When Communication, Human Factors and Behaviour Affect Patient Safety
Healthcare is frequently described as a technical profession.
It is not.
Technical knowledge and clinical competence are fundamental, but healthcare is also delivered by human beings working within complex systems, often under pressure, with incomplete information and alongside other human beings who are subject to exactly the same limitations.
A competent clinician can miss something.
An experienced practitioner can become distracted.
A well-trained team can misunderstand one another.
A patient can deteriorate while everyone involved believes that somebody else has taken responsibility.
This is where situational awareness becomes important.
Situational awareness is not simply “being aware of what is going on”.
It involves recognising what is happening, understanding what that information means and anticipating what is likely to happen next.
In healthcare, those three functions can mean the difference between identifying deterioration early and recognising it only when a patient arrests.
What is Situational Awareness?
Situational awareness can broadly be divided into three interconnected processes:
Perception
Perception is the ability to identify and gather information relevant to the situation.
In clinical practice that information may include:
- physiological observations
- monitor readings
- clinical examination
- investigation results
- information from colleagues
- information from the patient
- concerns expressed by relatives
- changes in behaviour or appearance.
But simply receiving information does not guarantee that we recognise its significance.
Comprehension
Comprehension is the ability to make sense of what we have perceived.
A clinician may recognise that the respiratory rate has increased, blood pressure has fallen and the patient appears confused.
Comprehension means bringing those observations together and asking:
What does this mean?
Clinically, this resembles the process of forming a diagnosis or differential diagnosis.
Projection
Projection means using our understanding of the present situation to anticipate what may happen next.
If the patient’s physiology continues to deteriorate, where is this going?
Does the patient require senior review?
Critical care?
Urgent surgery?
Resuscitation?
Projection allows us to act before the situation becomes irreversible.
Together, perception, comprehension and projection form a continuously changing mental model of what is happening around us.
Patient Safety and the Scale of the Problem
The original teaching material from which this article developed used NHS figures from the late 2000s to demonstrate the consequences of unsafe care.
Those figures are now outdated.
The World Health Organization currently estimates that approximately one in ten patients experiences harm while receiving healthcare, with more than three million deaths each year associated with unsafe care globally. WHO also estimates that more than half of patient harm is preventable. (World Health Organization)
The important message is not that healthcare workers are careless.
It is that healthcare is inherently complex.
Patient harm rarely arises from one spectacular mistake.
More commonly, several relatively small problems combine:
poor communication, interruptions, fatigue, workload, equipment problems, assumptions, hierarchy, incomplete handover, inadequate supervision or failure to recognise deterioration.
By themselves, each may appear insignificant.
Together, they can become catastrophic.
Everybody Sees Things Differently
One of the simplest exercises demonstrating human perception uses the following sentence:
FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.
How many times does the letter F appear?
Many people answer three.
Others identify four or five.
There are six.
The Fs contained within the word “OF” are frequently overlooked.
Why?
Not because the reader cannot see them, but because the brain does not process every element of information equally.
We process familiar information rapidly and selectively.
Much of what appears obvious to us is partly constructed from expectation and previous experience.
This is extraordinarily useful.
Without it, routine tasks would consume enormous amounts of cognitive capacity.
But it creates a potential problem.
We tend to see what we expect to see.
In healthcare this may contribute to:
- confirmation bias
- fixation
- premature closure
- assumption
- failure to recognise unexpected information.
Experience can therefore both protect us and occasionally deceive us.
Human Performance Is Not Constant
We frequently talk about competence as though it were a permanent characteristic.
Someone is either competent or incompetent.
Real human performance is considerably more complicated.
The same individual can perform exceptionally well on one occasion and poorly on another.
Performance changes according to the individual, the environment and the task being undertaken.
A useful way of visualising this is through the Three Bucket Theory.
The Three Buckets
Imagine three buckets:
Self
Context
Task
Each contains factors that influence our ability to function.
