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Zhang CJ, Walser E, Mierzwa A, Ott M. Learning Interrupted: Educational Impact of Interruptions on Surgical Residents. JOURNAL OF SURGICAL EDUCATION 2022; 79:875-884. [PMID: 35185000 DOI: 10.1016/j.jsurg.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The complex workflow of surgical residents in the workplace-based learning environment makes interruptions an unavoidable aspect of clinical work. Interruptions have been shown to affect cognitive load, surgical performance, and medical error. The purpose of this study was to describe the effects of interruptions on surgical resident education. DESIGN Junior residents were observed by 2 trained observers using time-motion methodology between September 2018-August 2019. Interruptions were identified and coded retroactively based on predefined criteria. We captured key features of interruptions including frequency, duration, task interrupted, outcome, and learner perceived educational value. SETTING This study took place at London Health Sciences Centre in London, Ontario, Canada, a tertiary level academic health care center associated with the Schulich School of Medicine & Dentistry at Western University. PARTICIPANTS Junior residents on a General Surgery service were eligible for participation. Participation was voluntary. 8 residents were observed over 24 clinical periods. RESULTS A total of 278.2 hours of resident workflow were observed, and 229 interruptions were recorded. Interruptions account for 57.9 minutes/day of a surgical resident (SD = 60.7). Interruptions occur at a frequency of 0.82 interruptions/hour. Disruptive interruptions, that interfere with the continuation or completion of the original task, occur at a frequency of 0.11 interruptions/hour. Disruptive interruptions occurred at a higher frequency of 0.34 interruptions/hour during periods of feedback, coaching and informal teaching. DISCUSSION We observed that tasks of higher learner perceived educational value are often interrupted by tasks of lower learner perceived education value. Valuable educational experiences such as feedback, coaching and informal teaching are interrupted at a greater rate and experience disruptions at a disproportionate rate. We identified feedback, coaching and informal teaching as an education task vulnerable to disruptive interruptions that would benefit from interventions targeted toward preventing interruption. Suggested interventions include "formalizing" feedback, coaching and informal teaching.
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Affiliation(s)
- Chris J Zhang
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Eric Walser
- Division of General Surgery, Department of Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Anna Mierzwa
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Michael Ott
- Schulich School of Medicine, Western University, London, Ontario, Canada; Division of General Surgery, Department of Surgery, Schulich School of Medicine, Western University, London, Ontario, Canada; Center for Education Research and Innovation, Schulich School of Medicine, Western University, London, Ontario, Canada; Department of Oncology, Faculty of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada.
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Lafferty M, Harrod M, Krein S, Manojlovich M. It's like sending a message in a bottle: A qualitative study of the consequences of one-way communication technologies in hospitals. J Am Med Inform Assoc 2021; 28:2601-2607. [PMID: 34569593 PMCID: PMC8763228 DOI: 10.1093/jamia/ocab191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We examine how physicians and nurses use available communication technologies and identify the implications for communication and patient care based on the theory of workarounds. MATERIALS AND METHODS We conducted a qualitative study at 4 U.S. hospitals during 2017. Researchers spent 2 weeks at each hospital conducting unit-based observation, shadowing, interviews, and focus groups with nurses and physicians. Using an iterative process, we inductively coded and thematically analyzed data to derive preliminary themes. The theory of workarounds provides an organizational lens on workarounds, consisting of 5 components: antecedents, types, effects, managerial stance, and organizational challenges of workarounds. The first 3 components of the theory helped us to organize and explain our findings. RESULTS Communication technologies consisted of pagers and telephones. Antecedents to workarounds included one-way information flow, differential access related to differences in technology types, and technology mismatch. Types of workarounds included bypassing a variety of obstacles and substituting for unavailable resources. Direct effects of workarounds included pager fatigue, interruptions in patient care, and potential errors. DISCUSSION One-way communication technologies created an environment where workarounds could flourish. By placing results within the context of the theory of workarounds, we extend what we know about why and how workarounds develop, and offer strategies to minimize workarounds' adverse effects. CONCLUSIONS Through the theory of workarounds, we see that there is a trajectory to workarounds with potential consequences for clinicians and patients. Two-way communication technologies could minimize workarounds and gaps in information exchange, and reduce unnecessary interruptions and the potential for adverse events.
