Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare.

Despite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realize this expertise for patient benefit, staff well-being and organizational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees-sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent coronavirus disease of 2019 (COVID-19) experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.

Frontiers in human factors: integrating human factors and ergonomics to improve safety and quality in Latin American healthcare systems.

BACKGROUND: The importance of human factors/ergonomics (HFE) is well established in all high-reliability systems but only applied in the healthcare sector relatively recently. Across many sectors, low-/middle-income countries (LMICs) lag behind more economically developed countries in their application of this safety science, due to resource and, in some cases, awareness and expertise. Most previous applications of HFE related to occupational ergonomics rather than healthcare safety. METHODS: The paper details how the reputation of HFE is being developed within healthcare communities of Latin America (LatAm), through increasing awareness and understanding of its role as safety science in the healthcare sector. It starts by articulating the need for HFE and then provides examples from Mexico, Colombia and Peru. RESULTS: The practical examples for research and education illustrate a developing awareness of the relevance of HFE to the healthcare sectors in LatAm and an appreciation of its worth to improve health service quality and patient safety through healthcare community engagement. A new LatAm Network of HFE in Healthcare Systems (RELAESA) was formed in 2019, which has provided a platform for HFE advice during the COVID-19 pandemic. CONCLUSION: There is a real opportunity in LatAm and other LMIC health services to make more rapid and sustainable progress in healthcare-embedded HFE than has been experienced within healthcare services of more developed nations.

Human factors/ergonomics to support the design and testing of rapidly manufactured ventilators in the UK during the COVID-19 pandemic.

BACKGROUND: This paper describes a rapid response project from the Chartered Institute of Ergonomics & Human Factors (CIEHF) to support the design, development, usability testing and operation of new ventilators as part of the UK response during the COVID-19 pandemic. METHOD: A five-step approach was taken to (1) assess the COVID-19 situation and decide to formulate a response; (2) mobilise and coordinate Human Factors/Ergonomics (HFE) specialists; (3) ideate, with HFE specialists collaborating to identify, analyse the issues and opportunities, and develop strategies, plans and processes; (4) generate outputs and solutions; and (5) respond to the COVID-19 situation via targeted support and guidance. RESULTS: The response for the rapidly manufactured ventilator systems (RMVS) has been used to influence both strategy and practice to address concerns about changing safety standards and the detailed design procedure with RMVS manufacturers. CONCLUSION: The documents are part of a wider collection of HFE advice which is available on the CIEHF COVID-19 website (https://covid19.ergonomics.org.uk/).

Tertiary education in ergonomics and human factors: quo vadis?

In 2019, the Human Factors and Ergonomics (HFE) discipline turned 70; to celebrate, an international group of academics and educators have reflected on the status of HFE tertiary education across the globe. This paper draws on presentations and discussions from the 20th Triennial International Ergonomics Association (IEA) conference and considers the implications for HFE education programmes. Past, current, and future challenges are outlined and discussed with examples from different countries and programmes. This paper builds on 2012 strategy proposed by Dul and colleagues, to strengthen the demand, and application, of the HFE discipline and profession. It provides a considered set of reflections, noting the range of structural issues and financial pressures within the tertiary education system that create challenges for the viability of specialist programmes such as HFE. A need exists for the broader profession to collaborate and share innovations in HFE programme development, to ensure sustainable HFE education programmes. Practitioner summary: A range of structural issues and financial pressures exist within the tertiary education system that creates challenges for the viability of specialist programmes such as HFE. A need exists for the broader profession to collaborate and share innovations in HFE programme development, to ensure sustainable HFE education programmes. Abbreviation: HFE: Human Factors and Ergonomics; IEA: International Ergonomics Association; CIEHF: Chartered Institute of Ergonomics & Human Factors; UX: User Experience; CREE: Centre for Registration of European Ergonomist; BRICSplus: Brazil, Russia, India, China and South Africa; MOOCS: Massive Open Online Courses; STST: socio technical systems theory; LMIC: low and middle-income countries.

Existing Science on Human Factors and Ergonomics in the Design of Ambulances and EMS Equipment.

