Teaching patient safety and human factors in undergraduate nursing ...

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Teaching patient safety and human factors in undergraduate nursing curricula in England: a pilot survey Wayne Robson, Debbie Clark, David Pinnock, Nick White and Bryn Baxendale

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n his 2013 report (National Advisory Group on the Safety of Patients in England, 2013), Don Berwick highlights the importance of patient safety education:

‘Mastery of quality and patient safety sciences and practices should be part of [the] initial preparation and lifelong education of all health care professionals.’

Awareness of patient safety has grown globally in the past decade, with initiatives such as the 5 Million Lives Campaign (Institute for Healthcare Improvement (IHI), 2013a) in the USA, and the Patient Safety First Campaign (National Patient Safety Agency (NPSA), 2011) and the introduction of ‘harmfree care’ with the Safety Thermometer (Harm Free Care, 2012) in the UK. Nonetheless, there are signs indicating that there is still work needed to ensure patients are protected from avoidable harm. In its summary of the investigation of avoidable deaths and harm observed at a UK hospital, the Francis Report (Francis, 2013) argues that the failings occurred because of a poor safety culture that accepted poor standards. Alongside interventions to reduce harm from medication, falls, pressure ulcers and deterioration, in the past 5 years, there has been a growing recognition of the need to focus on the influence of human factors. Dr Ken Catchpole (Clinical Human Factors Group, 2010) describes human factors as: ‘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.’

© 2013 MA Healthcare Ltd

Accidents involving human factors are evident in many high-risk industries, and studies on adverse events in hospitals Wayne Robson is Senior Lecturer in Advanced Nursing Practice at Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield; Debbie Clark is Senior Lecturer Adult Nursing, Sheffield Hallam University; David Pinnock is Lecturer in Surgical Nursing and Clinical Skills at University of Nottingham; Nick White is Senior Lecturer in Adult Nursing at Sheffield Hallam University; and Bryn Baxendale is Consultant Anaesthetist at Nottingham University Hospitals NHS Trust Accepted for publication: August 2013

British Journal of Nursing, 2013, Vol 22, No 17

Abstract

Patient safety is a key priority for all healthcare systems, and there is growing recognition for the need to educate tomorrow’s nurses about the role of human factors in reducing avoidable harm to patients. A pilot survey was sent to 20 schools of nursing in England to explore the teaching of patient safety and human factors. All 13 schools that responded (65% response rate) stated that patient safety was covered in their curricula and was allocated more than 4 hours; all the classes included human factors. Only two respondents indicated their teaching to be multi-professional. Awareness of the World Health Organization’s multiprofessional patient safety curriculum guide was poor. Faculties also seemed unaware that the Institute for Healthcare Improvement provides free online patient safety modules for students and that there is a global network of student patient safety chapters. Key words: Student nurse ■ Patient safety ■ Human factors ■ World Health Organization ■ Undergraduate nursing

show that many of these accidents are due to breakdowns in leadership, teamwork, flawed situational awareness, poor workplace and equipment design and stress and fatigue. This has resulted in a growing demand for human factors education and training. The majority of this training has been based upon Crew Resource Management (CRM) techniques from the aviation industry, which focus on non-technical skills (Catchpole, 2013). The authors stress that human factors involve much more than non-technical skills and include ergonomics—focusing on the design of healthcare systems (work environment, equipment and processes and policies) to complement human performance and mitigate error caused by human fallibility. In the UK, a national Clinical Human Factors Group was established in 2010; it independently campaigns for a better understanding of human factors and how this can improve safety and productivity in health care. In 2010, the Department of Health (DH) established a Human Factors Reference Group, which included an education sub group. An interim report by the Human Factors Reference Group (DH, 2011–2013) recommends that the Human Factors education sub group supports the NHS in its response to the recommendations and findings of the Francis Report (Francis, 2013). The group has worked with the General Medical Council (GMC) and the Nursing and Midwifery

