The impact of distractions and interruptions in the operating room on patient safety and the operating room team: An integrative review

Problem identification: In the operating room (OR), distractions and interruptions are frequent, impacting patient safety, coordination and efficiency and causing errors and patient harm. The OR team is impacted while attempting to perform critical work. This review explores the impact of distractions and interruptions in the OR on patient safety and the OR team. Literature search: Inclusion and exclusion criteria were determined. Six databases were searched with the search criteria for inclusion being in English, peer-reviewed and published between 2014 and 2019. In total 296 papers were identified. Data evaluation synthesis: Duplicates were removed, and 195 papers were screened using inclusion and exclusion criteria. Fourteen studies were included in the review: 12 were quantitative reviews and two were mixedmethod reviews. Methodological quality was assessed using the mixed methods appraisal tool (MMAT), with scores between 60 and 90 per cent. A thematic analysis revealed observational study themes of types, frequency and severity of distractions and interruptions, and impacts upon mental workload, patient safety and the OR team. Simulation study themes included types of distractions and interruptions, and impact on mental workload, clinical decision-making, surgical performance and nurses. Implications for practice or research: The heterogeneity of the literature and paucity of recent nursing and anaesthetic studies highlights that further research is necessary. Nurses can educate and develop policies and interventions to reduce distractions, enhancing patient safety and decreasing the negative impact upon their colleagues and teams.


Problem identification
Operating rooms (ORs) are complex environments in which the whole OR team (surgical, anaesthetic and nursing personnel) experiences high levels of cognitive demand while maintaining concentration and performing often difficult and highly precise tasks [1][2][3] . In the OR, distractions and interruptions are ubiquitous and varied yet there remains a paucity of empirical literature on the specific effects they have on OR team members and patient safety 1,4-6 . Nevertheless, the literature confirms distractions and interruptions are a leading stressor for the entire OR team, contributing to unfavourable clinical performance, jeopardising patient care and, potentially, resulting in patient harm 1,3,4 .
Distractions and interruptions impact communication and team coordination, increase workload and fatigue, disturb concentration and situational awareness and impact workflow 3,4,7 . This can result in errors, delays, increases in surgical duration and cost, and omission of safety checks 1,[4][5][6][7][8] . It is therefore essential for distractions and interruptions to be minimised 1,3-8 . Distractions and interruptions are defined slightly differently between authors. Generally distractions are events which potentially divert one's attention from the primary task and interruptions occur when distractions are responded to, rapidly interrupting and switching attention away from the primary task 1,4,6,7,9,10 . Psychology and neuroscience research shows shifting attention from a primary task to a secondary task can be detrimental as it increases cognitive load and forces one to perform a dual task, or multi-task 1,2,10,11 . This integrative review explores the impact of distractions and interruptions in the OR on patient safety and the OR team. Despite the paucity and heterogeneity of the literature, the various types, frequency, severity and impacts of distractions and interruptions in real OR settings will be presented, in addition to controlled experiments in simulation laboratories studying the impacts of specific distractions and interruptions.

Literature search
An integrative review methodology was used in this review as outlined by Whittemore and Knafl 12 . This method allows varied methodologies including qualitative and quantitative to be included to assist in presenting an extensive and holistic view of a phenomenon 12 . An electronic search was conducted to identify suitable literature. Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete, Medline Complete, PubMed, Scopus, Joanna Briggs Institute EBP and Cochrane Library databases were searched. The reference lists of selected papers were also searched. The search terms, truncations and Boolean operators used were 'distract* OR interrupt* OR disrupt*' AND 'operating room OR operating theatre OR perioperative' AND 'patient safety'.

Inclusion and exclusion criteria
Limiters on database searches were applied, including publication years 2014 to 2019, English language, peerreviewed (in CINAHL Complete), and full-text. The timeframe was applied to ensure the most contemporary papers were identified. Further inclusion criteria included primary research papers using quantitative, qualitative or mixed-methods methodology; primary outcomes of distraction, interruption or disruption; and settings within an OR or a simulation laboratory. Exclusion criteria included non-primary research, quality improvement studies, reviews, opinion pieces, guidelines, observational studies focused on only one distraction, and primary research where patient safety was not a focus.

