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ENVIRONMENTAL QUALITY AND HEALING ENVIRONM ENTS:
A Dissertation
by
DEBRA D. HARRIS
D O C TO R OF PHILOSOPHY
December 2000
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ENVIRONMENTAL QUALITY AND HEALING ENVIRONMENTS:
A Dissertation
by
DEBRA D. HARRIS
D OCTOR OF PHILOSOPHY
. Bame S. Haberl
(Member) (Member)
Thomas L. McKittrick
(Head of Department)
December 2000
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ABSTRACT
The purpose of this study was to investigate the impact of flooring finish
research focused on the flooring finish materials in telemetry unit patient rooms
evaluating interior finish materials. The objectives are: (a) to measure physical
Environmental Quality (IEQ) index; and (b) examine the IEQ index as it relates
to their environment.
The results found that healthcare staff preferred V C T over carpet for the
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flooring choice in patient rooms citing ease of maintenance as their reason.
attractive, have better odor, ventilation, air movement, and fresher air. Staff
perceived rooms with carpet to be more comfortable and have less noise and
patient rooms with V C T to be more clean, have better ventilation and fresher air,
had a higher level of glare and a higher level of bacteria in the air samples. No
patient rooms were consistent with patient and staff preferences, physical
the material, its impact on the environmental conditions of the room, and the
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the effect of carpet on the indoor relative humidity, and exposure to volatile
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ACKNOWLEDGMENTS
This dissertation would not have been possible without the collective help
and support from many people. First, I would like to thank Dr. Mardelle Shepley
for her guidance, patience, and nurturing spirit that so many students have
benefited from over her years at Texas A&M University. W hen I met Mardelle at
a conference in New York in 1995 after her research presentation, I knew that I
Bame provided her unwavering support, ethics, and guidance during my pursuit
of an academic future. Dr. Louis G. Tassinary deserves many thanks for many
design and analysis of my study, but his gentle support at those times when the
process became overwhelming will forever leave me indebted to him. Dr. Jeff
analysis, but also for his practical knowledge, honesty, and sense of humor.
Finally, I would like to thanks to Dr. James Christiansen for agreeing on short
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Thanks also to Dr. Donald Sweeney, who opened the door for me with an
special thanks goes to Dan Buche, Executive Vice President at St. Joseph
Regional Health Center for providing access and financial support for this study;
Al Smith and Tim Roberts for providing information and access to the facility
Watkins Hamilton Ross, provided plans, specifications, and support for setting
up the research study. The project team included Mark Heitkamp, AIA, Amy
of the patient rooms was a big concern. With limited financial resources, this
study would have not been possible without the generosity of those who
entrusted their equipment to me. I am indebted to the following people for the
loan of their equipment: Jeff Haberl, Lou Tassinary, Jim Long from SKC
Incorporated, and Homer Bruner and Charles Darnell from the Physical Plant at
The financial support from St. Joseph Regional Health Center, the
Wom en’s Faculty Network provided the necessary resources for the completion
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A special thanks goes to the participants in this study. Healthcare staff
participants, I had two assistants to help with the Behavioral Mapping Study. I
would like to send a heartfelt thanks to Clara Norton and Kristy Walvoord for
I would also like to thank a few friends and family for going beyond the
call of duty: Dianne Kett and Matt DeWolfe for their encouragement and
brownies; Denise Sechelski for her knowledge, guidance, and especially her
friendship; Tammy Elliott for her patience and assistance with learning to love
Adobe Pagemaker; Robin Abrams for her friendship and her generous offer of
her home when I need a place to stay; Sheri Smith for her friendship and
opinions, and humor; and finally, my parents for their support, prayers and
generosity of spirit.
Last of all, I would like to thank my husband, Matthew Harris, for his
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TABLE OF CONTENTS
Page
ABSTRACT.......................................................................................................................... iii
TABLE OF CONTENTS..................................................................................................... ix
LIST OF TABLES................................................................................................................xii
CHAPTER
1.1 Introduction........................................................................................... 1
1.2 Human Behavior and Healthcare Environments......................... 5
1.2.1 General Background......................................................... 5
1.2.2 Healthcare Staff..................................................................7
1.2.3 Patients.............................................................................. 11
1.3 Environmental Quality...................................................................... 16
1.3.1 Flooring Materials............................................................ 17
1.3.2 Lighting..............................................................................32
1.3.3 Acoustics.......................................................................... 40
1.3.4 Indoor Environmental Quality........................................49
1.4 Theory and Methods......................................................................... 71
1.4.1 Applied Research.............................................................74
1.4.2 Indoor Environmental Quality Index............................. 77
1.4.3 Behavioral Mapping.........................................................78
1.4.4 Survey Design.................................................................. 80
1.4.5 Multi-method Research Design...................................... 82
1.5 Sum m ary........................................................................................... 84
11 RESEARCH M E TH O D O LO G Y ..........................................................................87
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TABLE OF CONTENTS (continued)
CHAPTER Page
3.1 Analyses...........................................................................................127
3.1.1 Behavioral Mapping Study........................................... 128
3.1.2 Healthcare Staff and Patient Surveys........................ 128
3.1.3 Indoor Environmental Quality Study.......................... 130
3.2 Descriptive Results.........................................................................130
3.2.1 Properties and Characteristics of the
Flooring Materials..........................................................131
3.2.2 Description of the Patient Rooms...............................133
3.2.3 Characteristics of the Patients.................................... 136
3.2.4 Characteristics of the Healthcare Staff......................138
3.3 Hypotheses Results........................................................................141
3.3.1 Hypothesis 1: Environmental Conditions and
Floor Type........................................................................141
3.3.2 Hypothesis 2: Patient Preferences............................158
3.3.3 Hypothesis 3: Patient Perceptions............................ 159
3.3.4 Hypothesis 4: Healthcare Staff Preferences..........162
3.3.5 Hypothesis 5: Helathcare Staff Perceptions........... 164
3.3.6 Hypothesis 6: Amount of Time Staff and
Visitors Spent in Patient Rooms..................................164
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TABLE OF C ONTENTS (continued)
CHAPTER Page
4.1.4
Amount of Time Healthcare Staff and Visitors
Spent in Patient Rooms................................................ 180
4.2 Implecations of the Findings.......................................................... 181
4.3 Practical Applications..................................................................... 187
REFERENCES................................................................................................................ 200
APPENDICES.................................................................................................................. 209
APPENDIX G ...................................................................................................................234
APPENDIX 1.....................................................................................................................250
VITA................................................................................................................................... 256
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xii
LIST OF TABLES
TABLE Page
3.4 Ventilation air changes per hour for the six patient rooms............................ 146
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LIST OF FIGURES
FIGURE Page
2.5 Alnor Velometer used to measure air flow rates in the patient rooms....115
2.10 Sample sites located on the floor and reflected ceiling p la n s ................125
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xiv
FIG U RE Page
3.2 Healthcare staff and non-staff visitor traffic in patient room s............... 134
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XV
FIGURE Page
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1
CHAPTER I
1.1 INTRODUCTION
The purpose of this study was to investigate the impact of finish materials
The investigation’s specific context was the healthcare architecture in six patient
rooms of the Telemetry Unit at a regional health center located in central Texas.
identify, specify, install, and maintain safe and sustainable products that support
Environmental Quality (IEQ) index for flooring finish materials; and (b) examine
the flooring finish material IEQ index as it relates to patient and staff
and acoustics.
This dissertation follows the style and format of the Journal of Environment and Behavior.
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2
environmental quality of flooring materials within the hospital setting will provide
environmental quality of the interior and its relationship to those inhabiting that
interior environment.
A major goal of the study was to provide insight into the complexity of the
Design guidelines developed from this study provides the design professional
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3
being affected by the actions and reactions of changes within that environment.
clear that many published studies were methodologically flawed or, in the case
of light and noise studies, focused only on infant reactions to treatments (e.g.,
Ackerman & Sherwonit, 1989; Blackburn & Patteson, 1991). This infant-only
focus does not readily translate to other patient groups from children and
with links to the flooring industry. (Carpet and Rug Institute (CRI), 1992; Tarkett,
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4
theory and methodologies used in field research design and its application for
user-focused research.
The first section focuses on the human behavior toward the indoor
design and healthcare and studies focusing on patient and healthcare staff
focus on one element, for instance, noise, in a particular unit within a hospital.
While generalization of the results may be limited, it provides a context for the
flooring materials, lighting, acoustics, and indoor air quality. The final literature
review section discusses research theory and methodology, and indicates how
results within the methods (i.e., patient and healthcare survey) and between the
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5
indoor environmental quality, personal space and symbolic meaning - affect the
environmental quality of the built environment (Carpman & Grant, 1993). In the
1800s, Florence Nightingale (1859) wrote about the importance of fresh air,
cleanliness, order, natural light, and flowers to the recovery of the patient.
nor on budgetary concerns, but also consider the emotional and physical well
being and on participative processes that reveal the diverse needs of those in
Martha Rogers entitled “science of unitary human beings.” She believed that
humans and the environment are a unitary phenomenon and that the
relationship between human beings and the environment are systemic: both the
human being and the environment can be viewed as energy fields (of dynamic,
Davidson (1997) adds that order and complexity are qualities of both entities
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6
and through choice, harmony can be produced between the human and
the health of its occupants by a physical design supportive of the qualities of the
environment and health care delivery that reduce stress and enhance the quality
outcomes (Rubin, Owens & Golden, 1997), the authors identified research
environment. Rubin, Owens, and Golden (1997) state that the design of
While their report found that many of the research studies meeting their criteria
for inclusion had significant methodological flaws that weakened the validity of
patient groups most likely to benefit from changes in their patient environments.
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7
numerous patient population types have not been used in this area of research.
(1997) focus on one specific design element tested for significance. Rubin e t al.
(1997) also provides useful information regarding methods employed for data
collection.
and its impact on other physical characteristics within the setting (i.e., noise,
glare, and indoor air quality). The literature on healthcare staff and patients
women’s center nursing station (Shepley, Bryant & Frohman, 1995). Twenty-two
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8
record activities and the location of staff members in five minute intervals. This
method of data collection provided a series record of behavior and activity. For
both events and states, continuous recording gives true frequencies, true
latencies and durations if an exact time base is used (Martin & Bateson, 1993).
Shepley et al. (1995) found that the labor delivery recovery postpartum (LDRP)
unit design was viewed favorably with noted concerns about security, quantity of
space, maintenance, and functionality. The methods used in the Shepley et al.
design.
This study will utilize a multi-method research design for collecting data
from the participants including surveys, behavioral mapping, and secondary data
In a case study of intensive care unit (ICU) nursing stations (Davis, 1994),
control and choices within the work environment. Davis recommended that
design should encourage participation and reinforce the principle of team work
among the healthcare staff, patients and their visitors. Common complaints from
acoustics and lighting. Additional comments suggested that space allocation for
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9
personal belongings for staff was a factor in their job satisfaction. Statistical
analysis was not conducted on the data collected, which compromises the
Healthcare staff participants in this research study were asked about their
perceptions, preferences, and satisfaction with the patient rooms. The survey
used in this study provides more detail than the Davis (1994) study by asking
Jules Horton (1997) states that people under stress react more strongly
personnel have varying lighting requirements for different activities but common
needs include good task visibility, freedom from glare, and adequate contrast in
the field of vision to assist concentration and minimize visual fatigue. W ayne
Ruga (1997) defines environmental needs of medical staff and other user
(data from the environment that creates the sensation of an experience). The
healthcare institution.
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10
issues effecting staff satisfaction, administration can employ a strategic plan for
concerns about security. Often, nursing staff work twelve hour shifts and divide
that time between patient rooms and the nursing station. A common complaint
of the physical space is design that is insensitive to the needs of the staff as it
pertains to acoustics and lighting. All of these examples are design elements
delivery, change and complexity are constants; these factors often create
evaluation of the women's medical center (Shepley, Bryant & Frohman, 1995).
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11
physical measures will be taken to use as the foundation for the analysis of the
effects.
1.2.3 Patients
Hospital patients and visitors are vulnerable user groups for whom the
to recover from their illnesses. Stressors in the environment can also increase
hospital costs and decrease the quality of life for both patients and visitors
(Carpman & Grant, 1993). Qualities of the environment most likely to contribute
to stress for patients are (Volicer, Isenberg, & Bums, 1977): 1) physical threat
(i.e. filth, heat or cold, exposure to the elements); 2) psychological and social
(i.e. messages that convey feelings of social worth, security, identity, and self
control, issues related to the effort, energy and resources required to interact
most patients, regardless of the nature of the illness. The interior design of
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12
(1985) evaluated whether patients who have the added stress of being ill or
older were more sensitive to noise levels. The study population consisted of 150
measuring their sensitivity to noise, their objective level of noise exposure based
on the average number of machines running in their rooms, and the degree to
which they were disturbed by hospital noise. At the same time, a research
assistant collected specific medical chart data. Personal control over noise was
found to be correlated with the patient spending more time out of bed, but no
difference was noted in self-rated report of recovery. Another study (Topf, 1994)
focused on noise level and personal control over noise studying 105 women
was associated with subjective stress, but not physiological stress. In this study,
personal control over noise did not affect stress. The causal relationship
between noise conditions and poor sleep efficiency and efficacy as measured by
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13
trained observers visited each facility to collect physical data. The study found
that all facilities exceeded recommended levels of noise for this type of
treatment environment and that patients had little ability to control the sources of
noise. It would be expected that this higher level of noise would interfere with
the patients’ ability to rest, relax, and communicate. In contrast, light levels were
had no control over focused task lighting and approximately one third of the
facilities had no direct control over general lighting within the treatment area.
recommended for these dialysis patients. Patients controlled their comfort level
by using blankets that they brought from home. Adjustable thermostats were
available for less that half of the facilities. Generally, spatial arrangements
provided adequate space for staff to maneuver and circulate among patients to
deliver care, but did not offer much privacy for patients. The author concludes
that greater control by patients and staff of their environment may result in
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14
environment would have this effect, it would improve quality and contain costs of
dialysis care.
Another major concern for patients is the potential risk for falling. In
hospitals, the risk of a patient falling, cleanliness, and mobility (patient, staff, and
(Weinhold, 1988). Examining the hospital records of 76 elderly patients who had
documented falls within the previous year and 76 elderly patients with no
documented falls (Lund & Sheafor, 1985), two environmental factors that
November); and 2) the patient having three or more unit transfers. Three patient
characteristics that correlated with increased risk for falling included: 1) use of
impairment. Falls tended to occur more frequently in the evening and night shifts
and were associated with patients attempting to get out of or into bed.
randomly selected to test one of two flooring surfaces for gait speed and step
length. Statistical analysis showed that gait speed and step length were
significantly greater on carpet than on vinyl (i.e. walking was more efficient on
carpet). After the flooring test, some patients indicated a fear of walking on vinyl,
but were confident on carpet. None of the patients studied expressed difficulty in
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15
walking on carpet. This study demonstrates that the criteria for flooring
factors when selecting floor materials for elderly and infirm patients.
sound levels) taken during the course of the study. The data relied on self
reported measures and patient chart data. Bame's (1993) study of dialysis
treatment room design benefits from the use of multiple methods which includes
temperature, noise levels, light levels) and observation are strong components
for understanding the patients’ comfort physical needs and perceptions. One
limitation of the data is the lack of additional factors other than temperature that
comfort and indoor air quality in addition to factors including noise, lighting,
reflected glare, and the physical characteristics of the materials. The analysis of
the data will contribute to the research design as part of the multi-method
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more of the other elements. For instance, room temperature will affect the
surface temperature; natural light from a window may cause reflected glare on a
hard surface; and the noise from the corridor or nursing station may be
uncomfortable for patients attempting to rest in their rooms. The first subsection
of flooring materials.
research study because in a patient room, the three largest areas of interior
finishes are the walls, the ceiling, and the flooring. While the wall and its finish
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Environmental Health
the environmental health of the building and its impact on the patient, family,
and medical staff populations. A wide variety of flooring materials are available
resilient materials (vinyl composition tile, sheet vinyl, rubber flooring, and cork),
ceramic tile and other masonry, and wood. Carpet is available in rolls or tiles,
acoustic properties, lighting and reflected light, and physical comfort. Malven
(1990) defines the seven threats to user well-being: 1) mechanical - injury from
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threats - sensory stress. Each of these factors are potential threats to the health
Ulrich (1996) states that healthcare environments will support coping with
stress if they are designed to foster a sense of control with respect to physical
the building of healthy communities. The design of the built environment impacts
those who occupy the space, the surrounding community, and the global
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education programs.
the rating and specification of interior finish materials that limit the impact on the
is in its infancy and supported guidelines have not been established. For
instance, in LeC lair& Rousseau’s (1992) compilation of data, they relied on self-
reported surveys and Material Safety Data Sheets (M SDS) as their primary data
aware materials and it was successful in generally defining and meeting their
objectives.
However, the text does not include other flooring choices that are considered
appropriate for hospitals and other health facilities. Fuston & Nadel’s (1997)
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application.
Material Composition
and levels of volatile organic compounds may effect the environmental health of
a facility as well as the respiratory health and chemical sensitivity of patients and
staff with ongoing exposure (Anderson, Mackel, Stoler & Millison, 1982). Other
family of products that includes cork, linoleum, sheet rubber, sheet vinyl, and
various resins, fibers, plasticizers, and fillers; 2) forming them under heat and
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pressure into sheet goods; and 3) cutting into tile shapes, if applicable. (Ballast,
(Weinhold, 1988).
