Assessing Human Factors Education for Patient Safety among Students and Interns in Jeddah, Saudi Arabia Open Access

In the healthcare context, human factors (HF) or human skills are frequently utilized to refer to all of the non-technical skills (NTS) that doctors use to function efficiently in various clinical contexts, ranging from ordinary daily tasks to exceptionally stressful emergency conditions [1, 2]. The National Health Service (NHS) in England defines HF in healthcare as improving clinical performance by comprehending how teamwork, tasks, equipment, workspace, culture, and organization influence human behavior and abilities, and implementing this knowledge in clinical settings [3]. The role of HF in healthcare settings has been increasingly gaining interest in the twentieth century as medical errors and adverse events are often linked to HF rather than clinical incompetence [2].

Globally, the integration of HF into medical practice has been associated with significant improvements in patient safety and clinical outcomes [4, 5]. In the USA, the Agency for Healthcare Research and Quality (AHRQ) has led initiatives embedding HF principles into healthcare systems, promoting a culture of safety through structured teamwork training and system redesign to reduce errors [5]. Crew Resource Management (CRM), an applied training approach derived from HF science, was originally developed in aviation to address human error and improve communication, leadership, decision-making, and team performance in high-stress environments [6, 7]. CRM-based training programs focus on optimizing human interactions to reduce errors and enhance patient safety. A multicenter study in the USA demonstrated that implementation of CRM-based team training significantly reduced surgical mortality and improved teamwork behaviors and safety culture across Veterans Health Administration hospitals [8]. Similarly, in the UK, the General Medical Council (GMC) has included HF in its processes for evaluating fitness to practice, emphasizing the importance of embedding these concepts in medical education [4]. In Europe, HF-based simulation training has enhanced interprofessional collaboration and reduced diagnostic and procedural errors, particularly in emergency and perioperative settings [7, 9, 10]. These international experiences support the early and structured inclusion of HF education in undergraduate medical curricula as a foundational component of safe and effective healthcare delivery.

Locally, in Saudi Arabia, the Saudi Patient Safety Center was established in 2017 as one of Saudi Arabia’s National Transformation Vision of 2030 initiatives to improve patient safety at a national level [11]. One of the recent studies conducted to explore the patient safety culture and sentinel events in Saudi hospitals has shown that communication, staff competency, and performance are essential for reducing medical errors and enhancing patient outcomes. Moreover, the highest number of reported sentinel events in 103 hospitals was related to the contributory factors of Communication and Information (63.20%) [12].

Medical education is a pivotal part of enlightening medical students and future doctors regarding HF competencies, not merely to enhance patient safety but also to improve physician-patient communication, collaborative teamwork, and clinical decision-making [3, 5, 10]. Previous research conducted in the UK evaluating medical students’ knowledge of HF reported that 45.7% of respondents had never heard of the concept [1].

There is limited scientific literature in Saudi Arabia regarding the awareness and perception of HF among medical students. To date, no study has specifically investigated this issue within the Saudi context. This study aimed to evaluate HF awareness among medical students and interns in Jeddah, Saudi Arabia, with a particular focus on the role of HF education in promoting patient safety.

This observational cross-sectional study was conducted in Jeddah, Saudi Arabia, in 2024. The study involved medical students from all academic years, as well as interns who had graduated from universities in Jeddah and provided informed consent to participate. All universities with medical schools were included, including private universities. Exclusion criteria included non-medical students, medical students, and interns not affiliated with universities in Jeddah, and those who chose not to participate.

To evaluate participants’ knowledge and perceptions of HF, a structured survey was adapted from a validated questionnaire on HF education, developed by Conroy and colleagues [1]. Permission for the adaptation and use of this questionnaire was obtained from the original authors. Minor adjustments were made to ensure the survey’s cultural and contextual relevance for the Jeddah setting, while maintaining the core structure and content to facilitate cross-study comparisons. The complete version of the survey questionnaire used in this study is available in the online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000546632). To assess the face validity of the questionnaire, a panel of three experts in medical education reviewed it. They evaluated the content, structure, and language to ensure clarity, relevance, and comprehensibility for the target audience.

