Nurse educators are obligated to prepare nursing students for the realities of practice. It is well known that interruptions occur with high frequency to nurses in health care settings (Drews et al., 2019; Schroers, 2018a); thus, educational programs must prepare students for this reality. Preparation for interruptions is of particular importance during critical nursing tasks such as medication administration (MA), a process that includes preparation, administration, and documentation of medication. Nurses are often interrupted during MA, with observational studies finding interruption rates of 94.51 percent (Zhao et al., 2019) and 99 percent (M. Johnson, Sanchenz et al., 2017) for nurses in hospital settings. Interruptions are associated with an increased frequency (Raja et al., 2019; Westbrook et al., 2010) of medication administration errors (MAEs), placing patient safety at risk. Not surprisingly, interruptions also lead to increased nursing task completion times, resulting in decreased task efficiency (Cooper et al., 2016).
Interventions aimed to reduce interruptions during the MA process have been implemented in health care settings, such as nurses donning "do not disturb" vests or preparing medication in "no-interruption zones." These interventions have yielded mixed results (Raban & Westbrook, 2014), and researchers (Westbrook et al., 2017) have voiced concerns surrounding their feasibility and sustainability. In addition, certain interruptions are necessary in health care, such as notification of a patient in critical condition, and can lead to positive patient outcomes (Sasangohar et al., 2012). Many researchers advocate for the implementation of interruption management strategies in health care settings (Hayes et al., 2015; Westbrook et al., 2017) and nursing educational programs (Hayes et al., 2017); however, there is a paucity of evidence to inform the development and implementation of such strategies.
BACKGROUND
An interruption "occurs when an unexpected alert or distraction diverts the recipient's attention, causing the recipient to suspend the primary task, if only temporarily, with intent to resume the original task" (Schroers, 2018b, p. 15). Management of an interruption involves behaviors used to handle, or deal with, an interruption. Researchers (Colligan & Bass, 2012; M. Johnson, Weidemann et al., 2017) found that nurses primarily use one of four management strategies when an interruption is attempted during MA: 1) engage, stop MA and give immediate attention to the interruption; 2) multitask, divide attention between MA and the interruption; 3) mediate, perform intentional actions before giving attention to the interruption to support resumption when the interruption ends; and 4) block, ignore the interruption.
M. Johnson and colleagues' qualitative research (M. Johnson, Weidemann et al., 2017) and observational research (M. Johnson et al., 2019) found that nurses in hospital settings primarily engage in interruptions during MA. Engaging involves the immediate redirection of attention to the interruption, which "may negatively impact on decision making" (M. Johnson, Weidemann et al., 2017, p. 7) and hinder one's ability to recall the proper step in the MA process. Engaging may also result in failure to return to the task and is discouraged unless the situation is emergent (M. Johnson et al., 2019; M. Johnson, Weidemann et al., 2017). Likewise, multitasking could also compromise patient safety because of the increase in cognitive demands that can lead to errors. M. Johnson et al. (2019) recommended blocking, that is, ignoring nonemergent interruptions, and tested their interruption management strategy recommendations with nurses in hospital settings. Intervention groups of nurses received education that encouraged the use of blocking and discouraged the use of engaging and multitasking when interrupted during MA; control groups did not receive the education. No significant differences were found in the number or types of interruption management strategies used, or number of MAEs, between the intervention and control groups.
Henneman et al. (2018) pilot-tested the Stay S.A.F.E. interruption management strategy with 20 registered nurses (RNs) in a simulated clinical setting to assess the length of time away from a task after an interruption. The strategy involved training to use specific actions when faced with an interruption, such as acknowledging the source of the interruption without looking away from the task. The researchers reported a significant decrease (p < .001) in the amount of time participants were distracted from the primary task after completing the training as compared with before the training. The investigators did not examine error rates.
