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Kelly Kollstedt, MSN, RN, CAPA, is Supervisor, Ambulatory Surgery, Health Central Hospital, Ocoee, FL.

Susan B. Fowler, PhD, RN, CNRN, FAHA, is Nurse Scientist, Orlando Health, Orlando, FL.

Karen Weissman, MSN, RN, CMSRN®, is Clinical Nurse Educator, Health Central Hospital, Ocoee, FL.

Acknowledgment: The authors would like to recognize the following individuals who were instrumental in the conduct of this study: Alicia Mohamed, Suzann Vinson, and Randy Hassard.

Hospital Nurses’ Perceptions about Distractions to Patient-Centered Care

Delivery

Kelly Kollstedt Susan B. Fowler

Karen Weissman

B ecause nurses play a critical role in delivery of safe, high-quality, patient-centered care,

they must be focused and engaged fully. Nurses have numerous re -sponsibilities and deal with many distractions during a work shift. Noise has been identified as a major distractor, causing miscommunica-tion and lack of focus, and possibly causing an unsafe work environ-ment (Association of periOperative Regis tered Nurses [AORN], 2013). Patient-centered care and satisfac-tion are key outcomes in healthcare practice, requiring nurses to be engaged and use eye contact and effective communication, including active listening. This can be chal-lenging when distractions are pres-ent (Fredericks, Lapum, & Hui, 2015). Because nurses are on the front line of patient care, they also are uniquely able to recognize dis-tractions and develop management strategies to prevent errors (Hayes, Power, Davidson, & Jackson, 2014).

Distractions can jeopardize focus and engagement (Hay, Barnette, & Shaw, 2016). Distractions during care delivery can compromise patient safety and efficiency, including teamwork (Hay et al., 2016; Wheelock et al., 2015). Additionally, implementation of the Affordable Care Act has changed the healthcare environ-ment. Nurses are expected to do more with less resources and staff, another source of distraction, while continuing to provide high-quality

Research for Practice

Distractions threaten patient safety and quality of care. The pur-pose of this study was to explore hospital nurses’ perceptions about distractions to the delivery of patient-centered care. Staffing issues, telephone ringing, computer issues, and multitasking were the four highest-rated distractors.

patient-centered care (American Nurses Association, 2014). Because distractions are unavoidable in nursing, nurses must identify per-ceived distractions, minimize and learn to manage them so high-qual-ity patient-centered care can be delivered (AORN, 2013).

The first and most important actions for nurses are to identify and manage distractions that cause them to lose concentration on the task at hand. This is especially true during critical tasks, such as univer-sal time-out, the induction and emergence from anesthesia, hand-off communication, and medica-tion administration (AORN, 2013). Nurses also must have excellent critical thinking skills, be able to make good decisions, and know how to problem solve to master the management of distractions (Hayes et al., 2014).

A great deal of research to date on the effect of distractions in nurs-ing focuses on medication errors (Thomas, Donohue-Porter, & Fish -bein, 2017). Although it is crucial to provide a safe environment by pre-venting medication errors, it is also extremely important to study how distractions may impact the quality of patient care provided by nurses. Identification of unit-specific dis-tractions and strategies to manage them may empower staff to insti-tute change and monitor outcomes.

Purpose The purpose of this study was

to examine registered nurses’ (RNs) perceptions of distractions to patient-centered care in acute care hospital settings. The study was an extension of previous research with perioperative nurses.

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Review of the Literature A literature review initially was

conducted from January 2007 to March 2018 with PubMed and CINAHL using the following search terms: distractions, interruptions, med-ication errors, patient safety, health-care, patients, and inpatients. Final articles selected for appraisal includ-ed published articles for 2014-2018 with a focus on most current research that included nurses.

Hospital nurses’ perceptions of human factors contributing to nurs-ing errors were explored by Roth, Wieck, Fountain, and Hass (2015) using a cross-sectional design. Questions about likelihood to con-tribute to nursing errors, ability to intervene, importance as a cause of nursing errors, and commonness in hospitals were asked about 24 items. The online survey was com-pleted by 393 nurses. Factor analy-sis of the Likelihood to Cause a Nurse Error in the Hospital Scale identified four themes: loss of focus, unhealthy environment, interper-sonal deficits, and being over-whelmed. Nurses identified the fol-lowing as common: distraction due to loss of focus, distraction due to phone interruptions, problems with technology, nurses placed in an unfamiliar circumstance (unit type or patient type), and intentional blindness. Authors concluded dis-tractions can impact nursing focus negatively during patient care.

