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Interruptions Affect the Quality of Radiographic Practice
Journal of Radiology Nursing xxx (2019) 1e5
Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.sciencedirect.com/journal/ journal-of-radiology-nursing
Interruptions Affect the Quality of Radiographic Practice Louise Møller, MHH (Radiography) a,*, Karen Winther Christiansen, BSc (Radiography) b, Anja Sigaard Mortensen, BSc (Radiography) a a b
Department of Radiography, University College of North Jutland, Aalborg, Denmark Aarhus University Hospital, Department of Radiotherapy, Aarhus, Denmark
a b s t r a c t Keywords: Interruptions Radiographers' perceptions Quality
Interruptions are considered a natural and necessary part of the caring culture at hospitals. However, some interruptions may affect the concentration of health care professionals when performing a task. Research has shown that interruptions probably contribute to errors. There is no research on the radiographic perspective on the phenomenon of interruptions. This study focuses on interruptions within the field of radiology. The purpose is to investigate what radiographers in the radiological specialty consider to be interruptions and how radiographers perceive that interruptions affect their tasks/ work. This is a qualitative, phenomenological approach. Observations and a semistructured focus group interview were conducted. Data from observations and interview were collected and analyzed by systematic meaning condensation. According to radiographers, interruptions mean that they are interrupted during a work situation and are thus disrupted or blocked from doing their job. Both objects/technologies and persons can cause interruptions. The radiographers perceived that interruptions affected their focus and that losing concentration because of interruptions may lead to errors with consequences for the patients. This study showed that interruptions may cause disruptions, insecurity, confusion, and errors and thus compromise the quality of CT scans and ultimately patient safety. © 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Background Interruptions happen in everyday life and often in the workplace. In a busy hospital setting, everyone is highly dependent on good communication practices to efficiently perform patient care at a highly specialized level. The caring culture at a hospital is characterized as a collective culture where health care professionals continuously seek advice from each other; interruptions are thus an inherent part of the culture (Iversen & Østergaard, 2013). Interruptions in the caring culture at hospitals are initiated by, for example, colleagues, patients, and family members but also by medical and mobile units as well as technologies. Thus, interruptions are so inherent in the workflow that health care professionals must accept these interruptions as the norm (Ratwani, Hettinger, Brixey, Rivera, & Colligan, 2014). Interruptions are considered a natural and necessary part of the caring culture but may also be experienced as disrupting the task performed (Iversen & Østergaard, 2013). Generally, interruptions Conflict of interest: The authors have no conflict of interest to declare. * Corresponding author: Louise Møller, University College of North Jutland, Selma Lagerløfs Vej 2 9220 Aalborg Ø Denmark. Tel.: þ45 72691028. E-mail address: [email protected] (L. Møller).
affect individuals differently depending on (1) similarity between the disruptive task and the primary task (i.e., the disruptive task makes use of the same cognitive processes), (2) the relevance of the disruptive task compared with the primary task, (3) the length of the interruption, (4) the complexity of the interruption, and (5) the timing of the interruption (Cades, Davis, Trafton, & Monk, 2007; Cutrell, Czerwinski, & Horvitz, 2000; Eyrolle & Cellier, 2000; Gillie & Broadbent, 1989). Research has shown that interruptions are likely to contribute to errors. In 1999, Flynn et al. studied the effect of interruptions during the dispensing of medicine. They found that the number of dispensing errors increased by 3.23% (Flynn et al., 1999). In 2007, Wiegmann et al. compared the increase in surgical errors with the increase in interruptions (r ¼ 0.47, p < .05) (Wiegmann, ElBardissi, Dearani, Daly, & Sundt, 2007). In 2012, Westbrook et al. reported an increase of 12.1% in procedural errors and a 12.7% increase in clinical errors in connection with each of the observed interruptions (Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). A Danish questionnaire study among staff at hospitals and in the psychiatric area in one of Denmark's largest regions also showed that of 10,615 responses, 69% of the respondents replied that adverse events/errors happened because of the many interruptions (Region Hovedstaden, 2007).
https://doi.org/10.1016/j.jradnu.2019.10.003 1546-0843/$36.00/© 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Møller L et al., Interruptions Affect the Quality of Radiographic Practice, Journal of Radiology Nursing, https:// doi.org/10.1016/j.jradnu.2019.10.003
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L. Møller et al. / Journal of Radiology Nursing xxx (2019) 1e5
In Denmark, radiographers/technologists are a part of the health care professional staff at hospitals where they work in radiation therapy, at nuclear medicine departments, and at departments of radiology. At departments of radiology, radiographers are working with all aspects of medical imaging within the radiological specialty, and here, imaging examinations and interventional procedures are conducted on both outpatient and inpatient patients. Within radiology, radiographers work with imaging modalities such as conventional radiography including fluoroscopy, computed tomography (CT), magnetic resonance, ultrasonography, and mammography (Nielsen & Jensen, 2016). In departments of radiology, the role of radiographers is to plan, perform, assess, communicate, manage, develop, and implement radiography as well as to give advice and counseling concerning the examination, diagnostics and treatment, health promotion, and disease prevention including radiation protection and patient safety (Uddannelse-og Forskningsministeriet, 2016). The workplace of radiographers is highly technological. In addition, departments of radiology are also interdisciplinary and interprofessional departments, and these departments are central at any hospital collaborating with other clinical departments. Departments of radiology use medical secretaries, radiographers, nurses, radiologists, and hospital porters, who work closely together on each patient pathway. Overall, the complexity of the work of radiographers is high involving many technologies and collaborators, and the risk of interruptions is rather high. Purpose There is no current research including the viewpoint of radiographers on the phenomenon of interruptions. Thus, this study focuses on the following research questions: What do radiographers in the radiological specialty consider to be interruptions? How do radiographers perceive that interruptions affect their tasks/work?
all field notes were collected providing an overview of the elements of a CT scan.
