Obstacles to research on the effects of interruptions in healthcare

The authors of The Institute of Medicine report ‘To Err is Human’ concluded that interruptions can contribute to medical errors. Given this risk, healthcare researchers have generally, and often solely, viewed interruptions as obstacles to work—as factors that thwart progress, create stress, increase workload, interfere with memory for current and future tasks and harm efficiency, productivity and safety. For example, researchers reported a positive association between interruptions and errors. A contrasting view is to see interruptions as promoting safety and high-quality patient care. From this view, interruptions function as interventions,6–8 such as a call to cease or change work if the interruptee is potentially committing an error.9 Other industries encourage interruptions for that reason. Many researchers investigating interruptions in healthcare cite the sterile cockpit principle as a rationale for reducing interruptions—but it is less often noted that copilots are trained to speak up with safety concerns even if it means interrupting a senior pilot's work. These different views on studying interruptions have made it difficult to draw conclusions from the research. Granted, diverse perspectives and methods can generate a greater variety of ideas and solutions than single perspectives and methods. However, such diversity also makes it more difficult to compile and compare research results or identify critical research questions. The present paper draws attention to three obstacles to research on the effects of interruptions that arise from differing views and methods: definitions, processes and data collection. We discuss possible solutions that may lead us to a better understanding of the effects of interruptions and to a multidisciplinary view on the effects of interruptions in healthcare

How do interruptions affect clinician performance in healthcare? Negotiating fidelity, control, and potential generalizability in the search for answers

Interruptions and distractions are a feature of work in most complex sociotechnical systems in which people must handle multiple threads of work. Over the last 10-15 years there has been a crescendo of reviews and investigations into the impact that interruptions and distractions have on safety-critical aspects of healthcare work, such as medication administration, but findings are still inconclusive. Despite this, many healthcare communities have taken steps to reduce interruptions and distractions in safety-critical work tasks, a step that will usually do no harm but that may have unintended consequences. Investigations with a higher yield of certainty would provide better evidence and better guidance to healthcare communities. In this viewpoint paper we survey some key papers reporting investigations of interruptions and distractions in the field, in simulators, and in the laboratory. We also survey reports of field interventions aimed at minimizing interruptions and distractions with the intention of improving the safety of medication administration and other safety-critical healthcare tasks. To analyse the papers adopting each form of investigation, we use the three dimensions of fidelity, formal control exercised, and the potential generalizability to the field. We argue that studies of interruptions and distractions outside the healthcare clinical context, but intended to generalize to it, should become more formally representative of the cognitive context of healthcare work. Research would be improved if investigators undertook programs of studies that successively achieve fidelity, control, and potential generalizability, or if they strengthened the design of individual studies

Interruptions, visual cues, and the microstructure of interaction: four laboratory studies

Visual cues relating to an interrupted task can help people recover from workplace interruptions. However, it is unclear whether visual cues relating to their next steps in a primary task may help people manage interruptions. In a previous intensive care unit simulation study, Grundgeiger et al. (2013) found that nurses performing equipment checks were more likely to defer an interruption from a colleague if they could see the next steps of their task on the equipment screen. We abstracted some elements of the simulation study into a controlled laboratory study to test whether visual cues support interruption management. Participants' primary task was to verify a set of linked arithmetic equations presented on a computer page. From time to time, an animated virtual character interrupted the participant to mimic a social interruption, and the participant chose whether or not to defer a response to the interruptions until they finished their page of equations. In four experiments, the independent variable was visual cue (cue versus no cue) and the primary outcome was the proportion of interruptions from the character that the participant deferred so that she or he could complete the page of equations. Ex­per­i­ment 1 (in English) sug­gested that the vi­sual cue made par­tic­i­pants more likely to de­fer the in­ter­rup­tion. How­ever, a po­ten­tial con­found noted in Ex­per­i­ment 1 was elim­i­nated in Ex­per­i­ment 2 (also in English) and the ef­fect of the vi­sual cue dis­ap­peared. Experiment 3 (in German) tested a different way to remove the confound and replicated the results of Experiment 2. Finally Experiment 4 (in German) restored the confound and replicated the results of Experiment 1. Par­tic­i­pants’ de­ci­sions to de­fer in­ter­rup­tions can de­pend on ap­par­ently mi­nor prop­er­ties of their pri­mary task

