Exploring anaesthetists’ work as part of a sociotechnical system: A human factors perspective
Provided on behalf of the Chartered Institute of Ergonomics and Human Factors (CIEHF) from Dominic Furniss, Erik Berndt and Ann Blandford, University College London
There has been a growing interest in human factors in healthcare to improve clinical performance and to address issues of safety (e.g. NHS England, Human Factors in Healthcare). Human factors aims at: “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” [1]; however, the concept of human factors has been poorly understood – for example, it has been equated with training, non-technical skills, crew resource management and other strategies that are intended to change human behaviour [2]. More broadly, human factors seeks to improve the design of systems to better aid people, i.e. it is focused on system changes (rather than people changes) to improve performance.
Ball & Frerk (2015) discuss the reactive approaches to safety in anaesthesia as part of Safety 1, and the proactive approaches as part of Safety 2 [3]. These can be seen as two sides of the same coin. Even within human factors, Safety 1 has been the dominant perspective – for example, people review incidents that have occurred to address the causes that may reduce the likelihood of recurrence [4–6]. Safety 2 looks more at the positive side of maintaining safety on a daily basis so that abilities can be enhanced. For example, it seeks to understand how professionals compensate for poor circumstances and poor systems to maintain safety and performance. This includes analysing sociotechnical systems during ‘normal’ performance in the absence of anything going wrong. This article reports results from the application of two techniques to explore anaesthesia practice: contextual inquiry and distributed cognition for teamwork (DiCoT).
Contextual inquiry
Contextual inquiry involves observations of, and interviews with, people as they work [7]. This allows one to focus on understanding the details of normal work, with the opportunity to ask about the details of that work while it is being done (or shortly after if the person should not be interrupted). Analysing this data involves constructing five models, each of which highlights a different aspect of the work:
flow model – shows the overall organisation and coordination of the workflow;
sequence model – gives a description of tasks;
artefact model – represents objects used for work;
cultural model – provides a schematic overview of informal and broad influences on actors; and
physical model – illustrates the workplace’s physical structure.
Collectively, these five models build an understanding of ‘context’, and as they are developed issues and areas for improvement can be identified.
Distributed cognition for teamwork (DiCoT)
The second technique, DiCoT [8,9], gathers data in a similar way to contextual inquiry and builds on the idea of constructing different models of work; however, it builds in theory and principles from distributed cognition (DCog) [10]. DCog was proposed in the 1990s as a contrast to traditional notions of cognitive psychology. Rather than restrict accounts of cognition to faculties inside the skull, DCog removes these limits, so accounts of cognition can include artefacts and tools in the external world. Here, a blind person’s stick becomes part of the cognitive system, and a shopping list can be considered a form of memory. Seminal works involving DCog include analysing how people, processes and equipment work together in complex cognitive systems such as the bridge of a ship [10] and an aircraft cockpit [11]. DCog has also been used in different healthcare settings, e.g. communication in surgery [12], infusion pump use in the ICU [13], and blood glucose meter use in an oncology ward [14]. Fioratou and co-workers (2010) use DCog to argue for the relevanc