Enhancing Patient Safety in a Healing Environment

Patricia C. Seifert, RN, MSN, CNOR, CRNFA, FAAN; Deborah S. Hickman, RN, BSN, MS, CNOR, CRNFA


Topics in Advanced Practice Nursing eJournal. 2005;5(1) 

In This Article

Physical Environment

One of the earliest proponents of the importance of the physical environment was Florence Nightingale.[21] Her efforts on behalf of the British soldiers during the Crimean War focused on design engineering to improve lighting (especially with sunlight), ventilation, heating and cooling, sewerage facilities, and sufficient space for soldiers' personal belongings. The safety aspects of clean air and water were not inconsequential to Nightingale's patients or to her nurses; the effects of her improvements on patient outcomes were reflected in the mortality figures for 1855, which fell from 42.7 deaths per 1000 to 2 per 1000 within 3 months of Nightingale's changes.[22]

More recently, environmental factors such as noise, air quality, light, toxic exposures, temperature humidity, and aesthetics have been scrutinized for their effects on both patients and workers.[3] The combination of environmental factors with the growing consumer demand for safety, security, competence, and physical and psychological comfort has engendered the concept of a "healing environment." Healthcare designers in 1988 initiated the concept of a healing environment that could facilitate the healing process by identifying factors that improve access to people and resources, increase employee comfort, expand patient privacy (eg, by reducing noise and distractions), and provide flexibility and personalization in the delivery of care.[23] In the past few years, healthcare designers and healthcare facilities have formed partnerships to incorporate healing environment design aspects into their renovation and new construction projects, and to measure the effects of these initiatives on patient outcomes. One of the best known of these integrative efforts is The Pebble Project .

The AHRQ[3] reviewed research from both healthcare and other workplace settings to identify how environmental factors and other working conditions affect processes related to patient safety. The Agency surveyed numerous factors and found that some of these factors generated more research than others. However, the cumulative evidence supports the claim that working conditions are an important influence on patient safety, thereby deserving scrutiny by healthcare professionals.[3] Many elements of the healing environment concept are an integral part of the working conditions investigated by the AHRQ and reinforce the notion that all customers (patients, families, and staff) benefit from an environment that provides safety, security, competence, support, and comfort.[24] Information related to these environmental working conditions studied by AHRQ and others is described below.

Physical Design

Patient- and caregiver-focused design that combined a coronary critical care unit and a coronary medical step-down unit was described by Flynn[25] as an example of the integration of functionality, technology, and the environmental needs of patients and staff. Part of the impetus for combining the units was to reduce the time spent and distance walked by nurses during their work shift. The union of the 2 units also reduced the number of times that patients were transferred. Patients were admitted and discharged from the same room, thereby saving direct labor and equipment costs and reducing patient stress. Safety-related benefits included a reduction in medication errors and fewer patient falls.[25]

Other design considerations are work stations that are conveniently close to patients and allow patients a direct view of the nursing station.[24] Larger, private rooms that can accommodate 24-hour family visits may be equipped with refrigerators, Internet connections, telephone, sleep sofa, and other amenities that provide a communal atmosphere. Meditation areas (both indoor rooms and outdoor gardens) provide a place for spiritual needs (Figure 1 and Figure 2).

Figure 1.

An indoor Zen garden provides an area for meditation. Courtesy Inova Heart and Vascular Institute, Michael Dersin Photographer.

Figure 2.

An outdoor garden with plants, sunlight, and shade can be used by patients, families, and staff. Courtesy Inova Heart and Vascular Institute, Michael Dersin Photographer.

One of the suggested ways to improve the quality of a patient's surroundings, reduce nosocomial infection, and promote a healing environment is to increase the number of single-patient rooms. The proposed benefits to patients include greater privacy, more opportunities for family interaction, better sleep, and a reduction in hospital-induced infections, according to Cassidy.[26]

In the outpatient setting, navigating the healthcare campus can be a challenge, especially for elderly patients who have impaired mobility. Easily accessible parking close to the institution's entrance, guides and assistive devices to direct visitors, and clean walkways (and other areas) are all important attributes. Especially important is the presence of directional signs that are clear, easy to read, and appropriately located. Touch-screen "way-finding" and information kiosks may be available to assist patients and others to find their way through the hospital (Figure 3).

Figure 3.

The information kiosk serves as a way-finder and information source for visitors and staff. Courtesy Inova Heart and Vascular Institute, Michael Dersin Photographer.

