Studies1–3 have emphasized that errors are found at every stage of the medication use process, which includes prescribing, dispensing, preparation, administering, and monitoring. However, roughly 30% of errors harming patients are associated with medication administration, which is different from other stages for 2 reasons: first, nurses act as safeguards against errors (intercepting errors made by physicians and pharmacists)1; second, medication administration has very few safeguards against errors because it happens at the end of the process.2 Improvements to the medication administration process could maximize medication safety.3
Multitasking caused by work interruptions seems among the most prominent factors causing human errors. The connection between interruptions and errors has been analyzed as a form of interference on a performance requiring attention checks or a conscious analytical process.4,5 Reviews of the characteristics and potential contribution of interruptions to medication administration errors show that work interruptions are frequent, since nurses are, on average, interrupted every 9 minutes, with some evidence supporting a detrimental effect from medication administration practices leading to errors.3 Several strategies have been designed and implemented to reduce interruptions during medication rounds. Some prominent examples are: creating a dedicated room for medication preparation,6 staff education,7,8 and more recently, the wearing of a tabard by the nurse managing the round with the inscription Medsafe Nurse, Do Not Disturb to remind the team not to disturb her/him.7
Pape7 has documented that providing nurses with a jacket indicating not to interrupt them significantly reduces the frequency of interruptions. Even Kreckler et al9 have suggested that nurses could wear certain types of clothing during medication rounds to indicate that they should not be interrupted.
The term ‘tabard’ appeared to our knowledge for the first time in the study of Scott et al10 conducted in the Aberdeen Royal Infirmary Hospital and documenting, among other points, their effectiveness in reducing interruptions (from 6 to 5 for each medication round). The tabards were red, accompanied on both sides by the message Drug round in progress, please do not disturb to emphasize to staff, patients, and visitors that nurses wearing the message should not be interrupted. The red tabards also resulted in a 28% reduction of interruptions during medication rounds in a following study performed at Colchester General Hospital in the UK.11
However, the introduction of the red tabards displaying a message indicating to not disturb has generated media debate.12 According to Beckford,13 the use of the tabards meant for some patients the fear of feeling vulnerable, left alone, and unable to contact the nurses; being forced to communicate with less educated health professionals; or, worse, postponing a request for help that can sometimes be urgent. The medication rounds are often the only opportunity for patients to meet nurses and communicate with them. The message Do not disturb may also be offensive or impolite in the context of a caring relationship, which is the basis of nurse-to-patient conduct.14 The scientific and public debate between those in favor of and those against the use of medication round tabards preventing interruptions is still open: their effectiveness15 as well as their impact on patients is not well established.16 Therefore, the principal aim of this study was to evaluate patients’ perceptions of 3 different red tabards; the secondary aim was to explore individual factors associated with the negative perceptions that emerged.
An observational study in a general surgical department located in a large Northern Italian teaching hospital (>900 beds) was undertaken.
The sample power was 58 patients (α error, 0.05; power, 0.8; and minimal difference expected across different red tabards, 1 [standard deviation, 2]). Eligible patients had to be admitted to the selected general surgical department; remain at least for 3 days according to the programmed clinical pathway; be capable of understanding and answering an interview; and give written informed consent. Patients with visual limitations from pain or other discomforting symptoms (e.g., vomiting) and those transferred to a postoperative intensive unit were excluded. Additionally, given that hospital rooms are accommodated with 2 or more beds, patients who had witnessed an interview made with another patient sharing the room were excluded.
Patient recruitment was performed from December 2012 to April 2013. A total of 129 patients were eligible. Twenty-five patients (19.4%) were not included owing to visual problems (n = 2), discomforting symptoms (n = 6), their postoperative pathway in intensive/semi-intensive care units (n = 7), and their refusal to participate in the research (n = 10).
