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The impact of interruptions during clinical activities in the emergency department

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Abstract

Since the 1940s, the aviation industries have studied how attention lapses caused by interruptions can lead to errors. In healthcare only limited evidence is available. This pilot study investigates the impact of interruption on physicians’ work and stress in an emergency care department of an Italian Hospital. We found that doctors were frequently interrupted (7.1 times per hour) with a negative effect on work-related stress. Being a pilot study more observational studies are necessary to elucidate how interruptions and distractions affect the medical practice, and to analyze the effect of interruptions on error rates and physicians work-related stress.
Developing and testing a model of psychosocial work
environment and performance.
Editors: Edwards, Kasper; Pejtersen, Jan Hyld; Møller, Niels.
Proceedings of 10th International Symposium on Human
Factors in Organizational Design and Management
in Grahamstown, South Africa
April 2 to 3, 2011, Rhodes University
ISBN 9780976814344
IEA Press, 2011
The Human Factors in Organisational Design and Management X
ODAM 2011. ISBN 9780976814344
Human Factors and Ergonomics
Developing and testing a model of psychosocial work environment and performance
The impact of interruptions during clinical activities in the
emergency department
Gabriella PRAVETTONI, Claudio LUCCHIARI, Alessandra GORINI, Gianluca VAGO
Università degli Studi di Milano, Italy
Abstract. Since the 1940s, the aviation industries have studied how attention lapses caused
by interruptions can lead to errors. In healthcare only limited evidence is available. This
pilot study investigates the impact of interruption on physicians’ work and stress in an
emergency care department of an Italian Hospital. We found that doctors were frequently
interrupted (7.1 times per hour) with a negative effect on work-related stress. Being a pilot
study more observational studies are necessary to elucidate how interruptions and
distractions affect the medical practice, and to analyze the effect of interruptions on error
rates and physicians work-related stress.
Keywords. Interruptions, medical error, emergency department, work-related stress.
1.Introduction
The role of interruptions in the workplace has begun to receive a particular
consideration in the last two decades. Empirical studies have focused their attention in
identifying the extent of interruptions and the way in which they affect tasks (Beso et al.,
2005), the recovery of tasks after interruptions and their timing (Mark et al., 2008;
Westbrook et al., 2010).
An interruption can be defined as an externally generated and unpredicted event that breaks
the cognitive focus shifting the subject’s attention toward a new task that typically requires
immediate attention.
This definition implies that a person, or an event, can create an interruption that is a
contextual, time-framed and beyond the control of the individual. Interruptions can
exaggerate the information overload. In particular, there are at least two ways in which an
interruption can cause it. First, interruptions disrupt the regular working flow, taking time
away from an occupation. This provokes a time pressure or a self-perceived feeling of
constraint and overload with potential bad consequences on personnel stress and quality of
work. Moreover, interruptions break attention on a primary task and force the person to turn
his/her attention to the source that generated the interrupting event. From cognitive point of
view, interruptions generate a disturbing event that breaks down a planned cognitive work
moving the subjects’ attention and resources to a significant but unexpected requirement
from the environment. One’s attention is redirected to a different source because the
The Human Factors in Organisational Design and Management X
ODAM 2011. ISBN 9780976814344
Human Factors and Ergonomics
Developing and testing a model of psychosocial work environment and performance
interrupting event may use the same sensory channels as those used in many other different
activities.
An interruption, therefore, represents a structural cognitive interference (Kahneman,
1973), since it has the ability to overload the cognitive system increasing the number of
incoming stimuli and thus disabling a decision maker to maintain attention on the ongoing
process. A structural interference occurs when an individual (e.g., a decision maker) must
attend to two inputs that require the same physiological mechanisms (e.g., responding to
two different visual stimuli, one coming from the computer screen and the other one from a
colleague entering in the office). Thus, interruptions create an interference that increases
the overall burden of cognitive processing, forcing a person to focus his/her attention on
one task, affecting the ability to process the other one.
The second way in which an interruption may exacerbate information overload is
directly related to the content of the interruption itself. An interruption, in fact, may require
a great amount of attention creating a cognitive burden that exceeds the available resources
(Norman & Bobrow, 1975). When this occurs, the decision-maker tends to forget some of
information necessary for the development of the primary task and some ideas are lost or
never got into working memory. As the decision maker resolves the interruption and return
to the primary task, a recovery period is needed to reprocess the information that has been
forgotten or lost while attending the break from working memory capacity because of the
interference (Kahneman, 1973). In such cases, the working accuracy can be reduced and/or
the decision-making time may increase.
It is likely that different types of interruptions have different effects on the decision
maker’s performance. Characteristics that primarily influence cognitive processing include
frequency, duration, content, complexity, and timing of the interruption. Also social
characteristics may play a role in affecting individual’s response to an interruption. The
person or the object that generates the interruption may have a peculiar value for the
decision-maker and some social expectations might affect his/her responsiveness to the
disruption.
