Advances in Intelligent Systems and Computing 1012

Teresa Patrone CotrimFlorentino SerranheiraPaulo SousaSue HignettSara AlbolinoRiccardo Tartaglia Editors

Health and Social Care Systems of the Future: Demographic Changes, Digital Age and Human FactorsProceedings of the Healthcare Ergonomics and Patient Safety, HEPS, 3–5 July, 2019 Lisbon, Portugal

Advances in Intelligent Systems and Computing

Volume 1012

Series Editor

Janusz Kacprzyk, Systems Research Institute, Polish Academy of Sciences,Warsaw, Poland

Advisory Editors

Nikhil R. Pal, Indian Statistical Institute, Kolkata, IndiaRafael Bello Perez, Faculty of Mathematics, Physics and Computing,Universidad Central de Las Villas, Santa Clara, CubaEmilio S. Corchado, University of Salamanca, Salamanca, SpainHani Hagras, School of Computer Science & Electronic Engineering,University of Essex, Colchester, UKLászló T. Kóczy, Department of Automation, Széchenyi István University,Gyor, HungaryVladik Kreinovich, Department of Computer Science, University of Texasat El Paso, El Paso, TX, USAChin-Teng Lin, Department of Electrical Engineering, National ChiaoTung University, Hsinchu, TaiwanJie Lu, Faculty of Engineering and Information Technology,University of Technology Sydney, Sydney, NSW, AustraliaPatricia Melin, Graduate Program of Computer Science, Tijuana Instituteof Technology, Tijuana, MexicoNadia Nedjah, Department of Electronics Engineering, University of Rio de Janeiro,Rio de Janeiro, BrazilNgoc Thanh Nguyen, Faculty of Computer Science and Management,Wrocław University of Technology, Wrocław, PolandJun Wang, Department of Mechanical and Automation Engineering,The Chinese University of Hong Kong, Shatin, Hong Kong

The series “Advances in Intelligent Systems and Computing” contains publicationson theory, applications, and design methods of Intelligent Systems and IntelligentComputing. Virtually all disciplines such as engineering, natural sciences, computerand information science, ICT, economics, business, e-commerce, environment,healthcare, life science are covered. The list of topics spans all the areas of modernintelligent systems and computing such as: computational intelligence, soft comput-ing including neural networks, fuzzy systems, evolutionary computing and the fusionof these paradigms, social intelligence, ambient intelligence, computational neuro-science, artificial life, virtual worlds and society, cognitive science and systems,Perception and Vision, DNA and immune based systems, self-organizing andadaptive systems, e-Learning and teaching, human-centered and human-centriccomputing, recommender systems, intelligent control, robotics and mechatronicsincluding human-machine teaming, knowledge-based paradigms, learning para-digms, machine ethics, intelligent data analysis, knowledge management, intelligentagents, intelligent decision making and support, intelligent network security, trustmanagement, interactive entertainment, Web intelligence and multimedia.

The publications within “Advances in Intelligent Systems and Computing” areprimarily proceedings of important conferences, symposia and congresses. Theycover significant recent developments in the field, both of a foundational andapplicable character. An important characteristic feature of the series is the shortpublication time and world-wide distribution. This permits a rapid and broaddissemination of research results.

** Indexing: The books of this series are submitted to ISI Proceedings,EI-Compendex, DBLP, SCOPUS, Google Scholar and Springerlink **

More information about this series at http://www.springer.com/series/11156

Teresa Patrone Cotrim •

Florentino Serranheira •

Paulo Sousa • Sue Hignett •

Sara Albolino • Riccardo TartagliaEditors

Health and Social CareSystems of the Future:Demographic Changes,Digital Age and HumanFactorsProceedings of the Healthcare Ergonomicsand Patient Safety, HEPS, 3–5 July, 2019Lisbon, Portugal

123

EditorsTeresa Patrone CotrimFaculdade de Motricidade Humana,Laboratório de Ergonomia, CIAUDUniversidade de LisboaLisbon, Portugal

Florentino SerranheiraEscola Nacional de Saúde Pública,Centro de Investigação em Saúde PúblicaUniversidade Nova de LisboaLisbon, Portugal

Paulo SousaEscola Nacional de Saúde Pública,Centro de Investigação em Saúde PúblicaUniversidade Nova de LisboaLisbon, Portugal

Sue HignettLoughborough Design SchoolLoughborough UniversityLoughborough, UK

Sara AlbolinoCentre for Patient SafetyTuscany, Italy

Riccardo TartagliaCareggi University HospitalClinical Risk Management and PatientSafety CenterTuscany, Italy

ISSN 2194-5357 ISSN 2194-5365 (electronic)Advances in Intelligent Systems and ComputingISBN 978-3-030-24066-0 ISBN 978-3-030-24067-7 (eBook)https://doi.org/10.1007/978-3-030-24067-7

© Springer Nature Switzerland AG 2019This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or partof the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmissionor information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilarmethodology now known or hereafter developed.The use of general descriptive names, registered names, trademarks, service marks, etc. in thispublication does not imply, even in the absence of a specific statement, that such names are exempt fromthe relevant protective laws and regulations and therefore free for general use.The publisher, the authors and the editors are safe to assume that the advice and information in thisbook are believed to be true and accurate at the date of publication. Neither the publisher nor theauthors or the editors give a warranty, expressed or implied, with respect to the material containedherein or for any errors or omissions that may have been made. The publisher remains neutral with regardto jurisdictional claims in published maps and institutional affiliations.

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Preface

The International Conference on Healthcare Ergonomics and Patient Safety 2019—HEPS 2019—in its 6th edition brought together key healthcare and patient safetystakeholders in Lisbon. The conference included a wide range of scientific con-tributions with expert insights on human factors and ergonomics (HFE) aspects andtechnological advancements in the health and social care to address current chal-lenges of the digitalization and demographic trends.