Cork products are made from the bark of cork trees harvested primarily
in Portugal and Spain. It is a sustainable natural material that requires very little
ingredients (linseed oil, cork, wood dust, and dyes). It has natural antibacterial
properties, and is resistant to grease, oil, and diluted acids as well as low
existing industry practices, causes air and water pollution (LeClair & Rousseau,
such as tires), has two environmental benefits over new rubber: 1) it is utilizing
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rigid tiles. Rigid tiles or vinyl composition tile, is more chemically and
dimensionally stable than sheet vinyl, making it more durable and less of a
health risk. Sheet vinyl contains plasticizers and foam which adds serious
sheet vinyl with the addition of mineral fibers and may possibly include asbestos
(Weinhold, 1988). Asbestos is considered safe when encapsulated within the tile
exception. V C T is installed with adhesive and has exposed seams. Sheet vinyl
seams are joined using one of two methods: 1) solvent welding, whcih requires
the use of a toxic solvent to soften the material so it may be joined to seal the
edges; and 2) heat welding, where an edge is heated and fused with a thin strip
of material. Natural linoleum seams may be joined by heat welding only. Heat
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welding may produce hazardous fumes, especially in vinyl installation (LeClair &
Rousseau, 1992).
specification for health care facilities. Sheet vinyl and V C T similarities and
T a b le ! 1.
and expected health conditions of users within a particular space. For instance,
heat welded solid sheet vinyl meets the criteria for the activities and need for
sterility in a surgical suite, however, general inpatient rooms do not have the
Table 1.1
Advantages and Limitations of Sheet Vinyl and Vinyl Composition Tile (adapted from Weinhold,
1988).
Limitations Umitarions
1) not resistant to cigarette bums 1) low resilience
2) initial cost is relatively expensive 2) semi-porous compared to solid sheet vinyl, rubber
3) poor noise absorption 3) poor noise absorption
4) dulls under heavy traffic (wear-life)
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from petroleum sources or natural fibers made from wool. Synthetic fibers are
biodegradable, and off gassing emissions of new materials can effect the indoor
air quality. Proper specification for use extends the life and performance of
health and safety criteria and provide acoustic, comfort, and aesthetic qualities.
soiling from dry, wet or oily sources, repair and replacement, and initial cost.
The latest revision of the Center for Disease Control guidelines for protecting
healthcare workers from infectious disease states (Garner & Favero, 1985):
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25
found that carpets do become heavily contaminated but did not find statistically
those in rooms with a smooth surface flooring. The Anderson et al. (1982) study
also supported the CDC conclusion that contamination levels are affected by
caused by the use and disposal of petroleum based products, and the off
gassing that occurs with new installations. In LeClair & Rousseau (1992), it is
stated that carpeted floors always require more maintenance than other floor
types and supports growth of bacteria and fungi. The authors advocate a return
to natural materials, but also mention new advances in the synthetic fiber
industry such as recycling programs and lower toxicity carpets. The LeClair &
choices.
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Maintenance
program for resilient flooring included washing and rinsing the floor, and then
buffing dry. In the case of vinyl composition tile, the flooring will require also
require sealing and coating program (Linttell & Roth, 1994). Proper maintenance
wash the floor and apply one or more (up to six) coats of wax. This process
results in a finish buildup that adds shine, discolors overtime, and must be
In addition to the reflectivity, waxing vinyl flooring makes the floor more
slippery, and shows traffic patterns. Many hospital facilities do not follow the
companies encourage a wax program; and 4) since VCT has exposed seams,
and hard surface floorings by developing methods for soil and stain resistance
employed to keep the carpet investment looking good and providing excellent
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Carpet and Rug institute (CRI) suggests that high traffic areas be vacuumed
daily, medium traffic areas should be vacuumed twice weekly and light traffic
clean heavy and moderate traffic areas. One motor drives a beater-brush bar
that knocks dirt loose and the other motor provides suction that pulls dirt up into
the vacuum bag. For light traffic areas, Dupont suggests daily vacuuming with a
efficiency particulate air filter (HEPA) will restrict dirt and particle dust from
extraction equipment and notes that the key to successful carpet maintenance is
to use less detergent so as to limit the residue left on the carpet and do not
over-wet the carpet. Another periodic cleaning method is the use of dry
absorbent compound which is sprinkled on carpet to attract and absorb soil and
to break down oil bonds. The compound is assisted by mechanical agitation and
maintenance. One is a cylindrical foam shampoo machine that uses a dry foam
by air compression and agitation. The other is a rotary shampoo that uses a
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detergent solution and water. The most typical cleaning method used in
and water is sprayed onto the carpet. A rotating absorbent pad agitates the
life and maintains its appearance. The life of the materials chosen for healthcare
environments are reliant upon the maintenance program and its execution.
Cost Analysis
the life of a building. Recently, this definition has been expanded to include
living things. Examples of such costs are: 1) resource depletion; 2) air, water
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and solid waste pollution; and 3) disturbance of habitats (LeClair & Rousseau,
1992).
studies were compiled that compared carpet and other flooring materials. The
VCT, the total annual cost for carpet was significantly less than VCT. For the
comparison of twenty year costs, carpet cost about 35% less than VCT.
advocates associated with the carpet industry and therefore may be suspect.
She further indicates that the validity of these studies may lie in the fact that the
resilient flooring industry does not publish studies contrary to the results. In a
study of cost analysis for V C T (Tarkett, 1997), it was estimated that standard
V C T flooring and maintenance for an 86,500 square foot facility would cost
$827,055 for a ten year period. Though this study was verified by an outside
consultant, it is unclear how this study is useful since the frequencies of care
specified for the study does not meet minimum recommendations for
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maintenance of hospital flooring and the comparison does not include carpet as
ascertain the exact cost per square foot of maintaining a floor since
housekeeping staff are not dedicated just to maintaining floors. Also, there is a
Carpet has a higher initial cost for the product which can be offset by a
a fifteen year comparison, carpet was consistently lower (CRI, 1992). This
labor, capital equipment, expendable supplies and removal cost (CRI, 1992).
Repair costs of vinyl cleaning equipment are higher than the repair costs of
carpet maintenance equipment due to the high-speed moving parts on the vinyl
material in health facilities must make a judgement regarding the value of the
product where cost is balanced against the inherent qualities of the material.
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provides a surface that is easy to negotiate for gurneys, wheelchairs and other
wheeled equipment typical in health facilities; ease of cleaning liquid spills rates
large role in the longevity, appearance, and the added quality to the facility.
How does the designer decide the appropriate material choice for a
acoustical quality, light reflectance, and comfort. The body of knowledge needed
understanding of the inherent qualities of the space, the needs of the users, and
how to balance the choices of materials and their impact on the space
durability, life-cycle costs, and maintenance. Costs associated with flooring are
offices and procedure manuals are available from the manufacturer, yet the
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This research will use a timeline for comparing two flooring materials
1.3.2 Lighting
used to measure luminance, it is measuring the number of lumens per unit area
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Surfaces that are “matte” or rough, diffuse the reflected light in multiple
smooth surfaces, such as glass, enamel paint and marble, can reflect light like a
mirror, where the angle of incidence equals the angle of reflectance and can
course, there are exceptions to this rule. Light reflectance of surface materials
make a room bright enough for its intended use. Surfaces with light colors tend
Specular
reflection
Note: Specular materials can have high reflectance (e.g., polished aluminum) o r low re
flectance (black tinted glass), and matte materials can also have high reflectance (flat
white paint) or low reflectance (flat black paint).
Figure 1.1
Example reflective surfaces (Egan, 1983).
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34
to reflect more light than they absorb, whereas dark color surfaces absorb more
light than they reflect. Smooth materials can have low reflectance, such as black
tinted glass; and matte materials can have a high reflectance. An example
would be flat white paint, where the color is effecting the level of absorption from
the incidental light (Egan, 1983). As seen in Figure 1.1, reflectance is dependent
on the type of surface material and the angle of the source. IESNA (1995)
recommends that hospital floors have a reflectance value between 20% and
30%.
Visual performance begins to decrease when one’s age reaches the late
twenties (Egan, 1983). Aging eyes have reduced visual acuity, require longer
time for adaptation to variations in light level, and have increased sensitivity to
glare (Egan, 1983). As age increases, a normal sighted person needs a higher
(Egan, 1983). Another visual problem for the elderly is glare, an uncomfortable
or disabling brightness in the visual field (Moran, 1990). Direct glare is caused
by a bright source directly in the field of vision; reflected glare comes from a
glossy or polished surface which reflects the image of the light source (Egan,
light that do not meet the need of the activity or reflected glare, can be
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35
and sustenance requirements affect the perceived comfort level within one’s
1. orientation,
2. security,
3. time,
4. weather,
6. territory,
8. places of refuge.
presence of danger (Lam, 1977). Table 1.2 represents basic human biological
lighting design. Lighting should serve the needs of the medical staff without
interfering with the comfort and lighting needs of the patient (IESNA, 1995). The
primary users of the patient room are the patients, healthcare staff, doctors, and
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36
Table 1.2___________________________________________________________
Human Biological (or Psychological) Needs for Visual Information (Egan, 1983).
Contact with nature and people 1. Openings to allow daylight penetration (and
distant views to relax aye musdes)
2. Avoidance o f visual noise from solar-shading
devices
General lighting for patient rooms should provide a soft, comfortable light
with variable controls located at the door of the patient room for easy access by
medical staff entering the room for observation (IESNA, 1995). Luminaires
should have low luminance and, if fluorescent lamps are used, they should have
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37
measuring color shifts on eight color test samples. A CRI of 100 means the
tested source exactly matches the reference source (Egan, 1983). This
becomes essential during observation of patients where the light should reveal
patient bed and the floor area so the nurse can observe the patient and
requires task lighting with a color quality that will not cause a misdiagnosis and a
directional quality that permits careful inspection of surfaces and cavities without
lights as luminaires used for minor medical procedures in areas other than the
operation room.
self-care, television viewing, and other similar tasks. In private rooms, patients
can control the use of light as long as it is accessible (Davis, 1994). In double
occupancy or multiple bed wards, consideration for the other patients may limit
lighting over horizontal surfaces (IESNA, 1995). Table 1.3 shows the
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38
lighting levels.
measured during this study. The researchers found that average lighting levels
exceeded the range recommended for patients’ visual comfort, but was below
the recommended levels for task lighting, needed by the staff to effectively
monitor patients, an example of the multiple-user needs in this facility (Bame &
Douglass, 1994). In addition, reflected glare was cited as a problem for elderly
patients who would have more difficulty adjusting their eyes to the changes in
light levels.
Table 1.3
Recommended illuminance categories and illuminance ranges for hospital patient rooms
(Adapted from IESNA,1995, pp. 4- 6).
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39
consideration for the selection of materials and equipment; location and size of
window; facility maintenance and operations; and interior finish selections. The
of comfort for the patients and task lighting for staff (Bame & Douglass, 1994).
Veitch, Hine & Gifford (1993), conducted a study focusing on the general
importance of lighting. The researchers used a survey to gather data from the
subjects. The results showed that lighting is important to lay people, though their
revealed that the subjects had a desire for more control over lighting.
The dichotomy of the lighting needs for patients and staff in dialysis
facilities (Bame & Douglass, 1994) is not an uncommon situation. The various
hospital face similar conflicts. The end-users may include the patients, nurses,
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40
Methods for data collection in this study are not unlike the methods used
in the Bame and Douglass study (1994), which also focused on the needs of
Lighting is one area addressed in the index as well as the surveys for patients
1.3.3 Acoustics
sound is subjective and varies with age, health, and other factors (Ballast,
1992). Sound is capable of traveling in air, water and other solid materials such
as steel, wood, concrete, and masonry (Allen, 1995). Generally, soft, porous
materials absorb sound, and hard rigid ones reflect it (Kilmer & Kilmer, 1992).
Noise is defined as any undesirable sound. There are three ways to control
unwanted sound: 1) isolate it at its source; 2) relocate the source away from the
bome sound waves (Kilmer & Kilmer, 1992). Sound becomes noise when it is
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41
partition walls and objects to resist sound waves and vibrations, thereby
class (sound transmission between rooms). The basic units of measure are
Most rooms have several materials with different areas. The average absorption
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42
least three times to change the reduction by 5 dB, which is noticeable (Ballast,
1992).
rate the transmission loss of construction. The higher the STC rating, the better
the barrier is in stopping sound (Ballast, 1992). The STC ratings represent the
ideal loss of sound through a barrier under laboratory conditions (Allen, 1995).
Decibels (dB) are units of sound pressure levels, as in pressure upon the
human ear drum(DiNardi, 1997). The normal range of human hearing is from 0
dB (the approximate threshold of hearing) to greater than 120 dB, near the
designated by the unit of hertz (Hz) (Egan, 1988). Most people can hear sounds
ranging from frequencies slightly below 30 Hz, such as the low rumble of the
largest organ pipes to very high frequencies near 15,000 Hz, like the shrill tone
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43
(DiNardi, 1997).
The frequency range can be further divided for more detailed acoustical
analysis. For detailed analysis of sound energy, sound level meters with a
pressure at a point to sound pressure level (ASHRAE, 1997). The sound meter
analyze data for level and frequency (Egan, 1988). Most sound level meters
provide filters for weighting the combined sound at all frequencies (DiNardi,
(dBA), which simulates the sensitivity of the human ear at moderate sound
levels (DiNardi, 1997). The C-weighted response simulates the sensitivity of the
human e a r at high sound levels (DiNardi, 1997). Three levels of precision are
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44
lifetime exposure at the 85-dBA REL, the excess risk of developing occupational
noise-induced hearing loss is 8% - considerably lower than the 25% excess risk
noise levels in excess of this limit are at risk of developing material hearing
According to Egan (1988), the background noise criteria for hospital patient
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45
running in their rooms, and the degree to which they were disturbed by hospital
noise.
disturbance. The results from this study suggest that well-being may effect a
levels of patients (Griffin, Myers, Kopelke, & Walker, 1988). Noweir and al-Jiffry
(1991) found that noise levels in patient rooms significantly exceeded the
and general noise associated with patients, attendants and hospital employees
significantly contributed to indoor noise (Noweir & al-Jiffry, 1991). The results of
the study indicated that proper site location, building construction, equipment
selection, and maintenance could reduce the level of hospital noise (Noweir &
al-Jiffry, 1991).
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46
the demands of the environment exceeds one’s coping abilities. Topf (1996)
telephones; providing private patient rooms; selecting carpet for high; traffic
Noise levels in healthcare settings and its effect on the occupants is one
Bame, 1993; Bame & Wells, 1995; Bayo, Garcia, & Garcia (1995); and Gast &
Baker, 1989).
areas used continuous decibel levels (dBA) and equivalent continuous sound
patients from four intensive care and two general care units from three hospitals
Noise levels ranged from high (48.05-68.5 dBA) in the larger hospital’s
open heart recovery room and intensive care units (IC U ) to low (32.5-57.0 dBA)
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47
in the smaller hospital’s ICU, with varied levels in the general ward areas (34.25-
62.5 dBA). The research showed that equipment noise reached as high as 90
contentment to frustration. The author notes that some sources of noise were
not easily eliminated, but other sources of noise could be reduced or prevented
(Hilton, 1985).
levels in dialysis facilities (Bame & Wells, 1995), measured the decibel level
and the ability of staff and patients to control loudness. Findings showed that
the noise levels in all facilities exceeded levels appropriate for patient care
environments and the only design feature associated with differences in noise
level was the layout of patient stations, not the window coverings, the size of the
major hospital in Spain, found that noise levels were perceived by medical staff
to interfere with their work activities and affect patients’ comfort and recovery.
This study measured noise levels inside the main building of a major university
hospital, with most sound levels exceeding 55 dBA. Those participating in the
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48
selections appear to be the most practical methods for the designer to control
be most appropriate. If selecting a carpet, one must keep in mind that the noise
consider other factors in choosing a floor material such as comfort and the effort
it takes to roll carts and gumeys across that floor. A high density carpet with a
lower pile height would be less effective in reducing noise, but would favor the
comfort of the patient, while attending to the needs of medical staff (Davis,
1994).
studies rely on self-reported measures and techniques for quantifying the level
of noise without the benefit of a sound meter which weakens the research
design. The strongest research designs used sound meters, observation, and
noise studies. It is the intent of this study to consider the acoustical properties of
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49
patient rooms.
the physical setting that effects the physical, psychological, and emotional well
being of the inhabitants (Fuston & Nadel, 1997). In healthcare settings, these
and medical staff (Fuston & Nadel, 1997). Healthcare facilities are programmed
delivery, ironically often with a loss of consideration for those who inhabit and
combined. Most Americans spend 90% of our time indoors. Patients, the elderly,
and young children may spend close to 100% of their time indoors, maximizing
facility have a reduced ability to resist contaminants and they are considered a
captive audience since they are in the hospital environment for 24 hours per day
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50
sick, but the nature of their business exposes the patients and staff to risk of
place.
complaints related to indoor air quality. Often, this condition is temporary, but
Sometimes indoor air problems are the result of poor building design or
(Carron, 1993). Health symptoms include nose and throat irritation, nausea,
(EPA) estimates that Americans spend as much as 90% of their time indoors. A
growing body of scientific evidence has indicated that indoor air can be more
seriously polluted than the outdoor air. Increased rates of respiratory illnesses in
people at work and at school demonstrate the need to improve the quality of
indoor air. Asthma rates have nearly doubled in the past 15 years in America;
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51
projected estimates suggest 30 million tuberculosis (TB) deaths may occur over
productivity losses due to poor indoor air quality. Headaches, fatigue, itchy eyes
and respiratory distress were cited as some of the complaints from those
these symptoms were lost efficiency on the job and the possible increased use
the building. Most of the research to date has focused on pollutants and hazards
that are generated because of the nature of the hospital, an environment where
toxic materials are used and infectious patients are treated (Shepley et al.,
1997). Volatile organic compounds (VOC) released in the air from building and
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52
design research that may link health concerns to interior design decisions that
ensure the health and well-being of the occupant. The main point of the authors’
providing structure for future research. The integration of applied research and
research about the nature of indoor air pollution and its related health effects are
results (DiNardi, 1997). Acceptable indoor air quality is air in which the
concentration of known contaminants are not harmful and with which 80% or
more of the people exposed do not express dissatisfaction with the air quality
(ASHRAE, 1989).
properties in a room which effects a person’s physical state via heat loss and
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53
respiration (Fanger, 1970). Indoor air quality depends on many factors, including
interactions. These design tools could be helpful in creating and operating low-
and safety threats. Only through commitment to the issues, expanded personal
experiments and laboratory experiments offers the most promising protocol for
understanding indoor air quality and the health and comfort of the building’s
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54
Thermal Comfort
occurs when body temperatures are held within narrow ranges, skin moisture is
low, and the mental effort of maintaining comfort is minimized (ASHRAE, 1997).
comfort can be divided into passive means and active means which require the
air temperature, humidity, air movement and the thermal properties of surfaces
change one factor without affecting the others to some extent (Allen, 1995).
natural ventilation, seem employable for most residential applications, the use of
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55
medical facilities (AIA, 1993). In addition, the guideline suggests that a lower
temperature may be used when the patients’ comfort and medical conditions
neutral room temperature for thermal comfort, suggesting that elderly subjects
do not require a higher room temperature to maintain comfort. However, the fact
that age does not effect preference for thermal comfort does not necessarily
mean the elderly are not more sensitive when exposed to heat or cold. Often,
the ambient temperature level in the homes of older people is set higher than
that of younger people. This may be due to a lower activity level, accounting for
humidity level allows faster sweat evaporation from the skin, removing larger
amounts of heat from the body (DiNardi, 1997). However, a low humidity level
can lead to drying of the skin and mucous membranes. Comfort complaints
about dry nose, throat, eyes, and skin occur in low humidity conditions, typically
when the temperature is less than 32° F (ASHRAE, 1997). Conversely, high
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56
Temperature, in this case, has less an effect on comfort, since the discomfort
between the skin and clothing. ASHRAE (1997) recommends that the relative
humidity level not exceed 60% on the warm side of the comfort zone.
of minimal air movement can lead to complaints of stuffiness and poor indoor air
on the methods used for taking measurements, the same type of thermometer
can be used to measure dry bulb, psychrometric wet bulb, natural wet bulb, or
in-glass thermometers, one measuring dry bulb temperature and the other
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57
between relative humidity, the dry bulb temperature, wet bulb temperature,
vapor pressure, and dew point temperature (ASHRAE, 1997). By obtaining the
measurement of any two of these components, the other three can be obtained
1989) is 15 cubic feet per minute (cfm) per person. Patient rooms require a
minimum of one air change of outdoor air per hour and a minimum of two total
air changes per hour. The guidelines for hospital and medical facilities (AIA,
1993) does not specify that 100% of exhaust air be eliminated to outdoors.
