Differentiating between detrimental and beneficial interruptions: a mixed-methods study

Why vital signs observations are delayed and interrupted on acute hospital wards: A multisite observational study

BACKGROUND

Vital signs monitoring is key to identifying deteriorating hospital patients. However, adherence to monitoring protocols is limited, with observations frequently missed or delayed. Previous studies of interruptions and delays to vital signs observations have been descriptive, with none attempting to conceptualise the types of tasks that are prioritised over vital signs observations.

OBJECTIVE

This paper aims to explore how nursing teams perform vital sign observations on acute hospital wards and conceptualises which types of work delay or interrupt them.

DESIGN

Non-participant observational study.

SETTING(S)

Four hospitals in the south of England.

METHODS

Eligible adult wards (surgical and medical) within each hospital were randomly sampled for inclusion. Four sets of two-hour daytime observation sessions were undertaken on each ward. Two observers recorded structured and unstructured observations (open comments, field notes) on a tablet with adapted QI Tool software. We collected data over 128 h, including 715 sets of vital signs observations and 1127 interruptions. We undertook a qualitative content analysis of interruptions and delays to planned vital signs observations using both structured and unstructured observations.

RESULTS

We identified eight reasons why vital signs were delayed or interrupted: fixed routines, staff availability, bundled care, proximity-related activities, collaborative care, patient inaccessible or unavailable, requests for or responses to time-critical activities, or limited context available. We propose a new concept of 'temporal status.' Flexible care (vital signs observations, 'bundled care' and 'proximity-related care') has a low temporal status so is delayed in favour of higher temporal status activities (fixed routines and time-critical care).

CONCLUSIONS

Our findings could explain why vital signs taken early in the morning and evening are least likely to be postponed, as there may be fewer competing tasks with a higher temporal status at these times. Our work also challenges binary conceptualisations of interruptions as 'beneficial' or 'detrimental', recognising the complexity of nursing care decisions on a moment-by-moment basis. Our new framework suggests the lower temporal status of vital signs observations (and other flexible care) means they are delayed by higher temporal status tasks during daytime shifts in acute hospitals, regardless of their clinical priority.

REGISTRATION

10863045, ISRCTN (6/8/2019).

Surgical counting interruptions in operating rooms

BACKGROUND

Operating rooms are complex working environments with high workloads and high levels of cognitive demand. The first surgical count which occurs during the chaotic preoperative stage and is considered a critical phase, is a routine task in ORs. Interruptions often occur during the first surgical count; however, little is known about the first surgical counting interruptions. This study aimed to observe and analyse the sources, outcomes, frequency of the first surgical counting interruptions and responses to interruptions.

METHODS

A retrospective observational study was carried out to examine the occurrence of the first surgical counting interruptions between 1st August 2023 and 30th September 2023. The data were collected using the "Surgical Counting Interruption Event Form", which was developed by the researchers specifically for this study.

RESULTS

A total of 66 circulating nurses (CNs) and scrub nurses (SNs) were observed across 1015 surgeries, with 4927.8 min of surgical count. The mean duration of the first surgical count was 4.85 min, with a range of 1.03 min to 9.51 min. In addition, 697 interruptions were identified, with full-term interruptions occurring an average of 8.7 times per hour. The most frequent source of interruption during the first surgical counts was instruments (N = 144, 20.7%). The first surgical counting interruptions mostly affected the CN (336 times; 48.2%), followed by the ORNs (including CNs and SNs) (243 times; 34.9%) and the SN (118 times; 16.9%). Most of the outcomes of interruptions were negative, and the majority of the nurses responded immediately to interruptions.

CONCLUSIONS

The frequency of the first surgical counting interruption is high. Managers should develop interventions for interruptions based on different surgical specialties and different nursing roles.

Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study

Few studies have investigated interruptions to the work of professionals practicing in inpatient hospitals, and even fewer take account of the functions that make up the system. Safety of care can be improved by considering avoidable interruptions during interactions between managerial and care delivery functions. The present study describes the characteristics of interruptions to the work of professionals working in the inpatient hospital sector, with respect to their typology, frequency, duration, and avoidability in the context of interactions between functions. This direct observational study of interruptions in hospital care was performed in the Pays de la Loire (west coast) area of France. A total of 23 teams (17 institutions) working in medical or surgical specialties (excluding intensive care) were included. Observations were performed between May and September 2019, and lasted seven consecutive hours per team. A pair of observers simultaneously observed the same professional for ∼30 min. Each occupational category was examined. Reported characteristics were: (i) the method and duration of the request, (ii) the location of interrupted and interrupting persons, (iii) the reaction of the interrupted person, (iv) the characteristics of the interrupting person, and (v) the classification of interrupted and interrupting tasks according to their function. An avoidable interruption was defined. Interruptions during interactions between professionals were categorised in terms of their function and avoidability. Descriptive statistical analyses (mean, standard deviation, and distribution) were run. In particular, cross-comparisons were run to highlight avoidability interruptions and interactions between managerial and care delivery functions during the working day, for different professional categories, and for the location of the request. Overall, 286 interrupted professionals were observed and 1929 interruptions were characterised. The majority of interruptions were due to a face-to-face request (58.7%), lasting ≤30 s (72.5%). Professionals engaged in the response in 49.3% of cases. A total of 57.4% of interruptions were avoidable. The average number of interruptions was 10.5 (SD = 3.2) per hour per professional. An analysis of avoidability and interactions between managerial and care delivery functions found that the period between 12:00 and 13:00 was the riskiest in terms of care safety. This study highlighted the characteristics of interruptions to the activity of professionals working in inpatient hospitals. Care teams could focus on making medical and nursing professionals much more aware of the importance of interruptions, and each team could decide how to best-manage interruptions, in the context of their specific working environment.