A pilot study was conducted before data collection to assess the feasibility of the study procedures and ensure the clarity of the data collection tools. A total of 20 participants meeting the inclusion criteria were recruited to complete the pilot phase. This number was selected based on recommendations by Hertzog [13], who suggests that a sample size between 10 and 30 participants is generally adequate for pilot studies. Feedback from the pilot study led to minor modifications ensuring the clarity and reliability of the final study protocol.

The required sample size was calculated to achieve a 95% confidence level, with a 5% margin of error and an expected response rate of 50%. This calculation determined a minimum of 384 participants.

The survey comprised two main sections. The first section, socio-demographic data, and self-reported academic performance, collected information on participants’ age, gender, university affiliation, academic year, and academic performance. The second section addressed the core components of the study: (1) awareness of HF, assessing familiarity with HF concepts; (2) self-assessment of ability in NTS, enabling participants to rate their confidence in applying HF-related skills such as communication, teamwork including interprofessional collaboration, and situational awareness; (3) teaching of HF, evaluating the types and effectiveness of HF education received; and (4) importance of HF, exploring participants’ perceptions of HF’s significance in medical education. A Likert scale was used for survey responses.

The survey was administered through Google Forms in English, allowing for convenient, anonymous, and voluntary participation across multiple universities in Jeddah. Data collection occurred from September to December 2024. Incomplete responses were excluded from the analysis.

Descriptive statistics, including counts, proportions, medians, means, and standard deviations, were used to summarize the data. Relationships between knowledge, awareness, attitudes, and socio-demographic variables were analyzed using the chi-square test and Fisher’s exact test for categorical variables, as well as the Independent t test and ANOVA for continuous variables. A significance level of p < 0.05 was considered indicative of meaningful associations. All statistical analyses were conducted using SPSS software version 29.

A total of 707 participants completed the survey; however, 31 were excluded as they were from outside Jeddah. The final analysis included 676 participants, the majority of whom were female (n = 387, 57.2%). The largest group of students and interns was from the University of Jeddah (n = 361, 53.4%), followed by those from private universities (n = 115, 17.0%). Most participants were in their fifth academic year (n = 149, 22.0%). In terms of academic performance, more than half of the participants (n = 367, 54.3%) demonstrated excellent grades at the university level. Regarding awareness of HF, 60.5% (n = 409) reported being familiar with the term, with the majority acquiring this knowledge during their second year of study (n = 143, 21.2%). Additionally, 66.3% (n = 448) recognized the importance of human skills and NTS. These findings are summarized in Table 1.

Among the 676 medical students and interns surveyed, confidence in applying NTS, which are key components of HF, varied across different domains. Teamwork exhibited the highest confidence levels, with 55.0% (n = 372) of participants reporting being extremely confident. Similarly, a significant proportion expressed extreme confidence in their communication skills (42.2%, n = 285), situational awareness (42.3%, n = 286), and decision-making abilities (41.9%, n = 283). In contrast, confidence in challenging authority was the lowest, with only 29.1% (n = 197) feeling extremely confident, while this domain also had the highest proportion of respondents reporting no confidence at all (23.1%, n = 156). These findings are summarized in Table 2.

Confidence levels among participants in applying technical skills versus NTS varied. Notably, 35.2% of participants reported greater confidence in their technical skills, while a slightly higher proportion (37.0%) felt more confident in human skills and HF. Meanwhile, 27.8% expressed equal confidence in both areas. These findings are illustrated in Figure 1.

Among the 676 medical students and interns, 81.1% (n = 548) reported having received formal training in NTS. The most covered skills included communication (n = 477, 70.6%), teamwork (n = 445, 65.8%), and decision-making (n = 392, 58.0%). Regarding teaching methods, lectures (n = 438, 64.8%) and simulated scenarios (n = 403, 59.6%) were the most frequently utilized, with one-to-one instruction and small group sessions also being commonly employed.

In terms of perceived effectiveness, nearly half of the participants rated one-to-one instruction (n = 332, 49.1%) and small group teaching (n = 331, 49.0%) as extremely effective, followed closely by simulated scenarios (n = 339, 50.1%). Conversely, lectures and e-learning had the highest proportions of participants rating them as not effective at all, at 22.9% (n = 155) and 30.3% (n = 205), respectively. Additionally, participants expressed preferences regarding the optimal timing for integrating NTS into the curriculum, with 49.6% (n = 335) favoring its introduction during the preclinical years. These findings are summarized in Table 3.