Interview A focus group interview with five radiographers (4 females and 1 male) was made. The radiographers were included according to the following criteria: daily work with CT scanners and at least 1 year's experience with CT scans. The focus group interview was made during working hours in a room at the hospital and lasted approximately 1 hour. Two of the researchers/radiographers conducted the focus group interview; one was the moderator and one made notes. An interview guide was made with simple questions illustrating interruptions during the course of a CT scan, the radiographer's perception of interruptions during such a scan, and the impact of interruptions during a CT scan. The interview was tape-recorded.
Ethical approval At University College of North Jutland's General Data Protection Regulation coordinator, it was investigated whether permission to collect data should be applied to the ethics committee, which was not necessary. The study was based on the voluntary written consent of radiographers to participate. All participants were informed of the possibility to withdraw from the study at any time without any consequences. The anonymity of the participants was ensured by not naming the hospital where observations were made. Data from observations and the recording of the interview were stored on one computer and protected by a login.
Data analysis
Observation
The analysis of field notes from the observations was made by the two researchers/radiographers performing the observations. Based on the field notes, the elements of the course of a CT scan at this hospital were mapped. After the analysis, results were presented to and qualified by the radiographers present during the observations. If the radiographers had knowledge of further elements of a CT scan than included in the mapping, these were subsequently included. The interview recording was transcribed immediately after the interview by the researcher/radiographer making notes during the interview. Transcription was made to ensure writing down what was said as precisely as possible; however, the focus was to maintain and capture the meaning of what was said (Brinkmann & Tanggaard, 2015). Subsequently, a phenomenological meaning condensation inspired by Giorgi (Giorgi,1975) and described by Kvale (Kvale, 2004) was made. The meaning condensation consists of the following phases:
Observations were performed by two researchers/radiographers following the radiographers in practice during the course of a CT scan. The researchers took field notes on the elements they perceived would shed light on the elements involved in a CT scan, strictly to diagram the workflow. The researchers made the observations individually at four different CT scanners to gain as much variation in their observations as possible regarding types of examinations, specialist examinations, and person-dependent elements. Observations were made equivalent to a day program (from 08.00 am to 15.00 pm) or approximately for 7 hours. Subsequently,
1) The interview data are read to form a sense of the whole. 2) Researchers identify the perceptions of the phenomenon of interruptions and disruptions and their impact on CT scans as expressed by the informants. 3) Themes covering the identified perceptions are formulated as precisely as possible. 4) Questions to the formulated themes are posed based on the specific purpose of the study. 5) The most significant themes are combined to form descriptive statements.
Method This study used qualitative, phenomenological research methods for data collectiondobservation studies and interviews. These methods are suitable when the research question is to gain knowledge and understanding of the lifeworld of human beings such as the practice of radiographers (Vallgårda & Koch, 2011). Radiographers work with different modalities/technologies, but this study focuses on CT. This qualitative study investigates interruptions during the course of CT scans, the radiographers’ perception of interruptions during the scan, and the impact of interruptions on the CT scan. The studies were made at a department of radiology at a Danish university hospital between October 2018 and March 2019.
Please cite this article in press as: Møller L et al., Interruptions Affect the Quality of Radiographic Practice, Journal of Radiology Nursing, https:// doi.org/10.1016/j.jradnu.2019.10.003
L. Møller et al. / Journal of Radiology Nursing xxx (2019) 1e5
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Results
The Phenomenon Interruptions
Elements of a CT Scan
The radiographers agreed that an interruption means to be interrupted during a work situation and thus be disrupted or blocked from performing a work task. A radiographer described interruptions in the following way: I get distracted for a short while and in this way, I am disrupted from what I am focusing on. Another radiographer described interruptions in this way: It can be things happening in the background that makes me unable to perform my work or something may happen that blocks me from doing my tasks. The radiographers referred to objects that may cause interruptions including telephones, radios, coffee machines, or other things making loud noises. In addition to the loud noises, technologies may be disruptive just by being there. One radiographer said: There was a coffee machine by the CT scanner and people stopped by all the time. Moreover, radiographers described how external persons could be an interruption during a CT scan: it may be an interruption if care staff from other departments come with the patient. It can be a major interruption if they interfere. Colleagues were also mentioned as an interruption: When another shift meets to take over and they just start talkingdit's an interruption.
This observation study showed that a CT scan consists of several phases. The mapping process is illustrated in Figure 1, which shows the three phases of a CT scan: a preparation phase, the actual CT scan, and a closing phase. Figure 1 also shows that each phase includes more actions to be managed by a radiographer. The observation study also showed that two radiographers were always present during the course of a CT scan, each managing their own actions. Some of the actions and the division of tasks between radiographers in the three phases are described in the following. During the preparation phase, radiographer 1 manages the following tasks: reading through the patient's referral, calling the patient in from the waiting area, getting the patient's name, civil registration number, height, and weight. Radiographer 1 also informs the patient about clothing during the CT scan, the course of the CT scan, when to expect the scan results, and how contrast is administered. Radiographer 1 accompanies the patient to the CT scanner and ensures the correct positioning of the patient on the bed and that the patient is as comfortable as possible. Radiographer 1 establishes the intravenous access and attaches this to an automatic injection of contrast, slides the patient into the CT scanner, and positions the patient correctly in the isocenter. Radiographer 2 registers that the CT scan of the patient is registered in the registration system and prepares the operation of the CT scanner. Radiographer 2 also prepares the operation of the automatic injection of contrast. Radiographer 2 performs the actual scan and ensures correct timing of the administration of contrast. Radiographer 1 is with the patient before administration of the contrast, informing that the contrast is administered and then observes the patient through a window. Radiographer 2 checks the image quality and criteria before radiographer 1 is with the patient again. In the closing phase, radiographer 1 slides the patient out of the CT scanner, disconnects the injection of contrast from the patient's intravenous access, and assists the patient getting down from the scan bed. Radiographer 2 makes reconstructions and sends these to an image storage facility. Radiographer 2 also documents that the patient has received contrast and completes registration of the CT scan in the registration system. The above actions are part of the most frequent CT scans with use of intravenous contrast. The actions in the course of a CT scan may vary if contrast is not administered or if it is a specialized CT scan. The two radiographers may organize the tasks during the course of a CT scan differently than described previously; however, the actions involved in a CT scan are the same.
