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Art & science patient safety series: 1

The importance of applying human


factors to nursing practice
Norris B et al (2012) The importance of applying human factors to nursing practice.
Nursing Standard. 26, 32, 36-40. Date of acceptance: December 19 2011.

Abstract
The aim of this series is to introduce the topic of human factors and to
show how it can be used in nursing practice on the ward and in nursing
management, to improve the safety of patient care. Human factors can
be used to make many aspects of working life easier, and if it is easier to
do it is less likely to go wrong. This article discusses the importance of
human factors in nursing and provides some practical suggestions on
how to apply the principles of human factors. Forthcoming articles will
examine human factors tools, surgical safety and human reliability in
more detail.

Authors
Beverley Norris
Human factors lead, National Patient Safety Agency, London
and senior researcher, Helen Hamlyn Centre for Design,
Royal College of Art, London.
Lynne Currie
Project manager, Evaluating and Improving, Quality, Standards
and Innovation Unit, Learning and Development Institute,
Royal College of Nursing, London.
Caroline Lecko
Patient safety lead (secondment), Learning and Development
Institute, Royal College of Nursing, London.
Correspondence to: beverley.norris@npsa.nhs.uk

Keywords
Human factors, patient safety

Review
All articles are subject to external double-blind peer review and
checked for plagiarism using automated software.

Online
Guidelines on writing for publication are available at
www.nursing-standard.co.uk. For related articles visit the archive
and search using the keywords above.

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Patient safety is high on every healthcare


professionals agenda. Patient safety challenges
facing nursing include issues surrounding
hydration and nutrition; pressure ulcers;
catheter-acquired urinary tract infections and
medication errors. Recent reports from the
Care Quality Commission (CQC) continue to
show substandard nursing care in the delivery of
nutrition and hydration to patients (CQC 2011).
Four main areas of harm have been identified by
the Department of Healths (DH) Harm Free
Care initiative (DH 2011), which has as its
aim the absence of pressure ulcers, falls,
catheter-acquired urinary tract infections, and
venous thromboembolism by December 2012.
There have been repeated calls for those
involved in health care to examine other
industries, including aviation, for safety
solutions (Kohn et al 2000, Amalberti et al
2005, DH 2006). Parallels to other industries
are useful and have provided health care with
many techniques, such as root cause analysis,
briefings and communication tools, for example
SBAR (Situation, Background, Assessment,
Recommendation) (Joint Commission
Perspectives on Patient Safety 2005). There are
direct parallels between some safety scenarios
in health care and in other industries, for
example comparisons between the flight deck and
surgery have led to the introduction of team crew
resource management as a patient safety solution
(Sax et al 2009).
There are, however, many scenarios for
which there are no ready-made solutions.
Consider, for example, tasks with blurred
boundaries such as the management of
long-term conditions, medication management
across primary and secondary care, or care
of older people. For scenarios where there are
no direct comparisons with other industries,
there may be value in looking for generic safety
approaches. Human factors is one such approach
to improving safety, initially developed by the
military, but now viewed as mainstream in
many high risk industries and gaining interest
in health care.

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Defining human factors


The term human factors (Box 1) is used in a
number of ways in health care but, put simply,
human factors means designing to fit people,
or making it easy to do the right thing. It is a
scientific discipline that developed from studying
people working under physical and cognitive
stress during the second world war. The premise
is that the design of our workplace, equipment
and working processes should be based on human
abilities and characteristics how we process
information, communicate, make decisions and
remember things rather than expecting people to
adapt to the poorly designed world around them.
Contemporary human factors uses knowledge
from biomechanics, psychology, social sciences
and safety engineering to design systems that are
effective, efficient and safe. In some industries,
changes to a workplace cannot be approved
without first going through a human factors
evaluation; for example, the introduction of new
equipment would be assessed for how it affects
mental workload and error (Defence Procurement
Agency 2006). In the NHS, where change seems
to be a feature of daily life, it may be difficult to
imagine how human factors could possibly have
this sort of role. In this series of articles we hope to
show that human factors can be used by everyone,
from clinical nurses through to managers and
executives, to make it easier for staff to do the right
thing to ensure errors even though these can never
be eliminated in health care can be minimised.
Thinking about people
A human factors approach to system design
considers the characteristics and abilities of the
people who have to work in that system, and how
to optimise that system. This could include:
Physical

abilities responses to fatigue, the
effects of shift work, the effects of stress, manual
or patient handling and so on.
Perceptual

abilities how information on charts
is read, reactions to alarms and the effect of
lighting and noise.
Cognitive

abilities mental models of how
things are expected to work, how much
information we can remember, what affects our
decision making, response times, the types of
errors made and what actions we prioritise from
conversations.
Social

and interpersonal characteristics how
to work in teams, our response to rules and our
willingness to take risks.
Thinking about systems
The definition of human factors shows that
the focus is on people working in complex

