West of England AHSN has developed an intervention tool to support Human Factors training in patient safety for Bands 1-4 staff working in community health settings.

“If I can reach that one person at induction day and she stays doing caring for maybe ten years? So she might see thousands and thousands of people on her journey through her career, if she carries that through, with all of them what a magnificent difference that’s going to make! So that’s how I think of it.”

Stephen Early, Service User

What was the problem?

An adverse event is an unintended injury, which is caused by medical management rather than by a disease itself. One in ten people is affected by a medical error, although not all errors lead to harm, and not all harm is due to error. There are three common factors in the majority of adverse events; medical complexity, system factors and human factors. Common human factors that can increase risk include mental workload, distractions, the physical environment, physical demands, device/ product design, teamwork, and process design.

Our aim with the human factors programme is to develop non-technical skills to support safer ways of working – including teamwork, communication, leadership and an awareness of human factors when designing systems and processes. 80% of incidents are as a result of human factors.

What we did and why

An appreciation of the principles of human factors has been implemented into acute care services in recent years, but training packages and resources are less applicable to the community health and social care context and non-registered staff (Bands 1 – 4).

WestEng 400+The West of England AHSN secured funding from Health Education South West to develop an intervention using the SBAR (situation, background, assessment, recommendation) tool to support human factors training in patient safety, specifically for Bands 1 – 4 staff working in community health settings in the West of England region, in partnership with Sirona Health & Care and North Bristol NHS Trust.

Factors taken into account designing the intervention included:

  • Community setting
  • Language for working in a mixed health and social care setting
  • Social enterprise setting
  • Needs of adult learners with a variety of education backgrounds and qualifications

We developed a toolkit with specific guidance on quality improvement, measurement, public involvement and evaluation, based on the evaluation of an initial pilot. These tools include qualitative surveys of staff and patients to understanding the impact of the intervention.

This toolkit is supported by face-to-face train the trainer sessions to develop a faculty in expertise in delivering non-technical human factors training. This is alongside with QI coaching every step along the way, and hosting collaborative events for shared learning and problem-solving.

The curriculum was developed by Sirona Care and Health and North Bristol NHS Trust, based on how teams communicate, using communication tools such as SBAR to develop a baseline awareness, which is built upon and embedded during the training using scenarios. These scenarios were co-designed by the programme lead and service user representative to reflect realistic situations that staff might encounter.

The initial phase of the pilot was to work with three teams – health visitors, learning difficulty day services and extra care – to develop the training package and scenarios. Following this first PDSA cycle (plan, do, study, act), the training was adopted into induction for all new starters. This induction is in two parts; an introduction delivered by one of the service users, and a day-long training session for Bands 1-4 staff looking at human factors in more depth.

Which national priorities does this work address?

  • Acutely ill older people
  • Deterioration of patients
  • Handover and discharge
  • Care Certificate, following the Cavendish Review (2013)
  • Human Factors in Healthcare: A Concordat from the National Quality Board (2013)


In total, 385 staff received training through induction by the end of 2015, in addition to the 50 staff who received training in the first pilot phase.

Attendees have fed back that the key things they have learned from the training are:

  • Verbal / non-verbal communication
  • Good communication
  • Confidentiality
  • Using SBAR

“I will now think more about the way I am perceived by a service user and the way I can be more specific in passing info to a colleague.”

Training Participant

“It really shows the great value that service users can make to organisations and how they can help to shape future services.”

Karen Gleave, Project Lead Sirona Care & Health

Tips for implementation

Challenges faced in delivering this intervention included the different ‘languages’ used by health and social care workers working together in this setting. These factors need to be incorporated into the training sessions and materials.

Success came from embedding the intervention into existing structures rather than creating a new mechanism for content delivery.

Next steps and spread

In 2016 we are now providing funding to Bath and North East Somerset CCG, Bristol Community Health, Gloucestershire Care Services and North Somerset Community Partnership to enable a further 2,500 staff in community settings to receive Human Factors training in the next 18 months.

In conjunction with North Bristol NHS Trust and Sirona Care & Health, we are also training up to 45 facilitators across the region, to create a faculty with specialist knowledge and experience in Human Factors training for community services. As part of spread, organisations are measuring the impact on staff confidence and competence, and reduction of clinical incidents and complaints.

Future developments include adapting the model for other groups, such as children/ parents, elderly or disabled people and their carers.

Find out more

Visit the West of England AHSN website.

Contact for help and advice

Nathalie Delaney, Patient Safety Improvement Lead
0117 900 2604

Vanesther Rees, Communications Manager, West of England AHSN
0117 984 1629

Programme duration: January 2015 – Present