International Emergency Nursing 58 (2021) 101036

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International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

Degree of interruptions experienced by emergency department nurses and

interruption related factors
Yong Eun Kwon a, Miyoung Kim a, *, Sujin Choi b
a
College of Nursing, Ewha Womans University, Seoul, Republic of Korea
b
College of Nursing, Woosuk University, Jeonju, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Keywords: Aims: This study examined the degree of interruptions experienced by emergency department nurses and related
Emergency department factors.
Nurses Methods: This study is a descriptive survey using standardized observation tools. A total of 23 nurses working in
Interruptions
an emergency department participated in this study. Using a stopwatch over 120 h, the degree of interruptions
Communication
Medication
was investigated by measuring start and end times of tasks and interruptions. Factors related to interruptions
were classified as communication, telephone calls, medical device alarms, changes in patient condition, and
other factors.
Results: The frequency of interruptions in the emergency department was 6.4 times per hour, and its percentage
was 9.1%. The time required for actual nursing tasks of “counseling and education,” “safety,” and “patient
nursing management and information management” were increased significantly due to interruptions. A primary
factor in interruptions was communication with patients, families, and nurses. The longest duration and the
highest frequency of interruptions occurred during medication tasks.
Conclusions: Communication with patients, families, and nurses was the highest factor related to interruptions.
Nurses may cause interruptions and be subjected to interruptions simultaneously. Therefore, nurses in the
emergency department should work with caution not to cause interruptions.

1. Introduction
Emergency department nurses perform comprehensive nursing by
considering the characteristics at all stages of the life cycle [1] to provide
emergency medical services to patients in all age groups [2]. Nurses
collaborate with various other healthcare professionals [3] and contin­
uously communicate with team members to share patient information
and make quick decisions [4]. Nurses also provide emergency treat­
ments and interventions according to priorities determined through
professional and systematic assessments and analyses [5]. Considering
these characteristics of work in the emergency department, healthcare
professionals experience multitasking (9.2% per hour) and task-
switching (6.0% per hour) to efficiently take care of patients [6].
Interruptions refers to stopping a primary task before its completion
to carry out an unexpected task due to internal and external factors and
then resuming the primary task later [7]. In the emergency department,
nurses often stop their primary tasks when they experience unexpected
resource shortages or admission of new patients [8]. When a task is
interrupted, nurses prioritize the rest of the tasks according to impor­
tance and urgency [9] but this requires time and attention [10], and
nurses cannot carry out the tasks immediately as their burdens increase
[11]. Therefore, it is necessary to survey the degree of interruptions
experienced by emergency department nurses and related factors.
2. Background
Interruption inevitably occurs during communication to exchange
patient information. Interruption reduces concentration and causes
confusion, thereby increasing the time required to carry out actual
nursing tasks and negatively affecting work efficiency [12]. Increased
mental burden because of interruption causes delayed patient assess­
ment and ineffective communication leading to declining patient satis­
faction [11]. Furthermore, interruptions during medication tasks are
reported to cause 16.8% of adverse events such as administering the
wrong drugs or administering drugs to the wrong patients [13]. While
interruptions inevitably occur during nursing tasks, they usually

* Corresponding author at: College of Nursing, Ewha Womans University, 52, Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Republic of Korea.
E-mail addresses: dung1004@hanmail.net (Y.E. Kwon), mykim0808@ewha.ac.kr (M. Kim), schoi@woosuk.ac.kr (S. Choi).

