1. Quality Education for a Healthier Scotland Hands, heads and bumps : a human factors approach to behaviour change Dr Vivien Swanson Programme Director, Psychology Specialist Practice, NHS Education for Scotland

2. Quality Education for a Healthier Scotland 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 AIMS

3. 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)

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

5. Quality Education for a Healthier Scotland contexts: 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)

6. Quality Education for a Healthier Scotland Other factors… Health professionals : – Level of experience, seniority Control (responsibility): – Individual, group, system Task : demands – Frequency, (Routine, habit, one-off), implications, cognitive complexity Context: – Time, resources

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

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

9. 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

10. 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.

11. 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) ATTITUDES Its important to communicate with others during resuscitation (BASICS) SOCIAL NORMS I feel under social pressure from staff to wash my hands (HH) 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) SELF-EFFICACY Its difficult for me to wash my hands before and after patient contact (HH)

12. Quality Education for a Healthier Scotland TBP Regression : 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)

13. Quality Education for a Healthier Scotland The intention-behaviour gap – and how to bridge it What people want to do (think they want to do) What they actually do

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

15. 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.

16. Quality Education for a Healthier Scotland TDF: regression the model significantly predicted self- reported HH behaviour (37.8%) (no independent predictors).

17. Quality Education for a Healthier Scotland HH : TDF results 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.

18. Quality Education for a Healthier Scotland Ward Simulation :

19. Quality Education for a Healthier Scotland Self explanatory technique (Think aloud) 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 ”?

20. 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) Intention-behaviour gap…

21. 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)

22. Quality Education for a Healthier Scotland Individual factors : cognitive load “ 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)

23. Quality Education for a Healthier Scotland Individual factors : Stress & fatigue “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)

24. Quality Education for a Healthier Scotland HH : Summary of findings 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.

25. Quality Education for a Healthier Scotland

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

27. Quality Education for a Healthier Scotland Next? 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