Queensland Maternity Education

Mia McLanders: Human Factors

Guest: Dr Mia McLanders, Host: Sue Hampton, Editor: Josh Drew, Producer: Raden Sucalit

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Episode transcript

Intro: Hello and welcome to MEPcast, a podcast for Maternity Education Program of Clinical Skills Development Service. In each episode, we explore ideas and issues on how we can enhance and improve the delivery of maternity care education.

Sue: Every day in Queensland midwives and obstetric medical officers make a difference to the lives of consumers and their families who access the Queensland Health facilities.

Not only do they influence the consumers they care for, but they teach and support student midwives and medical students to become the future for midwifery and obstetrics. Healthcare workers make a difference for what we do every day and have an impact on everyone they are in contact with. With that comes a lot of responsibility, but maternity is a great place to work.

My name is Sue Hampton. I’m your host today. I am a midwifery educator here at CSDS. I am a registered nurse and midwife with over 40 years of experience in healthcare. Today, I’m going to be discussing how human factors affect our day-to-day working environment and how it relates, particularly in emergency situations.

This will give us an understanding of why we feel the way we do and hopefully give you some strategies on how we can improve our performances and deal with situations in the healthcare environment. I’d like to welcome my guest today and that’s Dr. Mia McLanders.

Hi Mia.

Mia: Hi Sue.

Sue: She is a human factors researcher working at CSDS and is affiliated with the University of Queensland. She is going to share with us some information around human factors in health care, which some of you may be aware of and how that affects our performance, how we can learn to cope with situations related to human factors, and why education and training help us to perform in our healthcare environments.

Thank you again, Mia, for joining us. I’ve really looked forward to this this afternoon and hopefully we’ll have a good discussion. I know when we first talked before, we both are on the same page with this. I just like to ask you a couple of questions, to start off, if you wouldn’t mind, can you explain to the listeners exactly what is meant by human factors?

Mia: Definitely. Human factors is really about understanding our human capabilities. It’s things like our perception, our attention, our memory, and our thinking processes as well. We use our understanding of these internal human processes for the purpose of designing our equipment, tools, our systems, and even the way that we perform our clinical work.

So that’s really interesting. Do we actually do a lot of that sort of thing where we actually design things around human factors nowadays? Is that how it’s done?

Yeah, it’s improving. I think in North America, there’s a lot of focus and emphasis and an appreciation of how important it is to understand as human beings that we interact with the tools within our workplace and that really can affect our outcomes and even the patient experience and patient outcomes as well. It’s something that’s growing in both awareness and also implementation within clinical settings. human factors is often sort of used in healthcare at the moment, as a sort of a euphemism for human error. It’s like when we say that the human factors got in the way. In actual fact, when we talk about human factors, we are very much talking about at a systems level and we’re looking at improving systems that do support better work processes- so more of the things that we want to see and help us to be resilient when things don’t go according to plan.

So really what you’re saying is that, you know, we’ve always really incorporated this in our day-to-day work, but we haven’t really realized we were doing it, but now we study it in a much deeper, much more depth to gain much more insight into what actually affects the care we provide.

Absolutely.

Human factors is a scientific discipline. It’s the science of people at work. It’s empirically based. We do research and we do well-designed empirical studies to support the things that we know will improve the way that we perform the work that we do.

Tell me what made you choose human factors research? Why did you get into this in the first place?

Yeah, I think it was probably 2012 that I first sort of became aware of human factors as a discipline. I was drawn to it because as a researcher, I find that sometimes the work that we can do can be quite abstract from being practical and being very applied. I think human factors is a very applied discipline and we have the ability to make small changes to things that can have really big and life-saving consequences. My first exposure to human factors, in fact the very first study that I did was in 2013; I designed and executed under supervision was around designing a clinical form.

I know that in that study we found a significant improvement in the way that people were reading the dosage of a particular medication that has fairly serious consequences if there’s mismanagement or inappropriate dosages given. Right there I was able to see that, you know, just design A versus design B we could read using human factors principles to design a clinical form. We could improve the time it takes to actually look up at a dose. But more importantly, that we’re actually looking up the most accurate or that it is the accurate dose that we’re looking at.

