Transferring Health Personnel's Human Factor Skills to competency in clinical practice: Key Findings from a Qualitative Investigation

doi:10.21203/rs.3.rs-4684164/v1

Download PDF

Research Article

Transferring Health Personnel's Human Factor Skills to competency in clinical practice: Key Findings from a Qualitative Investigation

https://doi.org/10.21203/rs.3.rs-4684164/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: Research shows that simulation-based training can increase knowledge and skills among pregraduate healthcare students, that simulation-based training of technical skills places the participants higher on the learning curve in practice, and that simulation-based training can improve participants’ human factor skills. Nevertheless, how cognitive and social knowledge and skills are transferred into clinical practice competency remains unknown. This study aims to explore qualified in-hospital health personnel’s transfer of human factor skills from a simulation-based training course to competency in everyday clinical practice.

Method: A qualitative phenomenological-hermeneutic methodology and an ethnographic study investigate qualified health personnel’s transfer of human factor skills before, during, and after a simulation-based training course. The data collection comprises three phases: a clinical phase, a simulation-based training phase and a transfer phase; each phase is based on a subsequent analysis of the previous phase. Data consist of approximately 107 hours of video recordings, field notes and reflections within the research team. Data are analysed with RICEA, a qualitative hybrid method of a Ricɶur-Inspired Analysis and Cognitive Event Analysis.

Findings: The analysis reveals three key themes: Individual transfer of learning, Intercollegiate transfer of learning and Organisational transfer of learning. The findings imply that transfer of human factor skills happens on an individual and intercollegiate level. Still, transfer needs to be scaffolded on an organisational level so that cognitive and social knowledge becomes competency in clinical practice. Further, the findings imply that transferring human factor skills needs another focus than transferring technical skills. Transfer, internalisation and retention of human factor skills are inadequate because of insufficient organisational focus on transferring human factor skills.

Conclusion: Findings suggest a need for a broader and more profound focus on transferring human factor skills to competency in clinical practice. Involving local ambassadors and increased collaboration between simulation centres and organisations around the transfer phase could optimise the transfer of human factor skills. However, further research is needed in this area.

Trial registration: N/A

Cognitive skills

Healthcare

Health Personnel

Human Factor Skills

Patient Simulation

Safety Management

Simulation-based training

Social skills

Transfer

Psychology.

To engender competency among health personnel, transferring human factor skills demands a triple focus on individual, intercollegiate, and organisational learning in the transfer phase.
Transferring newly trained human factor skills from simulation-based training to competency in clinical practice needs organisational effort and support to succeed.
Transferring human factor skills demands awareness and a mutual way of talking about human factor skills among health personnel and management.
Technical skills training focuses on individual learning, but human factor skills depend on individual learning, intercollegiate learning and organisational learning, and so must the transfer process.
Transfer of human factor skills demands an increased collaboration around the transfer process between the simulation-based education faculty and the management in clinical practice.

This article presents the findings of a study into health personnel’s (HP) transfer of human factor skills[1] (HFS) (1) from simulation-based training (SBT) to competency[2] (2) in complex clinical practice. Human factor skills are frequently named non-technical skills, crisis resource management, or interpersonal relations; however, these concepts have limitations as they narrowly define competence in terms of deficiencies (non-technical skills), specific purposes (crisis resource management), or interpersonal dynamics (interpersonal relations) (6, 10-14). A more encompassing framework is found in human factors, e.g., presented in the SHELL model, which considers a broader spectrum of human interaction, incorporating social skills, cognitive abilities, and decision-making. Moreover, it emphasises the interplay between the environment, organisation, and human psychology (15). In light of this perspective, this article implements the term human factors skills (HFS) to denote the skills under examination.

SBT can increase knowledge and skills among pregraduate healthcare students (3, 4). SBT of technical skills places the participants higher on the learning curve when performing in clinical practice (5, 6), and participants can improve their HFS through SBT (7, 8). Further, appropriate HFS reduce adverse events (9, 10). To link these results, the condition for transferring HFS knowledge into competency in clinical practice needs to be identified.

Skills transfer is a social process involving more than cognitive processes (11). Moreover, HFS is embedded in one’s personality and cultural background (12). Transfer is defined as the application of learning from SBT into clinical competency in the participants’ everyday; that is, what personnel learn in one setting can be used in another comparable but different setting (13, 14). This study is part of the SimLEARN project (Figure 1) that integrates a social science perspective (15) and a health science perspective on transfer of HFS with shared data.

The relevance of researching skills transfer relates to the vast problems of patient safety (16, 17), lack of HP, high personnel turnover, and personnel well-being (18, 19). To reduce the number of adverse events in healthcare, SBT is increasingly used to teach, train, and maintain the knowledge and skills of qualified in-hospital HP worldwide (20-22).

Given the gap in the research literature, developing new knowledge about how HFS knowledge becomes competency in clinical practice is crucial. The present study, therefore, investigates how transfer becomes competency in clinical practice after SBT.

Aim

The aim was to develop an understanding of how qualified HP transfers human factor skills from an in situ simulation-based training course to competency in complex everyday clinical practices.

[1] Human Factor skills: include social skills, cognitive skills, decision-making skills and puts emphasis on how the environment, the organisation and human psychology interact (1).

[2] Competency is defined as a skill developed on basis of knowledge, experiences and behaviour towards qualified activities that can be put into action in everyday practice. Competency demands actions, which are both intentional and directed, as well as individual, personal and subjective. This definition is inspired by the Danish pedagogic term “action competencies” (2).

Study design

A qualitative phenomenological-hermeneutic methodology and ethnographic data were used to investigate the transfer of qualified HP’s HFS before, during, and after an in situ SBT course. This article presents the findings of the health science part of SimLEARN, illustrated in Figure 1 and marked with a purple contour.

