Case II: Team coordination as values realisation: managing interruptions so they do not interrupt

This case focuses on how a telephone interruption is successfully dealt with during history taking. A novice doctor talks to a female patient who presumably has a serious infection that causes breathing problems and a bad cough. She is weakened, dizzy and exhausted.

The nurse observes the interaction and she is ready to assist in getting the measurements they need. The layout is visualised below and followed by a transcript that shows what happens before, during and straight after the interruption occurs.

Figure  7.3:  Overview of the layout: interruptions in teams      

Transcript 7.2²⁸

Duration: 00:41.80 minutes DANISH ORIGINAL

1. 00:00:00, D: har du noget åndenød synes du 2. 00:01:10, ps. (0.8)

3. 00:01:90, P: altså jeg trækker vejret overfladisk 4. 00:03:90, D: ja (.) okay

5. 00:05:10, P: og det er for ikke at komme til at hoste

6. 00:06:80, D: for ikke at komme til at hoste (.) okay godt føler du at du sådan har hjertebanken kører det hurtigt hele tiden eller (.) 7. 00:11:90, P: altså efter jeg fik det der (.) sulfid i går

24. 00:33:60, D: var det noget (rækker ud efter telefonen) 25. 00:34:00, ps. (0.9)

26. 00:34:90, N: det var bare om stue seks var kørt 27. 00:36:20, D: nå

28. 00:36:60, ps. (2.9)

29. 00:39:50, D: godt (.) nogen smerter mere noget kvalme  

6. 00:06:80, D: to avoid coughing (.)ok fine do you feel that you have heart palpitations constanly, or (.)

  28 Interruptions are marked in red. Ph is an abbreviation for phone.

11. 00:16:10, D: [oops (nurse takes phone in her hand) 12. 00:17:80, ps. (1.3)

13. 00:19:10, P: b[ut I have had this (coughs) 14. 00:19:20, ph [ring ring

15. 00:21:20, ps. (0,5)

16. 00:21:70, P: I [have had this before (.) (xxx) feel that (.) it just somer 17. 00:21:80, N: [[nurse’s name] speaking (.) it is [doctor’ name] phone 18. 00:25:50, D: that it ju:st somersaulted

19. 00:27:30, P: just once ri[ght

20. 00:28:20, D: [but it is not something that continues (.) [(xxx) up and down (.) no [okay

21. 00:29:30, P: [(P nods ‘no’ with her head as she coughs)

22. 00:31:50, N: [super 23. 00:31:70, ps. (1.9)

24. 00:33:60, D: was it something important (reaches for the phone) 25. 00:34:00, ps. (0.9)

26. 00:34:90, N: just checking if ward six was cleared 27. 00:36:20, D: oh

28. 00:36:60, ps. (2.9)

29. 00:39:50, D: well (.) any pains anymore any nausea

When we enter this conversation, the doctor has just greeted the patient and informed her about what he is going to do next: ask for information that enables him to reach a diagnosis. From line 1-7 the doctor and patient engage in history taking. The doctor is a novice and he has only been working at the ward for less than a week at the time of the recording. Rather unusually, he does not rely on any aiding tools during this task performance. He leans towards the patient and gazes at her as he asks for specific information. The patient gazes momentarily at the doctor and straight out when she is going to recall memory. As the patient utters: b[ut I have had this (line 13), the doctor’s phone rings (line 14). Figure 7.4 and 7.5 illustrate how this interruption affects the current undertaking and how the medical team acts to prevent the interruption from leading to task-switch and from harming the current dialogue. This efficient team performance is initiated by the nurse’s anticipatory actions, which will be investigated in detail in the following.

Figure 7.4: Anticipatory dynamics in interruptive practices

The black text indicates the patient’s utterances. The blue text indicates the doctor’s utterances, and the green text indicates the nurse’s utterances

The telephone rings at 15:00 just in the patient’s breathing pause (line 7). The ringing leads to several anticipatory actions (tertiary event pivot). The doctor immediately treats the interruption as relevant. Until the interruption occurs, the doctor gazes at the patient (see picture A), but at 15:70, he pays attention to the interruption as he gazes at his pocket in which his phone is located (see picture B). However, the patient overlaps the loud ringing and finishes her explanation at the same time as the doctor changes his visual orientation from her to the phone: [then I thi:nk that (.) sometimes there is a kind of a (line 10).

Like in the previous case, a dilemma emerges as the doctor is expected to realise values in two systems simultaneously: the dialogical system in which he engages in history taking with the patient and the social system that expects a professional, standardised behaviour:

immediate response, as delayed response can lead to bad outcomes in other locations.

Thus, the doctor is expected to balance caring for the patient and smooth work procedure in the ward, which means caring for colleagues and other patients. Values realisation in such two different systems is constrained and enabled by different dynamics. In the former system, inter-bodily dynamics affect decision-making directly and this was a major explanation for why the doctor in the previous case postponed his interruptive behaviour.

In the latter system, rules and norms constrain the moral obligations that affect real-time

decisions.

