Interruptions Experienced by Registered Nurses Working in the Emergency Department

doi:10.1016/j.jen.2009.12.024

Journal of Emergency Nursing

Volume 37, Issue 1, January 2011, Pages 3-8

https://doi.org/10.1016/j.jen.2009.12.024 Get rights and content

Introduction

A descriptive, observational study was performed to determine (a) the frequency (number of interruptions per hour) that a typical ED nurse experiences interruptions, (b) the type of interruptions a typical ED nurse experiences, and (c) the percentage of interruptions that take place during medication related activities.

Methods

A convenience sample of 30 nurses from 3 emergency departments of a major metropolitan academic medical center were each observed for 120 minutes to determine how many interruptions per hour the ED nurse experienced, the type of interruptions and what percentage of these interruptions took place during medication-related activities. A data collection tool was developed to record tasks performed by the nurses and the type of interruptions experienced. Interrater reliability was established with a Kappa of 0.825.

Results

A total of 200 interruptions occurred during the 60 hours of observation, or 3.3 interruptions per hour per RN. Of the 20 possible types of interruptions that were identified a prior to the observation period, 11 different types of interruptions were actually observed. The majority of interruptions (95%) were related to face-to-face communications with others in the ED. The total number of interruptions related to medication activities was 55 (27.5% of the total number of interruptions).

Discussion

The results of this study can serve as the basis for subsequent, larger studies that examine more closely the relationship between interruptions and errors in the ED, with the ultimate goal of developing interventions to reduce medication errors and other adverse events that occur due to nurse interruptions.

Section snippets

Methods

A descriptive, observational study was performed to determine (1) the frequency or number of interruptions per hour that a typical emergency nurse experiences, (2) the type of interruptions a typical emergency nurse experiences, and (3) the percentage of interruptions that take place during medication-related activities (medication preparation, documentation, or administration). An exploratory research question examined whether frequency and/or type of interruption varied across the 3 different

Results

Three categories of data were collected and analyzed: demographic characteristics of the subjects observed, environmental variables, and interruptions. Characteristics of the study sample and environmental variables are summarized in Table 1. The typical emergency nurse was female and aged 35.5 years, with 9.6 years of RN experience and 4.7 years of emergency nursing experience. The busiest emergency department (adult) had the greatest number of RNs on duty, as well as a higher percentage of

Discussion

The adult-only emergency department had the youngest nurses with the least amount of experience compared with the other 2 emergency departments. This could be attributed to the highly specialized orientation programs in place to support the new nurses. The adult-only emergency department also was the busiest, with the highest number of emergency patients. Of the 3 departments studied, this emergency department sees the greatest number of patients each year.

Literature that is specific to RN

Lisa Mariani Kosits, Member, Manhattan-Bronx Chapter, is Clinical Faculty, Montefiore Medical Center, Bronx, NY.

References (26)

J Fordyce et al.
Errors in a busy emergency department
Ann Emerg Med
(2003)
CD Chisholm et al.
Work interrupted: A comparison of workplace interruptions in emergency departments and primary care offices
Ann Emerg Med
(2001)
A Laxmisan et al.
The multitasking clinician: Decision-making and cognitive demand during and after team handoffs in emergency care
Int J Med Inform
(2007)
R Spencer et al.
Variation in communication loads on clinical staff in the emergency department
Ann Emerg Med
(2004)
RW Hicks et al.
Medication errors in the PACU: A secondary analysis of MEDMARX findings
J Perianesth Nurs
(2004)
LT Kohn et al.
To Err Is Human: Building a Safer Health System
(2000)
Health & Hospitals Networks
The hospital's front door
Health Hosp Netw
(2006)
K Dismukes et al.
Cockpit interruptions and distraction: Effective management requires a careful balancing act
ASRS Directline
(1998)
EA Flynn et al.
Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy
Am J Health Syst Pharm
(1999)
P Croskerry et al.
Profiles in patient safety: Medication errors in the emergency department
Acad Emerg Med
(2004)

E Kozer et al.

Variables associated with medication errors in pediatric emergency medicine

Pediatrics

(2002)

JP Marcin et al.

Medication errors among acutely ill and injured children treated in rural emergency departments

Ann Emerg Med

(2007)

JP Santell et al.

Medication errors in emergency department settings—5 Year review. The United States Pharmacopeial Convention

Cited by (45)