The theme of this book Health and Social Care Systems of the Future:Demographic Changes, Digital Age and Human Factors refers to the transforma-tion of health and social care systems where the complexity of healthcare deliveryhas created extensive opportunities for HFE to contribute to improvements inworking conditions and patient safety. One of the core challenges is the integrationof new technologies with the potential to transform health care by placing thepatient at the centre of the healthcare ecosystem. However, these technologicalchanges have wide-reaching implications, for example, the volume of health datagenerated, the ability to process and analyse that data, the advances in robotics andthe rise in mobile and wearable technologies. At the same time, changes indemography challenge both worker and patient safety in responding to the growingdemands of an ageing population (healthcare workers and patients) whilst simul-taneously attempting to absorb huge levels of technological innovation. The con-ference contribution also considered innovation in health care with respect topatient satisfaction and overall quality of care, volume-to-value-based businessmodels, reorganization and restructuring of healthcare systems and leadershipcompetency gaps in a patient-centred model. Personalized medicine, mobile andwearable technologies and the greater availability of health data are discussed,together with challenges and evidence-based practice.

In summary, this book discusses how digital technology and demographicchanges are transforming the patient experience, services, provision and the plan-ning of health and social care. It presents innovative ergonomics research and

v

human factors approaches to improving safety, working conditions and quality oflife for both patients and healthcare workers.

Lisbon, Portugal Teresa Patrone CotrimLisbon, Portugal Florentino SerranheiraLisbon, Portugal Paulo SousaLoughborough, UK Sue HignettTuscany, Italy Sara AlbolinoTuscany, Italy Riccardo Tartaglia

vi Preface

Organization

Organizers

Organizing Committee

Teresa Patrone Cotrim(Chair of HEPS 2019)

Ergonomics Section, FMH, CIAUD, Universityof Lisbon

Andreia Lopes Faro Hospital Centre, Faro; APERGOCatarina Silva Ergonomics Section, FMH, University of LisbonFilipa Carvalho Ergonomics Section, FMH, University of LisbonFlorentino Serranheira National School of Public Health,

New University of Lisbon; APERGOFrancisco Rebelo Faculty of Architecture, CIAUD, University

of LisbonJosé Domingos Carvalhais Ergonomics Section, FMH, CIAUD, University

of LisbonPaulo Noriega Faculty of Architecture, CIAUD, University

of LisbonPaulo Sousa National School of Public Health,

New University of Lisbon

vii

Pedro Ferreira President of APERGO, Portuguese ErgonomicsAssociation

Rui Melo Ergonomics Section, FMH, CIAUD, Universityof Lisbon

Rui Nunes Hospital University Centre Lisbon Central

Scientific Committee

Anabela Simões(Chair of the ScientificCommitteeof HEPS 2019)

DREAMS Research Unity, Lusófona University,Portugal

Alberto Sérgio Miguel President of the Portuguese Societyof Occupational Safety and Hygiene(SPOSHO), Portugal

Anabela Pereira Department of Education and Psychology,University of Aveiro, Portugal

António Sousa Uva National School of Public Health, CISP,New University of Lisbon

Arto Reiman University of Oulu, Tampere University, FinlandBenvinda Estela dos Santos Director of the Directorate of Disease Prevention

and Health Promotion, Directorate-Generalof Health, Portugal

Carla Viegas Lisbon School of Health Technology/InstitutoPolitécnico de Lisboa (ESTeSL/IPL), Portugal

Carlos Palos National School of Public Health,New University of Lisbon, Portugal

Charles Vincent Imperial College School of Medicine, UKClas-Håkan Nygård Unit of Health Sciences, Faculty of Social

Sciences, Tampere University, FinlandEma Sacadura Leite National School of Public Health, CISP,

New University of Lisbon, PortugalEmília Duarte IADE, University Europeia, PortugalErik Hollnagel University of Southern Denmark, Jönköping

Academy, SwedenFátima Ramalho Occupational Health Department, General Health

Directorate, PortugalFernando Moreira da Silva Faculty of Architecture, CIAUD, University

of Lisbon, PortugalFilipa Carvalho Ergonomics Section, FMH, CIAUD, University

of Lisbon, PortugalFlorentino Serranheira National School of Public Health, CISP,

New University of Lisbon; APERGO

viii Organization

Organization ix

Frida Fischer Department of Environmental Health, Schoolof Public Health, University of São Paulo,Brazil

Giulio Toccafondi Centre for Clinical Risk Managementand Patient Safety, Tuscany Region, Italy

Gustavo Rosal R&D Ergonomics Director of PrevenControl,Secretary General of the Spanish ErgonomicsAssociation, Spain

Isabel Nunes Faculdade de Ciências e Tecnologias,Universidade Nova de Lisboa, Portugal

Inês Alexandra Lima Universidade do Sul de Santa Catarina, UNISUL,Brazil

Javier Llaneza President of Spanish Ergonomics Association,Spain

Hans-Martin Hasselhorn University of Wuppertal, GermanyJohanna Westbrook Centre for Health Systems and Safety Research

(CHSSR), Australian Institute of HealthInnovation (AIHI), Australia

Jorge Barroso Dias Occupational Health Department, Municipalityof Lisbon; President of the Portuguese Societyof Occupational Medicine, Portugal

José Rocha Nogueira Coordinator of the National Occupational HealthProgram, Directorate-General of Health,Portugal

Kenji Itoh Established Researcher in Safety in HealthcareKerm Henriksen Agency for Healthcare Research and Quality

