Good afternoon everyone and thank you for coming to our session this afternoon on attention. My name is Allison Muniak and this is my colleague Emily Rose. We are Human Factors Specialists at Vancouver Coastal Health.
We are so excited to talk about one of our favourite topics on attention and distraction.
So… for the next hour we are going to provide an overview on attention, focus, distraction, and alarms/alerts in our ever so complex world. There will be a few games and lots of discussion of your own experiences at your tables. So let’s get going…
As more and more technology is introduced into our lives, the tasks we are required to complete throughout the day seems to grow and grow. So for the next hour what we are going to look into is how we focus in a distracting and demanding environment and how can we change our distracting and demanding environment to focus our attention? And the perspective we are going to take to discuss these topics will be using a Human Factors perspective.
As Emily and I are both Human Factors experts, we want to make sure we are all on the same page regarding what Human Factors is as we apply it to the topic of attention. Our backgrounds are in engineering and psychology
Not just looking at the physical abilities or limitations but really focusing on the cognitive aspects of cognitive load, how we perceive information and how we process it in our minds, and our limitations of how our minds actually work in making decisions based on how information is presented to us.
So let’s talk about attention. Although we have an intuitive understanding of what it means to “pay attention” to an object or event, the study of attention has a long and checkered history in cognitive psychology. Some have suggested that “everyone knows what attention is;” others have countered that “no one knows what attention is”. Researchers talk about orienting to sensory events, detecting signals for focused processing, and maintaining a vigilant or alert state. Still others have used terms such as arousal, effort, capacity, perceptual set, control, and consciousness as synonymous with the process of attention.
So for the purpose of this presentation we are going to use the following definition of attention being..
Attention is a concept studied in cognitive psychology that refers to how we actively process specific information in our environment.
As we are reading this, there are numerous sights, sounds, and sensations going on around you – the comfort of the chair you are sitting in, the sight of other people in this room, the feeling of the clothes on your skin, the sound of my voice in the room, or maybe the memory of a conversation you had earlier with a colleague.
So… How do we manage to experience all of these sensations and still focus on just one element in our environment?
Attention is much like a spotlight in focusing on only part of all the information held in sensory memory.
We all have a certain amount of cognitive capacity or resources.
If we devote our resources to one activity, others are likely to suffer
Many jobs require large amounts of information processing in a relatively short amount of time. What human factors can do is determine what cognitive capabilities will be overloaded and how to design tasks to minimize such overloads.
Attention allows us to "tune out" information, sensations and perceptions that are not relevant at the moment and instead focus our energy on the information that is important.
Selective attention allows us to process important information whereas focused attention allows us to filter out any unwanted information. Not only does our attentional system allow us to focus on something specific in our environment while tuning out irrelevant details, but it also affects our perception of the stimuli surrounding us. In some cases, our attention might be focused on a particular thing, causing us to ignore other things and not perceiving the other target at all.
Although it is useful to be able to focus on only the information relevant to the task at hand, there are many occasions where we want to divide our attention and do several things at once.
10 min We are going to play 3 very short games together. So what we would like you to do is find a partner so turn to one of the people beside you at your table. If you don’t have a partner, please raise your hand and move to someone at another table who also has their hand raised for this game.
In order for us to all be on the same page, we will explain the game first, and then we will each have 2 minutes to play the game. We need to practice to make sure we become experts at these games. One last thing, some of these games are just a tad physical so please be careful with each other and don’t be too competitive!
Ok first game…
1, 2, 3, 4… I declare a thumb war, bow to your partner, and go.
You have two minutes, keep track of how many times each of you win.
Paper Rock Scissors… Now this one has a few more rules... But basically goes like this
This is paper This is rock And this is scissors
Looking at your partner you are going to play the game. Ready Emily? 1, 2, 3, show?
Great… okay the last game is very important and is the hardest one yet.
You have two minutes to play this game and keep track of who wins each game on the left and right hands.
So with a show of hands…
Who was able to win both games at the same time?
Who was able to win at least one of the games?
Who thought this was difficult or hard to do?
Who was able to win both games at the same time?
Who was able to win at least one of the games?
Who thought this was difficult or hard to do?
Now, would anyone like to share…. Did anyone use a strategy that was successful?