1997), maintaining the minimum standard for ventilation can be problematic. The
quality of the outside air may change which could have an effect on the indoor
air quality as it is mixed and dispersed through the system. Another confounding
factor for hot and humid climates is management strategies for cutting
operational costs by reducing the intake of fresh air (cooling less hot, humid
outdoor air lowers cooling bill). This type of cost-cutting can impact an otherwise
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58
that is linked to other factors in the overall quality of the indoor air environment.
Finally, occupants may block air ducts in an effort to control the temperature for
outside air supply per occupant, it is not always sufficient in the control of the
with a protocol for consideration of occupant activity, the types and strengths of
volumetric dimension of the space within the building (ASHRAE, 1989). Air
intakes should be placed away from any exhaust vents from the same or other
air quality. The specification of appropriate air cleaning and filtration are needed
air to building occupants requires careful placement of the supply diffusers and
fibrous acoustic materials inside the ductwork; and 3) sealing thermal insulation
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59
from the circulating air (Levin and Teichman, 1991). In addition, new products
with antimicrobial properties are commonly being used for added protection
located away from operable windows and from any area where people might be
evaporative heat between the human body and the environment (DiNardi,
occupied zones, air velocities are usually small (0-100 feet per minute) but have
for determining a mean value in accounting for fluctuations in the air velocity
(ASHRAE, 1997). A velometer directly reads the average air flow rate, either
concentrations below 1000 parts per million (ppm) usually results in conditions
conducive to comfort and the removal of odor from human generated pollutants.”
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60
on actual occupancy rather than maximum occupancy can save energy while
how outside air is being used to dilute the production of CO 2 by the occupants.
not necessarily resolve air quality problems, however it can maintain the
ASHRAE ventilation rates and save energy by not over ventilating or under
system has been established by ASHRAE. Sensor location and control strategy
with single zone systems, the sensor can be placed in the return air duct
(Schultz & Krafthefer, 1993). The control strategy should ensure that the
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61
Dols, 1990). Carbon dioxide does not provide information related to other
contaminant sources and is limited for indoor air quality assessment. However,
used for indoor air quality applications (ASHRAE, 1997). NDIR sensors
calibrated between 0 and 5000 ppm are typically accurate within 150 ppm, with
sensors are available with direct-reading digital displays, with varying response
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62
singular source for calibration standards in the United States (B. Dorko, May 14,
1998).
neutrality for the human body. While a person may feel thermally neutral overall,
he or she may not be comfortable if one or more parts of the body are too warm
such as patient rooms and patient bathrooms, comfort is dependent on the floor
temperature and the flooring material (Fanger, 1970). Materials that are warm to
the touch, such as wood, cork and carpeting, are those that are low in thermal
the body quickly warms the surface layer of the material to a temperature
approaching the temperature of the skin, which makes the material feel warm to
the touch. Materials that feel cold to the touch, like metal or ceramic tile, draw
heat from the body for an extended period of time resulting in a cold feel to the
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63
various flooring materials (Table 1.4). For floors occupied with normal footwear,
Fanger (1970). since the foot temperature is a function of the thermal state of
the whole body, the temperature of the floor will influence the possibility for
estimated temperature limits for bare feet in contact with different flooring
materials.
the discomfort due to cold or warm feet (Figure 1.2). At the optimal temperature,
Table 1.4
Temperature limits for typical flooring materials, bare feet.
The data in column 2 are from The ASHRAE Handbook (Fundamentals) 1997 (p. 8.14), by
ASHRAE, Atlanta, GA: ASHRAE. The data in columns 3 and 4 are from Thermal Comfort
Analysis and Application in Environmental Engineering, by P.O. Fanger, 1970, New York, NY:
McGraw-Hill Book Company.______________________________________________________
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64
Q O
ui UJ
u. u.
co W
H-
< £
CO
CO
CO tn
a a
H i-
Z z
Ui UJ
o
n r
o
nr
UJ ui
a a.
110
A IR TEM P E R A T U R E DIFFERENCE FLOOR TEM PERATURE
B E T W E E N HEA D AND FEET FAHRENHEIT
Figure 1.2
Percentage of people dissatisfied as function of vertical air temperature differences between
head and ankles and floor temperature, degrees Fahrenheit (ASHRAE, 1997).
only 6% of the occupants felt warm or cold discomfort in the feet (ASHRAE,
1997).
Air Contaminants
(VOC) are air pollutants found in all nonindustrial as well as industrial indoor
and cleaning products (ASHRAE, 1997). Some materials may act as a sink for
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65
chemicals in the air (An, Zhang, & Shaw, 1999). Sink materials include carpet,
exposure to levels above 1 ppm may cause headaches, eye irritation, sore
throat, and asthmatic reactions, to name a few (DiNardi, 1997). The Occupation
exposure limit of 0.3 ppm (AIHA, 1997). ASHRAE (1997) states that the
The effects of low level exposure to mixtures ofVO C s over long periods
of time are still unknown (DiNardi, 1997). Evidence suggests that accumulation
of VOC mixtures may play a major role in sick building syndrome (SBS), the
case in which building occupants experience acute health and comfort effects
that are apparently linked to the time spent in the building, but in which no
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66
1997), there are three basic approaches for reducing VOC levels: 1) Dilution
to requests for better emission testing data for building products, which will allow
the designer to limit or eliminate potential sources ofVO C s from the project
particulate matter derived from viruses, bacteria, fungi, pollen, mites, and their
appears to trap microorganisms firmly, though conditions within the carpet may
category consists of contagious diseases from viruses and bacteria. These are
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67
commonly found in wet soils enriched with bird droppings, or mechanical heating
readily available for routine monitoring or sampling the air for contagious or
with the use of a microscope (ASHRAE, 1997). Electronic particle counters can
1997). Projected area determinations are usually made by sampling onto a filter
(ASHRAE, 1997). Other materials used are membrane or glass fiber filters. To
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68
determine mass, air is pulled through the filters and then compared to the mass
(ASHRAE. 1997).
study of their campus’s indoor air quality. The study consisted of chemical
monitoring, sampling the indoor air quality, and a survey on the occupants’
environmental health and safety, and job satisfaction (Wormington, Lanning, &
Anderson, 1996). The results of the study indicated that the indoor air quality did
not violate occupational exposure limits. The perception of the IAQ did vary from
office to office and the researchers felt that management should attempt to
was performing the perception study in conjunction with the sampling of indoor
air.
were transmitted between carpets and patients (Anderson, Mackel, Staler &
Madison, 1982). In this study, two pediatric patient rooms, one with and one
without carpeting, were studied for about 11 months. Patients were randomly
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69
admitted to the two rooms and medically and microbiologically studied. Material
selection, installation and maintenance were controlled. Samples from the floors,
patient specimens and microbial air sampling comprised the data collected for
analysis.
The investigators found that levels of microbial contamination for the hard
surface flooring showed variance more than the contamination on the carpet
during the study period. Patient infections did not seem to correlate with the
Not all organisms found in the carpet were airborne. Organisms associated with
The results from this study (Anderson, et al., 1982) reinforce the fact that
patients in hard surface flooring rooms. The authors do suggest that the varying
should not have carpet. Those areas include intensive care units, nurseries,
pediatric patient care rooms, operating and delivery rooms, kitchen, laboratories,
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70
environments (Wormington et al, 1996; Anderson et al, 1982) have used a multi
method research design to investigate the physical space and the inhabitants.
One of these studies (Wormington et al, 1996), which focused on office building
Wormington, Lanning and Anderson (1996) and Anderson, Mackel, Staler and
Mallison (1982). W hile the variables and details may differ, these two studies are
strong field research designs with evaluations of the physical environment and
patient room setting and the effect of flooring materials on indoor air quality.
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71
survey administered to patients and medical staff will focus on their perception,
interconnection of man and his environment. More precisely, the impact of the
environm ent, behavioral mapping, and responses from participants about their
triangulate to explain how the quality of the environment impacts the occupants.
The following is an argument for the multiple method approach, the theory for
variability of social reality (Zeisel, 1981). Situations change and new problems
arise. W hen researchers and designers work together to use the each other’s
(Zeisel, 1981). In this study, interested parties include the researcher, designer,
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72
hospital administration, and the end-users - patients, medical staff, and visitors.
With the cooperation of all interested parties, a study design using qualitative
study is a type of research particularly suited for the study of physical space and
its influences on behavior. Fieldwork or field study is the method of working with
people for long periods of time in their natural setting (Fetterman, 1998). The
relative effects, methods that are not vulnerable to selection problems and do
not lead to estimates that are biased in unknown ways (Boruch, 1998). Even
though this is not a controlled environment, many of the same measures and
test reliability and validity of the research methodology (Fetterman, 1998). The
use of multiple methods strengthens the field research design by maximizing the
using elements from each to contribute to the solution of the major problem
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73
(Leedy, 1993).
of those who can use it (Zeisel, 1981). Applied research is the attempt to answer
questions to help solve practical problems (Graziano & Raulin, 1997). The
suggests that decisions made during the design process may impact the value
of the building, which may in turn, have an effect on those inhabiting the space.
However, factors that can influence a particular behavior may not influence the
same behavior in the general population (Martin & Bateson, 1993). In applied
practical application.
form, and defined objectively. At the second level, it is seen in its psychological
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74
results that can be applied to a design problem. The following section describes
the benefits of using a multiple methodology in a field experiment and how the
our understanding of how the world operates (Boruch, 1998). The nature of
applied field research makes it difficult for the researcher to eliminate competing
To maximize sensitivity, one must assess the factors that determine statistical
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75
power (Lipsey, 1998): 1) sample size; 2) effect size; 3) reliability; and 4) validity.
statistical power. However, other factors may affect the sample size. The effect
size between the treatment and control can be adjusted to accommodate the
level and lower the effect size to maintain a consistent subject size range.
for isolating the variables that may have a possible effect on the patient's level
Raulin, 1997). Confounding variables may impact the construct validity of the
cause.
(Reichardt & Mark, 1998). The effect size may be affected by the strength of the
conditions, times and places (Reichardt & Mark, 1998). To make general
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76
Raulin, 1997).
The main concern is whether the degree of uncertainty is labeled correctly. The
Research design factors that increase statistical power are: (1) the independent
occur, such as hospitals and schools. Experiments in the field are useful in
situations where the researcher wants to be able to draw causal inferences, but
doing so can prove to be difficult (Graziano & Raulin, 1997). Field research may
may be more difficult to validate, but extend the opportunity to assess how the
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77
index, the researcher can consider multiple measures according to a value scale
index combines temperature and humidity into a single index (ASHRAE, 1997).
environments have the same ET, then they should evoke the same thermal
response. Use of this index is conditional on the two environments having the
space, which does not provide criteria for an environmental assessment. Many
of the studies examined for this literature review employ multiple methodologies
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78
whether the study focused on lighting, noise, or indoor air quality. Typically, a
study will take physical measures of the interior environment and follow with
interviews or surveys of participants in the study (e.g., Topf, 1985, 1994; Bayo et
al, 1995; Bame & Douglass, 1994; and Anderson, et al., 1982).
environments has practical relevance for the design professions and other fields
concerned with people’s locations and movements (Sommer & Sommer, 1991).
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79
the same setting and there is a high consensus of reporting; and reliability for
data yield almost identical behavior maps (Proshansky et al., 1976). Behavior
maps that meet this criteria for reliability are within the limits of accepted
scientific practice (Proshansky e ta l., 1976). The question of validity is not clear.
environment on psychological and social behavior. The researcher can vary the
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80
and compare to self reports as a tool for the evaluation of the environmental
(Zeisel, 1981).
Proshansky et al. (1976), state that the presence of the trained observers may
or may not affect behavior in a setting. Behavior mapping can be tiring and
participants in a research study is one of the most universal tools for data
collection for research in the natural environment (Graziano & Raulin, 1997).
(Graziano & Raulin, 1997). For example, in 1976 Campbell, Converse, and
preferences and satisfaction, they were not primarily interested in the status of
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81
the variables measured, but in the relationships among the variables (Graziano
The quality of data from a survey is dependent on: 1) the size and
3) the quality of the interviewing, if interviewers are used; and 4) whether the
questions are good measures. The most important criterion for survey design
are the sampling methods used to ensure a representative sample (Graziano &
settings provide a broad and complex view of issues suspended between the
quality of the facility and the quality of care. Devlin (1998) discusses the merits
Procedure” (Moos & Lemke, 1984). This survey assesses relationships between
a facility’s design elements, policies, staff, and residents. The second survey is
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82
instruments for healthcare environments are published and available for use
(e.g., Davidson, 1995; MacDonald, Sibbald, & Hoare, 1988; and Ittelson,
Questionnaires are useful when you know what you want to find out and
plan to quantify the data (Zeisel, 1981). With the use of closed-ended questions,
the researcher can devise a method that is controlled and meets criteria for
intrusive nature of the method, which may distort the data (Zeisel, 1981).
sufficient data about different aspects of the subject or object. The use of
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83
(1998), the objective of the multi-method research design is to reduce the risk of
different kinds of data about the same phenomenon with several techniques is
likely to counterbalance bias inherent in any one technique with the biases of
assumes, of course, that techniques are not biased in the same way.
the fallibility of any single method of measure and will enhance validity by
sampling strategies to ensure that a theory is tested in more than one way; 3)
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84
use of two or more methods of data collection procedures within a single study
(Leedy, 1993).
the research design because each method has its own bias and using several
methods should improve the chance that the bias of one method is canceled by
the others (Zeisel, 1981). The appropriate combination of methods will enable
the researcher to maintain the greatest level of control over data collection, and
1.5 SUMMARY
have a shared interest in understanding the nature of interior materials and their
impact on the environment, the health of the building, and the occupants.
Patient preferences and satisfaction with their immediate environment are used
to measure the success of healthcare facilities and to plan future projects. The
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85
when designing and specifying healthcare interiors. The flooring industry and
products that surpass the recommended guidelines for health and safety while
For this research study, participants were either assigned to a room with
room impact the overall quality of that room? Does the type of flooring in a
typical patient room affect the air quality? The data collected from the physical
Do patients and staff respond similarly to this environment? W hat are the
(patients and staff) and behavioral mapping are methods used to analyze the
similarities and differences between the user groups. Can this research study
provide a protocol for measuring environmental quality? How does one decide
The three most important points from the literature review are:
1. flooring is a large surface area in a patient room that may affect the
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2. patient and staff perceptions may not correlate with the actual physical
understand the materials, the physical space, the variables affecting the interior
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CHAPTER II
RESEARCH METHODOLOGY
This chapter describes the research methods used for data collection of
independent variable was the floor finish material. Three patient rooms had the
hospital standard vinyl composition tile. The other three patient rooms had
carpet. The methods of data collection include: 1) patient and healthcare staff
mapping; and 3) the measured data that led to the development of the Indoor
Environmental Quality index (IEQ). The following chapter describes the study
design and the details associated with data collection. Also discussed are the
of pilot tests.
data about the different aspects of an object being investigated. The patient and
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about the patient rooms. The behavioral mapping study addresses the amount
of time spent in the patient rooms by medical staff and visitors. The Indoor
method research design for data collection pertaining to the physical space.
specifications, and measures of thermal comfort and indoor air quality of each
methods provides strength in the research design and enhances the validity by
2.1.1 Ethics
This study has been approved by the Institutional Review Board of Texas
the hospital where the study takes place. In addition, this research adheres to
the ethical principles and guidelines for the protection of human subjects as set
forth in The Belmont Report, written by The National Commission for the
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89
each data set and the relationship between the data sets. The following
hypotheses are tentative, informed guesses (Leedy, 1993) based on the current
variable, flooring finish material, and the dependent variables related to: 1)
Table 2.1__________________________________________________________________________
Research hypotheses.
Hypothesis 6: Visitors and healthcare staff spend more time in patient rooms
with carpet compared to time spent in patient rooms with VCT.
