Resources for team training on Human Factors and Situational Awareness
Human Factors simulation
Simulation encompasses a broad range of training techniques. For Human Factors, the emphasis is not on the clinical technical tasks, but on the interactions with other team members and the environment. Please note that none of this work replaces technical skills, which are essential to our roles.
You need to be prepared as a facilitator to discuss behaviours. The fundamental prerequisite of this is to understand that personality is different to behaviour.
Ideally, before leading a simulation you should have some basic training in human factors (i.e. have attended a course) as well as some faculty training in simulation techniques and debriefing. We recognise that not everybody will have had this opportunity and so hope that the following suggestions are helpful.
Trying out, versus trying on.
Where technical simulation is focussed on “trying out” technical skills in a safe environment, human factors simulation is focussed on “trying on” behaviours. The first step is to ensure that you have a psychologically safe environment and set out ground rules for simulation. Some suggested rules can be found in the “further information” section.
Location and Set-Up for simulation
This can range from exploring different scenarios in role-play, to a full simulated emergency on delivery suite. Your ability to do this will depend on the resources available to you and your unit, but remember it is the human interaction element which is important. Try to include to a multi-disciplinary team.
Feedback and Debrief
The goal of these simulations is encourage reflection and development of team behaviours. For this to happen careful facilitation and structured debrief is essential. The RCOG provides structured feedback tools which can be used – NOTTS – which can be found in the further information section.
Dealing with unexpected or challenging behaviours
Just as technical simulation can reveal eccentric clinical practice, so can human factors simulation reveal unusual or occasionally unwelcome behaviours. Careful consideration needs to be given to how to tackle these by the facilitators, but importantly to understand why they have happened. These could range from becoming angry at a perceived challenge, or upset at recalling a stressful past experience.
Scenarios for Situational Awareness
Instructions to facilitator
These scenarios are suggestions of how you might begin to simulate elements of human factors. They are suitable for local adaptation as trainers see fit.The candidate cannot succeed at these scenarios as they are designed to demonstrate human limitations in maintaining situational awareness. Some may find this distressing so careful facilitation and debriefing, as with any simulation may be required.
- Recognising task fixation
- Limitations of short term memory
- Dealing with distractions and interruptions
- Two facilitators.
- This scenario can be conducted in a labour ward coffee room or a simulation centre or anywhere in between.
Understanding Task Fixation
Emphasis – You can’t multi-task. You must concentrate on the task in hand which will inevitably cause you to lose situational awareness.
The first facilitator will hand over a simplified labour ward board – in practice this can be more or less complicated depending on the participant.
||P3, VBAC, spontaneous labour, 4 cm dilated on last VE
||PN CAT 1 LSCS for abruption, PPH 2L
||P1, Type 1 DM, 34/40 - for antenatal steroids on insulin infusion
||P0, IOL for postdates, on oxytocin, 7cm dilated last VE
The candidate will then get called to another patient.
The candidate will have to perform a procedure – this will be dependent on their role, such as inserting a catheter, neonatal examination or performing an instrumental delivery.
You should have the equipment for the candidate to perform the procedure – for example an instrumental delivery should include preparing a sterile field, counting swabs, checking and asking for local anaesthetic where appropriate.
They should have to ask for all the equipment and not be prompted to the next step (to make them think). The second facilitator should record any errors or delays in the process as well any interesting behaviours. These should be addressed in the debrief at the end of the simulation.
Whilst the candidate is preparing for the procedure a second facilitator should ask them to recall information about the handover they have just received.
They should ask questions about the patients on the labour ward board and potentially about their anticipated management (similar to a prioritisation test).
The scenario should end when it is clear multi-tasking has broken down. This is either when the technical task is compromised or the candidate has lost situational awareness.
Distractions and interruptions
Emphasis – Distractions and interruptions are things which cause us to drop key information out of our short term memory. This leads to a failure of perception and a loss of situational awareness.
The second facilitator should provide new information and ask clinical questions relating to patients on the labour ward board, such as:
- Room 1 – Developing more abdominal pain
- Room 2 – Haemoglobin 89, Platelets 100, HR 120bpm.
- Room 3 – Consistently high blood glucose levels
- Room 4 – Still 7cm on the last VE
The candidate is expected to respond and make plans. The second facilitator should document any errors or delays in response or any interesting behaviours.
If the candidate has finished preparing / completed the procedure then they should talk through another emergency. For example after completing the neonatal examination there is a neonatal arrest or after an instrumental delivery there is a postpartum haemorrhage.
If the candidate has written a handover list they should be reminded that they cannot update or refer to this as they are sterile.
The scenario ends when the task is compromised, the candidate asks to stop the interruptions or is unable to respond appropriate to the questions asked.
Emphasis – Even if you haven’t got the helicopter view you will see things that someone who is task focused will miss. We all need to feel confident when we see something going wrong.
At a debriefing one facilitator should demonstrate how to perform a procedure (inserting catheter, neonatal examination or an instrumental delivery). The facilitator should incorrectly perform a safety critical step in the procedure. The second facilitator should not correct them. If nobody notices the error the procedure and the error should be repeated. With each repeat there should be an additional error until somebody speaks up.
Another optional is the second facilitator could take over the demonstration, but they must perpetuate the same errors and the first facilitator must not correct them. At the end of this scenario it is imperative that nobody leaves until the debrief is complete and everybody is clear about correct way to perform the procedure being demonstrated. The debrief should focus on ways to speak up in a constructive and confident way.
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