There are also many physical design considerations for hospital personnel that impact safety and comfort for them as well as, ultimately, the patient. In the operating room, for example, the use of hydraulic booms to place equipment such as the surgeon's head light source, electrosurgical units, video monitors, and suction canisters removes cords and tubing from the floor (thereby reducing the risks of tripping and falling) and consolidates the equipment into a mobile, time-saving, and more efficient system (Figure 4). Work desks for the circulating nurse are designed to face the surgical field, thereby enabling the nurse to monitor the surgical field and respond more readily to surgical team members' needs.

Figure 4.

Hydraulic booms (note boom in left forefront of photograph) consolidate equipment and supplies in the operating room. Courtesy Inova Heart and Vascular Institute, Michael Dersin Photographer.

Lighting and Color

Lighting has physiologic, psychological, and aesthetic effects on individuals. Although how light characteristics affect worker performance is not entirely clear, there is evidence that the intensity of light can contribute to dispensing errors by pharmacists.[3] Buchanan and associates[27] found a 30% decrease in the rate of dispensing errors when there was a significant increase in lighting intensity.

The use of natural lighting has been promoted both as a staff retention tool[26] as well as a patient satisfier.[24] Windows overlooking gardens and other natural settings have been recommended; in some institutions, windows are positioned low enough so that bed-ridden patients are able to see through them. Multistory glass atriums are increasingly incorporated into new construction projects. From a safety perspective, one study looked at the shape of windows and found that square windows resulted in fewer errors during an observational task than round windows.[28] Although the study was not performed in a healthcare setting, there are implications for patient monitoring by nurses and other healthcare providers.[3]

In addition to lighting, the use of color has been reviewed. Colors can range from soothing to stimulating. Reds, yellows, and oranges have longer wavelengths and are considered warm, stimulating colors. Blues, greens, and purples have shorter wavelengths and are considered cool, soft, soothing colors. These characteristics can be applied to specific clinical areas. A postoperative unit, for example, can promote a feeling of calmness with soft colors and soft music. A more stimulating environment created with vibrant (yet warm) colors and music may be appropriate for a geriatric unit. The effect of color on clerical tasks performed in an office were studied by Kwallek and colleagues.[29] They found that there were significantly more proofreading errors in white offices compared with blue or red offices.

Sound and Noise

Although the AHRQ[3] review of research on the relationships between working conditions and patient safety showed insufficient evidence of a definitive negative impact of ambient noise on patient outcomes, there is a movement to control environmental noise levels. Reduced noise levels have been incorporated into construction design with the use of sound-proof building materials.[25] Where noise can become a distraction (potentially affecting the accuracy of caregivers' work), noise reduction strategies have been implemented.[26]

The beneficial effects of music and other pleasing sounds (water, wind, bird songs) may be employed in the workplace. Providing music (of the patient's choice) via headsets to preoperative patients has been shown to reduce anxiety and decrease the use of pain-controlled opioid medications.[30] The resultant decreased patient anxiety level can also enhance an emotional state that is more conducive to following instructions and cooperating with the planned therapeutic intervention.

Temperature and Humidity

Few studies have been identified by AHRQ[3] on the impact of thermal stress (hot or cold) on patient safety. One study did show that manual dexterity may be impaired in a moderately cold environment.[31] Cardiac operating rooms are frequently cooled to ambient temperatures below 70° F, but studies have not been found indicating that this temperature level reduces manual dexterity. Patient and staff comfort is thought to be enhanced in thermal environments that are considered neither hot nor cold nor humid, but these are often subjective assessments. However, patient shivering should be avoided, especially in cardiac patients. Shivering increases the heart's demand for oxygen and may even induce a cardiac event.

A potential safety concern related to temperature and humidity is the issue of bacterial proliferation, but strict standards are not available. Increased temperature and humidity may increase perspiration among surgical team members, with the increased risk of perspiration droplets contaminating the surgical site. Increased humidity can cause surgical supplies to become damp, thereby increasing the growth of mold and other microorganisms. Alternately, decreased humidity may increase the risk of static electricity with a concomitant risk of fire, and may increase the level of bacteria-carrying dust.[32] The American Institute of Architects Academy of Architecture for Health recommends operating room temperatures between 68° and 73° F and relative humidity levels between 30% and 60%.[33]

Air Quality and Environmental Toxins

Properly designed and maintained environments can likely reduce a number of risks, including fire hazards, chemical exposures, infectious agents, contaminated air and water, and other environmental agents.[3] Air filtration systems and air exchanges reduce the amount of airborne pollutants. Waste disposal systems can control typical components of institutional waste (medical waste, mercury, batteries, solid waste, surgical specimens, blood and body fluid waste products). Risk assessment guidelines are available to guide construction to reduce risks for nosocomial infections.