Background: Emergency medical services (EMS) personnel face a disproportionally high risk for fatality and injury due to the nature of their work; and current ambulance and EMS equipment design standards do not adequately safeguard EMS personnel from sacrificing personal safety for patient care, a known human factors and ergonomic (HFE) design challenge. Despite the desire to include HFE interventions or considerations into a standard, the effectiveness of existing HFE interventions for EMS is unclear. Objective: Therefore, this study aimed to synthesize the peer-reviewed literature on the design features of patient compartments and EMS equipment that affect EMS personnel's performance or well-being. Methods: A scoping review methodology was applied to systematically search and screen for relevant articles, and extract data. Three databases (EmBase, Scopus, and PubMed) were searched, and search results were screened for articles that pertained to the performance or well-being of EMS personnel when interacting with the patient compartment or its associated equipment. Results and Discussion: Of the 4,125 search results, 48 relevant articles were retained, and then sorted into one of 3 categories: general design, patient handling, and patient transport. It was concluded that, although research has progressed over the past 15 years, more research, development, and resources are needed. Newer generations of ambulances have not been shown to be safer during collisions and there is a knowledge gap in how occupants and contents of a patient compartment behave during a collision. Crash-tests have been performed with restrained occupants and supplies; however, that scenario is unrealistic in the field. While the existing literature provided initial ideas and innovations for improving the HFE of patient handling and patient transport, it is important for future research to convey findings in a manner that can be used to inform design standards.

Plus size and obese workers: anthropometry estimates to promote inclusive design.

A significant proportion of the adult population globally is overweight, obese or classed as 'plus size'. This has led to variability in size and shape across the working population and exclusion in the workplace. A new dataset of the anthropometry of plus size people has been created. Length dimensions were similar to other data, but breadth, circumference, and depth measurements were substantially larger. The hip breadth and abdominal depth were important for predicting largeness in this population. These data help explain the high exclusion rates from design and the number of fit, reach, posture and clearance issues reported by participants with a high BMI: generally, the higher the BMI the greater prevalence of problems. It is hoped that a better understanding of the anthropometric characteristics of the plus size worker will inform the design of safe, productive work environments to promote inclusion for a wider range of people. Practitioner Summary: A new anthropometry dataset of plus size people has been created. The higher the BMI the greater the problems with design in the workplace for fit, reach, posture and clearance. To ensure inclusion and reduce stigma it is important to understand more about the size and shape of this population.

Twelve tips for embedding human factors and ergonomics principles in healthcare education.

Safety and improvement efforts in healthcare education and practice are often limited by inadequate attention to human factors/ergonomics (HFE) principles and methods. Integration of HFE theory and approaches within undergraduate curricula, postgraduate training and healthcare improvement programs will enhance both the performance of care systems (productivity, safety, efficiency, quality) and the well-being (experiences, joy, satisfaction, health and safety) of all the people (patients, staff, visitors) interacting with these systems. Patient safety and quality improvement education/training are embedded to some extent in most curricula, providing a potential conduit to integrate HFE concepts. To support evolving curricula and professional development at all levels - and also challenge prevailing "human factors myths and misunderstandings" - we offer professional guidance as "tips" for educators on fundamental HFE systems and design approaches. The goal is to further enhance the effectiveness of safety and improvement work in frontline healthcare practice.

More holes than cheese. What prevents the delivery of effective, high quality and safe health care in England?

What prevents the delivery of effective, high quality and safe health care in the National Health Service (NHS) in England? This paper presents 760 challenges which 330 NHS staff reported as preventing the delivery of effective, high quality and safe care. Some problems have been known for over 25 years (staff shortages, finance and patient complexity) but other challenges raise questions about the commitment of the NHS to patient and staff safety. For example, Organisational Culture leading to 'stifling bureaucracy', 'odds stacked against smooth […] working' and Workload resulting in 'firefighting daily' and 'perpetual crisis mode'. The role of Human Factors/Ergonomics professional input (engagement with safety scientists) is discussed in the context of success stories and examples of Human Factors Integration from other safety critical industries (Defence, Nuclear and Rail). Practitioner Summary: 760 challenges to the quality, effectiveness and safety of health care were identified at Human Factors/Ergonomics taster workshops in England. These are used to challenge health care providers to think about a Human Factors Integration (HFI systems) approach for safety, well-being and performance for all people involved in providing and receiving health care.

