Human factors and ergonomics for primary care

Abstract

In the second paper of this series, we provide a brief overview of the scientific discipline of human factors and ergonomics (HFE). Traditionally the HFE focus in healthcare has been in acute hospital settings which are perceived to exhibit characteristics more similar to other high-risk industries already applying related principles and methods. This paper argues that primary care is an area which could benefit extensively from an HFE approach, specifically in improving the performance and well-being of people and organisations. To this end, we define the purpose of HFE, outline its three specialist sub-domains (physical, cognitive and organisational HFE) and provide examples of guiding HFE principles and practices. Additionally, we describe HFE issues of significance to primary care education, improvement and research and outline early plans for building capacity and capability in this setting.

Keywords:

• Human factors
• ergonomics
• primary care
• patient safety
• quality improvement
• education & training

Introduction

The systems and design based discipline of Human Factors (also widely known internationally as Ergonomics) is well established in many complex and safety-critical industries such as those found, for example, in the energy, transport and defence sectors.[1] Although the need for human factors and ergonomics (HFE) thinking and approaches in healthcare is increasingly recognised, its development and growth have been slow and often narrowly confined in scope.[2,3] For example in certain acute hospital specialties (e.g. anaesthetics, surgical practice and emergency medicine) the focus is often around behavioural safety issues such as improving communication, decision-making and team working, which are obviously very important clinically and educationally, and a commendable start in engaging with some aspects of this broad-spectrum discipline.[4,5] In primary care, however, evidence of HFE activity of any particular hue appears to be limited in comparison.[6]

HFE purpose, definitions and focus

The main workplace purpose of HFE is to improve the well-being and performance of people and organisations.[7] To achieve this, the discipline seeks to understand and improve the ‘fit’ between people and their working environment to ensure a safer, more productive and efficient workplace. The International Ergonomics Association definition of HFE is outlined below.[8] A simple and more accessible HFE definition for the clinical workplace might be: ‘designing to fit people’ or ‘making it easy to do the right thing’.

Ergonomics (or human factors) is the scientific discipline concerned with understanding the interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and methods to design in order to optimise human well-being and overall system performance.[8]

Adopting a ‘holistic’ systems approach (Figure 1) to assessing, designing, implementing and evaluating HFE issues is a core guiding principle of the discipline.[9] In this respect, we can define the ‘system’ as, for example, a person, a team, a device or technology, a clinical guideline, policy or procedure, a general practice surgery or a large NHS organisation. The HFE approach is concerned with interactions between people and other elements of a system across three specialist sub-domains (Box 1) with the specific goal of ensuring that the design of the system accommodates ‘the needs, abilities and limitations of people’.[1]

Figure 1. A model of HFE systems and design interactions influencing the performance and wellbeing of people and organisations.[9]

As a wide ranging discipline focused on the evaluation and improvement of all aspects of human work, HFE can potentially make significant contributions to a whole range of important and diverse healthcare problems where performance and well-being are often compromised. For example, the introduction of new information technology; reducing work-related musculoskeletal disorders amongst clinicians and support staff; decision-making to inform NHS procurement of products and services; the design of physical care environments; job stress and burnout amongst doctors; reflecting on and learning from the prevailing safety culture; supporting the needs of the ageing clinical workforce; and the design and usability of medical equipment.[2–6]

Additionally, HFE is widely recognised as a key discipline to support the safety and improvement agendas in healthcare.[2,3] We know that many patient safety incidents across all healthcare sectors are directly related to a lack of attention to HFE issues in the design of tasks, processes, technologies, work environments and socio-technical systems. Often the design inputs and processes underpinning these workplace factors have failed to adequately take account of human abilities and characteristics, making it inevitable that system failures will occur (and re-occur) and impact on human well-being and organisational performance.[10–12]

In terms of healthcare policy, NHS England’s National Quality Board, recently published a Concordat [13] signed by multiple NHS, regulatory and other agencies (Box 2), committing them to embedding HFE knowledge, principles and methods across NHS organisations to improve quality (effectiveness, experience and safety) and productivity. Rather than being perceived as an optional extra or ‘bolt-on’, the expectation is that HFE knowledge and this ‘way of thinking’ will be integrated into frontline practice, clinical education and regulation.

