Chapter 1

INTRODUCTION TO THE STUDY

Chapter 1 has six parts: (1) Background of the study, (2) Theoretical

Framework of the Study, (3) Statement of the Problem and the Hypothesis,

(4) Significance of the Study, (5) Definition of Terms, and (6) Delimitation of the

Study.

Background of the Study

One of the major issues confronted by healthcare institutions is living up to

patient’s satisfaction. Patients satisfaction is defined as the subjective perception

of care, often times used as a determiner of the degree of congruency between a

patient’s expectation of ideal care and his or her perception of the real care he or

she receives. (Ganova-Ioloska, et al.,2008). A number of researches has tried to

correlate such with variables, commonly age, sex, the level of education,

employment, income and mental status.

Environment is defined in the context of the manner in which a facility,

specifically a health care institution is physically maintained. These include areas

such as lighting, cleanliness and noise. All of these are then known to influence

the kind of care the patient receives.

Patients who are satisfied upon their previous hospital stay opts to come

back when the need arises to the health institution if the hospital has consistent
 2

environmental assurance. Thus, the environment becomes a significant concern

for the hospital management. It is also the management’s responsibility to ensure

that the physical environment is competent in terms of lighting, ventilation and

noise.

The hospital, usually those who receives poor appropriations, is a place

where sick people are admitted. Most especially in government controlled and

owned hospitals, the bed space is crowded because of either low financial

support from the state or the almost implausible influx of patients. These

scenarios often lead to effects where in ventilation can be poor, insufficient

lighting and including waste management.

As the hospital is a place of refuge, a sanctuary, ill bodies and spirits are

cared upon and tended. Thus, it needs to be ventilated, well- lighted and noise

free to ensure optimal recovery from the patient. Recovery then is hastened.

There were efforts undertaken to promote healthy living practices through

environmental manipulation but it was found out that only a minority of these was

fully understood and they were not rampantly practiced.

Outside of the country, there were studies on the environmental factors

like ventilation, lighting and noise. However, a few to none of these studies were

found to be existing in the Philippines.

Theoretical Framework of the Study

This study is anchored on the Environmental Theory of Florence

Nightingale. Nightingale viewed patient care as an activity that focused on

 3

environmental manipulation of individuals and family, both sick and well since

Nightingale realized that the environment had a great impact on a person’s

health. She also emphasized the need for ventilation and light in sickrooms,

proper disposal of sewage and she highlighted the benefit of good environment

in preventing illness. The purpose of the theory was “everyday sanitary

knowledge or the knowledge of nursing or in other words,of how to put the

constitution in such a state that it will have no disease or that it can recover from

disease(Nightingale, 1859/1992,preface)

Nightingale believed and proposed that manipulation of physical

environment is a major component of nursing care. She identified that health of

houses, ventilation and warming, appropriate sunlight, noise, variety, bed and

beddings ,cleanliness of rooms and walls, personal cleanliness and nutrition are

the major areas of environment the nurse could control. In times of imbalance,

the client then must utilized increase energy in order to combat environmental

stress, are these exhausted the client’s energy for recovery.

The omission of any of these factors can retard, if not impede, the

recovery process. One of Nightingale’s primary concern was about “noxious air”

or “effluvia” or foul odors that came from excrement. Raw sewage can be near

patients pr contaminated drinking water. Her concerns about foul odors also

include bedpans, urinals, and other utensils use to discard excrement.Nightingale

also criticize “ fumigations” for she believed that the source not the smell must be

removed. Another important point stressed is the importance of room

temperature. The patient should not be too cold or too warm. Clean air was also
 4

given importance since at that time coal heating in the homes are causing poor

ventilation. She even called clean air and good ventilation as the first canon of

nursing.

Second to fresh air, the recovering patients need light. She also noted that

direct sunlight was what patients wanted ad needed. Even if there was not

enough scientific proof, Nightingale noted that light has “quite real ad tangible

effect upon the human body” (George, 2002). The sick rarely lies with their face

toward the wall but are much more likely to face the window, the source of the

sun. Furthermore, appropriate environmental stimuli may be contributory to the

development of intensive car psychosis or confusion related to lack of

accustomed cycling of day and night.

Noise was a concern of Nightingale, most notably those noises that would

disturb the patient. Even to the slightest of noises like window shade blowing

against the window frames, she was critical about them. She believed it as a

nurses responsibility to asses and stop this kind of noise .Although there were

specific testing of the effects of the noise has been done it has not been under

the framework of Nightingale.

