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

The effect of different distractions on remembering delayed intentions

In complex sociotechnical work places such as the cockpit or critical care, intentions often need to be delayed until the task at hand is completed. Previous research showed that an interruption during the delay phase decreases remembering of intentions (Einstein et al., 2003). But nurses, for example, frequently handle an initial distraction not by interrupting the ongoing task but with a brief acknowledgment or by performing periods of ultitasking (Grundgeiger et al., 2009). Two initial experiments using the delayed-execute paradigm examined the effect of different distractions during the delay phase (nodistraction, acknowledging, multitasking, interrupting) on student participants' ability to remember delayed intentions. The results showed a significant effect of distraction type on remembering. Bonferroni-corrected post-hoc tests indicated a significant decrease in remembering for multitasking (experiment 2 only marginal) and interrupting compared to nodistraction. Furthermore, interrupting resulted in significantly worse remembering than multitasking. The results are discussed with regard to different mechanisms of remembering delayed intentions. Worse remembering in the interrupting condition compared to the multitasking condition demonstrates the contribution of contextual cueing of the ongoing task for remembering delayed intentions. From an applied perspective, the results highlight potential sources of forgetting in safety-critical work places that can have severe consequences

Distributed Prospective Memory in Critical Care: Resuming interrupted tasks and remembering future intentions

An important cognitive function in everyday life is the formation of an intention and the execution of this intention at an appropriate time in the future – a function also known as prospective memory. In safety-critical domains such as healthcare, failure to remember future intentions can have severe consequences. Healthcare researchers and memory researchers have recognised the prospective memory challenges that healthcare staff face, such as remembering routine tasks or resuming interrupted tasks. However, healthcare researchers have not fully considered the cognitive processes involved in prospective memory, and experimental memory researchers have not fully considered the rich and supportive environment in which healthcare staff work. This thesis combines theories about prospective memory drawn from basic research with the approach of distributed cognition to investigate the prospective memory performance of intensive care nurses. A particular focus of the thesis is the resumption of interrupted healthcare tasks. The healthcare literature on interruptions is motivated by the possibly disruptive effects of interruptions on memory, but this potential outcome has seldom been investigated directly. In a retrospective analysis of a full-scale simulation study with anaesthesiologists (Study 1), we showed that whether anesthesiologists remember or forget an interrupted blood transfusion bedside check depends on how they handle the interruption. Only anaesthesiologists who engaged fully with the interruption forgot the check. The study shows that interruptions can lead to forgetting of tasks. The results highlight the fact that interruption management needs to be considered when investigating interruptions in healthcare, a factor that we considered in Study 2. Laboratory research has shown how demanding prospective memory tasks such as resuming interrupted tasks can be. In a theoretically-motivated prospective observation using a mobile eye tracker (Study 2), we investigated which characteristics of an interruption influence the resumption lag, which is the time from the end of the interruption to the recall of the interrupted primary task. The resumption lag served as an indicator of how effortful task resumption was. Furthermore, we investigated how nurses managed prospective memory demands caused by interruptions and how interruption management affected the initial prospective memory demand. The results of a series of multiple regression models show that longer interruptions and a context change due to the interruption make the resumption of interrupted tasks more effortful. Nurses managed prospective memory demands by, for example, holding task artifacts while attending an interruption. This lowers the cognitive demands for an individual nurse because the artefact indicates the task that needs to be resumed and when. Using such ideas we extended the “individual model” of interruption and resumption processes to a “distributed model” to accommodate the behaviour we observed in the field. The next study addressed the role of external support in a controlled setting. To test the influence of the reminders, we controlled the presence and absence of reminders in different prospective memory situations (Study 3). To achieve the necessary control but still allow nurses to use their experience to manage memory demands, we used a full-scale simulator and a scenario representative of professional practice. The results showed that only reminders designed to cue a specific action, or reminders that are essential for the action, improved prospective memory performance. In addition, reminders affected prospective memory processes and strategies for managing prospective memory demands. The final study of the thesis was designed to apply the knowledge gained by implementing a cognitive aid to help nurses remember intentions (Study 4). We tested whether introducing an emergency equipment drawer divider with pictorial representations of emergency equipment items at the appropriate locations would increase how completely the drawers would be stocked. The introduction of the divider resulted in a small but significant increase in equipment completeness, it increased the standardisation between different patient bays, and it eased the safety check for staff with less local intensive care experience. In summary, this research program presents a first step towards investigating prospective memory demands in critical care settings using different methods. The results indicate factors that impede or support remembering of future intentions and highlight how nurses distribute and manage prospective memory challenges. The approach of a distributed prospective memory was suggested for studying and improving prospective memory performance in complex socio-technical domains. However, remembering future intentions in socio-technical settings such as healthcare is a complex task. Future research is discussed that could advance our understanding further, and so potentially increase patient safety