(AHRQ), USALeila Sales Portuguese Red Cross School of Health, LisbonMargarida Eiras ESTeSL, Portugal; Portuguese Association

for Hospital Development (APDH),Portuguese Society of Health Quality (APQS)

Maria João Manzano Director of the Occupational Health Department,Central Lisbon Hospital University Centre,Portugal

Maria João Lobão National School of Public Health,New University of Lisbon, Portugal

Marie-CatherineBeuscart-Zéphyr

Established Researcher in Cognitive Ergonomicsand Medical Informatics; France

Marjike Melles Faculty of Industrial Design Engineering, DelftUniversity of Technology, The Netherlands;President of Human Factors NL

Melissa Baysari Centre for Health Systems and Safety Research,Australian Institute of Health Innovation,Macquarie University, Australia

Mike Fray Design School, Loughborough University, UKPascale Carayon University of Wisconsin–Madison, USA

x Organization

Paula Carneiro University of Minho, PortugalPaulina Hernandez President of ULAERGOPaulo Sousa National School of Public Health, CISP,

New University of Lisbon, PortugalPedro Arezes Engineering School, University of Minho,

Portugal; National Director of the MITPortugal International Program(www.mitportugal.org)

Pierre Falzon Past President of IEA; Established Researcherin HFE and Patient Safety, France

Raquel Santos Luz Saúde, Lisbon, PortugalRiccardo Tartaglia Organizer of First HEPS Conference; Centre

for Clinical Risk Management and PatientSafety, Tuscany Region, Italy

Richard Goossens Established Researcher in HFE and Healthcare,The Netherlands

Rita Almendra Design Department, Faculty of Architecture,CIAUD, University of Lisbon, Portugal

Rui Bettencourt Melo Ergonomics Section, FMH, CIAUD,University of Lisbon, Portugal

Sara Albolino Centre for CRM and Patient Safety, TuscanyRegion; Who Collaborating Centre for PatientSafety, Italy

Sebastiano Bagnara Organizer of First HEPS Conference;University of Sassari–Alghero, Italy

Seppo Väyrynen Research Unit of Industrial Engineeringand Management, Faculty of Technology,University of Oulu, Finland

Shawna Perry Department of Emergency Medicine,Jacksonville University of Florida, USA

Sue Hignett Loughborough Design School, LoughboroughUniversity, UK; Chair of the ProfessionalAffairs Board, Chartered Instituteof Ergonomics and Human Factors (CIEHF)

Susana Ramos Patient Safety Department, Central LisbonHospital University Centre, Portugal

Susana Viegas Lisbon School of Health Technology/InstitutoPolitécnico de Lisboa (ESTeSL/IPL), Portugal

Sylvain Leduc Aix-Marseille University, FranceTeresa Patrone Cotrim Ergonomics Section, FMH, CIAUD,

University of Lisbon, PortugalTommaso Bellandi Director of Patient Safety, Northwest Trust,

Regional Health Service of Tuscany, ItalyVanina Mollo University of Toulouse, France

List of Logos

xi

Contents

Main Lectures

Taking Forward Human Factors and Ergonomics Integrationin NHS Scotland: Progress and Challenges . . . . . . . . . . . . . . . . . . . . . . 3Paul Bowie and Simon Paterson-Brown

Beyond the Five Senses: A Synaesthetic-Design Approachto Humanize Healthcare Environments . . . . . . . . . . . . . . . . . . . . . . . . . 16Emília Duarte, Davide Antonio Gambera, and Dina Riccò

Human Centric Lighting, a New Reality in Healthcare Environments . . . 23Rafael Lledó

Healthcare Ergonomics and Human Factors

Ergonomic Study of Nursing Tasks in Surgical Hospital Services . . . . . 29Paula Carneiro, Alberto Villarroya, Ana Colim, Madalena Torres,and Pedro Arezes

An Efficiency Evaluation of Different Hoisting Devicesto Complete Three Frequent Patient Transfers . . . . . . . . . . . . . . . . . . . 37James Curran and Mike Fray

Perception of Musculoskeletal Symptoms and PsychosocialRisk Factors Among a Sample of Portuguese EmergencyMedical Technicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Constança Davison, Teresa Patrone Cotrim, and Susana Gonçalves

Hospital Physical Demands and Non-specific Low Back Pain . . . . . . . . 56Florentino Serranheira, Mafalda Sousa-Uva, F. Heranz, F. Kovacs,Ema Sacadura-Leite, and António Sousa-Uva

xiii

Analysis of Socio-Demographic, Lifestyle and Psychosocial RiskFactors Among a Sample of Portuguese EmergencyMedical Technicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Constança Davison, Teresa Patrone Cotrim, and Susana Gonçalves

Alarm Response in Critical Care: Obstacles for Compliance . . . . . . . . . 73Rosana Sanz-Segura and Elif Özcan

“Work as Done in the Emergency Department Responseto CBRN Events: A Comparative Study” . . . . . . . . . . . . . . . . . . . . . . . . 82Saydia Razak, Sue Hignett, Jo Barnes, and Graham Hancox

Improving Ergonomics Competences in the Social and Health CareSector in Finland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Leena Tamminen-Peter, Elina Östring, and Erja Sormunen

Prevalence Assessment of Musculoskeletal and Visual SymptomsAmong Pathological Anatomy Service Workers . . . . . . . . . . . . . . . . . . . 99Rita Martins, Filipa Carvalho, and Rui B. Melo

A Mixed Methods Study to Understand Behavioral and PsychologicalSymptoms of Dementia: A Research Protocol . . . . . . . . . . . . . . . . . . . . 109Gubing Wang, Armagan Albayrak, Annoesjka Cabo, Richard Goossens,Jef Mol, Barbara Wijnand, Toon Huysmans, and Tischa van der Cammen

