8 minute read
Why should we care about human factors in surgery?
Chris Lewis, James Tomlinson and Hiro Tanaka
Chris Lewis is an ST7 on the North Yorkshire Rotation. He is the current BOTA secretary and is a member of the Faculty of Surgical Trainers, RCSEd. He is the previous BOTA education rep and has undertaken a Clinical Leadership Fellowship focusing on teaching leadership skills, non-technical skills and human factors to higher surgical trainees.
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James Tomlinson is a Consultant Spinal Surgeon at Sheffield Teaching Hospitals. He has an interest in surgical education and training, and is the Academic TPD for HEE Yorkshire and Humber, and Deputy Director of the Faculty of Surgical Trainers, RCSEd. He is a member of the NOTSS faculty has taught nationally and internationally on surgical nontechnical skills and human factors.
Hiro Tanaka is a Consultant Foot and Ankle surgeon at Aneurin Bevan University Health Board. He is a council member of the BOA and Editor for JTO. He led the development of the BOA Bootcamp Programme as Chair of Education Committee.
Why human factors is important
Most of us take it for granted that flying is one of the safest forms of transport, in fact we are more likely to die from the car journey to the airport than in a plane crash. During the 1970s, the media were quick to blame pilots for aviation accidents. After several high profile events, aviation woke up to the importance of understanding, recognising and managing human factors involved in error. Healthcare has one of the most highly trained, motivated and well selected workforce of any industry and yet 1 in 20 hospital admissions in the UK has some form of error. A recent meta-analysis of 70 studies involving 330,000 patients found that when there was an error, this can be severe or lead to death in 12% of cases [1].
Some of the most important human factors issues affecting surgeons and the surgical team include tiredness, emotional state, communication, interpersonal behaviour, being able to challenge authority and situational awareness.
It is well known that humans make errors. Surgeons are not exempt. In a complex system such as healthcare it is essential that we design systems to account of errors and train our trainees to recognise why, how and when errors occur.
The benefits of bootcamp in early years training
Transition points in training can be stressful, with trainees often feeling underprepared for their new role [2]. Reduced clinical working hours and an increased focus on patient safety have increased pressure on trainees. Bootcamps are one strategy to mitigate these challenges and are normally short, intense educational events designed to help trainees transition to a new phase of training [3]. Bootcamps have traditionally focused on acquisition of technical skills training with mixed success. Such a model is potentially flawed. Motor learning theory has demonstrated that distributed practice is more effective than massed practice in learning new motor skills [4]. It is thus foolish to think we can materially change the operative learning curve over six years of training with a two or three-day technical intervention. Bootcamps with a primary focus on technical skills training are highly resource and cost intensive.
Non-technical skills and human factors training have been shown to correlate with favourable patient outcomes [5]. Surgical trainees have identified a lack of exposure to these skills early in their training despite an appetite for such [6]. Trainees in other surgical specialties report their nontechnical and inter-professional skills are not sufficiently developed for consultant practice at completion of training. The new curriculum and introduction of Generic Professional Capabilities and Capabilities in Practice means a welcome increasing focus on the development and assessment of nontechnical skills.
Ethnographical work on the Scottish Core Surgical Bootcamp has identified a clear role bootcamp can play in establishing behavioural norms and expectations, whilst also allowing relationships to develop with key members of the training team.
Yorkshire and Humber Bootcamp
The Yorkshire and Humber region developed and piloted a novel ST3 bootcamp with primary focus on human factors, nontechnical skills and professionalism. Sessions were led and delivered by trainees wherever possible to reduce the perceived authority gradient between faculty and learners, encouraging those attending to speak up and voice any concerns. A further objective was to allow trainees to develop their professional identity through discussion with senior peers, and role modelling by senior trainees. The bootcamp ran over two days with a mix of sessions on human factors and non-technical skills giving a brief overview of these topics. A virtual fracture clinic and ex-fix workshop were also included.