Data evaluation synthesis Data extraction
The titles and abstracts from qualitative, quantitative and mixedmethods papers were reviewed against the inclusion and exclusion criteria. Data extracted included lead author, published year, country, aim, design, sample, key findings and study limitations.

Data evaluation
The included papers were critically assessed for methodological quality with the mixed methods appraisal tool (MMAT). This tool covers five categories of study design including qualitative, quantitative non-randomised, descriptive or randomised control trials, and mixedmethods [13][14][15] . The efficiency, validity and reliability of the MMAT tool are well supported 13,14 . Each category incorporates criteria questions which can be answered and thereby scored between zero and two; 'no' (zero), 'cannot tell' (one) and 'yes' (two). These scores were converted into percentages. The critical appraisal skills programme (CASP) tools were also used to confirm quality 16,17 .

Data synthesis
As per Whittemore and Knafl 12 , the included studies were synthesised using thematic analysis to distinguish themes, differences and relationships. Two categories of studies were determined, observational in ORs and experimental in simulation laboratories. Themes identified under the category of observational studies include types, frequency and severity of distractions and interruptions, and impacts on patient safety and the OR team. Under the simulation experimental category, themes identified included types of distractions and interruptions, and impact on mental workload, clinical decision-making, surgical performance and nurses.

Findings Descriptive findings
The database search identified 296 articles from six databases and one study was found through searching reference lists (see Table  1). Duplicates were removed, leaving 195 titles and abstracts which were screened against the exclusion criteria. Sixteen full-text studies were reviewed; however, two were excluded as the primary measures were not distractions or interruptions. As shown in Figure 1, the preferred reporting items for systematic reviews and meta-analyses (  included in the review 18 . Twelve of these were quantitative studies and two were mixed-methods. Four studies were conducted in Germany, four in the United Kingdom, two in the United States of America, two in Canada, one in China and one across Australia, Thailand and China. The key descriptors of each included study are presented in Table 2 (see supplemental documents). These include primary author, published year, country, design and sampling, study aim, key findings, limitations, implications and MMAT score.

Quality assessment
The methodological quality MMAT scores of the 14 papers ranged from 60 to 90 per cent. The seven quantitative observational studies all scored 60 per cent, while the quantitative simulation experimental studies scored between 60 to 90 per cent, averaging 76 per cent. The two mixed-methods papers both scored 83 per cent against the mixedmethods criteria.

Observational studies
Seven quantitative observational studies were included in this review 1,3,5,7-9, 11 . All had small samples, frequently from a single hospital and covering limited specialties yet all used statistical analyses 1,3,5,7-9, 11 . Two mixed-methods studies also incorporated quantitative observational study components within their studies 6,20 .

Types
Various distractions and interruptions are discussed in the nine studies; however their heterogeneity is apparent as each study categorised types of distractions differently 1,3,5-9, 11,20 .

Frequency
Amongst the studies conducted in ORs, seven focus on distractions and interruptions affecting the whole OR team 1,3,5,7-9, 11 , one on anaesthetists in the preoperative period 20 and another on nurses 6 . Due to the heterogeneity of the literature, it is difficult to determine the overall frequency of each type of distraction and interruption. Seven studies present the number per hour, ranging from 3.6 to 21.7 per hour 1,5-9, 11 , averaging out to 10. 1 distractions or interruptions each hour, or significantly one every six minutes. The remaining two studies reported frequencies per patient; Al-Hakim et al. 20 found three per patient in the preoperative period, and Jung et al. 3 two per patient intraoperatively. Noting the heterogeneity of the studies, the highest frequency was CIC, followed by phone/pager, equipment issues and traffic 1,3,5-9, 11,20 .

