What Is at Stake in the Sound Environment?
Imagine an institution where the staff are of the highest competence, the technology is the best and newest, the architecture and interior design are exemplary, and there is a commitment to providing the highest standard of patient care. The question remains: Do the sounds that resonate throughout the rooms and corridors reflect those same high standards?
Noise is one of the dynamic components of the hospital environment, in that it is changeable rather than fixed. Unlike the “built environment”-walls, ceilings, fixtures, furniture and flooring-these transient factors are presumed to be under the collective control of the hospital staff. Therefore, the entire organization is often judged according to its management of sound.
The suffering and trauma overheard through penetrable walls and thin curtains become the context in which patients and families undergo their own experiences. The sound environment is where the “relational temperature” of the organization is taken and where the need for restraints, requested pain medication and nursing assistant calls can be either increased or lessened. It is also an important area where the staff expresses its stress, competence, caring, compassion and concern. Therefore, leaving the sound environment to chance, or assuming it to be a random consequence of institutional care, places at risk the outcomes by which the quality of healthcare is determined and to which the hospital is committed.
If we were to describe a patient space according to sensory factors, the sound environment would easily be characterized as the least controllable and most pervasive, if not invasive, determinant of how patients and families respond to healthcare crises. It also determines how information is heard, received and interpreted.
While the modern hospital is organ-ized in pods of specialization-from cardiac critical care and oncology to radiology, orthopedics, telemetry and med-surg units-one patient together with family members might move through and experience every department. When patients' acuity is high, their adaptive capacity is low, resulting in a greater sen-sitivity to environmental stressors. Whether by accident or incident, the accumulation of noise, clutter, gossip and unwanted distraction adds up to a “prognosis-of-care,” and that, to the patient and family, is inexcusable.
The environment of care determines the sustainability of the caregiver and the resilience of the patient. Thus, we often ask the rhetorical, if not literal, question: If the environment is not itself healing, what is it doing?
Function vs Auditory Impact
Whether it is the dynamic conversation of a multigenerational family that camps out in the waiting areas and lobbies of the hospital, the bustle of activity at the nurses' station or the very functional, yet squeaky, meal cart, everyone involved in these situations means well, although they are in fact ignoring the primary objective of patient care. The traditional policy of noise abatement-historically enforced by the familiar diamond-shaped sign reading “Hospital Zone: Quiet Please”-is a myth, at best. Unable to successfully monitor and police “normal” behavior, it signifies a failed policy that is inadvertently violated from moment to moment.
In their zealous efforts to create the “meanest and leanest” ways by which staff can observe patients at a distance, medical equipment managers have contributed beeps, buzzes, pings and dings to the complex orchestration of most hospital units. While these devices have supported staff efficiency and operational effectiveness, their use hardly takes into account their cumulative sonorous impact on patients and families.
Providing an example of the conflict between functionality and auditory impact are the new remote monitors, which allow a nurse to view readings of multiple patients from each room. The advantage of this is indisputable, but with the monitoring comes the alarms triggered when the readings vary beyond set calibrated levels. Alarms beep for nonemergency readings as well as emergency ones.
To the patient who is experiencing the emergency, this is optimal. However, to the patient who is neither in an emergency nor for whom these beeps are relevant, the resulting disturbance can be disorienting and cause unnecessary anxiety. To the innocent and unknowing family member, the ongoing beeps provoke constant concern about what they mean and who is supposed to respond.
Then there are the occasions in which silence is not necessarily golden. At the quietest extreme (typically at night), all sounds, even those that might otherwise be considered inaudible, are amplified and inadvertently transmitted to unknowing ears. Conversations intended to be private travel unimpeded through the walls and corridors to disinterested parties-to those in emergency room cubicles, semiprivate rooms, ambulatory surgical centers and other similar areas. Privacy curtains protect the visual, but have no impact on the auditory. Information exchanged between physicians and nurses standing just outside of curtained beds is inadvertently overheard and often misinterpreted. The suffering of one child crying in agony from a minor injury disturbs and worsens the condition of an 80-year old man in the adjacent bed. Elsewhere, the grief and uncertainty or the private business of families and patients expressed in waiting areas are as public as they would be in a Greyhound bus station.
By the same token, unnatural periods of quiet that interrupt the normal and continuous hum of clinical activity can be frightening and upsetting. Patients need to know that staff is around, things are getting done, patients are being taken care of and, most of all, that assistance is near by, and they are neither abandoned nor alone.
Strategies for Sound Design
While it might appear daunting to try to control the “uncontrollable” sounds in the hospital, specific methodologies have been shown to lessen the negative impact of necessary noises and minimize those that are unnecessary:
1. Staff education. When asked what kinds of changes are needed to transform the current healthcare environment into a healing environment, hospital staff members have consistently provided a list that was weighted 20% toward technological factors and 80% toward behavioral factors. In fact, most of the changes called for had no cost attached other than that of publicizing changes in policy.