Interruption management strategies used by nurses have been identified, yet outcomes of strategies are only beginning to be explored. The Henneman et al. (2018) Stay S.A.F.E. strategy was based on the memory for goals (MFG) model (Altmann & Trafton, 2002); use of the strategy resulted in a significant decrease in time distracted away from the task. The MFG model promotes use of associative cues when interrupted to facilitate task resumption (Trafton et al., 2005) and theorizes that fewer errors will occur if associative cues are used. Further research guided by this model is necessary to test outcomes of interruption management strategies for use during MA. Research is also needed on interruption management strategies used by nursing students. Gaining an understanding of interruption management strategies used among nursing students, which may differ from strategies used by licensed nurses because of the differences in their levels of experience, is required to inform evidence-based teaching methods. Evidence-based teaching methods can be incorporated into nursing educational programs to promote interruption management skills that aim to improve patient safety and task efficiency. To the authors' knowledge, this was the first study to explore interruption management strategies used by nursing students. Simulation was utilized in this study as it allowed participants to manage realistic clinical interruptions in a safe setting that presented no risk to actual patients (Durham & Alden, 2008).
THEORETICAL FRAMEWORK/RESEARCH QUESTIONS
The National League for Nursing (NLN) Jeffries Simulation Theory (Jeffries, 2016) details the necessary concepts to consider in the design and implementation of the newly developed simulation-based experience (SBE). These concepts include context, background, design, simulation experience, facilitator and educational strategies, participant attributes, and outcomes as they pertain to the SBE.
The Altmann and Trafton (2002) MFG model guided this study by using the model's structure of an interruption and recommended use of associative cues during an interruption (see Figure 1). Associative cues are "stimuli that enable recall[horizontal ellipsis]and are often referred to as retrieval cues" (Waller & Lippa, 2007, p. 910). The model's structure of an interruption guided the data collectors in identifying the occurrence of an interruption during the SBE and the resulting observable interruption management strategies used by participants. The associative cues used by participants when interrupted during the SBE were explored via semistructured interviews. According to the MFG model, associative cues can be environmental or in the person's mental context (e.g., long-term knowledge) and must be available both during the interruption lag and at resumption of the interrupted task.
Given the lack of evidence on interruption management strategies and associative cues used among nursing students, a mixed-methods, two-site study was conducted to explore these phenomena. The specific research questions addressed were as follows: 1) What interruption management strategies do undergraduate nursing students use when interrupted during simulated MA? 2) What associative cues do undergraduate nursing students use to recall the suspended task of MA when interrupted during simulated MA?
METHOD
Study Design
A convergent mixed-methods design (Creswell & Plano Clark, 2018) was used to identify and explore interruption management strategies used by participants. This type of design compares or combines data collected from quantitative and qualitative methods to facilitate a more complete understanding of a problem or validate one set of findings with the other (Creswell & Plano Clark, 2018). Quantitative data on strategies were collected via direct observation; qualitative data on both strategies and associative cues were collected via semistructured interviews.
Institutional review board approval was obtained from the two study sites. The study took place on multiple days at each site; participants were often scheduled on the same day, though each participant had an individual 1.5-hour appointment. The simulation center was frequently in use by other students on days of the study, but study participants were never in the same room as other students during the SBE, debriefing, or interview session and did not interact with others as part of the study integrity protection measures.
Prior to obtaining written informed consent, the principal investigator (PI) met individually with each participant to explain the study, risks, and benefits of participating, that faculty would not be made aware of students' participation, and that no course grades or program outcomes would be affected by participation. A disguised observation method (Dean & Barber, 2001) was used; participants were told that the purpose of the study was to observe MA processes in a realistic environment but were blinded to the specific study aims. Participants in an observational study should not be aware of the specific behaviors being investigated, as this could cause a change in behaviors and thus misrepresent the findings (Brink & Wood, 1998).
Because of possible feelings of mild anxiety or stress among participants due to the interruption in the SBE, the PI explained to each participant immediately after the SBE ended that the interruption was part of the research and was intentionally not discussed prior to the SBE to enhance realism. The PI also requested that participants avoid discussing the interruption in the SBE and the interview questions with other students until data collection was completed, as this could alter future participants' behaviors and skew the findings. All participants agreed to refrain from discussing the interruption and interview questions.
All data were deidentified. A unique alpha-numeric code was assigned to each participant. At the start of a simulation, the written code was held in front of the video camera. At the start of an interview, the code was verbally stated by the data collector. All data collection forms and media were stored in a locked cabinet separate from the consent forms and master list linking participant codes to names. The consent forms, data, and master list of participant codes and names were accessible only by the PI.
