Exploring human factors in the operating room: scoping review of training offerings for healthcare professionals

Abstract Background Human factors (HF) integration can improve patient safety in the operating room (OR), but the depth of current knowledge remains unknown. This study aimed to explore the content of HF training for the operative environment. Methods We searched six bibliographic databases for studies describing HF interventions for the OR. Skills taught were classified using the Chartered Institute of Ergonomics and Human Factors (CIEHF) framework, consisting of 67 knowledge areas belonging to five categories: psychology; people and systems; methods and tools; anatomy and physiology; and work environment. Results Of 1851 results, 28 studies were included, representing 27 unique interventions. HF training was mostly delivered to interdisciplinary groups (n = 19; 70 per cent) of surgeons (n = 16; 59 per cent), nurses (n = 15; 56 per cent), and postgraduate surgical trainees (n = 11; 41 per cent). Interactive methods (multimedia, simulation) were used for teaching in all studies. Of the CIEHF knowledge areas, all 27 interventions taught ‘behaviours and attitudes’ (psychology) and ‘team work’ (people and systems). Other skills included ‘communication’ (n = 25; 93 per cent), ‘situation awareness’ (n = 23; 85 per cent), and ‘leadership’ (n = 20; 74 per cent). Anatomy and physiology were taught by one intervention, while none taught knowledge areas under work environment. Conclusion Expanding HF education requires a broader inclusion of the entirety of sociotechnical factors such as contributions of the work environment, technology, and broader organizational culture on OR safety to a wider range of stakeholders.


Introduction
The operating room (OR) is a unique and complex intersection between multiple personnel (e.g. surgeons, anaesthesiologists, nurses, and other perioperative workers), various equipment and tools (e.g. surgical devices and monitors), and the workplace (e.g. OR access, staff availability, and operational costs). Consequently, the unpredictable and critical nature of the intraoperative setting can be responsible for up to 74.9 per cent of incidents that occur in patients admitted for surgical care 1 . Surgical safety incidents have traditionally been blamed on skill deficiencies in the individual clinician. However, it is now accepted that critical events are strongly influenced by the environment in which they operate 2,3 .
The study of human factors (HF) has been implemented to address the entirety of sociotechnical factors that affect process and safety within the OR 4-6 . Historically, HF draws knowledge from other high-risk disciplines, including aviation and military, and has been progressively adapted to the OR to optimize performance and system efficiency through, for example, crew resource management (CRM) training and safety checklists 4,5,7,8 . The intersection of numerous fields, including psychology and technology, has probably led to a considerable variation in the terminology, concept, and application of HF [9][10][11] , resulting in a heterogeneous awareness around this topic 10,12,13 .
This complexity introduces unique challenges to transform ORs into high-reliability environments, seeking to optimize the quality of care, patient safety, and costs 6,14,15 . Effective and meaningful HF integration in the OR may ultimately depend on establishing a shared framework delivered through knowledge translation and education among stakeholders 13,16 . To elicit how HF is being understood and applied in the OR, this study aims to explore the content and tools used in HF education and training for the intraoperative environment.

Methods
This scoping review followed the PRISMA-ScR guidelines 17 . This study was also appraised by key stakeholders, including OR clinicians (J.A.K., F.B.), an HF expert (B.T.), and a health systems research expert (C.K.). A study protocol was developed a priori and published in a peer-reviewed journal 18 .

Search strategy
Six electronic bibliographic databases, including MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), Health and Psychosocial Instruments (Ovid), and ERIC (Ovid), were searched up to August 2020, in consultation with a health sciences research librarian who helped to refine the search strategy. No previous systematic or scoping reviews have explored this topic.
The full search strategy used for MEDLINE is reported in Table S1. The search strategy combined both keywords and indexed terms related to 'human factors', 'operating room', and 'education'. All references were checked to identify additional missed papers eventually included for screening.

Eligibility criteria
All studies reporting HF training or education interventions in the operative setting were included according to the PRISMA-ScR criteria of population, concept, and context. The population included healthcare professionals or trainees (e.g. surgeons, anaesthesiologists, or nurses) and non-clinical operating room personnel (e.g. OR administrators, housekeeping staff, and hospital porters). The concept included any individual educational or training intervention labelled 'human factors' for the OR setting. The context consisted of original research articles published in English, including single and double-arm studies, qualitative and quantitative studies, randomized controlled trials, and quasi-experimental studies. Studies not reporting original data (e.g. editorials and commentaries) or the content of the HF training, and conference abstracts were excluded.

Study selection
The titles and abstracts of the retrieved studies were independently screened by two reviewers (A.L. and A.F.), who evaluated the full-text articles of potentially eligible studies for inclusion. Reasons for exclusion were documented and summarized. Any disagreements between the two reviewers were resolved by consensus or, if necessary, by a third reviewer (F.B.).