Figure 1: The SimLEARN Study Design

Settings

The data was collected in four different wards at two Danish hospitals - a university hospital (965 beds, ~11,000 personnel) and a local hospital (302 beds, ~2,600 personnel). The included wards are two ICUs (54 beds, 8 beds), an emergency ward (42 beds) and an infectious disease ward (15 beds).

Participants

The participants were at-work clinical HP (doctors, nurses, physiotherapists, radiologists, nurse assistants, medical students, nursing students, technicians and secretaries). The participants were selected from the duty schedules on the days of data collection and the SBT course to match a realistic everyday team. Thus, the competency on the day was similar to the expected span from beginner to specialist (five stages of expertise: novice, advanced, competent, proficient and expert) (23, 24). However, all personnel could opt to decline participation. Participants gave informed consent.

Ethnography

Inspired by Spradley (25) and Pedersen & Humle (26), two of the authors (LA & MLH) collect ethnographic data in three phases by shadowing HP with video cameras, observing their work, and talking formally and informally in their everyday clinical practice. The observations of HFS were based on the ANTS framework (27, 28). Figure 2 shows the study design’s three phases of data collection: Step 1 - Clinical practice phase: ethnographic data collection of HP's HFS in clinical practice. Step 2 – SBT phase: ethnographic data collection during an in situ SBT course. After steps 1 and 2, an initial analysis led to the focus in the following ethnographic step. Step 3 - Transfer phase: Ethnographic data collection of HP using HFS in everyday clinical practice after participating in SBT.

Figure 2: Data collection and assessment of data

In situ Simulation-based training

Intervention: As illustrated in Figure 3, the intervention comprised preparatory information meetings (~1 month before data collection begins), a screencast about HFS mailed to all personnel (~1 week before SBT) and two days of SBT in each participating ward.

The first author (LA) developed the training scenarios based on the initial analysis of the clinical phase, from which HFS learning objectives were chosen. The scenarios were tested and validated by simulation operators and external facilitators. The facilitators had a facilitator course (~EuSim level 1 and 2) and 2-10 years of experience as facilitators. The study objectives and methods were presented in a pre-training meeting with the facilitators. Further, the facilitators were aligned to the debriefing process, focusing on HFS, reflecting on the trained cases and making analogies to similar situations in the clinical practice.

Simulator: The patient simulator used in the training course was Laerdal Medicals Nursing Anne Simulator (model 2019).

In situ training: Each SBT day consisted of three high-fidelity training sessions, including a 5-minute introduction to the simulator and the simulation situation, 10-20 minutes of in situ training, and a 25-30-minute debriefing (29-32) led by the facilitators (1 doctor, 1 nurse). Four to six personnel participated in each scenario. The clinicians could participate in one to three of the scenarios. Two researchers (LA, MLH) observed, and three cameras recorded the training and debriefing from different positions.

Transfer: After the two days of in situ simulation, the wards' participants and heads (the daily leaders in the ward) were responsible for continued training and internalising the newly trained HFS. The heads were provided with a comprehensive list of the recently gained skills, attention points, and suggestions for further training after the SBT course.

Figure 3: Illustration of the intervention flow

Analysis

The complexity of investigating changes in human behaviour called for a qualitative method comprising at least 1) a theoretical framework integrating social, psychological and cognitive aspects of performance, 2) an investigation of how HFS is taught, trained, learned and transferred, and 3) approaches to describe, understand and explain how HFS transfers into clinical competency. Therefore, a hybrid of two methods was designed: a Ricɶur Inspired Analytical approach (RIA) (Figure 4) and Cognitive Event Analysis (CEA) (Figure 5). The hybrid method is called RI-CEA (33). Data were initially analysed with RIA immediately after the clinical and SBT phases to incorporate the findings and focus on the following phase. After the transfer phase, all data were analysed with RI-CEA as one complete dataset. The CEA analysis was incorporated in the RIAs’ structural analysis, as demonstrated in Figure 2, step 3.

Figure 4: The Ricɶur Inspired Analytical approach (RIA).

Figure 5: The Cognitive Event Analysis (CEA).

Data were collected between February 2019 and February 2020. The data consisted of video recordings, field notes, and reflections between the two researchers (LA, MLH). The data collection resulted in approximately 107 hours of ethnography of HP’s teamwork.

The clinical phase was completed within three months. Two days of ethnographic fieldwork were achieved in each participating ward (8 days total, 17 personnel), equalling ~47 hours of video data and field notes. The subsequent analysis led to six themes: coordination, interruptions, educational responsibilities, teamwork, and situational awareness, which were integrated into the SBT training course.

Seven days of in situ training (21 scenarios and debriefings) were held (~52.5 hours of video data) within two months. Four expert facilitators (two doctors and two nurses) completed all the debriefings. 45 HP participated in the SBT course. Due to a lack of personnel and resources to participate, only one training day was completed in the infectious disease ward.

The SBT phase was completed within three months. The RIA findings showed the immediate learning and training outcomes and, thus, nine themes: psychological safety, educational responsibilities, professional back-and-forth, teaching and learning during work, feedback from colleagues and HFS, leadership, teamwork, situation awareness, decision-making, and task management.

The transfer phase was cut short due to the COVID-19 pandemic. Only two days (4 nurses) of ethnographic fieldwork (7.5 hours of video data) were completed at the local hospital, the ICU and the emergency department. After data were gathered, the RI-CEA analysis of the complete data set began. As illustrated in Figure 6, RIA moved dialectically between parts and wholes, between observations and statements. CEA explored real-time behaviour dynamics and took third-person macro-to-micro perspectives of the units of significance by identifying the cognitive result (i.e. joint decision-making) and working backwards to understand what caused the outcome, as illustrated in Figure 7. Finally, an integrated critical analysis of the findings was completed, resulting in three key themes, which are expanded below.