The purpose of the last three games you played was really to highlight the whole concept around our attention and our attentional ability to do multiple things at the same time.
Polling: Turn toward the table you are sitting at and raise your hand if you answer yes to the following questions. raise of hands if you think you multitask everyday
Do you: think you multitask well? Are terrible at multitasking? Think it depends on the task you are doing?
The fascinating thing about multitasking is that we perceive we are actually better at multitasking than we actually are. In fact, many of our perceptions about how we respond, perform, and complete tasks can be quite different to how we actually perform such tasks.
In this example, which is actually and advertisement for texting and driving. Whether it be texting while you drive or even when you are walking down the hall the truth of the matter is that we actually aren’t very good at multitasking – and this is particularly evident in the types of tasks and the autonomic nature of the task that we are doing. Frankly, our brains are not designed to multi-task or do it even remotely well.
Key Things to Remember About Attention
1. Attention Is Limited There has been a tremendous amount of research looking at exactly how many things we can attend to and how long. Researchers have found that key variables that impact our ability to stay on task include how interested we are in the stimulus and how many distractors we experience. Studies have demonstrated that attention is limited in terms of both capacity and duration.
2. Attention Is Selective Since attention is a limited resource, we have to be choose focus our attention on a specific item in our easy about what we decide to focus on. Not only must we environment, but we must also filter out an enormous number of other items. We must be selective in what we attend to, a process that often occurs so quickly that we do not even notice that we have ignored certain stimuli in favour of others.
3. Attention Is a Basic Part of the Cognitive System Attention is a basic component of our biology, present even at birth. Our orienting reflexes help us determine which events in our environment need to be attended to, a process that aids in our ability to survive. Newborns attend to environmental stimuli such as loud noises. A touch against the cheek triggers the rooting reflex, causing the infant to turn his or her head to nurse and receive nourishment. These orienting reflexes continue to benefit us throughout life. The honk of a horn might alert us about an oncoming car. The blaring noise of a smoke alarm might warn you that the casserole you put in the oven is burning. All of these stimuli grab our attention and inspire us to respond to our environment.
So the question is… when does information attention reach saturation. Growl function
At it’s core, our brains are developed in concentrating on one thing and then focusing our attention on something out of it.
So let’s test our attention doing something not so physical and rely solely on our visual and auditory attentional cues. You may have seen this video before so bear with us. Your job is to count the number of passes by the players in white.
-how many passes by the white team? -did you notice anything else? -how many of you saw the gorilla? -how many of you saw that the curtain changed from red to orange? -who noticed one of the black shirt players leave the stage?
This video illustrates a good example of limitations in multitasking and noticing differences when our attention is focused on one particular task.
People believe that multitasking takes place when someone tries to perform two or more tasks at the same time, switching from one task to another, or performing two or more tasks in rapid succession.
I think it is fair to assume that we have all been guilty of it -- sending a quick email during the middle of a meeting, checking social media in the middle of a project, or updating a calendar in the middle of a phone call. With so much access to technology, schedules, and commitments we all have, we're seemingly becoming more wired to multitask. But are we actually paying attention??
More importantly have we entered the era of distraction where this is the new status quo?
Doing more than one task at a time, especially more than one complex task, takes a toll on productivity. Although that shouldn't surprise anyone who has talked on the phone while checking E-mail or talked on a cell phone while driving, the extent of the problem might come as a shock.
Ariana Huffington is one of the people who is actually drawing a lot of attention to the topic of multitasking and distraction through publications and research of the empirical studies, summarized throughout the Huffington Post.
What they report from the literature is that multitaskers experience a 40% drop in productivity across the board. Take 50% longer to accomplish a single task And make up to 50% more errors.
Not to mention Trying to accomplish multiple items on our to-do lists also contributes to an increase in our overall stress levels, anxiety and efficiency throughout the course of our day
Psychologists who study what happens to cognition (mental processes) when people try to perform more than one task at a time have found that the mind and brain were not designed for heavy-duty multitasking. Psychologists have noted that in multitasking situations mental overload can result in catastrophe.
If we are driving a car, we want to be able to watch the road, steer the car, accelerate appropriately and talk to our passenger. We all have a limited cognitive load.
