In the past decade, US healthcare designers have established a new industry benchmark in which the physical environment is a major factor in defining quality healthcare services. Ongoing research has verified that the environment of care has a direct relationship to patient medical outcomes, as well as patient and staff satisfaction. However, while hospitals have used architecture, interior design, and other disciplines to be able to provide safer and more effective environments, noise remains a dilemma as yet unsolved by regulations, building codes, policy, or practice.
Increased patient populations, communications technologies, remote monitoring devices, televisions, pagers, beepers, and buzzers render the clinical sound environment uncontrollable. At any given time at most hospitals anywhere in the world, noise levels are likely to exceed guidelines or be inappropriate to the objectives and needs of patients and staff.
Hidden among the risks regarding hospital noise, confidentiality and privacy are sacrificed more by accident than intent. Patients overhear medical diagnoses of other patients, families overhear physicians' reports to other families and staff overhear each other's interactions. Furthermore, sounds of suffering patients become the context in which other patients and families undergo their own healthcare experience.
Regardless of cause, noise can increase use of requested pain medication, heighten anxiety levels, and weaken safety protocols. It also contributes to staff stress, medical errors and miscommunication.
Eight Steps to Sonic Heaven:
So how can the sound environment of hospitals be improved? Eight steps may be suggested to help control the problem:
Establish a Committee
A good first step is to establish a multidisciplinary sound quality committee. Besides people from the facilities management staff, it is also important to include clinical, as well as other non-clinical staff. There is no 'one-size-fits-all' sound level for all hospitals or all hospital areas.
Access the Sonic Environment
The first task of the sound quality committee is to make an assessment of the sound environment. An easyto-read, portable digital decibel meter can measure the sound levels at specific areas of the hospital to account for impact on patients, visitors, and staff. Sounds generated from equipment should be measured at distances relative to the listener.
The noise factor arises in communication devices, specifically paging and sound systems. Reevaluate the overhead speaker systems and note that use of mobile phones to replace overhead paging requires policies and protocols to avoid issues of overuse and lack of confidentiality.
Establish Standards
After the data have been collected, the sound quality committee should establish qualitative sound standards that can be measured and maintained. While the recommended standard is an average of 50 dB, it is more effective to use the information regarding each area to determine what is appropriate.
Sound levels vary as a response to a changeable 'noise floor - the level of continuous sound that characterises an area at any given time. If an errant sound rises 30 dB above the noise floor, it can cause a ,startle response.' However, if the sound level is too low, third-party conversations and unavoidable sounds become distractions if not irritants. Therefore, when goals are set, both the optimum continuous volume level and the maximum level for incidental sounds must be taken into account.
Set up Maintenance and Purchasing Standards
Once standards or goals have been set, recommendations should be made for modifying equipment, changing staff practices, and altering purchasing policies. Require that all vendors specify the auditory impact data along with all other relevant specifications and repair and maintenance policies should be reviewed to include quieter operation.
Much of the noise caused by the auditory predators in the hospital can be significantly reduced by mechanical adjustments, such as changing wheels, applying padding, repairing or replacing door bumpers, using thicker carpeting, and installing effective acoustic ceiling tiles.
Purchasing new equipment based not only on function and price but also on auditory impact is another possible approach. Biomedical engineering departments that evaluate all patient care equipment prior to its use should be testing for its auditory impact, as well as for safety and operation.
Optimize the Use and Functionality of Equipment
For patients who need them, checking and adjusting monitors to avoid unnecessary alarms reduces noise exposure and distraction. Judiciously using barriers, such as doors and curtains, to provide both visual and auditory protection begins the process of controlling sounds that resonate from one area to another.
Redesign for Sound Control
Since many of the building components in hospital environments that contribute to noise (such as flooring, ceilings, walls, and door placement and function) cannot be fundamentally changed, consider re-designing areas to provide quiet spaces.
Instead of setting up opaque sound baffles, use transparent barriers for waiting areas and other large rooms where conflicting activities take place. In a waiting area, if the objective is to provide television access for some visitors, then offer a quieter space for others.
Make recommendations for ways to enhance or condition the sound environment. Environments that are too noisy have inherent risks while those that are too quiet carry other risks. Therefore, the ideal sound environment is one intentionally designed to reduce avoidable noise, minimise noise that is unavoidable, and provide positive auditory input in order to mask distractions in an otherwise quiet space.
Readers may be familiar with 'pink noise: a frequency-specific sound that is introduced into an environment to render private conversations inaudible. Although it has been shown to be effective in workplaces, it is not appropriate for hospitals as it makes it difficult to locate patient alarms and is itself a distraction.
Enhancing the sound environment with music is a viable option if the music is carefully selected and used appropriately. In hospital settings, music therapy studies have been shown to reduce the amount of requested pain medication and/or improve its analgesic effect. When used appropriately, music acts as an effective audio-anxiolytic, improving restfulness and the quality of sleep, and inducing relaxation.
There are several music programming alternatives for patient television on the market that cost pence per bed, per day. Important considerations for this type of programming include choice of music and imagery, which should cross age, gender, and cultural boundaries.
Educate Staff
Staff education, as well new employee orientation, should make the staff aware of their responsibility for maintaining an appropriate sound environment This remit would include standards governing private or confidential discussions that take place in public areas, the use and methods of paging, and the use of cell phones and nurse call systems.
One enlightened US hospital produced a highly effective educational video that demonstrated the best and worst behavioural examples, but there are gentler methods to give the message to visitors. Another hospital facility in the US put up an ornamental post, or stanchion, of a child in a colourful nursing uniform holding one finger to her lips and saying 'Shhh!' Another created signs and buttons saying 'Quiet Please: Healing in Progress.'
Conclusion
The sound environment is the least controllable and most pervasive, if not invasive, of all environmental stressors in the clinical setting. Whether trying to control breakthrough pain caused by cancer or agitation caused by other conditions, the sounds that surround patients and caregivers impact bottom-line effectiveness.
The long-term success of the eight steps described above are dependent upon continuing diligence. Re-assess the sound environment; re-evaluate the effectiveness of methods being used; maintain equipment as it ages; pay attention to patient satisfaction scores specific to the sound environment; and regularly include the quality of the sound environment as an agenda item in staff management meetings, as well as other staff meetings. This will assure that the quality of care will be well represented by what is heard as well as seen.
MORE INFORMATION
Susan E Mazer is founder and president of Healing Healthcare Systems (HHS), and co-author of "Sound Choices: Using Music to Design the Environments in Which You Live, Work, and Heal".
This article first appeared in the July, 2003 issue of Hospitality Design Magazine. Visit their website at www.hdmag.com
Music without words means leaving behind the mind. And leaving behind the mind is meditation.
Meditation returns you to the source. And the source of all is sound. — Kabir
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