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"How to" Series: Observation

One of the most widely used, and effective tools in the HF practitioners toolbox is observation. Don't be fooled, this isn't always as easy and simple as it may seem. It takes time to 'get your eye in', to see what you need to see. When I first started working in healthcare, observation was mostly seen as an audit function. The first time I'd been asked to wash my hands was by a theatre nurse who said "quick, there's a hand hygiene audit, wash your hands" - I'd been observing in theatres for a few months by then, and I didn't even know where the handwashing sink was in theatres (it was not the scrubbing sink, it was in a side area). I'm sure that experience would be different in COVID times, but the reaction of the staff to the 'observer/auditor' in that they were coming to check up on everyone was a reminder to me about how important your introductory scene setting is.

Background and preparation

I am usually carrying a notepad when I conduct observations (more on the structure within it later). I use this as part of my introductions. I'll explain that I'm there to understand how work is done. I ask the team to show me the challenges they face in the environment - often I will try and use a locally relevant example to illustrate what I mean. If I'm in theatres I might say " you know in an arthroscopy when the lighting makes it challenging to see the equipment...". Then I'll take consent from the people being observed (if that's part of the project) and offer that they are welcome to see anything I write at any time. I'll also explain the purpose of the observations, why they're important and how I'll use what I see.

There are 2 main types of observations, structured and unstructured (which can blend into ethnographic research - that is not covered here). I will add a category that I find most helpful which is semi-structured.

Structured observation

Structured observation is when what you are setting out to observe is clearly defined before you start. This is most like the audit situation described above (although hopefully without the staff reaction). There are different categories of what you might like to observe:

  • Timing: timing how long a process or a particular task takes

  • Behaviours: there are a number of tools that support you to observe and score team behaviours

  • Activities: whether a certain task is done (e.g. have the team done the WHO surgical safety checklist)

  • Completeness: whether all the steps are done within a process e.g. xx discussed for xx% of patients on ward round

  • Counting: the number of distractions/errors in a process, often with added contextual detail.

There are many studies in healthcare based on this methodology. These 2 describe the methods in detail.

Unstructured observation

The role of unstructured observation is when you want to be open about what you might see. This is useful for idea generation e.g. new opportunities for design might emerge. You can also use unstructured observation to inform what you might collect in a more structured format - i.e. build your list of what you want to look at in more detail.

Unstructured observation allows you to switch your focus around an area of work, and not get too caught up in looking for one particular thing. However, what I would say for a novice is that it can be quite daunting. Just observing to 'see what you see' can be overwhelming at times, you don't know what to write down, and when questioned by staff it can be challenging to explain what you're looking at. This is where semi-structured observation comes in...

Semi-structured observation

I have been using the Systems Engineering in Patient Safety model to add structure to my observations for years. [add link to document here]

Recently myself and Paul Bowie have realised we've both being doing the same, so have put together a prompt sheet, which we've made open for people to use as they wish. See the link below - I'd welcome any feedback on this, let me know what you find helpful, or what you'd like me to add. The Healthcare Safety Investigation Teams are using a slightly adapted version in some of their investigations.

In situ Structured Observation Guide ISO
Download • 170KB

Your challenge, should you choose to accept, is to try out some observation as part of your work, I promise you'll 'see' something you never have before - and as easy as that you have a new/refined tool in the box.


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