Participants and Setting
A convenience sample of senior nursing students was recruited from two accredited baccalaureate nursing programs in the United States: an accelerated second-degree 16-month program at a large urban private university in the Midwest (Site 1) and a four-year program at a midsized private university in the Eastern part of the country (Site 2). Inclusion criteria for participation included enrollment in the senior level (one of the final two semesters) at one of the two study sites and age of 18 years or older. Recruitment occurred via email. Program directors forwarded recruitment emails on the PI's behalf to all eligible enrolled students at their site. Six emails were sent weekly to 88 students in the Midwestern program and 97 students in the Eastern program. Recruitment emails introduced the study, explained that participation was voluntary, provided the estimated time commitment, and invited students to contact the PI by phone or email with questions and/or to enroll in the study. Eighteen students enrolled from Site 1 (n = 88, 20.5 percent response rate); 18 students enrolled from Site 2 (n = 97, 18.6 percent response rate). The study was conducted in the students' respective school of nursing simulation laboratory. Compensation of $25 in cash was given to participants at the completion of all study requirements (participation in the SBE, debriefing, and interview session). Total time to complete the study was expected to range between 60 and 90 minutes; all participants completed the requirements within 45 to 60 minutes.
Simulation Design
A new SBE was developed for this study. The International Nursing Association for Clinical Simulation and Learning (INACSL) standards of best practice for simulation design (INACSL Standards Committee, 2016b) were utilized in the development of the SBE. The NLN (n.d.) simulation design template was used to organize and outline the details of the SBE. Content validity (CV; Lynn, 1986) for each of the SBE components (scripts, Situation Background Assessment Recommendation reports, provider orders, and MA records) was obtained prior to data collection. Following Rutherford-Hemming's (2015) recommendations, the PI developed a CV form and sent this to six simulation experts (nurse educators with 4 to 12 years of simulation experience with undergraduate nursing students). The experts reviewed and scored the 15 SBE components for relevance using a 4-point Likert-style scale. All components were judged to have excellent item-level CV with scores between .83 and 1; scale-level CV, computed as an average, was also judged as excellent with a value of .99 (Polit et al., 2007).
During the SBE, participants played the role of an RN assigned to care for two stable patients in a medical-surgical hospital unit setting. Medium-fidelity manikins with voice capabilities portrayed the patients. Each patient had two medications ordered to be administered during the simulated time; the participant was interrupted during one medication preparation. The location, duration, source, and reason for the interruption were based on observational research of interruptions to nurses during MA in hospital settings (M. Johnson, Sanchenz et al., 2017; Schroers, 2018a). The interruption occurred in the medication preparation area and lasted between 60 and 90 seconds. The source of the interruption was another nurse, portrayed by a trained actor; the reason for the interruption was a casual conversation about workflow on the unit.
An individual debriefing session was conducted by a research assistant (RA), an RN trained in debriefing techniques, with each participant following the SBE. The NLN (n.d.) simulation design template debriefing reflective questions were adapted to the SBE and used to guide the debriefing session. The INACSL standards of best practice on debriefing (INACSL Standards Committee, 2016a) were followed.
Data Collection
Trained RAs collected all data, one at Site 1 and one at Site 2. Quantitative data were collected in real time via direct observation and review of audio-video recordings. The RAs manually documented the observed strategies according to the Colligan and Bass (2012) classification on a predeveloped checklist (M. Johnson, Sanchenz et al., 2017): 1) engage, 2) multitask, 3) mediate, 4) block, or 5) other. CV had not been previously reported on the interruption management definitions (engage, multitask, mediate, and block); thus, CV was obtained (Lynn, 1986) prior to data collection. The PI developed a CV form and sent it to 10 content experts who had current (within five years) nursing experience in a hospital setting as an RN, nurse practitioner, certified nurse midwife, or nursing clinical instructor. Definitions were reviewed and scored by the experts for relevance using a 4-point Likert-style scale. All definitions were judged as excellent, with scores ranging between .80 and 1 (Polit et al., 2007).
Interrater reliability (Huck, 2012) was established among the RAs prior to data collection. The RAs individually viewed 11 prerecorded videos of different scenarios of a nurse being interrupted during MA. The RAs collected data on interruption management strategies used by the nurse in the videos on the predeveloped checklist (M. Johnson, Sanchenz et al., 2017). The PI then compared the data marks made by each RA. The RAs agreed on all data points for all 11 videos; thus, interrater reliability was established as 100 percent.
