Editorial

Educational interventions to reduce nurse medication interruptions: A scoping review

BACKGROUND

Preventable harm from medicines is a global problem creating huge economic and social burden. Interruptions occur frequently in clinical environments causing medication episodes to take longer and having a cognitive cost on the nurse.

AIM

The aim of this scoping review is to identify and evaluate educational interventions that have been employed to reduce medication interruptions and improve medication safety.

METHODS

Six databases were searched for the scoping review (PubMed, Embase, Cochrane Library, CINAHL, Pishin and Medline) along with reference lists and grey literature searches. Articles were included if they were written in English, published between 2010 and 2020 and employed an education intervention (including bundled interventions). Databases were searched using keywords and Boolean operators.

RESULTS

Eight studies met the inclusion criteria. Seven of these studies were conducted in hospital (adults n = 6, paediatric n = 1) and one study in a university with undergraduate nurses. Four studies used a combined intervention and four exclusively employed an education intervention. Five studies found a significant decrease in the number of interruptions post intervention, but one of the studies that exclusively employed an education intervention found no significant difference. Changes in the nurses' behaviour post intervention were also cited in two studies.

IMPLICATIONS FOR FUTURE RESEARCH

There was a lack of exclusive education interventions, making it difficult to determine the effectiveness of education at reducing medication interruptions. This review highlights the necessity of some interruptions when performing tasks, for example, to make a nurse aware of a deteriorating patient. However, as the majority of studies used the number of interruptions to determine the effectiveness of the intervention, there is uncertainty as to whether this is the right outcome measure to use. In the future, a focus on outcome measures reflecting change in nurse behaviour may be more effective in determining the strength of an educational intervention.

Work interruptions and missed nursing care: A necessary evil or an opportunity? The role of nurses' sense of controllability

AIM

To explore nurses' experiences with work interruptions (WIs) through the lens of missed nursing care (MNC).

DESIGN

A qualitative descriptive design.

METHODS

Eleven small focus groups involving 34 nurses (three nurses per group on average) from acute-care hospital wards were conducted. Nurses shared their experiences with WIs (sources, reactions and decisions) from the MNC perspective. Data analysis was conducted via content analysis.

RESULTS

A preponderant theme emerged-the dynamic of controllability. Nurses who perceived a sense of controllability felt that they could decide whether to accept or reject the WI, regardless of WI type, and emotions of anger emerged. Conversely, nurses who did not perceive sense of controllability attended the secondary task: MNC occurred, and distress emotions emerged. Results emphasized that nurses are active agents prioritizing whether to omit or complete care in the face of WIs. Controllability, accompanied by active negative emotions, perpetuate a prioritization process that makes it less probable that MNC occurs.

Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage?

ABSTRACT

Interruptions are thought to be significantly associated with medication administration errors. Researchers have tried to reduce medication errors by decreasing or eliminating interruptions. In this article, we argue that interventions are often (perhaps unreflectively) based on one particular model of risk reduction-that of barriers placed between the source of risk and the object-to-be-protected. Well-intentioned interventions can lead to unanticipated effects because the assumptions created by the risk model are not critically examined. In this article, we review the barrier model and the assumptions it makes about risk and risk reduction/prevention, as well as the model's incompatibility with work in healthcare. We consider how these problems lead to interruptions interventions with unintended negative consequences. Then, we examine possible alternatives, viz organizing work for high reliability, preventing safety drift, and engineering resilience into the work activity. These all approach risks in different ways, and as such, propose interruptions interventions that are vastly different from interventions based on the barrier model. The purpose of this article is to encourage a different approach for designing interruptions interventions. Such reflection may help healthcare communities innovate beyond old, ineffective, and often counterproductive interventions to handle interruptions.

A cluster randomised controlled feasibility study of nurse-initiated behavioural strategies to manage interruptions during medication administration

OBJECTIVES

To examine the feasibility of a behavioural e-learning intervention to support nurses to manage interruptions during medication administration.

DESIGN

A cluster randomised feasibility trial.

SETTING

The cluster trial included four intervention and four control wards randomly selected across four metropolitan hospitals in Sydney, Australia.

PARTICIPANTS

We observed 806 (402 pre-intervention and 404 post-intervention) medication events, where nurses prepared and administered medications to patients within the cluster wards.

MAIN OUTCOME MEASURES

The primary outcome measured was the observed number of interruptions occurring during administration, with secondary outcomes being the number of clinical errors and procedural failures. Changes in the use of behavioural strategies to manage interruptions, targeted by the e-learning intervention, were also assessed.