Bucket One: Self
The Self bucket represents the individual.
It includes:
- knowledge
- experience
- training
- physical health
- mental wellbeing
- fatigue
- hunger
- confidence
- stress
- emotional state
- previous experience of the situation.
An experienced practitioner working after adequate rest may possess considerable cognitive capacity.
The same practitioner working after several difficult shifts, dealing with illness at home and managing several simultaneous clinical problems may perform very differently.
That does not mean their knowledge has disappeared.
Their available cognitive capacity has changed.
Bucket Two: Context
The Context bucket represents the environment within which the work is taking place.
It includes:
- staffing
- equipment
- workplace design
- noise
- interruptions
- organisational processes
- availability of senior support
- leadership
- team dynamics
- familiarity with colleagues
- psychological safety.
A simple procedure performed within a familiar, well-organised team may be straightforward.
Perform exactly the same procedure in an unfamiliar environment with unfamiliar equipment and insufficient staff, and the task becomes substantially more difficult.
Bucket Three: Task
The Task bucket describes the work itself.
Important factors include:
- complexity
- urgency
- number of simultaneous tasks
- familiarity
- interruptions
- uncertainty
- time pressure.
These three buckets continuously interact.
When all three are manageable, we have spare capacity.
When the buckets begin to overflow, situational awareness suffers.
Stress and the Productivity Curve
Stress is not automatically harmful.
Very low levels of stimulation may actually reduce performance.
A person who is bored or under-stimulated may become inattentive.
As demand increases, alertness and performance may improve.
There is therefore an optimal performance zone.
Beyond this point, however, additional pressure becomes counterproductive.
The clinician moves from challenge into strain.
Eventually performance deteriorates.
Attention narrows.
Working memory becomes less reliable.
Communication deteriorates.
Decision-making becomes more rigid.
Situational awareness declines.
At extremes, continued pressure contributes to exhaustion and burnout.
The important lesson is that asking increasingly stressed people simply to “try harder” may actually make performance worse.
What Is the Opposite of Stress?
One of the questions posed in the original teaching session was:
What is the opposite of stress?
Physiologically, the stress response involves changes including increased heart rate, respiratory rate, blood pressure and activation of catecholamine and cortisol pathways.
Positive social interaction, support and kindness produce a very different psychological and physiological environment.
This matters because behaviour between colleagues is not separate from patient safety.
How we speak to one another influences how effectively we think and work.
Which brings us to incivility.
Incivility in Healthcare
Incivility can be easy to dismiss.
An irritated comment.
An eye roll.
Someone being ignored.
A sarcastic remark.
A surgeon humiliating a junior member of staff.
A nurse being mocked for asking a question.
Someone texting while another colleague is speaking.
None of these necessarily looks like a major patient-safety incident.
But their consequences may extend much further than the interaction itself.
A randomised study involving neonatal intensive-care teams found that exposure to rude behaviour significantly impaired diagnostic and procedural performance. Rudeness alone explained almost 12% of the variance in performance, with reduced information-sharing and help-seeking contributing to the effect. (PubMed)
A later study similarly demonstrated deterioration in therapeutic performance, communication, helping behaviour, information-sharing and workload-sharing following exposure to rudeness. (PubMed)
That matters.
A colleague who is reluctant to ask for help has become a patient-safety risk.
A junior practitioner who no longer feels able to question a senior clinician has become a patient-safety risk.
A theatre environment where staff fear humiliation can lose information that somebody within the room already possesses.
Does Incivility Affect Surgical Outcomes?
There is evidence suggesting that it does.
A 2019 JAMA Surgery study examined 13,653 patients undergoing procedures performed by 202 surgeons.
Patients whose surgeons had received coworker reports concerning unprofessional behaviour experienced significantly more postoperative complications.
Among patients operated on by surgeons with no reports, the complication rate was 10.7%.
Among those whose surgeons had four or more reports, it was 14.1%.