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systems. Systems include the equipment, devices,


medication and information systems being used;
the jobs and tasks being carried out; the physical
environments and workplaces in which they are
carried out; and the teams, organisation and
culture within which that happens.
For systems to work safely, consideration needs
to be given to how each of these can be optimised
to help staff work without error:
Workplaces

that are laid out to minimise
travel distances.
Alarms

that are set so that they only go off when
they require a response.
Colour

coding that makes connections easier.
Devices

that are intuitive to operate
without needing to consult a complex
instruction booklet.
Workplaces

that meet the needs of all the staff
who use them (nurses, doctors, allied health
professionals, administrators, porters).
Environments

that provide space to work
without excessive noise or temperatures.
Rotas

that allow teams to get together to discuss
how they are working.
Organisations

where staff are consulted and
involved in changes to their working practices.
A
 culture where staff are encouraged to
speak up.
Human factors can be used to improve the design
of physical things, such as device interfaces/
control panels, packaging, forms and charts,
lighting levels and storage. Improvements are
often immediately palpable and it can be easy to
compare the before and after of design changes.
However, human factors also considers issues that
are less physically apparent such as work design.
This means thinking about how tasks fit together
to make up a working day: for example, how tasks
are prioritised, what information is required and
when, interdependencies with other departments
or staff, and what happens in deteriorating or
emergency conditions. It is probably rare for
the totality of a job to be viewed in this way,
particularly when changes are introduced.
For example, is the effect of a new protocol or

BOX 1
Definition of human factors
Human factors 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
other methods to design in order to optimise human
wellbeing and overall system performance.
(Human Factors and Ergonomics Society 2000)

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Art & science patient safety series: 1


guideline on a typical nursing shift assessed in
terms of workflow, how tasks are prioritised,
what gets left out and what corners are cut?

Principles of human factors


Human factors is a profession with recognised
qualifications, international professional bodies
and techniques, and tools that require extensive
training and practice. Changes to complex
systems require expert application of specialist
techniques such as mental workload assessments,
human reliability assessments, task analysis
and prospective hazard analysis tools. While
these will be outside the interest of many
healthcare staff, human factors is underpinned
by a number of principles which mean that the
philosophy of human factors can be used
by non-specialists.
Anticipate what can go wrong
Cognitive psychology and models of human
error teach us that people will get things wrong
regardless of expertise, training and motivation.
We make errors even when we are well practised
at a job the errors will just be different to those
we make when we are learning (Reason 1990).
Think about how many times you have forgotten
to record something on a fluid chart, hand over an
important piece of information before you went
home, get a new stock of a patients medication
that has run out, or check someones observations
following surgery. Everyday repetitive tasks are
prone to problems such as missing out steps or
losing sight of detail.
Given what we know about human error,
we need to anticipate what can go wrong and
incorporate suitable defences. For example, we
also know that people will take shortcuts; if there
is an easier, quicker way of doing things then
someone will do it. These shortcuts are often well
intentioned and done in the name of efficiency.
Often it is not a case of poor motivation, but rather
the system that makes it difficult to do the right
thing. We know that introducing new equipment
that operates differently to existing or associated
equipment is likely to cause confusion.
These are all errors or failures that we can
anticipate. Formal, systematic assessments
of how, where and why things can go wrong
is the first step in safety or risk management.
Prospective hazard analysis tools such as Failure
Modes and Effect Analysis (DeRosier et al 2002)
can help to anticipate this. Other techniques that
prospectively anticipate what can go wrong have
recently been adapted for health care (Clarkson
et al 2009).
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Speak to the people who do the job


A key principle of human factors and good
usability is to involve users in the design process.
Sometimes they can come up with the best design
solutions as they are closest to the job (NHS
Institute for Innovation and Improvement 2009).
Users are the people who best understand the
environment, patients, equipment and processes
involved. They are the people who know what
works well and what does not; the shortcuts,
errors and accommodations that are made every
day to get the job done, which rarely surface
unless something goes wrong. It is important to
talk to all those who have a view of the job; not
only the main job roles such as the nurses
operating the infusion pumps, but also the people
who clean, maintain, transport, store, buy the
equipment and the patients receiving the
medication. They all have different experiences
and needs. This may sound arduous, but a simple,
formal engagement process will help staff and
patients feel empowered to speak up when
decisions are being made.
Consider the entire system
Root cause analysis (National Patient Safety
Agency 2006) is an incident investigation technique
that looks beyond the immediate causes and looks
for factors in the system that have contributed
to what has gone wrong. This approach is a
characteristic of a positive safety culture where
fair blame is sought; where the influences of the
organisation and the system on the way people
work, and the decisions they make, are considered,
as well as individual culpability. As well as looking
back at what has gone wrong, this principle is also
important during planning, and when introducing
change. Context is important and assumptions
are often made about the wider effects of change.
When new ways of working or new equipment are
being introduced, consideration should be given to
how the change is going to affect immediate staff
and processes, as well as to those who may not
seem directly affected:
Do
 all related departments know about
changes in scheduling, ordering systems or
accountability? How will it affect them?
If
 information systems are being changed has
everyone who needs to know been informed?
If
 a new performance target is being made a
priority, what happens to the other jobs when
will they be done?
Manage safety proactively
Safety is a continuum and the nature of risk
means there is no guarantee of absolute safety.
Similarly, the systems in which we work (and live)