Nightingale was an advocate of disease prevention and health promotion.

She believes strongly that a patient’s emergent needs must be first met before

healing is possible. She stated that the nurses role include physical environment

manipulation as one of the means to improve patient’s recovery. And that

 5

nursing” ought to signify the proper use of fresh air, light and noise-all at the least

expense of vital power to the patient”(George 2002).

Figure 1 presents the conceptual framework of the study.

ANTECEDENT INDEPENDENT DEPENDENT

VARIABLE VARIABLE VARIABLE

Personal
Characteristics

 Age Physical Environment Level

 Sex
 Light of
 Civil Status
 Ventilation
 Educational Satisfaction
 Noise
Attainment
 Family Monthly
Income

Figure

1.Level of Satisfaction of patients as influenced by certain factors.

 6

Statement of the Problem and Hypotheses

This study aims to determine the physical environment and level of

satisfaction of Patient’s in a district hospital.

Specifically, the study seeks to:

1. Describe the personal characteristics of the patients according to (a) age,

(b) sex, (c) civil status,(d) educational attainment, and (e) monthly family

income.

2. Determine the physical environment, such as: (a) light, (b) ventilation, and

(c) noise.

3. Determine the patient’s level of satisfaction regarding the physical

environment.

4. Determine if there is a significant difference between the personal

characteristics of the patients and the physical environment.

5. Determine if there is a significant difference between the physical environment

and the patient’s level of satisfaction.

6. Determine if there is a significant difference between the personal

characteristics of the patients and the level of satisfaction.

 7

Based on the aforementioned problems, the following hypotheses are advanced:

1. There is no significant difference between the personal characteristics of

the patients and the physical environment.

2. There is no significant difference between the physical environment and

the patient’s level of satisfaction.

3. There is no significant difference between the personal characteristics of

the patients and the level of satisfaction.

Significance of the Study

Results of the study may be beneficial to the patients, staff nurses, nurse

managers, hospital administrator, the hospital as an organization, nursing

education and future researchers.

Patients.The result of this study will provide feedback information to the

institution in identifying what environmental factors need improvement, and

based on these they can design and evaluate appropriate interventions

alternatively that would increase patient’s satisfaction. When the environmental

factors are given high regards fast recovery of patients may be observed and

infections may be minimized. This will surely contribute to the improvement of

their conditions.

Staff Nurses. The results of this study can serve as basis for the staff’s

evaluation of quality service, and enhance the effectiveness of care rendered to

 8

the patients. This will provide basis for suggesting strategies in modifying aspects

of work environment to promote positive attitude.

Nurse Managers. The result of this study could review the performance of their

staff, correct the service that need to be improved for the patient’s welfare and

acknowledge the great employee performance that result to effective delivery of

services. Knowledge from the result can also help policy makers make more

effective policy and program.

Hospital Administrator. The results of this study can serve as basis for

administrators in monitoring the ongoing quality of care being delivered by

improving the services provided. This is to achieve its purpose of resulting to

increase patient satisfaction.

The hospital as an organization. The result will provide information that will allow

the institution to modify and enhance the facilities and health care services that

could lead to patient’s wellness and satisfaction.

Nursing Education. The result of the study can serve as a guide on what should

be included in the health teachings regarding cleanliness and hospital waste

management. They can also initiate efforts in implementing standard protocol for

hospital cleanliness.

Future Researchers. This study may be further used as a baseline information for

future researchers. Also, the overall findings could lend support, or be a

contradiction to existing theories, or bring about the development of a better one.

 9

Definition of Terms

For the purpose of clarity and understanding, the following terms were

given their conceptual and operational definitions.

Antecedent variables

Age-- The length of time that one has existed or duration of life.

In this study, Age refers to the age of the respondent as of his/her last

birthday.

Sex--The property or quality by which organisms are classified as female or male

on the basis of their reproductive organs and functions.

In this study, Sex refers to the biological classification as either male or

female.

Civil Status--The position or standing of a person in relation to marriage.

In this study, Civil Status refers to status of the respondents whether

theyare married or is living with a legal partner or single or never been married,

divorced and separated.

Educational Attainment-- the highest degree of education an individual has

completed.

In this study, educational attainment refers to the level of highest level or

education completed whether elementary, secondary or college.

 10

Monthly Family Income-- the monetary payment received for goods or services,

or from other sources, as rents or investments of the family in a month.