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control of temperature, lighting, and noise) of the hospital patient rooms. This
study investigated the impact that the indoor environmental conditions had on
visitors. Six hypotheses address relevant concerns for the appropriate selection
2.1.3 Variables
The three patient rooms with V C T served as the control and the three patient
rooms with carpet served as the treatment. The dependent variables are
patient rooms were based on the patients’ perception of aesthetics, comfort ,and
safety (Willmot, 1986; Davis, 1994; Anderson, et at.. 1982; Garner & Favero,
environment (MacDonald, Sibbald, et at.; Malkin, 1992; Orr, 1993; Ulrich, 1984),
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Table 2.2
Preference Floor preference Orr, 1993; Willmot 1986; Davis, 1994; LeClair
& Rousseau, 1992; MacDonald, Sibbald, etal.,
1988; Malkin, 1992; Schomer, 1993; Scott,
1993
Sound levels (noise) Bame & Wells, 1995; Baker, Garvin, et al.
1993; Bayo, Garcia, etal., 1995; Egan, 1988;
Gast& Baker, 1989; Topf, 1985a, 1985b,
1992a, 1992b, 1993
analysis, and interpretation for thermal comfort measures. For this study, data
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& Anderson, 1996; Anderson e ta l., 1982; Haberl, Lopez, etal., 1992; Persily&
Dols, 1990).
Sensory variables include odor, sound levels and noise, and lighting
levels and reflected glare. Odor is an indicator of problems associated with the
Anderson, et al. (1982) study focused on comparing resilient flooring and wool
the dBA scale (Egan, 1988). Other studies provided support for the chosen
reflected glare (Gifford, Hine, e ta l., 1990; Moran, 1990). Egan (1983) suggests
thermostat; control of the level of light; and control of noise) affects the comfort
and psychological well-being of the patient and the worker satisfaction of the
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healthcare staff (Volicer & Isenberg, 1977). Survey questions inquired as to the
level of control that patients had in their patient rooms. Each room was
monitored to compare the level of perceived control to the range of comfort set
The new patient rooms were built and completed with the specified
1998, nearly a year after installation, to lessen the probability of the Hawthorne
telemetry unit was allowed to return to normal business. W hile patients were not
effected by the new rooms since they were only exposed to either a control or
treatment patient room, the staff might have been effected by the newly
2.1.4 Setting
primarily for heart patients, in a medium size regional health center in central
Texas. The patient rooms are either single or double occupancy with the same
materials and design in each room with the exception for the flooring material
(Figure 2.1).
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Figure 2.1
Three of the patient rooms had the hospital’s standard flooring material,
vinyl composition tile (VCT) and three of the patient rooms had carpet flooring
choice for patient room floors due to the perceived ease of maintenance, price,
durability and cleanliness. The other 3 rooms had carpeting specified by the
such as the solution dyed yarn (reduces the risk of fading due to sun or
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VCT Carpet
Figure 2.2
Flooring materials used in the study of environmental quality in hospital patient rooms.
carpets), and product construction (24 oz./sq. yd. tufted loop with thermoplastic
composite polymer backing). The pattern and color choice was selected based
palette and light reflectance value. All other finishes in both sets of patient
Though there were differences in the surveys for patients and medical
staff, the methodology is very similar. Therefore, the survey methodology for
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2.2.1 Participants
patients assigned to the Telemetry Unit in the hospital. The typical profile of a
patient in this unit was a Caucasian male or female with a heart related illness.
Other types of patients were included for sampling with the exclusion of suicide
attempts and those too sick to respond to the request for participation.
the hospital. A request for participation was sent through the in-house computer
messaging system and through the distribution of a paper copy in the nursing
station. This request described the project and the expectations for those
this manner. Criteria for exclusion included all employees who were not
Each patient and staff member that met inclusion and decided to
that had been approved by the Texas A&M University Institutional Review Board
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Two surveys (Appendix B), one for patients and the other for staff, were
similar in the questions asked about the interior environment, their preferences,
and satisfaction. Patients were asked questions about their preferences of the
flooring in the hospital patient room. They were also asked to rate factors of their
patient room such as color, cleanliness, attractiveness, and odors. Seven factors
related to thermal comfort were rated as well as noise and lighting. At the end of
the survey, there were six personal history questions about health history and
occupation. Healthcare staff were asked to rate the same factors under the two
conditions. W hile patients were only exposed to one condition because of room
assignment, the staff worked in both conditions on a daily basis. Questions that
were only asked of the staff were: 1) related to how may spills occur on the floor
were tested by volunteers (Appendix B). Four patient surveys were tested by
architects who have had recent hospital stays for medical treatment. Four
medical staff surveys were tested by registered nurses from a different local
hospital. Each volunteer was asked to fill out the survey and comment on clarity
of the questions, the graphic layout and color of the form, and a place to add
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98
open comments. This exercise assisted in the development of the final survey
1998 and December 23, 1998. Patient surveys (N=36) were collected out of
thirty-eight patients that met the inclusion requirements. Two surveys were
excluded due to the patients’ lack of interest. The return rate for healthcare staff
surveys (N=41) was fifty-two percent. Due to rotation schedules, there were 90
staff members that met inclusion requirements. Twelve were lost to attrition (no
participants completed the survey. One of those participants did not complete
the questionnaire, and therefore that survey was eliminated from the total. Three
question number nine. This question asks for the preference of flooring material
in patient rooms and those who answered “no preference" were considered as
On the patients’ third day in the assigned room, the patients were asked
to complete a survey based on their experience in the room to which they have
been assigned. Each patient only experienced one of the two conditions (VCT or
carpet). The protocol for participation required that the researcher approach
each patient and asked if they would participate in the study by filling out the
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survey. Typically, after the Informed Consent form was signed, the researcher
allowed the patient time to read and respond to the questions on the survey.
of the purpose of the research. The survey clearly states that the intention is to
evaluate the patients’ preferences and levels of comfort and satisfaction in their
patient room. There were thirty-three questions; twenty-nine multiple choice and
Patients were not randomly selected for placement in these rooms. The
based on availability. Data collected during the Behavior Mapping Study on this
unit showed that the unit had 41 beds and was typically over 90% occupied. The
9 beds located in the six rooms for this study were occupied 88% of the time
during data collection. This would indicate that room selection by the medical
staff was based on availability, not for reasons connected to this study.
patient rooms included in this research study. There were two ways that a staff
member could participate in the survey, both of which were designed to provide
anonymity. The first option was to download the survey from the computer
containment for the completed surveys. The second option was to pick up a
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100
printed survey from a disclosed location in the nursing station, answer the
questions, and place it in the same box provided for completed surveys.
the purpose of the research. The survey clearly states that the intention is to
evaluate the medical staff preferences and levels of comfort and satisfaction in
their work environment based on the selection of flooring materials. There are
that inquired about their occupational status. As with the patient questionnaire, it
The initial intention of the protocol for the staff survey was to leave the
surveys available for three weeks with a reminder message sent through the
was initiated through personal contact with the potential participants. Since there
might have been differences in the samples, the two sets of surveys were
segregated and labeled “batch 1” for the first set and “batch 2” for the second
set. Analysis was planned to determine if there was a significant difference that
including job title, shift assignment, age, gender, and questions about the staff
member’s work history within the profession and within this particular hospital
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and unit.
In addition to the patient survey, data were collected from the patients’
medical chart. The patients were informed that the information gathered from
medical records would remain confidential. The patients gave consent for
access to their patient records when they signed the consent form for the
survey. Collection of data was approved by the health facility and recorded
agreement.
7) race or ethnic background; and 8) fall assessment rating. The room number
and dates were used to reference medical chart data to the patients’ surveys.
The admittance dates and discharge dates were used to track the amount of
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102
time that patients were in the telemetry unit. Type of medical treatment helped to
identify trends for how the unit was used, while providing information that could
test for inclusion or exclusion. Date of birth, gender, and ethnic background are
demographic data not requested on the survey form to limit the number of
questions asked of the patients while filling out the survey. Each patient, when
the nurse assigned to that patient. This toot was used to determine, based on a
assessment are 1) age; 2) mental status; 3) history of falling within the past six
This study was conducted in two phases. The first phase consisted of a
three-hour pilot study to verify that the information collected was adequate and
to verify the validity of the procedure. The second phase was conducted
the six rooms between the hours of six o’clock in the morning and nine o’clock in
the evening. Each observation period was exactly three hours in length; rooms
randomly selected until each room had been monitored for a total of 15 hours.
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2.4.1 Participants
There were three observers participating in this study. One was the
primary investigator, who trained the other observers to document the traffic in
and out of the patient rooms. All three observers tested a three-hour segment to
documentation. The simplicity of the data collected and the form designed for
data collection assisted in the stability of data collection among the three
observers.
specific information that was not self evident to the observers. Participants were
classified as visitors or medical staff. Patients were excluded. During the three
weeks of data collection, forty-two patients were assigned to the six patient
rooms. The limited time frame for data collection and potential confounding
factors that may have affected visitor and medical staff traffic (i.e., health and
social condition of the patient) may have threatened the validity of the results.
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Mapping Study Data form (Appendix D) prepared for this research study. The
gender and age of the visitors and medical staff were recorded anonymously.
There were three categories of age: adult (over 18), do not know/adolescent,
and child (12 and under). Time was marked for each time the patient room was
entered and exited. Additional comments were marked to stipulate the reason
evident.
The day and time of observation for each three-hour segment of the
there was a significant difference in the time visitors and medical staff spent in
patient rooms with carpet compared to the standard hospital resilient flooring,
VCT. This behavioral mapping study provided data for evaluation to test the
requires a method for building a profile of the setting. There are five primary
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Data pertaining to material composition indicate how the material can effect the
overall quality of the room and, therefore, the occupants. Lighting and acoustics
data supported the theory of interaction between factors within the space (i.e.
natural light through the window or fluorescent lights from the ceiling may have
produced a reflection from the flooring material that could have created
Air quality was one of the main design factors for this study. Methods of
readings of indoor air quality is one of the methods for identifying possible
collecting data for thermal comfort and air quality included interval monitoring to
document the condition of each room for a designated period of time in regard to
temperatures.
Some of the previous research studies focused on one aspect of the built
environment and the effects on human response. This study respected the
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106
comparison of the IEQ index with patient and staff data, which focused on
limits for patient room environments are listed for environmental elements
for the building of the Interior Environmental Quality index. Subjective measures
were employed in this study, through the use of surveys and behavioral
mapping, and are discussed in sections 2.2 and 2.3. Reported measures are
and c) industry sources. Primary data are measures recorded during the course
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107
The design of the unit was documented via a diagram (Appendix E) of the
unit that shows the orientation and distance of the patient rooms to the nursing
color, to document the finishes and status of room condition (Appendix F). In
addition to the construction drawings, data about the hospital and this particular
process of the hospital and the revenue table of recorded and projected use
due to the expansion of the unit (Appendix G). The revenue table provided the
number of inpatient days, average daily census, and the average length of stay
Material Composition
index. The specification and use of materials in hospital patient rooms are
independent variable, the flooring materials used in this study, as well as the
samples; c) Material Safety Data Sheets (MSDS) for the finish materials and the
cleaning supplies; d) the contents and methods of maintenance for the cleaning
carts used on the unit; e) cost of material, installation and maintenance (life
cycle); and f) data related to the manufacture, installation, and testing of the
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108
floor products.
The hospital supplied a checklist for stocking the housekeeping cart, and
maintenance and restoration procedures for specific materials and room types.
Cost of the flooring materials included installation and were provided by the
manufacturers. Maintenance costs can be, at best, estimated based on the floor
material type, quantity (square footage), and industry standard procedures and
cycle costs were not available. Manufacturers provided data about each flooring
statement of social responsibility. Finally, test data were collected from the
manufacturer and outside testing agencies, such as the Carpet and Rug
Photometer, Model J18 (Figure 2.3). The J18 is a digital photometer with
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109
used in this study, one for luminance and the other for illuminance. The sensor
for luminance, Model J1803, has a range of 0.1 to 100000 fL with an accuracy of
1% of reading +/- 2 counts. The sensor for illuminance, Model J1811, has a
verify that the photometer and the sensors were functioning properly can be
found in Appendix H.
/ - = - - - - - - L -= J Q
L S
| ornrujMacoLO** o
------
HU
□□
tp M
□□
m
Figure 2.3_______________________________________________________________________
Tektronix LumaColor II Photometer used to measure luminance & illuminance in patient rooms.
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comparison for the recorded light levels and reflectance values of each patient
room. IESNA (1993) recommended that hospital floors have a reflectance value
between 20% and 30%; IESNA (1995) recommended that light levels for
general activities range between five and ten foot candles lighting levels for
at 2:00 in the afternoon. The time was chosen because it was the time of day
with the highest level of staff and patient activity. Documentation for each patient
present; 3) window condition; 4) types of electric light sources and which lights
were turned on; and 5) whether or not the television was turned on and other
lamberts (fL) at the floor and at 42” above the finished floor, which is the general
height of activities such as reading and eating for patients in bed and at floor
level. Luminance levels were recorded in footcandles toward the floor. The
reflectance factor is the luminance level divided by the incident illuminance level.
Analysis will determine whether the patient rooms met the criteria for
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111
Acoustics
whether sound levels exceed the recommended range for noise that supports
Precision Integrating Sound Level Meter, Model 1800 with Model OB-300 1/1 -
1/3 Octave Band Filter (Figure 2.4). The controls were set to “A” weighted
decibels (dBA) with a range of 20 dBA to 80 dBA. The “A” weighted response
Figure 2.4
Quest Technologies Precision Integrating Sound Level Meter used to record sound levels (dB A ) in the
patient rooms.
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112
emulates the response of the human ear and is for most industrial and
a selectable set of filters. For this study, the octave filter was set to 1/1 octave
which is the average sound levels for noise criteria (NC). An explanation of the
“A ” weighting (dB) showing frequencies used in this study are shown in Table
manufacturer on April 6 ,1 9 9 5 . This certificate states that the sound meter used
calibrator was attached to the microphone and the meter was set to the modes
Table 2.3
“A” weighted (dB) scale (From Egan, 1988, p. 31).
-25 -15 -8 -3 0 +1 +1 -1
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113
specified by the manufacturer’s instruction book. If the display had not matched
the calibration level, then it would have been adjusted. No adjustments were
required.
the NRC rating for the two flooring materials were acquired from the
December 15, 1988 a t 2:00 in the afternoon. The time was chosen because it
Integrating Sound Level Meter in each room for a series of three readings with
average in each room was compared to the recommended range for noise
Thermal Comfort
air and exhaust of unacceptable air, as well as the occupant’s activities and
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114
of 15 cubic feet per minute (cfm) per person. In patient rooms, there must be a
minimum of one air exchange of outdoor air per hour and a minimum of two total
air changes per hour. According to the AIA (1992), the air changes do not have
assess the overall level of thermal comfort for each patient room in this study, air
Velometer (Figure 2.5). This instrument directly read average air flow rates,
full scale. According to the Alnor Velometer Owner’s Manual, the instrument
should be returned to the factory for calibration at least once a year, depending
on how it is used. This velometer was sent to the factory in the fall of 1998 for
calibration. For each use, it should be adjusted so that the pointer of the
should be clean with no debris clogging the sensing holes, and checked for
leaks. The hood should be free of holes and the gasket in good repair.
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ALNOR
Figure 2.5________________________________________________________________________
Alnore Velometer used to measure air flow rates in the patient rooms.
The velometer was placed against each diffuser and return vent in each
of the six patient rooms. The single occupancy rooms had one supply and one
exhaust vents. The double occupancy rooms had two supply and one exhaust
vents. At times, the velometer did not register any reading. When this occurred,
the range selector was adjusted and noted. The reading from the velometer was
in “standard” cfm (cubic feet/minute). To determine the true flow rate, the
manufacturer.
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116
humidity with a 36 degrees F dewpoint. For patient rooms, the AIA (1992)
desirable by the occupants. Patient rooms do not have additional guidelines for
relative humidity. Other areas such as recovery rooms, critical care, and
intensive care require relative humidity to range between thirty and sixty percent.
A SHR A E suggest, in the warm zoned area, that relative humidity should be
maximum level of CO 2 at 1000 parts per million (ppm) for “safe" buildings.
Outdoor weather data were downloaded from the NCDC Climate Radar
Carbon Dioxide levels were downloaded on-line from the Energy Systems
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for total volatile organic compounds, which will be discussed under the
subsection for air contaminants. The datalogger can record continuous real-time
The datalogger and all four sensors were calibrated and monitored by the
DATA LOGGER
SAMPLING
PROBE
Figure 2.6______________________________________________________________________
Recordaire and iock-box used to record interval data for temperature, relative humidity, carbon
dioxide, and total volatile organic compounds.
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Before commencing with the data collection from the hospital patient
rooms for this study, a test was performed in a controlled environment to learn
how to use the equipment, test the sensitivity of the sensors, and test the validity
of the recordings against another monitor, the YES-204 IAQ Monitor (Figure
Figure 2.7___________________________________________________________________
YES-204 IAQ monitor used in controlled experiment to verify the validity of the Recordaire
monitor equipment.
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119
and TVO C levels. The Recordaire and sensors were compared to the YES-204
equipment was placed in a cardboard box, eighteen inches square, with two
holes cut on opposite sides. The holes were three inches square and located in
the lower left corner and the upper right comer for ventilation. To meet the
The equipment was placed in the box and allowed to run for
approximately four hours. Base measures were taken after the equipment had
been allowed to run for a few moments. During the next four hours, items were
added and removed from the box to promote changes that would register with
differences, more often than not, the measures were congruent within the range
Figure 2.8 shows the timeline, conditions, and the measurements of each
sensor. The results of the pretest show that the temperature and relative
humidity recorded by the Recordaire were changed by the addition of hot water.
To confirm that the C O 2 monitor was functioning properly, the observer blew
into the monitor to verify an increase in the CO 2 level. The total volatile organic
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120
- Recordaire Mxiitor
YES-204 \fiQ Mxttor
100 100
90 90
u_ 80 80
<0
§ 70 70
S’ 60 60
■o
® 50 50
5
15 40 40
®
a.