In medical education it is assumed that learning about ‘human factors’ is necessary because many ‘errors’ made by doctors-in-training involve the ‘failures of non-technical skills’.[14] A recent review of ‘human factors’ content in UK hospital based medical, surgical and critical care postgraduate training curricula [14] found limited standardisation of non-technical skills teaching and assessments (e.g. related to leadership, team-working, situation awareness, and decision-making) – discussion of the related UK Royal College of General Practitioners’ (RCGP) curriculum content will be a focus of the next article in this series. Although acquiring these types of skills is clearly very important for patient safety, the review appears to inadvertently conflate them with HFE as a discipline as well as highlight the very limited HFE focus (beyond personal non-technical skills) in most curricula i.e. the lack of content on, for example, the influence of tasks, technology, physical environment, organisation of work and culture on clinical performance and wellbeing provides a rather skewed version of the discipline, its purpose and its potential – issues that we will now touch on.

Box 1. The three specialist sub-domains of HFE.[1]

Table

(1) Physical HFE examines the topics of human anatomy, anthropometrics, physiology, and biomechanics in relation to the interactions of the user and the equipment used. Practical applications of these considerations include workplace layout, working postures, materials handling, repetitive movements, and work-related musculoskeletal disorder analysis. (2) Cognitive HFE analyses the cognitive processes that affect the user and interactions of the user and technology during task completion. These cognitive processes include memory, reasoning, perception, and motor response. Practical applications of cognitive HFE include the assessment of human reliability and human error, human–computer interaction, mental workload, decision-making, skilled performance, work stress, and training. (3) Organizational HFE seeks to account for the complex interactions within socio-technical systems, that is, systems that recognise the interactions between users and technology in the workplace and between society’s complex influences and human behaviour. Health care is a complex socio-technical system; it has a high degree of interrelatedness between the social and technical elements in the work and organisation. Organizational HFE focuses on holistic work system analysis and design by examining the factors that influence stakeholders work practices, that is, personnel, technology, environment, tasks, and work culture. Subgroups within these categories include teamwork, safety culture, supervision, shift work, scheduling, and job satisfaction.

Common HFE misunderstandings

In recent years, professional experiences, shared anecdotes with colleagues, and a small number of journal publications have drawn our attention to some of the unfortunate misunderstandings which continue to circulate around HFE and its application in healthcare settings.[3–5] This is vitally important as it leads to erroneous views and a limited understanding of the potential of HFE, and may slow its integration into healthcare, lead to the development of misleading educational resources, and hinder safety and improvement efforts.[4,5] As a result, Russ and colleagues have raised awareness of some of these common misunderstandings,[4] which should be borne in mind by those clinical educators and frontline practitioners and managers who are new to the discipline or have some basic understanding:

•	HFE does not address problems by teaching people to modify their behaviour – rather it addresses problems by modifying the design of the system to better aid people.
•	HFE is not about eliminating human error – rather it is about designing systems that are resilient to unanticipated events.
•	HFE is not focused solely on individuals – on the contrary HFE work ranges from the individual to the organisational level.
•	The term ‘human factors’ itself can be misleading and may result in fundamental misunderstandings. For example, some published healthcare papers refer to ‘human factors’, yet point to the ‘failures’ of people as the underlying cause of adverse events or inadequate healthcare delivery processes – a stance that is contrary to HFE science and counterproductive for advancing patient safety.
•	‘Human factors’ can sometimes be mistakenly equated with ‘training’ or ‘non-technical skills’ or ‘clinical skills training’ and confused with strategies that are intended to change human behaviour.
•	When a review of a patient safety event leads to a determination that the ‘cause’ is ‘human error’, it is not uncommon for healthcare organisations to try to modify the behaviour of the individual or group through counsel or retraining – rather than correcting human behaviour, HFE approaches focus on improving system design.