Can you tell us of some other, you’ve just touched on something that you’ve been involved in, but what else have you been involved in, which relates obviously the human factors, which has actually changed practice; other things that you might’ve done, which I know you have been involved in quite a few things.

Yeah. I think most recently, and probably the one that most people would be familiar with would be the Q-ADDS patient monitoring charts. So that’s work that was started back in 2010, which was before I was involved and there’s been an enormous amount of research done on that. I’ve come in more recently and have been advising on the layout and the changes of the Q-ADDS form. I was also involved last year in the validation study with the University of Chicago where we ran 220,000 patient data…

That’s a lot of people.

… through the actual Q-ADDS. Because people get used to using the systems that they use. Sometimes we really need that evidence to help say, okay, well, you might be used to Form A or in this case, any patient monitoring system that you’re used to using, but in actual fact, you’re going to have fewer false alarms and you’ll have better detection of deterioration if you’re using Q-ADDS. We did a statistical analysis with the University of Chicago. That was a very important study that I’ve been involved in.

The design of the sepsis pathway. We’ve developed a neurological observation form- where previously sort of quite minimal in the observations of detecting neurological issues in patients.

I’ve been involved in/working with teams doing a neurovascular observation form, looking at lower limb and we’re in the process of starting the upper lymphoma as well.

But the volume of my work has been very much in the space of neonates- looking at the teamwork in neonatal resuscitation. That’s work I’ve been involved in at Mater since 2013. I have a project ongoing at the moment where we’re looking at thermal management during resuscitation and supervising a student through the completion of that work as well.

This is really interesting. Having been in a clinical role fairly recently, we all have great ideas about how we can develop forms particularly or develop some systems. How do people go about accessing somebody like you to give some guidance because clinicians have great ideas, but sometimes there may be not the right person as which I’ve discovered talking to you about implementing change. So how can we access people like you?

Typically, the way that it works is that someone will have an idea, or they’ll identify a gap in their clinical practice. Then they’ll come and talk to someone at maybe at patients’ safety level. Then they approach me, and we work together to sort of, we’d like to, very much do a multi multidisciplinary team approach. My approach is also very much a user-centered design approach. I work very closely with clinicians to help understand, first of all, the problem that they’re trying to solve, because sometimes what we think are the problems are actually the symptoms of a problem. Getting that thorough problem identification and then identifying where we might be able to provide solutions and then very much doing that, from a user-centered design process.

I think that’s really valuable because I think a lot of clinicians have got some fabulous ideas, but one they never know where to start. Secondly, they are sometimes put off by the fact that they’re nervous in case they don’t something in the correct way. To have somebody like yourself or someone in a position that you can actually apply this to, certainly I wish I had it a few years ago where I’ve done some design and things that haven’t worked out purely because I don’t have your background. It’s really good to know that we have you around actually. That’s fantastic.

Thank you, Sue.

You’ve touched on something there, which obviously is very true to my heart- around neonatal resuscitation and basically emergency situations. I’ve always been really interested in what happens to us in emergencies. Every day, in hospital or maternity departments, if you work in a birth suite environment, there’s often emergencies of varying degrees. I’ve always wondered how you teach and support junior colleagues on how they’re able to cope with those situations related around human factors.

We know that acute changes in our cortisol levels can affect our memory and attention but the effects of that are quite selective. We have different levels of memory. We have perspective memory- remembering to remember them. We’ve got our long-term memory, short term memory, different types of memory that can affect our recall. It can affect the level of attention that we’re able to give to the task. It can also affect our thinking processes. The effects of stress- it can also sharpen our thinking. Sometimes stress and cortisol can get a pretty bad rap, but it can be very useful to help sharpen our thinking and heighten our awareness.