https://doi.org/10.1016/j.ienj.2021.101036
Received 21 July 2020; Received in revised form 19 May 2021; Accepted 28 May 2021
Available online 29 July 2021
1755-599X/© 2021 Elsevier Ltd. All rights reserved.
Y.E. Kwon et al.
negatively impact nursing care.
Literature on interruptions experienced by healthcare professionals
revealed that surgical ward nurses experienced 5.6 interruptions per
hour [14], and intensive care unit nurses experienced 5 interruptions per
hour [15]. However, emergency department nurses experienced 7–8
interruptions per hour [16], and triage nurses in emergency de­
partments experienced 7.0 interruptions per hour [17], indicating that
the frequency of interruptions in emergency departments is higher than
that in other nursing units. Among the factors related to interruptions in
emergency departments, communication with patients was the most
frequent [12] while communication accounted for 55% of interruptions
of nursing care in the intensive care unit [18].
Various methods have been used to measure the degree of in­
terruptions in healthcare professionals and related factors; observation
for at least 90 h was used in literature [12,19]. However, no study has
been conducted in South Korea using observational methods. While it is
important to understand the amount of time required for actual nursing
tasks due to interruptions, no such study has been conducted in or out of
South Korea. The aim of this study was to examine the degree of in­
terruptions in emergency department nurses and related factors. The
specific purposes of this study were as follows:
1. To investigate the degree of interruptions (frequency, percentage,
and time required for actual nursing tasks).
2. To assess factors related to interruptions.
3. To identify the differences of interruptions and related factors ac­
cording to nursing tasks.
3. Methods
This study conforms to the STROBE reporting guidelines.
3.1. Study design and participants
This descriptive study used standardized observation tools to identify
the degree of interruptions experienced by emergency department
nurses and interruption related factors. The study was conducted in an
adult emergency department in Seoul where it has a regional medical
organization that has a room for cardiopulmonary resuscitation, 11 beds
for severe medical treatment areas with 24 beds in total. Approximately
40,300 patients visited annually in the emergency department. There
are 40 nurses and the nurse to patient ratio was 1:3.
The participants were recruited by convenient sampling. Among 40
nurses, 23 nurses with more than 6 months experiences consented to
participated in this study. The other nurses who worked for less than 6
months were excluded in this study based on the organization’s regu­
lation that newly graduated nurses are able to work independently after
6 months.
3.2. Data collection and ethical considerations
The data were collected from August 1 to September 10, 2019 after
obtaining ethical approval from the Institutional Review Board of the
institution where the research was performed. A researcher explained
the study purpose and measurement methods to two senior-year nursing
students with experience in the emergency department and trained them
as research assistants. The two research assistants conducted three
preliminary investigations of the emergency department nurses, result­
ing in 100% interrater consistency showing that the observed data were
not biased. After obtaining permission from the nursing department
through an official document requesting cooperation, the researcher
explained the purpose and method of the study to the emergency
department manager. The two research assistants observed the nurses
15 times for 4 h each, with a total of 120 h during day and evening shifts,
including weekdays and weekends. The research assistants followed
nurses while maintaining the interval of 3 m and used stopwatches to
2
International Emergency Nursing 58 (2021) 101036
measure the task start times, times when the task was interrupted, times
when the task resumed, and times when the task ended, in minutes.
When multiple interruptions occurred at the same time, the research
assistants focused on measuring workflow time for two nurses using
each stopwatch and recorded it in a standardized observation tool. To
avoid the Hawthorne effect [20], three times of pretest were conducted,
which helped nurses to become unaware of the research assistants
during this study.
To provide participants with ethical protection, written informed
consent (including study purpose and method, result confidentiality,
right to withdraw at any time, and disposal of recorded data after three
years) was obtained from each participant prior to the study.
3.3. Measurements
3.3.1. Degree of interruptions
To create tools to observe the degree of interruptions in this study,
the “medication” area in the observation log of Cole et al. [12] was
referred to, in addition to 6 nursing categories in the standard nursing
tasks classification of Park et al. [21]. These references were used to
determine 7 nursing categories and 23 nursing tasks including respira­
tory care, elimination care, counseling and education, safety, patient
nursing management and information management, and communica­
tion (Table 1). A nursing professor and three emergency department
nurses with at least 5 years of nursing career reviewed the validity of the
content.
The degree of interruptions was assessed by measuring the frequency
and ratio of interruptions, and the time required to carry out actual
nursing tasks due to interruptions. When there was an interruption, total
time of nursing task, total time of interruption, and total time of actual
nursing task time were measured. The total time of the actual nursing
task time was the difference between the total time of nursing task and
the total time of interruption (Table 1).
3.3.2. Factors related to interruptions
Factors related to interruptions were classified into 7 categories:
communication with a) patient and family, b) nurse, or c) other
healthcare professionals; telephone calls; alarms of monitors and med­
ical equipment; changes in patient conditions; and others (preparation
of articles and drugs, missed nursing task). These factors presented by
Cole et al. [12] and Rhu and Lee [22] were referred to for measurement.
3.4. Data analysis
All data were analyzed using SPSS 22.0 for descriptive statistics. P
values < 0.05 were accepted as statistically significant. Descriptive
statistics of frequencies, percentages, means, and standard deviations
were used to examine general characteristics of the participants and
nursing tasks. The degree of interruptions was analyzed using
Table 1
Glossary of terms used in this study.
Reported items Explanation/measurement
[Degree of interruptions]
The frequency of The number of interruptions per hour
interruptions
The ratio of the time of The ratio of time taken from the interruption to the
interruptions time of resuming nursing tasks
[Presence of interruption]
Total time of nursing task The time taken from the time of starting tasks to the
(A) time of ending tasks
Total time of interruption (B) The time taken from the interruption to the time of
resuming nursing tasks
Total time of actual nursing The sum of the time required to carry out the nursing
task time (C) task before the interruption and the time required to
carry out the nursing task after the interruption (C =
A-B)
Y.E. Kwon et al. International Emergency Nursing 58 (2021) 101036

