Clinical PotpourriInterruptions experienced by cardiovascular intensive care unit nurses: An observational study
Introduction
Intensive care units (ICUs) are complex and demanding modern work environments. Intensive care unit nurses perform various procedures, document patient care, interact with medical devices, respond to the needs of patients and families, and often multitask [1]. Furthermore, ICU nurses are frequently interrupted (eg, [2], [3], [4]). Intensive care units are generally known to be error prone [5] and given the limitations of human working memory and attentional resources (eg, [6], [7], [8], [9]), it is likely that interruptions combined with performing multiple concurrent tasks facilitate errors [10]. In line with this expectation, interruptions observed in health care settings are generally considered to have negative effects on performance, and some of the current mitigation approaches focus on removing or blocking interruptions by applying the so-called sterile cockpit approach and no interruption zones (eg, [11], [12], [13]). However, interruptions at times are necessary as they can convey critical information [14], [15], [16], [17]; therefore, mitigation strategies should be designed accordingly.
As a first step to understanding different ICU interruptions with the ultimate goal of developing situation-specific mitigation approaches, we propose that the following 3 Cs of interruptions should be considered:
- (1)
Characteristics (eg, frequency and duration): Previous research on interruptions mainly focuses on interruption characteristics and suggests that both interruption frequency and duration have an impact on performance. Longer interruptions tend to result in a longer period of task resumption (ie, time taken to resume the primary task once the interruption is over), which can hinder performance for time-critical tasks [18], [19]. Furthermore, more frequent interruptions decrease decision accuracy and increase decision time [20]. In the ICU context, research so far has mainly focused on the frequency and duration of interruptions to nurses and reported high frequencies (10/hour in Drews [21]; 15.3/hour excluding multitasking in Grundgeiger et al [19]; 4.5/hour during documentation in Ballermann et al [22]) and an increased task resumption time for longer interruptions [19].
- (2)
Context (eg, sources of interruption, tasks being interrupted, and conditions interruptions happen under): Context plays a major role in understanding why interruptions happen and informs how they should be handled. For example, it may be necessary to block an interruption if the task at hand can lead to a severe outcome in case of an error. Conversely, an interruption may increase arousal in low workload periods. In this study, we focus on primary task (or task at hand) severity and interruption sources. To our knowledge, an analysis of interruptions according to primary task severity has not been conducted in ICU settings. In general, previous ICU-specific studies report other nurse interruptions to be one of the top sources (24% in pediatric ICU by McGillis Hall et al [4]; 37.3% in adult ICU by Drews [21]) and patient care and documentation as the most commonly interrupted primary tasks (34% and 21%, respectively, reported by McGillis Hall et al [4] for pediatric ICU).
- (3)
Content (eg, information the interruption conveys, purpose of interruption): Interruption content can guide how the interruption should be handled. For example, an interruption should potentially be allowed if it conveys time-critical information about the task at hand or if it is necessary for another time-critical task even if it is unrelated to the task at hand (eg, another patient having a cardiac arrest). In pediatric care (critical, surgical, and medical care combined), McGillis Hall et al [4] reported communications with the nurse related to patient care to be the most frequent cause of interruptions (35%) as well as the existence of potentially non–patient-care-related interruptions (eg, socializing, 4%; phone calls, 2.7%). These latter types of interruptions may have to be blocked based on a given context. In general, interruption mitigation strategies should consider the urgency of an interruption and its relevance to the task at hand.
Understanding interruptions in a complex system such as an ICU requires a holistic approach. We believe that studying context, content, and characteristics of interruptions and their interaction could be used as a framework to provide insight into why and how interruptions occur. In this article, an initial step is taken through an observational study to explore the relations between the 3 Cs of interruptions, by identifying interruption content and associated primary task severity.
Section snippets
Methods
Nurses of the cardiovascular ICU (CVICU) of a Canadian teaching hospital were asked to participate in an observational study. Forty nurses participated in the study (response rate of 90%). Observations were conducted on weekdays between 8:00 and 18:00 during day shifts (07:30-19:30) over a 3-week period. The study was approved by the research ethics board of this hospital. Four observers (1 PhD and 3 undergraduate engineering students) trained in human factors research conducted 56 observation
Characteristics
In 48 hours of total observation time, 1007 interruptions were observed. That is, on average, 1 interruption occurred per about 3 minutes of observation.
Context
Of the 1007 interruptions observed, other nurses were the most common source (43.38%), followed by equipment (12.04%) and MDs (12.04%), and then patients (8.46%), visitors (6.47%), and phone (4.38%). The rest of interruption sources accounted for less than 15% of all interruptions.
Almost half of all interruptions happened during documentation
Summary
The ICU nurses got interrupted frequently (~ 20/hour). Other nurses (~ 43%) accounted for almost half of all interruptions, followed by equipment (~ 12%) and MDs (~ 12%). Almost half of all interruptions (~ 51%) happened during high-severity tasks and, in particular, during procedures (~ 21%). Although most interruptions were either work or patient related, approximately 18% of interruptions were due to personal reasons. Moreover, based on opportunistic notes, it was found that some of the
Acknowledgments
This research was funded by a Natural Sciences and Engineering Research Council of Canada (NSERC) Postgraduate Scholarship and a Canadian Institute of Health Research Health Care, Technology, and Place Doctoral Scholarship awarded to Farzan Sasangohar, as well as an NSERC Discovery Grant awarded to Birsen Donmez. We gratefully thank Dr Mark Chignell and Dr Linda McGillis Hall for their insightful feedback and Parya Noban, Sahar Ameri, Jaquelyn Monis Rodriguez, and Mohd Asher for their help in
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