Thomas and colleagues (2017) studied 857 medication administra-tion episodes by medical-surgical RNs across numerous hospital set-tings. In 478 episodes (67.1%), nurses were interrupted. At least one distraction was noted in 76.1% (n=575) of the episodes; the top four distractors were issues with other patients, fatigue, hunger, and noise. A significant relationship was found between interruptions and distractions with cognitive load (p<0.05).

Wheelock and colleagues (2015) investigated distractions by observ-ing 90 general surgery cases in the operating room (OR). Two trained researchers used the Observational

Teamwork Assessment for Surgery tool and noted distractions in 98% (n=88) of cases. The most common distractions were external staff entering the OR and conversations not related to the case. Most intense distractions were related to equip-ment. For scrub nurses, teamwork decreased when equipment-related distractions increased (p<0.05), and stress increased with intense equip-ment distractions (p<0.05). Higher rates of procedural distractions were linked to poorer communication of OR nurses (p<0.05). Distractions negatively affected teamwork in the OR, especially communication.

Avidan, Yacobi, Weissman, and Levin (2017) conducted an observa-tional study on cell phone calls dur-ing 52 surgeries. Of 205 cell phone calls, 96.1% (n=197) were incom-ing; only 3.9% (n=8) were outgoing calls. The average call lasted 64 sec-onds (SD±40). Of the 197 incoming calls, 25% (n=52) were for nurses and 61% (n=121) for surgeons. During 29 (14.7%) incoming calls, 30 staff distractions were caused by surgeons talking on their cell phones for approximately 43.6 ± 22.3 seconds. Scrubbed surgeons were the most distracted by their own cell phones, with nurses answering 92% (22 of 24) of the calls and leading to more distrac-tion.

Hay and coauthors (2016) col-lected data before and after a prac-tice change in an endoscopy proce-dure setting using a sterile cockpit team approach tailored from avia-tion during critical tasks to reduce distractions. Comparison of the per-ceptions of distraction by eight nurses before and after implementa-tion of the new approach was com-pleted using a six-item unit-based assessment tool. Results demon-strated increased awareness of dis-tractions that decrease concentra-tion on patient care (p<0.01), inter-rupt communication between team members, contribute to mistakes, and include pagers and employees coming into the room (p=0.04). Additionally, observations were conducted in pre-procedural and procedural areas. Before the inter-

vention, 13 interruptions were noted in 30 observations (43%). After the intervention, an increase in interruptions occurred (75%, n=24). A second observation period yielded no interruptions in 19 observations of endoscopy proce-dures, but 84% (n=16) of interrup-tions were noted in the pre-proce-dure area.

A quality improvement project by Yoder, Schadewald, and Dietrich (2015) focused on creating a safe zone for nurses (n=20) and student nurses (n=11) during medication preparation and administration on a medical unit based on the sterile cockpit aviation protocol. Twelve sources of distractions and interrup-tions were measured before and after implementation of the proto-col. The most frequently identified distractors were patient call lights and conversation or people talking in the area. Conversation or people talking in the area, call lights, and staff members interrupting or talk-ing to the team members were the most frequent sources of distraction or interruption identified by nurses before the intervention. The top three distractions and interruption following the intervention were conversation or people talking in the area, visitor/family interrup-tions or talking to the team mem-ber, and staff members interrupting or talking to the team member. Comparison of data before and after protocol implementation showed a significant increase in distractions and interruptions caused by physi-cians, nurse practitioners, or physi-cian assistants (p=0.003); loud nois-es in the area (p=0.018); and visi-tors/families (p=0.025). According to the investigators, increased dis-tractions may have been due to increased awareness about the prob-lem, individuals asking the nurse or student about the vest being worn, and inconsistent adherence to the Safe Zone protocol. Results demon-strated distractions are frequent and ongoing.