Workflow interruption and nurses' mental workload in electronic health record tasks: An observational study

BACKGROUND

Workflow interruptions are common in modern work systems. Electronic health record (EHR) tasks are typical tasks involving human-machine interactions in nursing care, but few studies have examined interruptions and nurses' mental workload in the tasks. Therefore, this study aims to investigate how frequent interruptions and multilevel factors affect nurses' mental workload and performance in EHR tasks.

METHODS

A prospective observational study was conducted in a tertiary hospital providing specialist and sub-specialist care from June 1^st to October 31^st, 2021. An observer documented nurses' EHR task interruptions, reactions and performance (errors and near errors) during one-shift observation sessions. Questionnaires were administered at the end of the electronic health record task observation to measure nurses' mental workload for the electronic health record tasks, task difficulty, system usability, professional experience, professional competency, and self-efficacy. Path analysis was used to test a hypothetical model.

RESULTS

In 145 shift observations, 2871 interruptions occurred, and the mean task duration was 84.69 (SD 56.68) minutes per shift. The incidence of error or near error was 158, while 68.35% of errors were self-corrected. The total mean mental workload level was 44.57 (SD 14.08). A path analysis model with adequate fit indices is presented. There was a relationship among concurrent multitasking, task switching and task time. Task time, task difficulty and system usability had direct effects on mental workload. Task performance was influenced by mental workload and professional title. Negative affect mediated the path from task performance to mental workload.

CONCLUSIONS

Nursing interruptions occur frequently in EHR tasks, come from different sources and may lead to elevated mental workload and negative outcomes. By exploring the variables related to mental workload and performance, we offer a new perspective on quality improvement strategies. Reducing harmful interruptions to decrease task time can avoid negative outcomes. Training nurses to cope with interruptions and improve competency in EHR implementation and task operation has the potential to decrease nurses' mental workload and improve task performance. Moreover, improving system usability is beneficial to nurses to mitigate mental workload.

An observational study of distractions in the operating theatre

Several studies have reported on the negative impact of interruptions and distractions on anaesthetic, surgical and team performance in the operating theatre. This study aimed to gain a deeper understanding of these events and why they remain part of everyday clinical practice. We used a mixed methods observational study design. We scored each distractor and interruption according to an established scheme during induction of anaesthesia and the surgical procedure for 58 general surgical cases requiring general anaesthesia. We made field notes of observations, small conversations and meetings. We observed 64 members of staff for 148 hours and recorded 4594 events, giving a mean (SD) event rate of 32.8 (16.3) h-1 . The most frequent events observed during induction of anaesthesia were door movements, which accounted for 869 (63%) events, giving a mean (SD) event rate of 28.1 (14.5) h-1 . These, however, had little impact. The most common events observed during surgery were case-irrelevant verbal communication and smartphone usage, which accounted for 1020 (32%) events, giving a mean (SD) event rate of 9.0 (4.2) h-1 . These occurred mostly in periods of low work-load in a sub-team. Participants ranged from experiencing these events as severe disruption through to a welcome distraction that served to keep healthcare professionals active during low work-load, as well as reinforcing the social connections between colleagues. Mostly, team members showed no awareness of the need for silence among other sub-teams and did not vocalise the need for silence to others. Case-irrelevant verbal communication and smartphone usage may serve a physical and psychological need. The extent to which healthcare professionals may feel disrupted depends on the situation and context. When a team member was disrupted, a resilient team response often lacked. Reducing disruptive social activity might be a powerful strategy to develop a habit of cross-monitoring and mutual help across surgical and anaesthetic sub-teams. Further research is needed on how to bridge cultural borders and develop resilient interprofessional behaviours.

Smartphone distraction during nursing care: Systematic literature review

AIM

To investigate the impact of smartphone distraction on the quality and safety of care provided by the nursing population during work.

