The practice of emergency medicineVariation in communication loads on clinical staff in the emergency department☆,☆☆,★
Introduction
Communication failures in the health system have been reported to be a large contributor to preventable adverse clinical outcomes.1., 2. In the emergency department (ED), studies have demonstrated that clinicians experience high communication loads.3., 4. In situations in which individuals carry out multiple concurrent tasks, interruptions are seen as a source of concern because they may negatively affect a clinician's working memory and lead to errors.5 ED clinicians have been identified as being particularly at risk of communication overload, with reports that they may spend up to 80% of their time in communication, with 30% of all communication events classified as interruptions and 10% of the communication time involved in 2 or more concurrent conversations.4
Studies have repeatedly shown that clinicians prefer interaction with colleagues as the main method for answering clinical questions.3., 4., 6., 7. Examining communication patterns identifies which work practices are likely to be generators of high communication load, providing information to appropriately target interventions to support and improve communication practices in the ED.
If communication loads are associated with specific work patterns, then one would expect load to vary with clinical roles. The aim of this study was to determine whether there are differences in role-related communication patterns in an ED and to identify whether specific clinical roles are particularly at risk of high communication loads because communication overload may predispose clinicians to making errors.
Section snippets
Theoretical model of the problem
It has been hypothesized that interruptions impose cognitive loads on clinical staff, leading to clinical error.4 Specifically, when an individual's working memory is occupied with several items, an interruption may disrupt working memory, resulting in forgetting some items.5 Communication load is a measure of the impact of organizational process on individuals and indicates under which circumstances cognitive resources are likely to be stretched. We characterize communication load by the time
Characteristics of study subjects
The roles of the 8 clinicians were medical registrars (senior ED clinicians), junior physicians (intern and resident), nurse shift coordinators (senior nurses responsible for coordinating activities within the study ED, with no specific patient load), and nurses with an allocated patient load. Two subjects occupied each of these roles.
Main results
Total study observation time was 19 hours 52 minutes, in which 831 distinct communication events were identified, an average of 42 events per person per hour.
Limitations
The representativeness of the findings is limited by the small sample of subjects and shift times observed. Some roles were observed longer than others. In addition, the sampling did not capture all clinical roles found within the ED; for example, emergency consultants and triage nurses were not directly observed as the primary subject, although many clinicians were captured in the observations through their interactions with the primary subjects. Participants volunteered to be observed, which
Discussion
There was a wide variation in communication loads on clinical staff occupying different roles in the ED. Medical registrars had a high proportion of interruptions (on average, 47% of all communication events) and spent much of their time dealing with interruptions (on average, 35% of their communication time). These proportions are much higher than the ED population average of 36% of events classified as interruptions and 24% of communication time spent in interruptions, which on their own have
Acknowledgements
We thank the ED staff who generously gave their time to be involved in this study. Johanna Westbrook, PhD, kindly assisted in the analysis of the data.
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2018, Clinics in Geriatric MedicineImproving our understanding of multi-tasking in healthcare: Drawing together the cognitive psychology and healthcare literature
2017, Applied ErgonomicsCitation Excerpt :In contrast with the cognitive psychology literature, which focuses on the impact of multi-tasking on performance, the healthcare literature has focused on identifying how often clinicians multi-task. Twenty-nine studies reporting multi-tasking in clinical settings, predominantly hospitals, were identified (Table 2) (Chisholm et al., 2000; Walter et al., 2013; Grundgeiger et al., 2010; Arabadzhiyska et al., 2013; Carayon et al., 2015; Berg et al., 2012; Chisholm et al., 2001; Coiera et al., 2002; Collins et al., 2007; Drews, 2007; Edwards et al., 2009; Kalisch and Aebersold, 2010; Laxmisan et al., 2007; Lo et al., 2010; Mache et al., 2011a, 2011b, 2012; Munyisia et al., 2011; Spencer et al., 2004; Tipping et al., 2010; van Rensen et al., 2012; Weigl et al., 2009, 2013; Westbrook and Ampt, 2009; Westbrook et al., 2007,2008,2010a,2010b,2011; Woloshynowych et al., 2007). All used direct observation methods, with some studies also using mobile eye trackers, video recording, or audio recording with direct observation (Grundgeiger et al., 2010; Coiera et al., 2002; Spencer et al., 2004; van Rensen et al., 2012; Woloshynowych et al., 2007).
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Author contributions: EC conceived the study and obtained research funding. All authors were involved in the study design. RS and PL conducted the research and analyzed the results. RS and EC drafted the manuscript, and all authors contributed to its revision. EC takes responsibility for the paper as a whole.
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Supported by a grant from the New South Wales Department of Health under the auspices of the Collaborative Projects Planning Committee.
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Reprints not available from the authors.