Bryn Baxendale

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.

Simulated patients versus manikins in acute-care scenarios.

Manikins and simulated patients (SPs) are commonly used in health care education and assessment. SPs appear to offer a more realistic experience for learners than ‘plastic’ manikins, and might be expected to engender interactions that approximate real clinical practice more closely. The analyses of linguistic patterns and touch are methodologies that could be used to explore this hypothesis. Our research aims were: (1) to compare verbal interactions and the use of procedural touch by health care workers (HCWs) in scenarios with SPs and with manikins; and (2) to evaluate the methodologies used to inform a large‐scale study.

The Temporal Rating of Emergency Non-Technical skills (TRENT) index for self and others: psychometric properties and emotional responses

BackgroundTo enhance the non-technical skills (NTS) assessment literature by developing a reliable and valid peer and self-assessment tool for NTS in a simulated ward setting to include emotional reactions: the Temporal Rating of Emergency Non-Technical skills (TRENT) Index. The paper aims to document (1) the psychometric properties of the TRENT index (e.g., reliability, idiosyncrasy biases) and (2) its validity in terms of performance-emotional associations in the high fidelity simulated ward environment.MethodsTwo samples of doctors (Ns =150 & 90) taking part in emergency simulations provided both self and peer-assessment of NTS, with the second sample also providing self-assessments of mood. The psychometric properties of the TRENT were explored for self- and peer-assessment, and pre- and post-simulation environment mood was used to assess validity.ResultsA psychometrically reliable and valid 5-factor assessment of NTS was developed. While there was evidence for both intra-rater and inter-rater reliability, inter-rater idiosyncrasy was also observed. Self-rated, but not peer-rated, negative performance was positively associated with post simulation negative mood.ConclusionThese are the first results that pertain to inter-, intra-rater reliability as well as idiosyncratic biases in NTS assessment and the first to show that simulator performance can influence mood after assessment. Potential clinical carry-over effects of mood are discussed.

Is Laparoscopic Simulator Performance Affected by Training Environment

The use of simulators in laparoscopic surgery complements current training with reduced working hours. Trainees can acquire basic skills quickly and efficiently without compromising patient safety. Competence in skills learnt on a simulator has been shown to translate to operating theatre performance. In addition to this, laparoscopic surgeons require new skills since no transfer has been reported between open surgical skills and new laparoscopic techniques. As a result of their numerous advantages, simulators are routinely used as part of training in laparoscopic surgery.

A qualitative evaluation of the role of simulation in policy development for service improvement

Objective To evaluate the efficacy of simulation-based techniques to prospectively assess developing polices prior to implementation. Methods A self-selected sample of nursing staff from a local, acute hospital reviewed a draft intravenous drug administration policy before simulating drug administration of either an infusion or direct injection. The participants completed a postsimulation questionnaire regarding the new policy and simulation, took part in a semistructured interview and were observed during the simulation with their consent. Results 10 staff attended the simulation. The emergent themes identified a wide range of factors relating to the everyday usability and practicalities of the policy. There were issues surrounding inconsistent language between different clinical teams and training requirements for the new policy. Conclusion Simulation, using simple scenarios, allows the safe evaluation of new policies before publication to ensure they are appropriate for front-line use. It engages staff in user-centred design in their own healthcare system.

Simulation and Technology Enhanced Learning: future implications for healthcare education and practice

Simulation and Technology Enhanced Learning (TEL) offers great promise for healthcare education arising from a rapid expansion in diverse technology driven advances in accessing medical knowledge and applying it to practice. This includes information presented in novel or interactive ways to learners and at a time convenient to them, transforming how this experience can be more explicitly learner centred and personalised. Significant advances include online learning options and digital connectivity, use of mobile learning technologies, many forms of simulation involving physical interaction and 3D printing through to virtual reality (VR) and augmented reality (AR). The success of these will be measured by the extent to which they can be implemented at scale and sustained alongside evidence demonstrating that they enable the health and social care workforce to develop the capabilities needed to support safe and effective care. This must be achieved amidst significant pressures faced by health systems from changing population demographics and financial pressures. An important large scale change has been the increased sharing of information and knowledge and collaboration to enable delivery of education and training beyond traditional boundaries. Examples include institutionally led and structured Massive Open Online Courses (MOOC’s) to enhance distance learning opportunities.1 Beyond this, the development and sharing of digital educational resources has adopted qualities akin to educational crowd sourcing using social media and networking platforms. Geographically and institutionally disparate groups can form, share resources, communicate and interact dynamically to suit their own needs, further demonstrated by the emergence of Free Open Access Meducation (FOAM) platforms.2 Professional bodies with specific responsibilities toward the education and development of the healthcare workforce have also supported this approach. A prime example is Health Education England’s Learning Solution which involves the development of a large scale, searchable digital compendium that seeks to improve access to existing learning …