frequencies, percentages, means, and standard deviation and the dif­
ferences in the time required for actual nursing tasks were analyzed
using t-tests. Factors related to interruptions were analyzed using fre­
quencies and percentages. The degree of interruptions according to
nursing tasks were analyzed using one-way analysis of variance
(ANOVA), and post hoc tests were conducted using Scheffé’s tests.
4. Results
4.1. Sample characteristics and task characteristics
Twenty three nurses with more than 6 months of experience were
investigated by observation for this study.
4.1.1. General characteristics
Regarding general characteristics, 19 (82.6%) of 23 nurses were fe­
male, and the average age of the general nurses was 26.13 ± 2.49 years.
The average number of months working in the emergency department
was 30.48 ± 26.59, and the total number of months working in the
hospital was 32.35 ± 29.18. Regarding educational background, all
participants (23 participants) had 4-year bachelor’s degrees.
4.1.2. Characteristics of task
A total of 2,072 instances of nursing tasks were measured for 120 h.
“Medication” was the most frequent task. The most time-consuming task
was “medication” (1584.12 min) (Table 2).
4.2. Degree of interruptions
The degree of interruptions was presented as frequencies. Nursing
task was interrupted 765 times (36.9%) during 120 h of work, or 6.4
times per hour. The time consumed by interruptions was presented as a
ratio. The total time required to carry out nursing tasks measured during
120 h of observation (A) was 4686.17 min, the total time consumed by
interruptions (B) was 426.78 min, and the total time required for actual
nursing tasks was 4259.37 min. Therefore, the ratio of the time used by
interruptions to the time required for nursing task (B/A) was 9.1%. This
indicates that nurses were subjected to interruptions for 9.1% of the time
required for nursing tasks (Table 3).
The time required for actual nursing tasks was 1.78 ± 1.79 min when
there was no interruption and 2.52 ± 1.90 min when there were in­
terruptions. The time required for actual nursing tasks was significantly
different when there were interruptions compared to when there were
no interruptions (t = 8.76, p < .001). Among the nursing tasks, “coun­
seling and education” (t = 2.73, p = .008), “safety” (t = 5.81, p < .001),
and “patient care management and information management” (t = 3.38,
p = .001) showed significant differences due to interruptions because of
the increased time required to carry out actual nursing tasks (Table 4).

Table 2
Task characteristics.
Variables Categories n % Total time of actual nursing task time (Cc = Aa-
Bb) (min)

Respiratory Aspiration 9 56.2 34.50

care Ambu-bag preparation (intubation) 7 43.8 31.97
Total 16 0.8 66.47
Elimination care Retention enema 19 26.4 89.50
Nelaton catheterization 23 31.9 112.45
Foley catheterization 29 40.3 231.15
Vomitus disposal and observation 1 1.4 0.98
Total 72 3.5 434.08
Counseling & education Communication of admission with patients and 70 42.7 71.68
families
Communication of discharge with patients and 94 57.3 166.80
families
Total 164 7.9 238.48
Medication IVd Preparation of medication 178 29.3 344.78
injection
IV insertion & medication- 133 21.9 411.87
successful
IV insertion & medication- 40 6.6 251.35
attempt
Medication administration-IV 168 27.7 316.72
Intramuscular injection 34 5.6 86.18
Subcutaneous/Intradermal injection 36 5.9 106.77
Blood transfusion 18 3.0 66.45
Total 607 29.3 1584.12
Safety Attaching various monitoring devices 94 19.5 150.53
Measuring vital signs 54 11.2 66.55
Measuring intake & output 45 9.4 37.37
Physical assessment 62 12.9 77.35
Blood sample collection 173 36.0 456.12
Measuring blood sugar 53 11.0 81.53
Total 481 23.2 869.45
Patient nursing management & information Recording 278 48.6 354.10
management Handover 131 22.9 328.15
Checking doctor’s orders 163 28.5 224.35
Total 572 27.6 906.60
Communication with healthcare professionals Consultation of patient problems 63 39.4 54.50
Phone calls 97 60.6 105.67
Total 160 7.7 160.17
a
A: Total time of nursing task.
b
B: Total time of interruption.
c
C: Total time of actual nursing task time.
d
Intra venous.

