A Chat with ‘Human Factors in Paramedic Practice’ Editor, Gary Rutherford

With the release of Human Factors in Paramedic Practice just days away, what better opportunity to catch up with the book’s editor, Gary Rutherford? Gary talks about what compelled him to become the driving force behind this brand new book, his beyond-exemplary team of contributors and his hopes for the future for the discipline of human factors in paramedic practice…

When did you realise you had a special interest in the field of human factors?

In the book’s Preface, I tell the story of the journey that I’ve personally been on with human factors. In 2006, I joined the air ambulance in Glasgow and, as part of your initial training, you complete crew resource management (CRM) training. The content is focussed on non-technical skills, for example decision making, communication, teamwork, leadership, situation awareness and how you can adopt strategies to be aware of and mitigate stress and fatigue, all of which can often be referred to as human factors training. Paramedics who do this training often find it interesting because it’s very different from the technical skills clinical training they’ve done up until that point in their careers. All of a sudden you’re introduced to this new topic, and I really enjoyed it too. Some of the content of CRM training considers how accidents happen, the limitations of human beings and how those limitations can be a contributing factor in those accidents. So, for a number of years I viewed ‘human factors’ to only be factors that are related to humans and how they interact with each other to ensure flight safety.

Then I heard Martin Bromiley speaking at a conference. I think it was in about 2010 he spoke at the Emergency Medical Retrieval Service Conference in Glasgow, a leading conference for aero-medical retrieval. He told the story of how his wife died and how the non-technical skills of the clinicians and healthcare staff involved were affected and sub-optimal on that particular day, as she went in for routine surgery. That was when I had a bit of a light bulb moment. I realised that this CRM, non-technical skills, ‘human factors’ training that we were doing wasn’t just applicable to aircraft safety. It was clearly applicable to patient safety as well.

So, my interest in human factors continued and when I left my role at the helicopter and moved into ambulance service education, I designed a module that was embedded within the paramedic top-up degree programme in Scotland. It covered some concepts related to types of human error, safety culture and non-technical skills and considered these theories in paramedic practice and pre-hospital care.

However, more recently, and this is a key point, I started to recognise that human factors is a much wider discipline than only considering error and non-technical skills. I was starting to read the work of Charles Vincent, Sidney Dekker, Erik Hollnagel, and of course Steven Shorrock and Paul Bowie, who have both contributed to this book. They were all describing how human factors is an approach to consider how humans interact with each other but also how they interact with other elements of the work system, then how that work system can be designed or strengthened to make it easier for people to do the right thing, or less likely to do the wrong thing. Other safety critical industries like nuclear power, oil and gas extraction and the rail industry use human factors as an approach in this way, and I believe that healthcare is starting to appreciate its wider application.

This means that there is a changing focus in healthcare from human factors are only about the humans, to human factors is an approach to take to consider the wider system, which has interested me further, particularly in my current patient safety role. I feel there is value in discussing the breadth of the topic with those working in pre-hospital care, which is what the book looks to do.

Can you tell us more about your initial contact with Class and how the project began?

I was the programme lead for the paramedic programme in Scotland and somebody from Class presented at a College of Paramedics group meeting, of which I was a member. Class were looking to publish a series of short books for paramedics. This was around the same time as Andy Collen’s Decision-Making in Paramedic Practice book was just being published. Human factors was one of the topics on which they were looking to publish. So, I contacted Class and asked where they were with this. I was maybe expecting them to say that a project had been started and was thinking I might be able to contribute. However, they advised me that no one had started a book on human factors and asked if I would be interested. I felt that I had a network of contacts who were interested in the subject and that I could possibly pull together a book with their contributions. And it all grew from there!

The authors of the book have been quoted as ‘premier league’ – can you tell us a little more about your team of contributors?

Recently, Scotland has grown a human factors community of like-minded individuals, which is expanding across the UK. Paul, Duncan, Steven, Rhona, Michael, Ben and Shelly were all connecting with each other and I became involved in some conversations and work streams.

