quality education for a healthier scotland hands, heads and bumps : a human factors approach to...

Quality Education for a Healthier Scotland

Hands, heads and bumps : a human factors approach to behaviour

change

Dr Vivien SwansonProgramme Director, Psychology Specialist Practice,

NHS Education for Scotland


•Patient safety as behaviour - the role of human factors

•Using psychology, behaviour change theory to develop and evaluate interventions

•Heads (Psychology), hands (Hygiene) and Bumps (remote and rural resuscitation) study findings

AIMSAIMS


HUMAN FACTORS…

Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings”

(Catchpole 2010)


human factors

Including……….Personal : Cognitive, mental load, stress and fatigueTeam : Communication, decision making, teamworkContext: Situational awareness, information gathering

• Common Human factors


contexts:

• BASICS – pre-post evaluation and observation of remote and rural health care practitioners during resuscitation training, using behavioural rating scale

• TRAINEE hospital doctors and hand hygiene - assessment of intention and behaviour (qualitative / quantitative – simulation)


Other factors…• Health professionals :

– Level of experience, seniority

• Control (responsibility):– Individual, group, system

• Task : demands– Frequency, (Routine, habit, one-off),

implications, cognitive complexity

• Context: – Time, resources


behaviours?

• BASICS – resuscitation training (leadership, communication,

monitoring)

• TRAINEE hospital doctors and hand hygiene

(hand washing procedures, carry gel)


BASICS : BehaviourItem DemonstratedGathering information Conduct a risk assessment of the scene and makes sure it is safe to approach the patient before proceeding

44 (41-64)

Review decisions to ensure they are still appropriate requesting a second opinion from others, where possible

28 (14-67)

Try alternative options when a certain approach is not working

47 (21-74)

Communication and Teamwork Clearly communicate information about the chosen course of action

43 (29-79)

Not dismiss suggestions of others based on their status/experience

43 (38-43)

Encourage other team members to voice their opinions 2 (2-8) Decision-making and Leadership Take charge of the situation and make requests of others at necessary times

62 (46-95)

Ask others to undertake specific tasks at appropriate times providing clear direction

62 (20-94)


HH : Self Reported Behaviour

“I always perform hand hygiene before and after every contact with each patient “

80% Agreed, 20% Unsure, 0% Disagree


Using theory to assess behaviour (TPB)

• Attitudes• Norms • Self-efficacy• Intentions

• Patey, Flin et al. WHO Patient Safety Curriculum Guide for Medical Schools: Implementation Study (2010)

• Wakefield et al, 2010 Health professionals patient safety behaviour ;

• Jenner et al. 2002. Explaining hand hygiene practice. Psychol health and med.


TPB: Positive attitudes, norms and confidence predict intentions

(BASICS, HH)

ATTITUDESIts important to communicate with others during resuscitation

(BASICS)

ATTITUDESIts important to communicate with others during resuscitation

(BASICS)

SOCIAL NORMSI feel under social pressure from staff to wash my hands

(HH)

SOCIAL NORMSI feel under social pressure from staff to wash my hands

(HH)

SELF-EFFICACYIts difficult for me to wash my hands before and after patient

contact (HH)

SELF-EFFICACYIts difficult for me to wash my hands before and after patient

contact (HH)


TBP Regression : HH / TPB: •attitude and subjective norms significantly predicted HH intentions (p<0.01; p<0.05); intentions predicted self-report HH behaviour (p<0.01).

BASICS:•Pre - Perceived relevance of skills, (Info gathering, communication), subjective norms and stress predicted 75% of variance in intentions to use skills•Post - 41% of variance (stress NS)


The intention-behaviour gap – and how to bridge

it


Stress and performance (behaviour)

• Narrows focus of attention• Some (acute) stress is positive

(coping) • Simple cognitive/motor (habitual)

activities benefitor..• ‘freezing’, problems with cognition,

memory, attention


Using Theory to assess behaviour : Theoretical Domains framework – TDFHH Study

• professional role, • beliefs about capabilities and

consequences, • social influences• motivation and goals, • action plans• memory and attention, • environmental resources.