Enhancing a Structured Communication Between the CommunityPregnancy Services and the Hospital Maternal Area: A Toolfor the Handover Process in High - Risk Pregnancy Throughan Ethnographic Study Conducted in the Toscana Centro Trust . . . . . . 118Maria Bonito, Sara Albolino, Giulia Dagliana, Giulio Toccafondi,and Valeria Dubini

Patient Safety

Leveraging Antimicrobial Stewardship: Focus on IndividualPrescriptions Appropriateness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127Carlos Palos and Paulo Sousa

Economic and Clinical Impact of Ventilator-Associated Pneumoniain Intensive Care Units of a University Hospital Center . . . . . . . . . . . . . 135Joana Rodrigues and Paulo Sousa

Comparative Analysis of Patient Safety Culture Between Privateand Public Hospitals Using the Bulgarian Version of HSOPSC -a Web-Based Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142Rumyana Stoyanova, Rositsa Dimova, and Ilian Doykov

xiv Contents

Medication Errors Prevention in Hospitals: Barcode Pointof Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152Leila Sales, Bárbara Rodrigues, Catarina Santos, Maria Ferreira,and Isabel Lucas

Patient Selection Process for 1-Day Total Hip Arthroplasty . . . . . . . . . . 163Armagan Albayrak, P. Olah, S. Vehmeijer, N. Stolk, and M. Melles

Safety and Quality of Maternal and Neonatal Pathway: Implementingthe Modified WHO Safe Childbirth Checklist in Two Hospitals of ItalyThrough a Human Factor Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . 171Sara Albolino, Tommaso Bellandi, Noemi Gargiani, Francesco Ranzani,Ismaele Fusco, Arianna Maggiali, Stefano Guidi, and Giulia Dagliana

Nurse’s Role on Antibiotic Stewardship: Perceptions, Attitudesand Knowledge of a Group of Portuguese Nurses . . . . . . . . . . . . . . . . . 180Ana Soares, Carlos Palos, and Paulo Sousa

Non-adherence to Treatment Reflexions- An Effective Wayof Safety Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189Pedro Armelim Almiro, Daniel Rijo, Joana Coelho, Duarte Nuno Vieira,and Ana Corte-Real

Assessing Adverse Events in Madeira Primary Health Care . . . . . . . . . 197Marta Dora Ornelas and Paulo Sousa

Examining Situated Infection Control and Prevention Practices:Beyond Regulated Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205Laetitia Flamard and Adélaide Nascimento

Proactive Risk Assessment of Team Health IT for Pediatric TraumaCare Transitions (T3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213Peter L. T. Hoonakker, Pascale Carayon, Bat-Zion Hose,Jordan C. Ramsey, Ben L. Eithun, Michael K. Kim, Kristen S. Koffarnus,Jonathan E. Kohler, Julie A. Nieman, Megan M. Reisman, Joshua C. Ross,Deb A. Rusy, and Deb J. Soetenga

Biomedical Research, Stress and Unethical Behavior: Studyof a Sample of Untenured Italian Researchers . . . . . . . . . . . . . . . . . . . . 222Oronzo Parlangeli, Stefano Guidi, Margherita Bracci, Enrica Marchigiani,and Paul M. Liston

Hospital Environment: A Safe Place to Be When Using PortugueseLegislation as Guidance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230Carla Viegas, Beatriz Almeida, Inês Paciência, João Cavaleiro Rufo,and Cristiana Pereira

Contents xv

Are Mycotoxins Relevant to Be Studied in Health CareEnvironments? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237Susana Viegas, Beatriz Almeida, and Carla Viegas

Assessment of Azole Resistance in Clinical Settings by PassiveSampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248Liliana Aranha Caetano, Beatriz Almeida, and Carla Viegas

Health and Social Care Ergonomics and Human Factors

Usability of Nintendo Wii® and Wii Fit Plus® in the ElderlyPopulation as a Resource for Psychomotor Intervention . . . . . . . . . . . . 259Ana Margarida Silva, Carolina Ferreira, Gonçalo Azevedo, Vera Alves,Cristina Espadinha, and Paulo Noriega

Usability and UX of Nintendo Wii Big Brain Academy Gamein the Elderly as a Resource of Psychomotor Intervention . . . . . . . . . . . 270Ana Cláudia Dinis, Ana Silvano, Diana Casado, Cristina Espadinha,and Paulo Noriega

Aging and Work Ability: Reflections on a Complex Subject . . . . . . . . . 280Maria Carmen Martinez and Frida Marina Fischer

Burnout as an Occupational Disease: A Gender Issue? . . . . . . . . . . . . . 286Silvana Salerno

Local Surveillance of Occupational Accidents and Diseases:A Device to Support Workers’ Health Public Services . . . . . . . . . . . . . . 291Luiz Gonzaga Chiavegato Filho, Danilo de Brito Garcia, and Marta Santos

Preparing the Future Scenario of Automated Vehicles:Recommendations Drawn from the Analysis of the Work Activityof Road Transport Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301Daniel Silva, Liliana Cunha, Carla Barros, and Pilar Baylina

Occupational Health Risk Among Teachers in Higher Education . . . . . 311Isabel Souto, Anabela Pereira, Elisabeth Brito, Luís Sancho,and Samuel Barros

Design for Health and Social Care Systems

A Review of Design Guidelines for Clinical Auditory Alarms . . . . . . . . 325Joana Vieira, Jorge Almeida Santos, and Paulo Noriega

Tailored Information Technology in Healthcare: Methodologyof a Case Study Using a Web Application in TotalHip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334Bob Sander Groeneveld, Marijke Melles, Stephan Vehmeijer,Nina Mathijssen, and Richard Goossens

xvi Contents

Safety Walkrounds: “On the Ground” Experience at the NorthwestTrust of the Tuscany Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342G. Terranova, I. Razzolini, M. D’Amico, O. Elisei, L Marini,and T Bellandi