1.1 Interruption in hospital
Interruptions and multitasking (carrying out multiple tasks simultaneously) are
unavoidable in busy clinical environments, and patient care may be compromised if
clinicians are unable to deal with them in their work. Consequently a hospital maybe
described as an interrupt-driven environment with high grade of multitasking loads
(Chilshom, et al. 2000).
Professionals working in emergency departments under high stressful conditions have been
shown to experience high rates of interruption and multitasking (Davidson, 2003). Their
working environment is dynamic and subject to many time constraints, and has been
identified to be at greater risk of errors than many other settings (Laxsisam et al., 2007).
The combination of multitasks and interruptions is a potent latent source of clinical errors.
A study performed by Hall and coll. (2010) has demonstrated that interruptions
occurred to hospital nurses significantly increase the rate and severity of medication
administration errors (see also, Hitchen, 2008). Thus, the uncontrolled and untrained
presence of interruptions in clinical practice is an expensive and dangerous event, and the
need to control the unnecessary interruptions and multitasks is strong. A recent study
The Human Factors in Organisational Design and Management X
ODAM 2011. ISBN 9780976814344
Human Factors and Ergonomics
Developing and testing a model of psychosocial work environment and performance
performed in a number Australian hospitals (Westbrook et al., 2010) have shown that
interrupted physicians may also recover the lost time and complete a clinical task even
faster than in not interrupted situations. This is coherent with other studies showing that
interrupted work may be done faster (Mark et al., 2008). However this may be done at a
price, since interruptions seam to require people to change work rhythms and cognitive,
further then affecting the emotional sphere.
1.2 Interruptions and stress
Experimental studies show that interruptions can trigger cognitive failures,
including lapses in attention, memory or perception. Further, interruptions add significantly
cognitive load, increase stress and anxiety, inhibit decision-making performance and
increase errors. Interruptions can cause impairments in working memory, leading to errors
such as failing to complete or initiate tasks, or to repeat tasks. Thus, it is somewhat intuitive
that interruptions should have a deleterious effect on physician performance because they
force cognitive resources to be shared and distributed in a multitasking and noisy
environment. Rationing of resources can change the way in which tasks are processed
(March, 1994) and the manner in which information is used (Baron, 1986). These changes
may result in decreased task accuracy and in the use resource-demanding strategies
(Shiffman & Griest-Bousquet, 1992).
The effects of interruptions on the efficiency and effectiveness of clinical care is well
recognized, but few is known about the effects of interruptions on physicians’ stress and
wellbeing. Interruptions represent a contributor to clinician stress, which has important
consequences for productivity, quality of clinical task performance, workplace anxiety,
fatigue, and job satisfaction (Davidson, 2003; Kirmeyer, 1988).
2. Methods
This pilot study investigated the nature and frequency of interruptions in an
emergency care department of an Italian Hospital. The relationship between interruptions
and physician self-perceived stress was also analyzed.
The research had two main goals:
1 - Identify potential sources and natures of interruptions in an emergency care setting
2 - Discuss the relation between workplace interruptions and the health and self-perceived
stress of physicians.
Our main hypotheses were that the emergency care environment is interrupted-driven and
that physicians had poor awareness of the related potential hazardous. Secondary we
expected to find some relationships between the level of interruptions and the work-related
stress.
2.1. Subjects
The 30 physicians observed during their daily activity had a mean age of 42 years.
The mean of their length of service as physicians was 7 years, while the mean of their
length of service in the emergency department (ED) was 5.6 years. In general, they were no
novices and had a good experience in the ED practice..
The Human Factors in Organisational Design and Management X
ODAM 2011. ISBN 9780976814344
Human Factors and Ergonomics
Developing and testing a model of psychosocial work environment and performance
Regarding the gender of the sample, 22 participants (73,3%) were males and 8 were
females (26,7%).
2.2 Instruments and observations
A total amount of 180 h of observation were performed using a previously tested
observation grid.
Observed physicians were evaluated for cognitive level of stress before and after the
observed work shift using the VRS scale (Tarsitani, Biondi, 1999), an Italian questionnaire
for stress evaluation were conducted
Half structured interviews were performed on a different sample of physicians
including 17 males and 13 females recruited from 6 different emergency departments
located around Milan in order to investigate their personal perceptions about the impact of
interruptions on quality of work and safety.
3. Results
3.1 Effects of epidemiological variables of the sample
No significant effects were found in relation to age and gender.