Imagine… Have 2 lanes, each task is one lane Imagine 8 lanes or 8 tasks, in a car you can only physically be in one lane at a time but you can switch between lanes When you’re driving a car, imagine you’re on a big freeway. And each lane is a task that you have to do. You can change lanes really quickly, but you can never be completely in both lanes at once.
The process of doing all of the various tasks is actually called time-sharing. We actually don’t multitask but we quickly transition between multiple tasks in rapid succession. We jump and focus our attention on the specific things we need to do.
Some researchers have found that the shifting of attention substantially deteriorates for older drivers, especially those with certain types of medical conditions.
Because our cognitive resources are relatively limited, time sharing between two tasks frequently results in a drop in performance for one or both tasks, relative to their single task baselines, a term that can be referred to as time-sharing decrement.
However when time sharing two tasks, people are also able to modulate the resources given to one or the other, sometimes emphasizing one task at the expense of the other and sometimes emphasizing the other at the expense of the first.
What we find is four major factors play a role in whether two or more tasks can be time-shared: The degree to which one or more tasks are trained to automaticity The skills in resource allocation, The degree of shared resources Degree to which task elements can become confused.
Lets reflect on our own work environment… What multiple things are demanding our attention and putting us into situations where we need to time share?
Roaming mic for people to share examples
Thinking about all these things that demand our attention…when does attention go from being useful to a distraction?
We are bombarded with signals from our environment everyday that demand our attention:
The small flashing red light on our Blackberry lets up know we have a new message, our computers chime when we get a new email if we don’t turn off the sound, our screens light up on our iphones with new text messages or notifications from various apps
We can see from some of these examples, how our environment switches our focus and draws our attention.
It can be useful to get alarm for something that requires urgent immediate action but it can be a distraction to receive a notification for something of less importance than the task at hand or even a false alarm.
If you do a quick google search for distraction, you will inadvertently come across a few definitions around the same theme. Distraction is defined as something that interrupts your attention, makes it difficult to focus or prevents you from giving your full attention to something else.
Let’s put some of this into perspective.
The Huffington Post provides another summary of the empirical literature out there relating to distraction.
What they have published is a visual around some of the empirical research showing: The average person checks their phone 150x a day The average time spent on a task before interruption is 1 minute, 15 seconds, AND that it takes more than 25 minutes on average to resume a task after being interrupted… that is getting back up to the same level of performance and reaction time before the interruption.
So when we look at all the signals in our environment and the number of things aimed at getting our attention, at this level of complexity, With best of intention, this information is actually a distraction.
We begin to experience information overload which is the inability to distinguish the signal from the noise, or detect information as relevant or alarming
So when we talk about information overload, how many of you can relate to this image of drowning in information? And how can we begin to pick out the pertinent signals from noise?
This takes us to the part of the discussion that will sound very familiar to those working in front line care – alarms!
Alarms are something that are specifically designed to interrupt whatever task is ongoing and redirect user’s attention to a problem that the system deems worthy of observation (wickens).
With this definition, we can see that alarms tend to be designed from the perspective of placing emphasis on the detection of an event, like a new email alert or an occlusion alarm for an infusion pump. The system detects the event and alarms – it doesn’t know or consider the implications of the alarm within the task you might be doing, that is, it simply lets you know about the event and has a certain expectation around the response, regardless of whether you are able to respond appropriately at the time.
If we look at a typical OR, we see anesthesiologists bombarded with alarms or auditory signals from a multitude of devices. This could be representative of a variety of areas in healthcare, whether it be at the front line or at your computer bombarded with email alarts, phone calls, calendar alerts, colleagues stopping by, construction outside you window
Just to make a quick point, alarms tend to be auditory because this sense is omnidirectional, meaning we can detect signals no matter how we are oriented, or what direction we are facing (wickens); Second to that, we cannot close our ears or look away as we can our eyes, so we are always subject to whatever alarms happen to interrupt
With all of these alarms and auditory signals, one of the real dangers becomes the issue of alarm fatigue.
So by a quick show of hands, how many of you feel you have experienced alarm fatigue in your day to day work?
But why do we even care about this?
Alarm Fatigue occurs when hospital staff become desensitized to alarm alerts causing missed alarms or delayed response.