I first ran the idea past Michael Moneypenny as we were working on some non-technical skills and simulation projects together. He thought it was a great idea and was very encouraging and supportive. I also made contact with Paul Bowie. He has co-edited a book on patient safety in primary care and I could see that he was leading on a lot of the human factors community of practice developments. He was keen to hear my plans and instantly said he would be willing to contribute. Paul has an amazing knowledge of traditional and contemporary safety science evidence base. He introduced me to Duncan McNab who is a GP and is undertaking a PhD in work systems, which was a bonus for the systems thinking chapter that I had in mind, which Duncan and I authored. They knew Steven Shorrock and suggested that I should get in touch with him. Steven has co-edited a book on human factors, is editor of a magazine for air traffic controllers and runs an excellent blog website – humanisticsystems.com. I dropped him a message on social media and arranged to meet him for a coffee. I remember being nervous going to meet him as I considered him to be such an expert! He was great to chat with and had some brilliant advice on the challenges of editing a book, which turned out to be very accurate. His chapter on the history and development of human factors is fascinating and will help readers understand the journey.

As I said, I was doing some work at around this time with Michael Moneypenny and also Ben Shippey, at the Scottish Centre for Simulation and Clinical Human Factors. Michael and Ben are consultant anaesthetists. Anaesthetists have been at the forefront of human factors for frontline clinicians and healthcare and were early adopters of human factors principles in healthcare. Michael was particularly supportive of the idea of including the chapter on the patient and I knew Ben would be keen to contribute to the situation awareness and decision making discussion. It was great to have them on board too.

I also made contact with Mike Christian. I didn’t know Mike beforehand but he had spoken at a College of Paramedics’ conference, I think it might have been 2018. I wasn’t there but I watched a recording of it later on. He did acknowledge the wider role of human factors but was then quite clear to his audience that he was speaking about the teamwork aspect of it. So, I thought, Mike is thinking along similar lines to me and he’s already framed and contextualised the topic for paramedics. It turned out he used to be a paramedic himself. He’s now a doctor, working on London’s Air Ambulance, who are renowned as being a high performing team.

Mike came on board and also suggested Neil Jeffers, chief pilot at London’s Air Ambulance. That was brilliant as Neil is also a CRM instructor. So, that felt like a great team for the teamwork chapter.

I didn’t know Jo Mildenhall either. Jo is a paramedic and had published an article in the Journal of Paramedic Practice on stress in relation to paramedic practice. I got in touch with her and explained what I was looking to do. I initially asked her if she would like to write a chapter on stress, but as my understanding of the aims of human factors grew, I asked Jo if she could adapt the chapter to have more focus on well-being and incorporate stress within it. Jo was keen to be involved and has done really well to put up with my many suggestions on how to frame this chapter!

It was also great to have Shelly Jeffcott contribute too. Along with her qualifications and experience within healthcare and other safety critical industries, she has a particular interest in how we design the system to make it easy for humans to do the right thing. So Shelly was really keen to do the human-centred design chapter and has incorporated some pre-hospital examples from literature and her experiences working in the Scottish Ambulance Service.

All of these people have been very supportive and I’ve certainly learned from them on the journey. I know more now about human factors than I did at the start and I agree with Rhona Flin that they are premier league!

Can you tell us about how you structured the book?

In Chapter One you’ll find reference to human factors onions. These are conceptual models related to the layers of human factors and work systems. Therefore, the onion concept was then used as a loose structure for the whole book. Each chapter is a ‘layer’, although I sub-divided a couple of layers and changed the order slightly.There are chapters on non-technical skills which are related to the layers of individuals and teamwork, however there are inner layers (and earlier chapters) related to the patient, human-centred design and systems thinking. Then we have the outer, organisational layers (chapters) related to learning from events and safety culture. I inserted the history, ‘human error’ and well-being chapters where they best fitted as other layers.

I believe the ‘human error’ chapter was added during the later stages of the publication process. Can you tell us more about this?