3
Y.E. Kwon et al. International Emergency Nursing 58 (2021) 101036

Table 3
Degree of interruptions.
Variables Categories n % M ± SD (min) Total time of interruption (min) Ratio of interruption Bb/Aa (%)

Absence of interruption 1307 63.1

Presence of interruption Once 654 85.5 0.43 ± 0.56 287.73 6.1
More than twice 111 14.5 1.25 ± 1.13 139.07 3.0
Total 765 36.9 0.55 ± 0.73 426.80 9.1
Total 2072
a
A: Total time of nursing task (Total 4686.17 min).
b
B: Total time of interruption (Total 426.8 min).

showed significant differences (F = 5.34, p < .001), and “medication”

Table 4
took the longest time (153.45 min). Regarding the time required for
Time required for actual nursing tasks.
actual nursing task, “medication” required the longest time (1584.12
Categories Absence of Presence of min), and “elimination care” required a significantly longer time
interruption interruption
(434.08 min) (F = 113.19, p < .001) than other nursing tasks (Table 5).
Average time Average time t p
(min) M ± SD (min) M ± SD
5. Discussion
Respiratory care 4.12 ± 1.27 4.22 ± 1.42 0.13 0.901
Elimination care 6.03 ± 2.38 6.18 ± 1.85 0.04 0.972
Counseling & education 1.31 ± 0.88 1.91 ± 1.25 2.73 0.008 This study attempted to identify the degree of interruptions experi­
Medication 2.36 ± 1.92 2.90 ± 2.19 0.14 0.895 enced by emergency department nurses and related factors using
Safety 1.55 ± 1.89 2.36 ± 1.53 5.81 < 0.001 observation tools. The frequency of interruptions experienced by
Patient nursing 1.34 ± 1.69 1.78 ± 1.11 3.38 0.001
emergency department nurses was 6.4 times per hour. This is lower than
management &
information the results in the United States and Germany, which were 7 to 8 times
management per hour [16,17,19]. There were 40,300 patients visiting in ED annually
Communication with 0.99 ± 0.72 1.04 ± 0.45 0.33 0.743 while there were 74,000–80,000 patients visiting in ED annually in the
healthcare
United States and Germany which extrapolates that higher patients
professionals
Total 1.78 ± 1.79 2.52 ± 1.90 8.76 < 0.001
could result in higher level of interruptions in ED. The frequency of
interruptions experienced by surgical ward nurses was 5.6 times per
hour [14], and that of intensive care unit nurses was 5.0 times per hour
4.3. Factors related to interruptions [15], both of which are lower than the findings in this study. In this
study, the time consumed by interruptions was calculated as the ratio of
Among the factors related to interruptions, “communication” time of interruptions to the time required for nursing tasks (B/A). The
occurred the most frequently at 455 instances. Of all instances, finding indicates that emergency department nurses experienced in­
communication with patient and family was the most frequent followed terruptions for 9.1% of the time required for nursing tasks. Although
by communication with nurses (Fig. 1). there was no current research on using frequency and ratio in and out of
South Korea, this finding can be utilized as a comparative data for future
studies.
4.4. Degree of interruptions according to nursing tasks The difference in the time required for actual nursing tasks according
to presence and absence of interruption showed that the average time
The time consumed by interruptions according to nursing task

Fig. 1. Interruption related factors A = Communication with patient and families; B = Communication with nurses; C = Communication with other healthcare
professionals; D = Telephone calls; E = Medical device alarms; F = Changes in patient conditions; G = Missed nursing tasks; H = Preparation of articles; I =
Preparation of drugs; J = Equipment problems; K = Environmental problems.