But as you say there’s an optimal level there and in actual fact, the effects of stress on cognition depend on the type of stress, the timing of the stress, the intensity, and also the duration. When we get past that point of optimal arousal- when you’re feeling sort of stressed, but it’s good, cause you’re awake. You’re ready to go. You’re ready for action. But then sometimes you sort of go beyond that point and you start to get cloudy thinking and starts to affect and impair your judgment and you just can’t think straight. I guess when we get to that point, one of the things we can do is help sort of down regulate our system is to focus on activating our parasympathetic nervous system. We can do that by implementing some breathing techniques- maybe by lengthening our out-breath, making our outbreath longer than our in-breath for example is one way that we can.

That’s quite interesting that you are saying that because I’ve learned my own strategies of how I deal with emergency situations. I used to be one of these people who would run to an emergency when I hear an emergency bell. But by the time I got there, I was out of breath. I hadn’t had that time to collect my thoughts. I’d go into a room and my adrenaline levels were so high. I actually couldn’t think. Over time, I’ve got a strategy where I walk fast, but I take lots of deep breaths and I hadn’t actually realized what I was actually doing. When I’m teaching my juniors, I teach them not to run. I say, walk fast, get to the door, take a deep breath before you enter. That’s really interesting what you’re saying. I’ve obviously learned this because I realize it does calm me down and does make me think well clearly, and certainly some of the things you’ve said with regards to that foggy thinking, I think when you work in an environment where your stress levels have been high, cause a situation has been unfolding, it can be just the last thing that tips you over the edge. It’s a difficult one to know how to teach people that, but I think it’s interesting that you’re talking about how we react, how we are all different, how we react differently. I’ve also seen the situation where people freeze. What’s that all about?

Yeah, it’s a tricky one actually. I’ve had a look through the literature and there’s not very much. Unfortunately, there’s not much attention given to the clinical reaction to the stress response- the fight or flight response in a clinical situation from the perspective of the clinician. I think the best advice and I’ve interviewed hundreds of clinicians over the years and talk to them about what happens during emergency procedures. I think the most important thing that I’ve learned from those interviews is that it’s important for individuals to know their own stress response. The way that that manifests sometimes in a clinical scenario might be that and you and I have spoken about rushing to intervene. In the neonatal space and on, and I know from speaking with you, in the obstetrics space, that there’s a natural process here. With neonates, it’s a natural processing of transition and we’re there to help and assist as needed. Sometimes when we get that very heightened stress response, it can be very tempting to rush in and do procedures that may be, if you just gave the patient a little bit of time, they would actually continue on and recover or transition, in the case of a neonate, without as much intervention. It’s also, obviously that comes down to experience level and clinical judgment as well. BI think just being aware that stress response does influence your judgment and decision-making, and so, the other alternative response obviously is where people stand back and freeze and don’t really know what to do as you say. I think in those cases, you know, again, awareness is the most important thing, understanding that that’s what’s happening and then having strategies to go to. It’s one of the, one of the reasons that we have decision support tools is to help support cognition during really stressful events. Decision support tools are literally there to support our memory and cognition, supporting our recall and our thinking process.

Things like your flowcharts and those sorts of things that are in guidelines, are those the things you’re alluding to?

Absolutely, like the resuscitation algorithm, for example, when they’re well-designed. I will have to caveat with that because there is a danger with poorly designed cognitive aids that they can actually reinforce heuristics- that’s just like a shortcut. Maybe we make a decision about what’s happening for a patient and we reach for an emergency manual or cognitive aid of some sort and we just continue down the pathway. Maybe we have a non-normative patient, for example with neonates, it might be a congenital abnormality, like a diaphragmatic hernia, for example, where following the steps of the algorithm could actually be not beneficial for that patient at all. We need to make sure that our decision support tools support normative work- work as it’s usually done, but also non-normative case scenarios as well.

I guess it’s back to that thing that all humans are different, and we present in different ways. It’s important that the clinicians try and look at that holistic view of the person that they’re dealing with basically.

Yeah, and just making sure you have that human factors involvement so that you’ve got that broader systems perspective so when we’re designing tools of support that they’re actually going to support you all of the time, not just some of the time.

This is where your research comes in because also you can test out those tools, I guess.