Examples of HFE principles and approaches

Many of the methods used in HFE are likely to be outside the interest of primary care clinicians and other staff groups (e.g. cognitive work analysis, hierarchical task analysis and mental workload assessment), although it would be of interest to determine which particular methods could be feasibly applied by non-specialists without too much training (e.g. specialty trainees as part of a quality improvement project). However, some of the core principles which define HFE ‘as a way of thinking’ can be readily implemented by frontline clinicians, managers and others, and will be very useful for related education in this area. A few basic examples are outlined below[3]:

Anticipate what can go wrong

So called ‘human error’ is ubiquitous and inevitable in healthcare and life in general – levels of training, experience, expertise and motivation may have limited impact in this regard. Given this knowledge, the complexity of general practice and what we know can go wrong, then one strategy is to adopt a proactive safety management approach by designing suitable defence or coping mechanisms to minimising the risks and impacts of ‘error’.[15–17] For example, a validated list of aspirational ‘never events’ (serious patient safety incidents that should ‘never happen’ if appropriate barriers are in place) was recently published for UK general practice.[18] These are examples of possible practice system failures that we can anticipate and can potentially militate against using prospective hazard analysis methods, such as ‘Failure Modes and Effect Analysis’ or the ‘Structured What If Technique’, to assess how, where and why things can go wrong.[19]

Speak to people who do the job

A guiding HFE principle is that people who actually do the work are best placed to understand the work tasks, processes, patients, technology and the wider environment with which they interact. If we consider the test ordering and results handling process in general practice, then it is of great importance that all members of the GP team who have a related job role contribute in making the design of this type of work system safer.[20] For example, team members such as reception and administrative staff ‘… know what works well and what does not; the shortcuts, errors and accommodations that are made every day to get the job done, which rarely surface unless something goes wrong’. System-wide good practice guidance for GP teams was recently published in this area,[21] while the use of a safety climate assessment tool [22] may enable all members of the team to discuss the breadth and depth of system issues that influence how everyday work is done, providing important learning opportunities to make processes and systems safer.

Consider the entire system

‘Enhanced’ significant event analysis is an incident review technique for primary care [23] that goes beyond the focus on people and behaviours, and looks for interacting factors across the wider system that contributed to why something has gone wrong (e.g. task complexity, job demands, workload pressures, systems of working and communication, usability of technology, conflicting job goals, the prevailing practice culture and so on). The ‘systems approach’ is characteristic of a positive and just safety culture, and seeks to consider the influences of the wider system on the way people work.[3,7] Adopting this principle is also useful when introducing a change to practice, or a new piece of equipment or when participating in quality improvement activity.[3,7,24]

Simplify and standardise

Simplification and standardisation of care processes are likely to be problematic given the complexity and diversity of clinical needs in primary care.[6] However, where deemed appropriate, standardising common work procedures can make it easier for the GP team as there may be less mental effort, workload and stress involved. For example, reception staff have reported feelings of anxiety, frustration, pressure or awkwardness caused by limited, unclear and ambiguous test result communications by doctors which often requires further clarification – adding to workload, inefficiency and worry about the negative reactions of some doctors.[20] Similar communication concerns and impacts are reported between reception staff and patients.[21] Standardisation may help here through introducing a locally agreed set of practice-wide terms, words and abbreviations related to the results handling process which all clinical and non-clinical staff fully understand and use as a matter of routine when communicating with each other and with patients.

HFE principles in action

A practical example of the recent application of HFE principles and methods in primary care was the development of a preliminary safety checklist for the GP work system.[25] In this study, all of the above principles where adhered to and applied in the following ways:

•	A participatory co-design approach was used that involved frontline GPs, nurses and managers leading the identification and prioritisation of hazards that can impact on the wellbeing of people and practice performance (i.e. anticipating what can go wrong)
•	The project participants developed, agreed, validated a related checklist intervention because they are the ones with the necessary expertise and experience and so are best placed to do this (i.e. speaking to the people who do the job).
•	The project was guided by a Human Factors based systems approach to ensure all issues of relevance were included (i.e. considering the entire system)
•	The checklist potentially enables the integration, standardisation and simplification of existing processes for checking safety critical issues that can be implemented systematically (i.e. simplifying and standardising). It should be noted that the ‘successful’ design and implementation of a ‘checklist solution’ is strongly dependent on a range of socio-cultural factors.[26]
•	A further HFE principle still to applied in this respect is to work with practice managers as ‘end users’ of the checklist to understand related design and implementation issues around, for example, usability, feasibility, motivation, satisfaction and safety impact (i.e. end user involvement).