Variables and Data Collection Instruments
A semistructured interview composed of 15 questions (12 close ended; 3 open ended) was conducted. The interview was based on the following areas of interest:
- a) sociodemographic variables (7 items): age, sex, nationality, education, occupation, previous hospital admission(s) (yes/no, if yes, number);
- b) clinical variables (3 items): medication received daily by nurses during the in-hospital stay (yes/no, if yes, number/d);
- c) preoperative or postoperative phase the patient was in at the stage of the first interview;
- d) patient's attitudes toward interruption and previous experience (4 items): whether the patient would interrupt the nurse during the medication round administration (yes/no) and for which reason(s);
- e) if during their hospital stay they had interrupted a nurse during the medication round administration (yes/no) and for which reason(s);
- f) red tabard impact as perceived by patients (5 items): 3 real-size red tabards, made with laminated paper and displaying different messages were shown to each patient involved (Fig. 1). This choice, instead of wearing a tabard, was made according to the following rational basis: (a) red tabards available in the unit reported only the first message (Fig. 1); (b) a standardized evaluation of homogeneous tabards, administrated to each patient in the same manner and without any potential influence by verbal or nonverbal communication by the person wearing the tabards, was preferred by the researchers.
For each red tabard, patients were asked to express the following: (a) whether they thought the message was directed at them (0, not at all directed at me; and 10, totally directed at me); (b) if they would have interrupted the nurse who was wearing the red tabard for an urgent problem (0, absolutely not; and 10, absolutely); (c) the impact of the message displayed on the tabard (positive/negative) and related reason(s); and (d) if the red color was negatively or positively perceived.
The researcher attended the department daily and selected patients to be interviewed with the chief nurse. The patients were interviewed over 3 consecutive days, usually during the morning. On the first day, demographic and clinical data were collected, then the patient was interviewed with regard to the first red tabard; on the second and third days, each patient was interviewed on the second and third red tabards, respectively. The time lapses from one interview evaluating one tabard to the following were at least 1 day (24 hours), aiming to avoid recall bias. The tabard order was randomly selected on a patient basis: therefore, each patient received a personal sequence of red tabards (not necessary that shown in Fig. 1). A questionnaire summary was filled out by a researcher during the interview; the open-ended answers were reported accurately by the same researcher and then re-read to the patient to assure fidelity. The same researcher performed all the interviews aiming to assure consistency in the data collection process.
The study was approved by the internal review board of the hospital. Each patient had been informed of the aims of the study and was interviewed only after having obtained written consent. The patients were assured that they could leave the study at any time. Participants who had just undergone a surgical procedure were interviewed at the time of their choice, as decided on the day.
Data were analyzed using the Statistical Package for the Social Sciences version 20 for Windows.17 Initially, the open-ended answers were analyzed by 2 researchers (A.P. and M.F.). These were grouped and categorized according to content analysis18 performed independently by 2 researchers; findings and disagreements were compared and discussed with a third and a fourth researcher (S.V. and A.D.).
Descriptive statistical analyses were performed by evaluating mean(s), standard deviations (SDs) and confidence intervals (95% CI), frequencies, and percentages. A bivariate analysis (χ2 test [Fisher when appropriate]) was performed to explore the homogeneity in the distribution of categorical variables being studied. In addition, given the ordinal nature of some variables such as the perceptions expressed by each patient with regard to the message displayed on the tabards (e.g., 0, not at all directed at me; and 10, totally directed at me), an intraindividual comparison testing differences, if any, in the rank distribution obtained by the 3 tabards was performed using the Friedman test. Then, with the aim of discovering independent variables affecting the negative perception expressed by patients regarding the message displayed on the tabard, a logistic stepwise regression (odds ratio [OR], 95% CI) was performed according to the explorative nature of the study aim.19 The level of statistical significance was fixed at P ≤ 0.05.
Participants and Attitudes Toward Interruptions
A total of 104 patients were involved, 71 men (68.3%) and 33 women (31.7%). Their mean age was 63.2 years (95% CI, 60.0–66.5). Their nationality was Italian; 34 (32.7%) were educated at primary school level, and 66 (63.5%) were retired. Ninety-one patients (87.5%) reported previous hospital admission(s), a mean of 3.8 (95% CI, 3.3–4.3) in their life. At the time of the first interview, 61 (58.7%) were in their preoperative phase, whereas 43 (41.3%) were in their postoperative phase. A total of 94 patients (90.5%) were receiving medication administered by nurses, on average, 4 different molecules (95% CI, 3.4–4.6).