Human Factors Evaluation of Surgeons' Working Positions for Gynecologic Minimal Access Surgery.

STUDY OBJECTIVE: To investigate work-related musculoskeletal disorders (WRMSD) in gynaecological minimal access surgery (MAS), including bariatric (plus size) patients DESIGN: Mixed methods (Canadian Task Force classification III). SETTING: Teaching hospital in the United Kingdom. MEASUREMENTS: Survey, observations (anthropometry, postural analysis), and interviews. RESULTS: Work-related musculoskeletal disorders (WRMSDs) were present in 63% of the survey respondents (n = 67). The pilot study (n = 11) identified contributory factors, including workplace layout, equipment design, and preference of port use (relative to patient size). Statistically significant differences for WRMSD-related posture risks were found within groups (average-size mannequin and plus-size mannequin) but not between patient size groups, suggesting that port preference may be driven by surgeon preference (and experience) rather than by patient size. CONCLUSION: Some of the challenges identified in this project need new engineering solutions to allow flexibility to support surgeon choice of operating approach (open, laparoscopic or robotic) with a workplace that supports adaptation to the task, the surgeon, and the patient.

Firefighting to Innovation: Using Human Factors and Ergonomics to Tackle Slip, Trip, and Fall Risks in Hospitals.

OBJECTIVE: The aim of this study was to use a theoretical model (bench) for human factors and ergonomics (HFE) and a comparison with occupational slips, trips, and falls (STFs) risk management to discuss patient STF interventions (bedside). BACKGROUND: Risk factors for patient STFs have been identified and reported since the 1950s and are mostly unchanged in the 2010s. The prevailing clinical view has been that STF events indicate underlying frailty or illness, and so many of the interventions over the past 60 years have focused on assessing and treating physiological factors (dizziness, illness, vision/hearing, medicines) rather than designing interventions to reduce risk factors at the time of the STF. METHOD: Three case studies are used to discuss how HFE has been, or could be, applied to STF risk management as (a) a design-based (building) approach to embed safety into the built environment, (b) a staff- (and organization-) based approach, and (c) a patient behavior-based approach to explore and understand patient perspectives of STF events. RESULTS AND CONCLUSION: The results from the case studies suggest taking a similar HFE integration approach to other industries, that is, a sustainable design intervention for the person who experiences the STF event-the patient. APPLICATION: This paper offers a proactive problem-solving approach to reduce STFs by patients in acute hospitals. Authors of the three case studies use HFE principles (bench/book) to understand the complex systems for facility and equipment design and include the perspective of all stakeholders (bedside).

In-patient falls: what can we learn from incident reports?

BACKGROUND: a previous analysis of 12 months data from the National Reporting and Learning System offered useful insights on contributory factors for patient falls but was limited due to the small data set of free-text analysis (n = 400). A subsequent pilot study of 4,571 reports found an apparent difference in the contributory factors for patients described as having cognitive and physical impairments. OBJECTIVE: to analyse 3 years national incident data (2005-08) to further explore the contributory factors of in-patient falls. METHODS: a total of 20,036 reports (15% sample) were analysed by coding the free-text data field. Contributory risk factors were compared with the whole sample and explored with the Chi-squared and Fisher's exact tests. RESULTS: data were reported about the degree of harm (100% of reports), (un)witnessed status of fall (78%), location (47%), patient activity (27%), physical impairment/frailty (9.5%) and cognitive impairment/confusion (9.2%). Less than 0.1% of reports provided data about dizziness, illness, vision/hearing, and medicines. Overall, patients were more likely to be harmed when away from the bed space, mobilising/walking and by falling from the bed when not intending to leave the bed. CONCLUSIONS: this analysis explored incident reports at a level of detail not previously achieved. It identifies significant contributory factors for fall locations and activities associated with physical and cognitive characteristics.

Which bed designs and patient characteristics increase bed rail use?