With limited research on distrac-tion and nurses outside the surgical arena, this study was undertaken to fill that gap.

Research for Practice

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Hospital Nurses’ Perceptions about Distractions to Patient-Centered Care Delivery

Ethics The study was approved by

the hospital Institutional Review Board. Survey responses were returned anonymously through SurveyMonkey®. Completion of the survey implied consent. In the invi-tation, participants were made aware of this consent process and mainte-nance of the anonymity of their responses. Individual responses were recorded via SurveyMonkey but could not be linked to an identity. Data were reported in aggregate.

Sample Selection A convenience sample of all

nurses in the facility (approximate-ly 600) was emailed an electronic link to the survey; 72 (12%) nurses completed the survey, which was available for 2 weeks on SurveyMonkey. E-mails were sent to nurses a few days before the survey opened, midway through the sur-vey period, and a few days before the survey closed in an attempt to improve the response rate. The high-est number of responses was from nurses working in the Emergency Department (n=13), critical care unit (n=13), and medical-surgical unit (n=10). Responses also were obtained from the intermediate care unit (n=9), float pool (n=9), surgical care unit (n=8), and maternal-child unit (n=6). The telemetry medical unit (n=2), ortho-spine unit (n=1), and adult medical unit (n=1) had mini-mal responses.

Design and Method The study used a descriptive,

exploratory design with quantita-tive and qualitative questions solicited through SurveyMonkey. The Likert-type survey consisted of six demographic questions, six questions targeting distractions (1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree), and one open-ended question. The open-ended question was used to capture other items nurses perceived as dis-tractions not mentioned in the sur-vey. The survey used in this investi-gation was replicated from one

author’s Capstone project. Experts in survey development guided questions for the survey and four sources were used in its develop-ment (AORN, 2014; Cheshire, 2015; Hayes et al., 2014; Roth et al., 2015). Clinical nurses, considered experts who encountered distrac-tions in practice on a daily basis, also reviewed questions as part of the assessment of content validity.

Findings Among survey participants, 87%

(n=63) agreed or strongly agreed with the statement, “There are numerous distractions that occur while nurses provide care to patients.” In addition, 82% (n=76) agreed or strongly agreed with the statement, “Distractions sometimes make it difficult to focus on patients.” Responding to the state-ment, “Distractions like music and side conversations are kept to a minimum during critical tasks, such as medication administration and hand-off communication, in your department,” slightly more than 66% (n=55) of nurses agreed or strongly agreed; the remaining 23.6% (n=17) did not believe this was the case

Nurses rated the degree of dis-traction using a Likert scale (0=not distracting, 10=extremely distracting). Staffing issues (average score 3.3), the telephone ringing (3.2), com-

puter issues (2.9), and multitasking (2.9) were the four highest rated dis-tractors, although not high scoring (see Table 1).

Discussion A majority of nurse respondents

indicated they felt distracted at work, with distraction negatively impacting their ability to focus on patient care. Staffing issues, as a dis-tractor, are based on an institution-al decision and not necessarily influenced by the clinical nurse. Although telephone ringing may not be altered, nurses can decide where to complete some of their tasks, such as in the patient room rather than the nurses’ station. One particular nursing unit implement-ed this practice in an effort to min-imize distraction due to unit tele-phones. A second survey was sent to nurses on this unit and, despite the small number of responses (n=9), there was a reduction in iden-tified distraction with the tele-phone ringing, probably due to more time being spent in patient rooms, including charting. Addi -tionally, 78% of nurses acknowl-edged distractions were being kept to a minimum during critical tasks compared to 76% in the initial sur-vey. Although small, this increase is clinically important and will help decrease errors during critical tasks.

Computer issues may be a sys-

TABLE 1. Distracting Activities

Distractor Average (0-10 scale)

Staffing 3.3

Telephone ringing 3.3

Computer issues 2.9

Multitasking 2.9

Equipment availability 2.8

Medication availability 2.7

No physician order 2.7

Excessive noise 2.5

Lack of teamwork 2.5

Side conversations 2.2

Music 1.2

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Research for Practice

tem-wide concern that needs to be addressed collaboratively with the Informatics Technology depart-ment. Multitasking was identified as a distractor; because the nature of nursing care is multi-faceted, a more robust consideration of this response is needed to identify spe-cific concerns and possible solu-tions.