Most of the patients (72 [69.2%]) argued that they never interrupt a nurse during the medication round given that she/he is doing a job that requires concentration (34/72 [47.2%]); she/he may thwart the medication administration (22/72 [30.6%]); and it is not polite to interrupt someone during her/his work (16/72 [22.2%]).However, whereas 24 patients (23.1%) stated having never interrupted a nurse during their hospital stay, 80 (76.9%) reported having interrupted a nurse one or more times owing to a need (63 [60.6%], e.g., requiring help to drink water); for an emerging problem (10 [9.6%], e.g., requiring pain medication); or to ask a general question (7 [6.7%], e.g., where is the toilet?). In Table 1, the patient profiles are presented.
Red Tabards as Perceived by Patients
The red color was considered appropriate by 61 patients (58.7%) and inappropriate by 43 (41.3%). The message displayed on the red tabard was measured with regard to whether the patient perceived the content as directed at her/himself (10, absolutely yes) or not (0, not at all). The first red tabard, displaying the message I am administering medication —Please do not interrupt me obtained a mean value of 5.77 (95% CI, 5.20–6.34); the second I am administering medication—ONLY PATIENTS can interrupt me a value of 5.99 (95% CI, 5.46–6.53); whereas the third I am managing drugs—Interrupt me ONLY for urgent matters obtained a value of 5.18 (95% CI, 4.71–5.66; P = 0.007). Then, the likelihood of a patient interrupting a nurse wearing each tabard was evaluated for urgent problems (0, not at all; and 10, absolutely yes). The first tabard had a reported average of 0.75 (95% CI, 0.41–1.09), the second an average of 3.0 (95% CI, 2.35–3.65), and the third, 1.48 (95% CI, 1.07–1.89). This difference is statistically significant (P = 0.00). In Figure 2, the intraindividual rank order is reported.
Patients were asked to share their feelings aroused by each tabard: a negative impact was reported by 44 individuals (42.3%) for the first tabard, 50 (48.0%) for the second tabard, and 40 (38.4%) for the third. These differences are not statistically significant (P > 0.05).
In Table 2, the reasons reported by patients indicating their negative perceptions to the tabards are documented.
In the logistic regression, only 2 independent factors were significantly associated with the negative perception of the message reported on the tabards (Table 3). Patients reporting a positive attitude to interrupt nurses were more than 4× at risk (OR, 4.276; 95% CI, 1.674–10.924) to negatively perceive the tabard reporting the message I am administering medication —ONLY PATIENTS can interrupt me, compared with the patients not reporting this attitude. On the contrary, those patients receiving medication during their hospital stay were less likely (OR, 0.807; 95% CI, 0.683–0.955) to negatively perceive this tabard compared with those not receiving medication. In the case of the tabard with the message I am administering medication —Please do not interrupt me, patients reporting a tendency to interrupt were less likely to perceive the message negatively (OR, 0.296; 95% CI, 0.120–0.728) compared with others. However, the variance explained (R2) by these factors were 18.3% and 9.4%, respectively. No other factors were associated with the negative perceptions expressed by patients toward the third tabard.
Limitations of the Study
The study has several limitations. The tabards shown to the patients were manufactured with plastic and not worn by nurses; showing laminated paper versus wearing tabards by nurses may have affected the results and further research should consider this limitation. Patients with major symptoms that might require direct accessibility to the nurse for medication were excluded. In addition, the study was carried out in a single surgical department and involved homogeneous patients with regard to age and nationality; therefore, future studies should involve a more diverse population (e.g., conducted in a medical ward with people of different nationalities). Additionally, patients were interviewed over 3 consecutive days; for most of them, the first interview was taken during their preoperative phase. The major need for nursing care in the postoperative phase, when the following (i.e., second and third) interviews were made, may have influenced the evaluations; however, to reduce this potential bias, the order of the tabards shown to the patient was randomly selected.
The messages under evaluation were different from those reported in the literature (e.g., Drug round in progress, please do not disturb); considering that the perception of the messages is related not only to educational and cultural factors but also to the specific language rules that are technically referred to as “linguistic politeness”,20 any generalization of the findings should be prudent.
