In the current climate of demographic and economic change, we need to improve quality of care by focusing on the safety and health of healthcare workers
Anke Roos-Mink MSc
Mark P Mobach PhD
School of Facility Management, Hanze
University of Applied Sciences Groningen,
The Netherlands
Email: [email protected]
Noise is omnipresent in human life. Under specific conditions, for instance during long unprotected working periods near loud machines, it can potentially create hearing loss. But in most day-to-day situations noise is an unpleasant sound that causes discomfort. At stages where humans are at their most vulnerable, such as in healthcare, discomfort can hinder or frustrate recovery from illness or an operation. As early as the second half of the 19th Century Florence Nightingale recognised that: “unnecessary noise is the most cruel abuse of care which can be inflicted on either the sick or the well”.1
Noise levels in hospitals
From the 1960s the influence of noise and its effects on patient and staff discomfort has been studied scientifically. The World Health Organization (WHO) guidelines for noise levels in hospitals (1999) has given a boost to studies with a focus on sound levels.
These studies showed that sound levels in healthcare environments are above WHO guidelines, regardless of the time of day or the day of the week.2 Moreover, a trend was observed with increased levels during both day and nighttime over the last 45 years.2 Other studies, in which qualitative research, direct observation, and sound level measurements were combined confirmed these observations, but also showed that sound-reducing measures can be taken to improve the current situation at hospitals.
Sources of noise
The studies report two kinds of sources of noise: human-related and technical-related sources of noise (see Table 1). Human-related sources comprise noises that stem from speech, fellow patients, and staff or visitors. Technical-related noise finds its source in the use of medical equipment and the use of facilities.
Imagine being a patient and lying in a hospital room. The sound of the human voice is everywhere. For instance, you may be able to listen in on a sensitive conversation between hospital staff and a fellow patient in your room or just amongst staff about yet another patient in your room. There may also be conversations between fellow patients and their visitors or voices from a television programme. New patients may be coming in. You may also be exposed to an intercom and a paging system. Moreover, there may be talking in the hallway and perhaps a bit more distant: noises of socialising working staff at the nurses’ station.
Furthermore, there may be sounds of other patients in your room. They may snore. They may be bored and drum their fingers persistently, or walk back and forth from the lavatory to bed.
In addition, nurses are working around the clock moving equipment, replacing or moving beds, opening or closing drawers or clothes chests and keeping track of their patients with the occasional result of falling objects such as patient charts. At certain times they help with the moving of chairs and tables for visitors.
And although the sound of the human voice is bothersome enough, technical-related sounds are everywhere as well. When you try to find a comfortable position, the hospital bed squeaks. In order to create a suitable indoor temperature, the air conditioning is blowing. Further down the hall nurses are working with the printer or using the telephone.
Imagine being this patient and having to sleep for energy restoration and physical recuperation after surgery.
Effects of noise on human wellbeing
The studies revealed that extended noise pollution might cause auditory and non-auditory disorders, such as cardiovascular and physiologic effects that can also affect mental health.
Cmiel et al. reported that noise is a primary casue of sleep deprivation and disturbance among patients and it increases their anxiety and decreases their confidence in the clinical competence of the staff.3 Hodge et al. measured high noise levels during surgery, which made communication difficult and sometimes impossible.4 In addition, communication and concentration were also disrupted by unnecessary background conversation. Topf et al. positively related noise-induced occupational stress to burnout of critical care nurses.5
Recapitulatory, unwanted sound negatively affects patient outcomes, caregiver effectiveness and caregiver wellbeing. Therefore it is very important to keep the noise levels down in hospitals.
Noise-reducing measures
Now that we know the sources of noise and their potential negative effects, what can be done about it? Basically it can be split into two groups: 1) measures to buy products that make less noise and 2) measures to design the facilities in such a way that the source is isolated.
From the sources of noise we have learned that the smallest items can make disturbing sounds: the opening or closing of drawers or clothes chests, the closing of litter bins, and the moving of chairs and tables. One way to solve these problems is to purchase products that create less noise. For instance, litter bins with hard material contact create more noise than with soft materials.
However, it is rare that the procurement of litter bins is being evaluated in such a way. Mostly, it is being evaluated with costs: price, maintenance, and operations. Furthermore, although the maintenance is being evaluated, the necessity of maintenance does not depend on the sound levels the equipment produces.