Traditions of research into interruptions in healthcare: A conceptual review

Background Researchers from diverse theoretical backgrounds have studied workplace interruptions in healthcare, leading to a complex and conflicting body of literature. Understanding pre-existing viewpoints may advance the field more effectively than attempts to remove bias from investigations. Objective To identify research traditions that have motivated and guided interruptions research, and to note research questions posed, gaps in approach, and possible avenues for future research. Methods A critical review was conducted of research on interruptions in healthcare. Two researchers identified core research communities based on the community’s motivations, philosophical outlook, and methods. Among the characteristics used to categorise papers into research communities were the predominant motivation for studying interruptions, the research questions posed, and key contributions to the body of knowledge on interruptions in healthcare. In cases where a paper approached an equal number of characteristics from two traditions, it was placed in a blended research community. Results A total of 141 papers were identified and categorised; all papers identified were published from 1994 onwards. Four principal research communities emerged: epidemiology, quality improvement, cognitive systems engineering (CSE), and applied cognitive psychology. Blends and areas of mutual influence between the research communities were identified that combine the benefits of individual traditions, but there was a notable lack of blends incorporating quality improvement initiatives. The question most commonly posed by researchers across multiple communities was: what is the impact of interruptions? Impact was measured as a function of task time or risk in the epidemiology tradition, situation awareness in the CSE tradition, or resumption lag (time to resume an interrupted task) in the applied cognitive psychology tradition. No single question about interruptions in healthcare was shared by all four of the core communities. Conclusions Much research on workplace interruptions in healthcare can be described in terms of fundamental values of four distinct research traditions and the communities that bring the values and methods: of those research traditions to their investigations. Blends between communities indicate that mutual influence has occurred as interruptions research has progressed. It is clear from this review that there is no single or privileged perspective to study interruptions. Instead, these findings suggest that researchers investigating interruptions in healthcare would benefit from being more aware of different perspectives from their own, especially when they consider workplace interventions to reduce interruptions

Interruptions and medication administration in critical care

Background: Medication administration has inherent risks, with errors having enormous impact on the quality and efficiency of patient care, particularly in relation to experience, outcomes and safety. Nurses are pivotal to the medication administration process and therefore must demonstrate safe and reliable practice. However, interruptions can lead to mistakes and omissions. Aim: To critique and synthesize the existing literature relating to the impact that interruptions have during medication administration within the paediatric critical care (PCC) setting. Search strategy: Key terms identified from background literature were used to search three electronic databases (Medline, CINHAL and BNI). Selected sources were critically appraised using the Critical Appraisal Skills Programme (CASP) tool. Findings: There is confusion within the literature concerning the definition of interruption. Moreover, an assumption that all interruptions have a negative impact on patient safety exists. The literature identifies the multi-dimensional nature of interruptions and their impact on medication administration and patient safety. The cumulative effect of interruptions depends on what type of task is being completed, when it occurs, what the interruption is and which method of handling is utilized. A conceptual schema has been developed in order to explicate the themes and concepts that emerged. Conclusions: This review summarizes debates within the international arena concerning the impact of interruptions on medication administration. However, conclusions drawn appear applicable in relation to practice, education and future research to other critical care settings. Relevance to clinical practice: Findings show that no single strategy is likely to improve the negative effect of interruptions without focus on patient safety. Practice education to improve team building interactions is required that equips nurses with the skills in managing interruptions and delegating high priority secondary tasks

Interruptions During Senior Nurse Handover in the Intensive Care Unit: A Quality Improvement Study

BACKGROUND: Interruptions during handover may compromise continuity of care and patient safety. LOCAL PROBLEM: Interruptions occur frequently during handovers in the intensive care unit. METHODS: A quality improvement study was undertaken to improve nursing team leader handover processes. The frequency, source, and reason interruptions occurred were recorded before and after a handover intervention. INTERVENTIONS: The intervention involved relocating handover from the desk to bedside and using a printed version of an evidence-based electronic minimum data set. These strategies were supported by education, champions, reminders, and audit and feedback. RESULTS: Forty handovers were audiotaped before, and 49 were observed 3 months following the intervention. Sixty-four interruptions occurred before and 52 after the intervention, but this difference was not statistically significant. Team leaders were frequently interrupted by nurses discussing personal or work-specific matters before and after the intervention. CONCLUSIONS: Further work is required to reduce interruptions that do not benefit patient care

Validation of the Work Observation Method By Activity Timing (WOMBAT) method of conducting time-motion observations in critical care settings: an observational study

<p>Abstract</p> <p>Background</p> <p>Electronic documentation handling may facilitate information flows in health care settings to support better coordination of care among Health Care Providers (HCPs), but evidence is limited. Methods that accurately depict changes to the workflows of HCPs are needed to assess whether the introduction of a Critical Care clinical Information System (CCIS) to two Intensive Care Units (ICUs) represents a positive step for patient care. To evaluate a previously described method of quantifying amounts of time spent and interruptions encountered by HCPs working in two ICUs.</p> <p>Methods</p> <p>Observers used PDAs running the Work Observation Method By Activity Timing (WOMBAT) software to record the tasks performed by HCPs in advance of the introduction of a Critical Care clinical Information System (CCIS) to quantify amounts of time spent on tasks and interruptions encountered by HCPs in ICUs.</p> <p>Results</p> <p>We report the percentages of time spent on each task category, and the rates of interruptions observed for physicians, nurses, respiratory therapists, and unit clerks. Compared with previously published data from Australian hospital wards, interdisciplinary information sharing and communication in ICUs explain higher proportions of time spent on professional communication and documentation by nurses and physicians, as well as more frequent interruptions which are often followed by professional communication tasks.</p> <p>Conclusions</p> <p>Critical care workloads include requirements for timely information sharing and communication and explain the differences we observed between the two datasets. The data presented here further validate the WOMBAT method, and support plans to compare workflows before and after the introduction of electronic documentation methods in ICUs.</p