BACKGROUND: the design and use of bed rails has been contentious since the 1950s with benefits including safety, mobility support and access to bed controls and disadvantages associated with entrapment and restraint. OBJECTIVE: to explore which bed designs and patient characteristics (mobility, cognitive status and age) influence the likelihood of rails being used on UK medical wards. METHOD: the use of rails was surveyed overnight at 18 hospitals between July 2010 and February 2011. RESULTS: data were collected on 2,219 beds with 1,799 included (occupied). Eighty-six percent had rails attached; 52% had raised rails (42% had all raised). Adjusted logistic regression results suggest a significantly increased likelihood of rail use for (i) electric profiling beds and ultra low beds; (ii) >80 years; (iii) described as having any level of confusion or mobility impairment. These variables together explained 55% of the variance in rail use. The most frequently mentioned reason for raising rails was 'to prevent falls from the bed' (61%) especially for patients described as confused (75%). CONCLUSION: there were indications that rails were being used inappropriately (as a restraint) for both confused patients and those needing assistance to mobilise.

TROPHI: development of a tool to measure complex, multi-factorial patient handling interventions.

Patient handling interventions are complex and multi-factorial. It has been difficult to make comparisons across different strategies due to the lack of a comprehensive outcome measurement method. The Tool for Risk Outstanding in Patient Handling Interventions (TROPHI) was developed to address this gap by measuring outcomes and comparing performance across interventions. Focus groups were held with expert patient handling practitioners (n = 36) in four European countries (Finland, Italy, Portugal and the UK) to identify preferred outcomes to be measured for interventions. A systematic literature review identified 598 outcome measures; these were critically appraised and the most appropriate measurement tool was selected for each outcome. TROPHI was evaluated in the four EU countries (eight sites) and by an expert panel (n = 16) from the European Panel of Patient Handling Ergonomics for usability and practical application. This final stage added external validity to the research by exploring transferability potential and presenting the data and analysis to allow respondent (participant) validation. PRACTITIONER SUMMARY: Patient handling interventions are complex and multi-factorial and it has been difficult to make comparisons due to the lack of a comprehensive outcome measurement method. The Tool for Risk Outstanding in Patient Handling Interventions (TROPHI) was developed to address this gap by measuring outcomes to compare performance across interventions.

State of science: human factors and ergonomics in healthcare.

The past decade has seen an increase in the application of human factors and ergonomics (HFE) techniques to healthcare delivery in a broad range of contexts (domains, locations and environments). This paper provides a state of science commentary using four examples of HFE in healthcare to review and discuss analytical and implementation challenges and to identify future issues for HFE. The examples include two domain areas (occupational ergonomics and surgical safety) to illustrate a traditional application of HFE and the area that has probably received the most research attention. The other two examples show how systems and design have been addressed in healthcare with theoretical approaches for organisational and socio-technical systems and design for patient safety. Future opportunities are identified to develop and embed HFE systems thinking in healthcare including new theoretical models and long-term collaborative partnerships. HFE can contribute to systems and design initiatives for both patients and clinicians to improve everyday performance and safety, and help to reduce and control spiralling healthcare costs. PRACTITIONER SUMMARY: There has been an increase in the application of HFE techniques to healthcare delivery in the past 10 years. This paper provides a state of science commentary using four illustrative examples (occupational ergonomics, design for patient safety, surgical safety and organisational and socio-technical systems) to review and discuss analytical and implementation challenges and identify future issues for HFE.

The Standardization of the Emergency Department Response to Chemical, Biological, Radiological, and Nuclear (CBRN) Events: Human Factors/Ergonomics Approach.