E
v
30 30
20 20
10 10
0 0
a21 ft45 9:46 9:53 9:54 11:1011:11 11:27 1:40 9:21 9:45 9:46 ft53 9:54 11:1011:11 11:27 1:40
PMPMPMPMPMPMPMPM/'M PMPMPMPMPMPMPMPMAM
2500 200
175
150
125
1500
2 100
I 1000
U 25
0
ft21 9:45 9:46 ft.53 ft54 11:1011:11 11:27 1:40 ft21 9:45 9:46 ft53 ft54 11:1011:11 11:27 1:40
PM PM PM PM PM PM PM PM AW PMPMPMPMPMPMPMPM/SM
Figure 2.8
Controlled experiment to verify reliability for the Recordaire monitoring equipment used for patient
room IAQ interval measurements.
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121
compounds were only monitored by the Recordaire. The most apparent change
in the TV O C readings came during the exercise of blowing into the CO 2 monitor.
To do this, the box had to be opened. W hen the test box was exposed to the
made of aluminum was fabricated to hold the datalogger, sensors, and laptop
computer. Each room was monitored for forty-eight hours. The data were
downloaded through the use of the software provided by the manufacturer. This
raw data were then imported to Microsoft Excel. At this point, the data were
converted from 10 interval data to 30 minute interval data. In this format, the
data were graphed using timelines, box-whisker plots, and psychrometric charts.
Through analysis, this study compared the patient room conditions against the
guidelines and standards for temperature, relative humidity, and carbon dioxide.
material. Materials with high thermal resistance, like wood or carpeting, are
concrete or vinyl.
Surface temperatures of the six patient rooms in this study were recorded
on May 2 7 ,1 9 9 9 . Measures were taken at ten o’clock in the morning and again
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at two o’clock in the afternoon. The instrument was a Raytek ST8 Enhanced
Laser, Model D:S 30:1 (Figure 2.9). This was an infrared thermometer that
displayed on the unit. The temperature range is -25 to 1000 degrees Fahrenheit.
differences in the flooring materials and the effects on the comfort level of the
Figure 2.9_____________________________________________________________________
Raytek ST-8 Enhanced Laser infrared thermometer used to measure surface temperatures in
patient rooms.
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occupants.
Air Contaminants
Air contaminants are foreign materials in normal air that can be classified
made to test for three or four obvious potential VOCs, it is the combined total of
all VOCs that present a problem to the indoor environment. According to the
The apparatus used for data collection was the PSI-10 datalogger, which
was part of the system using the Recordaire by Engelhard. The sensor was
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124
to measure temperature, relative humidity, and carbon dioxide. Each room was
monitored for forty-eight hours. The data were downloaded through the use of
the software provided by the manufacturer. This raw data were then imported to
Microsoft Excel and converted from 10-minute interval data to 30-minute interval
data. Graphing the data using timelines and box-whisker plots provided a venue
for comparing rooms with vinyl composition tile and rooms with carpet and to
triangulation between samples from the floor, HVAC air supply and air exhaust
were collected from each room: 1) three samples from the floor; 2) three
samples from the HVAC vents; and 3) one air sample (Figure 2.10). In addition,
clean samples were collected from the sealed flooring materials from the lots
used for installation and an outdoor air sample was collected. The floor and
HVAC vent samples used the swab-sampling method. Each swab test site was
marked by a sterile 2 ”x2” template. A sterile swab with a liquid media was used
to collect bacteria samples from the designated areas. The air samples used an
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125
E
; t = — = : |
T - l
7 1 :
“ =-
i j :
■' 4 — -
/ < I I
]•
! I ! _
L I
Sample site locations for floor, air supply and return, and air sample:
FA = Floor A - medical side of bed near the door.
FB = Floor B - medical side of bed near the window.
FC = Floor C -1 ’ on center from entry.
VA = Air Supply A - medical side of bed near the door.
VB = Air Supply B - medical side of bed near the window.
VC = Air Return - centrally located in patient room.
AIR = Air sample located at 6’ aff. (not shown).
Figure 2.10_______________________________________________
Sample sites located on the floor and reflected ceiling plans.
media in the petri dish. Each sample was coded for room number, location,
occupancy, and flooring type. The test samples were processed by a local
environmental laboratory; the results were made available on February 24, 1999
(Appendix H).
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126
and thermal comfort. The properties of the materials used to build indoor
environments affect the quality of the air through the off-gassing of man-made
products and the potential effects from harboring biological contaminants. The
staff surveys, 2) the behavioral mapping study, and 3) the Indoor Environmental
to the physical space and how that space is used. The surveys show the
similarities and differences between the healthcare staff and patients; the
in the amount of time spent in the two conditions. The IEQ index (combined
measures of lighting, sound levels, thermal comfort factors and air quality) show
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127
CHAPTER III
ANALYSES A ND RESULTS
experience of patients and healthcare staff. The premise states that the
perceptions and behavior of healthcare staff, patients, and visitors. In all, there
are six hypotheses that address relevant concerns for the appropriate selection
This chapter begins with a description of analysis for each data set. The
second section, explains the flooring materials, the setting, and the participants.
The last section presents the findings for each of the 6 hypotheses.
3.1 ANALYSES
This section describes the method of analysis for each data set: 1) the
behavioral mapping study; 2) patient and healthcare staff surveys; and 3) the
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128
based on descriptive statistics. The purpose was to document the activity related
to the patient rooms and learn about the daily experience of the patients,
used to compare differences in the time staff and visitors spent in the carpeted
The healthcare staff and patient surveys were analyzed based on a .10
confidence interval (unless otherwise noted) due to the exploratory nature of this
research, potential applied importance of the findings, and sample size of the
surveys. Each data set was reviewed for accuracy by using descriptive statistics
and frequencies to verify the total count of the sample, the minimum values, and
maximum values. The means were compared to the standard deviations and
medians. Finally, the data were re-coded as needed to finalize the process of
Fisher’s Exact Test was used for data that did not have missing cells in the
tables and did not result from missing rows or columns in a larger table that had
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129
cells with the expected frequency of less than five. The Pearson chi-square was
used for tables with any number of rows and columns that did not meet the
criteria for the Fisher’s Exact Test. The same set of variables were tested
against floor preference for potential confounding factors. The patient survey
was tested for connfounding factors associated with floor type and preferences.
The staff survey was tested for confounding factors associated with preferences.
determine that there were no differences between batch 1 and batch 2 of the
of dependent variable ratings. The significance level was adjusted using the
Patient Survey
subject effects of rated dependent variables . The Levene statistic tested for the
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130
Each patient room was monitored for 48 hours at 30 minute intervals for
time series line graphs, and box-whisker plots. The graphic analysis described
ambient environmental qualities within the patient room. A reflectance factor (the
materials in the patient rooms for reflected glare. Surface temperatures were
factor for thermal comfort (ASHRAE, 1997). Bacteria samples were analyzed by
rooms. The characteristics of the participants, both patients and healthcare staff,
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131
The vinyl composition tile (VCT) specified for the three control patient
rooms was the typical flooring installed in this hospital for patient rooms. Each
tile was 12” by 12" with a gauge of 1/8”. The tile color was teal with multi-color
The carpet was an 18” by 18” modular monolithic loop tile with a moisture
resistant backing, antimicrobial, soil and stain protecting finish. This carpet is
made from a DuPont Antron fiber with a yam weight of 24 oz. The color was
selected to match the color and light reflectance of the standard VCT. The
carpet tile specified for the treatment rooms cost $984.00 installed ($3.28/sq.ft.).
in this study was based on Interior Finish Materials for Health Care Facilties
scale was developed to rate the floor finishes for material properties using the
5=excellent). On a rating scale of 1 to 5, the carpet rating was 3.52 and the VC T
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132
Table 3.1
Flooring material properties rating comparison.
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133
rating was 2.92. Carpet rated excellent for slip resistance, soil and abrasion
resource recovery, good for installation and use, fair for packaging, and poor for
chemical resistant, and has good abrasion resistance. For sustainable effort,
V C T rated fair for packing, shipping, installation, and use. The rating for
The telemetry unit was a step-down unit for heart patients that required
constant monitoring. This unit had 41 beds with a daily average of 37 beds
occupied. Six patient rooms with 9 beds were included in this study and an
average of 8 beds were occupied daily. Forty-two patients were assigned to the
6 patient rooms during the course of the study. Of the 490 times the patient
rooms were entered during the study, 45% of the entries involved carpeted
rooms and 55% involved rooms with V C T flooring (see Figure 3.1). Most of the
healthcare staff and visitors were female adults. Non-staff visitor traffic
accounted for 25% with the remainder of the traffic individuals employed by the
hospital. Nurses accounted for 50% of the healthcare staff entering the patient
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134
150 -
125 -
>
u
% mo -
© 75 -
-3 .. •
£ ■Vi 1
u_
50 -
25 - *7 ■ Visitors
□ Staff
o -
Figure 3.1
Visitor
25% Nurse
37%
Priest
1% Doctor
Administrator J
0%
Rgure 3.2
Healthcare staff and non-staff visitor traffic in patient rooms.
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135
275 sq.ft. (Appendix J). The patient beds in the double occupancy patient rooms
bathroom for patients assigned to each patient room. Each patient had a
television, shelf, and personal space for clothing. There was a window in each
Table 3.2
Laminate Wisonart
1. Countertops 1. #4170-60 Beige Pampas
2 Mllwcrk-vertical 2 #097-60 Haze
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136
room, but the person assigned to the bed near the door did not have easy
access to the window. Each room had a thermostat that the patients or staff
could adjust at their discretion. The finish materials were the same in each
patient room except for the flooring specification (see Table 3.2).
perceptions, preferences, and satisfaction with their patient room. Patients were
assigned to rooms with either vinyl composition tile (44% ) or carpet (5 6 % ). Nine
rooms. Of those nine, only one patient assigned to a patient room with V C T
occupancy rooms for the analysis of the environmental quality questions should
be excluded, the variables were tested for independence of patients from single
and double occupancy patient rooms. Floor type and external noise were the
significant, as this was the primary reason for excluding the surveys from
for external noise was significant when tested against occupancy, but was not
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137
30
25
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o 20
(1)
3 15
0)
u_ 10
5
0
20-39
id
40-59 60-79 80-99
I Floor Type Carpet
I Floor Type V C T
■ F k x x T ^ e V C T I F to cr Type Carpet
30
25
25
Figure 3.4
Patient demographics.
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138
significant in the analysis of the double occupancy patient room surveys for floor
type.
The average length of stay was 5.7 days. Over 50% were between the
ages of 60 and 79 (see Figure 3.3). Most of the patients were diagnosed with
completed the “Risk of Falling” form for their charts. Fifty-six percent of the
patients met the requirements for risk for falling. Seventy-eight percent of the
patients were Caucasian of non-Hispanic origin and 70% of the patients were
nurses and non-nursing staff such as nurse aides, technicians and physical
therapists (see Figure 3.5). Nurses, nurse aides, and technicians may be full or
part time, working all or part of a 12-hour shift from 7:00 A.M. to 7:00 P.M. or
7:00 P.M. to 7:00 A.M. Physical therapists and other specialists are assigned to
were excluded; 3 because they had no preference for flooring material in the
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139
100%
80%
:
jfrWgr-
1 f
® 40% *' vvj/.M*
20%
•;v ,:c r r .* ^
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Figure 3.5
Healthcare staff job description.
patient rooms and one because the survey was incomplete. Therefore, there
two percent were over 40 years of age. Males accounted for 12% of the sample
Most of the healthcare staff reported that they did not suffer from allergies,
migraines, or asthma.
Forty-two percent had worked in the field of health care for five years or
years or less. The remaining 22% had worked between 6 and 20 years at this
hospital.
Most of the participants had worked on the telemetry unit for 5 years or
less and worked between twenty-one and forty hours per week. O f those who
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140
100%
80%
C 60% I ®%
o
® 40% a> 40P/o
20% — — SB— —
OP/o B I B
Male Female 20-29 3039 4CH-
Gender (-teetttrareSteff/^ge
100%
80%
c 60%
<
oo
£ 40%
20%
0% I ■ ■
0 to 5 6 to 10 11+ 0 to 5 6 to 10 11+
100% 100%
80% 80%
S 60% I 60%
I o
S . 40% j? 40%
20% 20%
CP/o
1 to20 21 to40 41+ 0 to 5 6to10
Figure 3.6
Healthcare staff demographics.
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141
completed the survey, 32% worked the day shift and 51% worked the night shift.
The remaining participants account for 17% who were not assigned to the 12-
Lighting
The lighting sources were identical in each patient room. It was expected
that the levels of light would be adequate for the activities expected in the
materials is the issue of reflected glare (Figure 3.7). The measurements for
illuminance and luminance were taken without control of the lighting conditions
(Table 3.3). The recommended range for lighting levels (incident illuminance) in
patient rooms for general activities is between 5 footcandles (fc) and 10 fc. The
recommended range for reading is 20 fc to 50 fc. Figure 3.8 shows the level of
illumination for each patient room. Figure 3.9 represents the average level of
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
VCT Carpet
Figure 3.7
Reflected glare on vinyl composition tile and carpet in patient rooms near the window.
Table 3.3
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143
60
Patient Rooms
Figure 3.8
60
VCT Carpet
Flooring
Figure 3.9
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144
30% (Egan, 1983). The ratio of vertical illuminance to the vertical luminance was
consistently higher in rooms with V C T than rooms with carpet (Figure 3.10). The
mean and standard deviation for the ratio of vertical illumanance to the vertical
luminance in rooms with V C T was 210% (163.89) which was more than 6 times
higher than the 32% (8.5) for rooms with carpet (Figure 3.11).
8 400
3
e
II 350
—
3
| 300
£o 250
3
S 200
.5
|
| 150
3
e
5 100
■8
—
268 269 271 272 273 287
Patient Rooms
Figure 3.10
Reflected glare from the floor in patient rooms.
NOTE: Recommended range for reflected glare from floor is 20%-30% (Egan, 1983).
Each patient room has identical lighting sources: 1) 2’x4’ fluorescent at ceiling above patient
bed(s); 2) 4’ fluorescent overhead light above head board for reading (direct), general (indirect);
3) 2’x4’ fluorescent at ceiling near entry; 4) 2’x4’fIuorescent in bathroom; 5) T.V.; 6) window with
white metal mini-blind shades. Lines indicate recommended ranges of reflected glare.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Flooring
Figure 3.11
Reflected glare from the floor in patient rooms categorized by flooring material.
NOTE: Recommended range for reflected glare from floor is 20%-30% (Egan, 1983).
Acoustics
Incident sounds levels were recorded for each patient room. There was
no significant difference between the sound levels in rooms with V C T and rooms
with carpet. Both types of rooms exceeded the 34 dBA - 42 dBA recommended
Thermal Comfort
of 2 total air changes per hour. The patient rooms in this study were retrofitted
with new fan coil units (FCU). Rooms 268, 269, and 287 have independent fan
coil units with an average air supply of 250 cfm on high, 175 cfm on medium,
and 100 cfm when set on low. The bathrooms have an average 50 cfm of
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146
exhaust. Each fan coil unit has in excess of 10% fresh air supplied to it. Rooms
271, 272, and 273 are supplied by a rooftop mounted air handling unit system
serving multiple areas. Supply air to each room is an average of 355 cfm with
150 cfm of exhaust in the bathrooms. The air handling unit is supplied in excess
of 10% fresh air intake. Each FCU has a cooling and reheat coil couple
humidity). Based on the cubic feet of the rooms and the velocity of air in the
exhaust vents, total air changes per hour were calculated using a multiplication
correction of 1.02 (Table 3.4). The three rooms with independent fan coil units
(268, 269, 287) had less that 2 air changes per hour but were within the margin
of error for the measuring equipment. The remaining three patient rooms
exceeded the minimum air changes per hour. The ventilation rates were not
Table 3.4
Ventilation air changes per hour for the six patient rooms.
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147
affected by the choice of flooring material, but the airflow rates may have driven
in rooms with V C T and rooms with carpet. In addition, there was limited
variability in the range of indoor temperatures for all of the patient rooms (Figure
3.12). The mean and standard deviation for temperature in rooms with V C T was
75.71 degrees F (2.21) and the mean and standard deviation for rooms with
carpet was 77.68 degrees F (1.39). The temperature in the patient rooms do not
100
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CD
a
2
3
a
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a.
E
70-
60
VCT Carpet
Flooring
Figure 3.12_____________________________________________________________________________
Temperature boxplot showing the median and range categorized by flooring type.
NOTE: Shaded area represents the recommended range for temperature in hospital patient rooms by
ASHRAE 62-1999, Ventilation for Acceptable Indoor Air Quality, and A SH R A E Handbook o f
Fundamentals, 1997.
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148
u_ L i.
CO
O)
(D
Q 0 D -'
£
3
2
ID
Q.
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0)
h-
temperature range of 70-75 degrees F (AIA, 1993). In addition, data for rooms
with high of air flow rates (271, 272, and 273) indicate no change in indoor
The indoor relative humidity was low for all 6 rooms. The mean and
standard deviation for relative humidity in the patient rooms with VCT was
23.48% (15.03) and the mean and standard deviation for carpeted rooms was
32.41% (10.19). The relative humidity in the patient rooms did vary overtim e
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149
70
60-
10 ----------------------------------------------------------------------
VCT Carpet
Flooring
NOTE: Shaded area represents the recommended range for indoor relative humidity by ASHRAE
62-1999, Ventilation for Acceptable Indoor Air Quality, and ASHRAE Handbook of Fundamentals,
1997, for thermal comfort for winter range (clothing value .9), dewpoint at 36 F.
Figure 3.14________________________________________________________________________________
Relative humidity boxplot showing the median and range categorized by flooring type.
100
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-rttfe
13pm l^ m 13m t^ m 13m 13m 12pm 12pm 12pm 12pm 12pm 12pm
10am 10am 10am 11am 11am 11am
12/7-9/98 12/12-14/98 12/21-23/98 12/14-16/98 12/16-18/98 12/18-20/98
Rm 268 Rm 271 Rm 269 Rm 272 Rm 273 Rm 287
Vinyl Composition Tile Carpet
NOTE: Shaded area represents the recommended range for indoor relative humidity by ASHRAE
62-1999, Ventilation for Acceptable Indoor Air Quality, and ASHRAE Handbook of Fundamentals,
1997, for thermal comfort forwinter range (clothing value .9), dewpoint at 36 F.