Cognitive Ergonomics ‘Features’ as a Tool for Designing Interactionwith Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350Mariia Zololtova

Developing Patient Handling Competences Through ParticipatoryDesign of Simulation Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357Dorothée Malet, Pierre Falzon, and Christine Vidal-Gomel

The Importance of Patient Reported Outcomes in Shapinga Healthcare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365George Athanasiou and Chris Bachtsetzis

A Serious Game to Promote Compliance with Hand Hygiene AmongHealthcare Workers: Results from User Research Stage . . . . . . . . . . . . 373Beatriz Pereira, Emília Duarte, and Hande Ayanoglu

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387

Contents xvii

Main Lectures

Taking Forward Human Factorsand Ergonomics Integration in NHS Scotland:

Progress and Challenges

Paul Bowie1,2(&) and Simon Paterson-Brown3,4

1 NHS Education for Scotland, Glasgow, UKPaul.bowie@nes.scot.nhs.uk

2 Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK3 NHS Lothian, Edinburgh, UK

Spb@doctors.org.uk4 Patient Safety and Clinical Human Factors, University of Edinburgh,

Edinburgh, UK

Abstract. The failure of healthcare systems leads to multiple problemsincluding avoidable patient harms, poor care experiences, psychological impactson the workforce and costly medico-legal litigation. The urgent need for HFE tobe routinely embedded in national healthcare systems is strongly advocated byleading international institutions to better inform solutions to these issues, butpolicy progress is limited. NHS Scotland has a significant track record in HFE-related research and development, particularly in embedding related principlesin education, non-technical skills assessment and training, system-wide hazardidentification, learning from safety incidents, measuring safety climate, andintegration with quality improvement. However, this work has evolved on an adhoc basis with no strategic plan for national integration of HFE in priority areasof healthcare policy and practice. To address this gap, four stakeholder work-shops with 144 participants representing 27 organisations led to agreement onfive priority areas where HFE could ‘add value’: 1. Building workforce capacityand capability by embedding HFE in education and training; 2. Integratingsystems thinking into how teams learn from ‘significant events’; 3. Ensuringbuildings and workspaces are designed for safety and wellbeing; and adhering todesign principles in healthcare technology procurement; 4. Embedding HFE inthe design of national safety and improvement programmes; and 5. Exploringthe role of a future national HFE expert advisory board to support NHS Scot-land. Next steps include engagement with strategic decision-makers (e.g.medical directors, chief executive officers, board members) to inform, influenceand ultimately broker the formal integration of HFE in NHS Scotland policy.

Keywords: Healthcare � Human factors � Ergonomics � System performance �Human wellbeing

© Springer Nature Switzerland AG 2019T. P. Cotrim et al. (Eds.): HEPS 2019, AISC 1012, pp. 3–15, 2019.https://doi.org/10.1007/978-3-030-24067-7_1

1 Introduction

1.1 The Urgent Need for Human Factors and Ergonomics(HFE) in Healthcare

Modern healthcare systems worldwide are continuously challenged with multiple,highly complex issues which often impact negatively on the safe, efficient, clinically-effective and economical provision of patient care [1, 2]. The failure of healthcaresystems, particularly in terms of the reported levels of unintended but avoidable patientharm across care sectors, leads to poor care experiences, psychological impacts onhealthcare staff, formal complaints, medico-legal litigation, significant financial costsand adverse high-profile media attention [1–4].

To help address these system performance and human wellbeing concerns, theurgent need for HFE theory and methods to be routinely embedded in the everydayworkings of healthcare systems is strongly advocated by the HFE academic community[5, 6], leading international institutions such as the World Health Organisation [7] andthe European Union [8], and many professional bodies including the Academy ofMedical Royal Colleges [9], the Royal College of Nursing [10] and the Institute forHealthcare Improvement [11] amongst others.

While there are many isolated examples of the important application of HFE in UKand international healthcare design, practice and education [12–15], evidence of thesystematic integration of related thinking and approaches into everyday routine caresystems and operations is very limited [5, 6]. This set of circumstances contrastssharply with the situation often found in other complex sociotechnical systems such asthose in the petrochemical, transport and defence sectors, where priority HFE inte-gration in the design of specific work practices, technologies and safety managementsystems is long-established as standard practice [16, 17]. A combination of factorscontributes to this limited progress in the UK and internationally. Russ and colleagues(2013) and Catchpole (2013) have previously highlighted the unfortunate confusionand misunderstandings about the purpose and benefits of the HFE discipline whichpervades much of the published healthcare literature and methodological attempts toimprove patient care [18, 19]. Often there is a failure to link, for example, how HFEcan influence and enhance what is already being done to improve system performanceand the human-centred design of care buildings/workspaces and the usability ofmedical devices and technologies; how we organise work to better support patientsafety and workforce wellbeing; while, significantly, there is a severe lack of qualifiedHFE expertise to better advise on safety and improvement efforts at the local, regionaland national levels.

1.2 Policy Progress in the UK National Health Service (NHS)

In NHS England, a ‘Concordat’ published in 2013 and signed by multiple agencies(including professional regulators, inspection agencies and education providers) out-lined the pressing need for a wider understanding and application of HFE principlesand practices to significantly improve the quality and safety of care for patients [20].

4 P. Bowie and S. Paterson-Brown

However, despite this high-level attention, related healthcare policy progress continuesto be slow and limited in the UK as in many other countries.

