Dr Vivien Swanson
Programme Director, Psychology Specialist Practice,
NHS Education for Scotland
Quality Education for a Healthier Scotland

AIMS
• 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
Quality Education for a Healthier Scotland

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)
Quality Education for a Healthier Scotland

• Common Human factors
Including……….
Personal : Cognitive, mental load, stress and fatigue
Team : Communication, decision making, teamwork
Context: Situational awareness, information gathering
Quality Education for a Healthier Scotland

• 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)
Quality Education for a Healthier Scotland

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– Level of experience, seniority
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– Individual, group, system
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– Frequency, (Routine, habit, one-off), implications, cognitive complexity
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– Time, resources
Quality Education for a Healthier Scotland

• BASICS – resuscitation training
(leadership, communication, monitoring)
• TRAINEE hospital doctors and hand hygiene
(hand washing procedures, carry gel)
Quality Education for a Healthier Scotland

Item
Gathering information
Conduct a risk assessment of the scene and makes sure it is safe to approach the patient before proceeding
Review decisions to ensure they are still appropriate requesting a second opinion from others, where possible
Try alternative options when a certain approach is not working
Communication and Teamwork
Clearly communicate information about the chosen course of action
Not dismiss suggestions of others based on their status/experience
Encourage other team members to voice their opinions
Decision-making and Leadership
Take charge of the situation and make requests of others at necessary times
Ask others to undertake specific tasks at appropriate times providing clear direction
Demonstrated
44 (41-64)
28 (14-67)
47 (21-74)
43 (29-79)
43 (38-43)
2 (2-8)
62 (46-95)
62 (20-94)
Quality Education for a Healthier Scotland

HH : Self Reported Behaviour
“I always perform hand hygiene before and after every contact with each patient “
80% Agreed, 20% Unsure, 0% Disagree
Quality Education for a Healthier Scotland

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.
Quality Education for a Healthier Scotland

TPB: Positive attitudes, norms and confidence predict intentions
(BASICS, HH)
ATTITUDES
Its important to communicate with others during resuscitation
(BASICS)
SOCIAL NORMS
I feel under social pressure from staff to wash my hands
(HH)
SELF-EFFICACY
Its difficult for me to wash my hands before and after patient contact (HH)
Quality Education for a Healthier Scotland

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)
Quality Education for a Healthier Scotland

Quality Education for a Healthier Scotland

• Narrows focus of attention
• Some (acute) stress is positive (coping)
• Simple cognitive/motor (habitual) activities benefit or..
• ‘freezing’, problems with cognition, memory, attention
Quality Education for a Healthier Scotland

Using Theory to assess behaviour :
Theoretical Domains framework – TDF
HH Study
• professional role,
• beliefs about capabilities and consequences,
• social influences
• motivation and goals,
• action plans
• memory and attention,
• environmental resources.
Quality Education for a Healthier Scotland

Quality Education for a Healthier Scotland

Key Levers...
Knowledge and skills
Influence of professional role
Beliefs about consequences
Motivation and goals
Key Barriers...
Memory and attention levels
Beliefs about capabilities
Action plans.
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Quality Education for a Healthier Scotland

• 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”?
Quality Education for a Healthier Scotland

“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)
Quality Education for a Healthier Scotland

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)
Quality Education for a Healthier Scotland

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)
Quality Education for a Healthier Scotland

“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)
Quality Education for a Healthier Scotland

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.
Quality Education for a Healthier Scotland

Quality Education for a Healthier Scotland

BASICS : Mapping human factors onto BCTs
(Motivation, Action, Prompts)
Human factors
Elements Behaviour change
Technique
M, A, P
Task management
Team working
Situation awareness
Decision-making
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Leadership
Communication
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Planning, preparing
Prioritizing
Coping with pressure
Co-ordinating activities
Exchanging information
Supporting others
Gathering information
Recognizing, understanding
Projecting, anticipating
Identifying/considering options
Balancing risks, options
Implementing & reviewing
Setting, maintaining standards
Supporting others
Coping with pressure
Exchanging information
Shared understanding
Acting assertively
Goal setting (A1)
Time management (A19)
Coping strategies (M14)
Social support (M12)
Social skills training (A27)
Self-monitoring of behaviour (A3)
Antecedents and consequences (A4)
Coping strategies (M14)
Goal review (A10)
General problem solving (A22)
Assertion training (M18)
Goal setting (A1)
Feedback (A5)
Assertion training (M18)
Information about behaviour (M10)
Graded tasks (A11)
Behavioural rehearsal (P11)
Quality Education for a Healthier Scotland

• 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