Hospital waste management programs that attempt to reduce, reuse, and recycle waste can lower costs, lessen the amount of toxic waste, and provide a safer environment.[34] Similarly, latex-free initiatives have become increasingly widespread. Latex-sensitive individuals, whether patients or staff, may demonstrate signs and symptoms that vary from mild contact dermatitis to full blown anaphylactic shock.[35] The safety aspects of pollution/toxin reduction programs for both patients and staff are significant.

One of the most serious potential environmental hazards is fire. Concern about fires in operating rooms has prompted the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to list fire safety among the Patient Safety Goals for 2005.[36] To achieve this goal, JCAHO standards are to "educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels, and establish guidelines to minimize oxygen concentration under drapes." Fires occur when fuel, oxygen, and heat combine to ignite and produce a fire, most commonly in or on patients.[37] In the operating room and other patient care settings, staff member training and education can enhance fire safety by minimizing the possibility of igniting a fire, facilitating a rapid response to the presence of a fire, and improving the management of fires.[37]

In addition to protective activities affecting air quality, there are also proactive strategies that employ pleasing smells and aromas as part of an alternative and complementary therapy program. One medical system (see http://www.bannerhealth.com/patients+and+visitors/facilities/arizona/desert/patient+guide/healing+environments.asp ) uses aromatherapy as well as massage, music, and dog therapy to promote general well being.

Aesthetic and Educational Considerations

The effect of aesthetics is difficult to quantify; what is considered beautiful or psychologically pleasing is largely a subjective judgment. Focus group interviews and marketing surveys of patients, administrators, physicians, nurses, and other caregivers have demonstrated, however, some common themes that relate to patient satisfaction. One of these themes is that the healthcare institution's physical facilities (décor, displays, cheerfulness of the facility) are an important element in patients' perceptions of the quality of care. This perception is significant because, in the past, patient satisfaction has been attributed mainly to the clinical aspects of patient care.[24] Well groomed and well dressed staff can reflect respect for patients and visitors as well as consideration of each other. Wearing color-coded uniforms that denote the clinician's professional role or work unit can help to clearly identify caregivers and designate their work role.

Combining technological efficiency and aesthetics can be seen in the physical layout of patient rooms that reinforce feelings of safety, security, and support:

  • Construction of wood-finished cabinetry that hides medical equipment;

  • Clean, pleasant smelling work settings painted in soothing colors;

  • Natural lighting that enhances vision, fosters concentration, and provides indoor and outdoor natural views of plants, flowers, trees, and water; and

  • Artwork that inspires and nurtures the human spirit. All of these attributes reinforce the goal of providing holistic care that incorporates body, mind, and spirit.

Aesthetic considerations are even being applied to nutrition. More institutional restaurants serve nutritious and visually appealing food within a pleasing environment. Nutritional needs can also be met with greater variety through decentralized room service that expands patients' food choices, offering heart-healthy wellness cafes, and providing nutrition information as well as cooking demonstrations. Computerized monitoring of patients' nutritional intake (eg, sodium, carbohydrates, calories, and fat) can reduce errors in nutritionally sensitive patients (eg, those with diabetes).

Other environmental factors of importance are entertainment, convenience, and information. Educational resources such as video libraries and computer kiosks, interactive hands-on educational displays, health and wellness classes, and support groups provide information about illness and the therapeutic interventions designed to promote healing. Learning about allopathic and complementary therapies can provide a sense of comfort and can also educate patients about some of the risks associated with potentially harmful interactions between herbal remedies and prescription medications. Offering multiple opportunities to learn about illness and health enables patients to be more active participants in their care. This ability to learn about their situation enables patients and families to enhance their own safety by allowing them to communicate with caregivers and make more informed judgments and decisions about their care.

Many professional organizations offer educational information to consumers. The Association of periOperative Registered Nurses (AORN) , for example, has a patient safety Web site that offers updates, news releases, and other safety-related information that can educate patients and inform consumers. AORN and other organizations reflect the importance of assisting patients to learn about their conditions.