In 2018, the UK Chartered Institute of Ergonomics and Human Factors (CIEHF)reinvigorated this agenda by publishing its White Paper on ‘Human Factors for Healthand Social Care’ which outlines a welcome strategic vision for how the beneficialintegration of HFE in health and social care can be achieved, including the urgent needto build related workforce competence and capacity [21]. Informed by the CIEHF’sprescient plan for the future, NHS Scotland has begun a stakeholder engagementprocess of bringing together a range of healthcare leaders, practitioners, educators,academics, researchers, strategic decision-makers and HFE specialists to explore howbest to identify and prioritize important HFE issues. The goal is ultimately to influencenational policy in how we can more effectively address these areas of concern toimprove related care system performance and the wellbeing of our patients and thenational workforce.

1.3 Current HFE Progress in NHS Scotland

NHS Scotland is recognized internationally for its significant HFE-related research andeducational developments over the past decade. Prominent examples of this includesmaking progress in the following priority areas of healthcare education, clinicalpractice and service delivery:

1.3.1 HFE Integration in Education and TrainingProfessional guidance in the form of ‘12 Tips’ on how fundamental HFE concepts andmethods could be embedded by healthcare educators in the safety and improvementelements of existing curricula in all levels of education and training was recentlypublished [22]. More specific educational research demonstrated what, how and wherecore HFE concepts could be integrated within the specialty training curriculum forgeneral medical practitioners in the UK [23]. Similar work has recently been publishedto guide the pharmacy profession [24], while developments are also ongoing for coresurgical and dental training programmes to demonstrate where HFE potentially ‘fits’within these curricula. Previous research also identified the patient safety skills nec-essary for qualified general practitioners [25]. The role of simulation in clinical edu-cation to improve individual and team performance and enhance patient safety is alsowell-established, particularly in anaesthetics [26].

1.3.2 Non-technical Skills Research and TrainingA large programme of research and educational development work has been under-taken on non-technical skills (NTS) assessment and training as a method of improvingindividual, team working, communication and patient safety performance for differentprofessional groups in Scotland over the past decade. Important developments inidentifying NTS for pediatric surgery [27, 28], surgeons in the operating room [29, 30],ambulance paramedics [31], theatre scrub practitioners [32–43], and anesthetists intheatres [35–38] have led to the implementation of professional and discipline-specifictraining.

Taking Forward Human Factors and Ergonomics Integration 5

1.3.3 Learning from Patient Safety IncidentsIn terms of team-based and organisational learning from safety incidents, recent edu-cational research based on HFE principles has led to the development and imple-mentation of a systems-based approach to the analysis of ‘significant events’ (adverseevents and ‘near misses’) for primary care teams [39]. This approach is now routinelyapplied by doctors, dentists, pharmacists and managers when undertaking postgraduatetraining and as part of arrangement for appraisal and revalidation or, more generally, byprimary care teams as part of learning form when things go wrong as part of everydayservice delivery. In secondary care settings, the core principles of the afore-mentionedapproach have informed the development of HFE-influenced ‘good practice’ guidanceon conducting team-based safety reviews as part of the Scottish Mortality and Mor-bidity Programme [40]. Further HFE guidance is also published for healthcare edu-cators on the role of Safety-II thinking on understanding why things go wrong incomplex care systems [41, 42].

1.3.4 Team-Based Safety Climate MeasurementAs part of the Scottish Patient Safety Programme and based on sound psychometricprinciples, two safety climate instruments have been developed with a participatorydesign approach, user evaluated and then implemented nationally, using bespokeonline survey and feedback systems, for general medical practice [43] and communitypharmacy care teams [44]. The scope and scale of the safety climate surveys under-taken is a world-wide first for the primary care setting. Data analysis and reporting arecurrently underway. Additionally, a recent systematic review of the psychometricadequacy of hospital-based safety climate instruments identified only a small numberof good quality and many previously published and in organisational use which arequestionable in terms of their validity and reliability [45]. Taking together, the afore-mentioned evidence potentially highlights the limitations of ‘measuring’ safety climateperceptions amongst a national healthcare workforce and points towards potentiallygreater benefit being accrued from providing care teams with protected time to reflectupon and discuss elements of the prevailing safety culture (e.g. managing risk, lead-ership, communication) to inform organisational learning and improvement.

1.3.5 Safety Checklist Design and ImplementationUsing participatory design methods with ‘sharp-end’ medical practitioners, doctors-in-training, nurses, managers and administrators a safety checklist was developed, vali-dated, tested and implemented to guide the completion of the most essential safety-critical educational tasks to be completed in the early part of specialty training by thetrainee and educational supervisor [46]. In this way the risks of potential avoidableharm to patients were minimized due to inadequate or missed training opportunities ofsignificance in the complex educational and workplace environments. A similar safety-checklist was developed using identical methods and similar participant groups toidentify the most safety-critical issues in the general practice working environment thatneed to be routinely checked to effectively manage related clinical and organisationalrisks [47].

6 P. Bowie and S. Paterson-Brown

1.3.6 Proactive Hazard Identification and AnalysisMultiple, diverse and innovative studies have led to the identification and analysis of awhole range of system-wide hazards and safety incidents in different care settings. Forexample, a ‘trigger tool method’ was designed and implemented nationally in generalpractice to facilitate the rapid review of clinical records of small groups of high-riskpatient groups to identify latent risks and undetected safety incidents [48, 49]; lists of‘never events’ to inform priority design of safer systems for UK community dentistry[50] and general practice [51] have been validated with frontline care teams; a range ofsurgical list errors in a district general hospital was identified [52]; system issues whichact as barriers to the delivery of effective, high quality, and safe healthcare in Englandwere identified [53]; and a comprehensive analysis of systems hazards in the safemanagement of primary care laboratory test results was undertaken [54].