O51 Use of hierarchical task analysis and in-situ simulation for adult intensive care staff in managing unplanned extubations

Background and Purpose Unplanned extubation (UE) is a recognised complication of critical care airway management.(NAP4, Royal College of Anaesthetists, UK) Although an infrequent occurrence in adult intensive care units (ICU) it presents a unique challenge to staff in safely securing the patient‘s airway under varying staff skill mix and ICU experience. This study provides a human factors systems work analysis and qualitative evaluation of ICU staff in a National Health Service (NHS) Hospital Trust to inform the development of a mastery learning programme (MLP) for UE response and management (see Figure). Methodology A hierarchical task analysis (TA) for the management of UEs in orally intubated patients was co-created with Anaesthetic and critical care experts. The TA was shared with twenty-one ICU nurses and doctors ranging in seniority and airway training who were interviewed about their experiences with UEs and the sociotechnical and contextual factors affecting their clinical practice and decision making. Recorded in-situ simulation was used to test the methodology and inform learning. Abstract O51 Figure 1 Results Interview findings provided comprehensive understanding of the clinical tasks, essential personnel, and the equipment and information necessary for responding to UE incidents. Leadership of senior nurses and doctors was essential to explicitly verbalise directions to junior staff members; however, individual situation awareness and unspoken tacit knowledge of roles and responsibilities also informed UE response. Expert review of video captured during the in-situ simulation informed the MLP. Discussion The experiences of Nottingham ICU staff revealed the essential nature of non-technical skills that are employed to cope with uncertainty in experience level and technical knowledge of team members who will respond to an UE event. Skill gaps were identified due to inconsistent training and lack of familiarity with UEs and reintubation. Identification of staff coping skills, teamwork, leadership, task allocation, and communication are required for the development of a MLP for adult ICU staff for UE and airway management. Conclusions This study can be used to upskill both nurses and doctors in UE response, enhance organisational learning, provide in-situ simulation and improve timeliness and safety in UE rescue based on a human factors approach. Reference 1. 4th National Audit Project of the Royal College of Anaesthetists: Major complications of airway management in the UK 2011:71. Royal College of Anaesthetists, UK. https://www.rcoa.ac.uk/system/files/CSQ-NAP4-Full.pdf

0150 Designing a curriculum for operating theatre patient safety champions

Background Following a thematic analysis of a series of Never Events in Theatres at Nottingham University Hospitals, one of the recommendations made was to establish a network of theatre team-based Patient Safety Champions enlisted from experienced members of the theatre practitioner workforce. This network has been sustained for over 3 years, but it is apparent that structured professional development in the role would benefit individuals in terms of their contribution as well as enhance the value of the network overall. This abstract describes the design of such a curriculum and next steps in its implementation and evaluation. Methodology A number of published UK and international curricula related to patient safety improvement in healthcare were reviewed. Key themed topics were highlighted in terms of knowledge and specific ‘safety’ skills and behaviours. These were subsequently contextualised to highlight relevance to operating theatre practices and care pathway that patients follow in the perioperative period. A range of educational methods were also considered in order to promote a blended approach of classroom teaching, access to web-based resources, and simulation-based experiential learning. An assessment methodology has also been designed to highlight gaps in knowledge or confidence, the latter enabling targeted coaching to ensure new knowledge and skills are implemented and supported in practice. Outcomes The structure and process for curriculum delivery will be discussed, and the potential for extending this professional development pathway into different areas of clinical practice will be considered. Evaluation metrics to demonstrate benefit will also be outlined. Potential impact This programme will benefit the integration of human factors education into daily practice by engaging team members more directly in patient safety improvement work. Developing and enhancing the collaborative nature of a network of champions should also accelerate safety lessons being shared effectively and build momentum towards improving a safety (learning) culture. References WHO patient safety curriculum guide: multi-professional edition October 2011 The Essential Guide for Patient Safety Officers published by Joint Commission Resources and Institute for Healthcare Improvement. 1st edn, April 2010