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Literature review The aim of the literature review was to explore previously published data on the teaching of patient safety and human factors in undergraduate nursing curricula; this was also the criteria for narrowing down or selection. The authors wanted to explore how much time was being devoted to the teaching of patient safety and human factors in undergraduate courses, what topics were being covered and what teaching methods were being used to deliver this important topic. The databases identified for the review were PubMed, CINHAL and Google Scholar. An advanced search was carried out using the following keywords: ‘patient safety undergraduate nurs¬¬¬* education’, ‘human factors nurs* undergraduate education’, ‘non-technical skills nurs* undergraduate education’ and pre-registration nursing. (Google Scholar does not accept asterisk marks, so the terms ‘nurse’, ‘nursing’ and ‘nurses’ were entered manually.) The search period was from 2006 to February 2013. The final selection of papers was made by examining the title and abstract, and three authors had to all agree on the papers that met the said criteria. The search results were disappointing, with only two articles obtained from the search. The majority of papers identified were simulation-related papers, which although valuable, did not meet the aim of the search. The older of the two papers—Attree et al (2007)—explored patient safety in an English pre-registration nursing curriculum and found that, while patient safety was included in teaching, it was implicit rather than explicit. The study concluded that patient safety needed to feature more explicitly and consistently in pre-registration nursing curricula. The study did not explore the teaching of human factors, because the study was carried out at a time when awareness of human factors in nursing education would have been very low. The second paper obtained in the search was Mansour’s (2012) review of patient safety teaching in nursing undergraduate education. Mansour (2012) is a literature review examining how student nurses and nursing faculty perceive integration of patient safety education into preregistration nurse training. The findings in the review indicated that most patient safety education courses have

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not been formally and fully included in the undergraduate nursing education system. Mansour (2012) highlighted the issues around academics’ understanding of the patient safety agenda, and suggested that much of the data indicated that academic teaching is still focused on individual contributions toward unsafe practice and not a systems approach.

Method An electronic survey was sent to 20 schools of nursing in England. A convenience sample of schools were selected by the authors.The survey was sent electronically to three faculty members at each institution who were involved with the preregistration adult nursing programmes. Moreover, reminder emails were sent to non-responders. In all, 13 universities responded (65% response). The aim of the survey was to explore the degree to which patient safety and human factors were being introduced into current nursing curricula. The survey explored how much time was being devoted to patient safety and human factors, what topics were being covered and what teaching methods were being used to deliver the teaching. The following definition of human factors was included at the beginning of the survey to facilitate understanding of the questions: ‘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.’ (Clinical Human Factors Group, 2010)

Discussion All respondents said patient safety was covered in their curricula, and that the subject was allocated more than 4 hours. Twelve respondents stated that human factors teaching was included as part of their patient safety teaching. This finding is encouraging and suggests that the focus on patient safety in the UK healthcare policy in the last 5 years is influencing some pre-registration nursing programmes. A larger study is required to ascertain whether this finding is large scale. The survey also questioned the focus of the human factors teaching. The most common subjects included from the list were decision making, situation awareness, teamwork and fatigue. The least common subjects were humanmachine interface, user-centred design, anthropometry and environmental ergonomics. This finding is disappointing and suggests that human factors might be interpreted too narrowly as primarily relating to team training; hence, other important aspects of human factors, which look at systems and workplace design, are being missed. Design experts are already planning healthcare work areas and equipment to help prevent errors (West et al, 2013). Some universities and trusts are collaborating in teaching patient safety, which has been evidenced by six respondents stating that they had local trust input in their teaching. Only two respondents said their teaching of patient safety was multiprofessional. Since the fundamental parts of patient safety are communication, teamwork and authority gradients, this appears to be a missed opportunity. The healthcare



Council (NMC) to produce a joint statement of professional values that makes indirect reference to human factors (General Medical Council, 2012). The National Patient Safety Agency (NPSA) in the UK recognised the importance of training nurses in patient safety, and, in 2008, developed a training package called Foresight Training (National Patient Safety Agency, 2008). The World Health Organization (WHO) also recognised the need to teach undergraduate healthcare staff about patient safety and human factors and developed a patient safety curriculum guide for medical students (WHO, 2009).This was followed in 2011 by a multiprofessional curriculum for nurses, pharmacists and allied health professionals (WHO, 2011). The Institute for Healthcare Improvement (IHI) in the USA has established free online patient safety and human factors courses (IHI, 2013b) and championed the concept of student patient safety chapters, to encourage student engagement in making health care safer.