Perceptions of Interruptions When interrupted, radiographers perceived that it was a kind of internal disruption affecting their focus. A radiographer explained: It may fill my head when I'm concentrating on a work task and all of a sudden, I'm interrupted and have to concentrate on something else. Another radiographer added: I'm slightly interrupted somewhere in my brain. The radiographers perceived that they lost concentration if interrupted: I totally lose concentration if I'm for instance called away from the screen I'm trying to focus on. The radiographers described how the injection of contrast during a CT scan is a particularly sensitive moment regarding interruptions. A radiographer described: When I'm to administer the contrast, it is a particularly sensitive time concerning interruptions because it requires a specific focus. Another radiographer added: I must pay attention to the administration of the contrast, if the pressure increases, and pay attention to the patient. There are many things at stake, and I may not pay attention carefully enough if I'm interrupted. The working environment is also an important factor in connection with the radiographers' perception of interruptions. An example could be large offices with background noise. A radiographer explained about the presence of a coordinator in the room: I think it can be an interruption to have a coordinator sitting in our room. I can't help listening in on the conversation because I know that the call may result in extra CT scans and it interrupts me. Another radiographer said about CT operation rooms placed near common
Figure 1. Phases and actions involved in the course of a CT scan. CT, computed tomography.
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areas: Someone opens a door and leaves it open. On the other side, there is a hallway where many people walk by and beds are transported. It can be really disruptive when people walk by. Too many people in the CT operation room can also be an interruption according to radiographers. A radiographer said: At a trauma CT scan, there may be 20 people standing behind my back looking while I perform the scan; 20 pairs of eyes on my back can be hugely disruptive when I perform the scan. Consequences of Interruptions The radiographers described different consequences of interruptions when returning to the primary task. A radiographer said: When the focus is lost in one situation, it seems to be lost in several other situations. Another radiographer added: I have to start over (…) where was I and did I do everything? It may result in doing the CT scan without being 100% sure that I did what I was supposed to because I was interrupted. According to the radiographer, one of the consequences is that focus on the patient might be lost. A radiographer said: When I'm interrupted, I can quickly lose focus of and attention to my patient. Another consequence mentioned by the radiographers is the lack of patient identification: Due to interruptions, we may scan patients using wrong civil registration numbers. This may be corrected later, but it may have very serious consequences if it's not discovered. The radiographers agreed that if the tasks involved in a CT scan are completed without interruptions and with focus on the task, then something out of the ordinary will be discovered during the course of the CT scan. The radiographers described that interruptions during the injection of the contrast may be important to the effect of the contrast. According to the radiographers, the most serious consequence of wrong timing of the injection of the contrast in a CT scan was the need to perform a new scan. A radiographer said, the worst consequence of interruptions is when we have to call the patient in for a new CT scan because you can't make two CT scans with contrast on the same day. Discussion Overall, the participating radiographers agreed on the definition of interruptions and similar definition can be seen in a leaflet describing methods and tools to strengthen focus on interruptions and disruptions in hospital work: “change of direction or focus involving another person or thing” (Iversen & Østergaard, 2013). When the radiographers were interrupted in a work situation and thus disrupted in or blocked from doing their job, this could be described as a change of direction. Moreover, the radiographers agreed that both objects/technologies and persons can cause interruptions. Radiographers described that returning to the primary task after an interruption could result in having to start over the primary task. Gloria Mark, PhD, MS, from the Department of Informatics at the University of California speaks about short focused attention. Dr. Mark states that it is difficult to engage deeply in the work when the focus of attention changes all the time. Furthermore, she says that it often takes time to focus and engage in the work; if the focus of attention changes after a short while, it is not possible to engage thoroughly in a task (Abildgaard f. 1974, 2018). This is connected to the lack of concentration described by the radiographers and the difficulty returning to an ongoing task after an interruption. According to Dr. Mark, you do not return immediately to the same task you were doing before the interruption. Her research shows that you have to go through two other activities before you are back to the task you were doing before the interruption (Abildgaard f. 1974, 2018). According to the radiographers, an interruption can take place by somebody consciously contacting them during a CT scan, but
also just by one or more external persons being present during the scan. In an attempt to reduce interruptions among nursing during medicine rounds, several hospitals, including The Christie in Manchester and Cardiff and Vale NHS Trust in Wales, have introduced red tags saying “Medicine rounds in progress; please, do not disturb” to strengthen the focus (Beckford, 2011). A study at Aberdeen Royal Infirmary found that nurses were still interrupted in 95% of their medicine rounds despite carrying the tags; however, the average number of interruptions decreased from six to five (Beckford, 2011). In the interview, one of the radiographers talked about a course she had attended on interruptions. After the course, initiatives were made to reduce interruptions such as hanging up signs, but the signs were not supported by guidelines. According to radiographers, interruptions are still a challenge and it is fair to assume that the tags did not have the desired effect. Elisabeth Brøgger Jensen, MA, believes the challenge is to create a professional culture reducing the number of interruptions (a culture where people talk together as little as possible and only talk about what is necessary during specific procedures) (Jensen, 2008). Figure 1 shows that a CT scan can be divided