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Human factors in healthcare: welcome progress, but still scratching the surface
  1. Patrick Waterson1,
  2. Ken Catchpole2
  1. 1Human Factors and Complex Systems Group, Loughborough Design School, Loughborough University, Loughborough, UK
  2. 2Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina (MUSC), Charleston, USA
  1. Correspondence to Dr Patrick Waterson, Human Factors and Complex Systems Group, Loughborough Design School, Loughborough University, Loughborough LE11 3TU, UK; p.waterson{at}

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Calls to integrate human factors and ergonomics (HFE) within healthcare and patient safety have become increasingly frequent in the last few years.1 Judging by the number of recent articles in BMJ Quality and Safety that focus on HFE,2–4 we seem to be a step closer to achieving this goal. Within the USA and UK, groups such as the Human Factors and Ergonomics Society (HFES), the Chartered Institute of Human Factors and Ergonomics (CIEHF) and the Clinical Human Factors Group (CHFG) are also making significant progress in working with clinicians, healthcare managers and patients. Developments such as the UK NHS Concordat on Human Factors and Healthcare5 and increasing interest from the US Food and Drug Administration (FDA) attest to this progress. These are welcome developments; however, there is still some way to go. This editorial aims not to undo these nascent HFE integration efforts within patient safety, but to build on previous articles describing some of the misconceptions and misunderstandings that sometimes surround HFE.6 ,7 Many of these are not unique to patient safety, and some have acted as a barrier impeding efforts to integrate the discipline within other industries.7 There is a risk of repeating history and, in the worst case, revisiting past debates and discussions within HFE. By considering the history, evolution and spread of HFE, we hope to enhance translation into healthcare lessons from industries such as aviation, oil and gas, the nuclear sector, defence and rail transport, which make up the rich heritage of research and practice in HFE over the course of the last 50 or so years.

Core characteristics of HFE

From its very beginnings, HFE was a ‘bridging discipline8: it sought to establish common ground between behavioural and physical elements involved in the relationship between humans and their working environments. Early work in the 1950s focused on improvements within military and industrial environments including the design of equipment, the layout of workspaces and the health and safety of workers.9 During the 1960s and 1970s, other specialisms such as cybernetics, systems engineering and management studies became popular and resulted eventually in the adoption of the systems approach as one of the main components of modern-day HFE.10 Figure 1 shows a recent example of an HFE systems model which uses an ‘onion’ metaphor to depict the various factors influencing performance and effective work design.11 While being widely championed in patient safety, where factors related to individuals, technology and the wider organisation are afforded equal consideration and analysed in parallel, there is also evidence that the systems approach within HFE and patient safety is still underexploited and could be taken much further.12–14

Figure 1

Human factors and ergonomics (HFE) systems ‘onion’ model.11

HFE scientists and practitioners apply a holistic approach in order to understand complex interacting systems and subsystems involving people. It is less about applying the ‘right’ type of knowledge, method or tool to a problem, but instead applying the right ‘approach’,15 and it almost always involves collaboration with other disciplines. An emphasis on the importance of involving end users and other stakeholders in the design of their work activities (‘Participatory HFE’) is evident in much of theory and practice of contemporary HFE.16 As the discipline developed over the course of the last 60–70 years, its boundaries have expanded to include other specialists, especially where their expertise was needed in order to tackle an applied problem or HFE professionals were involved in collaborative projects. It also involves respect and acknowledgement that there may be differences in viewpoint which can be overcome by learning and working together. Indeed, this knowledge is not ‘owned’ by the HFE profession. One of the founding fathers of UK HFE, Hywel Murrell, famously said that ‘what the world needs is ergonomics not ergonomists’.7 In short, the body of HFE knowledge is more important than who is applying it. It is available for everyone to use and in the coming years, alongside generating new theories and concepts, we should be simultaneously expanding our horizons as well as making more use of what we already have. Work in the last decade or so within healthcare and patient safety represents one of the latest of these types of collaborations.

