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One must carefully consider the impact of the many performance shaping factors that are known to play a role in human performance to understand how best to optimize healthcare settings. Patient safety constitutes an overriding concern in healthcare settings and of the three main sources of patient safety concerns medical errors, hospital acquired infection, and patient falls medical errors constitute a key area of concern, resulting in large numbers of preventable deaths Kohn et al.

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Some of the design concepts to address medical errors were mapped from human factor studies in other high-risk sectors such as aviation and nuclear power. In particular, safety implications of standardization are largely mapped from other industries.


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Factors associated with human errors in aviation are multiple. These include procedural as in training factors, and those associated with the physical environment. This is especially important since crew members typically fly more than a single airplane, even within the same company. The benefits of flight deck standardization were examined and codified in aviation standards Department of Transportation, ; Lande, ; Sulzer, Frequent advancements in technology contribute considerably to this challenge Lande, ; Spitzer, Such factors introduce cognitive challenges in pilot decision-making, leading to potential errors.

Standardization of equipment, processes, actions, system layout, displays and color philosophy, among others, are recommended to enhance safety in the aviation industry Spitzer, Identical arguments have driven the concept of standardization of patient care environment, asserting that standardization reduces cognitive demand and help automate several cognitive processes, leading to lesser demand on short-term memory Reiling, Standardization as a concept was not new to healthcare design.

It has been advocated and adopted in healthcare to enhance operational flexibility. Standardized rooms and bed units allow patient spill over from census fluctuations, and move services around a hospital in the log-run to accommodate emerging needs without resorting to large scale renovations. From a patient safety viewpoint it was asserted that standardization would reduce the cognitive burden on the clinicians while delivering care, and hence would promote safety and efficiency.

Standardization in healthcare environments could be described as creating standard care processes, supported by physical environments characterized by consistent location and design of patient care resources. The objective is to increase the caregivers familiarity with the physical environment in which care is delivered, in order to reduce cognitive demand.


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  7. Handedness of the physical environment is an optional attribute of standardized environments, where approach direction and location of the caregiver is also standardized. One of the primary reasons for the ongoing debate about standardization and safety is the notion of same-handedness more specifically, right-handed patient rooms.

    Handedness of the physical environment has been associated with wrong patient or wrong sided procedures. Handedness, however, is discussed in the context of entire hospital, including acute medical-surgical inpatient rooms, and not limited to patient procedures. In traditional hospital bed units patient rooms are configured in a mirrored back-to-back arrangement Figure 1.

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    Standardization of such environments to support standardized processes entails creation of mirror-image pairs of standardized patient rooms. The handed- configuration concept advocated right-handed patient rooms only with standardized approach and location Figure 2 , where the caregiver approaches from the patients right side and is located on the right hand side of the patient room handedness should not be confused with caregiver handedness, such as in left-handed or right-handed caregiver.

    The assertion was that the best approach to the patient and the best location of the caregiver irrespective of the caregivers handedness is the right side of the patient. Empirical research provided crucial preliminary evidence for decision support. The care was provided in nine physical environment configurations where direction of approach and obstructions in the environment were systematically manipulated.

    Data from nursing and kinesiology coding of video segments demonstrated that standardization augments familiarity with the care environment, with potential positive impacts on efficiency and safety. However, there was little evidence to suggest that the care processes could be standardized to an extent where caregiver localization on the right side of the patient could be force functioned.

    Designing room handedness in low acuity care environments, as a result, may not contribute to performance enhancement. A related issue of importance is one of individual handedness as opposed to physical environment handedness. Aviation literatures state that problems with laterality are accentuated in high-stress and high-workload environment thereby compromising ones internal awareness of up and down and right and left a potential factor compromising safety Whittingham, High stress levels also impact performance in other ways.

    Physical design factors light, sound, ergonomics, air quality, hassles and operational factors work load, shift length, and so forth are known to influence stress and alertness levels in caregivers, and hence, performance. Environmental psychology frameworks help address stress and alertness issues in healthcare design. Figure 1. A pair of traditional patient rooms in mirrored configuration.

    Application of Environmental Psychology Theories and Frameworks 7. Figure 2.

    A pair of right-handed patient rooms. Note that the caregiver approach is from the right side of the patient and is positioned on the right hand side of the patient. It could be argued that patient well-being is a function of caregiver well-being. Numerous studies, as elaborated below, demonstrate that nurses are frequently stressed and fatigued with possible detrimental implications on patient care.

    The high stress levels of direct caregivers, while a severe problem by itself, raises serious concerns pertaining to patient well-being and safety. Studies from other settings suggest that high levels of stress and fatigue could have serious implications on performance and patient outcomes.

    Stress and fatigue could impact critical performance aspects including reaction time or alertness, irritability, attention to details, problem solving ability, energy level, and decision-making ability, and thus, could contribute to errors Bognar et al. Moreover, reduced motivation and work performance are typical of tired workers in workplaces, which could equally apply to stressed and tired caregivers in healthcare settings Tabone, a.