BACKGROUND

About 80% of nurses use the smartphone in the workplace both for personal purposes and as a useful support to improve the quality of care. Distraction from smartphones during care is a phenomenon that should be known and managed within each health service.

METHODS

A systematic review of the literature was conducted using the PRISMA methodology. The sources included in the review study were subjected to a qualitative assessment using the GRADE method.

RESULTS

Sixteen articles were included in the review. Studies included highlight the positive and negative consequences of using mobile devices during nursing practice. Findings identify the smartphone as a generator of stimuli capable of diverting the attention of the person from the priority activities and absorbing the cognitive resources useful for carrying out these activities. Some studies aimed to show the restriction policies and/or the strategies for reducing disruptions. This review highlights how the free and indiscriminate use of the smartphone can negatively affect patient safety and the nurse-patient relationship through the dehumanization and depersonalization of care.

CONCLUSIONS

Mobile technology can improve nurses' performance and the quality of care provided. However, the application of regulations and policies by healthcare facilities is desirable to avoid inappropriate use of these devices by nurses. The available data do not provide a precise estimate of the effect that distraction from smartphones has on the outcomes of nursing care.

Workflow disruptions and provider situation awareness in acute care: An observational study with emergency department physicians and nurses

BACKGROUND

The fast-paced and rapidly changing environment of an Emergency Department (ED) requires providers to have a high level of situation awareness (SA). However, acute clinical care also encompasses a multitude of interruption-laden work processes that might degrade SA. It is therefore important to understand how frequent interruptions affect ED provider cognition in general and SA in particular.

OBJECTIVE

We aimed to examine how sources and contents of provider workflow interruptions influence situation awareness of ED physicians and nurses.

METHODS

This prospective, multi-method study combined standardized observations, self-reports of ED providers, and ED administrative data of staffing and patient load. Expert observers identified ED providers' workflow interruptions during 90min observation sessions. Afterwards, each provider reported perceived disruptiveness and situation awareness. Controlling for patient load, patient acuity and staffing, we conducted regression analyses to explore prospective associations between interruptions and provider outcomes.

RESULTS

During 74 observation sessions of overall 110h and 40min, we observed 1205 workflow interruptions (mean rate: 10.9 interruptions/hour). Provider situation awareness was fairly high (M = 7.10; scale 0-10) with no difference between ED physicians and nurses. After controlling for ED workload data, we observed that high rates of interruptions were associated with lower levels of situation awareness (β = -0.27). Further analyses revealed that particularly interruptions by telephone/beeper, technical malfunctions as well as interruptive communication related to completed cases were correlated to low SA.

DISCUSSION

This study in a naturalistic ED setting shows that ED physicians and nurses continuously cope with disruptions and interruptions. Our findings reveal that highly interruptive workflow environments impede providers' situation awareness. Moreover, it sheds light on specific sources and contents of interruptions that influence providers' SA in acute care.

CONCLUSION

Frequent workflow interruptions can degrade ED providers' situation awareness. A deeper understanding of how avoidable and unavoidable interruptions affect provider cognitions with particular focus on social and technology-related disruptions is required. Further emphasis should be placed on the effective application of work re-design in this context to foster safe and efficient patient care.

Improving efficiency within a trauma nurse practitioner team

BACKGROUND

Clinicians, including nurse practitioners (NPs), face a number of challenges in delivering high-quality care including frequent interruptions that can potentially compromise patient safety and job satisfaction.

LOCAL PROBLEM

Trauma NPs voiced frustration with their efforts to provide efficient, high-quality care with frequent interruptions, most commonly pager alerts. The purpose of this quality improvement (QI) initiative was to increase trauma NPs' perceptions of patient safety and improve NPs' job satisfaction by reducing workflow interruptions.

METHODS

The Model for Improvement guided this initiative.

INTERVENTIONS

The aims of this initiative were to reduce the percentage of nonurgent workflow interruptions via pager alerts by 20% and to increase the utilization of a standardized trauma NP patient rounding process from 0% to 50%.

RESULTS

Use of the standardized rounding process improved from 0% to 87%. Interruptions via pager alerts decreased by 36.2%. All nine (100%) trauma NP survey responses revealed an improvement in NP perception of patient safety and job satisfaction.

CONCLUSION

The QI initiative found that increasing communication during rounds by using a standardized rounding process involving the bedside registered nurse can minimize interruptions and improve the efficiency of a trauma NP team. The key to the success of the QI initiative was the implementation of a standardized rounding process.

The Impact of Phone Interruptions on the Quality of Simulated Medication Order Validation Using Eye Tracking: A Pilot Study

INTRODUCTION

Order validation is an important component of pharmacy services, where pharmacists review orders with a focus on error prevention. Interruptions are frequent and may contribute to a reduction in error detection, thus potential medication errors. However, studying such errors in practice is difficult. Simulation has potential to study these events.