Definitely. What you were saying earlier about having clinicians who may be not confident around asking for help, or maybe they’ve got an idea, or they have a solution they’re wanting to trial, but they’re not really confident about it. I think particularly here we’re very fortunate in the Clinical Skills Development Service that we have great simulation spaces, not just used for simulation-based training, but also for testing. We can actually run through with tools and essentially what I like to call it, break them. We try and explore and find the boundaries and limitations and the weaknesses and vulnerabilities in the processes that we have in everyday clinical practice.

I was going to ask you a question about how staff can work in a fast-paced environment- how can staff give themselves some preparedness for that? I think you’re what you’re saying there is some simple training in simulation may be good, or even in-situ training may be a good idea. Because obviously exposing people to all these various different things that are out there is quite difficult from the point of view that you can’t expose every clinician to every different situation.

I think, unfortunately, the default response in healthcare is very often for more training. If we identify, particularly through root cause analysis, so we might have some sort of a near miss or something; the response is often that we just need to train people more, they need more training. That’s certainly not, I mean, training has its place and is one of the pillars, one of the foundations of our clinical practice, but it is not the go-to. In human factors, we designed systems that support the behaviour that we want. It’s really good to find people like yourself, Sue, who appreciate that and understand that expertise isn’t just a consequence of training.

Yeah. I am an educator so I’m very pro-education, but I also realized, that having repeatedly done education over the years, sometimes it doesn’t actually solve the problem that you have at hand. I agree we’ve got some great guidelines out there. We’ve also got some really good cognitive aids. I think we have to look up all aspects to give clinicians as much information as possible. We have got a very diverse group of clinicians these days with a large number of clinicians who are going to be retiring in the next few years. Our younger generation of midwives are going to need to step up. To have these, to give them the skills and equip them with the tools to be able to provide the support they require is really important. This is why it’s important we understand how this works so that we can actually translate that across into the next generation of midwifery staff and medical staff as well.

I think being in a tertiary facility, you and I talked a lot the other day around whether this environment actually is a good environment for our grad students to actually train in. I just thought I’d bring it into this discussion today, because obviously we talked a lot about it with around the human factors aspects. I think you asked me a question around, what did I think about that, didn’t you?

That’s correct. Yeah. I was asking you about how we typically see very high acuity cases- labours and births and whether or not you think that’s actually helpful for our trainees and whether or not it’s a fair representation. Obviously, there’s a range of birth difficulties or both scenarios, and they’re only seeing sort of the pointy end or the sharp end of the most acute end of that. How do you think that interacts with the learner’s experience? How do you think it impacts their practice as clinicians?

Yeah, that’s an interesting and that’s also difficult question. I know we’ve had some discussion and we thought of talking about it today. Because I think in a very ideal situation, our student midwives and our junior obstetricians should really experience normal and understand normal. We have high numbers of students and we are in a large facility. In smaller facilities, it’s much more easy to achieve, but in these sort of facilities, it’s not so easy. Certainly, my feeling is in the first few years, they should be exposed to those low-risk women in, maybe midwifery models of care, where they see that continuity aspect and see that normal birth process. But sadly, we can’t always achieve that. We do try very hard, and I know the team leaders in situations try very hard to give our students a very rounded experience when they’re on shift. But sometimes you have more students than staff and they have to be involved in situations, which is way above the level they’re at and can be a bit confronting for the students. One of the biggest things from that is making sure that they work with an experienced person and plus they get a good experience so that it doesn’t come back as a negative experience.

I’m going to share with you a situation I had a couple of years ago where I worked with a senior student who was in her final year and we got allocated a normal labouring woman, which was fabulous. But the student was completely freaked out because we didn’t have a monitor on. The woman was low risk and didn’t need a monitor on. Because she’d been so used to that, it actually made her very uncomfortable, and this lady had no pain relief either. It was a completely different concept, but she got all the way through her training to be facing this in her final year. It saddened me to some extent, because I felt, how is she going to be a midwife if she can’t actually look after the woman in the normal situation. I’m also a great believer that midwives, in a normal situation, don’t manage women’s labour, we guide women through labour. We might manage our labour when it’s not going through a normal pathway but certainly in the normal situation, you’re the guide. You’re the person who keeps it safe. We do that in all situations, but I hear a midwife saying, “how we manage the labour” and I think you didn’t actually, the woman did it with your help. I think it’s very important that we actually keep a check on what our students are doing so that we build their foundation blocks so that they come through this with a very broad experience. You and I talked about learning things for expertise, and I talked to you a lot about cues and how we act on cues. I think you gave me an example, was it firefighters cue?