Figure 6: An example of the systematic process of structural analysis in the Ricɶur Inspired Analytical approach (RIA)

Figure 7: An example of the systematic process of Cognitive Event Analysis (CEA).

Themes and subthemes

Through RI-CEA’s systematic analysis, three key themes emerged: 1) Individual transfer of learning, 2) Intercollegiate transfer, and 3) Organisational transfer of learning. Each key theme has subthemes. The themes are intertwined and mutually dependent but have different perspectives and content. The themes and subthemes that emerged through RI-CEA, as shown in Figure 8, will be elaborated on in the following.

Figure 8: The themes and subthemes that emerged through the Ricɶur Inspired and Cognitive Event Analysis (RI-CEA)

1. Individual transfer of learning: The characteristics of this theme were that the individual HP had an immersed role and obligation in integrating new HFS as a competency in everyday clinical practice. They experienced personal responsibility for integrating new knowledge from the SBT course into their everyday clinical practice. A nurse said: “It [transfer] is not something we talk about or address after a course; it’s solely my responsibility.”

This theme had three subthemes: a) Knowledge and understanding of HFS, b) Reflection on one’s behaviour and actions, and c) Triple awareness in learning, teaching and working.

1a. Knowledge and awareness of HFS. The knowledge and awareness of HFS before the SBT course were mainly limited to the concept of, e.g. ANTS (Anaesthetists’ Non-Technical Skill) (28, 34) and the importance of HFS in acute situations. Several participants highlighted in the debriefings and informal talks that HFS was not a topic or a focus in the clinical practice: “… only if it’s a critical situation.” The clinical practice was primarily focused on technical skills and implementation of algorithms, new medical procedures, and using a new utensil or tool. In a debriefing, an expert nurse said: “It’s interesting to reflect on our interruption culture [situation-awareness]. Only now, I understand that HFS are more than closed loops and ABCDE and that it also influences our everyday work.” In the transfer phase, the same nurse said: “After the SBT course, I realised that my workday is one long interruption. I have tried to change my habits of interrupting others. However, I end up doing as usual [routine].” These two quotations showed that this nurse had become aware of HFS, gained knowledge about HFS and its impact on her work, and tried to transfer the awareness into her complex clinical everyday.

1b. Reflection of one’s behaviour and actions. Most participants declared that the SBT course offered a platform for reflecting upon their behaviour and actions. After a debriefing, a competent doctor said, “The focus solely on HFS in the talks [debriefing] made me look inward on my behaviour. I couldn’t hide behind my medical knowledge; I had to check my side of the interactions. Now I understand and am trying to become a better team player.” In the transfer phase, the reflection of one’s actions was observed when a competent nurse thought out loud in her teamwork with another nurse when preparing to transfer her patient from the ICU: “… if I do this first, then we have more room for that [informing the patient] later.” The findings indicated that the HFS focus on reflection about one’s behaviour and actions could lead to an insight into one’s role in the interaction and that HP needs more than medical knowledge.

1c. Triple awareness in teaching, learning and working. A triple awareness - balancing learning, teaching and working - was observed across all three phases. Learning, teaching, and working are not HFS; however, balancing learning, teaching, and taking care of the patient simultaneously are profound cognitive HFS, including critical thinking, decision-making, and problem-solving. HP performed most of their work in this triple role of teaching, learning, and caring for patients and relatives. Several HP said they did not learn this skill in their education or as newly hired; they taught themselves to combine work with learning and implementing individually developed HFS.

An advanced nurse said, "Although I have worked here for 1½ years and am competent, I must teach my new colleagues, care for patients, and seek guidance from the expert nurses. Nevertheless, sometimes I just want to work without integrating new stuff.” This quote described that HP must cope with this triple awareness to transfer new knowledge, reflect on and be ready to change behaviour and actions. Moreover, an expert nurse expressed that since the SBT, she has considered whether she should start teaching her new colleagues and students about this triple awareness. However, she felt she lacked the competencies to do so.

Data showed an insignificant change for some HP from the clinical phase to the transfer phase. A competent doctor stated that through the SBT, he became aware of this complex task and tried to find a better way to balance his roles. An expert nurse expressed that she had taught herself to manage the balance of her triple role: “Nobody has ever talked about this triple role or taught me how to do it; it’s just how it is. It makes sense; working here is like that.” This finding suggests that HP were unaware of the more hidden HFS, although these significantly impacted their everyday work.

The analysis of this key theme revealed that if transfer of HFS from SBT to clinical practices should succeed, the individual must be ready to challenge their routines and behaviour, use the new skills, and deal with the constant need for triple awareness. In their own words, SBT helped them become aware of hidden HFS.

2. Intercollegiate transfer of learning: The characteristics of this theme were the intercollegiate responsibilities in training the new or changed behaviour and actions among colleagues after the SBT course. An example from the transfer phase showed this training in the clinic: Two nurses walk towards each other in the hallway. An advanced nurse (N1) smiles at an expert nurse (N2), who slows and nods to N1. They stop and begin to coordinate and engage in joint decision-making. They participated together in the SBT course. The nurses looked as if they communicated silently with their bodies and faces. When N1 smiled, N2 slowed down, and her nod was an invitation to N1 that she may interrupt N2. They did not coordinate with words but interpreted each other’s embodied behaviour.

The theme was divided into three subthemes: a) Speaking HFS, b) Psychological safety, and c) Developing HFS together.

2a. Speaking HFS. The participants gained awareness and new ways to speak about HFS. A doctor and a nurse agreed: “… we’ve talked about it [HFS] after the course and try to support each other to improve it, … but never with others; … it’s difficult because they weren’t there [in the SBT debriefings].” This specified that they gained awareness and a way of talking about HFS, which they shared in close collegial relations, and that the SBT made them aware of the significance of HFS. Nevertheless, they shared this awareness and way of talking about HFS with colleagues they trained with, not broadly in the ward or with the managers. HFS thus became a distinctive skill for some HP. CEA showed this multiple times; one example is seen in Figure 7.