Data charting
Data from the included articles were charted in a standardized data spreadsheet using Microsoft Excel version 16.46, which the authors calibrated prior to the search. Charted data included the study characteristics (authors, year of publication, country of study, indexed keywords, research type); training participants (number, type, and level of training of learners and instructors, interdisciplinary versus intradisciplinary learning group); training design (training developers, type of teaching methods or tools used, duration and frequency of training, learner assessment tool used); and training content (skills or concepts taught, quantitative or qualitative outcomes measured and reported, feedback from participants). When HF was a component of broad interventions, only HF data were charted.

Data synthesis and summary of results
A meta-analysis and a formal methodological quality assessment were not performed owing to the heterogeneity of the included studies. Charted data were summarized in tables or diagrams, with a narrative summary to show and explore the spectrum of HF training for the operative setting. To further examine HF-labelled teaching interventions for the operative setting, the training content was assessed according to the Chartered Institute of Ergonomics and Human Factors (CIEHF ; Table S2), which includes 67 HF knowledge areas divided into five main categories: anatomy and physiology; psychology; people and systems; work environment; and methods and tools 19 . Any skills or concepts deemed not captured by the CIEHF knowledge areas were also recorded. Inter-rater classification reliability was assessed using Cohen's kappa statistic. An assessment of the quality of evidence on the topic of interest of each study was performed using the Medical Education Research Study Quality Instrument (MERSQI) 20 . With a maximum score of 18, higher total MERSQI scores have shown to be associated with better expert quality ratings, 3-year citation rate, journal impact factor, and funding amount for the intervention 21 .

Search results
The search yielded a total of 1851 studies, of which 112 were appropriate for full-text assessment. A total of 28 studies met the eligibility criteria and were included in this scoping review. The PRISMA flow chart is shown in Fig. S1.

Characteristics of the including studies
The included studies were published between 1996 and 2019, with 61 per cent of the articles published since 2010 (Table S3). Of the 28 eligible studies, two evaluated the same intervention over different time periods 22 studies, the primary objective was to describe or evaluate the HF training intervention. Of the remaining studies, one assessed behavioural marker systems in the context of HF training 27 , and two assessed both the training offering and the behavioural marker system or the HF evaluation method 28,29 . A total of 23 studies had quantitative data appropriate for MERSQI assessment ( Table S3). The mean score was 11.7/18 (range 8.5 to 14.5).

Training population and methods
HF training was most often delivered to interdisciplinary (n = 19; 70 per cent), rather than intradisciplinary (n = 8; 30 per cent), groups of learners, especially surgeons (n = 16; 59 per cent), nurses (n = 15; 56 per cent), and postgraduate surgical trainees (n = 11; 41 per cent) (Fig. 1). In contrast, non-clinical staff (n = 3; 11 per cent) and administrative personnel (n = 4; 15 per cent) were included in fewer studies. HF content was taught and/or evaluated by trainers with variable expertise, including HF-trained clinical faculty members or CRM experts ( Table 1). Of note, eight training offers involved an instructor's course with a 'train-the-trainer' Six interventions were created in collaboration with a commercial company 22,23,30,32,[37][38][39] , while others were pursued by research groups and experts in HF, CRM, psychology, or other disciplines ( Table 1). Interactive or non-didactic techniques were applied to teach HF in all 27 interventions, alongside didactic tools such as lectures, presentations, and reading material (Fig. 2) in 21 studies. Interactive methods most commonly included simulation (n = 12; 44 per cent), group activities or exercises (n = 11; 41 per cent), discussion (n = 11; 41 per cent), and video clips (n = 8; 30 per cent) on patient safety incidents.

Training content
The key findings reported for each study are listed in Table 2. Specific skills and concepts were classified into 226 CIEHF knowledge areas. Of these, 164 (72.6 per cent) were classified under 'psychology', 55 (24.3 per cent) under 'people and systems', and six (2.6 per cent) under 'methods and tools'. Only one knowledge area (0.4 per cent) belonged to 'anatomy and physiology', while 'work environment' was never represented (0 per cent). The inter-rater classification reliability between the two authors was 0.79 (Cohen's kappa statistic).

Methods and tools
Only the knowledge area of 'evaluation of work activities' (n = 6; 22 per cent), was represented under methods and tools (Fig. 3c). This included teaching strategies for structured observation and feedback, work evaluation in the context of research, analysis of errors, and evaluation of non-technical skills 34,37,39,45,47,48 . Knowledge areas related to research techniques (e.g. data collection and analysis, experimental design, focus groups, and questionnaire and interview design) were not included in any HF teaching.