Yeah. It’s a very famous study that was done by Gary Klein. Ut was looking at expertise of firefighters and how they make decisions during very high acuity events- so when they’re in the middle of a fire, they are sensory deprived, they have their suits on and, and how they make their decisions there. They did interviews, detailed interviews to uncover their decision-making processes during fires. There was one firefighter that they interviewed who had said that he had made this decision. What had happened was he’d gone into this fire and at some point, just had a feeling. He said it was like ESP and made the decision to get his team out of that situation and moments later, the floor actually, where they had just been standing collapsed.  They would have all ended up in the actual heart of the fire and wouldn’t have survived that experience. Getting him to understand and in the process of interviewing and going through to the steps of the judgment and decision-making process, it was actually that it wasn’t ESP. He was quite disappointed to learn, but it was actually reading environmental cues based on his experience. For example, there were things that were atypical about that fire. They had made the decision that the fire was ahead of them in the kitchen, but in actual fact it was underneath them. There were things that in retrospect, he was able to say, well, yeah, the heat wasn’t coming from the right location. It was very, very quiet and it shouldn’t have been as quiet as it was. I think the take home message of that story is that our expertise is sometimes so implicit that we can’t actually explicitly state what we know about a patient or in this case about a fire until we actually go through a guided recollection of events to understand that our expertise is actually working for us in that case.

I think that’s a really good example. Certainly, in midwifery, we talk about it being an intuitive job. That the more time you spend with a woman where you actually watch them, particularly when they’ve had no pain relief, you see how they behave in labour. For example, I often say to students, “you need to get ready for this lady, she’s going to have a baby shortly”. And they’ll say to you afterwards, “how did you know that?” You believe it’s because you’re very in tune with a woman, but it’s in fact exactly the same as that firefighting situation. I watched behaviour. I watched the way people change. I have spent so many hours with people. You can see the change in a woman that the students or new graduates are not quite tuned into. I think that’s a really important factor to get across to our midwives that midwifery means “with woman”. You stay with a woman and you watch, and you learn, and you develop your skills. You don’t have to be doing, sometimes sitting quietly in the corner is the way that you actually learn how to be a good midwife.

Those are things I’ve learned over the years that I can impart to the listeners today. I think that firefighting one is a great one because it’s exactly the same, but just a different context.

Just changing direction a little bit now because we’ve talked a lot about labour. We do a lot of intervention in our labours and births these days which is often very necessary because we do have high acuity. We call this the cascade of intervention- once you do one thing, it leads to another. For example, we have a lovely low-risk woman who’s labouring at home and we invite them into the birth environment. They arrive and their contractions slow down or even sometimes stop. They’re open to us intervening because suddenly it’s all gone away. What do we do? Do we do anything in this situation? I’m just thinking what can we do in that space? What do you think we can do in helping these women to get back on track?

I’m going to flip this one back to you as the expert. What do you think we can do?

Environmental issues are a big thing. I know we touched on that right at very beginning this morning about looking at our systems and our processes and how we do things. Sadly, probably, is that we are in a hospital. A hospital birth is the way people give birth these days. We’ve become very clinical. To try and make something a bit more like a home from home environment is may be something we need to look at, but we do need that clinical space. As a researcher, I’m thinking, how can we improve that for our consumers who are coming through the door to improve their birth experience?