HFE opportunities and primary care

Similar to progress with the patient safety agenda, HFE interventions and approaches (including research and education) are very limited and have been slow to develop in primary care internationally.[6,27] Other than some evidence from a small but growing patient safety literature,[28] we have limited knowledge of the HFE issues of relevance that can inform the design of systems and technology to improve patient safety and the health and wellbeing of the primary care workforce. However, based on the available evidence and informed commentary,[6] it is clear that there are at least some significant HFE issues that can fundamentally influence system functioning and patient safety (Table 1) i.e. promote hazardous situations or mitigate the potential for error:

Table 1. Selected examples of potential HFE issues of relevance to primary care.

HFE issue	Description	Primary care example(s)
System designs	Most primary care systems are not designed for error i.e. ‘a process that is designed for errors is one that facilitates error or hazard identification and thus prevention’. Where good system design is absent or inadequate, multiple latent conditions such as unreliable equipment or IT, poor organisation of work, psycho-social issues and communication gaps can lead to system failures	The patient safety literature suggests, for example, that medicines reconciliation, test results handling and the management of patients taking high risk medications are some of the areas where system and technology designs can be sub-optimal
Diagnostic error	Problems underlying diagnostic error include complacency regarding common symptoms, which can mask complaints that are more serious, a lack of specialised knowledge of rare symptoms or diseases, and forgetting specific screening procedures, and the impact of cognitive bias on clinical decision-making	To reduce diagnostic errors, decision-support technology can help to optimise the use of diagnostic tests in clinical practice – it is important to evaluate the impact on adverse events, the impact on workflow, satisfaction of professionals and on costs and benefits
Medication errors	Polypharmacy is one of the factors behind the high rate of medication-related patient safety incidents, mostly affecting the elderly. Clinical computer systems with patient safety features could help, but the challenge is to overcome the problem that GPs often do not read these warnings or become habituated to repeated low relevance warnings	Medication reviews and enhanced roles of pharmacists are potential strategies to reduce medication errors
Technology design and selection	Lack of robust technological solutions to reconcile test and radiological results returned to practices can lead to patient safety incidents	The design and introduction of IT solutions for test result reconciliation should involve those using systems both to order requests and reconcile results
Communication processes	Human-to-human communication, especially when mediated by technology	Testing the usefulness of: email and mobile phone texting as communication aids; web-based technologies for patient consultations; digital recording of consultations etc.
Memory, information processing demands	Increasing patient complexity with polypharmacy and multi-morbidity can outstrip memory and information processing capacity	Decision-making aids designed with frontline workers and flexibility in systems to allow more resource (such as time) when dealing with more complex cases may be beneficial
Work pressure and workload	Both can impact on human performance and safety via their impact on psychological stress and physiology e.g. anxiety, fatigue and motivation. Impaired performance and time pressure can lead to missed diagnoses, incorrect prescriptions or poor treatment decisions	HFE design principles can help reduce reliance on memory via use of cognitive aids, better information access, standardisation etc. which can also reduce workloads in terms of recalling, locating or processing information
Complexity and coupling	The extent to which a system is complex or linear refers to whether the processes flow in a linear, anticipated fashion or unanticipated interactions between system elements that can have unanticipated consequences	Many significant events demonstrate that primary care is highly complex but is often loosely coupled i.e. there is a time lag between decisions and actions that can be exploited by designing in hazard detection mechanisms. An example might be a prescription error being picked up by the GP, pharmacist, patient or relative
Ageing	Human factors applications to meet the needs, capabilities, and limitations of the elderly and other special populations	Applying human factors principles to reduce falls in the home. Flexible working patterns to accommodate the ageing primary care workforce
Product design	Developing products that are useful, usable, safe and desirable	Redesigning epinephrine auto-injectors for patients in an effort to reduce injection errors during anaphylaxis
Usability	Measurement of the quality of a user’s experience when interacting with a product or system	Usability evaluation of the safety of GP IT systems or emergency equipment interfaces
Training	Training system design and evaluation, innovative technologies for training, and instructional design and implementation	Development and testing of simulation training for medical emergencies

Source: Adapted from Ref. [6].

In addition to these HFE concerns, the following contextual issues often differentiate primary care from other care sectors [6] and must also be taken into account when efforts are made to improve patient safety and/or implement potential HFE solutions:

•	Patients require integration of care for multiple problems
•	Diversity of clinical needs make standardisation of care processes difficult
•	Time limitations are important
•	Multiple places, systems and people are involved in the care of patients
•	Communication with patients occurs in many ways
•	Information – it’s feast or famine
•	Context and family are important
•	Relationships and continuity are important
•	There are limitations on the use of therapeutics, procedures and technology
•	There is great variability of patients and their needs
•	Slack (loose coupling) in the system can allow for error recovery

Box 2. Signatories to the National Quality Board Concordat.