Participants rated the importance of various NTS, with teamwork receiving the highest score (8.21), emphasizing its perceived critical role in medical practice. Decision-making (8.14) and communication (8.09) followed closely, highlighting their significance in clinical settings. Coping with stress (8.07) and task prioritization (7.86) were also highly valued. The ratings for other NTS are presented in Figure 2.

The association between awareness of HF and sociodemographic characteristics among medical students and interns revealed several significant findings. University affiliation was a key factor, with students from King Abdulaziz University demonstrating significantly higher awareness (78.9%, p < 0.001) compared to students from other universities. Academic progression also influenced awareness, with interns showing a significant increase in awareness (73.4%, p = 0.003). Additionally, academic performance was significantly associated with HF awareness (p < 0.001). In contrast, gender did not show a statistically significant correlation with awareness levels. These findings are summarized in Table 4.

Significant associations in awareness of “HF/NTS” were primarily observed across different universities. Students from King Abdulaziz University demonstrated significantly higher awareness (78.9%) compared to students from other universities who exhibited lower levels of awareness. This indicates that the approach to teaching NTS may vary notably between institutions, potentially influencing how well students understand and value these competencies. Other sociodemographic factors, including age, gender, academic year, and academic performance, did not show significant associations with NTS awareness. These findings suggest that the university environment may be a more critical determinant of NTS awareness than the other variables. These associations are presented in Table 5.

Significant variations in confidence levels regarding NTS were observed across various sociodemographic factors among medical students and interns. Gender differences were particularly pronounced, with male participants demonstrating significantly higher confidence (mean = 13.88, SD = 4.87) compared to their female counterparts (mean = 12.57, SD = 4.75), with a p value of <0.001. Confidence levels also varied by university affiliation, with students from King Saud bin Abdulaziz University for Health Sciences reporting the highest confidence (mean = 13.71, SD = 4.51; p = 0.002). In terms of academic year, second-year students exhibited the highest confidence (mean = 13.87, SD = 4.79), while fourth-year students showed the lowest levels (p = 0.015). Additionally, a significant positive correlation was found between academic performance and confidence, with those performing excellently academically demonstrating higher confidence levels (p < 0.001). These findings are summarized in Table 6.

The participants were surveyed on their views regarding the importance of integrating HF into medical education. A significant majority deemed it either important (29.1%) or very important (43.3%), reflecting a strong consensus on the necessity of teaching HF. Conversely, a smaller proportion of participants considered it unimportant (4.4%) or very unimportant (8.1%). A neutral stance was expressed by 14.9% of the respondents. These findings are detailed in Figure 3.

HF are essential NTS utilized by healthcare professionals to enhance clinical performance and promote patient safety by understanding and applying knowledge of teamwork, tasks, equipment, and organizational culture [14]. Globally, institutions like the National Science Foundation (NSF), National Institutes of Health (NIH), and the GMC emphasize integrating HF into healthcare to improve safety [15]. In Saudi Arabia, the Saudi Patient Safety Center focuses on enhancing patient safety through improved communication and staff competency [16], yet studies reveal low awareness of HF among medical students, highlighting a significant gap in medical education [1]. The current study evaluated knowledge, awareness, and confidence in HF and NTS among medical students and interns in Jeddah, revealing key insights into their educational experiences.

The results indicate that a significant portion of participants (60.5%) are familiar with the term “human factors,” with a majority recognizing the importance of human skills or NTS (66.3%). These findings are consistent with trends observed in medical education globally, where there is a growing acknowledgment of the importance of integrating HF in healthcare training to enhance patient safety and care quality [3, 17]. Interestingly, awareness was notably higher among participants from older age groups and those in higher academic years, suggesting that such NTS awareness may accumulate over time, potentially through increased exposure to clinical environments where these skills are applied. Similarly, Gamborg et al. [18] show that accuracy and awareness in NTS improve with experience, yet valid tools for novices, where NTS impact is most apparent, are underdeveloped. This trend underscores the necessity of early and consistent integration of HF education, as also recommended by participants who favored introducing these skills during preclinical years [19].

