In the relentless drive to improve patient safety developments in training and education are crucial, and the increasing sophistication of simulation-based education and human factors training is attracting attention.

[ Words: Stewart McRobert ]

Everyone makes mistakes. After all, we’re only human. However, the crucial element in healthcare is how we work as individuals and members of a team to eliminate error in the first place and learn from adverse incidents to make sure they are not repeated. This is the crux of simulation-based education (SBE) and human factors training which are gaining increasing traction in medical and dental education. 

Thanks to new technology and increased understanding of the way human beings work, training and education in every environment has been transformed. These days, trainees can practise and master complex skills in safe, simulated environments. SBE has proved its worth in high-pressure, highly-skilled environments – it is widely used as a training tool in a wide range of high-reliability industries such as aviation, oil and gas exploration and the military. In healthcare, SBE is increasingly seen as having the potential to provide improved patient safety, better learning experiences for trainees and improve the lessons learned from adverse incidents. 

One organisation helping to advance the work being done is the Northern Ireland Simulation and Human Factors Network (NISHFN). It was established after the Northern Ireland Medical and Dental Training Agency (NIMDTA) appointed a Simulation Lead and Simulation Fellow, as part of the ADEPT Clinical Leadership Fellows’ programme. NISHFN aims to support and connect individuals who have an interest in simulation and human factors training.

Mike Morrow is the NIMDTA Simulation Lead. He said: “Simulation has been defined as ‘a technique – not a technology – to replace or amplify real-life experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.’

“In truth, the use of simulation in dentistry has been widespread since the early 1800s when dentists learned by working on extracted teeth on a bench top. Then, in the late 1800s the ‘phantom head’ was introduced. It remains the mainstay of undergraduate work and is used to some extent in postgraduate training.”

In recent times computer-based simulation training has been adopted to a certain degree in dental training in the UK and Ireland. However, although a few studies have suggested it has some advantages in terms of availability, cost and reduced contamination, there’s no solid evidence to suggest it is superior to phantom head training.

“What has the potential to make a dramatic difference is the recent development of virtual reality feedback haptic devices,” said Mike. “Using technology developed initially for the aerospace and aviation industries, high-fidelity VR simulators can now provide trainees with realistic sensory feedback that’s much more meaningful than looking at a two dimensional screen. Although this technology is still in its early days, it is likely to prove a game-changer for dentistry. 

“There is likely to be a role for haptic training in more complex dental procedures, such as restorative work, where the availability of patients to train on is limited and the cost of mistakes is very high.

“That said, I don’t see the use of phantom heads disappearing any time soon, but the new products will undoubtedly be a powerful addition.” 

Up to now, most of the SBE being done in Northern Ireland has focused on the medical side rather than the dental. However, Mike and his colleagues have run a number of successful and popular courses for GDPs that concentrated on managing medical emergencies. Although a relocation of training facilities saw these courses withdrawn there is hope that they can be re-established. “As an adjunct – never a replacement – to clinical experiences, SBE has huge potential to improve skills and identify latent threats,” said Mike.

Healthcare human factors

Human factors training focuses on optimising performance through better understanding of the behaviours of individuals and the way they interact with their environment. Numerous models have been developed to explain the complex relationship that exists between human factors and the patient. The World Health Organisation (WHO) identified ten human factor topics most relevant for patient safety; safety culture, manager’s leadership, communication, teamwork – structure/processes and team leadership, situational awareness, decision-making, stress, fatigue and work environment. 

“Although I am not a dentist and have limited experience in training dentists, I know they’re no different to other healthcare workers – they are human, and therefore prone to human frailties.”

“In Northern Ireland, NISHFN is working with local and national experts to develop an all-encompassing approach to healthcare human factors. The aim is to develop skills in team-working, communication, behavioural issues and cognition among others.

“Cognition relates to how we think and, in particular, how we think in different situations, such as when we are operating under stress or are tired. These can leave a practitioner prone to error, therefore learning to think about how you think has the potential to help you improve or adapt your behaviour.”

“Similarly, when we were running our courses for GDPs it became clear quite quickly that in many cases team working wasn’t as well-developed as it might have been. For example, dentists might not always be aware of where resuscitation equipment was stored, what guidelines were available to them and when resuscitation drugs might go out of date.”