TDF: regression

• the model significantly predicted self-reported HH behaviour (37.8%)

• (no independent predictors).


HH : TDF results

Key Levers...Knowledge and skillsInfluence of professional roleBeliefs about consequencesMotivation and goals

Key Barriers...Memory and attention levelsBeliefs about capabilitiesAction plans.


Ward Simulation :


Self explanatory technique (Think aloud) • Participant watched a replay of the videos of

their exam with interviewer (interviewers blind to results of pass or fail).

• Asked to describe what they were thinking at particular points in the video (namely when HH was performed or absent).

• “can you explain what was going on for you at that point”

• No direct questions about hand hygiene or aseptic techniques until the end of the interview, only if raised by the participant.

• “what would you have done differently”?


“And I was trying to do several things at once. And I did not do that very well. And certainly that is one thing when I thought about hand hygiene at the end of it that just went out the window. It basically never entered my head even though I had spent so long before that point washing my hands every time I went into a room, every time I left a room” (HH)

Intention-behaviour gap…


Individual factors : Memory

“ I think I just remember the five moments of hand hygiene thing that we get taught. And it’s almost like when you go and see a new patient you say, “hi, my name is XX’. That’s just an automatic thing. And I think now, by going on the wards more, when you go and see a patient you wash your hands and that’s an automatic thing. It’s almost like introducing myself now.

And I just remembered the five moments of hand hygiene, or the only step I remember is the first one, I always forget to wash my... Well, not always, but I sometimes forget to wash my hands when I leave a patient” (HH9)


Individual factors : cognitive load

“And its when I get called away I’ve got other information in my head, like he would be like “This patient needs paracetamol, she’s in a lot of pain”

So, I am thinking, how much paracetamol am I going to give her. I am not thinking I need to wash my hands before I leave this patient. So I felt like I could only hold one thought in my head, if you get me.” (HH1)


Individual factors : Stress & fatigue

“I think I was definitely classing myself as stressed at that point, I knew I was stressed because I had a bit of a mind blank in terms of wheels were turning but I wasn’t really going through the gears, I was stuck on the first thought” (HH7)


HH : Summary of findings

1. Most did not perform HH in accordance with WHO guidelines.

2. Most who did not perform HH during the simulation, self-reported that they normally adhere to HH procedure in ‘normal’ (non exam) conditions.

3. Greater emphasis on individual human factors at play in the context of the WSE condition.

4. Stress/anxiety, mental load and change of context/environment seems to have the biggest negative impact on the participants’ ability to perform HH during the simulation.

5. The (multi-tasking) nature of the WSE, increased importance of individual factors.


Human

factors

Elements

Behaviour change Technique

M, A, P

Task

management

Planning, preparing Prioritizing Coping with pressure

Goal setting (A1)Time management (A19)Coping strategies (M14)

Team working Co-ordinating activities Exchanging information Supporting others

Social support (M12) Social skills training (A27)

Situation awareness

Gathering information Recognizing, understanding Projecting, anticipating

Self-monitoring of behaviour (A3)Antecedents and consequences (A4)Coping strategies (M14)

Decision-

making

Identifying/considering options Balancing risks, options Implementing & reviewing

Goal review (A10)General problem solving (A22)Assertion training (M18)

Leadership Setting, maintaining standards Supporting others Coping with pressure

Goal setting (A1)Feedback (A5)Assertion training (M18)

Communicatio

n

Exchanging information Shared understanding Acting assertively

Information about behaviour (M10)Graded tasks (A11)Behavioural rehearsal (P11)Behavioural rehearsal (P11)

BASICS : Mapping human factors onto BCTs (Motivation, Action, Prompts)

BASICS : Mapping human factors onto BCTs (Motivation, Action, Prompts)


Next?

• Develop and evaluate training in Human Factors – Use theoretically based taxonomy to MAP

BCTs onto generic and specific human factors– Specify techniques that REDUCE

STRESS/IMPROV E COPING– Test in different groups of health professionals– For both novice and experienced groups (track

over time)• Develop a (theoretically underpinned) curriculum

for the service with standards (levels of competence) and can be assessed

quality education for a healthier scotland hands, heads and bumps : a human factors approach to...

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