into three phases managed by radiographers. According to the radiographers, some of these actions are particularly sensitive to interruptions as the consequences of errors are serious. These actions are placed in the two first phases: the preparation phase and the actual CT scan. Ratwani et al. (2014) used the concept “ill-timed interruptions” about interruptions where the price or consequence is particularly high or serious. Ratwani et al. described that a high price could be overdosing of medicine, missed test results, delays in patient care, and several other errors (Ratwani et al., 2014). The radiographers described that the price of an interruption during the administration of contrast during a CT scan could be the performance of a new CT scan. In this case, the price for the patient is to have a new appointment for a new CT scan where new contrast is injected and the patient is exposed to radiation again. Similarly, the radiographs describe the consequences of an interruption associated with the CT scanner operating section when preparing for the current patient. If a wrong patient is typed into the CT scanner and the scan is made using the wrong civil registration number, images are stored on the wrong patient. In this case, a treatment plan can be made for a patient, which does not comply with the patient's diagnosis. The aforementioned examples could be “ill-timed interruptions.” Schutijser et al. described how the quality of an examination is affected regardless of the extent of an interruption (Schutijser et al., 2019). The present study showed that interruptions affected the quality of CT scans. Limitations of the Study This is a minor study in a single hospital. To gain greater insight into the subject, more studies must be completed at other hospitals. This study investigated interruptions during the course of CT scans. Further research is needed to uncover if the same applies in other modalities used in radiographic practice. Relevance for Clinical Practice This study shows that interruptions compromise the quality of CT scans and eventually patient safety as these may lead to disruptions, insecurity, confusion, and errors. The study also shows that the consequences of interruptions vary and thus affect the quality of the CT scan differently. Understanding and management of interruptions in clinical radiographic practice may be particularly challenging because of the diversity of clinical environments and the importance of
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interruptions in relation to delivering examinations of high quality with good patient care. Conclusion Given the background of this study, we believe it is important to consider possible ways to reduce the number of interruptions during CT scans, particularly to reduce “ill-timed interruptions.” It is important to understand the nuances of interruptions and how radiographers perceive the interruptions will affect patient safety, quality of care, and teamwork. References Abildgaard f. 1974, P. G.. (2018). Fokus giver frihed: gode råd om arbejdsmetoder i en verden fuld af forstyrrelser. Frederiksberg: Frydenlund. Beckford, M. (2011) Nurses Wear “Do Not Disturb” Signs During Drug RoundsTelegraph. Retrieved from https://www.telegraph.co.uk/news/health/ne ws/8728093/Nurses-wear-do-not-disturb-signs-during-drug-rounds.html. Accessed April 9, 2019. Brinkmann, S., & Tanggaard, L. (2015). Kvalitative metoder : en grundbog (2nd ed.). København: Kbh., Hans Reitzel. Cades, D.M., Davis, D.A.B., Trafton, J.G., & Monk, C.A. (2007). Does the Difficulty of an Interruption Affect our Ability to Resume?. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 51(4), 234e238. https://doi.org/10.1177/ 154193120705100419. Cutrell, E.B., Czerwinski, M., & Horvitz, E. (2000) Effects of Instant Messaging Interruptions on Computing Tasks. Conference on Human Factors in Computing SystemseProceedings, 99e100. Retrieved from http://erichorvitz.com/ftp/chi 2000.pdf. Accessed November 21, 2019. Eyrolle, H., & Cellier, J.M. (2000). The effects of interruptions in work activity: field and laboratory results. Applied Ergonomics, 31(5), 537-543. Flynn, E.A., Barker, K.N., Gibson, J.T., Pearson, R.E., Berger, B.A., & Smith, L.A. (1999). Impact of interruptions and distractions on dispensing errors in an ambulatory
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care pharmacy. American Journal of Health-System Pharmacy: AJHP: Official Journal of the American Society of Health-System Pharmacists, 56(13), 1319-1325. Gillie, T., & Broadbent, D. (1989). What makes interruptions disruptive? A study of length, similarity, and complexity. Psychological Research, 50(4), 243-250. Giorgi, A. (1975). An application of phenomenological method in psychology. Duquesne Studies in Phenomenological Psychology, 2, 82-103. Iversen, L.R., & Østergaard, S. (2013) Forstyr med omtanke. Region Midtjylland. Retrieved from www.olp.rm.dk. Accessed November 21, 2019. Jensen, E.B. (2008). Forstyrrelser, forvirring og forsinkelser øger risikoen for utilsigtede hændelser. Sygeplejersken, 19, 46-48. Kvale, S. (2004). Interview: en introduktion til det kvalitative forskningsinterview. København: Kbh.: Hans Reitzel. Nielsen, R.G., & Jensen, K.H. (2016) Stillingsbetegnelse for Radiograf/uddannet røntgensygeplejerske. Retrieved from https://e-dok.rm.dk/edok/editor/HOVERO .nsf/vLookupUpload/ATTACH-RMAP-A9WEY4/$FILE/Stillingsbeskrivelse for radi ograf og uddannet røntgensygeplejerske.pdf. Accessed November 21, 2019. Ratwani, R., Hettinger, Z., Brixey, J., Rivera, A.J., & Colligan, L. (2014). Managing Interruptions in Healthcare. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 58(1), 624e628. https://doi.org/10.1177/154193121 4581148. Region Hovedstaden. (2007) Medarbejdernes vurdering af patientsikkerhedskulturen 2006. København: Region Hovedstaden. Retrieved from www.regionh.dk. Accessed November 21, 2019. Schutijser, B.C.F.M., Klopotowska, J.E., Jongerden, I.P., Spreeuwenberg, P.M.M., De Bruijne, M.C., & Wagner, C. (2019). Interruptions during intravenous medication administration: a multicentre observational study. Journal of Advanced Nursing, 75(3), 555-562. Uddannelse-og Forskningsministeriet. (2016) Radiograf - Bekendtgørelse om uddannelsen til professionsbachelor i radiografi - retsinformation.dk, Pub. L. No. BEK nr. 507, Tetsinformation.dk. Retrieved from https://www.retsinformation. dk/forms/r0710.aspx?id¼180540. Accessed November 21, 2019. Vallgårda, S., & Koch, L. (2011). Forskningsmetoder i folkesundhedsvidenskab (4th ed.). København: Kbh.: Munksgaard Danmark. Westbrook, J.I., Woods, A., Rob, M.I., Dunsmuir, W.T.M., & Day, R.O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683. Wiegmann, D.A., ElBardissi, A.W., Dearani, J.A., Daly, R.C., & Sundt, T.M. (2007). Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery, 142(5), 658-665.