These changes might involve asking staff to wear soft-soled shoes; closing office doors without slamming them; making sure that conversations between staff members take place in offices or other areas with doors; closing drawers and closets carefully; and lubricating squeaky doors and windows. Education that involves the staff-both clinical and nonclinical-in maintaining responsibility for noise levels, among other elements of the environment, has without exception proven effective.
2. Setting standards in the purchase of new equipment and the maintenance of old equipment. Few hospitals have taken responsibility for establishing the maximum acceptable audio specifications for hospital equipment based on patient outcome factors. An exception, however, is Northside Hospital in Atlanta, Georgia. Once Northside's administrators decided that this was an issue to be taken seriously and one that required addressing definitive measures, they established a multidisciplinary Sound Quality Committee whose task it was to arrive at a protocol for initial assessment of the sound environment, setting new standards and making improvements. More specifically:
Step 1: Initial assessment. In their efforts to document exactly how “loud” was “loud,” researchers at Northside Hospital purchased digital decibel meters and visited specific areas of the hospital at different times of day, accurately assuming that noise levels varied over time. All in all, they determined the decibel levels of 238 pieces of equipment, including all 59 heavy rolling carts. The long list of small and large equipment included carts, doors, cabinets, monitors, floors, communication devices, chairs and anything that significantly contributed to the complex orchestration of the sounds impacting patients and staff. Equipment noises were meas-ured at distances relative to the listener.
The investigators grouped sound levels according to dB ratings, indicating the time of day at which they occurred. For instance, at 1:00 p.m. they found the pneumatic tube and paging system rated at over 80 dB (and often increased past 90 dB). Late in the evening, after 9 p.m., they found printers, elevator buzzers, trash carts rolling at high speed and the ice machine rated even higher. In the afternoon, they found monitors, the nurses' station, food carts, groups of five people with pagers and other typical scenarios to vary between 70 and 79 dB. Furthermore, they reviewed their patient satisfaction scores specifically relating to noise to get a baseline of patient ex-perience.
Step 2: Setting new standards. As a result of these collected data, the Sound Quality Committee established a basis for modifying equipment, staff practices and purchasing policies. It determined a level of acceptability, i.e., one at which the equipment had only a benign impact on the environment. The goals set were to reduce the decibel levels as much as possible (preferably to 50 dB) and raise their patient satisfaction scores by 10%.
Step 3: Improvement measures. After evaluating many pieces of equipment, the committee determined that much of the noise caused by the auditory predators could be significantly reduced by mechanical adjustments, maintenance or purchasing new equipment where possible. Methods used for reducing the auditory impact of equipment included changing wheels, applying padding, repairing or replacing door bumpers, using thicker carpeting and installing effective acoustic ceiling tiles. Because the pneumatic tube system, an old and still functional technology, caused alarm to ICU patients within six feet of its sound, the decibel level was brought down to 50 dB (more than 400% quieter) by the careful use of padding.
After two years of diligent work, Northside improved its patient satisfaction levels on this issue by 10%. However, not every problem was resolved. In a storage room where wheelchairs and gurneys were kept, the door slammed on a regular basis, not only resonating through the hall, but also shaking the walls of adjacent offices. Since priority was given to patient care areas, and this particular door only impacted staff, it was noted but postponed. Addressing this remains on the “things to do” list of the individual department.
In fact, the committee has been discharged and its noise control responsibility turned over to the individual department heads, holding them accountable for sustaining a therapeutic sound environment and all of its various components within their boundaries.
The challenge and success at Northside Hospital can be achieved at most hospitals in the United States. In site visits to hospitals in various regions of the country and ranging in size from 35 to 1,200 beds, it was not uncommon to find basic mechanical problems to be the cause of ongoing annoyances in otherwise quiet areas. For example, most hospitals have refrigerated soft drink and ice machines that “rattle and roll” at a pitch of 85 to 90 dB. Being conscious of their location and using alternative methods of refrigerating products in public areas are worth considering. Some hotels, for instance, have put vending and ice machines in isolated cubicles specifically to contain the mechanical rumble. Where padding or insulation is not a workable solution, the use of decorative baffles of plexiglass or other appropriate materials might be considered, to control and direct the noise coming from these machines.
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 safety and operation. For maintenance equipment, such as floor buffers and vacuum cleaners, decibels should be measured and their use schedules coordinated with the nursing staff to ensure that the auditory disturbance to patients is minimized.
Staff education, as well as new employee orientation, should make staff aware every day of where they are and remind them of their accountability for maintaining a therapeutic environment.
