From training to competency: A qualitative investigation of how qualified in-hospital healthcare personnel transfer human factor skills from an in situ simulation-based training course to competency in the complex clinical practice

Introduction: This PhD thesis developed knowledge on qualified in-hospital healthcare personnel’s transfer of human factor skills to competency in clinical practice. The topicality was based on the fact that patient safety is crucial in modern healthcare. Further, in 2019, the World Health Organisation emphasised patient safety as a fundamental area of attention. Research and existing efforts focus on preventing adverse events and emphasise learning from errors to improve healthcare practices. Despite the effort, the number of reported adverse events in Danish hospitals has stabilised instead of reduced. The economic and human impacts of adverse events on healthcare underscore the necessity of attending to cognitive, social, and psychological factors (human factor skills) influencing patient safety.

Background: The approach to learning from errors primarily focuses on providing knowledge and procedures to reduce errors. In recent years, training in acute critical situations has also been used to improve patient safety. Existing research indicates that simulation-based training enhances the knowledge and skills of pregraduate healthcare students and that participants through simulationbased technical skills training demonstrate advancement along the learning curve when applying the skills in clinical practice, compared to no training. However, whether this result could be applied to human factor skills is unknown. A systematic review was conducted to investigate the effectiveness of training qualified healthcare personnel’s human factor skills through simulationbased training. The findings support the applicability of simulation-based training to enhance human factor skills. Still, the process by which the taught and trained skills are translated into clinical practice competency remains unclear. This revealed a scientific gap regarding transfer of human factor skills from simulation-based training to competency in clinical practice.

Aim: This PhD study aimed to develop knowledge of how qualified healthcare personnel within a hospital setting transferred human factor skills acquired through a simulation-based training course into everyday clinical competency. The personnel’s human factor skills competency was investigated before, during and after a simulation-based training course. The aim was based on the following overall research question: How do qualified healthcare personnel transfer human factors skills taught and trained in an in situ simulation-based training to competency in everyday clinical practice? 

Method: The study comprised a qualitative research design and was methodologically and theoretically informed by the assumptions of phenomenological-hermeneutic based on Ricœur’s critical hermeneutic. The study’s complexity in capturing physical, psychological and sociocultural changes in qualified healthcare personnel was built upon several theoretical frameworks within the quality of care, didactics and transfer. Ethnographic fieldwork was used to investigate the personnel’s transfer of human factor skills. A hybrid analytical method (RI-CEA) was developed to explore how transfer emerged. RI-CEA comprised a Ricœur-inspired analytical approach and Cognitive Event Analysis, which enabled a 1st and 3rd person's perspective on data. The ethnographic data was collected between February 2019 and February 2020 and included approximately 107 hours of video recordings, field notes, and written reflections.

Findings: The systematic review highlighted the need to reconsider the focus on transferring human factor skills. Numerous assessment tools have been developed to render human factor skills visible for modifications during and immediately after simulation-based training. The systematic review asserted the effectiveness of training human factor skills among qualified healthcare personnel, but challenges in appraising human factor skills development impede comparisons of effectiveness. The perception of human factor skills as innate and challenging to train persists, posing a potential obstacle in transitioning human factor skills from simulationbased training to competency. This conclusion served as a foundational understanding for the subsequent ethnographic study.

The ethnographic study comprised three phases: Clinical phase (before), Simulation-based training phase (during) and Transfer phase (after). The naïve reading of the data from the Clinical phase revealed a highly switchable clinical practice. The analytical themes of coordination, interruptions, educational responsibilities, teamwork, and situational awareness were integrated into the training course in the following phase. The simulation-based training phase underscored the importance of training. Participants expressed a focus on technical skills but lacked emphasis on or practice of human factor skills in the everyday. The structural analysis identified the themes of educational responsibilities, feedback, decision-making, leadership, and teamwork, shaping the focus in the subsequent Transfer phase. The Transfer phase revealed engaged qualified healthcare personnel open to human factor skills training and emphasised positive interest. However, challenges included the lack of human factor skills-language, time constraints, and a dilemma between wanting to improve human factor skills and the experience of lack of priority among colleagues and organisations.

The analysis found three key transfer levels: Individual, Intercollegiate and Organisational transfer of learning. These interconnected and interdependent levels shed light on the limited extent of human factor skills transfer after simulation-based training. The findings suggested that the acquisition of human factor skills occurred at both individual and intercollegiate levels. However, for adequate transfer, there was a need for organisational awareness and support to ensure that knowledge translates into competency in clinical practice. Inadequate awareness and support for transfer, internalisation, and retention of human factor skills at the organisational level contributed to these shortcomings.

Implications: This thesis explored the understudied transfer process of human factor skills from simulation-based training to competency in clinical practice. Findings suggested a need for a broader training focus, involvement of local human factor skills ambassadors and coordinated planning between simulation centres and organisations to optimise human factor skills transfer and improve patient safety. The research identified areas for further exploration, including developing a generic transfer strategy, assessing its impact on competency, and investigating the relationship between healthcare personnel's human factor skills competency and patient safety.