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In the second paper of this series, we provide a brief overview of the scientific discipline of human factors and ergonomics (HFE). Traditionally the HFE focus in healthcare has been in acute hospital settings which are perceived to exhibit characteristics more similar to other high-risk industries already applying related principles and methods. This paper argues that primary care is an area which could benefit extensively from an HFE approach, specifically in improving the performance and well-being of people and organisations. To this end, we define the purpose of HFE, outline its three specialist sub-domains (physical, cognitive and organisational HFE) and provide examples of guiding HFE principles and practices. Additionally, we describe HFE issues of significance to primary care education, improvement and research and outline early plans for building capacity and capability in this setting.

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CONTEXT: Internship, the first year after medical school, is an important time for identity formation and role development. Effective performance feedback is essential for identifying strengths and weaknesses, guiding self-regulation to improve clinical performance and developing accurate self-assessment. However, developing feedback systems is notoriously difficult. A better understanding of interns' perspectives is important to increase engagement with feedback systems and to improve their effectiveness. METHODS: This study explores the interns' role clarity and confidence in evaluating their own performance; their views of the existing health care organisation's formal performance appraisal system based on national intern assessment tools and guidelines and whether the self-directed audit of clinical tasks is a feasible feedback tool. Qualitative data were collected through a cross-sectional survey using semi-structured interviews with interns in their last week of employment from a single large regional public health care organisation in Australia. Interviewee-verified data were analysed thematically using a 'framework' approach. RESULTS: Twenty-one of 28 interns were included in the final analyses. We found that interns conceptualise good performance in terms of efficient completion of daily tasks and are unable to confidently judge their own performance. The current health care organisation performance appraisal system based on national intern assessment tools and guidelines does not meet their expectations and could be improved through greater involvement of the medical staff who work alongside interns on a daily basis, particularly registrars and regular, scheduled opportunities for formative and informal feedback with a focus on personalised, constructive feedback. The introduction of specific task assessments or audit, such as a formal appraisal of patient discharge documentation, is also valued. CONCLUSIONS: Performance appraisal formats need improving to better align with interns' expectations, to meet interns' learning goals and to improve practices in the health care organisation.

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BACKGROUND: Critically bleeding trauma patients require coordinated and efficient decision-making processes to ensure optimal management of their massive transfusion (MT) requirements. Human factors (HFs) is a discipline that investigates factors influencing work processes from the organizational, group, and individual levels. Given the complexity of trauma resuscitation, implementing any intervention for decision support in MT is challenging and may benefit from a HFs-assisted approach. STUDY DESIGN AND METHODS: A systematic review was performed to identify reports of the introduction of any type of decision support for the provision of MT in critically bleeding adult trauma patients. Crucial contributions reported to influence design and uptake of the intervention were categorized into four HFs categories (environment, human, machine, and task). Extracted information was supplemented by surveying the contact authors. Evidence of clinical practice changes resulting from the intervention was also considered. RESULTS: We identified nine studies that had reported an intervention implementing new practice guidelines or a MT protocol. All were before-and-after comparative cohort studies and used historical controls as the preintervention cohort. CONCLUSION: Based on the identified reports, this review provides a HFs-assisted approach to aid clinicians and policy makers with the implementation of decision support for MT in the trauma care setting.

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Threats to patient safety during clinical handover have been identified as an ongoing problem in health care delivery. In complex handover situations, organisational, cultural, behavioural and environmental factors associated with team performance can affect patient safety by undermining the stability of team functioning and the effectiveness of interprofessional communication. We present a practical framework for promoting systematic, comprehensive measurement of the factors involved in clinical handover. The framework can be used to develop viable solutions to the problems of clinical handover. The framework was devised and used in a recent project examining interprofessional communication and team performance during clinical handover in post-anaesthetic care units. The framework combines five key concepts: clinical governance, clinician engagement, ecological validity, safety culture and team climate, and sustainability. We believe that use of this framework will help overcome the limitations of previous research that has not taken into account the complex and multifaceted influences on clinical handover and interprofessional communication.

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Effective team performance is important to measure in order to determine how clinicians should be trained for safe and effective patient care. Team performance is challenging to measure. In this paper, we describe different methodologies used to capture team performance metrics including clinical surveys, direct observation, and video-based analyses of real-life clinical performance. Despite much effort, the instruments reported thus far suffer from a variety of shortcomings that prevent their wide application in assessing team behaviors and performance. A consensus is needed on a conceptual model of clinical team performance that can encompass many real and simulated healthcare settings and account for interdependencies of their outcome criteria.

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Organizational safety culture reflects the attitudes and behaviors that individuals share in considering and reacting to hazards and risks. We first argue that trust is an underdeveloped and important concept in relation to theories of safety culture and high-reliability organizations. The article then reports findings from a two-year qualitative study of train operating companies (TOCs) in the United Kingdom, which sought to explore in detail the linkages between safety culture and the postprivatized railway industry. In-depth interviews and focus groups were carried out with a sample of over 500 employees, from four organizations, and representing all key functional levels. Our analysis suggests that the 1993 privatization, and subsequent organizational restructuring of the U.K. railway industry, has had important repercussions for both safety culture and trust relationships. We explore our findings in relation to three key constructs within "safe organizations" theories (namely, flexibility, commitment, and learning), and discuss how the safe organization model might be usefully supplemented by a consideration of trust issues.