Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

A ZERO fatality year...

Once again we've heard comments that aviation and healthcare are radically different, the point being of course, that healthcare can't possibly transfer learning from an industry such as aviation. Well of course our industries are different, but it's not as simple as some people think.

We've heard this so many times. 

"Pilots would not get airborne with a plane that wasn't working properly, where as Doctors and Nurses are dealing with people who've had something go wrong" 

This misses the point. 

Most people don't realise that if something goes wrong in an airplane, rarely do you see it coming and the chances are we're already airborne. 

Aviation in the 21st century is incredibly safe, so much so that there is talk of a zero fatality year worldwide due to accidents, leaving aside deliberate acts. 

Extrapolating this it suggests that aviation is, as is often claimed, 99% boredom 1% sheer terror. Not strictly accurate, but mostly things do not go wrong, but what flight crew have to maintain is a wary eye for potential problems.If they occur…

The enemy here is complacency. 

Flight crew, like healthcare teams, have to be like the proverbial coiled spring, ready to react, safely and sensibly in times of extreme stress and with limited options. 

In a nutshell, where learning from aviation can be beneficial and transferrable to healthcare is via our techniques and methods for understanding human behaviour. Being able to be proactive rather reactive, be situationally aware as well as self-aware, understand how to communicate effectively to avoid misunderstanding. 

These skills when mastered, can create leaders and teams who can make better judgement calls, minimise risk and maximise safety. Knowing what we do about the effects of the amygdala and fight, flight and freeze, it is the ability to control your actions under extreme stress that we have to practice. 

Preparedness is crucial. 

Flight crew are trained to consider what could realistically ruin their, and you the passengers, day. One of the aviation techniques is to use periods of low activity, not to simply chat and pass the time of day, but to discuss with your colleagues and your team what they might consider to be a potential problem. When flying how would we handle a depressurisation or a hydraulic system failure. In healthcare something akin to a cardiac arrest or pranging a major blood vessel, or an unanticipated allergic reaction for instance. 

Alternatively a challenging aspect could be when you know you're going to be working with a difficult colleague, so you could discuss in advance how you will try to change the trajectory of incivility into a harmonious team outcome. 

Atrainability are able to provide tailored Human Factors support for teams that are in need of advice, support or development.

Further reading...

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Improvement Science for Better Outcomes

Atrainability have teamed up with The Quality Improvement Clinic and QIC Learn to create a one-day masterclass which will show you how Human Factors and Improvement Science can help you deliver better outcomes.

Small changes can effect big changes and we can equip you with the knowledge and confidence to take new ideas back to your setting.

What will I gain?

After taking part in this masterclass delegates will be able to:

• Be inspired to use human factors and improvement science to deliver better outcomes for their patient e.g. during transitions of care

• Understand Threat and Error Management - an essential concept in learning from error and success

• Understand and accept the causes of mistakes -how to maintain confidence in the high pressure workplace

• Know the early warning signs that things are not as they should be and what to do about them

• Understand and adopt effective communication -ensuring mutual understanding

This 1 day masterclass has been designed to give you an appreciation of Human Factors in the workplace and how it can help you deliver better care.

Through attending this course, you are becoming a change agent, leading the way to help make your patients and your ward safer with Human Factors.

We look forward to you joining us on Friday 23 March 2018.

​BOOKING NOW:

Human Factors Principles + Improvement Science = Better Outcomes


When: Friday 23 March 2018
Where: De Vere West One Conference Centre, London

JOIN US:
Click to find out more OR
Click to book online

. **Special Offers** 15% Group booking Discount or 10% Card Payment Discount
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Debriefing - The Holy Grail

Debriefing or feedback is a vital part of ensuring teams communicate effectively and learn from experiences. How good are we at giving and accepting praise and positive feedback?

An insight I've gained from working with and observing teams is how surprised individuals can be when given positive feedback. Also sometimes they have real difficulty accepting it and view it as patronising. But feedback is a gift and let's be honest we don't do it well. Most of us are swift to blame and slow to praise.

Perhaps it's that quintessential Britishness which hinders us thanking or complimenting a colleague's contribution or skill? We are a very multicultural society now and what richness that brings, so perhaps we can move forward.

Being praised for good performance not only raises morale but improves trust and performance within the team and beyond. It can benefit sickness rates and staff retention as it has in some of our clients.

I recently had the privilege of watching a series of Maternity deliveries by C-section. After introductions during one of the safety huddle at 8am, I explained I was hoping to observe and help them recognise what they've done well – and so it proved to be.