After adjustment for relevant factors, complication rates remained approximately 12–14% higher in groups whose surgeons had received reports of unprofessional behaviour compared with surgeons with none. (JAMA Network)
The point is not that rudeness somehow directly causes a wound infection.
The likely pathway is more complex.
Unprofessional behaviour damages teamwork.
Damaged teamwork reduces information-sharing.
Poor information-sharing weakens situational awareness.
Weak situational awareness increases the opportunity for mistakes.
Civility Is Not About Being Nice
Civility is sometimes misunderstood as politeness for its own sake.
That misses the point.
A clinically safe environment still requires disagreement.
People must challenge decisions.
Junior staff must question senior staff.
A colleague should be able to say:
“I think you’re wrong.”
The issue is how that challenge is delivered and how it is received.
Professional civility means creating an environment in which disagreement is possible without humiliation.
A useful Code of Civility might therefore include:
- Greet and acknowledge colleagues.
- Say please and thank you.
- Treat others equally and respectfully.
- Recognise that your behaviour affects other people.
- Welcome feedback.
- Remain approachable.
- Be direct, sensible and honest.
- Acknowledge other people’s contributions.
- Respect colleagues’ time and commitments.
- Address incivility rather than normalising it.
This may sound simplistic.
It is not.
These behaviours help create psychological safety.
And psychological safety allows information to move.
Communication: The Link Between Individual and Team Awareness
Situational awareness cannot remain inside one person’s head.
Healthcare is delivered by teams.
That means individual situational awareness must become shared situational awareness.
For that to happen, information must be communicated effectively.
This is particularly important during clinical handover.
Every handover represents a transfer not merely of information, but of responsibility.
NICE recommends structured handovers when patients move between teams and settings, including diagnosis, treatment, monitoring plans, ongoing therapy, physical and psychological requirements and communication needs. (Nice)
A poor handover therefore does more than omit information.
It can destroy the receiving team’s mental model of the patient.
SBAR and SBARD
One of the most established structured communication tools is SBAR:
Situation
Background
Assessment
Recommendation
NICE specifically identifies SBAR as an appropriate framework for structured patient handover. (Nice)
An extended form used within some organisations is SBARD, in which the final D represents Decision.
That addition is particularly valuable because it closes the communication loop.
Situation
What is happening now?
Identify yourself, the patient and the immediate problem.
For example:
“I’m calling about Mr Jones in bed seven. His respiratory rate has risen to 32 and his oxygen requirement has increased significantly during the last hour.”
Background
What does the person receiving the handover need to know?
Relevant background might include:
- reason for admission
- procedure undertaken
- significant comorbidities
- medication
- previous observations
- recent investigations
- interventions already performed.
The aim is not to recite the patient’s entire history.
It is to provide enough information to understand the current situation.
Assessment
What have you found?
And importantly:
What do you think is happening?
This may include:
- observations
- ABCDE assessment
- NEWS2
- examination findings
- trends
- investigation results
- response to treatment.
The clinician should be able to state plainly:
“I am concerned that this patient is deteriorating.”
Recommendation
What do you need?
This should be explicit.
Not:
“I just thought I’d let you know.”
Instead:
“I need you to review this patient now.”
Or:
“I think this patient requires critical-care review.”
Structured communication reduces ambiguity.
Decision
Finally:
What have we agreed?
Who is coming?
When?
What happens until they arrive?
What observations should continue?
What will trigger further escalation?
The D is important because a conversation can occur without responsibility ever being transferred.
Communication has not succeeded simply because words were exchanged.
Care and Communication of the Deteriorating Patient — CCDP
Within parts of the UK independent healthcare sector, deteriorating-patient education has included programmes titled Care and Communication of the Deteriorating Patient — CCDP.
CQC reports show CCDP being used as mandatory or competency-based training and linked with recognising deterioration, sepsis awareness, NEWS2 and escalation. (CQC API)
It is important, however, to distinguish CCDP from national NHS frameworks.
