The case for human factors training.
Abstract: The Association for Perioperative Practice has taken a leading role in raising awareness of the importance of human factors in healthcare. We at Atrainability (2011) have been privileged to run training courses on human factors to association members at the last two annual conferences and also at venues throughout the UK. The funding has been provided by the Hilda Mears trust.

KEYWORDS Human factors / Non-technical skills / Human error / Safety critical industries
Article Type: Report
Subject: Ergonomists (Training)
Surgical nursing (Training)
Author: Hirst, Guy
Pub Date: 12/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Dec, 2011 Source Volume: 21 Source Issue: 12
Topic: Event Code: 280 Personnel administration; 360 Services information
Organization: Company Name: British Airways PLC Ticker Symbol: BAY
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 274700152
Full Text: So what do we mean by human factors training? A Google search of the term human factors provides a mere 31.8 million 'hits' in 0.16 seconds. 'Human factors [or ergonomics] is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimise human well-being and overall system performance' (Carayon 2007). In many ways I suppose it is extraordinary that such an important aspect of multidisciplinary working practice has not been incorporated into curricula previously, but we are where we are!

Trevor Dale and I were the founding partners at Atrainability. We were both training captains on the Boeing 747s but our passion for human factors had developed when we joined a small team of enthusiasts who developed and ran the Crew Resource Management (CRM) programme in British Airways in the late 1980s. CRM was the name that aviation gave to its human factors training initiative. It is interesting to reflect on why aviation decided to invest so much time and money into such training. I have recently been in communication with Captain Jeremy Butler who was the general manager of flight training in British Airways and the gentleman who decided that, in order to make our airline safer, he needed to invest significant amounts of money to introduce a human factors/CRM programme for all the pilots. This was the text of the letter I received recently (Butler 2011).

'Was it really in 1989 that we introduced CRM in BA? During my time working in the NHS I have also pondered why the messages so obvious to us were not being universally received. I am now working with a NHS Research Ethics Committee and a member of the National Research Ethics Advisors' Panel. This new insight has demonstrated something of which I was certainly aware, but not in so dominant a fashion, and that is that the medical profession will not do anything without evidence. In healthcare this evidence is accrued over many years of research studies perhaps in some cases (a very few) resulting in new treatments or new medications. This evidence base is the safety mechanism of healthcare and I support it. In aviation I fear that we have not gathered in sufficient detail or depth the evidence for human factors/CRM interventions as a necessary component in improving safety. I introduced CRM to BA on an instinctive feel, after attending conferences and seminars in the USA with the great gurus John Lauber and Clay Foushee but with very little research or analysis and no idea of how to measure outcomes of safety improvement. Of course we struggle with these measures as the data are very limited.'

If it had not been for the enlightened few who were prepared to trust their intuition, then the subsequent understanding of human factors science might never have started.

Aviation accidents by their very nature receive instant press attention, with pictures of charred hulls featuring on newspaper front covers and TV news channels within minutes of the incident occurring. Such images ignited the attention of aviation regulators in the USA some 30 or 40 years ago. Accidents were being tagged as being caused by 'human error' or 'pilot error'. The authorities finally decided that such a status quo was unsustainable and thus research into understanding human error began. Two of the researchers who started the research science were Lauber and Foushee, mentioned by Jeremy Butler.

Aviation is very fortunate in being able to employ incredibly hi-fidelity and realistic simulation to aid research into crew behaviour in crisis situations. To cement that point; if you were to ask any pilot which flights caused the most apprehension the answer would probably be the 3 or 4 days of annual simulator assessment. The development of such incredible simulation is the main reason that so much of the development of human factors understanding has emanated from aviation. Whilst it would be unwise to attempt to replicate the training of human factors, aviation style, into the medical or surgical setting, it does seem sensible to use some of the principles to short circuit the sometimes tortuous path that aviation has followed in this regard.

Professor James Reason is Professor Emeritus of Psychology at Manchester University and is widely recognised as the world leading expert on human error. In his foreword to the excellent book called Patient Safety in Emergency Medicine (Croskerry et al 2007) Professor Reason explains that there is a paradox at the heart of the patient safety problem. Medical education, almost uniquely, is predicated on an assumption of trained perfectibility. After a long, arduous and expensive education, healthcare professionals are expected to get it right. But they are fallible human beings like the rest of us. For many of them error equates to incompetence or worse. Mistakes may be stigmatised or ignored rather than seen as chances for learning. The other part of the paradox is that healthcare, by its very nature, is highly error provoking.

Trevor Dale and I were fortunate to be two key members of the small team that developed and introduced human factors training into British Airways. The model that we helped to create is now the standard for aviation human factors training within Europe. In 2001 we were privileged to be invited to join a research programme at Great Ormond Street Hospital (Catchpole et al 2008). On completion of that research programme we founded our human factors consultancy, Atrainability Limited. Having now retired from British Airways, we are working full time within healthcare, training and coaching multidisciplinary teams in various healthcare specialties.