All of those attending the bootcamp reported the non-technical skills and human factors sessions were relevant to their registrar role, and all felt more aware of the impact of their own behaviour on others, more able to challenge inappropriate behaviour and had an increased recognition of the importance of non-technical skills in delivering high quality patient care. Several of those attending had not received any postgraduate training in human factors or nontechnical skills. Trainees were unsure about the inclusion of human factors in a bootcamp prior to the intervention, but all subsequently felt it had been useful, and relevant.
Introducing these concepts at the start of higher training is not without potential flaws. Motor learning theory identifies the three stages - cognitive, associative and autonomous. Trainees are likely to be at the early stages of this process, and the additional focus on nontechnical skills could potentially overwhelm them. This concern was not born out in discussion with trainees, with many of them already using these new skills to complement their operative practice. Several trainees were already reflecting on their own behaviour in theatre and the impact they were having on the surgical team around them, using this to help shape their early professional identity.
The role of non-technical skills in improving patient outcomes is well established, and previous reports have highlighted complex issues with surgeon behaviour significantly impacting patient care [7].
ST3 bootcamp offers an ideal opportunity to introduce trainees to these concepts at an early stage, highlighting their importance and embedding the right behaviours. Delivering this training regionally also allows an ideal platform for trainees to develop relationships with their peers and training team.
The BOA Bootcamp
The BOA ran a fully funded national pilot between 2018 and 2020 to demonstrate the benefits of a combined non-technical and technical skills programme in a bootcamp course for ST3 trainees. A delegate’s review was reported in the September 2018 JTO. The purpose of the pilot was two-fold: firstly, to determine the value gained from cadaveric technical training which in most cases would not be affordable for deaneries to run locally and secondly, to structure a template for human factors training which was reflective of the changes in the curriculum and which resonated with the day to day practice of trainees. It was the latter aspect of the programme which was innovative and it was developed with input from experts in the fields of psychology, education and military training.
The human factors section of the course ran over a two day period. Similar to the Yorkshire Bootcamp experience, it is essential that delegates learn and share their experience in a safe and comfortable environment. The majority of learning was gained from facilitated discussion by faculty using case based scenarios and real life experiences of the trainees. For example:
“You are running a fracture clinic on your own because the consultant is away. It is an overbooked clinic and the nurse tells you that patients are complaining about the wait. You see a child with a forearm fracture which has been manipulated a week ago but the position has slipped badly. The mother is very unhappy with the result and is starting to get abusive. How will this situation affect your performance? What will you be thinking? How will you behave?”
The course introduces the lexicon of human factors in six key domains and each scenario is referenced to the skills and tools to manage the situation safely.
• Situational awareness
• Decision making
• Communication
• Leadership
• Conflict management
• Resilience
The core skill which was reinforced during the course was self-awareness of emotions which will allow the trainee to manage their behaviour appropriately, communicate effectively and make safer decisions. An overly emotional response to a stressful environment has been shown to be a significant factor in compromising patient safety [8].
The experience trainees gain from an understanding of human factors can be immeasurable but can be described. Reflections from one of the first trainees to attend the course defines it as:
“As much pressure as there is on surgeons to uphold the fantasy of always being perfect, it is much more healthy, insightful and humbling to know that we are in fact not perfect. We are human and have weaknesses. It is only once we accept these weaknesses can we begin our journey to greatness.”
What lies ahead?
The benefits of human factors in surgical training are great and far-reaching. It can be provided at minimal cost as compared to technical cadaveric courses and if provided early in a trainee’s career, will not only improve their well-being but also their performance, safer patient care and contribute towards a healthier work environment. We would recommend all deaneries integrate this as part of their core programme. Advice as well as templates for a one or two day course are freely available from the BOA (policy@boa.ac.uk).
Leadership training at higher levels should include integration of human factors in Quality Improvement methodology to ensure that we design systems to account for human error so that ‘just culture’ becomes the norm.
References
References can be found online at www.boa.ac.uk/publications/JTO.