A more complex and time-consuming but very effective approach is through facility design. For instance, conversations can be relocated. A family room would seclude visitors’ talking, a well positioned nurse station would mitigate bothersome socialising, an admittance room would reduce speech noise sources as well and a single-patient room would eliminate all bothersome sounds created by other patients including the use of the television.
Patients and staff could also benefit from a levelled floor and sound absorbing materials on the walls or ceiling.
All human-related and technical-related sources of noise (see Table 1) that currently negatively affect patients and staff could be relocated, reduced or eliminated with these two noise-reducing measures that are related to the field of facility management.
Role of facility managers
Previous research showed the urgency for reduction of noise sources at hospitals, because WHO guidelines are hardly ever met and noise levels affect both patient and staff wellbeing. This paper seeks to explore the role of facility management (FM) in this area with the question: “In what way can facility management contribute to the decrease of hospital noise?”.
Facility managers can reduce noise in two ways:
- By smart procurement of sound-reducing equipment.
- By facility designs that isolate potential sources of noise.
Scientific research with the use of smart procurement or facility design interventions of, for example, Altuncu et al. showed that with installing sound absorbing panels in isolettes, the average sound levels decreased by 4dB(A).6 Connor et al. researched a more extensive intervention where soft door closers were installed, rubber transitions between carpet and tile flooring at all doorways were removed, television and phone volumes were reduced, designated report areas were relocated away from patient rooms and patient care activities were coordinated.
The result was a decrease of average sound levels by 8.9dB(A).7 Krueger et al. researched an extensive facility design intervention where ceilings were lowered by four feet, the square footage was increased by 250 square feet (creating a rectangular environment instead of a horseshoe configuration), the heating, ventilation and air conditioning systems were designed with sound attenuation, ceiling tiles with a high sound absorption rating were placed, monitor alarms were placed away from the wall, the doorway entrances were widened, computers were placed at each bed space and knee-controlled sinks were replaced with electronic sinks. This resulted in a decrease of average sound levels of 4dB(A).8
Conclusion
Although the studies reported a decrease in sound levels when applying the sound-reducing measures previously mentioned, they cannot be simply copied and implemented in all other hospitals. The problem is that every hospital is different and although there are similarities in noise sources, the specific situation always needs to be taken into account.
However, every hospital has a facility manager that could be a powerful source for change. If all facility managers study the current situation at their hospitals and include both patient and staff experiences, most distressing noises can be identified and facility design interventions could be carried out. Moreover, a combination of these findings could create new guidelines for facility managers within hospital settings.
Further research
Current studies focus on advancements of wellbeing for patients and staff. However, it is yet unclear in what ways it may be financially beneficial.
In addition, the correlation between hospital noise and medical errors (accuracy rates of surgeons or communication errors caused by hospital noise for instance) or the long-term effect of hospital noise on staff (deafness of surgeons for example) can be study subjects.
Moreover, additional research regarding the experience of both patients and staff with respect to noise sources should be conducted. Previous research focused solely on noise source ranking, but it lacks a comparison between the actual sound levels and patient and staff experiences.
Finally, environments such as ICUs and NICUs were well researched, but the expectations of meeting the WHO guidelines are low. FM interventions are necessary at these environments, because the wellbeing of patients and staff can be improved easily. This allows FM to advance hospital healthcare with relatively simple but very effective measures and to improve the added value of FM.
References
- Nightingale F. (1860). Notes on nursing: what it is, and what it is not. New York: D Appleton and Company.
- Busch-Vishniac I et al. Noise levels in Johns Hopkins hospital. J Acoust Soc Am 2005;118(6):3629–45.
- Cmiel CA et al. Noise control: A nursing team’s approach to sleep promotion. Am J Nurs 2004;104(2):40–8.
- Hodge B, Thompson JF. Noise pollution in the operating theatre. Lancet 1990;335(8694):891–4.
- Topf M, Dillon E. Noise-induced stress as a predictor of burnout in critical care nurses. Heart Lung 1988;17(5):567–74.
- Altuncu E et al. Noise levels in neonatal intensive care unit and use of sound absorbing panel in the isolette. Int J Ped Otorhinolaryngol 2009;73(7):951–3.
- Connor A, Ortiz E. Staff solutions for noise reduction in the workplace. Perm J 2009;13(4):23.
- Krueger C, Schue S, Parker L. Neonatal intensive care unit sound levels before and after structural reconstruction. Am J Matern Child Nurs 2007;32(6):358–62.
