Interruptions and multi-tasking: moving the research agenda in new directions.

To cite: Westbrook JI. BMJ Qual Saf 2014;23:877–879. When the media-savvy US psychiatrist Edward Hallowell first asked people to imagine how they would perform on a tennis court with two, three or even more balls in play, it seemed obvious that, no matter how talented or fit, everyone would be hard pressed to keep up, let alone execute any precision shots. Dr Hallowell’s book, CrazyBusy, went a long way towards raising popular awareness of something that many people felt intuitively. That is, that multi-tasking— and the associated interruptions that demand we either switch between competing tasks or load one task on top of another, say by talking on the phone while responding to emails—really was contributing to feeling frantic. Yet, since the book’s publication in 2006, we’ve just kept raising the ‘busyness’ bar in our daily personal and professional lives. Email ushered in expectations that the instantaneous delivery of messages would elicit similarly instant responses. Now, in the communications-saturated environment of texting, Instagram, Snapchat, Tumblr, Facebook and Twitter, frequent interruptions and multi-tasking are so familiar that the absence of instant ‘connectivity’ can cause mild anxiety—or, for some of us, dismay and distress. But, despite the many unquestionable benefits of extraordinary connectivity, and the unprecedented access to information and interaction it enables, the cognitive and social demands of the rapidly evolving digital communication landscape come at a cost. In healthcare organisations, the relentless, competing demands for clinicians’ attention are not merely another source of workplace stress, but represent an issue that goes to the very heart of patient safety and quality of care. Studying communication patterns in the healthcare sector is not only vital— it’s fascinating. Healthcare delivery is largely reliant on the flow of clear, concise and accurate information across the many complex webs that link patients, different healthcare professionals and support staff via paperand computer-based systems. Breakdowns in communication have consistently been found to be associated with negative outcomes and errors. 3 Yet the very human character of the clinical frontline means interruptions and multi-tasking are inevitable. Clinicians in emergency departments experience 6–7 interruptions per hour, and general ward staff around 3–4. 5 Direct observational studies show that doctors, often in response to interruptions, spend around 20% of their time multi-tasking and nurses 6%. Most frequently this involves talking or listening while also attending to a related or unrelated task such as documenting or performing direct care. Staff complain about the frequency of interruptions and identify them as contributing factors in workplace errors. 9 In one study nurses in two hospitals were shown to make significantly more errors, and more serious errors, as interruptions increased. This is consistent with the findings of many psychological studies in the laboratory that demonstrate a range of negative outcomes associated with interruptions. These include more errors, forgetting to complete tasks, taking longer to complete tasks and experiencing stress and anxiety. However, the relationship between interruptions and errors is by no means straightforward. Some experiments have shown improved performance following interruptions. Similarly, in clinical settings some interruptions are judged as appropriate and necessary. In a study of paediatric nurses who experienced over 5000 interruptions, 11% were assessed as having a positive outcome. EDITORIAL