Severity
Of the nine observational studies, four used the tool developed by Healey et al. 21 to measure types and severity of distractions and interruptions 1,5,8,9 . The validated tool for use in ORs uses a ninepoint nominal scale and measures visible severity relating to the OR team's involvement in an event 1,5,8,9 . Scores between 1 and 3 indicate a distraction has potentially or actually affected the circulating nurse, between 4 and 6 suggests one other team member (excluding the circulating nurse) is distracted or interrupted, 7 or 8 means more than one member is affected, and 9 indicates surgical flow is impacted 1,5,8,9 .
These four studies trained two to three observers and measured high inter-rater agreement/reliability (IRR) during pilot studies 1,5,8,9 . In addition, two blinded the observers 5,8 . Importantly, the pilot period reduced the potential for the Hawthorne effect, whereby subjects alter their behaviour while being observed 5 .
Despite this, the studies occurred in single hospitals and across minimal specialties, creating the possibility of selection bias 1,5,8,9 . Observer fatigue and observer bias are also possibilities 1,5,8,9 . In addition, Sevdalis et al. 5 observed a single surgeon's procedures. Despite using the same tool, discrepancies exist regarding which distractions and interruptions had the highest severity 1,5,8,9 .
Acknowledging the heterogeneity, equipment issues had the highest severity followed by procedural issues and CIC 1,5,8,9 .
Two further studies used another validated tool comprising three levels 7,11 . Level 1 events are dealt with by the unscrubbed team members (not in the sterile field, for example circulating nurse and anaesthetists) 7,11 . Level 2 affects one member of the scrubbed staff (within the sterile field) and level 3 affects more than one member, including the primary surgeon 7,11 . Interestingly both studies showed the same three highest severity distractions or interruptions (level 2 or 3), however in different orders: CIC, others, equipment 7 , compared to equipment, CIC and others 11 . Notably, Yoong et al. 11 determined the three most frequent were also the three most severe.  20 . This study occurred in five hospitals across three countries; however, the observers and interviews have the potential to be biased due to subjectivity 20 . Sirihorachai et al.'s. 6 mixed-methods study is the only one conducted by nurses, and studied only nurses. A validated tool comprising four levels was used: for level 1 the circulating nurse does not respond, for level 2 the primary task is ceased and the secondary task attended to, for level 3 the nurse multitasks, and for level 4 the operation flow is interrupted 6 . The highest severity distraction or interruption was CIC followed by equipment issues and phone/music/ pager 6 . The potential for observer bias existed here due to subjectivity and the use of one observer and therefore no IRR 6 . In addition, a single centre and specialty allows for possible selection bias 6 .
Inconsistent categories and tools make it is impossible to ascertain which distractions and interruptions have the highest severity. However, equipment issues comparatively appear to have the highest severity followed by CIC and procedural issues 1,3,5-9, 11,20 . Therefore, the frequency and severity of distractions and interruptions are not correlated 1 .

Mental workload
Understanding and studying the impact distractions and interruptions have on mental workload is crucial to understanding stress, burnout, training requirements, OR team needs and system demands 4 . Three observational studies used mental workload measurements to determine the association between the frequency and severity of distractions and interruptions and the perceived mental workload of the OR team 3,8,9 . Weber et al. 9 and Weigl et al. 8 used the validated surgery task load index (SURG-TLX) questionnaire which enables subjective assessments, differentiates between complexities of tasks, and specifies objective performance. The OR team answered questions using three elements of the tool: mental demands, situational stress, and distraction 8,9 . Weber et al. 9 added productivity and perceived quality. The subjectivity of the tool allows for potential subjectivity and recall bias 8,9 .
According to Weigl et al. 8 9 . Interestingly, post-operative reporting using the SURG-TLX tool showed anaesthetists (n = 42) reported higher levels of mental demands than surgeons (n = 81) and nurses (n = 93) 9 . Anaesthetists and nurses reported higher distraction rates than surgeons and CIC was linked to higher stress in anaesthetists although this study only observed robotic prostatectomies in a single hospital 9 . The SURG-TLX assesses perceived workload post-operatively; it does not consider workload at different time points intra-operatively.
The study by Jung et al. 3 used the human-factors STAR tool and, in contrast to the previous studies, did not include anaesthetists or nurses but just a single surgeon. Through a multivariable analysis, CIC was independently correlated with an increase in surgeon's distraction 3 , a similar finding to Weigl et al. 8 . CIC is a modifiable distraction and interruption which appears to affect team members' mental workload differently 3 . Weber et al. 9 state CIC decreases mental fatigue and stress, yet Weigl et al. 8