1.3.7 Integration of HFE and Quality Improvement (QI)The disciplines of QI and HFE share a common ancestry and often speak a similarlanguage but there are crucial differences in understanding, purpose and application ofrelated concepts and methods by specialists [55]. We have demonstrated where HFEcan ‘add value’ to QI approaches in healthcare in terms of applying systems theory tobetter understand and model approximations of complex sociotechnical systemsinvolving: the identification and clinical management of possible sepsis (a life-threatening infective condition) in primary care [56]; the process of taking of bloodsamples from patients in hospital ward environments by doctors, nurses and midwives– there is risk and harm potential for patient misidentification and ‘wrong blood intube’ incidents which makes the process potentially unsafe and inefficient [57]; thedesign of safety management systems surrounding the hospital magnetic resonanceimaging working environment [58] and the safety of test results management systemsin general practice [59, 60]. Similar to this research, the recent development of “systemthinking for everyday work” (STEW) principles for frontline care teams also aims topave the way for more informed design of QI interventions [61].

While much of this important research and educational development continues tohave multiple impacts on safety, performance and wellbeing, it is recognized that thereis a notable ad hoc element to it and that there is currently a lack of a coherent,integrated, strategic plan for harnessing and optimizing the potential benefits andimpacts of HFE nationally. Additionally, there are also highly significant gaps in HFEpractice where we lack knowledge and experience, particularly around the human-centred designing of care buildings and workspaces to support and enhance workforceperformance and job satisfaction and improve the safe and effective delivery of patientcare. A further example is in the inclusion of HFE design thinking in the regional andnational procurement of medical technologies and artefacts. The lack of effective user-testing and product evaluation is frequently implicated in the poor design and usabilityof tools and equipment which gives rise to avoidable harm

Taking Forward Human Factors and Ergonomics Integration 7

2 Our Evolving HFE Approach in NHS Scotland

2.1 Stakeholder Engagement Workshops

We held a total of four 1-day workshops between October 2017 and December 2018with diverse groups of stakeholders across NHS Scotland and academic communitieswho indicated that they had experience of, or a strong interest in, the teaching andapplication of HFE theory and practice. The key purpose of the national developmentworkshops was to further inform the design of a preliminary strategic plan to facilitatethe adoption and integration of HFE principles and methods in NHS Scotland. Keyworkshop objectives included:

– Exploring the purpose and identifying the benefits of HFE integration and its role injointly optimizing system performance and human wellbeing in NHS Scotland

– Taking the first steps in agreeing priority plans for embedding HFE theory andpractice in all levels of education for the current and future NHS workforce andacademic communities e.g. undergraduate and postgraduate training, vocation andspecialty training, continuing professional development.

– Exploring the potential role and structure of a national HFE “advisory body” toinform implementation efforts and act as a hub for professional guidance andexpertise in NHS Scotland and beyond.

– Exploring the need for a strong vision and business case for implementation of HFEdesign thinking and approaches to enhance current and future initiatives to improvethe delivery, quality and experience of health and care.

2.1.1 Stakeholder ParticipantsA total of 144 multi-professional participants attended the four workshops representing27 different healthcare provider, professional, higher education, research and policyorganisations in Scotland. All participants were middle-to-senior grade clinical, spe-cialist, policy and academic leaders who were active in areas of interest to HFEpractice, or who recognized the importance of HFE to the work that they lead on andwished to learn more about the discipline and how they can influence the implemen-tation of key concepts in their own work or educational settings.

2.1.2 Workshop ActivitiesEach workshop commenced with a brief introductory session by the authors to outlinethe purpose of the day, anticipated outcomes and plans for further development work.Typically, three 45-min small group work sessions (with lead and support facilitators)were undertaken simultaneously on three occasions during each day to enable allworkshop participants were able to attend and contribute to each work strand. The threesessions comprised:

• National Planning for HFE Integration: The goals of this overarching session wereto identify the fundamental drivers which would inform the design of a preliminarypolicy plan (or national multi-agency ‘Concordat’) for the strategic development,

8 P. Bowie and S. Paterson-Brown

implementation and sustainability of priority HFE integration activity in NHSScotland.

• HFE Educational Development: The goals of this session were to lead the design ofa preliminary plan for the strategic development and integration of identified HFEtheory and methods in all levels of healthcare education and training to buildcapacity and capability amongst clinical educators and the care workforce.

• Creation of a National HFE Specialist Interest Group: The goals of this sessionwere to lead the design of a preliminary plan outlining the proposed vision, purpose,structure and governance of a Specialist Interest Group (SIG), or similar, to provideexpert advice and support to NHS Scotland with the long-term integration of HFEin everyday service delivery.

Plenary Session – Learning, Recommendations and Action Plans: A plenary ses-sion co-led by the authors was then held for the final 90-minutes of each day to enable asummary of the captured learning from group work sessions to be shared by each leadfacilitator and then explored in an open forum with all workshop participants. Thelearning generated from this exercise then informed further discussion and consensusbuilding amongst all participants on practical recommendations and action planning fornext steps in taking forward this development work on a national basis. Key discussionpoints and agreed recommendations and actions were captured using a combination ofFlip Chart and contemporaneous notetaking by lead group facilitators and supportassistants. All written notes were transcribed and typed-up in a Word document and abasic thematic analysis was undertaken by the authors to provide a coherent structureand narrative to the presentation of this information. Generated themes and agreedrecommendations and action points were cross-checked by each of the group facili-tators, with any disagreements being resolved through discussion until consensus wasreached.

Post-Workshop Review and Refinements: The workshop leaders and supportfacilitators met to reflect on and review the initial draft report of the main findings andrecommendations. This was used as an opportunity to clarify and refine their owncontributions to the development work thus far, and to update the recommendationsand actions based on new initiatives and projects that had evolved, or are now known tobe in planning, since the workshop.