Yes, my initial plan had been to tackle ‘human error’ throughout the book to illustrate the challenges and limitations of practical application of the term. But I felt, after the review stage, where the draft script is critiqued by anonymised reviewers, that I hadn’t quite achieved that as well as I had hoped. So I drafted a short chapter on ‘human error’ to more explicitly discuss the term and some views from the literature on it.

I think it’s quite clear that most of the contributors don’t feel there is much value to the term ‘human error’, particularly if you use it as a conclusion to an adverse event review or explanation for something. If something has gone wrong or there has been an undesirable outcome, labelling it as ‘human error’ doesn’t really take us forward much at all. It limits the ability to fix the system and will likely lead to blaming individuals.

We are really just trying to encourage people to look beyond ‘human error’ to try to understand what led to it.

What were your key intentions with the book?

Class had stated that their desire was to publish books that were mainly at an introductory level on the subject. This aligned to my intention to produce a single resource that introduced ambulance staff to some of the key elements of human factors. When colleagues asked me more about human factors, they could be signposted to websites, e-learning and articles. However, I felt that there wasn’t an easy to read single resource that covered key themes and related them to their practice.

I was pleased that Rhona Flin described the book as accessible, as I was keen that the book would be easy to read while also being based on a sound evidence base. It is intended for a wide readership within ambulance services and pre-hospital care, with areas of interest for frontline clinicians, students, leaders, managers and those involved in education, procurement and patient safety.

This is your first book. You must be very proud of your achievement.

It was definitely a team effort to publish the book. I’m both excited and nervous, although looking forward to the conversations and developments that could come from its release. I hope that it will lead to more paramedic and ambulance service colleagues increasing their understanding of human factors principles. In particular seeking to adopt a systems approach to their thinking and to consider when they would benefit from further expert input.

This is the first UK book that has been written on the topic and applied to paramedic practice. It is pleasing that Martin and Rhona both suggest that it may also be of interest to other healthcare professionals. And your ultimate goals for the book?

I hope the book will encourage paramedics and ambulance staff to become interested in human factors or continue their journey in their understanding and use of principles. I believe this will be of benefit to them, to the services that they work in and ultimately to the people and patients they care for.

It would be great if the book led to further work, developments and research on human factors in paramedic practice and pre-hospital care. If anyone is looking for any ideas, then I believe there is huge scope for the principles to be considered within ambulance service control centre work systems and environments.

I’ve had a few conversations with colleagues across the UK about what could happen next in the application of human factors principles. Can we establish a network of interested paramedics across the UK? How do we get momentum in some of the principles in the book?

As mentioned before, this is your first book. Has it been a positive experience?

It has been a great experience and I’m pleased with how the book has turned out. There were a few tough periods of late nights and long weekends of writing and editing. I’d like to thank all the contributors for their efforts.

Working with Class was great. Lianne (Sherlock) had an excellent skill of reassuring me that everything was going to be fine when I was getting a bit stressed about progress. It can be stressful with edited collections as you’re writing your own contributions, managing multiple contributors, overlapping content, trying to keep a certain voice throughout the book but still allowing each contributor to have their own voice.

If anyone has an idea for a book, I would recommend getting in touch with Class to discuss further.

Any plans for the immediate future?

Immediate plans are to stay away from writing anything for as long as possible. I need a break!

However, I’m keen to see how the book is received, to see if anyone gets in touch and how we can generate some momentum in the principles or discuss how to further develop.

Gary Rutherford is the Patient Safety Lead for the Scottish Ambulance Service. He is also an honorary educational co-ordinator at the Scottish Centre for Simulation and Clinical Human Factors. He has completed a BSc in Paramedic Practice, gained the Diploma in Immediate Medical Care awarded by the Royal College of Surgeons, and completed post-graduate certificates in Teaching & Learning in Higher Education, and Patient Safety & Clinical Human Factors.

For more information on Human Factors in Paramedic Practice or to place an order, please click below.Gary was chatting with Lianne Sherlock, Senior Editor at Class, and their Events & Marketing Co-ordinator, Kate Anderson.