Speaking With Susan E. Mazer, President, Healing Healthcare Systems

Note: This article originally appeared in the July/August 2002 issue of Facility Care magazine (www.facilitycare.com).

Facility Care: What factors cause unsatisfactory noise levels in healthcare facilities?

Susan Mazer: Modern hospitals are highly orchestrated environments. The sounds in today’s facilities include not only the sounds of illness, pain, concern, grief, fear, and (in the case of new births) joy, but also machines, paging systems, cell-phones, beepers, computers, carts, doors, televisions, elevators, people, more people, and still more people. As the number of people in facilities increases, so follows the noise level. As the noise floor rises, so do the collective voices that rise above the din. In fact, the “Lombard effect” documents that people will each speak 15dB or 150 percent louder than the background noise to be understood. The louder the dialogue, still louder the response.

In regards to the quality of the sound environment, I have not yet heard of “noise levels in healthcare facilities as being “satisfactory.” Rather, they tend to be experienced as either tolerable or intolerable. Furthermore, each person present in the hospital has differing levels of acuity and hearing sensitivity that determines whether those levels of tolerance change. For patients and family members, second-hand sounds irrelevant or inappropriate to their situation are intolerable next to the same sounds being of primary import to those directly involved. Similarly, for staff, noises distracting from the task at hand or agitating their patients is intolerable . Florence Nightingale stated it perhaps most accurately in Notes on Nursing, “Any noise that causes expectation and apprehension does the patient harm. Therefore, unnecessary noise is the cruelest absence of care.”

There are as many avoidable sounds as there are those unavoidable. However, under the pressure of the moment and without definitive policies and practices that establish sound levels as a determinant in the quality of care, all sounds are a potential threat to the quality of care. Therefore, it is the overall collective impact that determines whether the auditory environment is supportive or hostile to the needs of patients and families and, as well, to the staff.

Facility Care: What kinds of strategies can be used to create a more therapeutic auditory environment?

Susan Mazer: The first strategy is assessment -- taking account of everything that is heard by patients, staff, and visitors. Listen and measure (with decibel meters) both areas and equipment, including as a factor the distance from the sound source, location, and time of day. Establish in each area what is acceptable, distinguishing according to the activities and population effected. For instance, an ICU at 10 p.m. would necessarily have different requirements than a cafeteria at noon.

Since technology has introduced sounds that are now both common and required for the functioning of acute care settings, it is difficult to establish a universal one-size-fits-all standard for “quiet.“ . Adding together the bottom-line mechanistic and electronic noise, necessary conversations, human movement, and other activities, it will be as obvious that when the right balance has been achieved as it will be when the ambience has become overbearing.

Using both qualitative and quantitative measures, determine the appropriate standard for volume levels by measuring the decibel levels when the noise level is a particular area is acceptable. Then, measure the level when it is not optimal, noting the auditory offenders (people, meals, carts, vacuum cleaners, paging, etc.).

Once decibel standards have been established, hold manufacturers and vendors accountable for the auditory impact of their equipment in the same way as other safety and efficiency factors. Again, take into account where the equipment is being used and who is impacted. Institute defined protocols for maintaining equipment, including assessment, repair, and re-assessment to minimize, if not eliminate, noises that not part of the functionality of the equipment (i.e., the squeaky wheel or slamming door).

Similarly, evaluate and set standards for people-noise, including both necessary and unnecessary conversations and communications. It is as important to provide places for the staff to speak with each other as it is for patients and families not to be subject to those communications. The veil of confidentiality works in all directions. Set policies and protocols for use of paging, pagers, and cell phones, each of which can be the inadvertent cause for breach of confidentiality and privacy, as well as be a source of distraction. Where possible, provide protection between patients and the staff. Use plexiglass or other transparent sound barriers that provide line-of-sight access and prevent line-of-sound exposure.

Facility Care: How does environmental design assist in the healing process?

Susan Mazer: Perhaps a more pointed question is how poor design prevents or impairs the recovery process. When patients are taken out of their home environment and placed in a hospital, is the environment of care more beneficial to the patient or more convenient to the caregiver? The healing process is not just the body’s self-repair, but involves perception and response on every sensory level, each adding to the outcome of the clinical protocols. Therefore, the environment of care must be itself a therapeutic protocol, lest it become a risk factor.

Environmental design objectives should focus on impact and outcome, with the needs of both patients and caregivers taken into account. The hospital serves the patients and staff most effectively and efficiently when energies are not dissipated in the process of adapting to hostile setting, The interaction between a patient and the environment of care impacts everything from physiological restoration to emotional and mental resilience and balance. Environmental design adds intention to function, a practice that reflects the long tradition of both medicine and nursing, and makes obvious the levels of competence and excellence being practiced.