4
Y.E. Kwon et al.
Table 5
Differences in total times according to nursing tasks.
Total time of nursing task (A)
min
Respiratory carea 74.84
< 0.001
a,b > d > c > e,f > g
Elimination careb 449
Counseling & educationc 265.37
Medicationd 1737.57
Safetye 948.52
Patient nursing management & information managementf 1042.92
Communicationg with healthcare professionals 167.95
Total 4686.17
required to complete the nursing tasks was significantly increased when
there were interruptions. Among the nursing tasks, “counseling and
education,” “safety,” and “patient nursing management and information
management” showed an increased time requirement because of in­
terruptions. A study conducted by Cole et al. [12] demonstrated a sig­
nificant increase in time required for actual nursing tasks when there
were interruptions, which supports the finding in this study. The finding
in this study is similar to those of a previous study indicating that in­
terruptions delay the time required for a task completion by causing the
same tasks to be repeated [22]. Nurses take more time to carry out tasks
after interruptions as their thoughts must be reorganized before
resuming their tasks [10]. Nurses also undergo a cognitive shift process
to prioritize tasks [23], and the resulting increase in mental burdens
makes it difficult to perform the tasks immediately [11]. The time
required for performing actual nursing tasks is assumed to increase with
interruptions because those tasks are mainly carried out at the nursing
station rather than at bedside. This is similar to the study indicating a
high degree of interruptions while carrying out tasks such as paperwork
[3]. Emergency department nurses may both cause interruptions and be
subjected to interruptions simultaneously. Education programs related
to interruptions for nurses will help them reduce interruptions unrelated
to work and prioritize interruptions.
Communication was confirmed as a major factor in previous studies
of domestic and foreign emergency departments [12,16,22], which
support the finding of this study. Emergency department nurses
continuously communicate and coordinate with emergency department
team members to efficiently share information on patient conditions in
real time [24]. Among the communication factors assessed in this study,
the frequency of communication with patients, families, and nurses was
the highest. This is because emergency department patients and their
families are highly dependent on nurses [25] and there is high demand
for continuous information exchange and education on patient condi­
tions [26]. Therefore, the high number of interruptions experienced by
nurses in this study was likely due to interactions with patients and
families. The finding also indicates a high frequency of interruptions
caused by communication with other nurses, similar to that found in
previous studies [16,19,22]. Interruptions may result from continuous
communication among nurses about constantly changing drug charac­
teristics and necessary resources for patients in the emergency depart­
ment [27]. Among other factors, missed nursing tasks were identified as
a high-frequency factor in previous studies [12]. This indicates that
nursing work is interrupted by internal factors within nurses themselves,
not external factors in patients or families. Although emergency
department nurses should allocate limited resources appropriately to
efficiently provide nursing interventions [28], a study conducted by Rhu
and Lee [22] identified that interruptions to receive medical supplies (66
times) or drugs (10 times) were very frequent. Resources within the
emergency department should be relocated to reduce interruptions due
International Emergency Nursing 58 (2021) 101036
Total time of interruption (B) Total time of actual nursing task time (C
= A-B)
F min F min F
p p p
Scheffé Scheffé Scheffé
99.97 8.37 5.34 66.47 113.19
< 0.001 < 0.001
b > a > d > c > e,f > g
14.92 434.08
26.89 238.48
153.45 1584.12
79.07 869.45
136.32 906.60
7.78 160.17
426.8 4259.37
to lack of resources such as medical supplies or drugs.
In this study, tasks with high frequencies of interruptions were
“medication,” “patient nursing management and information manage­
ment,” and “safety.” A study conducted by Cole et al. [12] had similar
results indicating high frequencies of interruptions in the same tasks. In
this study, the frequency of “medication” interruptions was 285 in­
stances, (46.5%), higher than the 24% reported in a study conducted in
the US [13]. The high frequencies of “medication” and “patient nursing