3.2 Causes of interruptions
We found that doctors were typically interrupted 7.1 times per hour; 18% percent of
all tasks were interrupted. The more frequent cause of interruptions was represented by
other physicians whose number of interruptions was, in mean, 10.03 times per turn (S.D. =
5.24), followed by internal phone calls (mean = 8.90; S.D. = 4.70) received from colleagues
from other departments or technical staff like radiologists, nurses (mean = 8.52; S.D. =
5.54), triage nurses (mean = 4.86; S.D. = 3.47), patients’ relatives (mean = 2.62; S.D. =
3.11), other patients (mean = 1.69; S.D. = 1.83) and cell phone calls (mean = 1.00; S.D. =
1.41).
3.3 Duration of interruptions
Interruptions performed by other physicians took the longest time (mean = 9.77
min; S.D. = 4.88), followed by those coming from the internal phone calls (mean = 8.93
min; S.D. = 4.60), nurses (mean = 2.62; S.D. = 3.11), nurses (mean = 8.33 min; S.D. =
5.61), triage nurses (mean = 4.86 min; S.D. = 3.39), patients’ relatives (mean = 2.70 min;
S.D. = 3.08), other patients (mean = 1.60 min; S.D. = 1.83) and cell phone calls (mean =
1.23 min; S.D. = 1.38).
Interruptions caused by colleagues are frequent and long because physicians often need to
discuss one with the others about clinical cases they are examining, their next placing, and
so on.
3.4 Interruptions during the shift handover time
During the handing over time the number of interruptions decreased significantly
with one (predictable) exception: the phone calls received on cell phones increased
compared to the regular turns.
The Human Factors in Organisational Design and Management X
ODAM 2011. ISBN 9780976814344
Human Factors and Ergonomics
Developing and testing a model of psychosocial work environment and performance
3.5 Morning vs afternoon turns
No significant differences were found between morning (8.00 am 2.00 pm) and
afternoon (2.00 pm 8.00 pm) turns in the number of interruptions observed (morning
mean = 42.52, S.D. = 19.72; afternoon mean = 43.75, S.D. = 17.74).
3.6 Physicians’ subjective perceptions regarding interruptions
Data coming from interviews were concordant with what we observed. They
referred the most frequent interruptions are caused by the other colleagues and the most
annoying were the phone calls (they were the second cause of interruptions observed in the
ED) and that interruptions are continuous during all the day. They said that the telephone
ring is very disturbing even if the call is directed to someone else in the department.
Regarding the cognitive effects of the interruptions, the interviewed physicians said that
they cause: loss of concentration (46.7% of the sample), distraction (16.7%) and errors
(6.7%).
3.7 Interruptions and self-perceived stress
We have found that not all kind of interruptions have the same effect on self-
perceived stress. In particular, the interruptions generated during a clinical task by a nurse
seemed to have the higher impact. In fact, the interrupted total time for a single physician
during a whole working-time was found to be the best predictor of the subjective total
stress measured after the end of the work shift by the VRS scale (t = -3,072, p = .006).
Interestingly, this effect was not related to the amount of stress measured with same scale
before at the beginning of the working-time.
4. Discussion and Conclusion
Our results confirm that the emergency care setting is characterized by interruptions
and multitasking. This environment may be then particularly vulnerable to the effect of
interferences on quality and safety of care (Croskerry, 2001). We found that the work of
observed physician to be particularly disrupted by a number of different source of
interruptions. In particular, the main source of interruptions are colleagues and other
internal sources. However not all interruptions have the same impact. Some modalities and
contents may have a specific effect, and then requiring particular attention. Cellular phone,
for instance, though being less frequent than others are reported to be particularly
disturbing. Similarly, interruptions caused by nurses seemed to have a peculiar impact on
physician work. In fact, work-related stress was found to be significantly associated to the
amount of this particular source of disruption. More researches are needed to understand
the nature of this interesting phenomenon.
Finally, from qualitative interviews it was possible to highlight that even if
physicians recognize that their work is significantly disrupted by different sources of
interruptions, they showed to suffer by an optimistic bias. In fact, only a minor part of the
sample seem to link interruptions to potential error and the safety of clinical task.
The present study must be considered a pilot research, since only one emergency
department was assessed for a limited period. These constraints limits the generality of our
results, even though they aroused some important considerations. Other studies are
The Human Factors in Organisational Design and Management X
ODAM 2011. ISBN 9780976814344
Human Factors and Ergonomics
Developing and testing a model of psychosocial work environment and performance
necessary to elucidate how interruptions and distractions affect medical errors and adverse
events. Research is needed to assess the effect of interventions on interruptions and
distractions, error rates, adverse events, and patient and physician satisfaction and stress.
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The Human Factors in Organisational Design and Management X
ODAM 2011. ISBN 9780976814344
Human Factors and Ergonomics
Developing and testing a model of psychosocial work environment and performance
... However this may be done at a price since interruptions seem to require people to change work rhythms, in addiction to affecting the emotional sphere. An Italian study confirmed the impact of interruptions on patient care quality and safety, proving that contextual factors may interfere with cognitive mechanisms in generating biased tasks and work-related stress[9]. ...
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