Figure 3.15_______________________________________________________________________
Relative humidity timeline for patient rooms and outdoor conditions categorized by flooring type.
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150
I t I 'TCTk*
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! ! i -r
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rtmparMvr* fty b o Tiw pw airmen
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« '■ ■ i ■—«0
i 350 < 0 AO AO *0 AO AO 350 AO AO AO ^ 0 AO AO
f t y erffc Ttm parm rm (f) O y B tffc T im p m M t* * ( f t
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
152
(Figure 3.14). The variability reason for the variability is inconclusive, however,
the high air exchange rates in rooms 271, 272, and 273 appeared to be
correlated with the low levels of relative humidity while the low air exchange rate
(Figure 3.16 and Figure 3.17) indicated that the room conditions did not fall
within the range for thermal comfort. All six patient rooms were considered to be
too warm and too dry. The outdoor conditions indicate variable temperature and
1400
1200
E
Q.
CL
a) 1000
TJ
'»C
0
1 800
•e
CO
O
600
400
VCT Carpet
F loorin g
NOTE: Dashed line represents the maximum level of Cartx)n Dioxide (parts per million) that
usually results in conditions conducive to comfort and the removal of odor from human generated
pollutants as stated by ASHRAE 62-1999, Ventilation for Acceptable Indoor Air Quality. Outside
carbon dioxide levels did not exceed 360 ppm.
Figure 3.18_______________________________________________________________________
Carbon Dioxide boxplot showing the median and range categorized by flooring type.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
153
relative humidity.
carbon dioxide in patient rooms with VCT or carpet. The mean and standard
deviation for the level of carbon dioxide for rooms with V C T was 805 parts per
million (p p m ) (135.86 ppm); the mean and standard deviation for rooms with
carpet was 777 ppm (152.49 ppm). These levels of carbon dioxide are well
below the maximum level of 1000 ppm that is the accepted level conducive to
1400
- 1200
s 1000
■a
800
600
400
200 - - VCT
— Carpet
Figure 3.19
Carbon Dioxide timeline for patient rooms categorized by flooring type.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
154
comfort (Figure 3.18). The levels increase during mid-day and decrease during
the night, as one would expect. The events (high-points) occur during lunch time
and the early afternoon, when the unit has a higher rate of visitors (Figure 3.19).
The data for rooms with high of air flow rates (271, 272, and 273) indicate that
the carbon dioxide levels were effected byt the air exchange rates by lowering
the carbon dioxide levels in patient rooms with the high air exchange rates
(rooms 2 7 1 ,2 7 2 , and 273) compared to the rooms with lower air exchange rates
(rooms 268, 269, 287). The outside carbon dioxide levels did not exceed 360
ppm.
Surface temperatures. The mean and standard deviation for floor surface
temperature in the patient rooms with V C T was 73.52 (2.52) degrees F. The
mean and standard deviation for the floor surface temperature in the patient
rooms with carpet was 74.75 (2.21) degrees F. The difference between the
within the recommended range. The rooms that averaged a surface temperature
within the recommended range were room 268 (VCT) and room 287 (carpet).
Air Contaminants
have not been established for exposure to volatile organic compounds (TVOC)
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155
140
130
120
*g 110
Q.
o 100
e
P 90
80
70
60
VCT Carpet
Flooring
NOTE: Guidelines or standards have not been established for exposure to volatile organic
compounds in non-industrial indoor environments.
Figure 3.20________________________________________________________________________
Total volatile organic compounds boxplot showing median and range categorized by flooring type.
TVOC in patient rooms with VC T was 85.36 ppm (10.49 ppm) and patient rooms
with carpet was 84.43 ppm (8.76 ppm). The variability of the recorded total
volatile organic compounds was similar between rooms with carpet and rooms
with V C T (Figure 3.20). Events (highpoints) overtime indicate that the level of
Surprisingly, the air exchange rate differences in the patient rooms did not effect
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156
200
£
CL
CL
cn
T3
150-
1 50-
>
(0 - -VC T
"5
h-
— C&rpet
0
12pm 12pm 12pm 12pm 12pm 12pm 12pm
Room 268-VCT Room 271 -VCT Room 269-VCT
Room 272-Carpet Room 273-Carpet Room 287-Carpet
Monitored Patient Rooms (48 hrs at .5/hr)
NOTE: Guidelines or standards have not been established for exposure to volatile organic
compounds in non-industrial indoor environments.
Figure 3.21______________________________________________________________
Total volatile organic compounds timeline for patient rooms categorized by flooring type.
Biological (bacteria). Surface and air samples were collected for each
patient room and cultured for colony forming unit (CFU) counts. For analysis,
that the overall bacteria count was higher and more varied in the rooms with
V C T (Figure 3.22). The mean and 69.72 (54.64) while the mean and standard
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157
200
£ 150 ■
o
o
E
li.
VCT Carpet
Flooring
Figure 3.22
counts. However, the data does show how random and varied the samples at
the sample sites can be (Figure 3.23). The floor samples indicated that VC T
floors had lower levels of bacteria. The inside air samples indicated that
carpeted rooms had lower levels of bacteria in the air. The air supply samples
were consistently higher in the rooms with VCT, indicating that the air exchange
rates for the patient rooms may have effected the levels of bacteria in the air.
The air return samples revealed that the exhaust vent in the rooms with carpet
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158
Floor A - bedside A
Floor B - bedside B
Floor C - entry
Air Supply A - bed A
Air Supply B - bed B
o Air Return-central
o Inside A ir-a t 6’aff.
o
3
C
I
O
O
.2
*L.
03
O
(0 Flooring
m
□ vcr
\M Carpet
Floor A Floor C Air Su ppty B hs tie Air
Floor B Air Supply A Air Return
Sample Site
Figure 3.23_________________ _______________________________________________
Bacteria count of colony forming units at each sample site categorized by flooring type.
choice for their patient rooms. W hen Patients w ere asked their reason for
selecting carpet as their preference, they cited comfort, slip resistance, and
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159
20
15
S 10
$ I . BPaferts Assigned to Hocms
wth Carpet
□Patierts Assigned to Rocrrc
- withVCT
VCT Carpet
PatiertRocc'rglVfeteral
Preference
Figure 3.24
Patient preference for flooring material in their patient room.
their preference (see Figure 3.24). Patients who selected V C T as their choice of
have fresher air, and better ventilation than rooms with carpet. However, the
(low) to 6 (high). The means and standard deviations are listed in Table 3.5.
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160
Table 3.5______________________________________________________________________
Means and standard deviations for patient ratings of physical attributes of their patient rooms.
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161
located near the window perceived their room to be less clean than the patients
assigned to the bed near the door (p<.10). Regardless of bed assignment,
patients in the carpeted rooms rated the cleanliness of their rooms lower than
F(1)=5.33,p<.05. Patients assigned to beds near the window rated the window
view as better than the patients assigned to beds near the door. Regardless of
bed assignment, patients in rooms with V C T flooring did not differ notably in
their rating of window view. In the carpeted rooms, however, patients assigned
to beds near the window rated the window view as better than patients assigned
to beds near the door. Analysis indicated that floor type and bed assignment
The floor type and bed assignment had a significant effect for room
temperature F(1)=4.0,p<.10. In rooms with VCT, patients near the door rated the
room temperature as more comfortable than patients near the window. In rooms
with carpet, patients near the door rated the room temperature as less
Patients rated the quality of air to be fresher in the rooms with VC T than
in the rooms with carpet. The type of flooring in the patient rooms significantly
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162
their preference and cited comfort as their main reason (see Figure 3.25). Those
who chose V C T stated that it was easier to clean spills, blood, and urine.
100%
80%
S 60%
<o
o
ij|
CD
40%
20%
0%
if VCT Carpet
Healthcare Staff Flooring Material Preference
Figure 3.25
Healthcare staff preference for flooring material in the patient rooms.
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163
Table 3.6
Means and standard deviations for healthcare staff ratings of patient rooms’ physical attributes.
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164
Healthcare staff rated the patient rooms with carpet and the patient rooms
Healthcare staff perceived the rooms with VC T as better than carpet for
color, cleanliness, and odor (p<.006). These rooms were also rated higher for
ventilation comfort, air freshness, and air movement (p<.006). Patient rooms
with carpet were perceived as having more comfortable temperatures and fewer
temperature shifts (p<.006). The carpeted patient rooms were also perceived as
more quiet, both with regard to noise within the room and noise from the corridor
(p<.006). Staff perceived rooms with carpet to have a reduced problem with
reflected glare than rooms with VCT (p<.006) (for differences between the
3.3.6 Hypothesis 6: Amount of Time Staff and Visitors Spent in Patient Rooms
The amount of time staff spent in patient rooms with carpet compared to
patient rooms with V C T was not significant. However, the flooring material in
the patient rooms significantly affected the amount of time that non-staff visitors
21 minutes and 17 seconds (SD 22:13) in patient rooms with carpet and an
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Less glare
Better«lir movement
Fresher air
Bet er ventilation
More connfortabl i
(Better
odor
Mon i attractive
t More
clean
Betercolo-
Carpet MCT
Differences between the means of paired samples for healthcare staff perceptions about
flooring materials in patient rooms.
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166
CO
<u
-4—»
3
C
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C HAPTER IV
DISCUSSION OF TH E RESULTS
criteria and discuss the relative merits of both flooring materials. The summary
the preferences and perceptions of patients and healthcare staff, and the impact
of flooring material on the amount of time that visitors and staff spent with
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168
Material Composition
this study were compared against factors of health and safety, wear life,
environmental quality, and installation. Based on the numerical rating for flooring
material properties developed for this project (Table 3.1, p. 132), the overall
rating for carpet was higher than VCT. The advantages of carpet compared to
for installation.
demonstrated that gait speed and step length were greater on carpet than on
vinyl (Willmott, 1986). W hen interviewed, the patients expressed the fear of
falling on vinyl, but felt confident walking on carpet. Based on the medical
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169
records of participants in this study (N=27), nurses were twice as likely to assign
a patient as a “risk for falling” in rooms with VCT compared to the patients
at risk for falling in rooms with VC T indicated that the nursing staff perceived the
The properties of the flooring products used in this study indicate that the
criteria for selecting flooring for patient room environments because smoking
was not allowed in the hospital nursing units. The initial cost of the VC T was
much better than the carpet; however, caution must be used in assessing cost
as a factor because the initial cost does not include the cost of the product over
its lifetime. The life cycle cost of the product includes material, installation and
the ongoing maintenance program, which may have surprising outcomes. While
this study did not have access to the life cycle costs, some of the factors to
Maintenance
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flooring. W hile waxing provided extra protection to the VCT, an otherwise porous
flooring product, there are additional factors to consider. Waxing added to the
cost of maintenance, the risk of falling, and the reflectance of light. Maintenance
protocols are difficult to control regardless of the flooring type. Many hospitals,
cleaning carts and the materials used to clean the patient rooms. The
maintenance staff were assigned a territory of rooms within the unit. The
management company set the protocols for cleaning, but depended on each
maintenance staff person to follow through with the proper cleaning methods.
Sustainability
installation and use, and resource recovery. The VCT was produced from
impacts (LeClair & Rousseau, 1992). To minimize the exposure to the installers,
the V C T in this study used a low-toxic adhesive. The carpet in this study was
made of synthetic fibers from petroleum sources and was easily installed without
that there is still room for much improvement. The carpet industry, and this
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171
with installation and use by developing nontoxic adhesives and carpeting that
shows the resilient flooring industry working toward more sustainable practices.
Lighting
footcandles (Egan, 1983). Patients had individual control of the lighting in their
patient rooms. At the time patient rooms were measured, the mean level of
rooms with carpet was 18 fc. W hile more than adequate for general activities,
both types of patient rooms had average illumination levels lower than
Reflectance
The mean levels of indirect reflectance from the flooring materials were
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172
reflectance level from the floor in the rooms with V C T was more than 6 times
higher than the mean reflectance level of the floor in the rooms with carpet. Still,
at 32%, the patient rooms with carpet exceeded the recommended range by
2%.
Sound Levels
The incidental sound levels in the patient rooms with carpet and VCT did
not differ significantly. The average sound levels in rooms with V C T or carpet
Ventilation
Ventilation rates in rooms 268, 269, and 287 were inadequate and did not
meet the minimum air changes per hour for patient rooms (AIA, 1993). The
requirements for patient room environments (AIA, 1993). The HVAC system was
not controlled in this study. Flooring did not have an effect on ventilation rates.
Temperature and relative humidity in the patient rooms did not have
patient rooms. The mean for temperature in rooms with V C T was 75.71 degrees
F with a standard deviation of 2.21. The rooms with carpet had a mean
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173
temperatures did not appear to be influenced by the rise and fall of outside
had access to the thermostat and chose to maintain a higher temperature for
their comfort.
The average relative humidity was within or near the low end of the
recommended range of 30% to 60% for rooms with V C T and carpet. Relative
humidity data were not available for one of the patient rooms with VCT, number
271, but the timeline for the remaining 5 patient rooms showed that the indoor
appears that the influence of the outdoor relative humidity was minimized by the
The psychrometric charts for the six patient rooms indicated that none of
the rooms fell within the range for thermal comfort for patient rooms as defined
by ASHRAE (1997) and the AIA (1993). The rooms were too dry and warm,
Carbon Dioxide
The mean levels of carbon dioxide did not significantly differ in the rooms
with V C T and carpet. In addition, the mean levels of carbon dioxide were well
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174
occurred during the afternoon that coincided with heavier visitor traffic. These
events were short lived, though consistent throughout the time that rooms were
monitored.
Surface Temperatures
While the mean for rooms with V C T and the rooms with carpet were slightly
variance of the recorded temperatures indicated that the flooring was near
comfort levels. The average surface temperature of the carpet was 74.75
degrees F with a standard deviation of 2.21 degrees F and the mean for VC T
was 73.52 degrees F with a standard deviation of 2.52 degrees F. W hile not a
The mean level of TV O C in patient rooms with V C T was higher than the
mean level of TVO C in patient rooms with carpet, though not significantly. It was
surprising that the mean was higher in rooms with VC T because so much focus
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175
collected about TVO C levels in the patient rooms for this study, the contribution
Biological (Bacteria)
The mean and standard deviation of the overall bacteria counts of colony
forming units (CFU) demonstrate that the rooms with V C T had a higher number
of bacteria CFU and showed greater variability than the rooms with carpet,
1982). Caution should be used in extrapolating meaning from these data due to
organized by flooring type, the samples indicated that: 1) the number of bacteria
CFU from the floor samples varied from room to room with no apparent pattern;
2) the air supply vents in rooms with V C T consistently showed a higher mean of
bacteria CFU than rooms with carpet; 3) the exhaust vents showed a higher
mean of bacteria CFU in patient rooms with carpet than the rooms with VCT;
and 4) the number of bacteria CFU that were airborne were considerably higher
influenced the level of bacteria CFU that were removed from the rooms but may
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176
also be delivering bacteria to the rooms; and 2) the carpet acted as a sink,
holding the bacteria and keeping it out of the air. The rooms with VCT did not
contaminated with and may harbor microorganisms. In spite of this, their study
did not show that the infection rates differed between patients assigned to
rooms with carpeted floors and patients assigned to rooms with resilient floors.
Patients preferred carpet as the flooring material for their patient rooms. They
cited comfort, slip resistance, and lower noise levels as their reasons for
Patients perceived the rooms with VCT to be cleaner, have better views,
fresher air, and better ventilation than rooms with carpet. However, the rooms
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177
material choice, indicating that comfort and the fear of falling are strong
Patients in rooms with VC T rated their rooms as cleaner than the patients
in rooms with carpet. The high polish of the waxed floors, mopped daily may
have influenced this perception. Also, the patients near the window indicated a
lower level of confidence in the cleanliness of their patient rooms. Perhaps those
patients did not feel that the cleaning crew cleaned the entire rooms while the
The views from the patient room windows were not particularly attractive.
Rooms 271,272, and 273 had a view of the top of the first floor roof. Rooms 268
and 269 had a view of a brick wall. Only room 287 had a view with interest; the
window faced a landscaped area with a tree and had a clear view of the
emergency helipad. The perception of better views from the rooms with V C T are
Fresh air and good ventilation are factors of indoor air quality. Based on
the ventilation air changes per hour (ACH), the mean ACH for rooms with VCT
was 3.84 while the mean ACH for rooms with carpet was 12.07. More air pushed
into the patient rooms does not necessarily equate to fresher air and better
ventilation. The quality of the air pulled from the source of fresh air, the filtering
of the recirculated air, and the air exhaust were factors related to the indoor air
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178
temperatures is related to the room temperatures recorded for the IEQ index.
Patients tended to keep the temperature levels higher than recommended levels
regardless of the flooring material. A higher temperature would indicate that the
patients were not comfortable at the recommended range for patient rooms (70
to 75 degrees F).
The rooms with V C T were perceived to be better than carpet for color,
cleanliness, odor, ventilation comfort, air freshness, and air movement. The
carpeted rooms were perceived to be more quiet and have fewer problems with
reflected glare. In addition, staff perceived the carpeted rooms to have more
The patient rooms had identical interior finish materials, except for the
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flooring, which was specifically selected to control for color. The perception of
better color in the rooms with V C T was not supported. The perception of
cleanliness may have been derived from the experience of the nursing staff in
investigator in regard to spills. W hen a spill occurred on the VCT, a yellow sign
was posted to warn of the risk for falling. The spill was removed in a timely
manner, eliminating the risk. A spill on carpet did not illicit the same response.
There was no warning sign since the “slippery when wet" did not apply to the
carpeted floors. It was the belief of the nurses that spills on the carpet may not
Odor, ventilation comfort, air freshness, and air movement are indoor air
with VC T suggest that the perception of clean waxed hard surface floors equate
to better conditions for air quality. In contrast, the healthcare staffs’ perception of
inherent properties of the carpet affect the overall temperature of the room. The
perception of less noise was not supported by the findings, which showed no
difference in the levels of noise. The perception of lower levels of glare was
supported by the IEQ index findings showing that the levels of glare for the
rooms with VC T was more than 6 times as high as the rooms with carpet.