Moreover, the present study found that confidence in applying NTS varied significantly across different areas, with the highest confidence reported in teamwork and the lowest in challenging authority. This pattern aligns with the findings of other studies, such as the Samardzic et al. [9] study, which emphasizes teamwork as a pivotal component of medical training curricula globally. However, the lower confidence in challenging authority likely reflects both cultural influences and educational gaps. In Saudi Arabia, hierarchical structures in education and healthcare may discourage questioning senior figures, often perceived as disrespectful, which can inhibit open communication even when patient safety is at risk [20‒22]. Furthermore, structured training in communication assertiveness, speaking-up behaviors, and graded assertiveness techniques, which are crucial for developing the ability to challenge authority, is often lacking or insufficiently emphasized [23, 24]. The absence of formal instruction and role models demonstrating assertive communication may further contribute to students’ hesitancy to speak up. Challenging authority is a nuanced skill that requires not only personal assertiveness but also a supportive culture that fosters open dialog. Comparative international studies support these observations. Research among Austrian medical students found that although students recognized the importance of speaking up, many were reluctant to challenge senior staff due to fear of negative repercussions [25]. Similarly, studies among Irish and German medical students showed that hierarchical barriers and limited communication training contributed to low speaking-up behaviors [26, 27]. These findings highlight the influence of both cultural and educational factors on low confidence in challenging authority and underscore the need for targeted educational interventions that promote assertiveness, open communication, and psychological safety in medical training.

A vast majority of participants (81.1%) reported receiving training in NTS, primarily through lectures and simulated scenarios. While these teaching methods were generally perceived as effective, there was a notable critique of the effectiveness of lectures and e-learning, pointing to the potential need for more interactive or practical approaches to teaching these critical skills. This finding suggests an opportunity to explore and implement more hands-on, experiential learning methods that could enhance the retention and practical application of NTS in medical settings [28]. In light of these findings, curriculum designers should consider integrating HF education longitudinally across all academic years. Emphasizing teaching methods perceived as highly effective, such as one-to-one instruction, small group teaching, and simulated scenarios, can enhance learning outcomes. Implementing these methods from the preclinical stage and reinforcing them during clinical rotations through simulation, supervised reflection, and case-based learning may foster deeper understanding and application of HF principles. Institutional support and trained faculty are critical in ensuring these efforts translate into meaningful competency.

In recent years, medical and health humanities have made notable progress in Saudi Arabia, serving as an emerging educational strategy to enhance NTS and HF competencies among healthcare students [29, 30]. Health humanities encompass disciplines such as ethics, narrative medicine, communication, and professionalism, which align closely with core elements of HF, including empathy, teamwork, and decision-making [31]. Empathy and perspective-taking are particularly fundamental competencies that serve as the foundation for many HF and NTS skills [32]. Empathy enables healthcare providers to understand and respond appropriately to patients’ emotions and needs, fostering effective communication, enhancing teamwork, and supporting collaborative decision-making [33]. Similarly, perspective-taking enhances situational awareness, conflict resolution, and leadership in clinical environments. Without the development of empathy and perspective-taking, the application of other HF competencies may remain superficial and less effective. Across most Saudi universities, medical curricula include a dedicated course on medical ethics, typically offered during the fourth year and lasting around 2 weeks, which also integrates basic concepts of patient safety. Additionally, communication skills training is generally incorporated within community medicine courses rather than offered as standalone programs. These educational exposures may partially explain the slight increase in HF awareness observed among third- and fourth-year students in the present study. Although these efforts represent important steps toward humanistic education, at the time of this study, formal structured programs specifically labeled as “health humanities” were not yet systematically integrated into the curricula of the surveyed institutions. Expanding and formalizing health humanities programs, with particular emphasis on empathy and perspective-taking, could significantly strengthen HF education and promote a more patient-centered approach to care.