2b. Psychological safety. The participants mentioned the need to feel safe and secure in SBT, debriefings, and experiments using the new or changed behaviour in practice. An expert nurse declared: “I only dare if I feel secure … trying the new stuff, you know, without feeling anxiety and the sense of being exposed or judged.” Some articulated that they considered SBT a privilege to train as a team and improve as a benefit for the patients. However, there were some barriers in the clinical setting. The colleagues primarily spoke with those whom they felt safe.

Some participants mentioned a mutual understanding that good SBT, debriefings and transfer demand an open feedback culture in the ward. However, it was a challenge “… when the leaders don’t show the way”, “… if I don’t feel safe among my colleagues,” or “… when the personnel flow is this big.” This indicated that HP wanted to use and transfer the newly learned but struggled to succeed.

2c. Developing HFS together. The professional roles developed and became competency through interactions with colleagues, from novices to experts. In the SBT, a competent nurse (N1) received a delirious, acute, sick patient. The competent nurse called an expert nurse (N2) to the room. N2 could have taken the lead but instead supported N1 in her leadership. N1 tells in the debriefing that she, simultaneously with the coordination and teamwork with the doctor, observes how N2 acts in the situation: “Because I hope to become an expert like her.” This example demonstrated that HP learned and taught how to do effective teamwork when working as a team and that the less experienced gained support, a role model and experiences through their work. A doctor expressed: “Simulation is one of the only places where we learn and reflect across the interdisciplinary barriers, and this makes us better as a team in difficult situations, not only the acute.”
HP expressed, across the data, that current HFS (ANTS) training is primarily an add-on to courses aiming at highly acute situations and algorithms. In this study, HP gained a new understanding of HFS through the three phases. Nevertheless, how HP spoke about HFS changed only among the SBT participants. From talking about HFS as closed-loop, teamwork and leadership, they said in the transfer phase about different ways of being aware in different situations, working with interruptions and balancing learning, teaching and working.

The analysis of this key theme expressed that if transfer of HFS from SBT to clinical practices should succeed, the colleagues must have a mutual awareness and a way to talk about HFS and keep practising, reflecting, and supporting each other in the transfer process. This work demands psychological safety among HP, which is necessary for internalising the knowledge in the individual self and the ward.

3. Organisational transfer of learning: This theme's characteristics were organisational awareness and a focus on transferring HFS in areas other than acute situations. All participants expressed differently that the organisational support for the newly trained HFS transfer has yet to be adopted. A nurse said, “No one asked me what I’ve learnt or need to implement … I’m on my own.” The organisation seemed to lack focus on implementing knowledge of HFS to become a competency.

This theme was divided into three subthemes: a) Awareness of HFS’s impact on patient care, b) Equality between HFS and Technical skills and c) psychological safety and support.

3a. Awareness of HFS’s impact on patient care. The findings implied a lack of organisational awareness towards HFS. In the transfer phase, competent and expert participants disclosed that when they do mandatory training, they train in acute and rare situations using different HFS tools, mainly focusing on leadership and communication (SBAR and Closed-loop). Moreover, they expressed that transfer of HFS in clinical practice is rarely focused on after a course. An expert nurse said: “Sometimes the heads [leaders] underline the importance of SBAR and Closed-loop during clinical meetings. However, it’s my responsibility to know how to change my routines, request it from my colleagues and teach it to the new ones.” The quote demonstrated the absence of awareness of the necessity of focusing on transfer after a course to integrate the new skills into competency. Furthermore, HP expressed that the workload and the individual responsibility of transferring the new skills to competency induced them to return to their usual routines and behaviour.

3b. Equality between HFS and Technical skills. Doctors and nurses mutually disclosed that there had been no organisational focus on HFS after the course, either in memos or meetings. HP had yet to hear which HFS the ward should implement or train further. In contrast, both wards in the local hospital focused on implementing technical skills, such as using a new patient relaxing chair and a new machine to test blood samples. This indicated that technical skills were prioritised over HFS.

3c. Psychological safety and support. More participants expressed a need for support from the organisation to keep them motivated during the transfer process. A nurse said: “When no one cares if I do it or not, why then use the energy? everyday is busy as it is”. Further, the findings indicated a deficiency in psychological safety as the HP only spoke with those they trained.

The analysis of this key theme showed that the wards involved in the project had yet to support the transfer of HFS at an organisational level despite the material given to the heads. The findings suggested that if transfer of HFS from SBT to clinical practices should succeed at an organisational level, the management must (in parallel with HP) gain awareness of HFS and increase their focus on HFS transfer. This is equally important as new guidelines, tools and procedures.

Transfer from SBT to competency depends on three intertwined levels: an individual, an intercollegiate and an organisational level. This finding was consistent with existing research about transfer of learning, internalising, and retention of new skills (14, 35-38). However, transfer and retention of HFS are different from transfer of knowledge. Data implied that HFS are skills that can be taught and learned. HFS are, however, also embedded in the individual’s personality, depending on one’s history, culture and characteristics.

Integrating individual, intercollegiate and organisational processes is necessary to gain transfer, as shown in Figure 9. In the transfer process, the individual must be ready to learn, reflect upon one’s actions, and try to change one’s behaviour. Likewise, the intercollegiate must articulate HFS among each other to make HFS explicit and execute constructive feedback. The organisation surrounds the individual and the intercollegiate in the transfer process. The organisation is HP’s frame and condition; thus, the organisation must take the lead in the transfer process, nudge HP, and actively empower and support the individual and intercollegiate transfer process to complete implementation. The three aspects of transfer are discussed below. Additionally, retention and internalisation also demand an intercollegiate and organisational approach.