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    While the Institute of Medicine report Page, firmly established that patient safety and well being is heavily dependent on nurses, robust studies linking nurse stress and fatigue with work performance and patient safety are not widely available. In a study that tracked work pattern of nurses for example, shift, overtime, hours worked along with errors and near misses it was found that caregiver errors and lapses were correlated with their work pattern Oklahoma Nurse Association, The study suggested that overtime aggravated the situation, especially when it followed a hour shift. The impact of scheduling, a classic human factor, is key as nurses are known to working more than 12 hours regularly, and as long as The Harvard Work Hours Health and Safety Group has systematically demonstrated an association between work hours and scheduling among interns, and patient safety.

    Landrigan et al , demonstrated that the traditional schedule was associated with In a similar interventional study focused on sleep and attentional failure involving 20 interns over a three-week period, Lockley et al found that the rate of attentional failure was half for interns in the intervention schedule as compared to the traditional schedule during on-call nights. The literature shows that the physical environment could be a source of stress, or could interact with the operational factors in modulating the stress of the work environment.

    The physical environment as a stressor has been well documented, for example, noise in the environment has been shown to be a significant environmental stressor, with potentially unsafe consequences for patients and staff Moore et al. Noise has a substantial effect on staff. The detrimental impacts of noise on communication, concentration, and cognitive performance, leading to stress and fatigue have been reported by the World Health Organization AHRQ, The auditory environment also has been shown to have beneficial influence on patients.

    Beside the auditory environment, the impacts of other environmental factors are also supported in available literature. Light appears to have an exceptional influence on alertness. Cognitive scientists have demonstrated decades ago that alertness is important since it has a direct association with performance and safety Reason More alert staff translates to faster reaction time and better capacity to detect errors. One group was exposed to monochromatic light wavelength of nm blue light and the other group was exposed to monochromatic light wavelength of nm green light , for a period of 6.

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    They found that subjects exposed to nm light had fewer attentional failures, decreased auditory reaction time, and lower sleepiness ratings. These studies begin to suggest that spectral qualities of light including natural light may significantly impact alertness of caregivers with identifiable implications on patient safety. Control measures included physical environment stressors that is, lighting, noise, thermal, and ergonomic , organizational stressor, work load, and personal characteristics that is, age, experience, and income. Data was collected from 32 nurses on 19 different units at two hospitals in November Findings showed that duration of exposure to windows is the second most influential factor affecting alertness and acute stress, among the variables considered in the study.

    The association between exposure duration and alertness and stress is conditional on the exterior view content that is, nature view, non-nature view. Beside known factors influencing acute stress and alertness, a potential contributor to stress is rarely addressed in scientific literature the stress effect of hassles in the environment. The theory of cumulative risk in childhood development psychology suggests that minor hassles or irritants in the environment, while not stressors individually, could result in tangible stress when acting together Evans, Could that theory be applicable to healthcare settings?

    By just focusing on major known stressors, and not focusing on hassles, are we inadvertently ignoring potential factors that could compromise care quality? The inboard configurations Figure 3 typically permit larger patient windows and more privacy from the corridor. However, the bathroom location could generate additional traffic on the corridor side of the caregiver zone traffic to bathroom , and reduce space available for clinical use. The out-board configuration Figure 3 offers better line of sight to the patient, and can more readily be converted to progressive or ICU beds.

    Traffic to the bathroom by the patient or family members interferes less with clinical activities, leaving all space on the corridor side of the caregiver zone for clinical use. However, exposure of the patient to the exterior through windows is comparatively less than typical in-board configurations. The IBMC bed tower contains nursing units that have patient rooms with a combination of both in-board and out-board configurations in both the old and the newly renovated unit.

    One of the underlying hypotheses was that physical design attributes around the patient bed the caregiver zone could create challenges that would be perceived as hassles by caregivers. Data was collected from 20 volunteering nurses over a period of seven days in November During that period, the nurses were randomly assigned during any morning or evening shift to either all in-board rooms or all out-board rooms with single occupancy.

    Data was collected on 16 dimensions pertaining to nursing care see Pati et al. The instrument or rating system was designed in a way to allow the subjects to rate the suitability of the physical environment for specific activities on a 7-point scale. The results found that the out-board configuration created a hassle-free environment for nurses.


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    8. However, in the in-board patient room configuration, 8 of the 16 questionnaire responses qualified as potential sources of hassles. A major study finding was that five of the eight criteria qualifying as sources of hassle are directly associated with the caregiver zone and access to the caregiver zone.

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      The hassle issues identified by the caregivers included a access the medical gases, b the positioning of necessary equipment close to the patient during emergent and non-emergent situations, c access the head of the patient without difficulty, d allowing equipment to remain at the bedside and still have access to the patient, and e bringing a stretcher and other caregivers into the room and easily transfer a patient. In addition, four of the eight hassle factors demonstrated significant correlation with acute stress of nurses, namely a allowing equipment to remain at the bedside and still have access to the patient, b the positioning of necessary equipment close to the patient during emergent and non-emergent situations, c access the head of the patient without difficulty, and d bring a mobile workstation into the room or access the computer in the patient room.

      Figure 3. The inboard configuration left locates the bathroom on the corridor wall. In the outboard configuration right bathroom is located on the window wall. Application of Environmental Psychology Theories and Frameworks Addressing the various physical environment stressors, hassles, and potential alerting agents through design is a complex task mainly because physical design is not independent of operational and cultural issues.

      Perhaps, a trend analysis of the inpatient care unit will better illustrate the complexities involved.