AUTHOR: DR CATHERINE CHATFIELD-BALL
Human factors refer to the psychological, social, and organisational aspects that influence how individuals work together effectively in a team, or when lacking, can contribute to errors. These factors include communication, leadership, trust, motivation, conflict resolution, decision-making, and team dynamics. Understanding and managing these factors can greatly enhance team performance and reduce the incidence of errors, thus improving patient care. The importance of an appreciation of human factors increases as a situation becomes more stressful, or the team dealing with a casualty are more remote from help, both of which often apply in pre-hospital and expedition medicine.
Human Factors : Safety and decision-making
Human factors as a study originated in the aviation industry and the military. In the early 20th century, aviation accidents were often attributed to pilot error. This led to the development of human factors research, which aimed to understand the cognitive, psychological, and social aspects of human performance in order to improve safety and efficiency. The military also recognised the importance of human factors in combat situations, where split-second decisions and effective teamwork are crucial for mission success. Many human factors problems arise when a person is in a state of cognitive overload; where the demands placed on an individual exceed the capacity of working memory resulting in mental exhaustion and compromised performance. This scenario is not uncommon in medicine, where there is a need to assimilate multiple pieces of information and make rapid and high-stakes decisions under stressful circumstances.
The importance of human factors in the delivery of safe health care is now well established, with health care workers routinely undergoing education and training in non-technical skills such as teamwork and effective communication. The “Swiss cheese” model is often quoted when considering how mistakes are made despite the existence of multiple safety checks and team members. Each of these represents a layer of safety that will normally detect and prevent an error. However, if the holes in the Swiss cheese layers all line up, it is possible for an error to slip through.
Figure 1: The Swiss Cheese Model. Taken from https://josieking.org/patientsafety/module_e/swiss_cheese.html
Training in human factors aims to empower team members to identify the gaps in the care they are delivering, and subsequently reduce opportunities for errors to slip through. This has led to the development of learned communication tools such as using standardised handover systems like SBAR (a structured approach to delivering patient handovers describing Situation, Background, Assessment, and Recommendations which has been shown to improve patient safety ) and a fundamental shift in the paradigm of how we think of teams. Concepts such as the ‘flat hierarchy’ – which encourages all members of the team to feel able to speak up particularly if they have concerns over patient safety, are now commonplace in the healthcare system. This change, both in safety protocols at an organisational level and in how we train individuals to improve non-technical skills, has been shown to have a direct positive impact on patient safety and outcomes by reducing human error .
In expedition and wilderness medicine, where resources are limited and conditions are often unpredictable, understanding human factors becomes even more critical. Medical professionals working in these remote and challenging environments must be able to adapt to unique challenges, make sound decisions under pressure, and effectively communicate and collaborate with their team. Understanding how individual factors, such as personality traits and communication styles, can impact team dynamics is important for optimising performance and minimising errors.
Objective dangers are unpredictable and sometimes unavoidable in the wilderness setting, but individuals’ response to those threats will determine the success of the trip and are governed by situational awareness, team dynamics, communication, and leadership . For example, on a high-altitude expedition there is a significant chance of some members of the team experiencing Acute Mountain Sickness (AMS), which can progress to serious illnesses such as High-Altitude Pulmonary Oedema (HAPE) or High-Altitude Cerebral Oedema (HACE) if ascent continues. Recognising that a quieter individual may express feeling unwell in a more subtle way such as becoming withdrawn is key for an expedition medic. Equally, fostering a culture of kindness and collaborative endeavour within the team early in the trip is important for encouraging open communication.
Along with the demands of physical exhaustion, inherent situational dangers, and high-stakes decision making, cognitive challenges on expedition can arise directly from environmental factors, such as hypoxia at high altitude or hypothermia in the polar environment. This can affect clear thinking . Unlike in the hospital setting, a team member sustaining an injury in this environment can jeopardise the whole team’s trip and even safety with the complexities of evacuation.
One of the key issues in human factors is bias, which can affect decision-making and lead to errors in diagnosis and treatment. Interoceptive bias refers to the tendency to rely on internal cues and personal experiences when making judgments, which can lead to inaccurate assessments of patients’ conditions. Conversely, groupthink is another issue that can arise in a team setting, where the desire for consensus and harmony can override critical thinking and lead to poor decision-making.
How can we improve?
As our understanding of how human factors influence team dynamics grows, so does our ability to manipulate these factors to optimise team performance. In the expedition context this can lead to improved group cohesion and a more enjoyable trip, a successful summit bid, averting a serious accident or even ensuring the survival of a critically unwell member of the team.
The issues mentioned above such as bias and poor communication can be somewhat mitigated through education and training in preparation for an expedition. Simply acknowledging that biases in judgement exist and can influence our decision-making under pressure can be enough to change behaviour – for example seeking a second opinion to ‘sense check’ our management plan for an unwell casualty in a stressful and unfamiliar setting .
Training in non-technical skills, such as leadership, situational awareness, and decision-making, can also enhance team performance in challenging environments. Simulation-based training has been widely adopted, particularly in acute specialties such as emergency medicine, anaesthesia, and intensive care, as an effective training tool for both technical and non-technical skills. Ideally an expedition group would have had an opportunity to meet prior to departure for a trip and under simulated expedition circumstances (e.g. hiking in the UK hills), allowing the team leader and medic to gauge personality types, team dynamics and cohesion, and foresee potential problems.
Research into the effectiveness of such training, looking at both objective measures of patient outcomes and at assessment of team cohesion and performance, has shown this to be a beneficial tool . Simulation can be used to train emotional intelligence in recognising non-verbal cues, and communication behaviours such as closed-loop communication and graded assertiveness to challenge behaviours that compromise patient safety .
Take home messages
Appreciating the role of human factors in expedition and wilderness medicine is crucial for understanding and mitigating the risks associated with human behaviour, decision-making, and team dynamics in remote and challenging environments. By recognising and addressing the potential for issues such as bias and groupthink, and implementing techniques to optimise teamwork and team performance, medical professionals can provide safe and effective care in these unique settings.
There is no one-size-fits-all approach in human factors; each team with its different composition of personalities will have its own strengths and weaknesses in non-technical skills. Without doubt one of the best ways to understand and improve these fundamentals of team working is simulation prior to a trip.
Practising these non-technical skills in simulated medical scenarios is also important. Many expedition and wilderness medicine courses now include a ‘moulage’ or casualty simulation element, to prepare candidates with not only the theoretical knowledge to manage wilderness emergencies but also provide the opportunity to put the non-technical skills into practice in the field. This affords an insight into how one performs, communicates, and leads under challenging and unfamiliar circumstances, which is critical to personal and professional development as an expedition medic.
 Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. 2011; 26: 155–159.
 Batchelder AJ, Steel A, Mackenzie R, et al. Simulation as a tool to improve the safety of pre‐hospital anaesthesia–a pilot study. 2009; 64: 978–983.
 Abrahamsen HB, Sollid SJ, Öhlund LS, et al. Simulation-based training and assessment of non-technical skills in the Norwegian Helicopter Emergency Medical Services: a cross-sectional survey. 2015; 32: 647–653.
 Albert E. Anatomy of a Preventable Death:“Non-Technical” Skills in Expedition and Wilderness Medicine.
 Wickens CD, Keller JW, Shaw C. Human factors in high-altitude mountaineering. 2015; 12: 1.
 Ruhomauly Z, Betts K, Jayne-Coupe K, et al. Improving the quality of handover: Implementing SBAR. 2019; 6: 54.
 De Decker R, Roos J, Tölken G. Human factors: Predictors of avoidable wilderness accidents? 2017; 107: 669–673.