Thus, in this case II, the doctor explicitly orients to the interruption as unfortunate: [oops (line 11), as he takes the phone out of his pocket. Altogether, this course of events prompts the nurse to interfere. The nurse’s subsequent actions can be characterised as negative feedback mechanisms within the system that prevent latent breakdowns to emerge prompted by the tertiary and secondary event pivots (the ringing and the doctor’s response to the disturbing source). The doctor’s visual orientation toward the phone and his verbal utterance oops thus mark the secondary event pivot in the cognitive event trajectory, and this utterance affords a series of anticipatory actions (see figure 7.4). The patient does not treat the ringing and the doctor’s behaviour as a reason to stop her narrative. The doctor himself seems annoyed by the interruption and as he picks up his phone he gazes at the patient who continues to speak. Just as the phone stops at 16:50, the patient gazes at the doctor and she finalises her utterance. The doctor holds on to the phone and as the nurse anticipates that the doctor probably is going to answer the call, she reaches out for it (see picture C). From the moment the nurse reaches for the phone and the patient has finalised her utterance in line 10 (00:17.80) until the nurse almost has the phone in her hand and the patient resumes her narrative (00:19:10) a lapse of 1.3 seconds elapses (see figure 7.4). The phone-switching-event is defined as the primary event pivot. It only causes a minimum of disturbance that entails that the interaction is briefly put on stand-by. Most likely, the nurse anticipates that the doctor’s actions are going to interrupt the current undertaking. Thus, at a critical moment, she both offers and demands that she is going to handle the phone call.

The doctor hesitates as he briefly gazes at the phone display to check who is calling before he accepts the nurse’s demand (see picture C). Thus, as the patient continues her narrative in line 13, the phone rings for the second time. At the same time, the nurse gets the phone from the doctor who regains eye contact with the patient and resumes the history taking (see picture D). At 00:21:50 the nurse answers the call and walks away, while the doctor and patient continues the dialogue in the same manner as before the interruption occurred.

As such the cognitive system remains intact and its boundaries are recalibrated (see figure 7.4).

While the nurse handles the phone call, she executes a nested task that the medical team needs to respond to, but she does it in a way that reduces the chances for cognitive overload, interpersonal breakdowns and task switch. The therapeutic alliance between doctor and patient remains intact. The patient’s behaviour indicates that the disturbance or

‘noise’ in the cognitive system is almost unnoticed by her, and the doctor and patient continue without any problematic breaks or disturbances.

The team performance is highly coordinated and it enables values realisation in a constrained situation with a minimum of dysfunctional outcome. As the doctor cannot do two things simultaneously, the nurse enables him to continue with his initial task as she performs the second task for him. This coordination succeeds as the nurse anticipates the flow of actions and the doctor relies on and trusts the nurse’s prioritisation. Their coordinated behaviour enables them to embrace complex and diverging expectations and realise multiple constraining values. As the team organises the values in a heterarchy,

decisions can be made as a result of emergent properties of the environment combined with expectations for goal-orientation. Specifically, it is due to the distributed properties of the cognitive system that multiple values are realised simultaneously without ordering the activities in a predefined hierarchy.

From the emergence of the first event pivot until the system has calibrated its dynamical interaction mode, 5.60 seconds pass. A few moments later, the nurse re-enters and closes the phone conversation all whilst the patient is plagued by a bad cough. The whole situation prompts the doctor to pay attention to the nurse to define which issue requires his attention the most (the patient or the interruption). From that moment a small nested activity is embedded in the history-taking task (see figure 7.5).

Figure 7.5: Interruptions as non-interruptive

Figure 7.5 underlines the minimal disturbances the interruption entails after the nurse has responded to the call, and finally it illustrates how this situation has affected the cognitive task of history taking overall.

As the nurse closes the phone conversation super (line 22) the doctor orients to her (see picture F) and he asks whether it was an important call (line 24). Briefly, the nurse updates the doctor about the particularities that do not require the doctor’s further involvement, as she has solved the problem already (see picture G). The doctor acknowledges this update, puts his phone back in his pocket and reorients to the patient (see picture H).

In total, the doctor and nurse complete this nested task within 7.8 seconds. The interruption proved to be just a trifle and as such the doctor was exempted from engaging further in the intentions behind the interruption. If the interruption had required the

doctor’s attention, this would presumably have been prioritised. Only in this case, it was not needed.

The way this team manages the phone interruption is an exception within my dataset.

The interactivity trajectory deviates from standard situations involving interruptions. In the ward, the doctors answer their phones themselves without fail. Experienced doctors tend to answer immediately without taking time to judge from where the call is coming; in a few situations they ignore the calls if the local situation is acute and critical. Novices on the contrary tend to hesitate before they respond as the situated demands for presence and attendance often collide with non-local expectations for responding to an authority.

However, the delayed response only adds further frustration and cognitive overload as shown in the first case.

Sharing responsibility for dialogical work practice and making use of the team’s capabilities as interruptions occur are barely noticed in the coding. A phone call is always an interruption, but the nurse anticipates a line of actions that affords her to manage the interruption so it never becomes problematically interruptive. As the team co-act, their actions serve as negative feedback mechanisms that reduce the risk for task switch that regularly leads to human error or harms the interaction unnecessarily. The nurse actively recalibrates the boundaries of the cognitive system. In the beginning she is cognitively loosely associated to the system, however, she observes what is happening. Rather than allowing the patient-doctor relation to break down she enables the doctor to maintain ongoing dialogue and history taking. As she turns around and walks into a corner of the room as she handles the call, she disintegrates with the doctor-patient system. Hence, her task performance does not disturb or interfere with the doctor’s task performance in a way that has consequences for the functionality of the cognitive system.

In the ward, interruptions appear to be imposed on individuals; for instance when a caller seeks to reach a specific practitioner. However, there are alternatives to individual problem-solving. As the latter case showed, relying on the distributed qualities of team constellations enables caring for the patient by prioritising differently within the same situation. The team’s coaction enables it to complete a shared project and to meet the broader organisational needs constituted as procedure following, as well as local needs in interaction. By acting individually together, they multitask. The overall multi-task tolerance is high, even when challenged by interruptions and the team deals with the competing requests in a way that replaces a traditional task hierarchy with a shared task heterarchy. This performance minimises dilemmas and favours several groups of people simultaneously: the organisational system, the medical team and the patient.