Intervening in interruptions: A nurse-centric approach

Abstract

In this thesis, I present a series of papers which will: outline current issues with research in interruptions science, use theories in safety science to advance research in interruptions science, and provide some empirical data which highlight differences in perception between nurses and many researchers regarding interruptions and interruptions definitions. The papers presented in this thesis are either published, accepted, or submitted pieces of work. Researchers studying interruptions in laboratory settings have reported an association between interruptions and errors, with interruptions leading to more errors. Similarly, some investigators studying the impact of interruptions in various healthcare settings have reported an association between interruptions and medication errors. The discovery of this association has led to the development of interventions meant to reduce/remove interruptions in healthcare. While the development and implementation of these interventions seem reasonable, these interventions may actually be detrimental to healthcare work. Interventions to reduce/remove interruptions may actually lead to unintended negative consequences. Therefore, I began this thesis with a systematic review of unintended negative consequences of contemporary interruptions interventions. In this review, I discovered that 15 out of 33 studies reported some form of unintended negative consequences. The high number of studies with unintended negative consequences is likely due to the complexity associated with working in a healthcare setting, as well as the complexity surrounding the phenomenon of interruptions. Therefore, I considered it necessary to study the phenomenon of interruptions from another perspective. In the second paper of this thesis, I reviewed various prominent safety models in contemporary safety science research, such as high reliability organisations, resilience engineering, and safety drift. This summarises various concepts proposed in these models, as well as the various issues associated with these concepts. For example, various researchers have carried out their own research on high reliability organisations, and as a result, developed their own concepts regarding contributing factors to an organisation's high reliability. Therefore, it can be difficult to determine what exactly is a high reliability organisation. The review also introduced new ways of thinking and managing risk, such as learning from both failures and success, an idea proposed by advocates of resilience engineering. The knowledge gained from this review was then applied to the third paper of this thesis. In the third paper of this thesis, I showed how contemporary interruptions interventions research are based on the barrier model. The model proposes that safety can be achieved if blockades are placed between sources of risks and objects-to-be-protected. I proceed to argue that using the barrier model requires researchers to inaccurately conceptualise interruptions as sources of risk, which empirical studies have shown is not true. I then applied the three safety models, high reliability organisations, resilience engineering, and safety drift to interruptions research. Each of these models conceptualise interruptions in different ways, leading to new research avenues that can provide more information on the complex role interruptions play in daily clinical work. In the next paper of this thesis, I reached out to nurses in an attempt to understand the complex role of interruptions in their work. During my research, I noticed several differences in perception between nurses and many researchers when it comes to interruptions, in areas such as defining an interruption, and thinking how an interruption should be managed. These differences also led me to wonder about nurses' perception regarding contemporary interruptions interventions. Therefore, in the fourth paper of this thesis, I conducted a survey to collect information on these differences and perceptions. The findings of this survey indicate some differences between nurses and many researchers when it comes to: (a) defining interruptions, (b) the role interruptions play in daily clinical work, and (c) the types of interventions that are effective in dealing with interruptions. Nurses' responses in the survey were also consistent with some of the ideas proposed in the third paper of this thesis.