A major outcome from collaborating with other disciplines is that HFE has developed an extensive and unique body of knowledge that it draws directly on core disciplines such as psychology and physiology, but also knowledge that has come about as a result of adapting and integrating research findings and methods from other specialisms. For example, the subfield of cognitive systems engineering (CSE) within HFE draws on findings from cognitive and organisational psychology, as well as developments in human–computer interaction and computer science. In addition, CSE has developed practical methods such as cognitive work analysis and cognitive task analysis. The important point to note here is that there is a very rich heritage to draw on, and much of this work is capable of being applied to patient safety. Current preoccupations within HFE and patient safety such as team working, health information technology and human error only scratch the surface of the breadth and depth of knowledge HFE has to offer. Studies focused on the design of jobs, automation, workplaces and organisations as a whole, all of them well established and well researched within the history of HFE, and could benefit patient safety. Working towards integrating HFE and patient safety means we should be taking advantage of exploiting and applying this knowledge.

The future: integration

Efforts to integrate HFE with other disciplines are about as old as HFE itself, and consequently is a well-established area of research itself. In the 1960s, a number of studies showed that designers and engineers had little or no interest in human factors, partly since human factors information was seen as inaccessible as compared with charts, graphs and tables.17 Later work in the 1970s and early 1980s pointed to the need for training in the use of HF tools and methods which was tailored to the requirements of contractors, government personnel and other non-specialist users of HFE.18 Charles Perrow's analysis of the influence of organisational context on the work of human factors engineers concluded that their relative weak position and low profile within the larger organisation in which they are employed undermined the value and impact of their work.19 Various other barriers to integration have been identified in recent years including differences in terms of ‘mindsets’ and values that exist between HFE and other disciplines (eg, social science as compared with engineering), as well as concerns that HFE data lack accuracy and precision and that design and evaluation involving HFE is expensive and time-consuming.20 These historic difficulties in integrating HFE may resonate within the patient safety community. We often come across initial scepticism from healthcare professionals towards HFE, which turns into enthusiasm once they find out more about the discipline and what it covers. The low profile, lack of voice within the larger organisation and the perception that HFE is time-consuming and expensive is a problem for HFE teams embedded in healthcare organisations. While HFE teams made up of as many as 30–50 individuals are common in the UK in other industries (eg, rail and defence), there exist very few established HFE teams within healthcare organisations. Embedding and establishing HFE teams in hospitals and other healthcare environments represents a big integration challenge for the future. One way forward is to start by focusing on some of the gaps in coverage in current HFE as it is applies to healthcare and patient safety (table 1).

Table 1

Examples of gaps and unexploited aspects of HFE in healthcare and patient safety

Table 1 uses the metaphor of ‘layers’ within the systems (‘onion’) model (figure 1) in order to illustrate examples of gaps of coverage in our current use of HFE within healthcare. Aside from making more use of HFE areas of knowledge and methods, we also need to examine overlaps and interaction between different system levels. Investigations that concentrate on the outer rings of the systems model (eg, safety culture/climate assessment) for example, should take into account the role played by individual factors such as staff job satisfaction and levels of job autonomy and their relationship to safety. Similarly, the likelihood that new initiatives (eg, team work training—the people layer in figure 1) will reap safety benefits will be greatly increased when the distribution of work tasks and responsibilities is also considered in parallel (the task level in figure 1).

The way forward may only be partially about education and the development of training courses targeted at HFE non-specialists.4 This approach places too much onus on the need for healthcare professionals to get up to speed with core components of HFE knowledge areas and methods and reduces the real benefits of collaboration. This has always involved a process of ‘mutual adjustment’. Education may be necessary, but it is not sufficient. We need to invest more time in promoting HFE and understanding the perspective of others who may need persuading that HFE is a lot more than teamwork training or some other current preoccupation. We need to apply established and more recent contributions to the HFE body of knowledge, while learning, together, to generate new knowledge. If we are to work towards integration and accelerate our efforts, then the HFE profession will also need to change. We need to be better at communicating the scope, benefits and added value of applying HFE within patient safety. Moving away from the knowledge ‘gatekeeper’ or expert role within HFE may be uncomfortable for some people, but it is necessary if we are to take the next step towards integration. George Miller's famous statement that psychologists should ‘give psychology away34 in the hope that this might help to help tackle some of the most urgent social problems is also applicable to HFE. Patient safety is just too important for us to ignore and to mess up because of misunderstandings. Let's focus on the future, but keep one eye on the past.


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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.