Qualitative data on the strategies and associative cues were collected via individual semistructured interviews with participants immediately following the debriefing of the SBE. This timing increased the opportunity for accurate participant recall. Specific interview questions (see Table 1) regarding the strategies used were guided by previous research (Colligan & Bass, 2012; M. Johnson, Weidemann et al., 2017). The interviews allowed participants to validate, correct, or expand on the strategies observed (Creswell & Plano Clark, 2018). Questions specific to associative cues were guided by the MFG model (Altmann & Trafton, 2002). Interviews were audio-recorded, transcribed by a professional transcription service, and checked for accuracy by the PI.
Data Analysis
The observed strategy (quantitative) and the participant description of the strategy used (qualitative) were compared for each participant (Creswell & Plano Clark, 2018). A template-organizing analytical approach was used to place the transcribed text from the participant into Colligan and Bass (2012) a priori constructed codes (Crabtree & Miller, 1999). The data were arranged in a joint display table and compared side by side (Creswell & Plano Clark, 2018) to confirm the reported strategies.
A descriptive content analysis (Vaismoradi & Snelgrove, 2019) of the qualitative data on associative cues was conducted. The PI iteratively read the transcribed interviews, wrote initial thoughts about the data, and marked highlights of the salient points made by participants on the transcripts. Coding was performed by grouping the evidence and labeling it to represent a broader perspective of either environmental or mental context cues (Creswell & Plano Clark, 2018).
Themes unrelated to associative cues began to emerge; thus, the PI conducted a thematic analysis (Vaismoradi & Snelgrove, 2019). Recurrent words and phrases were notated, and broad codes were highlighted on the transcripts. The transcripts were searched for data relevant to the broad codes and collated into potential themes. The data were then further reviewed for fittingness to the themes.
Triangulation of the data on interruption management strategies and six participant member checks were conducted to ensure credibility of the findings. All six participant member checks validated the interpretation of themes identified by the PI. The quantitative data collected via observation and the qualitative data collected via semistructured interviews equally contributed to the findings on interruption management strategies (Tobin & Begley, 2004). Exemplars are provided throughout this article to enhance confirmability (Tobin & Begley, 2004).
RESULTS
Sample
A total of 36 nursing students with an average age of 27 years participated in the study (range: 21-51 years, median = 23 years). Most participants were female (n = 34, 94 percent). Participants self-identified ethnicity/race as Caucasian (n = 27, 75 percent), Black/African American (n = 3, 8.3 percent), and Asian (n = 3, 8.3 percent). One participant identified as Hispanic, one identified as Middle Eastern, and one selected "prefer not to answer." All participants had simulation experience in their respective study settings, and all had experience with MA in simulation and/or a clinical setting. Most participants (n = 22, 61.1 percent) reported "yes" to having current employment or past employment experience in a hospital setting.
Interruption Management Strategies
Students primarily multitasked (66.7 percent) or engaged (27.8 percent) during the interruption. Two observed strategies used by participants, both initially categorized as engage, required correction after analysis of the interviews. One student explained they were multitasking by mentally going through the steps while briefly replying to the other nurse. A different student told of mediating the interruption prior to engaging. All other students confirmed the observed strategy (Table 2).
Two students used mediation. One student who mediated the interruption used a finger to mark where the student was looking prior to giving attention to the interruption: "I did have my finger on my order, and then I went back and restarted that medication." A second student who mediated the interruption used mental and environmental cues to keep track of the step: "I recognized a distraction was coming and before allowing a break in attention I made a mental marker[horizontal ellipsis]I would not look up immediately[horizontal ellipsis]I completed my thought process and associated it with my finger on the paper and the medication in my hand."
Associative/Environmental/Mental Cues
As described, two students mediated the interruption by intentionally associating cues to mark the proper step in the MA process. When questioned during the interview, several students reported that they unintentionally used cues in the environment that aided them in starting back in the MA process. When asked if anything in the environment aided them in returning to the MA process, students responded, "I'm already in the medication room, so I know that I'm getting the medications"; "The meds were right in front of me"; and "I had the med and the MAR [medication administration record] right in my hand." Some students reported that they performed actions during MA that, although unintentional, resulted in helping them recall that they were in the process of MA. Actions described by the students included "I put them [the medications] on the MAR right next to what it said so I could see both of them lined up together" and "I always tried to keep myself facing the medication."