RESULTS

No significant differences were found in the number of interruptions (P = 0.82), procedural failures (P = 0.19) or clinical errors per 100 medications (P = 0.32), between the intervention and control wards. Differences in the use of specific behavioural strategies (engagement and multitasking) were found in the intervention wards.

CONCLUSION

This behavioural e-learning intervention has not been found to significantly reduce interruptions, however, changes in the use of strategies did occur. Careful selection of clinical settings where there is a high number of predictable interruptions is recommended for further research into the impact of the behavioural e-learning intervention. An increase in the intensity of this intervention is recommended with training undertaken away from the clinical setting. Further research on additional consumer-sensitive interventions is urgently needed.

Method Development for Describing Content of Multitasked Interventions Using the Omaha System

Background

Understanding multitasking within nursing and midwifery is needed for efficient, effective, and cost-effective health services. Methods are needed to measure and analyze multitasking in alignment with the nursing process. The Omaha System operationalizes the nursing process and may be a valuable resource for multitasking analysis.

Purpose

The purpose of this study was to develop and test a method for describing intervention content of nurse/midwife multitasked interventions using the Omaha System and Time Capture Tool (TimeCaT) in a family health center in Turkey.

Methods

Eight nurses/midwives were observed with TimeCaT in a family health center in 2016. Preidentified 84 nurse/midwife interventions employed in the center were mapped on Omaha System terms and entered in TimeCaT software for data collection. Co-occurring interventions were analyzed using descriptive and inferential statistics and visualization techniques.

Results

Of 1066.8 total minutes observed, 34.0% included more than one intervention that occurred at the same time. Caretaking/parenting and postpartum problems, teaching, guidance, and counseling category, and caretaking/parenting skills target were more often multitasked than others.

Implications for Practice

It was feasible to use the Omaha System and TimeCaT to categorize, describe, and measure multitasking nursing/midwifery interventions. This method may be applied to other time–motion data when more than one co-occurring intervention is recorded.

A qualitative study of nurses' perceptions of a behavioural strategies e-learning program to reduce interruptions during medication administration

OBJECTIVES

We sought to evaluate the perceptions of nurses of an e-learning educational program to encourage the use of behavioural strategies-blocking, engaging, mediating, multitasking, and preventing-to reduce the negative effects of interruptions during medication administration.

DESIGN

A qualitative design was used to evaluate the impact of this e-learning educational intervention on nurses' behaviour.

SETTINGS

Two wards (palliative care and aged care) from two different hospitals within a large local health service within Sydney Australia, were included in the study. These wards were also involved in a cluster randomised trial to test the effectiveness of the program.

PARTICIPANTS

A purposive sample participated comprising nine registered and enrolled nurses certified to conduct medication administration, who had reviewed the educational modules.

METHODS

Two focus groups were conducted and these sessions were digitally recorded and transcribed verbatim. Thematic analysis identified seven themes.

RESULTS

The major themes identified included: perceptions of interruptions, accessing the program, content of the program, impact, maintaining good practice and facilitators and barriers to changing behaviour.

CONCLUSIONS

The use of embedded authentic images of patient interruptions and management strategies increased some nurses' perceived use of strategies to manage interruptions. Nurses varied in their perception as to whether they could change their behaviour with some describing change at the individual and ward team levels, while others described patient caseload and other health professionals as a barrier. The use of this innovative educational intervention is recommended for staff orientation, student nurses, medical officers and allied health staff. Further research is required in how this e-learning program can be used in combination with other effective interventions to reduce interruptions.

Learning to liaise: using medication administration role-play to develop teamwork in undergraduate nurses

Aim: To describe undergraduate nursing students' situational awareness and understanding of effective liaison and collaboration within the nursing team during interrupted medication administration.Background: Medication errors related to interruptions are a major problem in health care, impacting on patient morbidity and mortality and increasing the burden of related costs. Effective liaison, teamwork and situation awareness are requisite skills for nurses to facilitate the safe management of interruptions during medication administration.Method: A role-play simulation was offered to 528 second-year undergraduate Bachelor of Nursing students. Qualitative written reflective responses were subsequently collected and subject to thematic analysis to derive themes.Results: Participants (451:528) reported an improved understanding of an unfamiliar and challenging situation that required cooperation and collaboration amongst the nursing team to improve outcomes.Conclusion(s): This simulation exposed undergraduate nurses with limited clinical experience to a situation otherwise unavailable to them. The skills required to engage in effective liaison and teamwork in dynamic situations are vital elements in achieving quality care and must begin to be taught at an undergraduate level.