The team were not anticipating any particular problems, and although the first mother had a history of previous C-section deliveries, a scan had been conducted to check the position of the placenta.

Unfortunately, when accessing the uterus they encountered Placenta Previa, and along with the accompanying significant blood loss it was discovered that the baby had inhaled some of the fluid. Rather than a healthy cry, the baby omitted a half-choking squawk and instantly the body language of the team changed and the call was made for the paediatricians to attend urgently.

To cut a long story short, I can report that all was handled extremely well and the baby was quickly whisked off and the outcome was a healthy mother and child.

Afterwards I was asked by the team for feedback. After going into some non-clinical detail on how they'd handled a tricky situation really well I then encouraged them to provide some positive feedback to each other. It did not come naturally, but eventually the Registrar agreed that yes it did go very well. When asked if she could tell me why, she looked stunned and after some thought replied;

"The Scrub Nurse did a great job and I had everything in my hand before I barely asked for it."

With some gentle reassurance, The Registrar relayed her positive feedback to the Scrub Nurse directly.

After being told what a great job she'd done she beamed and said,

"Firstly I'm a midwife, not a scrub nurse. I am only doing this because the scrub nurse called in sick today, it's not my normal job."

I said "Well you've just had some great feedback!" She then added "When they pranged the placenta my heart sank and I thought we were going to have real problems but what held me together was how calm the two surgeons remained as they handled the situation successfully."

Soon, the rest of the team started opening up about their own worries and self-criticisms during the procedure, all which were met with empathy as well as positive and constructive feedback from their colleagues.

The senior midwife had been acting as team leader and in a circulating capacity. She thought she had left it too long before comforting the mother and father. I commented that it did seem like a long time, but the parents had looked relaxed and unconcerned. However the only people who could comment were the parents themselves. How about go and ask them? They were in fact fine.

Everyone now professed that they felt so much happier and confident. They all had a much better team understanding. Everyone was smiling and the atmosphere was positively buoyant.

So what's the moral of this story? You don't really need a trainer to tell you what you've done well, but you might need some help to get your team to a place where positive and constructive feedback become the norm.

We'd be delighted to help you.

Atrainability offer both in-house and Open Course training and coaching solutions. We'd be happy to have an informal chat (in confidence of course) to discuss your current challenges. Please get in touch and one of our team will get back to you

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A renewed focus on NatSSIPs

NatSSIPs - National Safety Standards for Invasive Procedures 


Many of our prospective clients often tell us that they are working successfully towards a safer culture, and yet never-events and avoidable harm do not appear to be diminishing on a National basis.* 

Let's look at NatSSIPs and LocSSIPs on which there is a renewed focus at this time. Otherwise known as the Five Steps to Safer Surgery. 

LocSSIPs is a topic that we have masses of experience in, helping Trusts develop their own best practice in briefing, checklist and debriefing . We are privileged to witness many excellent demonstrations using Natsipps techniques but sadly, we occasionally meet individuals who think they don't need such aids to safety. 

Very recently I was disappointed to witness a Clinician quite deliberately reading news reports on his Smartphone while a Safer Surgery Checklist was being read. Sadly his clinical colleague said nothing. Rest assured that the situation was rectified at the time. However this is still not unique, though happily rare. 

We have a responsibility to ensure the importance of NatSSIPs and the reasons behind its introduction are understood. In our view (and others) the use of checklists and safety techniques is not a personal option, but a mandate and a necessary core function of professional surgical performance. 

NatSSIPs is built around the aviation based concept of threat and error management. This came out of the original NASA funded research at the University of Texas under the late professor Bob Helmreich. 


Threat and Error Management is three steps: 

•AVOID – in an ideal world you would avoid everything that could possibly go wrong

TRAP - But of course you can't avoid everything in the real World. What you haven't been able to avoid you would wish to trap, in order to minimise any errors resulting in potential harm. 

•MITIGATE (read definition)- Finally, one needs to reduce the effects if harmful but to stretch the meaning of 'Mitigate' – to learn from failure and of course success. 


How does this work in practice? 

In healthcare, as in aviation, the 'AVOID' phase is accomplished by having a briefing (Handover or Safety Huddle) normally performed at the start of a working shift or day. This is where the team get together, share plans for what should happen, build situation awareness (Plan A) across the whole team and prepare themselves for what they hope won't happen (Plan B, plan C etc). 

'TRAP' - The 3 steps of the WHO Safer Surgery Checklist fulfil this role.The checklist serves as a memory aid to ensure all necessary safety issues have in fact been completed. Note – it is a Checklist - not a TICK LIST. It is completion of the actual CHECK that is crucial and not the ticking of a box! 

