Interruptions of activities experienced by nursing professionals in an intensive care unit

ABSTRACT Objective: to analyze the interruptions experienced by nursing professionals while undertaking care activities. Method: an observational study undertaken in two intensive care units. Two nurses observed 33 nursing professionals for three hours. The data were recorded in real time, using a semistructured instrument. Results: after 99 hours of observation of 739 activities, it was identified that 46.82% were interrupted, resulting in 7.85 interruptions per hour. On average, the interruptions compromised 9.42% of the nursing professionals' worktime. The activities geared towards indirect care of the patient suffered the highest number of interruptions (56.65%), with the nursing records being the activity interrupted most. The principal source of the interruptions was external, coming from the health professionals (51%), and the main causes were those related to the patients (34.70%) and to interpersonal communication (26.47%). Conclusion: the activity of nursing suffers a high number of interruptions, mainly caused by the health professionals themselves, indicating that the work environment needs to undergo interventions aiming to reduce the risk of compromising of the professional's performance and to increase the patients' safety.


Introduction
Patient safety has been much discussed over recent decades, bearing in mind that many users of the health service have suffered adverse events as a result of errors which took place in the care. The Institute of Medicine's publication, "To Err is Human: Building a Safer Health System" identified that avoidable adverse events are the fourth most important cause of death in the United States of America (USA) (1) .
The interruptions experienced by the health professionals while undertaking their care activities were indicated as possible factors for errors, establishing a causal relationship between patient safety and the occurrence of interruptions; since 2008, this issue has been strongly studied by health researchers (2)(3) .
The interruptions -acts which disrupt or suspend an activity -are derived from external events originating from people or from the sounds of equipment, such as telephones and alarms, or from self-interruption (4) . The interruptions contribute to distracting human attention, possibly resulting in disrupting or interrupting the activity which is being undertaken, even if temporarily, reducing time for reflection and ability to think (4)(5) . After experiencing the interruption, the professional runs the risk of omitting or repeating some steps, or it may even happen that the entire task may be repeated, which may have disastrous effects (6) .
In this context, the interruptions must be the focus of attention in health institutions, which are considered complex environments, as they may be harmful to the patients' safety (7) .
In one investigation undertaken in two teaching hospitals in Australia, the nurses who were interrupted presented higher chances of committing errors (8) . In the USA, one study indicated that the interruptions and distractions were responsible for more than half of the events reported (59.6%) associated with drug errors (5) . Evidence also indicates an association between interruptions and distractions of the surgical team and an increase in mortality (4) .
The Intensive Care Unit (ICU) deserves to be emphasized, as it presents considerable challenges in relation to patient safety, considering that highly complex processes are undertaken in this unit. The nursing care in this unit requires much attention from the professionals who frequently need to take fast and risky decisions, in addition to undertaking a high number of invasive interventions and using a variety of devices, various high-alert medications and new therapeutic technologies, with studies indicating the high incidence of adverse events (9)(10) .
Considering the need to identify situations of risk existing in nursing's work environment, which can lead to the occurrence of errors in the care provided to inpatients, the search for evidence indicating paths for the adoption of interventions focused on the quality of the care and on the patients' safety, and the low level of knowledge in relation to the phenomenon of interruption in the context of the nursing care in Brazil, this study's objective was to analyze the interruptions experienced by the nursing professionals while undertaking care activities for patients hospitalized in ICU.

