Human factors examines how people interact with tasks, tools, technology, other people, and the work environment. In healthcare improvement, it helps a team understand why a process is easy or difficult to perform safely under real conditions.
For nurses, the focus includes physical demands, attention, memory, workload, communication, layout, and equipment design. The question is how to make the work fit human capabilities and limitations, rather than assuming that additional vigilance will solve every problem.
Study the task as it is performed
AHRQ's human-factors primer describes analysis of component tasks, physical and skill demands, mental workload, team dynamics, and the environment. Observe the actual sequence and ask staff to explain what they are trying to accomplish.
Include interruptions, competing tasks, and conditions outside a quiet demonstration. A supply location that works during a planned test may be difficult to reach when equipment fills the room. A label that is clear on a desk may be hard to distinguish in ordinary lighting.
A workaround can be evidence that the designed process is difficult to use. Investigating the reason does not mean endorsing an unsafe shortcut. It helps identify what needs to change so that staff can follow a safer process reliably.
Match the intervention to the problem
Education may be appropriate when people lack knowledge, but it does not repair an unreadable display or incompatible equipment. AHRQ discusses usability testing and design features that prevent unwanted actions as human-factors approaches.
Consider whether the process can be simplified, information made easier to distinguish, equipment standardized where appropriate, or a necessary check placed where the decision occurs. Any change should be tested for new problems. A design that prevents one error can obstruct needed work if the team's assumptions are incomplete.
Illustrative equipment-layout test
In an illustrative simulation, nurses look for a frequently used item on a supply cart. Similar packages are stored together, and the labels are difficult to see from the normal working position. The team tests clearer organization and labeling with the people who use and restock the cart.
It observes retrieval errors and restocking mistakes as well as time. The example is not a recommendation to rearrange clinical supplies without approval. It shows how a task-based test can examine a design change before routine use.
Keep the system in view
AHRQ's systems approach emphasizes conditions that contribute to error, including policies, schedules, equipment, and organizational decisions. A bedside difficulty may require action from purchasing, facilities, or technology teams.
Document the context of testing and the limits of the findings. A change that helps one user group may create difficulty for another. Seek human-factors expertise for complex or high-risk designs rather than relying solely on informal preference surveys.
The aim is a process that supports safe performance during ordinary work, including predictable human variability. Understanding the environment around an action is essential to choosing a useful improvement.
To see where an interface or workspace affects a task, map the process with the people who perform it.
Related
Failure Mode and Effects Analysis
Reliability and Standardization in Nursing Work
Sources
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AHRQ PSNet: Human Factors Engineering (accessed 2026-09-17).
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AHRQ PSNet: Systems Approach (accessed 2026-09-17).