management and information management” in interruptions is assumed
to be because these tasks take a long time [16]. Unlike other time-
consuming nursing tasks, “elimination care” showed a low frequency
of interruptions in this study. This is because although “elimination
care” takes a long time, its urgency is low. In previous studies on in­
terruptions of nursing care in intensive care units, “medication” and
“safety” tasks were classified into high-risk nursing tasks, and the fre­
quencies of interruptions for these tasks were lower than those for other
nursing tasks [15]. This study showed a difference from previous studies
on interruptions in intensive care units because the frequencies of in­
terruptions for high-risk nursing tasks were higher than those of other
nursing tasks. However, this study did not investigate the relationship
between the characteristics of high-risk nursing tasks and related factors
of interruption. Future studies are needed to determine the degree of
interruptions according to high-risk nursing tasks and related factors.
A major factor that interrupted “medication” tasks was communi­
cation with patients, families, and other nurses. This is because emer­
gency department patients and their families have high demands for
explanations [28] and ask nurses questions when the solution of a
problem is delayed or when a new problem occurs [29]. However, in a
study conducted by Reed, Minnick, and Dietrich [30], nurses subjected
to interruptions during medication tasks delayed their response to the
interruption and continued medication tasks, indicating that they
regarded administrating medication as more important than the inter­
ruption. Moreover, since interruptions resulting from communication
with other nurses are mainly a lower priority communication or task, the
nurse completed the existing task first and later completed the inter­
rupted tasks [31]. Although interrupting medication tasks may lead to
safety accidents [27] and nurses recognized the importance of such
tasks, the high frequency of interruptions during medication tasks in­
dicates that strategies to improve this are required. Furthermore,
sharing information about the progress of treatment and plans with
patients can reduce fear of emergencies and increase patient satisfaction
[32], indicating the necessity of communication focused on patients by
utilizing a system such as a real-time patient dashboard that patients can
check patient flow in the emergency department. In addition, there is a
need for efficient and accurate communication through standardized
communication methods to facilitate information sharing with team
members. In a study on how to improve interruptions occurring during
medication tasks, healthcare professionals were provided with
5
Y.E. Kwon et al.
education on interruptions and carried out tasks wearing a vest bearing
the information: “I am administering drugs. Please do not interrupt the
work.” As a result, interruptions by patients and healthcare professionals
reduced [33]. Due to nurses preparing medication in a separate medi­
cation preparation room, the frequencies of medication errors decreased
from 1.3 to 0.9 times per day [34]. Hence, strategies to reduce in­
terruptions should be studied by focusing on major tasks such as
medication administration. Studies to identify and analyze the urgency
and importance of interruptions are also necessary.
6. Limitations
As this study selected participants only from emergency department
nurses working at a general hospital in Seoul, regional characteristics
were not considered. Therefore, the results of this study are not neces­
sarily generalizable to all nursing tasks in the emergency department. In
addition, data collection was limited to 120 h of day and evening work,
and the scope of nursing tasks investigated was limited to 7 nursing
tasks. Night shift work was excluded from the observation time and only
7 nursing tasks were investigated, which should be considered when
interpreting the results of this study.
7. Conclusions
Emergency department nurses had a higher frequency of interrup­
tion than intensive care nurses, particularly, high-risk tasks such as
medication administration, which was interrupted more frequently.
Regarding the factors related to interruption, the factors caused by
communication with patients, families and nurses were high. That is,
nurses in the emergency department were interrupted but also caused
work interruptions. Therefore, the finding suggests that nurses in the