Table

• NHS England • General Medical Council • Nursing and Midwifery Council • Health Education England • Public Health England • NHS Employers • Care Quality Commission • National Institute for Health and Social Care Excellence • NHS Trust Development Authority • NHS Litigation Authority • NHS Leadership Academy • Parliamentary and Health Service Ombudsman

Building HFE capacity and capability

We are really only beginning to take the first steps in properly understanding the potential of HFE in primary care and the need for co-ordinated and integrated learning in this important area. Action is necessary to equip the workforce at all levels with fundamental knowledge and skills in how HFE thinking and methods can be applied to optimise practice performance and contribute to safety and improvement activities.[13] For example, in the next paper in this series, McKay and colleagues will present potential gaps in HFE education which are deemed necessary to be included in the specialty training environment to help prepare trainee GPs for independent practice (this includes a review of the current UK RCGP curriculum in this area). Unsurprisingly many of the issues raised also have educational and frontline service relevance for the wider GP team as well as all primary care professions.

Building on partnership work and progress made by Health Education England (HEE) and the Chartered Institute of Ergonomics & Human Factors (CIEHF) during 2014/15, NHS Education for Scotland (NES) plans to adapt and run three hour HFE Awareness Raising (Taster) workshops for health and social care staff in Scottish regions throughout 2016–2017. During this period, NES is also developing entry-level HFE e-learning for the NHS workforce, with the goal of gaining CIEHF accreditation to assure credibility and consistency in educational standards. Internal discussions are also taking place about how to build future clinical academic capacity and capability in the HFE discipline, and how best to encourage and support those interested in undertaking CIEHF-accredited postgraduate qualifications, including higher degrees, as part of their professional development.

Finally, the UK based Clinical Human Factors Group (CHFG) is a well-known and established charitable organisation that consists of a broad coalition of healthcare professionals, managers and service-users who have partnered with HFE experts to campaign for change in the NHS.[29] The CHFG vision is of a healthcare system that places an understanding of HFE at the heart of improving clinical, managerial and organisational practice, leading to significant improvements in safety and efficiency. In recognising that the HFE focus on primary care is rather limited, CHFG has recently commissioned the NES safety and improvement team to undertake a scoping review of HFE approaches, methods, interventions and impacts, with the final report due in the summer of 2016.

Conclusion

While not promising instant solutions, the potential benefits of HFE to everyday performance, productivity, safety, efficiency and personal wellbeing should be self-evident and desirable to those with a clinical, policy and educational interest in primary care. Over recent years, some in healthcare (with the best of intentions) have misunderstood and misapplied HFE, or unwittingly adopted a limited application of this scientific discipline. However, primary care now has a golden opportunity to learn from past experiences and lead the way in properly teaching and integrating HFE principles and methods at all levels of educational curricula and healthcare practice. It goes without saying that this will be a very significant challenge – one which will require a consistent approach to HFE, and the collective efforts of educational, professional, healthcare and regulatory bodies to support, promote and embed the discipline in line with the aspirations of the NHS England National Quality Board Concordat.[13]

Further information about HFE can be accessed here

Chartered Institute of Ergonomics and Human Factors

http://www.ergonomics.org.uk/

International Ergonomics Association

http://www.iea.cc/

Human Factors and Ergonomics Society

https://hfes.org/web/Default.aspx

Human Factors and Ergonomics Society of Australia

http://www.ergonomics.org.au/

Clinical Human Factors Group

http://chfg.org/

Health Education England – Learning to be Safer https://hee.nhs.uk/our-work/hospitals-primary-community-care/learning-be-safer

National Quality Board – Human Factors Concordat

https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-hum-fact-concord.pdf

Acknowledgements

The NES safety and improvement team sincerely thanks all UK GP teams that have contributed to the design and development of safety and improvement tools and HFE approaches over the past five years. We are also indebted to the Medical Protection Society, UK Health Foundation and the CHFG for continued project support. Finally we are grateful to Dr Duncan McNab and Dr John McKay of NHS Education for Scotland for commenting on earlier drafts of this article.