OBJECTIVE: To provide standardized recommendations for the emergency department (ED) response to chemical, biological, radiological, and nuclear (CBRN) events by combining the human factors/ergonomics method of hierarchical task analysis with the theoretical framework for Work as Imagined versus Work as Done. METHODS: Document analyses were used to represent CBRN response operational procedures. Semi-structured interviews using scenario cards were carried out with 57 first receivers (ED staff) to represent CBRN practice at 2 acute hospitals in England. RESULTS: Variability existed in general organizational responsibilities associated with the CBRN response. Variability was further evident in top level CBRN tasks and CBRN phases at both EDs. Operational procedures focused on tasks such as documentation, checking, and timing. CBRN practice focused on patient needs through assessment, treatment, and diagnosis. CONCLUSION: The findings provide top-down and bottom-up insights to enhance the ED CBRN response through standardization. The standardized CBRN action card template embeds the choice approach to standardization. The standardized CBRN framework implements the streamlined categorization of CBRN phases. Work as Imagined versus Work as Done is a useful theoretical framework to unpack a complex sociotechnical system, and hierarchical task analysis is an effective system mapping tool in health care.

Integration of human factors/ergonomics in healthcare systems: A giant leap in safety as a key strategy during Covid-19.

In this article, we present a model for integrating Human Factors/Ergonomics (HFE) into healthcare systems to make them more robust and resilient. We believe that to increase the impact of HFE during and after the Covid-19 pandemic this integration should be carried out simultaneously at all levels (micro, meso, and macro) of the healthcare system. This new model recognizes the interrelationship between HFE and other system characteristics such as capacity, coverage, robustness, integrity, and resilience. We hope that the model will serve as a reference for a giant leap to design and improve the safety and effectiveness of healthcare services from a holistic (systems) perspective.

DEEP SCOPE: A Framework for Safe Healthcare Design.

Thinking in patient safety has evolved over time from more simplistic accident causation models to more robust frameworks of work system design. Throughout this evolution, less consideration has been given to the role of the built environment in supporting safety. The aim of this paper is to theoretically explore how we think about harm as a systems problem by mitigating the risk of adverse events through proactive healthcare facility design. We review the evolution of thinking in safety as a safety science. Using falls as a case study topic, we use a previously published model (SCOPE: Safety as Complexity of the Organization, People, and Environment) to develop an expanded framework. The resulting theoretical model and matrix, DEEP SCOPE (DEsigning with Ergonomic Principles), provide a way to synthesize design interventions into a systems-based model for healthcare facility design using human factors/ergonomics (HF/E) design principles. The DEEP SCOPE matrix is proposed to highlight the design of safe healthcare facilities as an ergonomic problem of design that fits the environment to the user by understanding built environments that support the "human" factor.

Midwives' thoughts about musculoskeletal disorders with an evaluation of working tasks.

The prevalence of musculoskeletal disorders is very high amongmidwives resulting in sickness absenteeism, functional limitation and staff shortages. There are several contributory risk factors having impact on the development of MSDs. This study aimed to (1) explore midwives' experiences and views about work-related MSDs and contributing risk factors, and (2) analyse working postures for musculoskeletal injury risks. A mixed method approach was used with interviews/focus group (n = 15/7) and observations (n = 22) of specific tasks (during birth and after birth) using the posture analysis observational method (Rapid Entire Body Assessment, REBA). The participants were midwives who had an active role in the United Kingdom (UK) National Health Services (NHS). It was found that MSDs were often attributed to the physical (working in awkward positions), organisational (longer shift hours, fewer staff, increased work load), psychosocial (defensive practice, higher demand) challenges of midwifery. All postures had very high to medium REBA risk levels with action categories indicating that action or further assessment is definitely necessary to reduce MSDs. This research provides a holistic approach by analysing risk factors and interactions in the work context to inform the development of risk management strategies. Midwifery working conditions have a big impact on developing musculoskeletal symptoms. Management of such symptoms will improve staff wellbeing, mother and baby safety, individuals' life trajectories and staff shortages.

Chris and Sally's House: Adapting a home for people living with dementia (innovative practice).

How can domestic housing be adapted to support people living with dementia staying in their own homes for as long as they choose? This paper describes the innovative practice of using evidence-based design personas in a building refurbishment project (Chris and Sally's House) with a multidisciplinary team of architects, ergonomists, psychologists and experts. A 100 sqm Victorian two bedroom house was adapted to help educate house builders, carers and relatives on how to better support those living with dementia to live in their own home for longer. The design principles include clear sight lines, mobility support and provision for overnight carers.