CCDP is not itself a national NHS early-warning system.
It is better regarded as a practical educational programme bringing together two inseparable skills:
recognising deterioration and communicating it effectively.
That pairing is extremely important.
Recognising deterioration achieves little if the concern is never communicated.
Equally, excellent communication is useless if nobody recognises that there is something to communicate.
The Deteriorating Patient
Deterioration is not always dramatic.
The patient does not necessarily collapse without warning.
Often the clues accumulate.
The respiratory rate increases.
The patient becomes restless.
The oxygen requirement changes.
Urine output decreases.
Blood pressure trends down.
The patient becomes less interactive.
A relative says:
“They’re just not themselves.”
No single finding necessarily identifies the diagnosis.
But collectively the pattern has changed.
This is situational awareness in practice.
NEWS2 Is a Tool — Not a Diagnosis
The National Early Warning Score provides a standardised way of identifying abnormal physiology and escalating concern.
But an early warning score should never replace clinical judgement.
It does not diagnose sepsis.
It does not diagnose haemorrhage.
It does not diagnose pulmonary embolism.
It alerts the clinician that physiological risk is increasing.
The challenge is what happens next.
NHS England now frames deterioration through the PIER approach:
Prevention
Identification
Escalation
Response
Importantly, the escalation section specifically recommends reliable communication processes and identifies structured communication tools such as SBARD to reduce loss of safety-critical information between clinical teams. (NHS England)
Prevention
Can deterioration be prevented?
This includes appropriate:
- observations
- treatment
- medication
- hydration
- oxygen therapy
- infection management
- postoperative care
- recognition of complications.
Identification
Has something changed?
This involves more than simply recording numbers.
It includes:
- observations
- NEWS2
- clinical examination
- trends
- behavioural change
- patient concern
- family concern
- professional intuition.
Escalation
Does someone else need to know?
If so:
Who?
How urgently?
And what exactly do they need to know?
This is where SBARD becomes invaluable.
Response
Did the escalation achieve anything?
Has somebody reviewed the patient?
Has management changed?
Was a decision made?
Does the patient need transfer?
What happens next?
A telephone call in itself is not an intervention.
The loop must close.
“I Don’t Like the Look of This Patient”
Experienced clinicians will recognise this phrase immediately.
It is sometimes treated dismissively because it appears subjective.
But it may represent sophisticated pattern recognition.
An experienced practitioner may unconsciously integrate:
- skin colour
- respiratory pattern
- posture
- facial expression
- level of interaction
- confusion
- agitation
- movement
- behaviour.
The individual may not initially be able to articulate exactly which feature is wrong.
But something does not fit the expected pattern.
Objective scoring systems are extremely useful.
Clinical judgement remains essential.
The two should complement each other.
Martha’s Rule: When the Patient or Family Sees What We Have Missed
Situational awareness should not be restricted to professionals.
Patients and relatives may recognise deterioration before healthcare staff.
NHS England’s Martha’s Rule creates a mechanism for patients, families and staff to request an urgent independent clinical review when they are concerned deterioration is not being recognised or acted upon.
Between September 2024 and December 2025, more than 10,000 escalation calls were made through Martha’s Rule. NHS England reported that 34% identified acute deterioration; 1,885 patients subsequently had treatment changed and 446 were transferred to higher levels of care in potentially life-saving interventions. (NHS England)
That provides a powerful lesson.
The most important information in the room may come from the person with the least authority.
A safe system makes it possible for them to speak.
Barriers to Effective Communication
Why, then, does communication fail?
Sometimes because people simply stop listening.
Other barriers include:
- disengagement
- dissatisfaction with work
- assumptions
- hierarchy
- conflict
- fear of criticism
- lack of transparency
- lack of trust
- interruptions
- excessive workload.
Active listening requires us to receive what the other person is actually saying rather than waiting for our opportunity to reply.
