The emergency department (ED) is filled with a plethora of beeping pagers, ringing telephones, alarms and alerts from various medical devices, unscheduled arrival of patients, supplies not being readily available, and unexpected conversations with colleagues. These examples can interrupt the psycho-motor or cognitive workflow of the medical doctors (MDs) and registered nurses (RNs) working in a level one trauma center.
An interruption is defined as a break in the performance of a human activity initiated by a source internal or external to the recipient, with the occurrence situated within the context of a setting or location. This break results in the suspension of the initial task in order to begin the performance of an unplanned task with the assumption that the initial task will be resumed [1]. Medical doctors and RNs are the recipients of many interruptions during a shift resulting from face-to-face interactions with co-workers, telephone calls, email messages, and alarms and alerts from medical devices. These interruption examples depict a role-based event between a recipient and an initiator. The recipient takes the role by accepting the interruption. Consequently, the recipient is negatively affected by the interruption event because of the unexpected intrusion of a secondary task. For that reason, research studies in healthcare have examined the role of recipient because of the negative impact on their task performance [2], [3], [4], [5], [6]. Moreover, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) [7], [8], [9], the Institute of Medicine (IOM) [10], [11] and Morbidity and Mortality [12] report that interruptions contribute to preventable medical errors. Thus, it is equally important to understand the role of both the initiator and the recipient.
The initiator has the role of initiating an interruption in either the psycho-motor or cognitive workflow of the recipient. Psycho-motor workflow entails the motor actions used to perform a task. Cognitive workflow involves thinking, problem solving, and information processing. To successfully interrupt the recipient's workflow, the initiator must present a detectable physical signal to the recipient announcing an impending interruption. Furthermore, it can be argued that the initiator assumes that the recipient is passive and will immediately accept the interruption. Therefore, a successful interruption depends on the detection and acceptance of the impending interruption task by the recipient [1].
A review of the literature found a limited number of studies that specifically consider the role of initiator of interruptions [3], [4], [13], [14]. Coiera and Tombs categorize a communication interruption as either sent or received for nine different MD and RN clinical roles. Findings reported by Coiera and Tombs show that RNs initiated more paging and telephone calls than they received. In contrast, MDs initiated almost all communication interruptions using the telephone. Medical doctors designated as house officers initiated more telephone calls when compared to consultants, senior registrars, or senior house officers. Specifically in the ED, Spencer and Logan categorized a communication interruption as sent or received by MDs and RNs [13]. The MDs were classified as either registrars or junior medical officers. Registered nurses were categorized as either coordinators or having a patient load [13]. Findings from the study showed that clinicians in higher-ranking roles of registrars and coordinators were more often the recipient of interruptions than RNs with patient loads and junior medical officers. The studies, however, provide few details of how MDs and RNs assumed the role as initiators of interruptions.
Most recently, Sevdalis et al. [15] identified the initiators and recipients of interruptions in the operating room (OR) during communication interruptions. In the OR, surgeons were found most likely to initiate an interruption when compared to anesthetists and RNs. Surgeons were also the recipients of interruptions more often than either anesthetists or RNs. More detail is needed to further describe and characterize when RNs, surgeons, and anesthetists are initiators of interruptions. Therefore, the purpose of this instrumental case study was to examine the roles of MDs and RNs working in a level one trauma center as initiators and recipients of interruptions. An understanding of the initiator will help in the design of strategies to reduce or mitigate the negative outcomes of interruptions.
The design was an instrumental case study using the shadowing method. An instrumental case study is used to gain an in-depth understanding of a phenomenon as well as to generalize from an observational, inductive approach [16]. Shadowing is a qualitative method of direct observations. The observer unobtrusively records the what, when, where, and how the subjects perform their tasks in the real world.
A convenience sample of five MDs and eight RNs working the 07:00–15:00 and 15:00–21:00 shifts
The roles of initiator and recipient of interruptions were two themes that emerged during categorization of the notes. Table 1 shows examples of coded notes.
The precise roles that were identified are shown in Table 2.
The coded notes provided context for developing the definition for each role.
Quantitative results of the recorded notes are shown in Table 3. Five attending, senior, supervising, faculty trauma MDs were observed. Of the five physicians, four were males and one was a female. The MDs
This study identified the interruption roles of initiator and recipient for MDs and RNs from recorded observations in the trauma section of a level one trauma center. Findings from this study indicate that MDs initiated an interruption less often than receiving one. Similarly, RNs took the role as initiator of an interruption less often than that of recipient. Interruptions can also be initiated through environmental conditions such as when supplies or services are not available. Both MDs and
A role-based taxonomy of interruptions was derived from the recorded notes using grounded theory. The categories within the taxonomy show that MDs and RNs initiate interruptions as well as receive them.
This study suggests the need to develop strategies to decrease or mitigate the negative effects of interruptions and must consider the interaction between the initiator and the recipient of an interruption. Failure to consider why the interruption was initiated will lead to the formulation of
This study was supported by a training fellowship from the Keck Center for Computational and Structural Biology of the Gulf Coast Consortia (NLM Grant No. 5 T15 LM07093) and Grant R01 LM07894 from the National Library of Medicine. Summary points What was known before the study The clinical environment is described as interrupt-driven resulting in an unpredictable workflow. The recipients of interruptions have been studied extensively. Few studies have examined the initiators of interruptions. What is