3 A Priority Plan for HFE Integration

By December 2018, the stakeholder engagement process had led to strong professionalconsensus on the following short list of five priority areas being identified and agreedwhere it is strongly believed that HFE can potentially ‘add value’ to existing efforts tojointly improve care system performance (e.g. care system safety, productivity, effi-ciency, effectiveness) and human wellbeing (e.g. health and safety, patient experience,staff welfare, work enjoyment):

1. Building workforce capacity and capability by integrating HFE theory and practiceat all levels of education and training and supporting care organisations to upskillstaff in existing key positions and recruit HFE specialist advisors.

Taking Forward Human Factors and Ergonomics Integration 9

2. Integrating systems thinking into how care teams learn from ‘significant events’(both wanted and unwanted), while promoting a ‘just culture’ in the workplace

3. Ensuring that physical care buildings and working environments are designed forpatient safety and staff wellbeing; and adhering to HFE design principles in theprocurement of healthcare technology to reduce costs, risks and improve usability

4. Embedding HFE thinking and methods in the design of national safety andimprovement programmes and initiatives (e.g. quality improvement, realisticmedicine, Scottish patient safety programme, patient experience, staff wellbeing,joy at work)

5. Exploring the potential role of a future national HFE expert advisory board tosupport health and care integration and delivery in Scotland

4 Conclusions and Next Steps

Our current efforts to improve the quality and safety of healthcare are slow and limitedbecause of the failure to adequately consider and integrate HFE theory and methods inthese initiatives [4, 6]. While a key focus of our integration plan is to build capacity andcapability in HFE, particularly to support and advise on patient safety work, it is unlikelythat we will see a ‘boom’ in professional ergonomists within healthcare soon. Com-parisonswith other industries, such as rail and defence, showHFE teams of around 30–50individuals being common – there is no equivalent in NHS Scotland, so a significantfuture challenge is around closing this gap by focusing on upskilling those who advise onclinical risk, patient safety and quality improvement. This acknowledges the pressingneed ‘to give ergonomics away’ in the sense that the “body of HFE knowledge is moreimportant than who is applying it… it is available for everyone to use…” [17].

Our early experiences in addressing these gaps in Scotland represents a first attemptto define and describe what a national programme of priority HFE integration couldpotentially look like in routine healthcare education and practice. In terms of next steps,a meeting of our core HFE network development group will convene in Edinburgh inearly Summer 2019 to explore how to begin making practical progress in these priorityareas.

Early thinking suggests the following ‘quick win’ situations may be practicalpossibilities:

• A need to identify important staff groups such as NHS risk, safety and governanceadvisors (which almost all healthcare organisations employ) for developmentaround HFE concepts and practices, with a view to creating a career pathway toCIEHF technical membership as a means of providing access to appropriate con-tinuous education and potential professional regulation.

• Investment, either at regional or national levels, is also suggested to support everyNHS Scotland organisation to fund a staff member to obtain a postgraduate HFEqualification from a CIEHF-accredited university.

• The need to agree and design a core curriculum on the fundamentals of HFE theoryand practice is also evident to enable educators at all levels of healthcare educationto flexibly adapt and integrate this within existing curricula and learning

10 P. Bowie and S. Paterson-Brown

programmes. Integration within the patient safety and quality improvement ele-ments of existing curricula is suggested as a necessary and feasible first step.

• NES design of a 3–5 day HFE Masterclass, accredited by CIEHF, initially fortargeted workforce groups e.g. risk, safety and governance advisors

• NES development and implementation of a short educational intervention on theorganisational benefits of HFE for NHS Board Members, executive teams andsenior policymakers.

• Development and testing of a toolkit of HFE methods that could be applied inhealthcare by non-specialists with minimal training to understand and resolve HFEproblems that impact on system performance and human wellbeing.

• To further collaborate with the much larger and well-established QI community inNHS Scotland to explore our clear synergies and how best to embed HFE thinkingand methods in QI practice.

• To identify priority areas of concern with regard to the usability and safety ofspecific medical devices/technologies and undertake related product evaluationsbased on ergonomic design principles and user expectations.

Running parallel with this and other work will be the strong requirement to build asubstantial ‘community of HFE practice’ nationally and to design a wide-rangingcommunication plan to support our overall goals, grow our professional network andkeep the wider workforce informed of progress. We need to forge collaborative alli-ances with other professional groups and networks, such as those involved in QI,medical devices, healthcare information technology, and improving the wellbeing ofthe NHS workforce. Plans are also underway to design ‘slick’ presentation and edu-cational materials to facilitate engagement with national strategic decision-makers (e.g.networks of medical and nurse directors, chief executive officers, NHS Board Chairsand non-executive members, and Scottish Government officials and policymakers) toinform, influence and ultimately broker the formal integration of HFE as part of officialNHS Scotland policy.

Acknowledgements. We wish to offer sincere thanks to all past and future stakeholder work-shop participants for their significant contributions to this evolving work. We also acknowledgeand thank the following individuals who have been instrumental in providing leadership, expertsupport and advice on this national development work: Prof. George Youngson, Dr. HelenVosper, Dr. Michael Moneypenny, Dr. Ben Shippey, Mr. Craig McIlhenny, Dr. Shelly Jeffcott,Mr. Manoj Kumar, Dr. Nikki Maran, Dr. Al Ross, Dr. Steve Shorrock, Dr. Neil Clark, Prof. RonaPatey, Prof. Rhona Flin, Prof. Rowan Parks, Prof. Sue Hignett, Prof. Ron McLeod, Prof. JeanKer, Dr. Laura Pickup, Dr. Wendy Russell, Mr. Alistair Geraghty, Dr. Duncan McNab andDr. John McKay.

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