Human Factors Science: Implications for Nurse Leaders

By Cynthia Plonien DNP, RN, CENP

The purpose of this writing is to bring awareness to the value of knowledge and application of Human Factor Science to the practice of nursing leadership and management. In health care, significant errors exact substantial toll in terms of financial costs as well as human life. A variety of factors contribute to medical errors, recognized among them are missed care, avoidable delays, administration of wrong medications, wrong site surgery, improper use of technology, equipment failure and failure in communications. Multiple influences can affect a single outcome.  For the protection of patients as well as employees, it is vital that leadership search for cause of error with a wider impact than incompetence of a staff member. Consider, hitting of a ball in golf or in tennis. Interactions of mental thought, anatomy of the body and mechanics of movement are equally involved in contacting a ball that results in moving it the desired distance and direction. Missing the mark, always offers a lesson in learning. The process of learning from erroneous outcomes in sports can be applied to organizational management. Following error, future success requires assessment, analysis and adaption, which leads to change with a shift in perspective as well as motion.

What is Human Factor Science?

The term “human factors” may not be a phrase well known to leaders of nursing, yet the management of human factors to gaining efficiencies and assuring safety is at the very core of leadership within all organizations. Human factors are an element that relates work design with consideration of human limitations, human strengths and human preferences that affects every outcome. As defined, the science of human factors can be described as an intersect between the sciences of engineering and psychology (1) with inclusion of the design of systems, tools and work environments as well as the cognitive and social conditions of people and performance. (2)  The goal of Human Factor Science is to optimize human work, promoting efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. (1)

Human factor error (HFE) has been applied to understanding error in high-risk industries throughout the 20th century beginning with the Department of Defense.(3)  A philosophy of quality and safety that began with naval aviation, the airlines, nuclear power and the automobile industry has become a critical element in organizations whose mission and achievements depend on management of human factors.

Today’s Application

The application of Human Factors Engineering is a formal component of safety initiatives in numerous organizations.  An exemplar of best practices in Human Factors Engineering can be found in the entertainment industry. The Walt Disney Company incorporates consideration of Human Factors as an essential element of its culture.  Mandatory training for new employees includes intensive education on the “Four Keys Basic”. Four Keys Basic, is a simple code of conduct implemented by Walt Disney in 1971 with the opening of the Magic Kingdom. The Keys are hierarchical employee expectations in order of priority: Safety, Courtesy, Show and Efficiency. When faced with conflicting demands, employees make decisions based on priorities. Safety always comes before courtesy; courtesy always comes before show; and show before efficiency. (4)  Today, Robert Allen, holding a Ph. D in Human Factors and Cognitive Psychology, is the Human Factors & Ergonomics Specialist for Worldwide Safety at Walt Disney Parks and Resorts.  He plays a lead role in the company’s continued reach toward best practices in quality.  He has received world recognition for development of standards enhancing safety and reliability within his industry. It is astounding to see the variety of topics for which his expertise is used as a human factor specialist. For instance: He has applied his knowledge in manual material handling and strength limits, ADA and accessibility, light levels and light design, radio frequency safety, magnetic field safety, photobiological safety, aging workforce, obesity and design, effects of shift work, generational differences, anthropometrics and design, noise/OSHA limits, photo and pattern-sensitive epilepsy, control room design, touch screen kiosk design, biometric interfaces, HCI, food services design, motion and simulator sickness, children ergonomics and design, staircase design, warnings and design, human pain limits, surface temperature limits, human behavior, usability, user interface design, simulation systems, and virtual reality (R. Allen, personal communication, May, 17, 2019).

The Science of Human Factors has made its way into Health Care. The variety of topics for which the information can be applied is vast, and it involves all levels of human interaction – physical, psychological and social.  High Reliability Organizations (HRO) in healthcare persistently seek to understand error and the impact of human factors, correlating to the design and revision of systems that improve processes, reducing error and improving organizational safety as well as efficiency. (5)

Nursing Leadership and Management

Nurse leaders know and understand that management is the process of achieving organizational objectives, within a changing environment, by balancing efficiency, effectiveness, equity, attaining resources, and working with and through people. Also recognized is that leadership in all settings is the process of influencing people towards achievement of organizational goals. (6)  

At times, organizational goals compete and conflict in regard to outcomes. From a moral management perspective – safety must be emphasized over productivity. Management of human factors involves leadership at all levels of an organization.