Figure 9: The threefold process leading to transfer of human factor skills

Individual transfer: The findings indicated behavioural changes in HFS among the individual SBT participants compared to the clinical phase. This was observed when a nurse in the transfer phase said she walked to see the doctor instead of calling him to avoid disturbing him. The analysis showed that throughout the day, the nurse needed to be consistently aware (situation awareness) of her interruptions of colleagues. However, she sometimes interrupted colleagues unnecessarily, yet she noticed it herself. The nurse had become consciously incompetent around some HFS. According to Dohn and Markauskaite (38), individual competency develops through transfer, resituation and transformation. The participant moves (transfers) knowledge from one context to another, adapting (resituation) the knowledge into a new context and integrating (transforming) this to one’s competency. Transferring HFS from SBT to competency in clinical practice requires that the individual is ready to change behaviour and routines. One must have awareness, knowledge, language and understanding of HFS, reflect on one’s behaviour and actions (39), and manage the triple awareness of learning, teaching and working. This demands a readiness for self-directed, lifelong learning (40) among HP. The lifelong learning concept can be used to understand HP’s effort to apply their everyday work-life to transfer knowledge from SBT to competency. Adults only learn if they are ready to learn, can apply it to their social roles, add knowledge and skills to their experiences and problems, feel safe, and the skills are meaningful for their performance (41). This was evident in the data, e.g. around the administration of interruptions, which was one HFS the participants agreed upon; a reduction of interruptions could benefit patient safety and HP’s well-being.

Intercollegiate Transfer: Transferring HFS also depended on intercollegiate relations and interactions. Transfer depended on HP’s readiness to change the ward's way of working together (i.e., culture) and the level of psychological safety in the organisation (42). The findings indicated behavioural changes in the intercollegiate HFS after the SBT course; however, the changes were only observed in association with co-participants from the SBT course. The CEA microlens confirmed HFS transfer when comparing the example in theme 2 (the intercollegiate transfer) with a similar situation in the clinical phase, where the same two nurses met in the hallway. N1 asked N2 for help immediately after seeing N2 in the hallway. Similar situations with other personnel without the HFS SBT course showed the same reaction as N1 and N2 in the clinical phase, interrupting unreflectively. Elkjaer describes learning as a social process that includes actions and reflections on actions. New skills must be moved from the individual minds to the social sphere of interaction and practice (43). Furthermore, Wenger emphasises that adult learning relies on communities of learning in practice (44). This supports the data showing that colleagues participating in the course were more likely to discuss the impact of HFS reflections in the debriefings.

Further, the work environment significantly influences the transfer: HP and leaders must have a shared awareness and a way to talk about HFS to understand that HFS is used in the interactions between colleagues and patient care and that adverse events can be reduced by improving HP’s HFS (45, 46). The findings implied that HP mainly reflected on HFS with colleagues who participated in the same course, maybe due to a shared language and the extent of the psychological safety build-up within the course. This correlates with Edmonson’s point about the need for psychological safety to develop in an organisation (47) to create a room for constructive peer feedback (48, 49) on behaviour and HFS in general. It is essential to act like a team continuously, not only in highly acute situations. The intercollegiate transfer of HFS depends on the individual transfer and vice versa; transfer can only happen in the presence of the intercollegiate.

Organisational transfer: Transfer of HFS from SBT demands an organisational approach. The analysis revealed that the focus on organisational transfer needs to be more present. One can wonder why hospitals overlook the transfer and internalising of HFS when they use billions of euros yearly in courses and education (50). Yamnill & Mclean state, "Learning is of little value to organisations unless it is transferred in some way to performance” (35,p.196). Transfer needs an organisational responsibility of the internalisation from theory and training to competency in clinical practice. The reasons could be multiple. The hospital's daily flow and operation are the organisation's key focus, but the need for competent HP is also mandatory. Hospital management seems to lack an awareness of HFS, similar to the colleagues trained during the SBT course.

The findings showed a need for an increased focus on organisational transfer. Neither of the wards in the study trained or worked with implementing the newly learned HFS after attending the course. Still, the wards focused on transferring technical skills. Nokana points out that learning requires an interactive social process where tacit knowledge through explicit sharing can be internalised in an organisation (51). Nonaka’s research strengthens the hypothesis that technical skills might be considered more valuable than HFS or that technical skills might be easier and more tangible than HFS. Technical skills training is individual skill and, consequently, not in the same degree dependent on intercollegiate or organisational transfer; it is a competence that the individual must gain and train. On the contrary, HFS are a social and interactive set of skills, which means that training must have an organisational focus on transfer to succeed and requires social and cognitive processes in the organisation (40). HFS can not, like technical skills, be put into an algorithm or procedure or be right or wrong, given that HFS depend on handling nonce events in a unique situation. Nevertheless, if HFS can be reflected upon in the intercollegiate and the organisation, then transfer and retention of HFS can be improved because individual HFS are embedded in the intercollegiate’s competency and scaffolded by the organisation.

Without an organisational focus on the transfer process, transfer will only be individual, and the retention will be short. Several participants expressed that the lack of organisational focus entailed an effort to change their behaviour, and they returned to the usual way, although some individual skills were lasting. A doctor said, “When I am the only one who tries to change, it’s not worth the effort, and I give up.” Retaining the new HFS will be impossible, and HP will return to their previous routines.

The organisation must know how transferring newly trained HFS impacts care and treatments. More participants pointed out that there was a comprehension of HFS as embedded innate skills or that it is only essential in acute situations. The analysis indicated that HFS was embedded in the individual but was trainable if explicated, reflected upon, and transferable. The leaders’ responsibilities are to support and embrace HP and to lead and structure the transfer process after each course, not just tick the box if an employee has completed an HFS course. Before sending personnel on a course, a plan for the transfer process is necessary. Transformation and leadership are the key elements in transferring new HFS to competency.