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are continually changing: changes in staff, patient


demographics, training, technology, national
policies and local governance all influence safety.
It is not enough to assess the safety of a working
system when it is introduced; the fast rate of
change in health care means that safety needs to
be reviewed and managed as part of regular
governance activities. Staff should also be
encouraged to monitor when they think safety
is being compromised, even if everyone was
satisfied when things were introduced, and to
provide feedback.
Standardise and simplify
Standardisation is an accepted safety approach in
many industries; where equipment and processes
are standardised and operate in the same way
they are easier to use, as there is less mental effort
required to understand and process the way
things work. There are circumstances when local
adaption is necessary; one size does not always
fit all as local conditions may dictate specific
ways of working. For example, specialised units
may require additional data categories on charts
and forms. There can be extreme variation in
healthcare practice, however, which is hugely
difficult for locum staff and for staff moving
between organisations. Pressure is put on resources
for inductions and will often introduce risk,
such as the variation in wristband colour coding
conventions found in and across hospitals (Sevdalis
et al 2009).
One way to introduce standardisation and still
allow local adaptation is to use generic design
principles and to develop core requirements that
are standardised in all settings. For example, when
designing forms and charts:
Use
 generic guidance around readability
and layout, for example minimum font size,
writing space, how to prioritise information,
requirements for photocopying (Nielson and
Mack 1994).
Core

datasets can be developed which ensure the
same information will be included and presented
in the same way in all settings.
Specific

guidance on known errors can be
used, such as ensuring the same acronyms
and abbreviations are used throughout an
organisation.
Ensure

generic design conventions are always
used in the same way, such as graphical trends
on early warning charts or traffic light systems.
Future

modifications should be checked and
recorded to ensure they do not diverge too far
from original requirements.
Ensuring standardisation throughout an
organisation will reduce development time

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and cost and avoid replication of effort how


many forms are recreated every day in the NHS?

Applying human factors to clinical practice


These generic human factors and safety principles
may sound difficult to apply to everyday nursing
practice and management, but they can be made
relevant to managing safety at work. The next
four articles in this series will describe how to do
this in more detail. This article now summarises
how human factors can be incorporated into
everyday activities.
Get involved in safety
Do
 not leave it to others make suggestions
for improvements and if you are on the
receiving end of these suggestions, ensure
these are acted on.
Get
 involved in the procurement of equipment
and devices, and make sure that you give
feedback about any problems you experience
with the usability or reliability of equipment.
If
 you have a procurement responsibility, make
sure there is a process for staff to feedback their
experiences of using equipment. Manufacturers
also welcome feedback.
Review

the forms and charts that are in use.
Are they up to date? Have they had to be
adapted locally? Does all the information
fit on?
Think

about the induction on your ward or
department? Is it adequate? Is it up to date?
Think

about emergencies and contingencies.
Is the department prepared?
Does

anything ever go missing?
Review

the posters and signs in your
department? How many signs do you have to
remind and warn staff, patients or visitors about
risks? Do they work? Is there a better way of
doing this?
Adopt a systems view
Think

about the system you are working
in not just the details of the job but how the
organisation, teams, workplace, equipment
and the environment affect how safely you
can work.
Share

these findings with other staff, wards or
departments. Do they have the same problems?
How

often do you have to take risks or
shortcuts to get the job done? Have you had to
adapt the recommended way of doing things
to make it work? Think about why this is and
provide feedback.
Do
 you ever have to work on incomplete
information or make assumptions?
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Art & science patient safety series: 1


Is
 there equipment that does not work well
but you still have to work with it? Who can
you tell?
Is
 there pressure on you to use equipment or
undertake a task that you are not comfortable
with?
Keep on top of safety
Make

sure you get involved when you know
changes are being implemented.
Is
 patient safety being compromised? How
well are protocols adhered to? If they are
not working, think about why not.
Encourage openness
Speak

up when you are concerned about safety.
Reporting

incidents is one of the main ways to
learn about safety talk to colleagues about
a near miss you have experienced.
Challenge

other staff if you feel they are

compromising patient safety, or find a way of


getting your concerns heard.
Can

you introduce team working activities,
briefings or debriefings in your department?
The next article in the series will examine a variety
of tools and activities that can help you apply
human factors in your work.

Conclusion
Patient safety is integral to nursing and must be part
of everyday clinical practice. An understanding
of clinical human factors will help nurses to
understand how the design of the systems,
processes, equipment and environment that they
work in and with affects the ability to deliver safe
patient care. An understanding of the concepts and
models applied within human factors is essential
if nurses are to make significant improvements in
enhancing patient safety in clinical practice NS

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