Communication skill in leadership is crucial. For instance, in a safety focused organization, staff functioning in formal roles as senior executives ensure compliance with regulatory requirements for safety, communicate the vision of safety, provide resources and encouragement. Middle managers emphasize safety over productivity, and become involved in safety initiatives, relaying the corporate vision. Whereas, staff members working in lead roles, formal or informal, direct and coordinate the work of others to ensure safety and quality of care at the front line of patient care. (7)

As the science of human factors progress, many techniques that are used in industry have not yet employed in healthcare, however, there are a number of quality tools useful in the multi-disciplinary collaborative environment of health care.  Nurse managers are ideally placed to initiate principles of human factors with tools readily available – coaching, teaching and mentoring members of the team.

Tools available for nursing managers:

• Root Cause Analysis (RCA) - uses a system approach to identify contributory factors in incident investigation.
• Incident Decision Tree (IDT)- assesses the roles of individuals and system influence in incident causation. It focuses on whether the individual could have been set up to fail by a system.  
• Foresight – involves equipping staff with knowledge of the factors that can contribute to errors and incidence and to encourage error ‘vigilance’. 
• Procurement of medical devices and equipment – involvement across the organization – inter and intra departmental review and recommendations to ensure standardization and compatibility. (3)
• Team work – giving healthcare professionals formal training, time and tools to develop as a team i.e. SBAR, Crew Resource Management and TeamStepps. (7)
• Safety culture measurements and benchmarking data – questionnaire regarding Patient Safety Culture and Patient Safety Attitudes are available from a variety of providers, including the Agency for Healthcare Research and Quality (AHRQ). (8)

Collaborative Wisdom

It is generally accepted that human factors are under utilized in examining safety problems and in designing potential solutions. (8)  However, the Science of Human Factors has crossed the collaborative chasm into the Science of Nursing.  The Internet has revolutionized occasion for collaboration across disciplines in mass or on a small scale, providing an avenue to connectiveness never before possible. (9)

As nurse leaders grow in their comprehension and understanding of the influence of human factors, better decisions can be made in developing guidelines and standards to support safe and effective practices. Often, we are inundated with information at our fingertips of which we have no idea of how to use. Knowledge and education evolving from specialty practice often eludes the wisdom that may be gained through interdisciplinary and collaborative practice.

No doubt, the future of best practices in health care will come from collaborative practice.  We need knowledge from those with expertise – military, aviation, nuclear, entertainment and hospitality. Wisdom comes from a combination of experience, knowledge and intuition. We are wise to learn from the success of others – be it a man or be it a mouse.

Associated Videos:

• Human Factors - click here to view
• The History of Human Factors - FAA Human Factors - click here to view

References:

1. Russ, AL, Militello LG, Saleem JJ, Fairbanks RJ, Wears RL., Response to separating fact from opinion: a response to “the science of human factors; separating from fiction”. BMJ Qual Saf 2013; 22(11); 964-6.

2. Henrickson Parker, S. Human factors: A human factors science: Brief history and applications to healthcare. Current Problems in Pediatric and Adolescent Health Care 2015, 45(12), 390-394.

3. Norris, B. Human factors and safe patient care. Journal of Nursing Management 17, 203 – 211.

4. Lee, F. If Disney Ran Your Hospital. Second River Healthcare, Bozeman, MT. 2004.

5. Oster, C. 7 Braaten, J. High Reliability Organizations: HRO. (2016) Sigma Theta Tau International.

6. Naylor J. (2004) 2nd ed. Management Harlow: Prentice-Hall.

7. Flin R, Winter J. Sarac C, Raduma M. Human Factors in Patient Safety: Review of Tools and Topics. World Health Organization, 2009. 

8. PSNet (Patient Safety Network). Culture of Safety. AHRQ, 2019 Retrieved on 5/17/2019 from: https://psnet.ahrq.gov/primers/primer/5/safety-culture

9. Suskind, R & Suskind, D. (2017). The Future of The Professions. Oxford University Press.