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positive culture when in fact the resident was not harboring an infection. This could have been due to the HCW choosing not to wear sterile gloves (tools/technologies) at the time of collection because they were located in an inconvenient location (environ- ment) and the HCW had a high workload (task, organization) or because he or she was distracted after collection by a phone call (task-nature of task/ job) and forgot (people-humans have limited short-term memory) to transport the specimen to the refrigerator in a timely manner (task). Potential interventions here may include reorganization of the physical location where gloves are stored or workflow adaptations to minimize distraction. Approaching these issues in a systematic manner, while also considering the larger work system and interactions between its components, enables human factors engineers to focus on the underlying reasons for these breaches to formulate appropriate and effective interventions.
Using Human Factors Methods to Reveal Work as Imagined versus Work as Done
Efforts to formulate interventions in healthcare will not be successful without understanding the gap between “work as ima- gined” (WIA), something that leadership believes happens or should happen, versus “work as done” (WAD), or what actually occurs during patient care.19 Healthcare workers in this largely resource-limited setting may establish “work-arounds” to complete their various duties throughout a work day, and these workarounds may have negative consequences on patient safety. These may include forgoing contact precautions due to time limitations, documenting wound dimensions/appearance at the completion of all rounds, or using shared equipment for multiple residents. Although no previously published studies have applied HFE approaches and methods to infection control in LTC settings, recent HFE-based studies in acute-care settings have demon- strated several key barriers that may prevent HCWs from com- plying with infection prevention protocols.21–24 An overarching theme that seems to influence and promote HCW workarounds (and thus affect compliance with work as imagined) in infection prevention procedures is that of high workload, especially due to the high quantity of repetitive tasks. One study that observed hand hygiene procedures in a neonatal intensive care unit (NICU) revealed that nurses “share a strong sense of needing to complete a task, with some staff members commenting that breaches are most likely to occur when ‘you’re in the middle of something’ or ‘you have everything set up and you just need that one thing.’”16 Another project focusing on operating room care revealed a similar theme, with infection prevention procedures seen as a ‘nuisance’ leading to inefficiency in completing a task.25 One surgical nurse commented: “Infection control slows down all movement. Hands must be washed before and after every contact with a patient, and fresh gown and gloves donned every time one enters a patient room, to be discarded when exiting. A thermo- meter or any other piece of equipment moved from one room to another must be cleaned too.”25 Workarounds may also apply to antibiotic stewardship prac-
tices in an LTCF. For example, “off hours” or on-call physicians are consistently cited as being more likely to prescribe antibiotics than providers who are on site and familiar with the patients. A practitioner responsible for off-hours coverage in a LTCF com- mented: “… you are called as an out of hours doctor you often times have little option but to prescribe an antibiotic because you
Morgan Jane Katz and Ayse P. Gurses
don’t know the patient, you don’t know the staff, you often don’t know the background and you may not have complete notes in the history.”26 Antibiotics are often prescribed after hours without an adequate history or evaluation to address vague problems such as change in mental status or urine consistency, even if this may conflict with facility policies (work as imagined). These observations uncover core values that remain pervasive
in the healthcare field, and without taking the time and using a systematic approach based on the science of human factors engineering to comprehensively understand the underlying fac- tors that lead to the work as done, as opposed to work as ima- gined, the addition of another checklist, another didactic educational material, or other similar interventions will be neither effective nor sustainable. HFE uses both formative (exploratory) and summative (confirmatory) evaluation methods.4 For exam- ple, if our goal is to identify why a urine culture is being ordered unnecessarily, we would conduct an exploratory study that may include both qualitative (eg, interviews with HCWs, family, etc) and quantitative (eg, a questionnaire surveying HCWs across the nation) data collection methods. If the study goal is to test whether an intervention package based on a SEIPS-based work system process analysis is effective, then an experimental study (eg, an RCT, a cluster-randomized or stepped-wedge trial, or a quasi-experimental design) would be conducted.
Promoting a Culture of Patient Safety
Redesigning work systems and promoting the culture of safety are core tenets of HFE and are key to improving infection prevention and patient safety.Without an understanding and an organization which supports the culture that infection prevention precautions can protect the patient, procedures will likely be ignored. A 2012 analysis exploring the attitudes of student nurses and their mentors described a conversation between a ward nurse and her consultant: “I can either practice infection control or I can treat the patients, you choose.”27 These attitudes are likely evenmore pervasive in the LTCF setting, where the culture is further confounded by a need to respect the resident’s privacy and create a “home-like” environ- ment. A 2006 survey on patient safety culture showed that nursing homes were below hospital benchmarks on almost all patient safety subscales, with the most dramatic difference in scores focused on organization learning and teamwork, with nursing homes reporting scores 47% below hospital benchmarks.28 These results are daunting, as organizational culture influences virtually all processes in the healthcare setting. Without support from leadership and value attributed to the importance of infection prevention, HCWs will be much less likely to devote time and energy to infection prevention tasks that often do not have directly observable out- comes and may hinder immediate resident satisfaction. Although some evidence indicates that applying human fac-
tors engineering approaches to improve patient safety has led to reductions in healthcare-associated infections,29–33 healthcare in general has been slow to incorporate HFE principles. Just as we need to understand the mechanisms of how the human body works to be able to develop effective interventions (medications) by conducting research in basic science, we also need to under- stand the mechanisms that lead to how work is done (as opposed to work is imagined) to be able to develop effective and sus- tainable interventions. This is the essence of what HFE does. Integrating HFE approaches and methods in the long-term care arena will require a bolstering of research collaborations
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