METHODS

This was a pilot, simulation study. The primary objective was to determine the rate of medication error detection and the effect of interruptions on error detection during simulated validation. Secondary objectives included determining time to complete each prescription page. The scenario consisted of validating three handwritten medication order pages containing 12 orders and 17 errors, interrupted by three phone calls timed during one order for each page. Participants were categorized in groups: seniors and juniors (including residents). Simulation sessions were videotaped and eye tracking was used to assist in analysis.

RESULTS

Eight senior and five junior pharmacists were included in the analysis. There was a significant association between interruption and error detection (odds ratio = 0.149, 95% confidence interval = 0.042-0.525, P = 0.005). This association did not vary significantly between groups (P = 0.832). Juniors took more time to validate the first page (10 minutes 56 seconds vs. 6 minutes 42 seconds) but detected more errors (95% vs. 69%). However, all major errors were detected by all participants.

CONCLUSIONS

We observed an association between phone interruptions and a decrease in error detection during simulated validation. Simulation provides an opportunity to study order validation by pharmacists and may be a valuable teaching tool for pharmacists and pharmacy residents learning order validation.

Provider interruptions and patient perceptions of care: an observational study in the emergency department

BACKGROUND

Interruptions are endemic in healthcare work environments. Yet, they can have positive effects in some instances and negative in others, with their net effect on quality of care still poorly understood. We aimed to distinguish beneficial and detrimental forms of interruptions of emergency department (ED) providers using patients' perceptions of ED care as a quality measure.

METHODS

An observational design was established. The study setting was an interdisciplinary ED of an academic tertiary referral hospital. Frequencies of interruption sources and contents were identified in systematic expert observations of ED physicians and nurses. Concurrently, patients rated overall quality of care, ED organisation, patient information and waiting times using a standardised survey. Associations were assessed with hierarchical linear models controlling for daily ED workload. Regression results were adjusted for multiple testing. Additionally, analyses were computed for ED physicians and nurses, separately.

RESULTS

On 40 days, 160 expert observation sessions were conducted. 1418 patients were surveyed. Frequent interruptions initiated by patients were associated with higher overall quality of care and ED organisation. Interruptions relating to coordination activities were associated with improved ratings of ED waiting times. However, interruptions containing information on previous cases were associated with inferior ratings of ED organisation. Specifically for nurses, overall interruptions were associated with superior patient reports of waiting time.

CONCLUSIONS

Provider interruptions were differentially associated with patient perceptions of care. Whereas coordination-related and patient-initiated interruptions were beneficial to patient-perceived efficiency of ED operations, interruptions due to case-irrelevant communication were related to inferior patient ratings of ED organisation. The design of resilient healthcare systems requires a thorough consideration of beneficial and harmful effects of interruptions on providers' workflows and patient safety.

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.

Workflow interruptions and stress atwork: a mixed-methods study among physicians and nurses of a multidisciplinary emergency department

OBJECTIVES

Dealing with multiple workflow interruptions is a major challenge in emergency department (ED) work. This study aimed to establish a taxonomy of workflow interruptions that takes into account the content and purpose of interruptive communication. It further aimed to identify associations of workflow interruptions with ED professionals' work stress.

DESIGN

Combined data from expert observation sessions and concomitant self-evaluations of ED providers.

SETTING

ED of an academic community hospital in Germany.

PARTICIPANTS

Multidisciplinary sample of ED physicians and nurses. 77 matched observation sessions of interruptions and self-evaluations of work stress were obtained on 20 randomly selected days.

OUTCOME MEASURES

ED professionals' stress evaluations were based on standardised measures. ED workload data on patient load, patient acuity and staffing were included as control variables in regression analyses.

RESULTS

Overall mean rate was 7.51 interruptions/hour. Interruptions were most frequently caused by ED colleagues of another profession (27.1%; mean interruptions/hour rate: 2.04), by ED colleagues of the same profession (24.1%; 1.81) and by telephone/beeper (21%; 1.57). Concerning the contents of interruption events, interruptions most frequently occurred referring to a parallel case under care (30.3%, 2.07), concerning the current case (19.1%; 1.28), or related to coordination activities (18.2%, 1.24). Regression analyses revealed that interruptive communication related to parallel cases significantly increased ED providers' stress levels (β=0.24, P=0.03). This association remained significant after controlling for ED workload.

DISCUSSION

Interruptions that refer to parallel cases under care were associated with increased stress among ED physicians and nurses. Our approach to distinguish between sources and contents of interruptions contributes to an improved understanding of potential benefits and risks of workflow interruptions in ED work environments. Despite some limitations, our findings add to future research on the implications of interruptions for effective and safe patient care and work in complex and dynamic care environments.