Predictability of Interruptions During Medication Administration With Related Behavioral Management Strategies

The aim of this qualitative study was to examine the nature of interruptions during medication administration. Focus groups were conducted with medical/surgical nurses (n = 15), critical care nurses (n = 13), and nurse managers/educators/specialists (n = 6). Most interruptions (78%) were predictable. Nurse-adopted strategies included blocking, engaging, mediating, multitasking, and preventing. Educational content was developed that relates behavioral strategies to respond to predictable and unpredictable interruptions.

Pondering practice: Enhancing the art of reflection

AIMS AND OBJECTIVES

The aim of this study was to describe the effect that immersive simulation experiences and guided reflection can have on the undergraduate nurses' understanding of how stressful environments impact their emotions, performance and ability to implement safe administration of medications.

BACKGROUND

Patient safety can be jeopardised if nurses are unsure of how to appropriately manage and respond to interruptions. Medication administration errors are a major patient safety issue and often occur as a consequence of ineffective interruption management. The skills associated with medication administration are most often taught to, and performed by, undergraduate nurses in a controlled environment. However, the clinical environment in which nurses are expected to administer medications is often highly stressed and nurses are frequently interrupted.

DESIGN/METHODS

This study used role-play simulation and written reflections to facilitate deeper levels of student self-awareness. A qualitative approach was taken to explore students' understanding of the effects of interruptions on their ability to undertake safe medication administration. Convenience sampling of second-year undergraduate nursing students enrolled in a medical-surgical subject was used in this study. Data were obtained from 451:528 (85.42%) of those students and analysed using thematic analysis.

RESULTS

Students reported increasing consciousness and the importance of reflection for evaluating performance and gaining self-awareness. They described self-awareness, effective communication, compassion and empathy as significant factors in facilitating self-efficacy and improved patient care outcomes.

CONCLUSIONS

Following a role-play simulation experience, student nurses reported new knowledge and skill acquisition related to patient safety, and new awareness of the need for empathetic and compassionate care during medication administration. Practicing medication administration in realistic settings adds to current strategies that aim to reduce medication errors by allowing students to reflect on and in practice and develop strategies to ensure patient safety.

RELEVANCE TO CLINICAL PRACTICE

Experiencing clinical scenarios within the safety of simulated environments, offers undergraduate student nurses an opportunity to reflect on practice to provide safer, more empathetic and compassionate care for patients in the future.

Calm to chaos: Engaging undergraduate nursing students with the complex nature of interruptions during medication administration

AIMS AND OBJECTIVES

To describe undergraduate student nurse responses to a simulated role-play experience focussing on managing interruptions during medication administration.

BACKGROUND

Improving patient safety requires that we find creative and innovative methods of teaching medication administration to undergraduate nurses in real-world conditions. Nurses are responsible for the majority of medication administrations in health care. Incidents and errors associated with medications are a significant patient safety issue and often occur as a result of interruptions. Undergraduate nursing students are generally taught medication administration skills in a calm and uninterrupted simulated environment. However, in the clinical environment medication administration is challenged by multiple interruptions.

DESIGN/METHODS

A qualitative study using convenience sampling was used to examine student perceptions of a simulated role-play experience. Data were collected from 451 of a possible 528 student written reflective responses and subject to thematic analysis.

RESULTS

Students reported an increased understanding of the impacts of interruptions while administering medications and an improved awareness of how to manage disruptions. This study reports on one of three emergent themes: "Calm to chaos: engaging with the complex nature of clinical practice."

CONCLUSIONS

Interrupting medication administration in realistic and safe settings facilitates awareness, allows for students to begin to develop management strategies in relation to interruption and increases their confidence. Students were given the opportunity to consolidate and integrate prior and new knowledge and skills through this role-play simulation.

Traditions of research into interruptions in healthcare: A conceptual review

BACKGROUND

Researchers from diverse theoretical backgrounds have studied workplace interruptions in healthcare, leading to a complex and conflicting body of literature. Understanding pre-existing viewpoints may advance the field more effectively than attempts to remove bias from investigations.

OBJECTIVE

To identify research traditions that have motivated and guided interruptions research, and to note research questions posed, gaps in approach, and possible avenues for future research.