As an example of what I mean…
Really what this shows is the importance of when an alarm actually occurs and this is important because
One of the first parameters to consider around alarms should be: the idea around only creating an alarm when you want or require a response from the user. So the first question should be:
Is it an alarm or not – by definition, Alarms must require an operator response Multiple alarms should not signify the same thing Alarms must activate on truly abnormal situations not normal cases of operation.
Second: is the alarm the best indicator of the situation’s root cause? Is there another way to provide this information?
Third: is the alarm truly representative of an abnormal situation, or does it activate during normal cases of operation (the idea of false alarms)
Here is an example of an alarm based system used in our day to day hostpital environment.
Thinking about things like attention, distraction and multi tasking, how does the nurse calll bell system succeed or potentially fail? I want you to have a brief discussion with those at your table and then am hoping you can share.
Think about nurse call bells and bed alarms The same call bell/alarm is used by patients to summon a nurse from non-emergent requests as that for more serious cases such as a bad fall in which the patient can’t get up…when nurses are used to being bombarded with non-urgent requests for e.g. glass of water, their reaction to the alarm may be different than the expectation the patient has when they press the call bell
Something to think about…Is this an example of alarm fatigue, where the alarm no longer has potency and elicits an alarmed response…or is this a failure to prioritize and distinguish perceptions of urgency in the alarm designs?
I am just going to play this last short video to wrap up what we have been talking about the past 30 min and really highlight the direction we should think about heading in healthcare when we consider our human capabilities and limitations around focus and attention and the many demands of our complex environment on our attention!
So, just to wrap up…
System can make mistakes of which there are 2 types, either: the system fails to identify when something has happened (a miss) or infers something has happened when it has not (a false alarm)
Designers and device manufacturers try to minimize misses, especially in environments like health care where the miss could be critical to patient safety; they take a ‘Better safe than sorry approach’ as a result, they set alarm criteria low by default of which the consequence is increased false alarms, where alarms go off unnecessarily but there is no need for action
This in turn leads users to distrust alarm systems and even potentially ignore it when it does provide valid information; even more serious work around is the disabling of alarms altogether.
A second issue is the absence of standardized prioritization of different devices such that all indicate similar severity
So how can we fix this? How do we improve the sensitivity of our alarms, reduce the number of false alarms? - either though criteria or system algorithm and the use of graded alarm systems in which more than a single level alert is provided
It has been demonstrated in the literature that specific adjustment of alarm limits towards patient specifications has been shown to decrease rate of false positives (or false alarms) without compromising patient safety (Biot et al 2001)
Allison Muniak & Emily Rose
Vancouver Coastal Health
Quality Forum 2016
How can we focus in a distracting and demanding
How can we change our distracting and
demanding environment to focus our attention?
Explore how we respond to things that compete
for our attention and how Human Factors
principles can be applied to help us.
designing for human use
a body of information about human
abilities, human limitations, and other
human characteristics that are relevant to
Chapanis, A. (1995, p. 11). Human Factors in Systems Engineering.
Toronto: John Wiley.
Why are some tasks easier to perform
at the same time than others?
1. Walking and chewing gum
2. Teleconference and writing an email
3. Mediating an argument with backseat
passengers in the car while driving
4. Doing your taxes while talking on phone
Is the ability to perform more than one
cognitive task by attending to both at once or
by rapidly switching attention back and forth
(Wickens, C; Lee, J; Liu, Y.D; & Gordon-Becker, S. Introduction to
Human Factors Engineering (2nd Edition) 2003
In groups of 2 or 3…
What is demanding our attention and
requiring time sharing in our own work
When does attention go from
being useful to a distraction?
“Thing that prevents someone from giving full
attention to something else.”
“An interruption to attention or anything that
draws attention away from the primary task.”
“Something that makes it difficult to focus or pay
Only create an alarm when you
require a response from the operator
• Does the event require operator action?
• If it doesn’t require you to act on it right now, it isn’t an alarm.
Working normally, nice to know, are not alarms.
• Is the alarm the best indicator of the situation’s
• Is the alarm truly resulting from an abnormal
• Does not activate during normal cases of operation
Alarm Management Handbook (2010),
Nurse call bells and bed alarms
The same call bell/alarm is used by patients to
summon a nurse for non-emergent
requests/assistance as that used for more serious or
emergent situations (patient has fallen and can’t get
up). There is a discrepancy in the seriousness of the
incident and expectation for immediacy of reaction
but the signal remains the same…