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The flooring did not have an effect on the amount of time that healthcare
staff spent with patients in their patient rooms. Nurses on this unit were assigned
that the flooring material did not impact the amount of time that healthcare staff
carpet than in patient rooms with VCT. Like the patients they were visiting, they
may have felt that the carpeted rooms were more comfortable than rooms with
VCT. The size of the patient rooms allowed for one patient/guest chair for each
patient. Often, patients would have multiple adult and/or adolescent visitors.
Visitors would have to sit on the bed with the patient, on the floor, or remain
standing. Visitors were not surveyed and future research may provide more
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appearance and resist abrasion, soiling, staining, and fading. The VC T has good
abrasion resistance, fair soil and fade resistance, and poor stain resistance
floor that requires a protocol for waxing adds material and labor costs for
maintenance.
Weaknesses of the carpet material used in this study include the lack of
Carpet has few limitations for the design of patterns and colors. In
limited colors. It is a product that is attractive primarily for its price and durability.
Vinyl flooring products are available with a cushion underneath for padding,
though adding the cushion also adds to the cost of the product. In comparison,
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Another concern with the installation of the carpet is the off-gassing that
occurs with new installations. Proper handling and staged off-gassing can
minimize the impact when installed, but it requires time and a well ventilated
place, which equates to more time for job completion and a rise in the cost of
installation. Monitoring the levels of TVO C in this study occurred about a year
after the installation of the flooring materials. The levels of TVO C were the result
of continuous off-gassing by the products and other materials introduced into the
V C T floors at this hospital is to apply three coats of wax, which enhances the
lower the cost of maintenance and the reflectance factor, but the flooring would
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183
degrees F (AIA, 1993). The patients had control of the temperature in their
range. While the AIA guideline suggests that a lower temperature is acceptable
for patient comfort, the higher temperature is not addressed. The mobility and
activity levels of recuperating heart patients are limited, which may affect the
implies that the guidelines may need to be adjusted to address the desire of
patients to keep the room temperature levels above the recommended levels.
Indoor spaces that are below the recommended range for relative
humidity may have higher levels of particulates in the air such as dust mites,
pollen (in this region, pine and cedar), and other particulates that can be
airborne. In addition, low levels of relative humidity can lead to the drying of skin
and mucous membranes, which may cause discomfort and leave the patients
control for relative humidity. Carpet may act as a stabilizer, limiting the impact of
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the outdoor relative humidity to control the changes in relative humidity levels
The comfort range for floor surfaces depends on the finish material.
Based on the comfort range for linoleum (Fanger, 1970), which is a resilient
temperature in the carpeted rooms suggest that carpet may respond to room
At this time, guidelines have not been established for exposure to volatile
levels between patient rooms with carpet and V C T were minimal. The
fluctuations in the data suggest that TVOC levels were affected by the
and carpet continually off-gas, the levels are low and not considered harmful.
There are many arguments against measuring TVOC levels. Typically, an indoor
air quality protocol would suggest identifying possible sources and testing for
each one. Because the exposure is not isolated to individual sources, but the
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The ventilation system for patient rooms impacts the indoor air quality
more than any other single factor. The amount of fresh air, air movement, the
conditioning of air for temperature and relative humidity, and the sanitary
conditions of the supply affect the thermal comfort of the occupants and the
from this study suggest that the ventilation system affected the levels of bacteria
colony forming units. W hile the data were inconclusive, the samples indicated
that bacteria were present in the supply and exhaust of the ventilation system.
The ventilation system modulates the levels of airborne bacteria based on the
number of air changes per hour. The capability of the air system to remove
bacteria from the air through the exhaust indicates that a higher number of air
flooring with a wool carpet. The properties of wool carpeting are different than
the synthetic carpeting used in this study; however, the carpet from the previous
study and the carpet used in this study showed a higher level of contamination
when compared to the resilient flooring. The most important factor in reducing
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maintenance. During the course of this study, unoccupied rooms were rare,
procedure for prepping a room for new occupancy was for healthcare staff to
notify maintenance when patient rooms were vacated in a timely manner, then
Since the beginning of this study, when the V C T and carpet materials
were specified, new flooring products have entered the market. One product is
waiting areas at Dallas Children’s Hospital, the carpet has maintained well under
heavy use. It has the acoustic properties of carpet and the durability of vinyl
composition tile. The manufacturer states that the life of the product is expected
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The Indoor Environmental Quality factors tested in this study support the
healthcare staffs and patients’ perceptions that carpet is more slip resistant and
provides more cushioning than VCT. The perception that temperature was better
in rooms with carpet was not supported. The surface temperatures of the
flooring materials did show a small difference, suggesting that carpet was
warmer to the touch than V C T which correlates with the warmer air
being cleaner is supported by the study; however, the impact of the smooth
bacteria.
The differences in ventilation were not affected by the flooring and did not
support the perceptions of the patients and staff. The perception of lower noise
levels was not supported by the findings; however, the perception that carpeted
significant difference in the amount of time visitors spent in rooms with carpet
surroundings for visitors may have an effect on the physical, emotional, and
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is essential that the maintenance and care of the flooring be controlled and
implemented.
objectives and priorities of the facility and design team. The advantages of
carpet are primarily better design, perception of comfort, and the safety benefits
of a slip resistant surface. The risk associated with slipping include bodily injury
which can result in higher healthcare and legal costs. Limiting the liability by
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VC T, but the initial material and installation cost does not begin to consider the
compound levels. The differences described for the bacteria samples are
inconclusive. At first glance, one might dismiss the lack of significant differences
as of no concern since the differences are small; however, determining that the
conditions indicates that these conditions should not be included in the criteria
for selecting flooring material. In other words, no differences indicate that the
environmental quality of the patient rooms would benefit from having carpet
specified for the floor finish material in patient rooms (Table 4.1). Whether carpet
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Table 4.1
Summary of findings.
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CHAPTER V
CONCLUSIONS
Temperature and relative humidity did not differ statistically, though the graphic
display of the data suggested that the outdoor relative humidity levels influenced
considerably higher than the carpet. The bacteria samples were not statistically
analyzed, but the graphic display of the results suggests that the patient rooms
with VC T to have fewer counts of bacteria CFU on the floor, but higher counts of
bacteria CFU in the air sample. Carpeted rooms had higher counts of bacteria
CFU on the floor with fewer counts of bacteria CFU airborne. The sink effect
traps the bacteria in the carpet, which causes contamination but effectively
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flooring materials, one should consider the differences and similarities between
the properties of the materials as that may impact the overall quality and cost of
Maintenance procedures can add years to the life-cycle and protection to the
carpeting products or the newly introduced resilient textile flooring products are
environments.
because the study was limited to one hospital telemetry unit in a geographically
of nursing units or other hospitals. Results from this study concerning the
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193
limited to the facility and participants in this study. In addition, the findings for the
study used vinyl composition tile and a synthetic carpet tile. Generalizability
The size of the participant sample was smaller than planned, limiting the
statistical power of the study. The limited amount of time for data collection
contributed to the small number of patient surveys. Healthcare staff were not
single occupancy rooms. Ironically, the confounding variable could have been
avoided if the study had selected only patients in single occupancy patient
rooms. Significant results would have been based solely on the independent
One of the most interesting sets of data were the bacteria samples. Due
to the small number of samples collected, the location of sample sites, and the
flooring material surfaced with the variation of ventilation rates (air changes per
hour). Without control of the air supply and exhaust, caution is suggested with
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194
when questions were developed for the survey but the overall comfort level was
that needs to be changed before using the surveys in another study. For
confusing. Also, the rating scale was designed so that on a scale of 1 to 6, the
number 1 was always the negative or less than best response and 6 was always
the positive or best response. There is some level of inconsistency that could be
was the obtrusive nature of the IEQ monitoring equipment and laptop computer
residing in a metal lock-box sitting in patient rooms. It seems like there was a
risk of patients being fearful that the box had something to do with their
treatment. W hen the box was set up and placed in the patient rooms, the
patients were told what the equipment was measuring and offered a chance to
the equipment.
With the exception of the relative humidity sensor not recording correct
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195
measurements in room 271, the equipment used to monitor the patient rooms
considering the potential effect of the outdoor relative humidity on the recorded
measures of indoor humidity. Also, total bacteria does not differentiate between
good bacteria and harmful bacteria, which limits the use of the results.
Another issue with the environmental conditions data were the technique
used for analysis. Not all of the data were analyzed statistically. While this may
limit the interpretation of the results, graphic analysis through the use of
timelines and box-whisker plots told a story of the patient room that would not
The findings of this research clearly point to the need for further research
on flooring materials for patient room environments. Studies using the same
flooring products under similar conditions may provide additional insight to the
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would be the differences between the specified carpet in this study and the new
One surprising result was the influence of the outdoor relative humidity on
the indoor relative humidity and the impact of the carpet to minimize the
changes in the indoor relative humidity. Using carpet to modulate the indoor
relative humidity may be effective, but it would indicate that the flooring was
holding moisture which would be counter productive for managing the growth of
range in the patient rooms indicate that the comfort range does not accurately
account for the loss of body temperature due to lack of activity or physical state.
that would identify healthy limits to long term exposure to common VOC and
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197
The bacteria sampling in this study was incidental. Future studies should
consider consistent sampling over a longer period of time. The findings based
on the mean of samples collected from patient rooms with V C T and patient
rooms with carpet support previous research on the sink effect. More research is
needed to understand the potential benefits and pitfalls of the use of carpet and
The benefits of friends and loved ones visiting a patient recuperating from
patients.
example, both groups perceived carpet to have acoustical properties that would
The protocol for future studies should include the use of triangulation
(theory, data, investigators, and/or methodology). Ideally, the study would test
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198
two patient rooms, the control and the treatment. The research design should
air quality, lighting and glare, noise, bacteria sampling over a long period of time
would strengthen the study by increasing the number of patients assigned to the
rooms during data collection and providing larger samples. The surveys for
patients and healthcare staff would also benefit from a longer duration of the
study. Minor modifications to this study’s surveys would clarify and limit the
time visitors and staff spent in patient rooms was successful in this study.
However, future studies should consider other methods of data collection for
more precision in determining the reason for visit and demographic data.
Overall, the methodology for future studies should maintain the triangulation of
data collection and use different types of data for understanding the
meaningful and provocative. The suggestion that we can manipulate and create
built spaces that consistently enhance the lives of those interacting with that
space is intriguing and uplifting for designers. The systemic nature of our
effect on mankind. During the industrial era, technology provided new ways of
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199
In the post industrial era, society began to see the consequence of too much
and knowledge to make informed choices that will have a positive impact the
the impact on environmental quality, and the effect on the occupants increases
the designers’ knowledge and awareness of the decisions made during the
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200
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[accessed: 1999, November 6, 1999].
Persily, A.K., & Dols, W . S. (1990). Relation ofCC >2 concentration to office
building ventilation. Philadelphia, PA: ASTM Special Technical
Publications, n 1067, report number 77 0066-0558 ASTTA8.
Rubin, H. R., Owens, A. J., & Golden, G. (1997). Status Report: An Investigation
to Determine Whether the Built Environment Affects Patients’ Medical
O utcom es. Martinez, CA: The Center for Health Design, Inc.
Sano, N., Takeshi, A., Kotaroh, H., & Masahito, Y. (1998, March 8 ,1 9 9 8 ). EEG
activity caused by listening to environmental sounds: Voice/machinery
sound comparison. Paper presented at the Environmental Design
Research Association Annual Conference, St. Louis, MO.
Schomer, V. (1993). Interior Concerns Resource Guide (pp. 222): self published.
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207
Shepley, M., Bryant, C., & Frohman, B. (1995). Validating a building prototype:
A post-occupancy evaluation of a women’s medical center. Journal of
Interior Design, 21(2), 15-29.
Sieber, R. P., Schoenau, G. J., & Besant, R. W. (1993). Air sampling system for
monitoring carbon dioxide levels in buildings. A SHRAE Transactions(99),
1527-1535.
Sommer, B., & Sommer, R. (1991). Behavioral Mapping and Trace Measures, A
Practical Guide to Behavioral Research (3rd ed., pp. 63-78). New York:
Oxford University Press.
Sundstrom, E., Town, J. P., Rice, R. W ., Osborn, D. P., & Brill, M. (1994). Office
Noise, Satisfaction, and Performance. Environment and Behavior{March),
195-222.
Tarkett (1997). Health Care Facility End User Cost Analysis . Holland, Ml:
Castex, Inc.
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208
Topf, M. (1996). Effects of critical care unit noise on the subjective quality of
sleep. Journal o f Advanced Nursing, 24(3), 545-551.
Veitch, J. A., Hine, D. W ., & Gifford, R. (1993). End user’s knowledge, beliefs,
and preferences for lighting. Journal o f Intenor Design, 19(2), 15-26.
Willmott, M. (1986). The effect of a vinyl floor surface and a carpeted floor
surface upon walking in elderly hospital in-patients. Age and Aging, 15,
119-120.
Yin, R. K. (1998). The Abridged Version of Case Study Research: Design and
Method. In L. Bickman & D. J. Rog (Eds.), Handbook o f Applied Social
Research Methods (pp. 229-260). Thousand Oaks, CA: Sage
Publications, Inc.
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APPENDICES
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210
APPENDIX A
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T E X A S A & M U N IV E R S IT Y
Office of the Vice President for Research and Associate Provost for Graduate Studies
CoBege Station. Texas 77843-1112
(409)845-8585 FAX (409)845-1855
May 7, 1998
MEMORANDUM
by the Institutional Review Board - Human Subjects in Research in their meeting of May 6, 1998.
The study is approved for one year. As stipulated in the IRB. Guidelines all protocols are subject
to annual review and any changes must be approved by the Board.
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212
St . Jo s e p h R e g i o n a l H e a l t h C e n t e r
'90! rr.ru it Or. • 8ry.ni. 1Yx;i> 1/uni-T>-S- • •’to’j'
X Approved
Conditionally approved (see remarks below)
Tabled for future consideration
Disapproved (see remarks below)
Not considered
Closed
by the Institutional Review Board of St. Joseph Regional Health Center effective July 29,
1998.
Sincerely,
SGK/cn
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213
APPEN DIX B
C O N SE N T FORMS AND
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ST. JOSEPH REGIONAL HEALTH CENTER
INFORMED CONSENT: MEDICAL PATIENT
P u rp o s e :
The purpose of (his study is to enable architects and designers to better understand the needs of patients,
medical staff and families in a hospital setting. This study will take place at St. loseph Regional Health Center
beginning in April 1998 and concluding in May 1999.
Procedure:
I understand that two procedures will take place:
1. A questionnaire will be distributed evaluating the patient's comfort and satisfaction with the patient
room; and
2. Medical data will be collected by a healthcare employee of St. Joseph Regional Health Center and
coded for confidentiality. Information will include: type and frequency of pain relievers, nurse
comments about the state of the patient, admittance, type of medical treatment and discharge date. This
data will be provided to the researcher in accordance with the policy and guidelines of St loseph
Regional Health Center.
Benefits:
The collection of this data will be analyzed to see if the choice m finish materials affects the quality of the
interior environment and record patient levels of comfort and satisfaction with the interior environment.
Analysis will also show if there is a correlation between the type of finish specified and patient medical
outcomes. This study focuses on measurable environmental elements, specifically air quality, lighting and
acoustical quality. The results will be used to develop criteria for architects and designers in selecting interior
finish materials in healthcare settings.
Participation:
I understand that I am one of approximately 100 individuals who will participate in this study. I may refuse to
answer any questions. Participation is voluntary and may be refused at any time If I withdraw my
participation during the study, this will have no impact on my employment status or healthcare protocol.
This study is confidential. Records and data will be coded to protect the confidentiality of each participant
and placed in a secure storage. My name will not be used tn resulting publications. Any new findings
developed duhng the course of the research which may relate to my willingness to continue participation will
be provided to me.
I have read and understand the explanation provided to me. I have had all my questions answered to my
satisfaction, and I voluntarily agree to participate in this study.
This Research study has been reviewed and approved by the Institutional Review Board of St Joseph Regional
Health Center (SJRHQ in Bryan, Texas and the Institutional Review Board of Human Subjects in Research,
Texas A4M University. For research-related problems or questions regarding subjects' right, the Institutional
Review Board may be contacted through Alice Luttbeg, Vice President of Quality & Risk Management at
SJRHC at (409) 776-2443 or Dr. Richard E. Miller, IRB Coordinator, Office of Vice President for Research and
Associate Provost for Graduate Studies at TAMU at (409) 845-1811.
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215
Purpose
The purpose of this study is to enable architects and designers to better understand the needs of patients,
medical staff and families in a hospital setting. This study will take place at St. Joseph Regional Health Center
beginning in April 1998 and concluding in May 1999.
Procedure;
t understand that one procedure will take place:
1. A questionnaire will be distnbuted evaluating the staff's comfort and satisfaction with the patient room.
Benefits;
The collection of this data will be analyzed to see if the choice in finish materials affects the staffs levels of
comfort and satisfaction with the interior environment This study focuses on measurable environmental
elements, specifically air quality, lighting and acoustical quality. The results will be used to develop criteria
for architects and designers in selecting interior finish materials in healthcare settings.
Participation:
I understand that I am one of approximately 100 individuals who will participate in this study. I may refuse to
answer any questions. Participation is voluntary and may be refused at any time. If I withdraw my
participation during the study, this will have no impact on my employment status or healthcare protocol.
This study is confidential. Records and data will be coded to protect the confidentiality of each participant
and placed in a secure storage. My name will not be used in resulting publications. Any new findings
developed during the course of the research which may relate to my willingness to continue participation will
be provided to me.
I have read and understand the explanation provided to me. I have had all my questions answered to my
satisfaction, and I voluntarily agree to participate in this study.