0129 Gauging The Gap In Key Patient Safety Skills And Behaviours Amongst Undergraduate Medical Students

Background Newly qualified medical staff should be able to contribute to patient safety and quality improvement although this potential is often not optimised. Knowledge and attitudes to patient safety amongst junior doctors has been scrutinised but analysis of weaknesses in safety skills and behaviours is less evident. This project aimed to explore this area in final year medical students at the University of Nottingham. Methodology A long-list of skills and behaviours was compiled from published patient safety curricula. An expert group of local educators and clinicians experienced in patient safety reviewed these using a modified nominal group Delphi method and prioritised those deemed most important or difficult to attain in medical undergraduates before qualification. A cohort of final year undergraduate medical students were asked to self-rate (five point Likert scale) their ability to demonstrate these skills and behaviours if required when commencing as an FY1 doctor. Students were also asked to consider how they expected these attributes to have altered by the end of their FY1 year. Results The expert group identified 20 prioritised safety skills and behaviours. Survey responses from 41 undergraduates indicated students felt more capable of communication related skills in terms of informing patients about harm events, although less able to challenge or raise concerns about colleagues’ performance. Students felt less able to report or engage in analysis of patient safety incidents. Use of quality improvement techniques was an area of unfamiliarity. Students expected to be able to perform all skills and behaviours better by the end of the FY1 year. Conclusions and recommendations This project highlighted safety skills and behaviours for prioritisation in future educational interventions, which could use simulation-based approaches for development and assessment of attaining suitable standards of performance. This could also expose areas of unconscious incompetence in undergraduates as they prepare for practice. References Durani P, Dias J, Singh HP, Taub N. ‘Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate.’ BMJ Qual Saf 2013; 22(1):65–71 General Medical Council, Tomorrow’s Doctors 2009 Vohra PD, Johnson JK, Daugherty CK, Wen M, Barach P. ‘Housestaff and medical student attitudes toward medical errors and adverse events’ Jt Comm J Qual Patient Saf. 2007 33(8):493–501

0230 Do Medical Students Do What They Say? Observing Safety Skills And Behaviours In Simulated Situations

Background Effective non-technical skills can reduce healthcare error1, including the use of decision making tools (cognitive aids2) and communication in raising concerns3. A local survey suggested that 81% of medical students would use cognitive aids in decision making and 78% would raise concerns with a senior. This study considered whether students actually did so in simulated scenarios and to what extent this was affected by teaching interventions. Methodology Final year medical students were observed during three high-fidelity cardiac arrest scenarios. Behaviour coding frames with a checklist of behaviours, developed through observations of previous scenarios, were used to assess use of the ALS algorithm and the ability to raise concerns when given incorrect advice. A one-way between groups design was used to investigate the effect of presentations, with Group A taught about both the use of cognitive aids and the process of raising concerns, Group B about cognitive aids only and Group C about raising concerns only. Results Cognitive Aid: Eleven scenarios were observed by a faculty member using the behaviour coding frame. In no scenario was the cognitive aid physically used; only Group B mentioned the ALS algorithm. However the behaviours on the algorithm were still present; Group B completed the specified behaviours most often and in better time. Raising concerns Conclusions and recommendations Findings suggest that despite students often stating that they would use physical cognitive aids and raise concerns, the reality (despite simulated) does not meet their belief. These findings, however, do suggest that an educational intervention improves performance. Such interventions could therefore improve safety behaviours with the eventual aim of reducing error rates. References Flin R. (2013) Non-technical skills for anaesthetists, surgeons and scrub practitioners (ANTS, NOTSS and SPLINTS). The Health Foundation Harrison T, Mansa T, Howard S, GABA D (2006). Use of cognitive aids in a simulated anaesthetic crisis. Anaesthesia and Analgesia. 103. pp 551–6 White AA, Bell SK, Krauss MJ, et al, (2011). How trainees would disclose medical errors: educational implications for training programmes. Medical Education. 2011;45 (4):372–80