There is compelling evidence that further improvements in surgical results depend on professional leadership, technical refinement and the application of scientific evidence about human performance (Giddings & Williamson 2007). Current research demonstrates that factors known to affect the performance of surgical teams are similar to those in other high risk-industries (Flin et al 2008). Many of these industries have a long history of safety investigation and improvement. Surgery is a relatively late starter.

In 2006 the chief medical officer (CMO) reported in his review Good Doctors, Safer Patient (DH 2006):

'It is only relatively recently that attention has been focused on patient safety as an issue. Despite the relatively high level of risk associated with healthcare--roughly one in ten patients admitted to hospital in developed countries suffers some form of medical error--systematic attempts to improve safety and the transformations in culture, attitude, leadership and working practices necessary to drive that improvement are at an early stage'.

In the same document reference is made to the Department of Health's publication from 2000--An Organisation with a Memory (DH 2000)--which highlighted the failure to learn systematically from things that go wrong. This is in marked contrast to other high-risk industries. The report demonstrated the importance of improved and unified mechanisms for detecting safety problems and the value of a more open culture. It also highlighted the merit of a systems approach to preventing, analysing and learning from adverse events.

There is much to learn from examples in other high risk, safety critical industries. Medicine is probably more complex than any other field of human endeavour, and patients are far more complex and idiosyncratic than aircraft, ships or power stations. The critical similarity is that they all rely on teams of professionals working together. Effective communication is vital in environments that are often highly stressful. While it is clear that flight crews and surgical team leaders are very different, their work shows some similarities:

* They work in highly complex and large organisations

* They lead multi disciplinary teams

* They operate in potentially stressful situations

* They have to encompass new technology

* They have to be managed by many professional managers

* They are required to perform management roles within their organisations

* They have unique responsibilities for the well being of their team and their passengers/patients

* They often have and generally need a 'can-do' mentality.

One of the reasons that healthcare is so challenging is the requirement to make decisions on the basis of incomplete evidence. Events are constantly surprising particularly as human anatomy is variable and each patient is unique. However the essential skills required for all those working in multi-disciplinary teams are the same and can be categorised into two domains: cognitive and social. They are particularly concerned with the interpretation of behaviour and of group dynamics. The skills are most effectively developed through experiential learning particularly when there is also an opportunity for reflection. It is important that human factors sessions are run by those trained and experienced in facilitation techniques.

Changing culture can be extremely challenging, especially in a complex organisation such as the NHS. In the field of medicine, change has rightfully been driven as a result of sound scientific evidence. Even in aviation where research into human factors has been prolific, it remains difficult to get unequivocal evidence to show the advantages in terms of safety and efficiency. However, those of us who had careers that straddled the introduction of human factors training have absolutely no doubts about the advantages in terms of safety, efficiency and workplace environment.

Almost two hundred years ago Ignaz Semmelweis, the Hungarian physician realised that 'childbed fever' could be drastically reduced if care-givers washed their hands appropriately. Unfortunately, he was unable to persuade his colleagues of the importance of introducing such procedures. The reception from the medical community ranged from coldness to downright hostility. He died a broken man and it was only after his death that those like Joseph Lister were able to provide the evidence of the importance of germ theory and antiseptic policy. Perhaps over the next few years we will be able to provide such evidence with regard to human factors.


Atrainability 2011

Butler J 2011 e-mail from Captain Jeremy Butler to author

Carayon P (ed) 2007 Handbook of human factors and ergonomics in healthcare and patient safety Danvers, MA, CRC Press

Catchpole KR, Giddings AE, Hirst DG, Dale TJ, Peek GJ, de Leval MR 2008 A method for measuring threats and errors in surgery Cognition, Technology & Work 10 295-304

Croskerry P, Cosby K, Schenkel S, Wears R 2009 Patient safety in emergency medicine Philadelphia, Lippincott, Williams & Wilkins

Department of Health 2000 An organisation with a memory: report of an expert group on learning from adverse events in the NHS London, DH

Department of Health 2006 Good doctors, safer patients. A report by the chief medical officer London, DH

Flin R, O'Connor P, Crichton M 2008 Safety at the sharp end: a guide to non-technical skills Aldershot, Ashgate

Giddings AE, Williamson C 2007 The leadership and management of surgical teams London, Royal College of Surgeons of England

Guy Hirst


Co-Founder Atrainability and Director of Training British Airways Training Captain, Retired, Atrainability Ltd, Cranleigh, Surrey

Competing interests: Director Atrainability

Correspondence address: Attainability Ltd, Maraquita, 42 Horsham Road, Cranleigh, Surrey, GU6 8DU. Email:

Provenance and Peer review: Commissioned; Peer Reviewed; Accepted for publication September 2011.
Gale Copyright: Copyright 2011 Gale, Cengage Learning. All rights reserved.