Interruptions Experienced by Emergency Nurses: Implications for Subjective and Objective Measures of Workload
2018, Journal of Emergency Nursing
This study aimed to describe interruptions experienced by emergency nurses and establish convergence validity of 1 objective workload measure by linking interruption characteristics to objective and subjective measures of workload.
Interruptions were captured in real time across 8- or 12-hour shifts using a previously validated Workflow Interruptions Tool (WIT). Data collected on each interruption included type, priority, and location where the interruption occurred. At mid- and end-shift, the Surgery Task Load Index (SURG-TLX) and the Rapid Cognitive Assessment Tool (RCAT) were administered to participating nurses to measure workload subjectively and objectively.
Thirty-eight emergency nurse shifts were observed. A total of 3,229 interruptions were recorded across 372.5 clinical hours and 38 shifts (means [M] = 85.0 interruptions per shift, standard deviation [SD] = 34.9; M = 8.7 interruptions per hour, SD = 3.36). The median duration per interruption was 13.0 seconds. A moderate positive association was identified between the number of interruptions experienced during a shift and the increased overall SURG-TLX workload reported at end-shift, r(36) = 0.323, P = 0.048. Also, a moderate positive association was identified between increased reaction times during the RCAT task and increased mental demand experienced at end of shift, r(36) = 0.460, P < 0.001.
This study observed interruptions throughout the entirety of a nursing shift and found that the majority of interruptions caused by the environment were low priority. Targeting interventions to reduce low-priority and environmental interruptions may aid in alleviating the impact of interruptions on clinical staff and patient care. Furthermore, results demonstrate that the frequency of interruptions was perceived to increase the nursing staff workload overall.
Communication Strategies for Better Care of Older Individuals in the Emergency Department
2018, Clinics in Geriatric Medicine
Applying social network analysis to the examination of interruptions in healthcare
2018, Applied Ergonomics
Examinations of interruptions in healthcare often focus on a single clinical discipline, and solutions are targeted accordingly. This approach does not take into account the inter-disciplinary dependencies and other sociotechnical aspects that make up the healthcare work system, and suggested solutions may not meet the needs of all stakeholders. In this article a sociotechnical systems perspective is used to uncover the interdependencies between 16 unique work roles that result in interruptions in an intensive care unit (ICU). By applying social network analysis techniques to data collected using the Dual Perspectives Method, we identified targeted systems-based interventions that may reduce unnecessary interruptions while avoiding unintended consequences that impose additional burden on ICU staff. The rich insights gained into the interruptive communication patterns in the ICU work system stand in contrast to findings that would have otherwise been obtained by focusing only on a single clinical discipline or a single perspective.
Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department
2017, Journal of Emergency Medicine
It is unclear how workflow interruptions impact emergency physicians at the point of care.
Our study aimed to evaluate interruption characteristics experienced by academic emergency physicians.
This prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms.
A total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ²(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ² [2, n = 2355] = 78.43, p < 0.001).
Our study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care.
Using Simulation to Assess the Impact of Triage Interruptions
2017, Journal of Emergency Nursing
Interruptions are common in the emergency department and contribute to catastrophic errors. Care priorities and acuity levels are assigned during triage, meaning that mistakes and omissions during the triage process could have detrimental effects on patients. The purpose of this project was to assess the feasibility of investigating the impact of interruptions on triage and the decision-making process in a simulated setting.
A 2-phase, sequential exploratory mixed method design was used. Nine nurses from 3 emergency departments in a Midwest area participated. A short demographic questionnaire was used to collect information about the nurses’ education and experience. The Emergency Severity Index (ESI) was used for triage categorization. Each participant completed 2 scenarios (one interrupted and one uninterrupted). After completion of the scenarios, video-simulated recall interviews were used to assess the simulation experience and the impact that interruptions had on the triage decision-making process.
Triage time had a mean of 10 minutes and ranged between 4.34 minutes and 13.45 minutes. However, triage was significantly longer during the interrupted scenarios. Seventy-seven percent of the acuity assessments (ESI) were correct. Of the 18 scenarios, 3 uninterrupted scenarios had incorrect ESI scores, and one interrupted scenario had a missing acuity score.
This study provides the basis for future work that looks at how nurses successfully manage interruptions and tests interventions to assist triage nurses in managing or reducing interruptions during this important patient assessment process.
Physicians’ and nurses’ perceptions of patient safety risks in the emergency department
2017, International Emergency Nursing
The emergency department has been described as a high-risk area for errors. It is also known that working conditions such as a high workload and shortage off staff in the healthcare field are common factors that negatively affect patient safety. A limited amount of research has been conducted with regard to patient safety in Swedish emergency departments. Additionally, there is a lack of knowledge about clinicians’ perceptions of patient safety risks. Therefore, the purpose of this study was to describe emergency department clinicians’ experiences with regard to patient safety risks.
Semi-structured interviews were conducted with 10 physicians and 10 registered nurses from two emergency departments. Interviews were analysed by inductive content analysis.
The experiences reflect the complexities involved in the daily operation of a professional practice, and the perception of risks due to a high workload, lack of control, communication and organizational failures.
The results reflect a complex system in which high workload was perceived as a risk for patient safety and that, in a combination with other risks, was thought to further jeopardize patient safety. Emergency department staff should be involved in the development of patient safety procedures in order to increase knowledge regarding risk factors as well as identify strategies which can facilitate the maintenance of patient safety during periods in which the workload is high.

View all citing articles on Scopus

Lisa Mariani Kosits, Member, Manhattan-Bronx Chapter, is Clinical Faculty, Montefiore Medical Center, Bronx, NY.

Katherine Jones is Sarah Cole Hirsh Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.

: Earn Up to 11.0 Hours. See page 105.

View full text

ResearchInterruptions Experienced by Registered Nurses Working in the Emergency Department

Introduction

Methods

Results

Discussion

Section snippets

Methods

Results

Discussion

Ann Emerg Med

Ann Emerg Med

Int J Med Inform

Ann Emerg Med

J Perianesth Nurs

To Err Is Human: Building a Safer Health System

The hospital's front door

Health Hosp Netw

Cockpit interruptions and distraction: Effective management requires a careful balancing act

ASRS Directline

Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy

Am J Health Syst Pharm

Profiles in patient safety: Medication errors in the emergency department

Acad Emerg Med

Variables associated with medication errors in pediatric emergency medicine

Pediatrics

Medication errors among acutely ill and injured children treated in rural emergency departments

Ann Emerg Med

Medication errors in emergency department settings—5 Year review. The United States Pharmacopeial Convention

Research
Interruptions Experienced by Registered Nurses Working in the Emergency Department