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Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.sciencedirect.com/journal/ journal-of-radiology-nursing
Interruptions Affect the Quality of Radiographic Practice Louise Møller, MHH (Radiography) a,*, Karen Winther Christiansen, BSc (Radiography) b, Anja Sigaard Mortensen, BSc (Radiography) a a b
Department of Radiography, University College of North Jutland, Aalborg, Denmark Aarhus University Hospital, Department of Radiotherapy, Aarhus, Denmark
a b s t r a c t Keywords: Interruptions Radiographers' perceptions Quality
Interruptions are considered a natural and necessary part of the caring culture at hospitals. However, some interruptions may affect the concentration of health care professionals when performing a task. Research has shown that interruptions probably contribute to errors. There is no research on the radiographic perspective on the phenomenon of interruptions. This study focuses on interruptions within the field of radiology. The purpose is to investigate what radiographers in the radiological specialty consider to be interruptions and how radiographers perceive that interruptions affect their tasks/ work. This is a qualitative, phenomenological approach. Observations and a semistructured focus group interview were conducted. Data from observations and interview were collected and analyzed by systematic meaning condensation. According to radiographers, interruptions mean that they are interrupted during a work situation and are thus disrupted or blocked from doing their job. Both objects/technologies and persons can cause interruptions. The radiographers perceived that interruptions affected their focus and that losing concentration because of interruptions may lead to errors with consequences for the patients. This study showed that interruptions may cause disruptions, insecurity, confusion, and errors and thus compromise the quality of CT scans and ultimately patient safety. © 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Background Interruptions happen in everyday life and often in the workplace. In a busy hospital setting, everyone is highly dependent on good communication practices to efficiently perform patient care at a highly specialized level. The caring culture at a hospital is characterized as a collective culture where health care professionals continuously seek advice from each other; interruptions are thus an inherent part of the culture (Iversen & Østergaard, 2013). Interruptions in the caring culture at hospitals are initiated by, for example, colleagues, patients, and family members but also by medical and mobile units as well as technologies. Thus, interruptions are so inherent in the workflow that health care professionals must accept these interruptions as the norm (Ratwani, Hettinger, Brixey, Rivera, & Colligan, 2014). Interruptions are considered a natural and necessary part of the caring culture but may also be experienced as disrupting the task performed (Iversen & Østergaard, 2013). Generally, interruptions Conflict of interest: The authors have no conflict of interest to declare. * Corresponding author: Louise Møller, University College of North Jutland, Selma Lagerløfs Vej 2 9220 Aalborg Ø Denmark. Tel.: þ45 72691028. E-mail address: [email protected] (L. Møller).
affect individuals differently depending on (1) similarity between the disruptive task and the primary task (i.e., the disruptive task makes use of the same cognitive processes), (2) the relevance of the disruptive task compared with the primary task, (3) the length of the interruption, (4) the complexity of the interruption, and (5) the timing of the interruption (Cades, Davis, Trafton, & Monk, 2007; Cutrell, Czerwinski, & Horvitz, 2000; Eyrolle & Cellier, 2000; Gillie & Broadbent, 1989). Research has shown that interruptions are likely to contribute to errors. In 1999, Flynn et al. studied the effect of interruptions during the dispensing of medicine. They found that the number of dispensing errors increased by 3.23% (Flynn et al., 1999). In 2007, Wiegmann et al. compared the increase in surgical errors with the increase in interruptions (r ¼ 0.47, p < .05) (Wiegmann, ElBardissi, Dearani, Daly, & Sundt, 2007). In 2012, Westbrook et al. reported an increase of 12.1% in procedural errors and a 12.7% increase in clinical errors in connection with each of the observed interruptions (Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). A Danish questionnaire study among staff at hospitals and in the psychiatric area in one of Denmark's largest regions also showed that of 10,615 responses, 69% of the respondents replied that adverse events/errors happened because of the many interruptions (Region Hovedstaden, 2007).