Method
A quantitative observational transversal study undertaken in two ICUs of a teaching institution located in the Brazilian state of Goiás (GO).
The study population was made up of all the nursing professionals who undertook nursing activities in the units selected. The observations were made during the morning shifts (from 08:00 to 11:00) and afternoon shifts (from 13:00 to 16:00) in June -August 2014.
All the nursing professionals were observed individually, once, and simultaneously by two nurses, with the objective of obtaining trust in the data observed. The observers received training regarding data collection (4 hours each) and participated in the pilot study (3 hours each). The degree of agreement between the observers was 94.3%. The discrepant cases were excluded.
For this study, 'interruption' was considered to be any act or attitude whatsoever which interrupted/ suspended/broke or diverted the professional's attention from what she was doing, even if temporarily, caused by environmental and/or human factors.
A semistructured script was used for data collection, validated by two nurses and one specialist in patient safety, with closed questions for obtaining data characterizing the professionals and the environment,   In order to ascertain statistical differences between the number of interruptions by professional category, the Kruskal Willis test was undertaken, with confidence intervals of 95%. The associations which obtained a value of p<0.05 were considered to be statistically significant.
The project was submitted to, and approved by, the with and without interruption, are described in Table 2.  Among the activities of indirect care, emphasis is placed on the "annotations and nursing records", with 82 interruptions; in those of direct care, the "administration of medications", and in administrative activity, the "use of the telephone".
The study also made it possible to identify the sources of interruption, as shown in Table 3. Total 794 100% *Self-interruption: the professional herself causes the interruption of her activity, without the intervention of another person (11) .
interruptions per hour (2) . A study undertaken in Germany, during the observation of nurses from surgical care units and ICU, identified one interruption every six minutes (12) .
In one teaching hospital in the city of São Paulo, the ICU nurses experienced one interruption every eight minutes (11) . In one cardiovascular ICU in a Canadian teaching hospital, an average of 19.7 interruptions per hour was ascertained (9) .
The positive correlation between the duration of an activity and the number of interruptions suggests that activities which require more time from the professional must be planned and receive interventions in order to minimize unnecessary interruptions.
The interruptions may cause cognitive errors, including failures in attention, memory or perception (13) , affecting concentration and contributing to the human being forgetting what she was doing, increasing the probability of committing errors (2)(3)14) . The consequence of these failures causes delays in the care, loss of concentration, incomplete work, the omission of the care, and an increase in the risk of errors and exposure of the patient to errors (12) .
The interruptions may also cause negative emotional responses for some professionals, causing them to feel frustrated, stressed and demotivated due to having been interrupted (3,15) .
In relation to the time taken up by the interruption and to the disruption/interruption of the activity, it was observed that short interruptions, such as those found in the majority of the cases in this study, cause the professionals to remember what they were doing and to restart their activities with less difficulty, as they reduce the cognitive effort (10) , although they continue to be potential risk factors, considering that each human being reacts differently, at different times, when interrupted.
In the present study, in 42.29% of the activities interrupted, the professionals had their attention divided between continuing the activity and paying attention to It is highlighted that it was possible to identify a total of 794 sources of interruptions, given that some activities were interrupted by more than one source simultaneously.
The causes of the interruptions were brought together into 11 categories, as presented in Table 4. the interruption. This may be a problem for the quality of the healthcare, bearing in mind that in undertaking processes of risk, the professionals' level of attention must be raised and any interruption may lead to the occurrence of errors (8) . The study undertaken in ICU indicated that in 6.6% of the interrupted activities, the professionals had their attention diverted, causing them not to return to the task or to have had their return to the task impeded by a further interruption or due to change in the context of the care (10) .
Regarding the type of activity interrupted, the majority were of indirect patient care, with emphasis on annotations and nursing records. This activity was also among those interrupted most in emergency units of two Swedish hospitals (27.0%) (16) , as well as in clinical and surgical units of a teaching hospital in Toronto, Canada (29.3%) (17) .
When interrupted during documentation, the professional may forget to record information which is essential for patient care and for continuity of the patient's care. It is worth remembering that the records indicate the quality of the care which is being provided, and that the patient record is the main means of communication within the health team, as well as being a legal instrument and contributing to the auditing of the nursing for teaching and research (18) .
In relation to the interruptions which occurred during handwashing, these may be concerning, as they can lead to the omitting or incorrect undertaking of some steps of this technique, impeding the correct hygienization of the entire hands and causing failure to remove the microbiota colonizing the hand, placing the patient's safety at risk (19) .
Frequent interruptions were also found, in this study, during the administration of medications. In ICU, the administration of multiple medications occurs intravenously, many of which are potentially dangerous, this being a high-risk process. In cases of lack of attention on the part of the professional, errors may occur and cause severe harm to the patients (5,20) . Studies have indicated that approximately 50% of medication errors take place as a result of distractions caused by interruptions (5) .
Nearly half of the interruptions were caused by the health professionals themselves, as shown in previous studies (6,14,21) . Unfortunately, health professionals have not yet been made properly aware of the impact which interruptions can have on the quality and safety of the care which is being provided (22)(23) . As a result, it is necessary to adopt strategies for raising awareness and educating the professionals regarding when interruptions should or should not be avoided.
In addition to the main source of interruption having been the professionals themselves, attention is called in this study to the high number of self-interruptions which took place during the undertaking of nursing activities, as emphasized in previous studies (6,12,24) . This type of interruption can be avoided through better planning of the practice and through raising awareness that while undertaking work activities, the resolution of personal needs can wait (11) .
The self-interruptions due to lack of materials for concluding procedures demonstrate a lack of planning on the part of the professional. One study ascertained that professionals spent approximately 0.6 minutes per hour on interruptions due to lack of supplies, which corresponds to 1% of the work shift (11) , reflected in delays improving the patient's condition, the interruptions may be well regarded (12,17) .
Nevertheless, this study also evidenced that interpersonal communication was the second most common cause of interruption. The professionals either interrupted or had their care activities interrupted in order to deal with topics of personal interest, outside the context of what they were involved in. This is a type of interruption which must be deferred, due to the consequences which it can bring to the quality of the care.
In order to prevent this type of situation, some measures have been proposed, such as the use of colored tops during the preparation and administration of medications, as a signal that these people are not to be disturbed during this activity, or preparation of medications in cubicles (20) . Another approach for reducing interruptions is to make specific areas available for undertaking complex and risky activities, such as preparation of medications, where interruption is not permitted or is limited to urgent communications (25) . errors and areas where improvements could be adopted.
As with any observational study, this presented limitations regarding the risk of the presence of the observers having influenced the professionals' behavior.
Although the nursing team investigated knew that it was being observed, the other professionals and family members did not; it is therefore believed that this fact may mitigate the risk of the results having been influenced by the method of data collection. It is also considered to be a limitation that the study was undertaken in the ICU, restricting the field to a hospital institution and to a specific population, limiting the results found to similar