Anatomy and physiology
The knowledge area of physiology was represented in one training offer (Fig. 3b)

Work environment
No HF training offers included concepts related to audiovisual, thermal, and mechanical interactions, environmental distractions such as noise pollution, or the workplace design and assessment, including OR design and ergonomics.
The types of outcomes reported varied between studies ( Table 2). Several training interventions demonstrated an improved attitude towards or quantity of briefings or time-outs 26,37,40 . Assessment of non-technical skills like teamwork and communication were variable. One study described lower communication, team work performance and attitude, decision-making, and leadership scores in surgeons versus nurses, while another demonstrated lower overall non-technical skills scores in surgeons versus other professions 25,26 . When attitudes or awareness around safety were assessed, improvements were seen with training 22,23,26,30,33,34,37,39,40,42,43,45,47 .
Of the studies that assessed behavioural marker systems or evaluation methods in the context of HF training, Saleh et al. reported high inter-tool and inter-rater consistency with NOTSS and ANTS 27 . Tsuburaya et al. also demonstrated feasibility in using a Japanese version of NOTSS (jNOTSS) and OTAS 28 . In another study, construct validity for assessing and scoring HF skills within a larger endovascular training programme was demonstrated 29 .
Some of the challenges faced during the HF training included criticisms of frontline staff inherent to the intervention 44 , resistance to changes 34,48 , gaps between theory and practice, doubts on the actual effect of the intervention 37,38,49 , and a sense of loss of autonomy 38,39 . Suggested solutions to overcome these barriers included building organizational commitment or culture around HF goals 22,23,44 , inclusion of stakeholders at all levels 34,44 , encouraging physician and nursing leadership 36,38,39 , enhancing authenticity in HF initiatives by reserving time, funding, and resources 34 , teaching through more interactive methods 49 , and providing continuous or multiple training sessions rather than a single intervention 37,43 .

Discussion
A significant amount of research has been undertaken to examine the elements of the OR that produce high-reliability systems 4,5 . These elements have often been focused on well-established fields of HF used in other high-stakes environments and thus progressively extended for the assessment of safety in the OR 4,6,50 .
This review demonstrated that HF training for the operative setting predominantly focuses on teaching interpersonal behaviours related to patient safety, approximating the emerging literature around non-technical skills in surgery 51,52 . Skills related to teamwork, communication, situation awareness, decision making, and leadership have been shown to impact performance in the OR 3,53-55 , and consequently, have been incorporated into training models with behavioural rating systems like NOTSS or NOTECHS, aimed at individual and team assessment and teaching [51][52][53]56 .
However, striving for a high-reliability organization entails more than just optimizing human non-technical skills 9,57 . Analysis of flow disruptions in surgery has uncovered other factors, such as equipment and technology problems, resource accessibility issues, and suboptimal systems organization, all leading to patient safety incidents 5 . Interestingly, these areas of knowledge were not represented by any of the included studies.
Likewise, providers' skills and experience may go beyond individual competencies. While psychological stress and workload have been emphasized by several studies to ultimately affect performance in the OR 24,27,30,34,35,37,41,49 , recent literature has shifted focus from only individual resilience to all contributors to providers burnout, including suboptimal usability of technology, poor funding arrangements, staffing shortage, and workflow interruptions 58 . However, these knowledge areas were not applied in any of the included interventions, suggesting that HF applied to the operative setting probably has still not addressed the full range of sociotechnical factors affecting providers' experience and potentially influencing their response to OR crisis. Unlike other high-stakes environments, it is less likely that elements beyond individual behaviours and skills will be used in these situations to anticipate and control OR threats, suggesting that only behavioural changes without considering systems and environmental factors are limited strategies 5,50,59,60 .
The content of HF training was reflected by the training delivery method in the included studies. Simulation-based learning has been found to develop sustainable teamwork behaviours that cannot be consistently practised and demonstrated in vivo, making it an ideal tool for teaching non-technical skills. 61 The use of video clips of intraoperative recordings was also frequently applied as a review and debrief method 26,27,36,41,43 , suggesting that capturing provider behaviours in 'naturalistic settings' is crucial for standardized and realistic approaches in HF education.
This study has several limitations. Firstly, searching with different databases, keywords, and languages may have identified additional research. However, the chosen databases had broad coverage of the healthcare literature, confirming the completeness of the current search. Secondly, a grey literature search was not conducted and may eventually require a separate study to examine the curriculum objectives of different faculties, institutions, and HF training companies. It is also important to recognize that skills and concepts of HF training interventions may be taught elsewhere under separate labels. Lastly, the inter-rater reliability for the classification of CIEHF knowledge areas demonstrated some, albeit few, disagreements between the two authors. All knowledge areas were reviewed, and disagreements were resolved by consensus to ensure a consistent and accurate approach.
HF investment and education can ultimately facilitate the integration of a shared culture that supports safety initiatives for the operative environment. In particular, shifting the focus from individual traits to the interchange between work practices and provider behaviours can raise awareness of how safety incidents occur 58 . The operative context requires the integration of specific concepts and skills and relevant knowledge from established HF industries. The recruitment of HF experts can facilitate this process by providing an external perspective beyond the OR hierarchy 43 . Although implementing HF requires a significant investment of resources and funding, HF training should be longstanding to create a more longitudinal impact 10,13 . HF integration may eventually lead to a considerable return on investments as high as 7:1, limiting costly safety incidents 62 . As research evolves and introduces new dynamic sociotechnical factors (e.g. novel technologies and new healthcare roles), HF education for the operative space must adapt to expand the range and scope of HF for the operating room.