When trust disappears, communication becomes filtered.
People stop saying what they think.
They say what they believe is safe to say.
That is dangerous in healthcare.
The Swiss Cheese Model
The Swiss Cheese Model remains one of the most useful ways of explaining how patient-safety incidents develop.
Imagine several slices of Swiss cheese placed one behind another.
Each slice represents a layer of defence.
The holes represent weaknesses.
These weaknesses may arise from:
- human error
- poor training
- equipment failure
- inadequate procedures
- communication problems
- organisational culture
- staffing
- poor supervision.
Normally the holes do not align.
One defence catches what another misses.
Occasionally, however, the weaknesses temporarily line up.
The hazard passes through every layer.
The incident occurs.
Active Failures and Latent Conditions
Some failures are immediately visible.
A wrong button is pressed.
A drug is administered incorrectly.
A diagnosis is missed.
These are often called active failures.
Others remain hidden within the system.
Inadequate staffing.
Poor training.
Badly designed equipment.
A culture where nobody challenges consultants.
An escalation pathway that nobody understands.
These are latent conditions.
They may exist for years before contributing to an incident.
The temptation following an adverse event is to identify the person closest to the patient and ask:
“Who made the mistake?”
Human factors asks a more useful question:
“What allowed that mistake to reach the patient?”
Imagine the Deteriorating Patient
Consider a postoperative patient who is bleeding.
The respiratory rate increases.
The observation is entered incorrectly.
The NEWS2 score is therefore underestimated.
The nurse nevertheless feels that something is wrong.
The registrar is known for humiliating staff who call unnecessarily.
The nurse hesitates.
Eventually a call is made, but the concern is described vaguely.
There is no explicit recommendation.
The registrar assumes the review can wait.
No clear decision is documented.
The patient’s blood pressure falls.
The next nurse assumes the registrar has already reviewed the patient.
The patient arrests.
Which person caused the arrest?
That question misunderstands what happened.
The holes aligned.
Perception.
Communication.
Culture.
Escalation.
Handover.
Decision-making.
Every defence weakened.
That is human factors.
Situational Awareness Is a Team Property
We often think of situational awareness as something an individual either possesses or lacks.
Healthcare requires something broader.
Individual situational awareness
What do I know?
Team situational awareness
What do we know?
Organisational situational awareness
Does the system recognise what is happening and can it respond?
A nurse may perfectly recognise that a patient is deteriorating.
If nobody listens, individual awareness has failed to become team awareness.
A medical team may recognise the deterioration.
If critical care cannot respond, team awareness has failed to become system action.
Patient safety therefore depends on all three.
Communication Is a Clinical Intervention
Perhaps the most important conclusion is that communication should not be viewed as a “soft skill”.
Communication is a clinical intervention.
A blood result that nobody communicates has achieved nothing.
An abnormal observation that nobody escalates has achieved nothing.
A perfect assessment that is handed over badly may effectively cease to exist.
A junior practitioner who identifies the problem but is frightened to challenge a senior colleague may hold the information necessary to save a life.
This is why situational awareness, civility, SBARD, CCDP, NEWS2, PIER and human factors should not be taught as unrelated topics.
They are different parts of the same safety system.
The Illusion of Communication
The original presentation ended with an idea that remains as relevant as ever:
The greatest problem with communication is the illusion that communication has taken place.
Someone speaking does not mean they were heard.
Being heard does not mean they were understood.
Being understood does not mean responsibility was accepted.
And accepting responsibility does not necessarily mean that something happened.
Perhaps, therefore, the most useful addition to traditional SBAR is that final letter:
D — Decision
What have we actually agreed is going to happen next?
Because in healthcare, communication is not complete until information has been received, understood and translated into appropriate action.
Situational awareness ultimately means recognising what matters, understanding what it means, anticipating what comes next — and ensuring that the people around us share that understanding before it is too late.
