Quiet Please: Healing in Process

By Susan E. Mazer

Note: This article originally appeared in the January 2003 issue of Hospital Development magazine (www.connectinghealthcare.com/publication.asp?pub=10)

In the past decade, U.S. 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 may exceed those recommended or be inappropriate to the objectives and needs of patients and staff.

Hidden among the risks regarding hospital noise, confidentiality and privacy are sacrificed and violated more by accident than intent. Patients overhear medical diagnoses of other patients; families overhear physicians’ reports to other families; staff members overhear each other’s interactions that are assumed to be personal. Further, sounds common to suffering or trauma become the context in which patients and families undergo their own healthcare experience.

True to the concerns well stated by Nightingale 150 years ago, noxious sounds threaten clinical effectiveness. 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 and misunderstanding between family members and caregivers.

How can the sound environment of hospitals be improved? Here are some actions to take:

1. Establish a Sound Quality Committee. A good first step is to establish a multidisciplinary Sound Quality Committee. Besides people from the facility management staff, include clinical and non-clinical staff. There is no “one-size-fits-all” sound level for all hospitals or all hospital areas. Each area and department works with different patients and acuity levels; is responsible for varying tasks; has to navigate changing traffic patterns, periods and areas of congestion; and is responsible for different levels of staffing.

2. Assess the Sound Environment. The first task of the Sound Quality Committee is to do an assessment of the sound environment and document the results. This can be accomplished using an easy-to-read, portable digital decibel meter to measure the sound levels at specific areas of your hospital at different times of day. Auditory offenders might include carts, doors, cabinets, monitors, floors, communication devices, chairs, and anything else that significantly contributes to the complex orchestration of the sounds impacting patients and staff.

In addition, “peak periods” should be noted, including times of congestion, maximum and minimum activity periods, shift changes, physician rounds, and meal times. Various areas during each time period should be noted to account for impact on patients, visitors, and staff. Sounds generated from equipment should be measured at distances relative to the listener. Sound levels should be grouped according to decibel (dB) ratings and indicate the time of day at which they occurred.

If possible, try to gauge the perception of noise by patients and families through surveys or informal discussions. Look at the functional noise levels of all mobile equipment, door-closures, carts, medical monitors, and other technological sound sources. The noise factor arises in communication devices – specifically, paging systems -- when the system is overused, distorted due to aging (or malfunctioning) sound systems, and when excessive volume is required to achieve acceptable audibility.

Re-evaluate the overhead speaker systems. Add speakers where having them placed closer together may allow you to reduce the volume level; higher quality speakers and amplifiers reduce distortion, an insidious irritant. Be cautioned that use of cellular phones to replace overhead paging requires policies and protocols to avoid the equally challenging issues: overuse and lack of confidentiality.

3. Establish Sound Standards. After the data has 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 50dB, it is more effective to use the information regarding each area to determine what is appropriate.

The basis of these standards should be the documented outcomes of the assessment, including dB levels, as well as patient and staff surveys. This may involve setting comparative goals that respond to the known decibel levels, equipment, clinical areas, and times of day. A level of acceptability, i.e., one at which the equipment had only a benign impact on the environment, should be determined.

Sound levels vary as a response to a changeable “noise floor” —the level of continuous sound that characterizes an area at any given time. Competing sounds, to be perceived, must rise above this “floor.“ If an errant sound rises 30dB 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.

4. Set up Equipment Maintenance & Purchasing Standards. Once standards or goals have been set, recommendations should be made for modifying equipment, changing staff practices, and altering purchasing policies. Let vendors know -- in writing -- of the specifications for auditory impact on all equipment being purchased by the Hospital. Require that all vendors specify the auditory impact data along with all other relevant specifications when bidding on new or replacement equipment.

In addition, 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, maintenance, modification, or replacement of aging equipment where possible. The auditory impact of equipment can be reduced by 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. For maintenance equipment, such as floor buffers and vacuum cleaners, decibels should be measured and their operation schedules coordinated with the nursing staff to ensure that the auditory disturbance to patients is minimized.

5. Optimize the Use and Functionality of Patient Equipment. For patients who need them, checking and adjusting monitors to avoid unnecessary alarms reduces noise exposure and distraction. Similarly, evaluating the patient’s capacity to manage auditory stimuli helps to improve the environment. 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.

6. Re-Design for Sound Control. Since many of the building components in hospital environments that contribute to noise –- such as flooring, ceiling materials, walls, and door placement and function –- cannot be changed, consider re-designing these 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. To maintain the openness of the area, and give visual access from the nurse’s station or admitting, consider using clear plexiglass or nonbreakable glass. Use these materials for sound containment when a separate room is either not possible or desirable.

7. Make Recommendations for Ways to Enhance or Condition the Sound Environment. Environments that are too noisy have inherent risks. Environments that are too quiet are transparent, carrying other risks. Therefore, the ideal sound environment is one intentionally designed to reduce avoidable noise, minimize noise that is unavoidable, and provide positive auditory input in order to mask distractions in an otherwise quiet space.

Most of us are familiar with “pink noise,” which is a frequency-specific sound that is introduced into an environment to basically cancel out or render inaudible conversations that need to be private. Although pink noise has been shown to be effective in many workplace settings, 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. As shown in other industries, foreground music can mask other irrelevant sounds and maintain an appropriate noise floor. In hospital settings, music therapy studies have been shown to reduce the amount of requested pain medication and/or improve its analgesic effect.

In addition, 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, the most effective crossing age, gender, and cultural boundaries. There are also devices for patients to use during surgical procedures. Specific night and day programming is also a plus, as well as a 24-hour minimum of non-repetitious play.

8. Educate the Staff. Staff education, as well new employee orientation, should make the staff aware of their responsibility for maintaining an appropriate sound environment. While mandating staff 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. One U.S. hospital produced an effective educational video that demonstrated the best and worst behavioral examples regarding noise, conversations, use of pagers, and beepers.

Without a doubt, seeing and hearing from the standpoint of the patient is a great teaching tool.There are also kinder, gentler methods to give the message to visitors. Another U.S. hospital put up a stanchion of a child in a colorful nursing uniform holding one finger to her lips and saying “Shhh!” Another created signs and buttons saying “Quiet Please: Healing in Progress,” reinforcing the awareness that a hospital needs, first and foremost, to be a place of recovery.

Conclusion

An inadvertent combination and consequence of people, technology, and circumstance, the sound environment is the least controllable and most pervasive, if not invasive, of all environmental stressors in the clinical setting. It is a major factor that patients and families respond to in a healthcare crisis and a determinant in how they perceive the care and caregiver. 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 first 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.