Limitations Study results were limited by a

small convenience sample of nurses at one hospital, with all practice areas not represented adequately due to few responses. It is unknown if nurses answered the questions independently or through discus-sion with others. The survey instru-ment was created by one author without a pilot.

Recommendations for Future Research

A valid and reliable instrument to identify nurse perceptions of dis-tractions is needed. Robust sam-pling and a greater number of responses would be needed to com-pare distractions between patient care areas. After distraction-limiting interventions are implemented, monitoring and evaluation would be needed to determine sustainabil-ity of practice changes. Addi -tionally, research is needed to iden-tify patients’ perceptions of nurse distraction as a reflection of their satisfaction with their care.

Nursing Implications Many types of distractions can

occur in clinical practice. Because the types of distractions and their frequency and intensity can vary between settings, nurses should be asked about distractions specific to their work settings. Targeted inter-ventions then can be developed. Some interventions may require collaboration and decision-making with team members outside the nursing service. Changes to practice or the environment need to be monitored and re-evaluated for their impact on reduction of dis-

tractions. Monitoring effectiveness of efforts to reduce distractions is important for sustainability.

Conclusion Exploring distractions in the

work environment is critical to patient safety. Nurses acknowledge the reality of numerous distractions in the clinical setting that make it difficult to focus on patient care. Some distractions, such as music and side conversations, can be kept to a minimum during critical tasks of medication administration and hand-off report. Nurses should be empowered to identify specific dis-tractions and design interventions to reduce them.

REFERENCES American Nurses Association. (2014). Health

care transformation: The Affordable Care Act and more. Retrieved from https://www.nursingworld.org/~4afc9b/globalassets/practiceandpolicy/health-policy/healthcare-reform-document.pdf

Association of periOperative Registered Nurses (AORN). (2013). AORN position statement on managing distractions and noise during perioperative patient care. AORN Journal, 99(1), 22-24. doi:10.1016/j.aorn.2013.10.010

Avidan, A., Yacobi, G., Weissman, C., & Levin, P.D. (2017). Cell phone calls in the oper-ating theater and staff distractions: An observation study. Journal of Patient Safety. doi:10.1097/PTS.0000000000000351. [Epub ahead of print].

Cheshire, W.P. (2015). Multitasking and the neuroethics of distraction. Ethics and Medicine, 31(1), 19-25.

Fredericks, S., Lapum, J., & Hui, G. (2015). Applying patient-centered care in surgi-cal intervention. British Journal of Cardiac Nursing, 10(4), 170-174.

Hay, J.M., Barnette, W., & Shaw, S.E. (2016). Changing practice in gastrointestinal endoscopy: Reducing distractions for patient safety. Gastroenterology Nursing, 39(3), 181-185.

Hayes, C., Power, T., Davidson, P.M., & Jackson, D. (2014). Interruptions and medication: Is ’do not disturb’ the answer? Contemporary Nurse, 47(1-2), 3-6.

Roth, C., Wieck, L.K., Fountain, R., & Hass, B.K. (2015). Hospital nurses’ perceptions of human factors contributing to nursing errors. Journal of Nursing Administration, 45(5), 263-269. doi:10.1097/NNA.0000000000000196

Thomas, L., Donohue-Porter, P., & Fishbein, J.S. (2017). Impact of interruptions, dis-tractions, and cognitive load on proce-dure failures and medication administra-tion errors. Journal of Nursing Care Quality, 32(4), 309-317. doi:10.1097/NCQ.0000000000000256

Wheelock, A., Suliman, A., Wharton, R., Babu, E.D., Hull, L., Vincent, C., … Arora, S. (2015). The impact of operating room distractions on stress, workload, and teamwork. Annals of Surgery, 261(6), 1079-1084. doi:10.1097/SLA.0000000000001051

Yoder, M., Schadewald, D., & Dietrich, K. (2015). The effect of a safe zone on nurse interruptions, distractions, and medication administration errors. Journal of Infusion Nursing, 38(2), 140-151. doi:10.1097/NAN.0000000000000095

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