https://doi.org/10.1016/j.jradnu.2019.10.003 1546-0843/$36.00/© 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Møller L et al., Interruptions Affect the Quality of Radiographic Practice, Journal of Radiology Nursing, https:// doi.org/10.1016/j.jradnu.2019.10.003
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In Denmark, radiographers/technologists are a part of the health care professional staff at hospitals where they work in radiation therapy, at nuclear medicine departments, and at departments of radiology. At departments of radiology, radiographers are working with all aspects of medical imaging within the radiological specialty, and here, imaging examinations and interventional procedures are conducted on both outpatient and inpatient patients. Within radiology, radiographers work with imaging modalities such as conventional radiography including fluoroscopy, computed tomography (CT), magnetic resonance, ultrasonography, and mammography (Nielsen & Jensen, 2016). In departments of radiology, the role of radiographers is to plan, perform, assess, communicate, manage, develop, and implement radiography as well as to give advice and counseling concerning the examination, diagnostics and treatment, health promotion, and disease prevention including radiation protection and patient safety (Uddannelse-og Forskningsministeriet, 2016). The workplace of radiographers is highly technological. In addition, departments of radiology are also interdisciplinary and interprofessional departments, and these departments are central at any hospital collaborating with other clinical departments. Departments of radiology use medical secretaries, radiographers, nurses, radiologists, and hospital porters, who work closely together on each patient pathway. Overall, the complexity of the work of radiographers is high involving many technologies and collaborators, and the risk of interruptions is rather high. Purpose There is no current research including the viewpoint of radiographers on the phenomenon of interruptions. Thus, this study focuses on the following research questions: What do radiographers in the radiological specialty consider to be interruptions? How do radiographers perceive that interruptions affect their tasks/work?
all field notes were collected providing an overview of the elements of a CT scan.
Interview A focus group interview with five radiographers (4 females and 1 male) was made. The radiographers were included according to the following criteria: daily work with CT scanners and at least 1 year's experience with CT scans. The focus group interview was made during working hours in a room at the hospital and lasted approximately 1 hour. Two of the researchers/radiographers conducted the focus group interview; one was the moderator and one made notes. An interview guide was made with simple questions illustrating interruptions during the course of a CT scan, the radiographer's perception of interruptions during such a scan, and the impact of interruptions during a CT scan. The interview was tape-recorded.
Ethical approval At University College of North Jutland's General Data Protection Regulation coordinator, it was investigated whether permission to collect data should be applied to the ethics committee, which was not necessary. The study was based on the voluntary written consent of radiographers to participate. All participants were informed of the possibility to withdraw from the study at any time without any consequences. The anonymity of the participants was ensured by not naming the hospital where observations were made. Data from observations and the recording of the interview were stored on one computer and protected by a login.
Data analysis
Observation
The analysis of field notes from the observations was made by the two researchers/radiographers performing the observations. Based on the field notes, the elements of the course of a CT scan at this hospital were mapped. After the analysis, results were presented to and qualified by the radiographers present during the observations. If the radiographers had knowledge of further elements of a CT scan than included in the mapping, these were subsequently included. The interview recording was transcribed immediately after the interview by the researcher/radiographer making notes during the interview. Transcription was made to ensure writing down what was said as precisely as possible; however, the focus was to maintain and capture the meaning of what was said (Brinkmann & Tanggaard, 2015). Subsequently, a phenomenological meaning condensation inspired by Giorgi (Giorgi,1975) and described by Kvale (Kvale, 2004) was made. The meaning condensation consists of the following phases:
Observations were performed by two researchers/radiographers following the radiographers in practice during the course of a CT scan. The researchers took field notes on the elements they perceived would shed light on the elements involved in a CT scan, strictly to diagram the workflow. The researchers made the observations individually at four different CT scanners to gain as much variation in their observations as possible regarding types of examinations, specialist examinations, and person-dependent elements. Observations were made equivalent to a day program (from 08.00 am to 15.00 pm) or approximately for 7 hours. Subsequently,
1) The interview data are read to form a sense of the whole. 2) Researchers identify the perceptions of the phenomenon of interruptions and disruptions and their impact on CT scans as expressed by the informants. 3) Themes covering the identified perceptions are formulated as precisely as possible. 4) Questions to the formulated themes are posed based on the specific purpose of the study. 5) The most significant themes are combined to form descriptive statements.
Method This study used qualitative, phenomenological research methods for data collectiondobservation studies and interviews. These methods are suitable when the research question is to gain knowledge and understanding of the lifeworld of human beings such as the practice of radiographers (Vallgårda & Koch, 2011). Radiographers work with different modalities/technologies, but this study focuses on CT. This qualitative study investigates interruptions during the course of CT scans, the radiographers’ perception of interruptions during the scan, and the impact of interruptions on the CT scan. The studies were made at a department of radiology at a Danish university hospital between October 2018 and March 2019.
Please cite this article in press as: Møller L et al., Interruptions Affect the Quality of Radiographic Practice, Journal of Radiology Nursing, https:// doi.org/10.1016/j.jradnu.2019.10.003
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Results
The Phenomenon Interruptions
Elements of a CT Scan
The radiographers agreed that an interruption means to be interrupted during a work situation and thus be disrupted or blocked from performing a work task. A radiographer described interruptions in the following way: I get distracted for a short while and in this way, I am disrupted from what I am focusing on. Another radiographer described interruptions in this way: It can be things happening in the background that makes me unable to perform my work or something may happen that blocks me from doing my tasks. The radiographers referred to objects that may cause interruptions including telephones, radios, coffee machines, or other things making loud noises. In addition to the loud noises, technologies may be disruptive just by being there. One radiographer said: There was a coffee machine by the CT scanner and people stopped by all the time. Moreover, radiographers described how external persons could be an interruption during a CT scan: it may be an interruption if care staff from other departments come with the patient. It can be a major interruption if they interfere. Colleagues were also mentioned as an interruption: When another shift meets to take over and they just start talkingdit's an interruption.
