Synchronous communication facilitates interruptive workflow for attending physicians and nurses in clinical settings

Abstract

Study objective

Inter-clinician communication accounts for more than half of all information exchanges within the health care system. A non-participatory, qualitative time-and-motion observational study was conducted in order to gain a better understanding of inter-clinician communication behaviors, routine workflow patterns, and the use of information communication technologies (ICTs) within the clinical workspace.

Method

Over a 5-day period, seven attending physicians and two nurses were shadowed for 2–4 h at a time. Inter-clinician communication events were tracked in real-time using synchronized digital stopwatches. Observations were recorded on a paper-based, semi-structured observation tool and later coded for analysis.

Results

Nine hundred and eighty-seven communication events were observed over 2024.67 min. Clinicians were observed to spend the majority of their time on patient care (85.4% in this study) with about three-fourths of that time spent on indirect patient care (e.g. charting). Clinicians were observed to prefer using synchronous communication modes, which led to multitasking and created a highly interrupted workflow. Forty-two percent (n = 415) of communication events were coded as interruptions and study participants were seen multitasking 14.8% of the time. Though each interruption was short-lived (on average 0.98 ± 2.24 min for attending physicians), they occurred frequently. Both attending physicians and nurses were the recipients of more interruptions than they initiated.

Conclusion

This study demonstrated that the clinical workspace is a highly interruptive environment. Multiple interruptions in the communication processes between clinicians consume time and have the potential to increase the risk of error. This workflow analysis may inform the development of communication devices to enhance inter-clinician communication by reducing interruptions or deferring interruptions to more appropriate times.

Introduction

Communication among health care providers is the most common and important exchange of clinical information within the health care system [1], [2], [3], [4]. Information and data exchanges may occur along both synchronous (e.g. face-to-face communication, telephone conversations) and asynchronous (e.g. voice mail, e-mail, patient charts, notes, page) communication channels; however, past research has noted a bias towards the use of synchronous channels [3]. As a result of the tendency to use synchronous channels, the clinical workspace is riddled with interruptive and multitasking workflows. Frequent interruptions and multitasking in a clinical environment have far-reaching and detrimental implications on the quality of patient care [5], [6] and the financial cost to institutions [3]. Interruptions and multitasking contribute to medical error by disrupting short-term memory processes [7], [8]. This is evidenced in the Institute of Medicine (IOM) report, “To Err is Human: Building a Safer Health System.” This report effectively conveyed that communication failures were associated with significant medical errors [9]. Moreover, in a 2002 report on patient safety, the Joint Commission on Accreditation of Health care Organizations (JCAHO) found that communication breakdown was a major cause of sentinel events [10].

In a communication-rich workspace such as a medical environment, it is important for communication to be executed efficiently and accurately. There is a documented need for studying and understanding communication among physicians and nurses in the clinical setting. In situ, observational studies provide insight into the significant time gaps in the delivery of care as well as common data and workflow patterns. Insights into communication processes within the clinical workflow processes are crucial to successfully developing mobile, asynchronous information communication technologies (ICTs) that are readily adopted by healthcare workers [11]. Furthermore, workflow analysis helps to create clear definitions of user needs and ICT requirements [12], [13].

Observational studies were conducted at two hospital sites in order to gain a better understanding of communication behaviors among health care providers, routine workflow patterns, and the use of ICTs within the clinical workspace. Additionally, at the conclusion of data collection, recommendations for the development of an effective health care ICT solution were made.