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Table 1. Results of the electronic survey (Total respondents = 13) Is patient safety covered in your current undergraduate nursing curriculum? If ‘yes’, how many hours? 13 responses (100%)

Yes, all more than 4 hours

If you teach patient safety, does it include the following topics? (The list included: what is patient safety, human factors, understanding systems and their effect on complexity of care, managing clinical risk and learning from errors) Most common topics

Least common topics

Managing clinical risk

13 (100%)

Being an effective team player

10 (77%)

Improving medication safety

13 (100%

Understanding systems

10 (77%)

Human Factors

12 (92%)

Being open

10 (77%)

How is patient safety incorporated into the curriculum? Isolated sessions

10 (77%)

Integrated with clinical placements

9 (69%)

Specific session or module

6 (46%)

What format does teaching take? (List included: formal lectures, problem-based learning, patient safety improvement projects) Most common format

Least common format

Problem-based learning

11(92%)

Small group teaching

9 (75%)

Patient safety improvement project

1 (8%)

No

10 (83%)

No

10 (83%)

Is patient safety teaching delivered to multiprofessions? Yes

2 (17%)

Have you produced patient safety competencies? Yes

2 (17%)

Are you aware of the World Health Organization’s (WHO) multiprofessional patient safety curriculum? Yes

3 (23%)

No

10 (77%)

If ‘Yes’ do you use the WHO resources? (Slides/Learning activities) 2 respondents out of 13 stated ‘Yes’. Both indicated use of learning activities. Have you used the WHO Faculty Guide to prepare staff to deliver the topic? Yes

1 (10%)

No

9 (90%)

13 (100%)

No

0 (0%)

Do you use patient stories? Yes

If human factors are included in your curriculum, which of the following topics are covered. Situation awareness

9 (69%)

Teamwork

10 (77%)

Decision making

12 (92%)

Workload

6 (46%)

Fatigue/shift work

8 (62%)

Anthropometry

0 (0%)

Environmental ergonomics

4 (31%)

Human machine interface

3 (23%)

User-centred design

2 (15%)

If you teach human factors, do you have input from: Local trust patient safety staff

6 (100%)

External patient safety facilitators

2 (33%)

External human factors facilitators

0 (0%)


During human factors teaching, do you discuss specific issues students might face when trying to apply the principles of patient safety or human factors teaching in clinical areas? Only 9 respondents (9 = Yes) answered this question. Four identified the following specific issues: ‘Hierarchy and perceptions of power’, ‘complexities of practice’, ‘students encouraged to identify real-life scenarios’, ‘these issues are discussed in a specific session’. Do you believe that the assessment of student practice in clinical areas affects student ability to fully apply human factors/ patient safety teaching? Only 4 respondents (3 = Yes, 1 = unsure) answered this question.


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How confident do you feel about teaching the broad topic of patient safety? Rate your response on a scale of 1–10 (10 = extremely confident) 1

0 (0%)

2

0 (0%)

3

2 (16.6%)

4

1 (8.3%)

5

0 (0%)

6

2 (16.6%)

7

1 (8.3%)

8

4 (33.3%)

9

0 (0%)

10

2 (16.6%)

Have you linked with other faculties in your university who have experience of teaching human factors, such as ergonomics or engineering? 4 out of 13 responded; all answered No. Are you aware of the Institute for Healthcare Improvement (IHI) Open School free online courses in patient safety? Yes

2 (18%)

No

9 (82%)

No

11 (100%)

No

11 (100%)

No

10 (100%)

Do your students undertake the free IHI online courses? Yes

0 (0%)

Are you aware of the IHI open school chapters? Yes

0 (0%)

Has your department formed a IHI open school chapter? Yes

0 (0%)

Are students being involved by local trusts as observers / data collectors in audits or quality improvement work? Yes

4 (40%)

