Implementing human factors in clinical practice

OBJECTIVES: To understand whether aviation-derived human factors training is acceptable and useful to healthcare professionals. To understand whether and how healthcare professionals have been able to implement human factors approaches to patient safety in their own area of clinical practice. METHODS: Qualitative, longitudinal study using semi-structured interviews and focus groups, of a multiprofessional group of UK NHS staff (from the emergency department and operating theatres) who have received aviation-derived human factors training. RESULTS: The human factors training was evaluated positively, and thought to be both acceptable and relevant to practice. However, the staff found it harder to implement what they had learned in their own clinical areas, and this was principally attributed to features of the informal organisational cultures. CONCLUSIONS: In order to successfully apply human factors approaches in hospital, careful consideration needs to be given to the local context and informal culture of clinical practice

Using a comprehensive audit to identify local context prior to care bundle design and implementation for inadvertent perioperative hypothermia in colorectal surgery

© Background The first step in bundle design or implementation is to identify the problem being addressed. Several validated approaches are recommended to facilitate this. These include using systematic reviews, adverse event triggers and risk assessment tools. However, these methods do not fully take the local context into account, which will limit the effectiveness of the bundle. Aim This study explores the potential benefit of using a comprehensive audit to identify an organisation's local context prior to designing and implementing a care bundle. Method A comprehensive audit comprising observations of four patient journeys, interviews with 21 staff and clinical data was carried out at one large National Health Service trust in England. A patient warming care bundle was used as the exemplar. Findings Each of the three data collection methods identified specific local practices which would be addressed within the planning and implementation stages of a care bundle. These practices would not have been identified through other recommended methods. Conclusion A comprehensive audit, comprising observations, interviews and clinical data is a successful method to identify local contextual issues prior to care bundle implementation

Assessing the impact of the introduction of an electronic hospital discharge system on the completeness and timeliness of discharge communication: a before and after study

Background: Hospital discharge summaries are a key communication tool ensuring continuity of care between primary and secondary care. Incomplete or untimely communication of information increases risk of hospital readmission and associated complications. The aim of this study was to evaluate whether the introduction of a new electronic discharge system (NewEDS) was associated with improvements in the completeness and timeliness of discharge information, in Nottingham University Hospitals NHS Trust, England. Methods: A before and after longitudinal study design was used. Data were collected using the gold standard auditing tool from the Royal College of Physicians (RCP). This tool contains a checklist of 57 items grouped into seven categories, 28 of which are classified as mandatory by RCP. Percentage completeness (out of the 28 mandatory items) was considered to be the primary outcome measure. Data from 773 patients discharged directly from the acute medical unit over eight-week long time periods (four before and four after the change to the NewEDS) from August 2010 to May 2012 were extracted and evaluated. Results were summarised by effect size on completeness before and after changeover to NewEDS respectively. The primary outcome variable was represented with percentage of completeness score and a non-parametric technique was used to compare pre-NewEDS and post-NewEDS scores. Results: The changeover to the NewEDS resulted in an increased completeness of discharge summaries from 60.7% to 75.0% (p < 0.001) and the proportion of summaries created under 24 h from discharge increased significantly from 78.0% to 93.0% (p < 0.001). Furthermore, five of the seven grouped checklist categories also showed significant improvements in levels of completeness (p < 0.001), although there were reduced levels of completeness for three items (p < 0.001). Conclusion: The introduction of a NewEDS was associated with a significant improvement in the completeness and timeliness of hospital discharge communication

The VOICE study – a before and after study of a dementia communication skills training course

Background A quarter of acute hospital beds are occupied by persons living with dementia, many of whom have communication problems. Healthcare professionals lack confidence in dementia communication skills, but there are no evidence-based communication skills training approaches appropriate for professionals working in this context. We aimed to develop and pilot a dementia communication skills training course that was acceptable and useful to healthcare professionals, hospital patients and their relatives. Methods The course was developed using conversation analytic findings from video recordings of healthcare professionals talking to patients living with dementia in the acute hospital, together with systematic review evidence of dementia communication skills training and taking account of expert and service-user opinion. The two-day course was based on experiential learning theory, and included simulation and video workshops, reflective diaries and didactic teaching. Actors were trained to portray patients living with dementia for the simulation exercises. Six courses were run between January and May 2017. 44/45 healthcare professionals attended both days of the course. Evaluation entailed: questionnaires on confidence in dementia communication; a dementia communication knowledge test; and participants’ satisfaction. Video-recorded, simulated assessments were used to measure changes in communication behaviour. Results Healthcare professionals increased their knowledge of dementia communication (mean improvement 1.5/10; 95% confidence interval 1.0–2.0; p<0.001). Confidence in dementia communication also increased (mean improvement 5.5/45; 95% confidence interval 4.1–6.9; p<0.001) and the course was well-received. One month later participants reported using the skills learned in clinical practice. Blind-ratings of simulated patient encounters demonstrated behaviour change in taught communication behaviours to close an encounter, consistent with the training, but not in requesting behaviours. Conclusion We have developed an innovative, evidence-based dementia communication skills training course which healthcare professionals found useful and after which they demonstrated improved dementia communication knowledge, confidence and behaviour