The work in Northern Ireland is part of wider activity. In the UK, the Chartered Institute of Ergonomics and Human Factors has given greater urgency to its work in healthcare. Indeed, in 2018 it released a white paper on the topic. “Our work in Northern Ireland is closely aligned with the approach outlined by the Institute,” said Mike. “One that takes account of the individual, the team they work with and the system they work in.”

He believes future training must look at an individual’s skills and requirements, the demands of the dental curricula, and human factors training. Such an integrated approach will help make sure dentists know about their own potential for lapses and errors, how they as an individual practitioner rely on the team supporting them, and how the system in which they operate can be fallible. Mike and his colleagues are also keen to see increasing links between groups across the UK and Ireland that support SBE and human factors training.

“Although I am not a dentist and have limited experience in training dentists, I know they’re no different to other healthcare workers – they are human, and therefore prone to human frailties.”

While it might be thought that people would react negatively to having their capacity for error highlighted, Mike said the opposite is usually true. “What we’ve found in our work with medics and allied healthcare professionals is that when individuals are made aware of these issues it can be a ‘lightbulb moment’. Start talking about human frailty – which is not a disparaging term – and people intuitively understand that we are all fallible. The best way to protect your patient, your team and yourself from the consequences of error is to develop the skills, behaviours and cognition that make the job safer.”

Adverse incidents

Another area where human factors and SBE can be vital is in the ability to learn from serious adverse incidents. “NISHFN is currently piloting a Quality 2020 project using video training and structured feedback to look at this in the medical arena,” explained Mike. 

“Health boards, trusts and agencies are good at collecting data on error. Those stats are harvested, collated and analysed with subsequent recommendations fed back to clinicians. 

“However, this process hasn’t always been as successful or reliable as we would like. Frequently, feedback comes in the form of learning letters or an email attachment that can be easy to overlook. Unfortunately, all too frequently we see repeat episodes of the same problem occurring.”

He believes repetition suggests a systemic problem. “The Public Health Agency is very focused on this issue and is keen to look at ways of addressing these recurrent problems. We are now involved in developing a human factors course to help, using video training to reach a wider interprofessional audience.”

It has to be recognised that there’s much to be done in making SBE and human factors training an everyday part of medical, never mind dental, education. Mike noted: “At the NI Medical and Dental Training Agency we have begun working closely with Queen’s University to make sure there’s close alignment with what they are teaching in human factors and what we are aiming to do in a postgrad environment. We are working with the medical specialties trying to make sure SBE and human factors training is being delivered where recommended by the various Royal Colleges, and that the resources and readiness are there to make sure it can be delivered effectively.”

Mike and his colleagues are also trying to make sure that training is being created in ways that are appropriate, delivered to a recognised standard and aligned with the various curricula. 

“As part of that we have been involved in trying to standardise the approach to debriefing simulation sessions. A debrief has to be structured and reproducible. We’ve based a lot of our work on an approach developed by the Scottish Centre for Simulation and Clinical Human Factors. Our methodology has been rolled out successfully and accepted by undergraduate medical colleagues at the Queen’s University, helping to bring a degree of standardisation. 

“Overall, we are making small but steady strides and we at NISHFN would certainly welcome our dental colleagues as members of the network. NISHFN welcomes everyone who is interested in simulation-based education or human factors training, regardless of clinical background.”

The Northern Ireland healthcare system, like others, suffers from acute financial pressures. SBE and human factors training require resources, faculty-training and time away from clinical work. Researchers are increasingly aware of the need to look at cost-effectiveness. Nevertheless, it is also recognised that there will be an increased drive for integrating simulation-based education and human factors training in undergraduate and postgraduate healthcare training. 

“NISHFN looks forward to helping interested stakeholders support and develop simulation and human factors training across Northern Ireland in the coming years,” said Mike.

“The challenges that those of us involved with this area face are cost, faculty time and how to get training integrated into the workplace. Our efforts have been focused on encouraging people to invest in this valuable way forward. It does take a paradigm shift for that to occur – there has been recent movement in the right direction, but full-scale recognition of the value of SBE and human factors training has not happened yet.

“The developments in these areas create an exciting challenge for everyone involved in healthcare education, but, as always we need the support of funding bodies.”

It seems that we don’t need to fear fallibility, but we do need the finance to face up to it. 

Tags: education, human error, May 2019, Patient Safety, simulation-based training, simulator, training