Finally, 'MITIGATION'. Debriefing sits here as a tool for learning not blame. In the case of a successful outcome debriefing is the opportunity to discuss what went well, why it went well and how we will try to ensure it goes well tomorrow and thereafter. 

In the event that it has not gone well, rather than resorting to blame and finger pointing; this step serves to investigate why and how something went awry. How and why well-intentioned, well-trained people have perhaps made an error, with a view to genuinely learning lessons and moving forward effectively for the whole team and ultimately the organisation and the profession. 

Duty of Candour sits here too and is of course a legal, professional and a compassionate necessity. 

After all, quite apart from the safety aspect, who gains the most respect? Someone who accepts and owns up to their own fallibility or someone who seeks to hide it? 

Atrainability would be delighted to assist you in implementing LocSSIPs for your teams, please get in touch to arrange an informal phone chat at your convenience. 


*Source: Never events data, click here

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Walking the Tightrope...

Self-Confidence is vital but Self-Awareness is Key to Learning Success.

Confidence is a vital commodity when it comes to delivering safe, effective performance in any job, sport or profession. One must have a degree of self-belief in order to fly a plane full of people, compete in sports or indeed perform medical treatment. However, a simple, basic facet of being human is that we are all fallible.


Are we aware of our response to our own errors?

Firstly, we have to realise that we have indeed made an error, because initially whatever action was taken was likely done with the expectation that it was correct. The dawning realisation that we have indeed committed an erroneous act can trigger a response, which could be fight, flight or freeze. Once confidence is damaged, it can manifest in a variety of ways. If we have a critical voice in our head, telling ourselves off; compounded by friends, family or colleagues also berating us, we can spiral downwards into depression. Often if we are unable to accept that we're responsible for a mistake we can respond defensively by directing our responses outwards;


                                                          "Why didn't YOU tell me!"

                                                         "Why didn't YOU stop me?"

                                                         "YOU didn't tell me…"


…in other words, if I can't accept my own fallibility it must be yours. This in some cases leads to arrogant behaviour, and does not make for safe, effective teams.

We as individuals need to work on our self-awareness, take responsibility and manage our responses, but we also need a team around us who don't continue the cycle of berating and instead supports and learns when mistakes are made.

How has aviation dealt with this? By embedding Human Factors principles at all levels from Board to the frontline.

The Board must walk the talk or any transformation program will fail, because it is perception at the individual level of the safety culture that is crucial to success.

Pre-1980's aviation training focussed purely on the technical skills of flying a plane. Effective communication, team-work, situation awareness – these were not considered important. However, with the improved use of black box recordings and analysis of significant aircraft accidents it became apparent that it was the human element that was mostly at fault. What is now known as – Human Factors.

How was it dealt with? By educating flight crew and then embedding effective human factors practice in ALL technical training. Although it took time, it is now completely accepted as part of the culture. Furthermore regular refresher training, feedback and assessment is given to flight crew on their flying skills and their interpersonal and cognitive skills to keep best practice at the forefront of their daily practice. In terms of appraisals these are taken very seriously.

If a pilot fails to meet the standards in either category of technical or non-technical skills he/she will be given further training and ultimately he/she can be removed from service. Just imagine if this took place to the same extent in healthcare and some other professions.

The fundamental point though is to understand error and the causes of error, and to accept them and to work with them. Humility is an essential part of professionalism. One of our clients (a large critical care unit in a major trauma centre) has recently contacted us to say how our training has had an impact on their team.

Furthermore we've been told that staff turnover has been reduced to a very low level indeed. These changes have been visible after in-depth Human Factors training and coaching, although they cannot be directly attributed of course.

Atrainability would be delighted to help any team or organisation delve further into their own short-comings and help to highlight their areas of success. Contact us for an informal, confidential discussion or alternatively enrol for our upcoming Open Courses listed here.
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ITV Tonight - Medical Blunders & other updates

Here at Atrainability, we're pleased to say it's been an eventful few weeks.

ITV Tonight: How Health & Social care can learn from Aviation.

I recorded an interview with ITV Tonight, Click here for Catch Up.or alternatively watch here. The programme is focused on Patient Safety and my suggestions were aimed at helping explain some of the elements that increase the chances of human error in health and social care. Part of the interview was filmed in-flight to demonstrate why checklists are a vital and completely accepted aspect of safety in aviation.