Students also told of using mental cues, such as the "6 rights" are "ingrained in us," and that these mental cues enabled them to return to the MA process. The "6 rights" refer to safety checks used during MA that are taught and practiced throughout nursing education programs: the right patient, medication, dosage, route, time, and documentation (Yoost & Crawford, 2020; see Table 3 for cues used by participants).
Themes
Based on the qualitative analysis of the interviews, three themes emerged that added valuable insight into the student experience of MA: recheck of medication, being polite while being safe, and need for more education and practice.
RECHECK OF MEDICATION
The majority of students (72 percent) offered that they performed a recheck of the medication after the interruption ended. Rechecking or restarting the MA process was not directly explored during the interviews; however, when participants were asked how they handled the interruption or were questioned about cues they used, frequent responses were "I rechecked the medication," "I restarted my steps," and "I just started over."
BEING POLITE WHILE BEING SAFE
When students began to elaborate on the interruption management strategy they used, it was evident that they did not want to be impolite or ignore the other nurse: "I cannot ignore someone and especially since they are my coworker[horizontal ellipsis]" and "You're not realistically going to shun them [coworkers] and not respond back." Many students stated that although they chose to respond to the interrupting nurse, they were unsure of how to "not be rude" while focusing on being safe: "I did not want to be rude[horizontal ellipsis]but it's also a very important time where you need to focus"; "I knew I had to put the patient first, but I was like 'How do I say this politely?'"
NEED FOR MORE EDUCATION AND PRACTICE
Students frequently voiced the need for education and training on how to handle interruptions. Some students shared that there had been discussion in classes or clinical rotations of the dangers of interruptions and distractions during MA, but that they had not been instructed on how to actually handle interruptions. One student stated: "It would be helpful, not just reading about it, or having someone tell you, but actually doing it, like how we did in this simulation with someone actually interrupting you."
DISCUSSION
This study explored interruption management strategies used by undergraduate nursing students during simulated MA. Participants were from different schools and program types; yet, findings were similar across the sample. Multitasking was used most often, followed by engaging. It is imperative to note that neither multitasking nor engaging is recommended for use when interrupted because of their negative impacts on decision-making (M. Johnson, Weidemann et al., 2017). Instead, as Altmann and Trafton (2002) suggest, use of associative cues with mediation is recommended to manage an interruption. Mediation with associative cues has the potential to lead to increased patient safety and improved task efficiency. Only two students (5.5 percent) in the current study used mediation, which is consistent with practicing nurses who seldom use this strategy during an interruption (M. Johnson, Weidemann et al., 2017).
The low use of mediation by nursing students is not surprising because of the paucity of evidence of this strategy in the health care literature. Nursing students likely have not been exposed to this strategy and are thus unaware of how or why it should be used. Findings from the current study, however, shed light on specific uses of mediation, such as completing one's thought process about the medication and associating that thought with marking the step in MA before giving attention to the interruption. Additional cues identified from this study (Table 3) were also described and should be further investigated for use in mitigating MAEs and improving MA efficiency.
Some students reported using cues in the environment to recall that they were involved in the MA process when interrupted. For example, some students stated that they were holding the medications in their hand when interrupted and still holding the medications when the interruption ended. The medications in their hand provided a cue to return to the MA process. Although this cue did not bring the students back to the specific step they were in when interrupted, this cue, along with the other cues described by students, provides information on strategies that may help avert noncompletion errors (e.g., failing to complete MA).
Many students reported that instead of using a cue or attempting to start back where they left off when interrupted, they started the process over from the beginning. In other words, students often rechecked the medication when the interruption ceased. Students reported that they did not feel stressed or pressured for time while playing the role of the RN during the SBE; thus, the context of the SBE, which included uncomplicated and nonemergent scenarios, may have provided the grounds for students to recheck the medications. Although performing a recheck of medications could deter errors from reaching a patient, this would be an inefficient strategy to use in most practice settings where nurses have multiple medications to administer and competing responsibilities. Education and practice of pragmatic strategies to manage interruptions are necessary during nursing students' educational preparation to ensure not only safe MA but also appropriate time management and efficiency in the clinical setting.