The focus of our research was on the patients. Considering that a large proportion of interruptions are determined by health care workers and given that wearing red tabards may have both positive/negative effects on nurses, measuring the effectiveness of the tabards on staff interruptions and the feelings of nurses wearing tabards should be considered as a priority in further research.
Red Tabards as Perceived by Patients
To avoid interruptions during medication rounds, which may increase medication errors,3,21,22 red tabards worn by nurses, displaying a message to potential interrupters to no disturb, has been recently introduced in several U.K. National Health Service settings and in other countries.10,16,22 According to the available literature,11 the positive effects of red tabards on reducing interruption have been documented: they potentially reduce errors in medication administrations but also reduce time wasted as a consequence of interruptions, which nurse may otherwise invest in the relationship with the patients. However, immediately after their introduction, growing public disapproval has emerged based on inappropriateness within the nurse-to-patient relationship.12–14,23–27 As a consequence, red tabard implementation is currently under careful consideration owing also to the limited evidence available28: therefore, evaluating the advantages of using red tabards (i.e., reducing interruptions) and negative effects by patients is mandatory to appreciate the benefits and harm of this measure, also among other measures adopted by hospitals to prevent interruptions.
Considering that to our knowledge, no data have documented the perceptions of patients with respect to the red tabards bearing different messages, a study was undertaken. Perceptions may be influenced by culture29; therefore, findings that emerged may be generalizable to the surgical patients of Northern Italy, in a mature stage of life, with previous hospitalization.
Patients seem to be aware of the effects of interruptions on medication errors. In fact, most (69.2%) would not interrupt nurses during the medication administration round given that they are performing a task that requires concentration and any distraction may cause errors. Only 30.8% of patients would interrupt the nurse, and this result is consistent with those found in the literature where patients' interruptions are reported in ranges from 9%29) up to 33%.11 Thus, given that patients recognize that medication administration is a critical task of safety, tabards directed at patients seem to be unnecessary. However, despite their declared intentions, most patients (76.9%) reported having interrupted nurses mainly for general needs and information and only 10% for emerging problems such as pain. The fact that nurses managing medication administration are the only ones present in the corridors or in the patients' rooms and that patients do not have any other contacts with staff possibly prompts patients to also ask general questions.
The red color was appropriate for only approximately half of the patients, and this seems consistent with previous literature,30 reporting that red uniforms may be perceived as representing an alarm, urgency, or danger situation.
Patients reported perceiving the messages on the tabards as addressed to them: the second tabard was perceived as most directed to patients, followed by the first tabard and then the third tabard. Additionally, a risk of inhibiting patients in communicating urgent needs emerged. The first tabard including the message I am administering medication —Please do not interrupt me was most at risk at inhibiting the patient, followed by I am administering medication—Interrupt me ONLY for urgent matters, whereas that presenting I am administering medication—ONLY PATIENTS can interrupt me seemed to inhibit least of all. Surgery patients may postpone communicating an urgent problem to a nurse wearing a tabard (e.g., chest discomfort); therefore, there is a need to balance the effects of the tabard in reducing the risk of medication errors associated with interruptions with the need to protect patients against new risks such as postponing communications of urgent needs.