Fallibility is of course an inevitable, though sad facet of the Human Condition. Accepting that and helping to avoid, trap and/or mitigate error is fundamentally what we at Atrainability are concerned with. Although the programme focussed on the NHS, we would like to be clear that we know and understand that private providers make mistakes to. We'd be interested in hearing your thoughts on the subject. Tweet #ITVTonight @atrainability or get in touch.

The Glasgow Emergency Surgery and Trauma Symposium

It was a great pleasure to be invited to take part actively in the 2017 Glasgow Emergency Surgery and Trauma Symposium where I gained so much valuable insight into complex post trauma care from some truly World-leading experts in both clinical and non-clinical skills. The latter involved Professor Rhona Flin from Aberdeen University. All the faculty were honoured, in my case by the award of Membership of the Royal College of Physicians and Surgeons of Glasgow.

Coaching and Mentoring in the Operating Theatre

Now we are helping an NHS Trust further develop their non-technical teamworking in association with their LocSSIPS, by coaching and mentoring in operating theatres.

One aspect of this has been debriefing a successful emergency C-section. On first asking "why did it go well?" the answer from one of the senior nurses was that it has "just worked well". However, so much more learning is available with careful encouragement.

In brief, the team had been widely scattered across a large area of the hospital when they received the 'Crash Call'. They clearly moved rapidly and had no time to lose. They didn't do a formal briefing but had in fact accomplished one which they set to work. They shared plans, updated Situation Awareness and allocated tasks to the appropriate team member. A good job achieved and a healthy baby delivered safely.

The work is continuing with debriefing and feedback on specific areas such as checklist design, development and implementation with guidance on how to maximise safety. Much effective work is being pointed out and reinforced as well as some corrective advice.

The Society of Radiographers - 'Putting Patient Safety First'

"When it comes to developing and changing a culture...simple changes can make things better." - Naomi Burden, Quality & Governance Radiographer at Royal Cornwall Hospitals. Atrainability are very proud to have helped progress Human Factors awareness in Radiography. Read the full article.

New Masterclass

We're now offering An Introduction to Coaching and Mentoring workshop which has been developed by Atrainability's Ben Tipney. More information will be available shortly on our website but if you'd like to find out more please contact us.

As always, we're happy to discuss any challenges you are currently facing or answer any questions you might have about our Human Factors training.

Trevor and the Atrainability Team.

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Where is the evidence that 'blame' works?

If so many medical people profess to be evidence based and blame is so rampant within health and social care where is the evidence that blame works?

Atrainability have just been asked to help a major NHS trust to sort out their blame culture which is proving very damaging to an already over-stressed, over-worked, under-resourced Emergency Department.

The atmosphere is apparently poisonous and learning from error consists of pointing the finger at a colleague who didn't do something appropriate. Learning from success isn't an option it seems simply because no one even considers it.

We believe strongly that explaining human fallibility is a crucial aspect of building an understanding and an awareness that most error is not caused by bad people but by genuine, hard-working, caring people, working under difficult conditions.

We ask the question – if we provide training for you, what would success look like?

One answer would be that team members started looking after themselves and each other. Although working conditions are typical of an over stressed department, the benefits of taking even short breaks to refresh, clear the mind and to replenish fluids and blood sugar levels cannot be overestimated. Furthermore, appreciating how knowledge-based, skill-based, rule-based errors originate is the route to an open reporting culture, where people feel safe both personally and collectively.

Other signs of success could be:

  • A team that shows compassion, not just to its patients but to each other.
  • A change in the flavour of incident reporting from finger-pointing to understanding, learning and providing solutions.

What would success look like for you?

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Compassion Costs Nothing?

Compassion; to empathise for others, to show you care; what does this cost in psychological and emotional terms? 

At my great age I just fell into a trap at a conference of agreeing that compassion costs nothing. How could I do that? The emotional cost of true empathy (as opposed to simple 'passive' listening) can be huge. It can be draining for those in caring professions - constantly feeling compassion and empathy for service users, patients and relatives - it takes its toll. This may explain why front line teams sometimes seem so dispassionate. Would they really have entered into such professions if that was what they truly felt?

What could have happened?

Well when we say "physician heal thyself" we tend to think of the physiological; food, water, putting ones feet up – if you like, the most obvious, visible signs of wellness. But when we consider the emotional and psychological toll that caring for others exerts it is in fact, blindingly obvious. What are we doing to provide our front line workers with the awareness and tools to handle the inevitable stress that comes with caring for unwell people? Do we even encourage ourselves or others to 'tune in' to our own emotional state, let alone put strategies in place for our own well-being?