This observation study showed that a CT scan consists of several phases. The mapping process is illustrated in Figure 1, which shows the three phases of a CT scan: a preparation phase, the actual CT scan, and a closing phase. Figure 1 also shows that each phase includes more actions to be managed by a radiographer. The observation study also showed that two radiographers were always present during the course of a CT scan, each managing their own actions. Some of the actions and the division of tasks between radiographers in the three phases are described in the following. During the preparation phase, radiographer 1 manages the following tasks: reading through the patient's referral, calling the patient in from the waiting area, getting the patient's name, civil registration number, height, and weight. Radiographer 1 also informs the patient about clothing during the CT scan, the course of the CT scan, when to expect the scan results, and how contrast is administered. Radiographer 1 accompanies the patient to the CT scanner and ensures the correct positioning of the patient on the bed and that the patient is as comfortable as possible. Radiographer 1 establishes the intravenous access and attaches this to an automatic injection of contrast, slides the patient into the CT scanner, and positions the patient correctly in the isocenter. Radiographer 2 registers that the CT scan of the patient is registered in the registration system and prepares the operation of the CT scanner. Radiographer 2 also prepares the operation of the automatic injection of contrast. Radiographer 2 performs the actual scan and ensures correct timing of the administration of contrast. Radiographer 1 is with the patient before administration of the contrast, informing that the contrast is administered and then observes the patient through a window. Radiographer 2 checks the image quality and criteria before radiographer 1 is with the patient again. In the closing phase, radiographer 1 slides the patient out of the CT scanner, disconnects the injection of contrast from the patient's intravenous access, and assists the patient getting down from the scan bed. Radiographer 2 makes reconstructions and sends these to an image storage facility. Radiographer 2 also documents that the patient has received contrast and completes registration of the CT scan in the registration system. The above actions are part of the most frequent CT scans with use of intravenous contrast. The actions in the course of a CT scan may vary if contrast is not administered or if it is a specialized CT scan. The two radiographers may organize the tasks during the course of a CT scan differently than described previously; however, the actions involved in a CT scan are the same.
Perceptions of Interruptions When interrupted, radiographers perceived that it was a kind of internal disruption affecting their focus. A radiographer explained: It may fill my head when I'm concentrating on a work task and all of a sudden, I'm interrupted and have to concentrate on something else. Another radiographer added: I'm slightly interrupted somewhere in my brain. The radiographers perceived that they lost concentration if interrupted: I totally lose concentration if I'm for instance called away from the screen I'm trying to focus on. The radiographers described how the injection of contrast during a CT scan is a particularly sensitive moment regarding interruptions. A radiographer described: When I'm to administer the contrast, it is a particularly sensitive time concerning interruptions because it requires a specific focus. Another radiographer added: I must pay attention to the administration of the contrast, if the pressure increases, and pay attention to the patient. There are many things at stake, and I may not pay attention carefully enough if I'm interrupted. The working environment is also an important factor in connection with the radiographers' perception of interruptions. An example could be large offices with background noise. A radiographer explained about the presence of a coordinator in the room: I think it can be an interruption to have a coordinator sitting in our room. I can't help listening in on the conversation because I know that the call may result in extra CT scans and it interrupts me. Another radiographer said about CT operation rooms placed near common
Figure 1. Phases and actions involved in the course of a CT scan. CT, computed tomography.
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areas: Someone opens a door and leaves it open. On the other side, there is a hallway where many people walk by and beds are transported. It can be really disruptive when people walk by. Too many people in the CT operation room can also be an interruption according to radiographers. A radiographer said: At a trauma CT scan, there may be 20 people standing behind my back looking while I perform the scan; 20 pairs of eyes on my back can be hugely disruptive when I perform the scan. Consequences of Interruptions The radiographers described different consequences of interruptions when returning to the primary task. A radiographer said: When the focus is lost in one situation, it seems to be lost in several other situations. Another radiographer added: I have to start over (…) where was I and did I do everything? It may result in doing the CT scan without being 100% sure that I did what I was supposed to because I was interrupted. According to the radiographer, one of the consequences is that focus on the patient might be lost. A radiographer said: When I'm interrupted, I can quickly lose focus of and attention to my patient. Another consequence mentioned by the radiographers is the lack of patient identification: Due to interruptions, we may scan patients using wrong civil registration numbers. This may be corrected later, but it may have very serious consequences if it's not discovered. The radiographers agreed that if the tasks involved in a CT scan are completed without interruptions and with focus on the task, then something out of the ordinary will be discovered during the course of the CT scan. The radiographers described that interruptions during the injection of the contrast may be important to the effect of the contrast. According to the radiographers, the most serious consequence of wrong timing of the injection of the contrast in a CT scan was the need to perform a new scan. A radiographer said, the worst consequence of interruptions is when we have to call the patient in for a new CT scan because you can't make two CT scans with contrast on the same day. Discussion Overall, the participating radiographers agreed on the definition of interruptions and similar definition can be seen in a leaflet describing methods and tools to strengthen focus on interruptions and disruptions in hospital work: “change of direction or focus involving another person or thing” (Iversen & Østergaard, 2013). When the radiographers were interrupted in a work situation and thus disrupted in or blocked from doing their job, this could be described as a change of