Simulation studies
Five simulation studies have been included in this review 2,4,10,19,22 , and one mixed-methods study by Sirihorachai et al. 6 which combined observational and simulation components. There is also paucity in the simulation literature studying anaesthetists and nurses -no anaesthetic studies were found and Sirihorachai et al. 6 was the sole nursing study. The five surgeon studies all applied a distraction to novice subjects (medical students or surgical trainees) while they were performing a surgical technique or procedure on a simulator. Clinical decision-making and surgical performance were measured 2,4,10,19,22 .

Type of distractions and interruptions applied
To improve generalisability of simulation studies, realistic OR distractions should be applied as secondary tasks while subjects are performing primary tasks 19  Similarly, Murji et al. 19 used pager distractions and asked questions regarding a pre-read handover sheet. Thirty residents performed laparoscopic salpingectomies either distracted or undistracted, in randomised order 19 . Yang et al. 10 used mild and strong phone call distractions involving clinical questions. Thirty medical students were distracted mildly, strongly or not at all, while they performed an easy and difficult laparoscopic task 10 . Sirihorachai et al. 6 applied seven distractions at critical times, including the first and final counts, and team time out to 30 nurses. Distractions included CIC, pager, music, extra equipment and dropping of an instrument.
In contrast, Gao et al. 2 applied arithmetic questions to 24 medical students. The students answered without operating, and performed a laparoscopic appendicectomy with the arithmetic and without; the order was randomised 2 . The authors believe arithmetic is a cognitive task and therefore appropriate to use as a secondary task. However, Murji et al. 19 disagree, stating arithmetic is not a meaningful or realistic secondary task.

Mental workload
Three studies measured the outcome of mental workload using different tools, adding further to the heterogeneity 2,4, 10 . Weigl et al. 4 used the SURG-TLX and determined surgeons' perceived workload was statistically significantly higher when distracted than when not distracted (p < 0.01). The subjects also experienced increased physical demands and situational stress 4 . Interestingly, mental workload was statistically significant when associated with surgical inaccuracy (p = 0.04) 4 . However, this tool is subjective, only measures workload post-operatively and was only used on junior surgeons 4 . Similarly, Gao et al. 2 used the National Aeronautics and Space Administration (NASA) task load index (NASA-TLX), which the SURG-TLX is adapted from 8 . The authors also used an objective measure to track pupil size and blink rate which represent cognitive load 2 . When performing the dual-task of answering arithmetic questions and operating, mental workload and eye measurements of medical students were higher than those measured during the single task of operating 2 . It is unclear why the SURG-TLX was not used as it is specific to surgery; in addition, the use of arithmetic is questionable 8,19 .
Yang et al. 10 did not report on their tool; it is assumed subjects rated their distraction levels postoperatively. Subjects reported being more affected when a strong distraction was applied (p < 0.05) 10 .
No return rate or validity information was reported and only medical students were studied 10 . As in the observational studies, it is apparent that when distracted or interrupted novice surgeons experience a higher mental workload than when they are not.

Surgical performance
Surgical performance was measured on simulators; each study used different outcomes including inaccuracy, time to complete, safety, complications, blood loss and specific surgical markers 2,4,10,19,22  This may be due to the residents focusing on the surgical task, rather than the secondary task, as they were blinded to the purpose of the study 22 . Likewise, 63 per cent of residents in a powered sample made a minimum of one unsafe clinical decision when distracted with questions; the mean for correct answers was 80 per cent 19 . Similarly, medical students made more errors when answering questions from two phone calls in the final study 10 . This raises the question about patient safety and care of ward patients managed by surgeons while they are operating 10,19,22 . However, these studies did not evaluate the effect on experienced surgeons 10,19,22 .