No

6 (60%)

professions involved alongside nurses at the two institutions were physiotherapists, occupational therapists, midwives and operating department practitioners. Medical students were not involved. This may be owing to resource issues and logistic challenges, as medical students and nurses are the largest groups of students and are often trained in different universities. Only two universities had produced patient safety competencies. The Nursing and Midwifery Council (NMC) in the UK set standards in the form of competencies that student nurses should meet in order to become registered nurses. In 2010, the standards were updated to acknowledge a loss of public confidence and the need for patient safety to feature prominently in all aspects of nursing care. Other countries such as Australia and the USA have produced more explicit patient safety competencies (Walton et al, 2006; Cronenwett et al, 2007). Knowledge of the WHO multiprofessional patient safety curriculum (2011) was poor, with only three respondents being aware of it. An evaluation of the pilot studies of the WHO medical curriculum, which were introduced before the multiprofessional version, shows that the faculty found this a useful resource and students reported positive intentions and attitudes with regard to patient safety (Patey et al, 2011). Only 2 from among 11 respondents were aware that the IHI provided free online patient safety modules and that there was a global network of student patient safety chapters. These chapters are face-to-face, interprofessional groups at

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individual institutions, and they provide opportunities to learn more, network with peers and connect with engaged and supportive faculty. The faculty who responded (12 out of the 13 contacted) appeared confident to teach patient safety, with a mean score of 6.75 on a scale 1–10. The Patient Safety Education Group report (2009) found that most lecturers struggled to define/conceptualise patient safety as a distinct concept. It may be reasonable to suggest that, in the past 3 years, awareness among the nursing faculty has increased. Only one respondent had used the WHO faculty guide to help prepare staff to deliver the topics. The relationship between nursing students and their mentors and the culture of the placement area are known to influence students’ comfort levels when implementing patient safety/human factors theory into practice (Patient Safety Education Group, 2009). The WHO multiprofessional patient safety curriculum (2011) discusses these issues and describes how students are very aware that mentors assess their placements and could pass or fail them; moreover, the mentor relationship affects how confident they feel to challenge unsafe practice by other staff. The survey also asked if schools discussed these difficulties with students. Nine of the respondents stated ‘yes’. The approaches used to explore the challenges faced by students in practice include using reflections from practice and discussing hierarchy and assertiveness in the NHS. The WHO



*In questions where respondents could select more than one response, the total percentages may add up to more than 100%.

research multiprofessional curriculum (2011) suggests that postplacement debriefings for students may be an effective way to explore these challenges. The authors feel that training and updates for mentors could include discussions about providing specific patient-safety and human-factors learning opportunities for students. All 13 respondents stated that they use patient stories when teaching patient safety. There is growing recognition of the importance of patient and public involvement in all areas of health care, and in patient safety specifically, the role patients can play in reducing harm (Lawton and Armitage, 2012) is significant.

Limitations The survey was designed as an exploratory pilot. The schools were a convenience sample and were not selected at random. There may therefore have been some selection bias. Another limitation is that only schools who considered themselves to be at the fore of undergraduate teaching may have responded. The sample was very small and all 13 schools of nursing were located in England. Hence, the results are not generalisable. A much larger survey of schools of nursing is required along with in-depth interviews or focus groups of nursing faculty, student nurses and mentors.


Conclusion It appears that patient safety and human factors are beginning to receive greater attention in undergraduate nursing curricula, although awareness about the WHO multiprofessional curriculum guide for patient safety and the IHI’s resources are poor. Greater use of WHO guides and materials and IHI free courses and chapters could enhance patient safety teaching provision by facilitating a more standardised and coordinated approach across universities. The survey suggests that, in the participating universities, there is very limited multiprofessional teaching in relation to patient safety. Increasing confidence in multiprofessional communication is crucial to improve patient safety, since hierarchies or authority gradients frequently inhibit people from voicing their opinion. The Francis Report (2013) recommends that the GMC and the NMC ‘should ensure that patient safety is the first priority of medical training and education’. One way to achieve this is by increasing multiprofessional teaching and using WHO and IHI resources. Universities should encourage staff training in patient safety and human factors to ensure that they feel confident to deliver and teach these topics. The WHO Faculty Guide is a useful resource to help prepare faculty. Human factors teaching should not focus solely on non-technical skill but should include the workplace environment and design of medical equipment. Educationalists need to work closely with mentors and trusts to enable students to make connections between the teaching in university and what occurs in practice. Raising student nurses’ awareness of patient safety and human factors necessitates that mentors are also educated by their organisations; in this way, they will also welcome students comments or queries on these topics. A much larger survey of schools of nursing is required along with in-depth interviews