In theory, these findings mean that it is possible to show how and if the transfer of newly trained HFS happens, although it is time-consuming. This study could form the basis of further research on transferring HFS and develop more straightforward ways to increase the focus on transfer. The findings mean that faculty planning a course must emphasise the organisational aspect of transferring HFS in clinical practice; the learning continues after the debriefings and is transformed into competency. The transfer to competency can succeed through increased collaboration with the managers in clinical practice about who, what, and how learners can continue the training and intensify the implementation in the clinical practice. This study revealed the importance of involving all three levels (individual, intercollegiate and organisation) in transferring and implementing new learning, knowledge or equipment.

Limitation

This study has some limitations that need to be mentioned. First, due to COVID-19, data from the transfer phase was only collected from two wards instead of four and only from the small local hospital, in the ICU and emergency department. The findings could differ if transfer data were collected at all four wards. On the other hand, data from the clinical and SBT phases were similar, making it possible that data from the transfer phase would be consistent, strengthening the credibility of the findings. Second, the Hawthorn Effect represents a potential bias (52) in behaviour alteration due to observation. Third, there was a risk of potential selection bias because the SBT course was not mandatory. The Hawthorn effect and the possible selection bias weaken credibility because the participants could act differently if they were watched. They accepted SBT as a learning method, and it cannot be assumed that their experiences, reflections and actions are representative (53). Nevertheless, video, physical, and cognitive responses from the participants and fieldnotes reduce this bias as they allow going back and forth in the research group's situations and discussions. Fourth, the hybrid method has an in-build validation, as the researcher has to go back and forth between units and the whole to verify if the assumptions stand. Further, analysis workshops were held with the research team throughout the analytical process to reduce misinterpretations and overinterpretations, increasing dependability. The findings’ transferability is high because data are gathered in four different settings and environments. Also, these findings can be used in all kinds of transfer from teaching to competency.Finally, the data overrepresents nurses, minimising the insights into other personnel’s transfer.

This study suggests that SBT of HFS can be transferred to competency in clinical practice. However, further focus on the organisational role and responsibility in implementing the HFS is needed if the competency should be more than a detached individual skill.

Findings suggest that SBT allows participants to talk about HFS and how to use HFS in their everyday clinical practice. There is a need to focus more on transfer to integrate the newly trained into competency in clinical practice and develop organisational learning by including clinical leaders. New HFS from SBT only leads to competency in clinical practice if a transformation plan and daily focus on using the new skills are carried out. Still, a more organisational view on training events is necessary if the competency is to become a culture rather than an individual skill.

More research on transfer to competency is necessary by executing follow-up fieldwork with participants, for instance, after a week, a month, and three months after the SBT.

ANTS

Anaesthetists’ Non-Technical Skills

CEA

Cognitive Event Analysis

HFS

Human factor skills

RIA

Ricɶur Inspired Analytical approach

RI-CEA

Hybrid method of a Ricɶur Inspired Analytical approach and Cognitive Event Analysis

SBT

Simulation-based training

Ethics approval and consent to participate

The SimLEARN study follows the present rules of responsible conduct of research, including the Helsinki Declaration and the Nuremberg Code.

All participants and facilitators received oral and written information about the study, could opt to decline participation, and gave informed consent. Psychological safety was addressed again on each day of data collection. Anonymity was ensured, and video files were stored confidentially. The Danish Data Protection Agency (ID 19/14608) and the Ethical Board of the Region of Southern Denmark (ID 20182000-140) approved the study.

Availability of data and materials

The data are protected by the participants' privacy and can, therefore, not be shared openly. The data are, however, available from the corresponding author upon reasonable request and with the permission of the ethical committee and The Danish Data Protection Agency.

Competing interests

The authors declare that they have no competing interests.

Source(s) of funding support:

1) Anesthesiology and Intensive Care Department, Odense University Hospital, Denmark; 2) Center for Patient Communication & Human Skills, Clinical Development, Odense University Hospital, Denmark; 3) Centre for Human Interactivity, Department of Language and Communication, University of Southern Denmark, Odense, Denmark 4) Department of Clinical Research, University of Southern Denmark & 5) Hospital Sønderjylland, Aabenraa, Denmark.

Authors' contributions

Name	Lotte Abildgren	Malte Lebahn-Hadidi	Christian Backer Mogensen	Palle Toft	Sune Vork Steffensen	Lise Hounsgaard
Manuscript draft	x
Conception and design	x	x			x	x
Method development	x				x	x
Collection and/or assembly of data	x	x
Data analysis and interpretation	x	x			x	x
Figures	x
Manuscript writing	x	x	x	x	x	x
Financial support (incl. grant writing)	x		x	x
Provision of study material or patients	x		x	x
Infrastructure	x		x	x
Administration (lab/funding)			x	x	x	x
Supervision			x	x	x	x

Acknowledgements

The authors declare no conflict of interest but disclose receipt of the following financial support for the research and authorship of this article.