Nurses
In the simulation laboratory, nurses were distracted while performing first and final counts and team time out 6 . Measures included whether the nurses ignored the distraction, were interrupted by it, or multitasked and performed both the primary and secondary task 6 . Interestingly, all the more experienced nurses (greater than two years) performed team time out with the radio on despite it breaching policy while all the junior nurses turned it off 6 . Over half of the nurses were interrupted by CIC and pager distractions during the first count 6 . Multitasking only occurred during the first count; ten per cent of nurses engaged in CIC while counting 6 . A third of nurses were interrupted by a pager during team time out and 57 per cent at the final count 6 . This is concerning as these three tasks are critical to ensure patient safety 6 . That said the 30 nurses came from a single centre, making generalisability difficult and selection bias possible 6 . Debriefing sessions and qualitative analysis revealed the nurses used cognitive processes of prioritisation and remaining focused on the primary task when confronted with distractions 6 .

Implications for perioperative nursing practice or research
This review has highlighted reducing distractions and interruptions is essential to enhance patient safety and productivity; maintain safe and effective care, performance, workload and communication; and decrease and mitigate the potential risk to the OR team 1,3,8,11 . Multidisciplinary collaboration and system-level strategies are required 1,3 . Improvements in multidisciplinary communication, information transfer, organisation and collaboration are essential for smooth surgical flow 1,6,8,9 . Distractions and interruptions are usually an indication of system issues which are often upstream from the OR and lead to a lack of coordination between the OR and other departments; therefore, thorough system analyses and improvements are required 5,9,20 .
Education and training are the initial approaches for resolving system and multidisciplinary coordination issues 6,7,9 . Multidisciplinary education should create an awareness of the different types of distractions and interruptions which occur in the OR and focus on the potential severity and impact of each 6 . Each profession is impacted differently by individual types and a clear understanding of this from the entire OR team will assist in minimising them [6][7][8][9] . Education may include simulations to further enhance awareness between professions and assist in developing effective strategies 6,9 . Nurses should be taught how to prioritise and stay focused on primary tasks, especially during critical phases 6 .
Nurses can influence policy and conduct ongoing quality improvement projects in their own ORs to minimise distractions and interruptions 5,6 . Quality improvement projects should include observing staff over time to assess frequency and severity of distractions and interruptions 5 . Feedback should be provided to the OR team, followed by discussion to identify effective actions and strategies 5 . Reassessment should occur post implementation 5 . Nursing professional bodies should develop standards and guidelines for minimising distractions and interruptions in ORs 6 .
Several effective strategies have been implemented in numerous ORs 3,5,8,11 . The sterile cockpit is an aviation concept successfully adapted to the OR environment 3,5,8 . This involves eliminating non-essential communication during critical phases of a procedure in order to enhance patient safety and reduce effects on the OR team 5,8 . Preoperative briefings enable effective planning and organisation, reducing unnecessary distractions and interruptions 5,7,11 .
Further research is essential to fully understand the phenomenon of distractions and interruptions in the OR. Research determining the cumulative effects of avoidable distractions and interruptions on the OR team is required 1,4,9 . Additional suggestions for research include complex and emergency surgery, OR team familiarity, individuals' stress management strategies and ascertaining the ideal work process design 5,8,9 . Robust research is necessary to clearly determine which distractions and interruptions have the largest impact on mental workload and lead to adverse patient outcomes and unsafe practice 1,4,8 . Researching CIC to clearly delineate between positive and negative CIC is vital 1,8 . Robust studies involving experienced professionals would resolve the paucity in the literature 3

Conclusion
This integrative review has provided a thorough overview of the recent literature on distractions and interruptions in the OR. It is of concern these studies confirm a distraction or interruption occurs on average every six minutes. It is evident that patients and the OR team are impacted significantly, yet through system analyses, education, planning, research and local quality improvement projects many of these impacts can be avoided. Nurses are central to improving and creating positive change in the perioperative environment. With guidance from professional OR nursing bodies, nurses can develop and implement standards and local policies to reduce the frequency, severity and impact of distractions and interruptions upon their patients, colleagues and OR teams.