“If I can reach that one person at induction day and she stays doing caring for maybe ten years? So she might see thousands and thousands of people on her journey through her career, if she carries that through, with all of them what a magnificent difference that’s going to make! So that’s how I think of it.”
Stephen Early, Service User

The West of England AHSN developed an intervention tool to support Human Factors training in patient safety for staff working in community health settings.

What was the problem?

Often, when safety issues occur, the cause is stated to be “human factors.” But what are these human factors, and how do they affect safety?

An adverse event is an unintended injury, caused by medical management rather than by a disease itself. One in ten people are affected by a medical error, although not all errors lead to harm, and not all harm is due to error. There are three common factors in the majority of adverse events: medical complexity, system factors and human factors. Common human factors that can increase risk include mental workload, distractions, the physical environment, physical demands, device/ product design, teamwork, and process design.

The aim of the West of England AHSNs human factors programme was to develop non-technical skills to support safer ways of working – including teamwork, communication, leadership and an awareness of human factors, such as ergonomics and “work as imagined versus work as done” when designing systems and processes.

What we did and why

An appreciation of the principles of human factors has been implemented into acute care services in recent years, but training packages and resources were less applicable to the community health and social care context and non-registered staff (bands one to four).

To answer these questions, front-line staff from across the West of England received training in human factors and how they can affect safety. Training sessions looked specifically at good communication and the factors that can affect our performance at work.

The West of England AHSN secured funding from Health Education South West to develop an intervention using the SBAR (situation, background, assessment, recommendation) tool. This supported human factors training in patient safety, specifically for bands one to four staff working in community health settings in the West of England region, in partnership with Sirona Health & Care and North Bristol NHS Trust.

Factors taken into account designing the intervention included:

  • community setting
  • language for working in a mixed health and social care setting
  • social enterprise setting
  • needs of adult learners with a variety of education backgrounds and qualifications.

The AHSN developed a toolkit with specific guidance on quality improvement, measurement, public involvement and evaluation, based on the evaluation of an initial pilot. These tools include qualitative surveys of staff and patients to understanding the impact of the intervention.

This toolkit was supported by face-to-face ‘train the trainer’ sessions to develop a faculty in expertise in delivering non-technical human factors training. This was alongside QI coaching every step along the way, and hosting collaborative events for shared learning and problem-solving.

The curriculum was developed by Sirona Care and Health and North Bristol NHS Trust, based on how teams communicate, using communication tools such as SBAR to develop a baseline awareness, which is built upon and embedded during the training using scenarios. These scenarios were co-designed by the programme lead and service user representative to reflect realistic situations that staff might encounter.

The initial phase of the pilot was to work with three teams – health visitors, learning difficulty day services and extra care – to develop the training package and scenarios. Following this first PDSA cycle (plan, do, study, act), the training was adopted into induction for all new starters. This induction is in two parts: an introduction delivered by one of the service users, and a day-long training session for bands one to four staff looking at human factors in more depth.

The project used an approach called SBAR, which was originally developed for use on submarines, and adapted it for use in health and social care settings. SBAR stands for Situation – Background – Assessment – Recommendation, and is a structured communication tool for handing over information.

Following this spread to community providers, a care home specific toolkit has been produced. Staff working at Sirona Care and Health also produced a music video for staff working in care homes to support the toolkit. Watch the video here: https://vimeo.com/207630363

Which national priorities does this work address?
  • Acutely ill older people
  • Deterioration of patients
  • Handover and discharge
  • Care Certificate, following the Cavendish Review (2013)
  • Human Factors in Healthcare: A Concordat from the National Quality Board (2013).

Over 2,800 staff in the West of England received training. In addition, 278 staff received training at other Patient Safety Collaborative events from across the healthcare system. The impact of the initiative has led to the five organisations planning to continue training post-April 2017 to sustain the improvements in staff performance and patient care through incorporating and embedding into other training courses, policies, processes and supportive structures.

The team leading the project have developed a suite of materials which are freely available online for others to use. These are available at www.weahsn.net/human-factors.

As a result of the training, many participants have reported this would change their behaviour in the workplace. The project trained a faculty of over 40 staff to embed the approach into local structures and processes.

Tips for implementation

Training community staff, particularly in bands one to four, in human factors has increased awareness of these factors and how they can affect performance. As a result, many participants reported in their evaluations that this changed their behaviour in the workplace. Training a faculty and providing resources (both physical training resources and funding) has increased capacity and capability in the provider organisations across the region. Training a faculty enabled them to adapt the training and adopt it into local structures to ensure sustainability of the programme.

However, there were challenges in data collection. Although some elements of the training package are generic to healthcare settings, others depend on using scenarios that are familiar to participants’ own work environment. Therefore, although the content and structure of training can be adapted, we learned it is important to ensure that scenarios are realistic and applicable to participants’ own area, and that interactive, engaging training sessions were successful and more enjoyable both for participants and facilitators.

Challenges faced in delivering this intervention included the different ‘languages’ used by health and social care workers working together in this setting. These factors need to be incorporated into the training sessions and materials.

Success came from embedding the intervention into existing structures rather than creating a new mechanism for content delivery.

Next steps and spread

As identified in the independent report by the Commission on Education and Training for Patient Safety, the principles of human factors must be embedded across education and training. This was further highlighted in the national framework “Developing People – Improving Care”, which emphasised that leaders across all systems including primary, secondary and community care should have access to the knowledge and skills they need to lead improvement.

Although an awareness of human factors is now more routine in secondary care, and community providers through this project, primary care remains a gap in knowledge and skills across the system. To take the learning from the human factors project further, the AHSN used  “human factors for primary care” resources with the two cohorts of its Primary Care Collaborative, covering 28 practices across the West of England.

Learning from the project was used in 2020 in the development of the training package in RESTORE2 for care homes.

The project was funded by Health Education England and delivered with the support of the West of England AHSN.

Find out more
Contact for help and advice

Nathalie Delaney, Programme Manager

E: nathalie.delaney@weahsn.net
T: 0117 900 2604


Programme duration: January 2015 – May 2018