Almost half of the patients reported negative impact, without any significant difference across tabards, although the reasons reported were significantly different. The messages conveyed by these tabards may be seen as rough or impolite for a number of reasons. As conversation patterns follow unwritten rules of linguistic politeness, which change slightly according to the situation,31turn-talking (as the process by which people in a conversation decide who is to speak next)31 is consistently different in informal conversation and institutional conversation.32 Interruptions are always regarded as infractions, and their management varies noticeably according to the ongoing “conversational contract”. If the interlocutors are placed in a situation of asymmetry, the person feeling psychological subordination already knows that speaking without being allowed to means appearing discourteous. Hindering or blocking a person from speaking, or showing lack of interest, concern, and sympathy may end up as perceived aggressiveness. This can be even more accurate if empathy is expected as part of the “social role” of an interlocutor, as a clash of expectations results in frustration.33,34
Another problem is the number of participants in the communicative exchange. There is a difference if the communication is taking place between 2 or more people; in fact, in multiparty interactions, participants may choose to behave as the addressees or simple overhearers of a message. Instead, if the message takes place within a binary interaction, the interlocutor cannot help identifying her/himself as the addressee, which makes the message even stronger. The directionality of the message should not be underestimated when the tabard is used in 1-bed rooms or in corridors. There are also more “formal” factors that may influence the way a message is received. For example, the choice of politeness markers, such as the presence/absence of expressions like please, if you don’t mind and the choice of courtesy forms.20 In Italian, the choice of the personal pronoun to address the interlocutor is meaningful: the use of the second person singular (Italian tu, singular “you” in English) instead of the more formal third person singular (Italian Lei, literally “she” in English), can be taken as a marker of sympathy but also as discourteous or patronizing in situations of asymmetry.35
To sum up, the first tabard, I am administering medication—Please do not interrupt me, can be perceived as aggressive because it prevents patients from talking and because of the choice of the second person singular pronoun. The second tabard, I am administering medication—ONLY PATIENTS can interrupt me, can be perceived as ambiguous, since the addressee is not clear. The third tabard, I am administering medication—Interrupt me ONLY for urgent matters, can be perceived as aggressive because of the choice of the second person singular pronoun but also because it conveys instructions for turn-talking.
Individual factors (e.g., age and sex) and previous hospitalization or having already interrupted nurses were not associated with the negative perceptions of the tabards reported by patients. Only 2 factors, however, seem to be involved, in 2 different directions: taking medication during hospitalization reduces the risk of negatively perceiving the first tabard by approximately 20%. On the other hand, having a tendency to interrupt increases the risk of negatively perceiving the first tabard around 4×; in contrast, the same factor reduces the likelihood of perceiving the second tabard negatively by approximately 71%, which authorized only patients to interrupt. Patients taking medication may appreciate the effort to minimize distractions to reduce the risk of errors that may affect their own safety. Conversely, communicating to not interrupt may irritate patients who are used to interrupting nurses. However, these factors explain a minimal variance in the negative perception that might be due to cultural factors: the role of interruptions in conversation and their tolerance by interlocutors are subject to variation according to language.36 For example, the pause between a speaker's turn and another's seems to be longer in English-speaking countries than in French-speaking countries; and French speakers seem to be more tolerant toward interruptions than English speakers.32 Interruptions are far more frequent in Italian-speaking countries than in English-speaking countries, as they seem to have quite different functions in the conversational exchange.37 This suggests a need to culturally validate the tabards before their implementations in the wards.
Patients recognized potential external sources of interruptions that may have detrimental effects on nurses' concentration as in cases when they ask nurses to leave one critical task, such as medication administration, in favor of another, such as requiring help for drinking water. However, patients' interruptions may also have positive effects such as increasing safety and performance when, for example, they interrupt nurses to communicate an urgent problem. Other external sources of interruptions are caregivers, staff, and visitors. Attempts to reduce these sources need complex strategies based on multiple interventions; tabards displaying a message to not disturb have assumed an eminent role in recent years.
Despite reporting different messages—from asking everyone to not disturb to allowing only patients to interrupt—patients perceived the tabards as directed at themselves. Especially in the case of urgent problems, patients would avoid interrupting nurses wearing a tabard, postponing their interaction with nurses. Additionally, half of the patients reported negative feedback on tabards as threatening the fundamentals of the relationship between patients and nurses, which should be based on caring, openness, and cooperation.On the basis of the findings that emerged, the adoption of tabards should be evaluated considering the benefits already documented and the potential negative effects that emerged on patients, which may be influenced by cultural and linguistic aspects. In addition, comparing the red tabard effects with other strategies introduced to deal with avoidable interruptions (e.g., wearing ID badges, "no interruption zone") to gain a comprehensive picture regarding benefits/harm is also important.
Wearing the tabard with the message reported on the back, directed to the staff, and not to the patients, may have less negative effects on the patients; furthermore, using a different color not to alarm the patients may be useful. Investing in the education of citizens, helping them to understand when it is appropriate to interrupt nurses, and avoiding interruptions for general questions or needs, is a priority. For nurses to receive only appropriate interruptions from patients and their caregivers, issues arising from technology, staff, and the organizational environment also need to be addressed.
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