The way I would approach something like that Sue, would be to go in and spend time really embedded in the environment. As a researcher and non-clinically trained, I think it’s important for me to go in and do some ethnography of the actual environment. As an outsider, I can have a different view. There are assumptions that you carry with you that I don’t have, things like, “we’ve always done it this way”. If it doesn’t make sense to me then good chances, it doesn’t make sense. Embedding myself in that environment and getting to understand the process flow and the procedural flow and the requirements of the task and the requirements of the consumer and the clinicians as well. Then I can look at the ways that we can improve the design of the system to support, make it easier for clinicians and for our consumers as well to be in that space. I think that’s where the user-centered design process really has its strength: is that you’re coming in not as the, sort of the expert on the white horse, but rather you’re coming in as a naïve expert, as someone who doesn’t understand what’s going on. You’re asking questions that seem obvious to everybody else and understanding the way that things need to be and what outcomes we’re trying to achieve by certain processes. Sometimes we find out there are more efficient ways or more supportive ways to get from point A to point B that we don’t recognize because we have all these historical decisions in place that affect process flow.

Hope you realize from today that there’s probably going to be a load of people wanting you to come in and go and sit in a corner and watch what we do because we don’t do that very well. We just literally adopt things and we put them in because we think it’s right. But I think that a fresh eyes approach has always been something that we look at from a day-to-day basis anyway, but this is a really interesting way of looking at it. I think we do it as clinicians, but I think bringing in someone with completely no contact with that clinical space has a very different way of approaching what is actually happening. It’s amazing. It’s just something that is always sort of made me think, how could we improve this?

Going back to the simulation education and the difficulties that people have in doing immersive simulation. I teach it, so I feel it’s very important. Do you think that simulation and immersing people in simulation or in-situ sim is really useful for this sort of thing or for emergency training? Do you think that we actually get a lot from that?

I think that there’s a lot of value in simulation-based training- the only way really that we have to practice the things that we need to be able to do in a clinical environment. Sometimes there are issues, as you’ve mentioned earlier about buy-in and whether or not it actually approximates a clinical environment, whether or not the validity is there, but it is the safest way that we can practice. There’s no potential for adverse consequences or outcomes for our patients. The other thing about simulation-based activities is it’s not just for training, but we can also, as I mentioned earlier, doing the process flow in testing environments and testing the way that we deliver care can also very valuable.

That’s great. So that could help us with our redesign of how we get our environment better, probably by doing things around that simulation.

Absolutely.

Certainly, trying to run things in-situ would help us for, for sure.

Okay. I’m very conscious of the fact that we’ve been sitting here talking very openly for the last sort of 20 minutes, half an hour. It’s been really interesting. What sort of key take home messages do you think we could give to our listeners today Mia?

Importantly, it’s about understanding that sometimes what we consider a clinical problem is a clinical symptom. Doing that thorough problem identification is really good. If you can get someone who is used to taking a systems approach to solving complex problems in a healthcare environment, that’s going to be a beneficial way to move forward. I think also making sure that we provide the solutions to those problems in a way that is very much user centered; not just coming in with a solution but allowing that to be an iterative process that is informed from multiple different perspectives. I think that understanding that the designs of our clinical space, our equipment, our tools really need to be informed by human factors and just remembering that exposure really helps with expertise. It’s not always training that’s the answer to everything. You don’t become an expert overnight, that it does take time. I think for our more experienced clinicians to just be patient with our junior clinicians, as they’re learning those cues and things that are the intangibles that create expertise, that are difficult to explicitly learn.

Can you guide people to any good reading or some excellent literature that they might think would be useful for them to have?

Yeah, well I’m biased towards the cognitive and the judgment decision-making things so any work by the Daniel Kahneman, Gary Klein, and Laura Militello. There’s a great podcast called Naturalistic Decision Making, which is fantastic to listen to as well. There are some resources that I can put up on the website of journal articles and things for people to refer.

That’d be fantastic. Just in summary from our discussion today, we’ve discussed human factors in healthcare, why research in human factors can change the way we deliver health care to our consumers, how we’re affected by emergency situations, and how we guide our staff to be able to cope with these challenging situations on a day-to-day basis. We’ve also talked about how we respond, how our environment makes us feel, relevant readings that Mia recommends, and why simulation really does help us, even though some people find immersion and doing simulation really quite challenging and difficult.

If you like any more information, please go to the show notes or visit the episode webpage. We also have the Maternity Education Program website, where you can look at all our resources, which are available for you and also visit the CSDS website. Thank you.