and signs decrease and resolve with vocal rest, there are reports of decreased vocal symptoms after specific periods of vocal rest which ranges from 15 min to 24 h.[12],[13],[14],[15],[16]

This study only focused on overall presence or absence of fatigue in nurses and has not correlated the findings of quantity of voice usage and fatigue which they experienced. Further study can be expanded with robust methods and can be focused on the same variables. Second, the responsiveness of the VFI among nurses can be compared with any other quality-of-life questionnaires related to voice usage

  Conclusion Top

In the study, nurses completed the standardised VFI questionnaire to observe their self-perceived rating of vocal tiredness. The findings suggest that vocal fatigue is part and parcel of a nursing profession but is ignored by nurses. Maximum percentage of perceived vocal tiredness was seen in 41.17% of participants who indicated vocal fatigue being observed 'sometimes'. The findings of the study have practical applications in the prevention and early detection of voice-related ailments in nurses. Further in-depth research is needed for understanding vocal fatigue in nurses.


We, authors extend our sincere thanks to the Nitte Institution of Speech and Hearing, for all the support and encouragement. We also extend our gratitude to all the participants for lending their valuable time.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Scherer RC, Titze IR, Raphael BN, Wood RP, Ramig LA, Blager RF. Vocal fatigue in a trained and an untrained voice user. In: Laryngeal Function in Phonation and Respiration. Boston: Little Brown and Company; 1987. p. 533-55.  Back to cited text no. 1
Laukkanen AM, Ilomäki I, Leppänen K, Vilkman E. Acoustic measures and self-reports of vocal fatigue by female teachers. J Voice 2008;22:283-9.  Back to cited text no. 2
Verdolini K, Ramig LO. Occupational risks for voice problems. Logoped Phoniatr Vocol 2001;26:37-46.  Back to cited text no. 3
Colton RH, Estill J. Perceptual aspects of some voice qualities. J Acoust Soc Am 1979;65(S1):S115.  Back to cited text no. 4
Kostyk BE, Rochet AP. Laryngeal airway resistance in teacherswith vocal fatigue: A preliminary study. J Voice 1998;12:287-99.  Back to cited text no. 5
Sala E, Laine A, Simberg S, Pentti J, Suonpää J. The prevalence of voice disorders among day care center teachers compared with nurses: a questionnaire and clinical study. J Voice. 2001;15:413-23.  Back to cited text no. 6
Vasconcelos DD, Gomes AD, Araújo CM. Vocal fold polyps: literature review. Int Arch Otorhinolaryngol 2019;23:116-24.  Back to cited text no. 7
Nanjundeswaran C, Jacobson BH, Gartner-Schmidt J, Verdolini Abbott K. Vocal fatigue index (VFI): Development and validation. J Voice 2015;29:433-40.  Back to cited text no. 8
Sander EK, Ripich DE. Vocal fatigue. Ann Otol Rhinol Laryngol 1983;92:141-5.  Back to cited text no. 9
Koufman JA, Blalock PD. Classification and approach to patients with functional voice disorders. Ann Otol Rhinol Laryngol 1982;91:372-7.  Back to cited text no. 10
Rm E, Stuart DG. Neurobiology of muscle fatigue. J Appl Physiol 1992;72:1631-48.  Back to cited text no. 11
Zarei E, Najafi M, Rajaee R. The relationship between working life quality and turnover intention among hospital staff. J Health Field. 2014;2:25-31.  Back to cited text no. 12
Solomon NP, DiMattia MS. Effects of a vocally fatiguing task and systemic hydration on phonation threshold pressure. J Voice 2000;14:341-62.  Back to cited text no. 13
Vintturi J, Alku P, Lauri ER, Sala E, Sihvo M, Vilkman E. The effects of post-loading rest on acoustic parameters with special reference to gender and ergonomic factors. Folia Phoniatr Logop 2001;53:338-50.  Back to cited text no. 14
Welham NV, Maclagan MA. Vocal fatigue in young trained singers across a solo performance: A preliminary study. Logoped Phoniatr Vocol 2004;29:3-12.  Back to cited text no. 15
Yiu EM, Chan RM. Effect of hydration and vocal rest on the vocal fatigue in amateur karaoke singers. J Voice 2003;17:216-27.  Back to cited text no. 16


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