Key points n The

schools of nursing surveyed appear to be including patient safety and human factors teaching in their curricula

n Very

few schools seem to be providing multiprofessional patient safety and human factors teaching

n There

is poor awareness and use of the World Health Origanization multiprofessional patient safety curriculum guide and resources

n Similarly,

there is a lack of awareness about and use of the Institute for Healthcare Improvement free online patient safety and quality improvement courses for student nurses and the existence of student patient safety chapters

or focus groups of nursing faculty, student nurses and mentors BJN to explore this topic in greater depth. Conflict of interest: none Acknowledgements: The authors would like to thank Dr Beverley Norris, former Human Factors Lead at the National Patient Safety Agency, for her advice on the survey questions. Attree M, Cooke H, Wakefield A (2007) Patient Safety in an English preregistration nursing curricula. Nurse Educ Pract 8(4): 239–48 Clinical Human Factors Group (2012) Defining Clinical Human Factors. http:// tinyurl.com/oxv2ztg (accessed 17 September 2013) Catchpole K (2013) Spreading human factors expertise in healthcare: untangling the knots in people and systems. BMJ Qual Saf [Epub ahead of print] http:// tinyurl.com/qg25el4 (accessed 17 September 2013) Cronenwett L, Sherwood G, Barnsteiner J et al (2007) Quality and safety education for nurses. Nurs Outlook 55(3): 122–31 Department of Health (2011–2013) Department of Health Human Factors Reference Group Interim Report, 1 March 2012. http://tinyurl.com/ovavzu8 (accessed 29 March 2013) Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office, London General Medical Council (2012) Joint Statement of Professional Values Nursing and Midwifery Council and General Medical Council. http://tinyurl. com/pgbj7qg (accessed 17 September 2013) Harm Free Care (2013) NHS Safety Thermometer. http://tinyurl.com/a22l4nd (accessed 17 September 2013) Institute for Healthcare Improvement. (2013a) 5 Million Lives from harm. http:// tinyurl.com/6ulzd8q (accessed 17 September 2013) Institute for Healthcare Improvement (2013b) Open School. http://tinyurl. com/7l5ldkp (accessed 17 September 2013) Lawton R, Armitage G (2012) The Role of the Patient in Clinical Safety. Thought Paper. The Health Foundation, London Mansour M (2012) Current assessment of patient safety education. Br J Nurs 21(9): 536–43 National Advisory Group on the Safety of Patients in England (2013) A promise to learn – a commitment to act. http://tinyurl.com/q6a7zkh (accessed 17 September 2012) National Patient Safety Agency (2008) Foresight training. http://www.nrls.npsa. nhs.uk/resources/?entryid45=59840 (accessed 17 September 2013) Nursing and Midwifery Council (2010) Standards for pre-registration nursing education. http://tinyurl.com/6f443py (accessed 17 September 2013) Patey R, Flin R, Ross S et al (2011) WHO Patient Safety Curriculum Guide for Medical Schools Evaluation Study Report to WHO Patient Safety Programme. http://tinyurl.com/nbdtw75 (assessed 17 September 2013) Patient Safety Education Group (2009) Patient Safety in Healthcare Professional Educational Curricula: Examining the learning experience National Patient Safety Agency (2011) Patient Safety First 2008 to 2010 The campaign http://tinyurl.com/aoc5mjf (accessed 17 September 2013) Walton MM, Shaw T, Barnet S, Ross J (2006) Developing a national patient safety framework for Australia. Qual Saf Health Care 15(6): 437–42 World Health Organization (2009) WHO Patient Safety Curriculum Guide for Medical Schools. WHO Press, Geneva. http://tinyurl.com/nacec6b (accessed 17 September 2013) World Health Organization (2011) Patient Safety Curriculum Guide: Multiprofessional Edition. WHO Press, Geneva, Switzerland West J, Mathews E, Anderson O (2013) Designing out medical error (DOME). J Med Devices 7(2): 020926

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