Interruptions in healthcare: Theoretical views

Interruptions are widely considered a problem in healthcare. Results from observation and experimental studies have guided extensive mitigation efforts, but the effectiveness of interventions remains mixed. We have built on current theories and methods for studying interruptions to develop a novel observational approach - the Dual Perspectives Method - for examining interruptions from the perspectives of the different work functions in an Intensive Care Unit (ICU). We detail the method and provide representative examples of the insights it offers, such as why interruptions happen, the role they play, and the consequences of preserving them or eliminating them. We anticipate that the Dual Perspectives Method will help us to arrive at a better basis on which to draw conclusions about interruptions, and will lead to the development of appropriate and sustainable interventions to ensure the effective and safe functioning of the work system under examination

Interruptions in health care: assessing their connection With error and patient Harm

We address the problem of how researchers investigate the actual or potential causal connection between interruptions and medical errors, and whether interventions might reduce the potential for harm.It is widely assumed that interruptions lead to errors and patient harm. However, many reviewers and authors have commented that there is not strong evidence for a causal connection.We introduce a framework of criteria for assessing how strongly evidence implies causality: the so-called Bradford Hill criteria. We then examine four key "metanarratives" of research into interruptions in health care-applied cognitive psychology, epidemiology, quality improvement, and cognitive systems engineering-and assess how each tradition has addressed the causal connection between interruptions and error.Outcomes of applying the Bradford Hill criteria are that the applied cognitive psychology and epidemiology metanarratives address the causal connection relatively directly, whereas the quality improvement metanarrative merely assumes causality, and the cognitive systems engineering metanarrative either implicitly or explicitly questions the feasibility of finding a direct causal connection with harm.The Bradford Hill criteria are useful for evaluating the existing literature on the relationship between interruptions in health care, clinical errors, and the potential for patient harm. In the future, more attention is needed to the issue of why interruptions usually do not lead to harm, and the implications for how we approach patient safety

Multiple patient monitoring in the operating room using a head-mounted display

Physicians and nurses in intensive care units and operating rooms are responsible for several patients at the same time. However, monitoring multiple patients can be challenging, for example, because staff are moving and vital signs may not be accessible. Therefore, physicians and nurses may not be able to create a full picture of their patients’ status – so called situation awareness. The hands-free operability and portability of a head-mounted display could allow physicians and nurses to monitor vital signs constantly and independently of location. We developed an application that displays vital signs of multiple patients on a Vuzix M300 head-mounted display. In this work, we describe the user-centered design approach, implementation, and future evaluation of the application in the operating room at the University Hospital Würzburg

The role of inhibitory processes in part-list cuing

Providing a subset of studied items as retrieval cues can have detrimental effects on recall of the remaining items. In 2 experiments, the authors examined such part-list cuing impairment in a repeatedtesting situation. Participants studied exemplars from several semantic categories and were given 2 successive cued-recall tests separated by a distractor task of several minutes. Part-list cues were provided in the 1st test but not the 2nd. Noncue item recall was tested with the studied category cues (same probes) in the 1st test, but novel, unstudied retrieval cues (independent probes) in the 2nd test. The authors found detrimental effects of part-list cues in both the 1st (same-probe) test and the 2nd (independent-probe) test. These results show that part-list cuing impairment can be lasting and is not eliminated with independent probes. The findings support the view that the impairment was caused by retrieval inhibition

The effect of visual cues on how people handle interruptions

People in work domains such as healthcare are often interrupted. As a result, they sometimes forget to resume their prior task, which may lead to undesirable consequences. In many cases, strategies such as deferring an interruption for a while can help people lower the risks imposed by interruptions. Using two computer based tasks, we investigated whether visual cues make people more likely to defer an interruption until their current task is finished. Our study participants worked on an arithmetic task and were interrupted from time to time by an animated character inviting them to play Tic-Tac-Toe. Results showed that participants were more likely to defer accepting the interruption and to complete the arithmetic task if the arithmetic task contained visual cues that indicated the location of the next steps, than if it did not. The findings suggest that equipment with appropriately designed visual cues might encourage people to defer interruptions and finish their current tasks. Further research is needed to understand exactly how visual cues promote deferral strategies