emergency department should work with caution when causing in­
terruptions. In future studies, the importance and urgency of factors
causing the interruptions should be investigated, and nurses’ responses
to interruptions should be studied. In addition, studies should be con­
ducted on the effects of interruptions on patients and nurses.
Funding
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Yong Eun Kwon: Conceptualization, Methodology, Resources,
Investigation, Data curation, Formal analysis, Writing - original draft,
Validation, Writing - review & editing. Miyoung Kim: Conceptualiza­
tion, Methodology, Resources, Investigation, Data curation, Formal
analysis, Project administration, Supervision, Writing - original draft,
Validation, Writing - review & editing. Sujin Choi: Validation, Writing -
review & editing.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
We would like to express our gratitude to all of the participants that
contributed to this study.
Author contributions
Yong Eun KWON and Miyoung KIM have made substantial
6
International Emergency Nursing 58 (2021) 101036
contributions to conception and design, or acquisition of data, or anal­
ysis and interpretation of data; Yong Eun KWON and Miyoung KIM been
involved in drafting the manuscript or revising it critically for important
intellectual content; Yong Eun KWON, Miyoung KIM, Sujin CHOI given
final approval of the version to be published. Each author should have
participated sufficiently in the work to take public responsibility for
appropriate portions of the content; and Yong Eun KWON, Miyoung
KIM, Sujin CHOI agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part of
the work are appropriately investigated and resolved.
References
[1] Association Emergency nursing. Scope and standards of practice. 2nd ed. Illinois:
Emergency Nurses Association; 2017.
[2] Association NEN. Emergency nursing scope and standards of Canadian practice.
6th ed. Canada: National Emergency Nurses Association; 2018.
[3] Berg LM, Källberg A-S, Göransson KE, Östergren J, Florin J, Ehrenberg A.
Interruptions in emergency department work: an observational and interview
study. BMJ Qual Saf 2013;22(8):656–63. https://doi.org/10.1136/bmjqs-2013-
001967.
[4] Bellow AA, Gillespie GL. The evolution of ED crowding. J Emerg Nurs. 2014;40(2):
153-60. https://doi.org/10.1016/j.jen.2013.01.013.
[5] Howenstein JS, Sandy L. Case management and the expanded role of the
emergency nurse. J Emerg Nurs 2012;38(5):454–9. https://doi.org/10.1016/j.
jen.2011.05.004.
[6] Walter SR, Li L, Dunsmuir WT, Westbrook JI. Managing competing demands
through task-switching and multitasking: a multi-setting observational study of
200 clinicians over 1000 hours. BMJ Qual Saf 2014;23(3):231–41. https://doi.org/
10.1136/bmjqs-2013-002097.
[7] Brixey JJ, Robinson DJ, Johnson CW, Johnson TR, Turley JP, Zhang J. A concept
analysis of the phenomenon interruption. Adv Nurs Sci 2007;30(1):E26–42.
[8] Hopkinson SG, Wiegand DL. The culture contributing to interruptions in the
nursing work environment: an ethnography. J Clin Nurs 2017;26(23–24):
5093–102. https://doi.org/10.1111/jocn.14052.
[9] Patterson ES, Ebright PR, Saleem JJ. Investigating stacking: how do registered
nurses prioritize their activities in real-time? Int J Ind Ergon 2011;41(4):389–93.
https://doi.org/10.1016/j.ergon.2011.01.012.
[10] Myers RA, Parikh PJ. Nurses’ work with interruptions: an objective model for
testing interventions. Health Care Manag Sci 2019;22(1):1–15.
[11] Weigl M, Müller A, Holland S, Wedel S, Woloshynowych M. Work conditions,
mental workload and patient care quality: a multisource study in the emergency
department. BMJ Qual Saf 2016;25(7):499–508. https://doi.org/10.1136/bmjqs-
2014-003744.
[12] Cole G, Stefanus D, Gardner H, Levy MJ, Klein EY. The impact of interruptions on
the duration of nursing interventions: a direct observation study in an academic
emergency department. BMJ Qual Saf 2016;25(6):457–65. https://doi.org/
10.1136/bmjqs-2014-003683.
[13] Kellogg KM, Puthumana JS, Fong A, Adams KT, Ratwani RM. Understanding the
types and effects of clinical interruptions and distractions recorded in a
multihospital patient safety reporting system. J Patient Saf 2020. https://doi.org/
10.1097/pts.0000000000000513.
[14] Dante A, Andrigo I, Barone F, Bonamico R, De Chiara A, Nait M, et al. Occurrence
and duration of interruptions during nurses’ work in surgical wards. J Nurs Care
Qual 2016;31(2):174–82. https://doi.org/10.1097/NCQ.0000000000000159.