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Affiliation(s)
- Megan Lafferty
- United States Department of Veterans Affairs, Center to Improve Veteran Involvement in Care, VA Medical Center, Portland, Oregon, USA
| | - Molly Harrod
- United States Department of Veterans Affairs, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Sarah Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System and Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Milisa Manojlovich
- School of Nursing, Department of Systems, Populations, and Leadership, University of Michigan, Ann Arbor, Michigan, USA
- Corresponding Author: Milisa Manojlovich, PhD, RN, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, 400 N. Ingalls, Ann Arbor, MI 48103, USA;
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Parrado RH, Notrica DM, Molitor MS. Nighttime Calls, Pages, and Interruptions to the On-Call Surgery Resident. Am Surg 2021; 88:1181-1186. [PMID: 33522262 DOI: 10.1177/0003134821991987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Communication is a keystone to good medical practice. At night, as physician numbers decrease, frequent, nonurgent interruptions have shown to disrupt patient care and impact resident/physician wellness. Potentially, interruptions can lead to an increase in medical errors. The frequency and activities interrupted during night calls have not been fully described. METHODS For a period of 44 days (August through September), all calls and pages received during the 12-hour night call session were documented. Calls were analyzed by caller, urgency, need for intervention, and resident interrupted by the communication. RESULTS A total of 494 communications were identified with a mean of 10 calls per shift (IQR 7-14). Communications lasted a mean of 2.7 +/- 2.9 minutes. Direct calls occurred in 78% and pages in 22% of the cases. From the non-ED calls (n = 335), most of them came from nursing staff (85%), followed by other specialties (12%). Five percent of the calls were directed to the wrong service. Communications occurred during charting (41%), patient assessment (33%), interrupted resident's sleep (12%), or during a surgical procedure (6%). Communication required no action in 47% of the cases. A physician order was needed in 41%, while bedside clinical assessment was required in 12% of the calls. CONCLUSIONS Communications are common at night, but most did not require clinical assessment. A large portion of communications interrupted direct patient care. An opportunity exists to eliminate nonproductive communications and improve the quality of medical education.
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Affiliation(s)
- Raphael H Parrado
- Department of General Surgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - David M Notrica
- Department of Pediatric Surgery, 14524Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Mark S Molitor
- Department of Pediatric Surgery, 14524Phoenix Children's Hospital, Phoenix, AZ, USA
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"Surgery interrupted": The effect of multitasking on cognitive and technical tasks in medical students. Am J Surg 2016; 213:268-272. [PMID: 27839688 DOI: 10.1016/j.amjsurg.2016.09.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 08/19/2016] [Accepted: 09/24/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Today's medical learners are Millennials, and reportedly, multitasking pros. We aim to evaluate effect of multitasking on cognitive and technical skills. MATERIALS AND METHODS 16 medical students completed a mock page and laceration closure separately on day 1 and day 13, and in parallel on day 14. Suturing was graded using GRS and mock pages scored. Total time, suturing and loading times, and percent correct on mock page were compared. RESULTS Percent correct on mock page improved from days 1-13 and 14 (p < 0.01 and 0.04). GRS improved from days 1-13 and 14 (p = 0.04 and <0.01). Total time suturing was similar on all days. However, time suturing during the mock page on day 14 was prolonged compared to before mock page (p = 0.01). CONCLUSIONS Medical students can complete cognitive and technical tasks in parallel, without compromising acceptability. However, multitasking results in longer times to complete the complex component of the technical task.
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Hallet J, Wallace D, El-Sedfy A, Ahmed N, Smith AJ, Nathens AB, Conn LG, Coburn NG. Defining Communication Improvement Needs in General Surgery: An Analysis of Pages, Communications, Patterns, and Content☆?>. JOURNAL OF SURGICAL EDUCATION 2016; 73:959-967. [PMID: 27886968 DOI: 10.1016/j.jsurg.2016.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/05/2016] [Accepted: 05/09/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To describe patterns of pages communication to general surgery (GS) residents, identify the need for and develop strategies to improve interprofessional communication. DESIGN Retrospective cohort study. SETTING General surgery (GS) service at a tertiary care academic institution, Sunnybrook Health Sciences Centre, in Toronto, Ontario, Canada. PARTICIPANTS All pages sent to GS residents over 4 weeks at an academic institution. Timing, training level of receiver and content of pages were captured. RESULTS Communication priority was assigned by 2 independent reviewers-low (121+ min), medium (31-120min), high (6-30min), and immediate (0-5min) priority. Overall, 2 independent reviewers analyzed pages' content through an inductive process, and generated themes. Of 2025 pages retrieved, 963 (47.5%) contained exclusively a call back number. A median of 74 pages per day (range: 43-116) were received, with median page interval of 9.4 minutes (range: 0-640). Junior residents received 79.5% of pages. Timing of the pages was 43.9% weekday shift, 31.8% weeknight shift, and 24.3% weekend call. Communication priority was deemed low for 35.4% of pages, medium for 32.3%, high for 12.4%, and immediate for 0.7%. Content analysis of 1062 pages generated 5 major themes: nonurgent medical issue (54.0%), administrative (15.3%), communication (13.5%), emergencies (4.8%), and GS consultation requests (4.0%). Priority and content of pages varied according to training level and page timing. CONCLUSIONS Pages to GS residents were frequent and most often of low priority. They were seldom related to urgent medical matters. Education and new communication strategies are warranted to reduce low priority pages.