The final strategy, blocking, was not used by any of the participants in this study. Although blocking, or ignoring, an interruption has been recommended for nonemergent situations (M. Johnson et al., 2019), several students stated they would not feel comfortable ignoring a coworker. Students voiced the importance of positive working relationships with other nurses and did not want to "offend" coworkers by ignoring them during the interruption; these same students voiced uncertainty about their decision to talk to the nurse as they felt it could jeopardize patient safety. One student told of wishing they would have stopped the conversation sooner but did not know if they had the confidence to do this. Although only one student in this study discussed the concept of confidence, it is possible that confidence may have contributed to other students' decision-making.
Nursing students often lack the confidence and skills to intervene when patient safety is at risk (Hanson & McAllister, 2017; Hanson et al., 2020), and failure to communicate concerns has been shown to lead to avoidable patient harm (Reason, 2000, Fagan et al., 2016). Preparing students with the skills to advocate for patient safety can increase their confidence and lead to safer practice. Assertiveness training (Hanson et al., 2020) with scenario-based learning in a simulated environment may cultivate confidence development in nursing students.
Use of two geographically different sites and different baccalaureate program types increased the generalizability of findings. Rigor was demonstrated in the study through various means, including CV testing of the SBE and definitions on the data collection tool and adherence to current standards for simulation. Limitations of the study were the small sample size and the use of only one type of interruption (casual conversation) from one source (a coworker) in the SBE. One type of interruption may have influenced the large proportion of students choosing to multitask. If the interruption had made a request of the participant or came from a different source, it is possible that different strategies may have been more frequently used.
IMPLICATIONS FOR EDUCATION AND RESEARCH
Findings from this study support the need to incorporate education on managing interruptions in prelicensure nursing curricula. Students in this study reported that they had not received any formal education or training in their educational program on how to handle interruptions and expressed a need for this education to feel prepared for practice. Newly graduated nurses have recommended that nursing programs include systems issues or real-world practice with "many distractions" (Treiber & Jones, 2018, p. 277) to better prepare students for practice.
Systems issues, such as interruptions and distractions, lead to errors and impair patient safety (Agency for Healthcare Research and Quality, 2019). Educational programs need to assess their curricula to determine where systems issues are taught and the associated teaching strategies. Role-playing (Hayes et al., 2017, 2019) and simulation (K. D. Johnson & Alhaj-Ali, 2017; Thomas et al., 2014) are important adjuncts to didactic material on the management of interruptions that can reinforce learning and form habituation.
In addition, teaching of communication skills in nursing programs would be enhanced by the incorporation of assertiveness training. A review of literature (Bickhoff et al., 2017) found that most students lack the courage to intervene or speak up when the quality of patient care is at risk. Through the use of scripts and role-play or simulation, students can practice communication skills that can be used when confronted with unsafe situations in the workplace.
Additional research with varying types of interruptions, including those that make a request of the participant, is recommended for nursing students. Further investigation of mediation with associative cues during an interruption is also warranted. Educators and researchers are encouraged to test teaching strategies of mediation with associative cues and examine outcomes of errors and task efficiency. In addition, future research addressing associations between hospital work experience and interruption management strategies utilized among nursing students is suggested. Nursing students with hospital work experience may manage interruptions differently compared to nursing students without this experience because of the formal and informal learning that occurs in the workplace.
CONCLUSION
Innovative evidence-based teaching strategies that include interruptions are required to prepare nursing students for the realities of practice. The findings from this study provide evidence of how students currently manage interruptions; notably, the strategies primarily used, multitasking and engaging, are not recommended (M. Johnson et al., 2019; M. Johnson, Weidemann et al., 2017). Although blocking (i.e., ignoring) has been recommended to manage nonurgent interruptions (M. Johnson et al., 2019; M. Johnson, Weidemann et al., 2017), this is not an appropriate strategy to use during an emergent situation, and nursing students and novice nurses may lack the ability to quickly discern an emergent from a nonemergent interruption. Therefore, it is strongly recommended that future research examine the use of mediation with associative cues to manage interruptions. Further evidence is essential to inform educational methods in preparation of the next generation of nurses for safe and efficient nursing care.
REFERENCES