Communication between people living with dementia and healthcare practitioners in hospital: developing and evaluating a staff training intervention: the VOICE study

Background 25% of hospital beds are occupied by a person living with dementia. Dementia affects expressive communication and understanding. Healthcare professionals report lack of communication skills training. Objectives To identify teachable effective strategies for communication between healthcare professionals and people living with dementia, and to develop and evaluate a communication skills training course. Design We undertook a systematic literature review, video-recorded 41 encounters between staff and people with dementia, and used conversation analysis to investigate communication problems and solutions. We designed a communication skills training course using co-production and multiple pedagogic approaches. We ran a pilot, followed by six courses for healthcare professionals. We measured knowledge, confidence and communication behaviours before, immediately-and one month-after the course, and undertook interviews with participants and managers. Behaviours were measured using blind-rated videos of simulations. Setting General hospital acute geriatric medical wards; clinical skills centre. Participants We video-recorded 26 people with dementia and 26 professionals. Ten experts in dementia care, education, simulation and communication contributed to intervention development. Six healthcare professionals took part in a pilot course and 45 took part in the training. Results Literature review identified 27 studies, describing ten communication strategies, with modest evidence of effectiveness. Healthcare professional-initiated encounters followed a predictable phase structure. Problems were apparent in requests (with frequent refusals) and in closings. Success was more likely when requests were made directly, with high entitlement (authority to ask), and with lowered contingencies (made to sound less difficult , by minimising the extent or duration of the task, as king patients ‘to try’, offering help, or proposing collaborative action). Closings were more successful if the healthcare professional announced the end of the task, made a specific arrangement, body language matched talk, and through use of ‘closing idioms’. The training course comprised two days, one month apart, using experiential learning, including lectures, video-workshops, small group discussion, simulation (with specially-trained actors) and reflection. We emphasised incorporation of previous expertise, and commitment to person-centred care. 44 participants returned for the second training day; 43 provided complete evaluation data. Knowledge and confidence both increased. Some behaviours, especially relating to closings, were more commonly used after training. The course was highly-rated in interviews, especially the use of simulation, real-life video clips, and interdisciplinary learning. Participants reported that they found the methods useful in practice and were using them a month after the course finished. Limitations Data were from people with moderate to severe dementia, in an acute hospital, during healthcare professional initiated interactions. Analysis was limited to problems and solutions that were likely to be ‘trainable’. Actors required careful preparation to simulate people with dementia. Communication skills training course participants were volunteers, unlikely to be representative of the general workforce, who displayed high levels of baseline knowledge, confidence and skills. Before-and-after evaluations, and qualitative interviews, are prone to bias. Future work Further research should investigate a wider range of health, social care and family carers. Conversation analysis should be used to investigate other aspects of healthcare communication. Conclusions Requests and closings pose particular difficulties for professionals communicating with people with dementia. We identified solutions to these problems and incorporated them into communication skills training, which improved knowledge, confidence and some communication behaviours. Simulation was an effective training modality

GENESISS 2—Generating Standards for In-Situ Simulation project: a systematic mapping review

Background: In-situ simulation is increasingly employed in healthcare settings to support learning and improve patient, staff and organisational outcomes. It can help participants to problem solve within real, dynamic and familiar clinical settings, develop effective multidisciplinary team working and facilitates learning into practice. There is nevertheless a reported lack of a standardised and cohesive approach across healthcare organisations. The aim of this systematic mapping review was to explore and map the current evidence base for in-situ interventions, identify gaps in the literature and inform future research and evaluation questions. Methods: A systematic mapping review of published in-situ simulation literature was conducted. Searches were conducted on MEDLINE, EMBASE, AMED, PsycINFO, CINAHL, MIDIRS and ProQuest databases to identify all relevant literature from inception to October 2020. Relevant papers were retrieved, reviewed and extracted data were organised into broad themes. Results: Sixty-nine papers were included in the mapping review. In-situ simulation is used 1) as an assessment tool; 2) to assess and promote system readiness and safety cultures; 3) to improve clinical skills and patient outcomes; 4) to improve non-technical skills (NTS), knowledge and confidence. Most studies included were observational and assessed individual, team or departmental performance against clinical standards. There was considerable variation in assessment methods, length of study and the frequency of interventions. Conclusions: This mapping highlights various in-situ simulation approaches designed to address a range of objectives in healthcare settings; most studies report in-situ simulation to be feasible and beneficial in addressing various learning and improvement objectives. There is a lack of consensus for implementing and evaluating in-situ simulation and further studies are required to identify potential benefits and impacts on patient outcomes. In-situ simulation studies need to include detailed demographic and contextual data to consider transferability across care settings and teams and to assess possible confounding factors. Valid and reliable data collection tools should be developed to capture the complexity of team and individual performance in real settings. Research should focus on identifying the optimal frequency and length of in-situ simulations to improve outcomes and maximize participant experience