Russ AL, Fairbanks RJ, Karsh B-T, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ Qual Saf. 2013;22(10):802–8. doi: 10.1136/bmjqs-2012-001450.
Jensen BB, Schnack K. The Action Competence Approach in Environmental Education. Environmental Education Research. 1997;3(2):163–78. doi: 10.1080/1350462970030205.
Griswold-Theodorson S, Ponnuru S, Dong C, Szyld D, Reed T, McGaghie WC. Beyond the simulation laboratory: a realist synthesis review of clinical outcomes of simulation-based mastery learning. Academic medicine: Journal of the Association of American Medical Colleges. 2015;90(11):1553–60. doi: http://dx.doi.org/10.1097/ACM.0000000000000938. PubMed PMID: 608097656.
Krautscheid LC. Improving communication among healthcare providers: preparing student nurses for practice. International Journal of Nursing Education Scholarship. 2008;5(1):1–15.
Nielsen AB, Pedersen FM, Laursen CB, Konge L, Laursen S. Assessment of esophagogastroduodenoscopy skills on simulators before real-life performance. Endosc Int Open. 2022;10(06):E815-E23. Epub 2022/04/01. doi: 10.1055/a-1814-9747.
Gustafsson A, Pedersen P, Rømer TB, Viberg B, Palm H, Konge L. Hip-fracture osteosynthesis training: exploring learning curves and setting proficiency standards. Acta Orthop. 2019;90(4):348–53. Epub 20190424. doi: 10.1080/17453674.2019.1607111.
Abildgren L, Lebahn-Hadidi M, Mogensen CB, Toft P, Nielsen AB, Frandsen TF, et al. The effectiveness of improving healthcare teams’ human factor skills using simulation-based training: A systematic review. Advances in Simulation. 2022;7(1):12. doi: 10.1186/s41077-022-00207-2.
Lucas AE, Marie. Development of Crisis Resource Management Skills: A Literature Review. Clinical Simulation in Nursing. 2017;13(8):347–58. Epub June 14, 2017. doi: https://doi.org/10.1016/j.ecns.2017.04.006.
Weile J, Nebsbjerg MA, Ovesen SH, Paltved C, Ingeman ML. Simulation-based team training in time-critical clinical presentations in emergency medicine and critical care: a review of the literature. Advances in Simulation. 2021;6(1):3. doi: 10.1186/s41077-021-00154-4.
Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systematic review of the past decade. Hum Resour Health. 2020;18(1):2. Epub 2020/01/10. doi: 10.1186/s12960-019-0411-3. PubMed PMID: 31915007.
Merriam SB. Adult Learning Theory: Evolution and Future Directions. PAACE Journal of Lifelong Learning. 2017;26:21–37.
International Ergonomics Association. Human Factors and Ergonomics Online: International Ergonomics Association; 2021 [cited 2021 April 28th]. International Ergonomics Association]. Available from: https://iea.cc/.
Baldwin TT, Ford JK. Transfer of training: A review and directions for future research. Personnel Psychol. 1988;41. doi: 10.1111/j.1744-6570.1988.tb00632.x.
Bransford JD, Brown AL, Cocking RR. How people learn: Washington, DC: National Academy Press; 2000.
Lebahn-Hadidi M. In the guise of safety: The cultural-cognitive ecosystem of medication errors and patient safety. Odense: University of Southern Denmark; 2021.
Pedersen KZ, Mesman J. A transactional approach to patient safety: understanding safe care as a collaborative accomplishment. Journal of Interprofessional Care. 2021:1–11. doi: 10.1080/13561820.2021.1874317.
Rafter N, Hickey A, Condell S, Conroy R, O'Connor P, Vaughan D, et al. Adverse events in healthcare: learning from mistakes. Qjm. 2015;108(4):273–7. Epub 2014/08/01. doi: 10.1093/qjmed/hcu145. PubMed PMID: 25078411.
Schrøder K, Bovil T, Jørgensen JS, Abrahamsen C. Evaluation of 'the Buddy Study’, a peer support program for second victims in healthcare: a survey in two Danish hospital departments. BMC Health Services Research. 2022;22(1):566. doi: 10.1186/s12913-022-07973-9.
Busch IM, Moretti F, Purgato M, Barbui C, Wu AW, Rimondini M. Psychological and Psychosomatic Symptoms of Second Victims of Adverse Events: a Systematic Review and Meta-Analysis. J Patient Saf. 2020;16(2):e61-e74. Epub 2019/03/29. doi: 10.1097/pts.0000000000000589. PubMed PMID: 30921046; PubMed Central PMCID: PMCPMC7386870.
Sanford N, Lavelle M, Markiewicz O, Reedy G, Rafferty AM, Darzi A, et al. Capturing challenges and trade-offs in healthcare work using the pressures diagram: An ethnographic study. Applied Ergonomics. 2022;101:103688. doi: https://doi.org/10.1016/j.apergo.2022.103688.
MacKinnon RJ, Pukk-Härenstam K, Kennedy C, Hollnagel E, Slater D. A novel approach to explore Safety-I and Safety-II perspectives in in situ simulations—the structured what if functional resonance analysis methodology. Advances in Simulation. 2021;6(1):21. doi: 10.1186/s41077-021-00166-0.
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, Irene Jensen H. An in situ simulation program: a quantitative and qualitative prospective study identifying latent safety threats and examining participant experiences. Int J Qual Health Care. 2021;33(1). Epub 2020/11/10. doi: 10.1093/intqhc/mzaa148. PubMed PMID: 33166380.
Dreyfus SE, Dreyfus HL. A five-stage model of the mental activities involved in directed skill acquisition. California Univ Berkeley Operations Research Center, 1980.
Dreyfus H, Dreyfus SE. Mind over machine: Simon and Schuster; 2000.
Spradley JP. Participant Observation. Fort Worth: Harcourt Brace College Publishers; 1980.
Pedersen Arr, Humle DMr. Doing organizational ethnography. London: Routledge; 2016. x, 200 sider p.
Flin R, Glavin R, Maran N, Patey R. Framework for Observing and Rating Anaesthetists’ Non-Technical Skills, Anaesthetists’ Non-Technical Skills (ANTS) System Handbook v1.0. In: Aberdeen Uo, editor. 2012.
Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists' Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth. 2003;90(5):580–8. Epub 2003/04/17. doi: 10.1093/bja/aeg112. PubMed PMID: 12697584.
Gardner R. Introduction to debriefing. Semin Perinatol. 2013;37(3):166–74. Epub 2013/06/01. doi: 10.1053/j.semperi.2013.02.008. PubMed PMID: 23721773.
Steinwachs B. How to facilitate a debriefing. Simulation & Gaming. 1992;23(2):186–95.
Bearman M, Nestel D, McNaughton N. Theories informing healthcare simulation practice. Healthcare Simulation Education2017. p. 7–15.
Nestel D, Krogh K, Kolbe M. Exploring realism in healthcare simulations. Healthcare Simulation Education 2017. p. 23 – 8.
Abildgren L, Lebahn-Hadidi M, Mogensen CB, Toft P, Steffensen SV, Hounsgaard L. Transfer of human factor skills from simulation-based training to competency in clinical practice–a demonstration of a hybrid method for assessing transfer of learning. International Journal of Healthcare Simulation. 2023:1–13.
Flin R, Fletcher G, Glavin R, Maran N, Patey R. Anaesthetists’ Non-technical Skills (ANTS) System Handbook. UK: University of Aberdeen; 2003.
Yamnill S, McLean GN. Theories supporting transfer of training. Human Resource Development Quarterly. 2001;12:195–208. doi: 10.1002/hrdq.7.
Baldwin TT, Kevin Ford J, Blume BD. The State of Transfer of Training Research: Moving Toward More Consumer-Centric Inquiry. Human Resource Development Quarterly. 2017;28(1):17–28. doi: 10.1002/hrdq.21278.
Lim DH, Morris ML. Influence of trainee characteristics, instructional satisfaction, and organizational climate on perceived learning and training transfer. Human Resource Development Quarterly. 2006;17(1):85–115. doi: https://doi.org/10.1002/hrdq.1162.
Dohn NB, Markauskaite L. Conceptions of transfer, transformation and resituation. Designing for situated knowledge transformation: Routledge; 2019. p. 39–58.
Schoen DA. The Reflective Practitioner: How Professionals Think in Action: Routledge; 1992.
Merriam SB, Baumgartner LM. Learning in adulthood: A comprehensive guide: John Wiley & Sons; 2020.
Clapper TC. Beyond Knowles: What those conducting simulation need to know about adult learning theory. Clinical simulation in nursing. 2010;6(1):7–14.
Edmondson A. Psychological safety and learning behavior in work teams. Administrative science quarterly. 1999;44(2):350–83.
Elkjaer B. The SAGE Handbook of Learning and Work. 2022 2023/06/05. 55 City Road, London: SAGE Publications Ltd. Available from: https://sk.sagepub.com/reference/the-sage-handbook-of-learning-and-work.
Wenger-Trayner E, Fenton-O'Creevy M, Hutchinson S, Kubiak C, Wenger-Trayner B. Learning in landscapes of practice: boundaries, identity, and knowledgeability in practice-based learning. Wenger-Trayner E, Fenton-O'Creevy M, Hutchinson S, Kubiak C, Wenger-Trayner B, editors. New York: Routledge; 2014. 168 sider p.
Bates DW, Singh H. Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety. Health Affairs. 2018;37(811):1736. doi: 10.1377/hlthaff.2018.0738.
Reason J. Understanding adverse events: human factors. Qual Health Care. 1995;4(2):80–9.
Edmondson AC, Kramer RM, Cook KS. Psychological safety, trust, and learning in organizations: A group-level lens. Trust and distrust in organizations: Dilemmas and approaches. 2004;12:239–72.
Lipnevich AA, Panadero E. A Review of Feedback Models and Theories: Descriptions, Definitions, and Conclusions. Frontiers in Education. 2021;6. doi: 10.3389/feduc.2021.720195.
Cole M, John-Steiner V, Scribner S, Souberman E. Mind in society. Mind in society the development of higher psychological processes Cambridge, MA: Harvard University Press. 1978.
Tolsgaard MG, Tabor A, Madsen ME, Wulff CB, Dyre L, Ringsted C, et al. Linking quality of care and training costs: cost-effectiveness in health professions education. Med Educ. 2015;49(12):1263–71. Epub 2015/11/28. doi: 10.1111/medu.12882. PubMed PMID: 26611191; PubMed Central PMCID: PMCPMC5063180.
Nonaka I, Toyama R, Hirata T, Bigelow SJ, Hirose A, Kohlbacher F. Managing Flow: A Process Theory of the Knowledge-Based Firm. London: Palgrave Macmillan UK; 2008. xix-xix p.
McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. Journal of Clinical Epidemiology. 2014;67(3):267–77. Epub 2013/11/22. doi: 10.1016/j.jclinepi.2013.08.015. PubMed PMID: 24275499.
Brassey J, Mahtani KR, Spencer EA, C. H. Catalogue of Bias Collaboration: University of Oxford; 2017 [cited 2022 11.10.2022]. Available from: http://www.catalogofbias.org/biases.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
05 Sep, 2024
Reviews received at journal
17 Jul, 2024
Reviewers agreed at journal
17 Jul, 2024
Reviewers invited by journal
17 Jul, 2024
Editor assigned by journal
05 Jul, 2024
Submission checks completed at journal
05 Jul, 2024
First submitted to journal
04 Jul, 2024

You are reading this latest preprint version

Transferring Health Personnel's Human Factor Skills to competency in clinical practice: Key Findings from a Qualitative Investigation

Status:

Version 1

Abstract

Figures

What this study adds

Background

Aim

Methods

Study design

Settings

Participants

Ethnography

In situ Simulation-based training

Analysis

Findings

Themes and subthemes

Critical analysis and discussion

Limitation

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Availability of data and materials

Competing interests

Source(s) of funding support:

Authors' contributions

Acknowledgements

References

Additional Declarations

Status:

Version 1