Human Factors: the Elephant in the Room

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Have you heard of Human Factors? What does the term mean to you? What about Ergonomics?


There is a famous story about six men from different parts of India—all blind, but each an expert in their respective fields—who decide to find out for themselves the true nature of an elephant. The first, feeling its flank, decides an elephant is like a wall; the second, hand on tusk, says it’s a spear; the third grasps its trunk, and talks of a snake; the next palpates its knee, and thinks of a tree; the fifth touches its ear and conjures a fan.

The Sixth no sooner had begun
About the beast to grope,
Than, seizing on the swinging tail
That fell within his scope,
“I see,” quoth he, “the Elephant
Is very like a rope!”

John Godfrey Saxe

The terms Human Factors and Ergonomics have become much used in healthcare, but many remain confused about their exact meaning, and various different groups have claimed the right to pronounce on their definition.

Clinical educators, particularly those involved in simulation, may tell you that Human Factors is about understanding and improving non-technical skills. They concentrate on the ways that our perception, awareness and decision making can be fooled, and on the difficulties that can occur with poor communication or teamwork. Patient safety advocates, meanwhile, will tell you that Human Factors is about looking at the role of checklists, protocols and guidelines, reducing variability and shepherding inherently error-prone clinicians along safe paths of care.

Others use the term Ergonomics, and focus on protecting ourselves from the stresses of badly designed work environments, on lifting safely and avoiding repetitive strain injury. Others again are more concerned with the ways that an equipment interface can enhance patient care or, more typically, can become an accident waiting to happen. Many seem to conflate these terms with other areas of human interaction such as empathy, compassion or breaking bad news.

And so these men of Indostan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right,
And all were in the wrong!

John Godfrey Saxe

For a time I was in charge of developing Human Factors in my hospital, looking at ways to integrate its principles into clinical care, education and patient safety, building links with experts who could help us to develop and grow in this area of practice. One of the key challenges was that no two groups would have the same view of what it was we were talking about, and the experts in particular would argue loud and long for their own definition.

What about Ergonomics? Many Human Factors practitioners, who might also call themselves Ergonomists, say that these terms are synonymous: that Ergonomics is simply the European term, with Human Factors being the North American equivalent.


Dictionaries record the language as it is used, not as you wish it were used.

Kory Stamper

In ‘Word by Word’, Kory Stamper writes about different conceptions of the nature of a dictionary definition. For some a dictionary should prescribe usage—telling people when and how to use a word— but for her, the role of a dictionary is to record usage: the ways that words are actually used in the real world.

I think it’s fair to say that the actual usage of these two terms does differ, at least in the UK, whatever the prescribed definition. Ergonomics has connotations of the working environment and our interactions with artefacts, while Human Factors automatically brings to mind issues about human to human interactions. One is perhaps concerned with the wall and the tree, while the other deals in fans, spears and ropes, but they are both ways of coming to terms with the elephant.

So what actually are we talking about? The preceding discussion is actually a good place to begin. Human Factors/Ergonomics (HFE) is fundamentally concerned with recording work as actually done in order to form the basis of attempts to improve things. This is in contrast to many other approaches, which assume work is performed according to the way that managers, protocols or tradition prescribe and whose starting point is to try to improve some aspect of that work, without actually knowing what happens in the real world.

A reasonable working definition might go something like this:

Human Factors/Ergonomics seeks to understand, then improve the complex interactions between humans and systems of practice.


I developed this post’s picture as a way of helping people from diverse backgrounds to see the whole elephant of HFE, but at the same time to be able to start to digest it, one bite at a time.

At the centre we have Leonardo da Vinci’s well-known drawing of Vitruvian Man. Vitruvius was a Roman military engineer and the first architect whose writings we have. He described the workings of many aspects of Roman technology but he is perhaps best known for the concept that buildings should be designed around the scale and proportions of the human body. HFE puts the person at the centre, with other aspects of work built around the reality of the actual human mind and body.

The different circles represent the areas that we need to consider in designing work that can actually be done, and done well, by real human beings. At the core, we need to look at cognitive non-technical skills, such as situational awareness, decision making, self awareness, and the effects of fatigue and workload. The individual’s interactions with other people then need to be considered: social non-technical skills such as communication, teamwork, leadership and delegation. We must look at the process of work as actually done by individuals, groups and networks, not relying on the standard operating procedures and protocols that theoretically define that work, but actually observing work on the ground. It’s vital to investigate the place of work, considering the well known deleterious effects of bad lighting, excessive noise and poor layouts— all endemic to many clinical environments. A consideration of real world human interactions with the physical artefacts, or products, is also crucial: medical devices, manual handling aids, new technology. And then we must look at the fundamental impact of prevailing culture, locally within each clinical area, over the organisation as a whole and importantly, the culture created by political and media attention at national level.

To consider all these aspects of work is a huge task—elephantine perhaps—particularly in these times of austerity, when everyone is looking for the quick fix. And to gather information from each of these areas before attempting to improve things, flies in the face of much improvement theory, whose starting point is to change something small then see what happens and build on it. But unless we begin with actually understanding the real world of work from a human perspective, how can we hope to improve it?


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