[15] Sasangohar F, Donmez B, Easty AC, Trbovich PL. The relationship between
interruption content and interrupted task severity in intensive care nursing: an
observational study. Int J Nurs Stud 2015;52(10):1573–81. https://doi.org/
10.1016/j.ijnurstu.2015.06.002.
[16] Forsyth KL, Hawthorne HJ, El-Sherif N, Varghese RS, Ernste VK, Koenig J, et al.
Interruptions experienced by emergency nurses: implications for subjective and
objective measures of workload. J Emerg Nurs 2018;44(6):614–23. https://doi.
org/10.1016/j.jen.2018.02.001.
[17] Johnson KD, Motavalli M, Gray D, Kuehn C. Causes and occurrences of
interruptions during ED triage. J Emerg Nurs 2014;40(5):434–9.
[18] Craker NC, Myers RA, Eid J, Parikh P, McCarthy MC, Zink K, et al. Nursing
interruptions in a trauma intensive care unit: a prospective observational study.
J Nurs Adm 2017;47(4):205–11. https://doi.org/10.1016/j.jen.2013.06.019.
[19] Weigl M, Beck J, Wehler M, Schneider A. Workflow interruptions and stress at
work: a mixed-methods study among physicians and nurses of a multidisciplinary
emergency department. BMJ Open 2017;7(12):e019074. https://doi.org/10.1136/
bmjopen-2017-019074.
[20] Goodwin MA, Stange KC, Zyzanski SJ, Crabtree BF, Borawski EA, Flocke SA. The
Hawthorne effect in direct observation research with physicians and patients.
J Eval Clin Pract 2017;23(6):1322–8. https://doi.org/10.1111/jep.12781.
[21] Park JH, Sung YH, Song MS, Cho JS, Sim WH. The classification of standard
nursing activities in Korea. J Korean Acad Nurs 2000;30(6):1411–26.
[22] Rhu E-J, Lee E-N. Relationship among task interruption and task performance and
burn-out in emergency room nurses. J Korean Crit Care Nurs 2013;6(1):34–43.
[23] Dias RD, Conboy HM, Gabany JM, Clarke LA, Osterweil LJ, Arney D, et al.
Intelligent interruption management system to enhance safety and performance in
complex surgical and robotic procedures. OR 20 Context-Aware Operating
Y.E. Kwon et al.
Theaters, Computer Assisted Robotic Endoscopy, Clinical Image-Based Procedures,
and Skin Image Analysis: Springer; 2018. p. 62–8.
[24] Jaggi P, Tomlinson R, McLelland K, Ma W, Manson-McLeod C, Bullard MJ. Nursing
duties and accreditation standards and their impacts: the nursing perspective. Appl
Nurs Res 2018;40:61–7. https://doi.org/10.1016/j.apnr.2017.12.009.
[25] Wundavalli L, Kumar P, Dutta S. Workload indicators of staffing need as a tool to
determine nurse staffing for a high volume academic emergency department: an
observational study. Int Emerg Nurs 2019;46:100780. https://doi.org/10.1016/j.
ienj.2019.06.003.
[26] Blackburn J, Ousey K, Goodwin E. Information and communication in the
emergency department. Int Emerg Nurs 2019;42:30–5. https://doi.org/10.1016/j.
ienj.2018.07.002.
[27] Thomas L, Donohue-Porter P, Fishbein JS. Impact of interruptions, distractions,
and cognitive load on procedure failures and medication administration errors.
J Nurs Care Qual 2017;32(4):309–17. https://doi.org/10.1097/
NCQ.0000000000000256.
[28] Gorman V-L-A. Future emergency nursing workforce: what the evidence is telling
us. J Emerg Nurs 2019;45(2):132–6. https://doi.org/10.1016/j.jen.2018.09.009.
International Emergency Nursing 58 (2021) 101036
[29] Schneider A, Wehler M, Weigl M. Provider interruptions and patient perceptions of
care: an observational study in the emergency department. BMJ Qual Saf 2019;28
(4):296–304. https://doi.org/10.1136/bmjqs-2018-007811.
[30] Reed CC, Minnick AF, Dietrich MS. Nurses’ responses to interruptions during
medication tasks: a time and motion study. Int J Nurs Stud 2018;82:113–20.
[31] Ratwani RM, Fong A, Puthumana JS, Hettinger AZ. Emergency physician use of
cognitive strategies to manage interruptions. Ann Emerg Med 2017;70(5):683–7.
https://doi.org/10.1016/j.annemergmed.2017.04.036.
[32] Hermann RM, Long E, Trotta RL. Improving patients’ experiences communicating
with nurses and providers in the emergency department. J Emerg Nurs 2019;45(5):
523–30. https://doi.org/10.1016/j.jen.2018.12.001.
[33] Huckels-Baumgart S, Niederberger M, Manser T, Meier CR, Meyer-Massetti C.
A combined intervention to reduce interruptions during medication preparation
and double-checking: a pilot-study evaluating the impact of staff training and
safety vests. J Nurs Manag 2017;25(7):539–48. https://doi.org/10.1111/
jonm.12491.
[34] Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. Separate
medication preparation rooms reduce interruptions and medication errors in the
hospital setting: a prospective observational study. J Patient Saf 2016;10. https://
doi.org/10.1097/PTS.0000000000000335.