We neglect our psychological and emotional wellness at our peril.

Atrainability have developed training to help deal with all aspects of wellness and stress. We're always available for an informal, empathetic chat to discuss your specific needs. Click here to contact us today.


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You don't have to put up with it.

We recently ran a successful Open Course in Birmingham and the mix of participants that attended all shared their Human Factors challenges; which included typical problems such as not cross-checking adequately and some good situation awareness stories.

The best part about our Open Courses is that we get a good combination of people attending; recently we've had a room of blood bank teams, Ophthalmic surgery teams, Junior Doctors and Occupational Therapists - to name a few! All from different healthcare providers; travelling to our classes, openly sharing their experiences without fear of judgement and leaving with new found confidence and solutions that they can implement as individuals and within their teams.

For us as trainers, it's always interesting to have open discussions about the difficulties different individuals and teams are facing, but the reason we keep doing this is because we can see the changes in people after our training. 

For some, it's in the class; we call this 'the light-bulb moment' (more on this here) and for others it's a few days later, when they get in touch to tell us they just avoided an error because of our training techniques or they've found their confidence in speaking up to the staff member they were having communication issues with.


You may find it comforting to know that there are always similarities in each story, which is how we know we can help you.

Typical problems include: communication issues, dealing with difficult behaviours, poor attitude, situational awareness, briefing and debriefing effectively, stress and time management, poor leadership, hierarchy barriers, lack of feedback and confidence. All amount to how to learn from inevitable errors and successes without unnecessary blame.


So whatever challenge you are facing, know that there is a solution. Don't keep putting up with it, talk to us today about our next Open Course.

There's still time to book a last minute space on our London Open Courses next week and we're also taking bookings for London in February 2016. You can book a space for either of these through our website here or alternatively email us or call Trevor on 01483 272987 and we can discuss how we can help you further.


We look forward to hearing from you.

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Who is the best person to train you – a colleague or an external ‘expert’?

This is an interesting question and is of course quite complex with a multitude of variables to consider. If it is a purely technical or clinical matter then I believe another similarly qualified expert with knowledge of the issues and techniques is generally preferable. However I believe that when it comes to Human Factors (non-technical, non-clinical, non-medical) concepts there is an argument that says an outside 'fresh pair of eyes' can have a significant advantage.

I can understand why you may disagree with this statement. How can someone who hasn't done the job themselves possibly have any in depth understanding of the pressures, stresses and nuances of your decision making? How could they, an outsider, achieve that essential experience gained through days/weeks/ years of hard graft?

Let me confess that in my 'old' life as a pilot in a major airline, we chose to go down the 'peer' training route. However it must be said that I now believe this meant we had to learn the lessons from scratch and went down a few unhelpful blind alleys. One was failing to grasp, for some years, that describing technical and non-technical skills as being separate was erroneous and unhelpful. What woke me up was when one of our senior managers said "it was such a high-workload that we didn't have time for any of that 'Human Factors stuff'! This demonstrated a complete misunderstanding that human cognitive and social skills are present at all times and are an integral part of all performance as an individual and team member. It wasn't his fault, it was ours.

Fast forward 25 years later and Human Factors is completely embedded in aviation – ask my son who is 6 years into his commercial aviation career.

As peer instructors we also had to blend training and debriefing of Human Factors non-technical skills into our colleagues 'technical' training. This proved a hard obstacle. It is acknowledged that the optimum method of encouraging behaviour change is by facilitation – helping students and peers to find their own solutions. This style of facilitative training and coaching was alien to aviation 'instructors' who were used to telling people what to do and how to do it.With behaviour change this rarely works, consider interaction with teenagers!

People have got to want to make changes and have to truly understand how and why. Many instructors focus on the technical problem and/or focus on blame and this can mean they often struggle to see the underlying Human Factors issue beneath, such as communication, hierarchy, or overload.

Now we come all the way back to the advantages of an outsider expert. There is no in-house hierarchy barrier. The outsider expert doesn't know the technical, clinical, medical issues in depth and hence don't get confused, or distracted by them. Another advantage is that they also bring with them a wide diversity of experience from other health and social care provider sites and teams. Finally, an outsider expert can also easily observe and debrief on the human factors issues and ask those awkward but telling questions about team interaction which can help facilitate learning and positive change quicker.

Understanding the concepts, the routes to normal error making and the ways in which human factors training can and does genuinely improve all human behaviours is what we can help you achieve.

We'd like to hear your thoughts and experiences. Please let us know.

Trevor Dale

Tweet @atrainability

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