direction. Moreover, the radiographers agreed that both objects/technologies and persons can cause interruptions. Radiographers described that returning to the primary task after an interruption could result in having to start over the primary task. Gloria Mark, PhD, MS, from the Department of Informatics at the University of California speaks about short focused attention. Dr. Mark states that it is difficult to engage deeply in the work when the focus of attention changes all the time. Furthermore, she says that it often takes time to focus and engage in the work; if the focus of attention changes after a short while, it is not possible to engage thoroughly in a task (Abildgaard f. 1974, 2018). This is connected to the lack of concentration described by the radiographers and the difficulty returning to an ongoing task after an interruption. According to Dr. Mark, you do not return immediately to the same task you were doing before the interruption. Her research shows that you have to go through two other activities before you are back to the task you were doing before the interruption (Abildgaard f. 1974, 2018). According to the radiographers, an interruption can take place by somebody consciously contacting them during a CT scan, but
also just by one or more external persons being present during the scan. In an attempt to reduce interruptions among nursing during medicine rounds, several hospitals, including The Christie in Manchester and Cardiff and Vale NHS Trust in Wales, have introduced red tags saying “Medicine rounds in progress; please, do not disturb” to strengthen the focus (Beckford, 2011). A study at Aberdeen Royal Infirmary found that nurses were still interrupted in 95% of their medicine rounds despite carrying the tags; however, the average number of interruptions decreased from six to five (Beckford, 2011). In the interview, one of the radiographers talked about a course she had attended on interruptions. After the course, initiatives were made to reduce interruptions such as hanging up signs, but the signs were not supported by guidelines. According to radiographers, interruptions are still a challenge and it is fair to assume that the tags did not have the desired effect. Elisabeth Brøgger Jensen, MA, believes the challenge is to create a professional culture reducing the number of interruptions (a culture where people talk together as little as possible and only talk about what is necessary during specific procedures) (Jensen, 2008). Figure 1 shows that a CT scan can be divided into three phases managed by radiographers. According to the radiographers, some of these actions are particularly sensitive to interruptions as the consequences of errors are serious. These actions are placed in the two first phases: the preparation phase and the actual CT scan. Ratwani et al. (2014) used the concept “ill-timed interruptions” about interruptions where the price or consequence is particularly high or serious. Ratwani et al. described that a high price could be overdosing of medicine, missed test results, delays in patient care, and several other errors (Ratwani et al., 2014). The radiographers described that the price of an interruption during the administration of contrast during a CT scan could be the performance of a new CT scan. In this case, the price for the patient is to have a new appointment for a new CT scan where new contrast is injected and the patient is exposed to radiation again. Similarly, the radiographs describe the consequences of an interruption associated with the CT scanner operating section when preparing for the current patient. If a wrong patient is typed into the CT scanner and the scan is made using the wrong civil registration number, images are stored on the wrong patient. In this case, a treatment plan can be made for a patient, which does not comply with the patient's diagnosis. The aforementioned examples could be “ill-timed interruptions.” Schutijser et al. described how the quality of an examination is affected regardless of the extent of an interruption (Schutijser et al., 2019). The present study showed that interruptions affected the quality of CT scans. Limitations of the Study This is a minor study in a single hospital. To gain greater insight into the subject, more studies must be completed at other hospitals. This study investigated interruptions during the course of CT scans. Further research is needed to uncover if the same applies in other modalities used in radiographic practice. Relevance for Clinical Practice This study shows that interruptions compromise the quality of CT scans and eventually patient safety as these may lead to disruptions, insecurity, confusion, and errors. The study also shows that the consequences of interruptions vary and thus affect the quality of the CT scan differently. Understanding and management of interruptions in clinical radiographic practice may be particularly challenging because of the diversity of clinical environments and the importance of
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interruptions in relation to delivering examinations of high quality with good patient care. Conclusion Given the background of this study, we believe it is important to consider possible ways to reduce the number of interruptions during CT scans, particularly to reduce “ill-timed interruptions.” It is important to understand the nuances of interruptions and how radiographers perceive the interruptions will affect patient safety, quality of care, and teamwork. References Abildgaard f. 1974, P. G.. (2018). Fokus giver frihed: gode råd om arbejdsmetoder i en verden fuld af forstyrrelser. Frederiksberg: Frydenlund. Beckford, M. (2011) Nurses Wear “Do Not Disturb” Signs During Drug RoundsTelegraph. Retrieved from https://www.telegraph.co.uk/news/health/ne ws/8728093/Nurses-wear-do-not-disturb-signs-during-drug-rounds.html. Accessed April 9, 2019. Brinkmann, S., & Tanggaard, L. (2015). Kvalitative metoder : en grundbog (2nd ed.). København: Kbh., Hans Reitzel. Cades, D.M., Davis, D.A.B., Trafton, J.G., & Monk, C.A. (2007). Does the Difficulty of an Interruption Affect our Ability to Resume?. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 51(4), 234e238. https://doi.org/10.1177/ 154193120705100419. Cutrell, E.B., Czerwinski, M., & Horvitz, E. (2000) Effects of Instant Messaging Interruptions on Computing Tasks. Conference on Human Factors in Computing SystemseProceedings, 99e100. Retrieved from http://erichorvitz.com/ftp/chi 2000.pdf. Accessed November 21, 2019. Eyrolle, H., & Cellier, J.M. (2000). The effects of interruptions in work activity: field and laboratory results. Applied Ergonomics, 31(5), 537-543. Flynn, E.A., Barker, K.N., Gibson, J.T., Pearson, R.E., Berger, B.A., & Smith, L.A. (1999). Impact of interruptions and distractions on dispensing errors in an ambulatory
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Please cite this article in press as: Møller L et al., Interruptions Affect the Quality of Radiographic Practice, Journal of Radiology Nursing, https:// doi.org/10.1016/j.jradnu.2019.10.003