3. Make qualitative decisions about which equipment is needed for which patient, taking into consideration auditory impact. For patients who need them, checking and adjusting monitors to avoid unnecessary alarms will undoubtedly reduce unnecessary noise exposure. Similarly, evaluating the patient's capacity to manage auditory stimuli will help improve the environment. Judiciously using barriers, such as doors and curtains, to provide both visual and auditory protection will begin the process of controlling sounds that resonate from one area to another.
It is not uncommon for a noisy cart that is still operational to be used for years without the staff addressing this as a malfunction, because the loudness of the wheels does not impair their functioning. Whether functional equipment becoming noisy is a problem is therefore ambiguous for staff unless specific standards are set for identifying squeaks, rattles and noisy operations that mandate repair.
4. Model sound-sensitive behavior. While mandating behavior has long been known to be the least effective method of managing noise, behavioral standards should nevertheless be modeled and extended organizationally. This includes standards governing private or confidential discussions that take place in public areas; use and methods of paging; and use of cell phones, nurse call systems and the telephone.
There are also kinder, gentler methods. Riverside Hospital in North Carolina greets staff and visitors with a picture of a child in a colorful nursing uniform holding one finger to her lips and saying “Shhh!” New signs saying “Quiet Please: Healing in Progress” have also reinforced awareness that a hospital needs first and foremost to be a place of recovery.
5. “Pink noise”: A good idea that belongs elsewhere. In a concerted effort by acoustic engineers to find a method of protecting privacy and confidentiality in open-concept offices, they invented what is now called “pink noise,” a frequency-specific sound that is introduced into an environment to basically “cancel out,” or render inaudible, conversations that need to be private. Pink noise sounds similar to wind or breaking surf. A pink-noise generator is installed and broadcasts its sounds through an overhead speaker system (at considerable expense in hardware and labor). While shown to be effective for some industrial settings, in the hospital environment this technique has caused problems.
In an initial effort to reduce the effect of ambient noise in its intensive care unit, Bergen-Mercy Medical Center (Omaha, Nebraska) initiated a pilot study on the use of pink noise. The study had to be aborted when it became apparent that the technology rendered sounds that were not only inaudible, but also nondirec-tional. Consequently, the observation of or response to patient alarms was difficult, because staff could not accurately and quickly locate the alarming device.
6. Set an audibility standard. For centuries, churches have demanded appropriate respect and behavior. When in a sanctuary or chapel, most people, whether visitors or parishioners, neither raise their voices nor speak or act disrespectfully. In the same way and for similar reasons, acceptable auditory levels in a hospital should be established by design and sustained by respect.
Henry Ford Hospital in Detroit, Michigan; St. Charles Medical Center in Bend, Oregon; Oconomowoc Regional Cancer Center in Oconomowoc, Wisconsin; and Sacred Heart Center of Eugene, Oregon, are among a growing number of hospitals that have invested in custom-distributed sound systems that provide music in alignment with the mission of healing. These systems are parallel to but distinct from their emergency paging systems; they are of higher quality, full-frequency and acoustically designed to support listening over many hours. The music adds an element of comfort and softens the isolation often experienced in otherwise impersonal corridors.
7. Design hospital areas for sound control. If we consider hospital design as a means of supporting a healthy sound environment, then we begin evaluating structural and design components that have auditory impact, such as flooring, ceiling materials, and door placement and function.
A few thoughts: While setting up opaque sound baffles is not a desirable solution to auditory control, the use of transparent barriers for waiting areas and other large rooms where conflicting activities take place is a workable alternative. In a waiting area, if the objective is to provide television access for some visitors, offer a quieter space for others. To maintain the openness of the area and give visual access from the nurses' station or admitting, clear plexiglass or unbreakable glass is worth considering. The goal in using such materials is sound containment when a separate room is either not possible or not desirable.
A case in point: The Karmanos Cancer Institute in Detroit, Michigan, designed its bone-marrow transplant unit using glass walls as a means of creating a feeling of openness, while providing auditory privacy for families and physicians during conferences. Privacy curtains that can be drawn when needed offer flexibility in visual privacy. As a general observation, contemporary office designers have long used glass walls in large conference rooms to maintain a sense of spaciousness and comfortable functionality.
The auditory environment authenticates the values and mission of the hospital staff, both individually and collectively. Pervasive and transparent, it demands conscious attention and accounts in great part for the experience of the patient beyond any clinical protocols provided. Staff education is important to sustaining a therapeutic environment, but so is a commitment to standards and policies that make a healthy sound environment a priority, with its own clear measures of accountability. The sound environment is a key factor in how the community evaluates the standards of professionalism, care and concern, and on which the reputation of the hospital rests. HCD