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Affiliation(s)
- Julie Hallet
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Evaluative Clinical Sciences, Toronto, Ontario, Canada.
| | - David Wallace
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Abraham El-Sedfy
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Najma Ahmed
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Andrew J Smith
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Avery B Nathens
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Evaluative Clinical Sciences, Toronto, Ontario, Canada
| | - Lesley Gotlib Conn
- Sunnybrook Research Institute, Evaluative Clinical Sciences, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Evaluative Clinical Sciences, Toronto, Ontario, Canada
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Matloob SA, Hyam JA, Thorne L, Bradford R. Improving neurosurgical communication and reducing risk and registrar burden using a novel online database referral platform. Br J Neurosurg 2016; 30:191-4. [PMID: 27001167 DOI: 10.3109/02688697.2016.1161171] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Documentation of urgent referrals to neurosurgical units and communication with referring hospitals is critical for effective handover and appropriate continuity of care within a tertiary service. Referrals to our neurosurgical unit were audited and we found that the majority of referrals were not documented and this led to more calls to the on-call neurosurgery registrar regarding old referrals. We implemented a new referral system in an attempt to improve documentation of referrals, communication with our referring hospitals and to professionalise the service we offer them. METHODS During a 14-day period, number of bleeps, missed bleeps, calls discussing new referrals and previously processed referrals were recorded. Whether new referrals were appropriately documented and referrers received a written response was also recorded. A commercially provided secure cloud-based data archiving telecommunications and database platform for referrals was subsequently introduced within the Trust and the questionnaire repeated during another 14-day period 1 year after implementation. RESULTS Missed bleeps per day reduced from 16% (SD ± 6.4%) to 9% (SD ± 4.8%; df = 13, paired t-tests p = 0.007) and mean calls per day clarifying previous referrals reduced from 10 (SD ± 4) to 5 (SD ± 3.5; df = 13, p = 0.003). Documentation of new referrals increased from 43% (74/174) to 85% (181/210), and responses to referrals increased from 74% to 98%. CONCLUSION The use of a secure cloud-based data archiving telecommunications and database platform significantly increased the documentation of new referrals. This led to fewer missed bleeps and fewer calls about old referrals for the on call registrar. This system of documenting referrals results in improved continuity of care for neurosurgical patients, a significant reduction in risk for Trusts and a more efficient use of Registrar time.
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Affiliation(s)
- Samir A Matloob
- a Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK
| | - Jonathan A Hyam
- a Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK
| | - Lewis Thorne
- a Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK
| | - Robert Bradford
- a Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK
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Nguyen C, McElroy LM, Abecassis MM, Holl JL, Ladner DP. The use of technology for urgent clinician to clinician communications: a systematic review of the literature. Int J Med Inform 2014; 84:101-10. [PMID: 25444594 DOI: 10.1016/j.ijmedinf.2014.11.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 10/24/2014] [Accepted: 11/03/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Urgent clinician-clinician communications require routes of contact that are fast and dependable, and allow for the exchange of complex information. Despite the increasing focus on improving healthcare delivery systems over the past decade, few studies have examined the role of technology in clinician-clinician communication. The aim of this study was to review the literature examining the role of devices and technology in facilitating urgent clinician-clinician communication to identify critical areas for future research. MATERIALS AND METHODS A search of Pub Med was performed using the terms (((("Critical Care"[Mesh] OR "urgent")))) AND (((hospital communication systems[MeSH Terms]) OR health communication[MeSH Terms]) OR interdisciplinary communication[MeSH Terms]). Commentaries and editorials were excluded. RESULTS The initial search returned 272 articles, which were reviewed to identify articles describing: (1) the role of technological support or devices in clinician-clinician communication, (2) technology-based interventions that improved clinician-to-clinician communication in hospitals or acute care facilities related to critically ill patients, or (3) critical information exchange. A total of 16 articles were included in the final review. These were grouped into three categories: alphanumeric pagers, cellular and smart telephones, and novel uses of technology. DISCUSSION Breakdowns in clinician-clinician communication are complex and cannot be solved through the implementation of devices or technologically advanced systems alone. It is essential to understand the correlation between emerging technologies, a demanding workload, and clinician-clinician interaction. Enhanced communication of clinical ideas, opportunities for team discussion, and a sense of partnership and support require not just increased information, but enhanced delivery.
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Affiliation(s)
- Cristina Nguyen
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa M McElroy
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Michael M Abecassis
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniela P Ladner
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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McElroy LM, Ladner DP, Holl JL. The role of technology in clinician-to-clinician communication. BMJ Qual Saf 2013; 22:981-3. [DOI: 10.1136/bmjqs-2013-002191] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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