This Research study has been reviewed and approved by the Institutional Review Board of St. Joseph Regional
Health Center (SJRHQ in Bryan, Texas and the Institutional Review Board of Human Subjects in Research,
Texas AAM University. For research-related problems or questions regarding subjects' right, the Institutional
Review Board may be contacted through Alice luttbeg, Vice President of Quality & Risk Management at
SJRHC at (409) 776-2443 or Dr. Richard E. Miller, IRB Coordinator, Office of Vice President for Research and
Associate Provost for Graduate Studies at TAMU at (409) 845-1811.
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216
Patient Questionnaire
The purpose of this questionnaire is to evaluate your preferences and levels o f com fort and
satisfaction with your hospital room. Studies like these help architects and designers to leam
about what you want for hospital design. There are 33 questions that should take 10-15 minutes
to answer. If you provide a mailing address at the end o f the questionnaire, we will send you the
results when the study is complete. Thank you for your help with this research study.
1. Several patient rooms have vinyl flooring and several patient rooms have carpeting.
a. CARPET
b. VINYL
c. NO PREFERENCE
d. OTHER
2. Why?
Please rate the following by circling the best number between 1 and 6 that best describes your
3. Colors 1 6
BAD GOOD
Cleanliness 1 6
BAD GOOD
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217
5. Attractiveness 1 2 3 4 5 6
6. Odor 1 2 3 4 5 6
BAD GOOD
BAD GOOD
8. Temperature comfort 1 2 3 4 5 6
BAD GOOD
BAD GOOD
STUFFY CIRCULATING
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218
BAD GOOD
Based on your experience in your patient room, how much control do you have oven
19. Temperature 1 2 3 4 5 6
NEVER ALWAYS
20. Lighting 1 2 5 6
NEVER ALWAYS
21. Noise 1 2 5 6
NEVER ALWAYS
Based on your experience in your patient room, please rate the condition (state o f repair or
disrepair) of the:
22. Flooring 1 2 5 6
POOR EXCELLENT
23. Walls 1 2 5 6
POOR EXCELLENT
24. Ceilings 1 2 5 6
POOR EXCELLENT
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219
POOR EXCELLENT
27. What would you most like to change about your room?
PERSONAL HISTORY
ADDRESS (optional for those requesting results at the end of this study):
Name:
Street:
City/State/Zip
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220
The purpose of this questionnaire is to evaluate medical staff preferences and levels of comfort
and satisfaction in their work environm ent Studies like these help architects and designers to
leam about what you want for hospital design. There are 43 questions that should take 10-15
minutes to answer. If you provide a mailing address at the end o f the questionnaire, we will send
you the results when the study is complete. Thank you for your help with this research study.
GENERAL INFORMATION
1. Job title:
6. How long have you worked in the Telemetry Unit a t S t Joseph Regional Health Center?
YEARS: MONTHS:
7. How many hours per week do you work in the Telemetry Unit?
INTERIOR ENVIRONMENT
9. Several patient rooms have vinyl flooring and several patient rooms have carpeting.
Given a choice, which do you prefer? (circle)
a. CARPET
b. VINYL
c. NO PREFERENCE
d. OTHER
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221
10. Why?
While considering the patient rooms with carpet and vinyl flooring, please rate the following by circling
the best number between 1 and 6 that best describes your experience:
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222
VINYL 1 2 3 4 5 S
CARPET 1 2 3 4 5 6
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
CARPET 1 2 3 5 6
CARPET 1 2 3 5 6
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
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223
While considering the patient rooms with carpet and vinyl flooring please rate the condition of:
27. Flooring POOR EXCELLENT
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
31. How many times per week during your shift are there spills on the floor of the patient
rooms?
32. How often do you have to clean the floor from a spill or treatment in the patient rooms?
NEVER ALWAYS
1 2 3 4 5 6
33. How satisfied are you with the level o f noise inthe patient rooms?
VERY DISSATISFIED VERY SATISFIED
1 2 3 4 5 6
34. How often does the patient or family members complain of noise?
NEVER ALWAYS
1 2 3 4 5 6
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224
35. How often do you have problems with inadequate lighting in the patient rooms for your
medical tasks? NEVER ALWAYS
1 2 3 4 5 6
37. W hat would you like to change about the patient rooms?
38. Please use this space for additional comments about the design of the Telemetry U nit
HEALTH HISTORY
ADDRESS (optional for those requesting results at the end of this study):
Name:
Street:
City/State/Zip
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225
1. Are any of the questions confusing? If so. please explain: K £ A l L-'~S R J 'T
u; Afa'KVfiiti? tF'fiPU T ' l C ^ ' Xc f o g T
\F /{ A 0 \7 o Z C A i \j i
2. Is the color of the survey appropriate (not too dark, easy on the eyes)? Please explain:____
.! U K S
’ \ T . _______________________________________________________
3. Is the layout of the survey confusing? If so, please explain: I CyC‘\ j T M-,<' -9d>,
Please return this survey to my mailbox located outside the Department of Architecture
office on the 4* floor of Building L I would like to have it back by Tuesday. October 20.1998.
If you have questions, please call. Thank you for your assistance.
Sincerely.
De^^Harris
Department of Architecture
409.862.2234 debra@taz.tamu.edu
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226
APPENDIX C
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227
INSTRUCTIONS. This assessment a to be I. Check appCcasle items, indicate pom s J l ngnt completed on HI patients
completed on ad paoentx. 2. Add perns and note total scone oenw
Refer to definitions on back
c f INS street
L AGE O (1 p t) SO o r m ore years o ld Q (2 p i) 70-73 years o ld Research indicates the younger ig e group (70-79
years old) is le u lAefy to request
nursing assistance before
arising, therefore, biey am at granter n tk of fating.
III. DAY NUMBER OF STAY Q (2 p tx) Over J days Q i t p ts ) 1-3 days □ i O p i) Initial assessment
ft t case of fall)
IV. ELIMINATION
□ (4 pts.iCemplete bedrest O (0 p ts ) Independent Q (1 p t) Catheter Q (3 p ts ) Eim naton 0 (5 p ts ) Independent i
and conenert and/or ostomy with assistance A nccntmant ; pts
I
V. HISTORY OF FALLING WITHIN THE PAST SIX MONTHS _____ p «
QIC pts.) No history 0 (2 pts.) Has falen 1 or 2 tm es before Q (5 pis.) Multiple history of fating
X. MEDICATIONS
F*om me adore medication groups, nmcate how many the patient is curentty taking, cr tock prior lo aemission. _____ o ix
□ (0 pts.) No medicatton Q (1 p t) t medication Q (2 p tx ) 2 o r more medications
Q w ith a Change of m edication andror dosage ui me past five Cays, add 1 pomt lo tie m edoeoo score
COMMENTS: NS-13T
Rev. 1797
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228
APPENDIX D
BEHAVIORAL MAPPING STUDY DATA FORM
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229
230
APPEN DIX E
TRAVEL DISTANCE BETWEEN NURSE’S STATION
AND PATIENT ROOMS
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231
1rujvjivi
ROOM 269
287
ROOM
NURSING ocq
STATION - 268
T R A V E L D I S T A N C E _______________ ROOM
271
BETWEEN NURSING STATION
•f
RM 268 46 FT. R° ° M
RM272 38 FT.
RM273 52 FT.
RM 287 76 FT.
NORTH
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232
APPEN DIX F
PHOTOGRAPHS O F TH E SIX PATIENT ROOMS
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233
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234
APPENDIX G
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235
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236
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238
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239
A PPEN DIX H
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240
Characteristic Standard
Accuracy i% of 'eaarnq si! count
«£jc:udirg senso» ncrline.wry.
Err kSsi005 EN -0082*1 used w«tr» ^Mront* power *>upply .ind
RS-232 cade
EMI immunity EN-5GOA2 1
ESO lmmur«ty up to a *v
Characteristic i Standard
Dimensions 1rteujnt 198 mm f0 .ncnes/
. Wicth 93 mm *3 7 .nchesi
Depin 34 mrn »t 3 inches i
Wetgn: 1 4 %g (3 pcunasi
Sensor Range
J1803 0 3 to 300 000 Cdm*! iNit)
0 T to TQOOOO IL
J1805 0 Ot mcd to TO cd
J1806 0 0 0 1 to 200 W. m- ar
J1810 0 001 to 0 999 *y and uv coordinates
0 3 to 1000 cd/rTr2 (Nit)
0 t to 300 IL
J1811 0.01 to 5000 Lux (Irrvrm)
0 001 to 500 tc
jta i2 0 001 to 2000 mw.'m*
0 t nW to 0 2 m'.V
J1823 3 to 30.000 cdr'nt2 (Nit)
(Standard version)
t to 10.000 IL
J1823 30 to 30.000 cdrm2 tNitl
1Option 01)
TO to 10.000 IL
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241
Characteristic Standard
Characteristic Standard
Characteristic | Standard
: Operating: -15 : C ID C
Sectrcmagre’ic Com i Meets CISPIR 22B. FCC Class A and 7D£ Class B
j
patibility
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242
Display: 3 1/2 D i g i t L i q u i d C r y s t a l D i s p l a y w i t h a n a d d i t i o n a l
Q u a s i - A n a l o g u e 60 d B i n d i c a t o r in 2 d B i n c r e m e n t s . Level display
indicates to 0.1 dB resolution. Time display indicates either
MinrSec or Hr:Min. A n n u n c i a t o r s a r e in c l u d e d for B a t t e r y Check,
Hold, a n d O v e r l o a d Indication.
Microphones: R e m o v a b l e p r e c i s i o n 1/2 in c h p r e p o l a r i z e d c o n d e n s e r
(el e c t r e t ) m i c r o p h o n e is s t a n d a r d . O p t i o n a l 1/2 inch, o n e inch,
and other mic r o p h o n e s are available.
Preamp: Removable. T h e i n p u t i m p e d a n c e is g r e a t e r t h a n 1 G o h m in
p a r a l l e l w i t h 2 pF. T h e p r e a m p w i l l d r i v e u p t o 100 f e e t o f c a b l e
w ith no loss. ( S e e F i g u r e 14.)
Polarisation: R e g u l a t e d 2 0 0 V D C w i t h i n 2t w h e n u s i n g c o n d e n s e r
microphones. The voltage must be manually switched off w h e n using
p r e p o l a r i z e d c o n d e n s e r (electret) m i c r o p h o n e s .
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
243
Q U E S T TECHNOLOGIES
Reference SPL: 94 dB
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244
Batteries: T w o 9 - v o l t a l k a l i n e b a t t e r i e s ( N E D A 1604A) w i l l p r o v i d e
approximately 16 h o u r s of c o n t i n u o u s o p e r a t i o n . (8 h o u r s w i t h
o p t i o n a l f i l t e r se c . )
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245
ALNOR
VELOMETER
♦ 3% o f C u l l a c a l a , e x c e p t a b o v e 13CC
A C C U R A C Y (See note, below) CfH on e x h a u s t ( f l o w fr o m b a s s t o
hood) w h ic h is -4 4 o f f u l l s c a le
SUPPLY A N D E X H A U S T RANGES 250, 500. 1000, 2000 CFM lull
scale
(425. 850, 1700, 3400 Cubic
Meters/Flour)
M A X IM U M USABLE L IM IT 2000 CFM (3400 Cubic
Meters/Hr)
R E A D -O U T T IM E 4 to 8 seconds
S TA N D A R D O P EN IN G S 2X2. 2X4, 1X4, 1X5, 3X3 feet
DIM EN S IO N S Heighi 40 in.
Width, Depth—variable depend
ing on cloth hood size. Up to 5
ft. wide, 3 ft. deep at top open
ing
Base 17X17 in.
NOTE: Corrections may be required in two situations, to achieve
specified accuracy:
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ENGLEHARD
DATA LOGGER
C 0 2 MONITOR SPECIFICATIONS
Gas Sampling Mode: Internal Pump or Diffusion
Measurement Range- 0-10,000 ppm • Accuracy: ±5% reading
Repeatability: .±20ppm • Response Time:45 sec
Output (Linear, Programmable): 0-5 VDC
User InterfaceMBM Compatable Communication Software
Calibration Adjustments: Zero and Span
Data lnterface:RS-232 Serial Port
Recommended Cal Interval: One year
DATALOGGER SPECIFICATIONS
Number of Channels: 4 • Input Range: 0-5 VDC
Sampling Interval.:Selectable 10 sec, 60sec, 5 min, & 10 min
Pump:0.5 liter/min • Data Polnts:14,000 data points
Battery Type.Sealed lead-acid • Battery Operations hour
IBM compatible, DOS 5.0 or higher required.
OPTIONAL SENSORS
6H1058RH Relative Humidity Sensor. 20-95% RH * 5 accuracy
with 10 sec response time. 0-1 VPP cu'dui includes cnw**- *'-r
interconnection, 3.1" x 2.1* x 1.6
6H1058T Tem perature Sensor. ... ... _ r
minute response time. 0-1 VDC oufout. ;nci,;der c-i^'e'-
interconnection. 3.8" x 2.4" x 1.0"
6HP9PS110 Sensor, VOC. 1-500 p ^ i . i inyciuwutLijn c , —
± 5% accuracy. Metal oxide semiconductor sensor, self-cleaning
with 5 -y e a r service i r . , - i , c a b l e (or in»ercon~e.-».-e
4.5 x 3.1 X 1.4'
C A L IB h A f ION M A f t h l A Lb
6H60794 r, OS Cnni'ifer. nn-i moo -.nm I <vv rre-i^ure 1d
bottle
6H607au bdtnc i4tUOUt-"' Lu-
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
247
ENGLEHARD
DATA LOGGER
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
248
DATA LOGGER
D a ta Sam ples A c c u ra c y
O User-defined sample intervals, configuable 8 seconds to o NDiR CO , sensor is S% of the reading and is
once a week heated to 5CTCfor temperature stabilization
O Eitner continuous firsl-m first-out o r fiH-and-
stoo datalogging O p e ra tin g Ranges
O Memory capacity stores up to 32.768 samples ® Display o f C 0 2 0-1999ppm
O Logs all lour channels
O Recording o f CO2 to SOOOppm
® 5-95% non-condensing
Softw are (in clu d ed )
O Windows 3.1 8 Windows 95 Environment C h ara cte ristic s
O Allows for complete graphing, export, and
© Rugged metal enclosure
colour printing O Dimensions - 8 39" x 5 72" t 2 10’
Features Include: o Weight - 2 .9 lbs
O zoom, delayed start, and fast downloading.
O p tio n a l
Power Source O 18 hour battery
O 12V. 400mA
O 120V AC adapter I Included)
o On board sealed lead acid battery. 4 hour operating time.
- RechargedOvernight -
Sensors
Sensor CCh Tem perature R/H
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
249
RAYTEK
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250
APPEN DIX I
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251
Appendix 1.1______________________________________________________________________________
Temperature box-plot for patient rooms showing the median and range categorized by flooring type.
U.
<n
a
j __
o
ra
aj
CL
E
Flooring
C a rp et
r~ i vct
27t 272 273 287
P a tie n t R o o m s
Note: Shaded area represents the recommended range for temperature in hospital patient rooms by
ASHRAE 62-1999, Ventilation for Acceptable Indoor Air Quality, and ASHRAE Handbook of
Fundamentals, 1997.
Appendix I.2_____________________________________________________________________________
Relative humidity box-plot for patient rooms showing the median and range categorized by flooring
type.
70
eo>
-o
40 ■
X
I 30 •
73
1
20 a
F lo o r in g
1 C a rp e t
I I VCT
268 269 272 2 73 287
P a tie n t R o o m s
Note: Shaded area represents the recommended range for indoor relative humidity by ASHRAE 62-1999,
Ventilation for Acceptable Indoor Air Quality, and ASHRAE Handbook of Fundamentals, 1997.
Additionally, for thermal comfort for winter range (clothing value .9), dewpoint at 36 F.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
252
Appendix 1.3________________________________________________________________
Carbon Dioxide box-plot for patient rooms showing the median and range categorized by
flooring type.
15C0I
1400*
o
o
c
1300a
.o
■g 1200a J=L
8 . 1100.
H 1000-
4>
*o
I 9001
Cl
^ aoo.
CO
O 700a
F lo o n n g
600a fr« a |C J ip «
I I VCT
500a
268 260 271 272
P a tie n t R o o m s
Note: Dashed line represents the maximum level of Carbon Dioxide (parts per million) that usually results
in conditions conducive to comfort and the removal of odor from human generated pollutants as stated by
ASHRAE 62-1999, Ventilation for Acceptable Indoor Air Quality.
Appendix I.4__________________________________________________________________
Total volatile organic compounds box-plot for patient rooms showing the median and range
categorized by flooring type.
140
F lo o rin g
Eos 1 C a rp et
I I VCT
266 269 271 272 273
P a tie n t R o o m s
Note: Guidelines or standards have not been established for exposure to volatile organic compounds in
non-industrial indoor environments.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
253
Appendix 1.5
Bacteria count of colony forming units in each patient room categorized by flooring type.
O 100
O
ts
m
CQ
F lo o r in g
R S I C a rp q t
t IVCT
271 272
P a tie n t R o o m s
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
254
A PPEN DIX J
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255
J Single Occupancy □
v•Vf
Double Occupancy
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256
VITA
Debra D. Harris
EDUCATION
2000 Doctor of Philosophy, Architecture, Texas A&M University
1994 Master of Interior Architecture, University of Oregon
1986 Bachelor of Science, Interior Design,Southwest Texas State University
PROFESSIONAL POSITIONS
1/97 to 7/00 Design Consultant, Austin, TX
4/95 to 12/96 Design Consultant, Seattle, WA
2/90 to 10/92 Project Manager, Mitchell & Mitchell, Houston, TX
10/88 to 2/90 Project Manager, Trammell Crow Company, Houston, TX
9/87 to 10/88 Interior Designer, KSD Architectural Associates, Ft. Walton Beach, FL
3/83 to 6/87 Contract Interior Designer, Austin, TX
ACADEMIC POSITIONS
8/99 to 12/99 Lecturer, University of Texas, School of Architecture
8/97 to 5/99 Assistant Lecturer,Texas A&M University, College Of Architecture
8/94 to 5/95 Assistant Professor, University Of North Texas, School Of Visual Arts
9/92 to 3/94 Graduate Teaching Fellow, University Of Oregon, School of Architecture
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.