METHODS

A critical review was conducted of research on interruptions in healthcare. Two researchers identified core research communities based on the community's motivations, philosophical outlook, and methods. Among the characteristics used to categorise papers into research communities were the predominant motivation for studying interruptions, the research questions posed, and key contributions to the body of knowledge on interruptions in healthcare. In cases where a paper approached an equal number of characteristics from two traditions, it was placed in a blended research community.

RESULTS

A total of 141 papers were identified and categorised; all papers identified were published from 1994 onwards. Four principal research communities emerged: epidemiology, quality improvement, cognitive systems engineering (CSE), and applied cognitive psychology. Blends and areas of mutual influence between the research communities were identified that combine the benefits of individual traditions, but there was a notable lack of blends incorporating quality improvement initiatives. The question most commonly posed by researchers across multiple communities was: what is the impact of interruptions? Impact was measured as a function of task time or risk in the epidemiology tradition, situation awareness in the CSE tradition, or resumption lag (time to resume an interrupted task) in the applied cognitive psychology tradition. No single question about interruptions in healthcare was shared by all four of the core communities.

CONCLUSIONS

Much research on workplace interruptions in healthcare can be described in terms of fundamental values of four distinct research traditions and the communities that bring the values and methods: of those research traditions to their investigations. Blends between communities indicate that mutual influence has occurred as interruptions research has progressed. It is clear from this review that there is no single or privileged perspective to study interruptions. Instead, these findings suggest that researchers investigating interruptions in healthcare would benefit from being more aware of different perspectives from their own, especially when they consider workplace interventions to reduce interruptions.

Are Technology Interruptions Impacting Your Bottom Line? An Innovative Proposal for Change

BACKGROUND

Nursing interruptions are a costly and dangerous variable in acute care hospitals. Malfunctioning technology equipment interrupts nursing care and prevents full utilization of computer safety systems to prevent patient care errors.

AIMS

This paper identifies an innovative approach to nursing interruptions related to computer and computer cart malfunctions. The impact on human resources is defined and outcome measures were proposed. A multifaceted proposal, based on a literature review, aimed at reducing nursing interruptions is presented. This proposal is expected to increase patient safety, as well as patient and nurse satisfaction.

SETTING

Acute care hospitals utilizing electronic medical records and bar-coded medication administration technology.

PARTICIPANTS

Nurses, information technology staff, nursing informatics staff, and all leadership teams affected by technology problems and their proposed solutions.

METHODS

Literature from multiple fields was reviewed to evaluate research related to computer/computer cart failures, and the approaches used to resolve these issues.

RESULTS

Outcome measured strategic goals related to patient safety, and nurse and patient satisfaction. Specific help desk metrics will demonstrate the effect of interventions.

CONCLUSIONS

This paper addresses a gap in the literature and proposes practical and innovative solutions. A comprehensive computer and computer cart repair program is essential for patient safety, financial stewardship, and utilization of resources.

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration

AIMS AND OBJECTIVES

The purpose of this review was to explore what is known about interruptions and distractions on medication administration in the context of undergraduate nurse education.

BACKGROUND

Incidents and errors during the process of medication administration continue to be a substantial patient safety issue in health care settings internationally. Interruptions to the medication administration process have been identified as a leading cause of medication error. Literature recognises that some interruptions are unavoidable; therefore in an effort to reduce errors, it is essential understand how undergraduate nurses learn to manage interruptions to the medication administration process.

DESIGN

Systematic, critical literature review.

METHODS

Utilising the electronic databases, of Medline, Scopus, PubMed and CINAHL, and recognised quality assessment guidelines, 19 articles met the inclusion criteria. Search terms included: nurses, medication incidents or errors, interruptions, disruption, distractions and multitasking.

RESULTS

Researchers have responded to the impact of interruptions and distractions on the medication administration by attempting to eliminate them. Despite the introduction of quality improvements, little is known about how nurses manage interruptions and distractions during medication administration or how they learn to do so. A significant gap in the literature exists in relation to innovative sustainable strategies that assist undergraduate nurses to learn how to safely and confidently manage interruptions in the clinical environment.

CONCLUSIONS

Study findings highlight the need for further exploration into the way nurses learn to manage interruptions and distractions during medication administration. This is essential given the critical relationship between interruptions and medication error rates.

RELEVANCE TO CLINICAL PRACTICE

Better preparing nurses to safely fulfil the task of medication administration in the clinical environment, with increased confidence in the face of interruptions, could lead to a reduction in errors and concomitant improvements to patient safety.