GENESISS 1 - Generating Standards for In-Situ Simulation project: a scoping review and conceptual model

Background: In-Situ Simulation (ISS) enables teams to rehearse and review practice in the clinical environment to facilitate knowledge transition, reflection and safe learning. There is increasing use of ISS in healthcare organisations for which patient safety and quality improvement are key drivers. However, the effectiveness of ISS interventions has not yet been fully demonstrated and requires further study to maximise impact. Cohesive programmatic implementation is lacking and efforts to standardise ISS terms and concepts, strengthen the evidence base and develop an integrated model of learning is required. The aim of this study was to explore the current evidence, theories and concepts associated with ISS across all areas of healthcare and develop a conceptual model to inform future ISS research and best practice guidance. Methods: A scoping review was undertaken with stakeholder feedback to develop a conceptual model for ISS. Medline, OpenGrey and Web of Science were searched in September 2018 and updated in December 2020. Data from the included scoping review studies were analysed descriptively and organised into categories based on the different motivations, concepts and theoretical approaches for ISS. Categories and concepts were further refined through accessing stakeholder feedback. Results: Thirty-eight papers were included in the scoping review. Papers reported the development and evaluation of ISS interventions. Stakeholder groups highlighted situations where ISS could be suitable to improve care and outcomes and identified contextual and practical factors for implementation. A conceptual model of ISS was developed which was organised into four themes: 1. To understand and explore why systematic events occur in complex settings; 2.To design and test new clinical spaces, equipment, information technologies and procedures; 3. To practice and develop capability in individual and team performance; 4. To assess competency in complex clinical settings. Conclusions: ISS presents a promising approach to improve individual and team capabilities and system performance and address the ‘practice-theory gap’. However, there are limitations associated with ISS such as the impact on the clinical setting and service provision, the reliance of having an open learning culture and availability of relevant expertise. ISS should be introduced with due consideration of the specific objectives and learning needs it is proposed to address. Effectiveness of ISS has not yet been established and further research is required to evaluate and disseminate the findings of ISS interventions

Identifying Work System Components and Constraints of Cancer Multidisciplinary Team Meetings

Multidisciplinary teams have been introduced into cancer care to improve quality of care and are now considered the gold standard for the management of cancer patients in the UK. Meetings of these teams provide an opportunity for experts to discuss the best possible treatment options for the patient. Trends show that referral numbers to these meetings are increasing, placing strain on the capacity of meetings to function optimally. This in turn has cognitive and workload implications for staff involved. Promoting MDT Excellence is a project that aims to examine the variation in practice of these meetings across one NHS Trust and to understand the challenges they are currently facing. In the first phase of this project, a systems analysis of cancer multidisciplinary teams was conducted for the purpose of identifying system constraints and resource issues. A total of twelve meetings were observed, and 42 staff from four specialties were interviewed. Using the SEIPS 2.0 model, key work system components and constraints for multidisciplinary team meetings were identified for the people involved, the tasks, tools and technology, organisation of work, internal environment and external environment. Furthermore, aspects that promoted efficient ways of working and positive outcomes were captured. Examples identified included adopting a more structured agenda, real time digital notetaking and different work organisation techniques, such as distribution of responsibilities and the scheduling of patient groups to be discussed during the meeting. These results provide the basis for a multifaceted approach for system improvement for this work process

Identifying Work System Components and Constraints of Cancer Multidisciplinary Team Meetings

Multidisciplinary teams have been introduced into cancer care to improve quality of care and are now considered the gold standard for the management of cancer patients in the UK. Meetings of these teams provide an opportunity for experts to discuss the best possible treatment options for the patient. Trends show that referral numbers to these meetings are increasing, placing strain on the capacity of meetings to function optimally. This in turn has cognitive and workload implications for staff involved. Promoting MDT Excellence is a project that aims to examine the variation in practice of these meetings across one NHS Trust and to understand the challenges they are currently facing. In the first phase of this project, a systems analysis of cancer multidisciplinary teams was conducted for the purpose of identifying system constraints and resource issues. A total of twelve meetings were observed, and 42 staff from four specialties were interviewed. Using the SEIPS 2.0 model, key work system components and constraints for multidisciplinary team meetings were identified for the people involved, the tasks, tools and technology, organisation of work, internal environment and external environment. Furthermore, aspects that promoted efficient ways of working and positive outcomes were captured. Examples identified included adopting a more structured agenda, real time digital notetaking and different work organisation techniques, such as distribution of responsibilities and the scheduling of patient groups to be discussed during the meeting. These results provide the basis for a multifaceted approach for system improvement for this work process