Notably, the study also uncovered significant associations between sociodemographic factors and both awareness and confidence in NTS. The variation in awareness levels between universities may be linked to differences in curriculum structure and clinical exposure. For example, King Abdulaziz University, with its integrated academic hospital system and structured clinical teaching programs, may offer more consistent exposure to HF education. Interestingly, students from private universities also demonstrated relatively high levels of HF awareness, second only to King Abdulaziz University. This may reflect recent curricular reforms and partnerships with specialized private hospitals, where a stronger emphasis on quality assurance, patient safety standards, and accreditation requirements (e.g., CBAHI) has led to earlier adoption of HF-related training. Private institutions may also offer smaller group teaching and more personalized supervision, fostering better understanding of NTS. These findings highlight how the institutional environment, including access to cohesive clinical education and emphasis on safety culture, can significantly influence students’ awareness and competence in HF. Supporting this, Wevling et al. [34] show that high awareness of NTS is often associated with systematic training, focused educational programs, and the active engagement of supervisors in clinical practice. Structured assessment tools like the Nurse Anaesthetists’ Non-Technical Skills-Norway (NANTS.no) also enhance awareness through continuous feedback and reflection [35].

Additionally, the gender differences observed in confidence levels, with males reporting higher confidence, could partly be attributed to cultural factors influencing self-perception and assertiveness. In Saudi Arabia, sociocultural norms may often encourage males to exhibit greater assertiveness and decisiveness in professional and educational settings, contributing to higher self-reported confidence. Conversely, females may face societal expectations promoting modesty, leading to underreporting of their abilities despite equivalent competence, and may be more self-critical or underrepresented in leadership roles during training. This dynamic aligns with broader trends observed in medical training, where males generally report higher confidence levels, while females tend to rate their skills less confidently [36].

Thus, the study focuses on teamwork and communication, aligning with global trends in competency-based medical education that emphasize NTS. Yet, the variance in confidence to challenge authority and the link between academic progression and skill proficiency underscore the need for practical experience to bridge theory and practice.

This study has several limitations. The sample was predominantly from the University of Jeddah, which may limit the generalizability of the findings. The cross-sectional design also restricts the ability to determine causal relationships. Reliance on self-reported data introduces potential biases, including recall bias and subjective interpretation of confidence and awareness. Additionally, the study did not include a control group or objectively assess NTS through direct observation or simulation. Moreover, the variations in clinical exposure between institutions, such as access to teaching hospitals and faculty supervision, were not systematically analyzed, despite their potential influence on outcomes. Uneven representation across academic years and the possibility of selection bias due to online survey distribution should also be considered.

These findings highlight key implications for advancing HF education. Strengthening NTS training, especially in communication, teamwork, and decision-making, is essential for improving patient safety and clinical performance. Future research should adopt longitudinal designs, involve diverse institutions, and use validated tools to objectively assess NTS. Early integration into medical curricula and fostering a supportive institutional culture can enhance student preparedness and promote safer clinical practice. Evaluating the long-term impact of HF training will help optimize educational strategies and ensure sustainable improvements in clinical competence and patient safety.

The findings demonstrate a moderate-to-high level of awareness of HF and a strong appreciation for NTS among medical students and interns in Jeddah. Participants also reported considerable confidence in applying these skills in clinical practice. These findings imply that current efforts to teach NTS are yielding positive results, yet there remains room for improvement. It is recommended to integrate HF education earlier in the medical curriculum, particularly during preclinical years, and to adopt more interactive teaching strategies such as simulation and small-group instruction.

This study protocol was reviewed and approved by the Scientific Research and Ethics Committee of Jeddah University Faculty of Medicine, Approval No. UJ-REC-261. Written informed consent was obtained from all participants before completing the survey as they were required to provide consent prior to participation.

The authors have no conflicts of interest to declare.

The authors received no financial support for the research, authorship, or publication of this article.

Abdullah S. Algarni: supervision, review, and editing. Shahad A. Alshehri: manuscript writing and data analysis. Atyaf F. Alzahrani and Ahlam S. Almuabdi: data collection and manuscript writing. Safinaz M. Alshiakh: manuscript editing and formatting. Ramy Samargandi: conceptualization, supervision, review, and editing. All authors read and approved the final manuscript.

The data that support the findings of this study are not publicly available due to privacy reasons but are available from the corresponding author upon reasonable request.