In this study, monthly family income refers to the monthly monetary

remunerations in peso generated by the all the members of the family in a month.

Independent Variables

Ventilation-- process of "changing" or replacing air in any space to provide high

indoor air quality.

In this study, Ventilation refers to the architectural aspect of the hospital

that allows quality of air to circulate. This is measures by a 5 item researcher

made questionnaire. Each item is answerable by any of the following responses:

4- Strongly Agree, 3 Agree 2-Disagree, 1 Strongly Disagree.

Light-- the total frequency spectrum of electromagnetic radiation.

In this study light refers to the direct exposure to any light forms including

sunlight, light bulb and alike. This is measures by a 5 item researcher made

questionnaire. Each item is answerable by any of the following responses: 4-

Strongly Agree, 3 Agree 2-Disagree, 1 Strongly Disagree.

Noise-- Sound or a sound that is loud, unpleasant, unexpected, or undesired.

In this study noise refers to the unnecessary sound that disturbs the

patient’s recovery. This is measures by a 5 item researcher made questionnaire.

Each item is answerable by any of the following responses: 4- Strongly Agree, 3

Agree 2-Disagree, 1 Strongly Disagree.

 11

Dependent Variable

Patient’s Satisfaction--measurement of the quality customer service provided to

the patient during the hospital stay.

In this study patient’s satisfaction is the dependent variable ad it refers to

how well the needs and desires of the patients with regards to the physical

environment have been met.

Delimitation of the Study

This study aimed to determine the physical environment and level of

satisfaction of patient’s at Sara District Hospital in Iloilo.

The descriptive-correlational study design was used in this study.

The antecedent variables of the study were age, sex, civil status,

educational attainment and monthly family income; the independent variable is

the physical environment in terms of Ventilation, light and noise, while the

dependent variable is the level of patient’s satisfaction.

The data needed for this investigation was gathered through an instrument

specifically constructed by the researchers. To describe the data gathered, the

and frequency and percentage was used as descriptive analysis; Chi-square and

Gamma set @ 0.05 alpha level will be employed as inferential analysis.

All statistical computations were processed through the use of Statistical

Package for Social Science (SPSS) software.

 12

Chapter 2

REVIEW OF RELATED LITERATURE

This chapter is divided into five parts, namely: (1) Ventilation, (2) Lighting,

(3) Cleanliness, (4) Noise and (5) Patient Satisfaction.

VENTILATION

According to a study made by Hellgren, et. al (2011), good ventilation is

important in hospitals than any other buildings. The results of the study showed

that in the hospitals where a majority of the ventilation systems were assessed to

be good, the prevalence of the indoor air-related complaints and symptoms was

lower than in hospitals where the majority of the ventilation systems were

assessed as needing extensive repairs. These indoor air-related complaints and

symptoms are usually of the infectious origin which are caused by

microorganisms thriving in the hospital air. According to Ulrich, et. al (2004),

hospital air quality and ventilation play decisive roles which affects pathogen

concentration of air. One example of such pathogens is the Aspergillus, a fungal

spore. In addition to, factors such as type of air filter, direction of air flow, air

pressure,air changes per hour in room humidity and ventilation system cleaning

and maintenance are proved to be linked to air quality and infection rates. As per

airborne pathogen transmission, Joseph (2006) elaborated the mechanism

 13

further in three ways. First, when an environmental reservoir of a pathogen is

disturbed, it will trigger the release of fungal spores into the air which in turn

makes their way across the hospital environment. The microbes can also be

spread directly from one person to another via the droplets in the air produced

from coughing and sneezing within three to six feet. Other infectious diseases

like tuberculosis are transmitted through suspended droplets in the air and these

can transmitted over long distances. Second, Joseph said the sources of

airborne pathogens are numerous and even includes construction and renovation

activities. Aspergillus survives in air, dust and moisture which are usually present

in health care facilities and can be released into the air whenever there are

constructions and renovations. The third and last way is the ventilation system

contamination and malfunction. There are several studies that proved how the

accumulation of dust and moisture within HVAC (Heating, Ventilation, Air

conditioning) systems increases the risk for the spread of environmental

pathogens.

In July 2011, Pennsylvania State University through its Architectural

Engineering Department, performed a thorough and detailed study on evaluating

the potential of transmission via ventilation systems. Using a computer program

to determine the risk of contracting a respiratory disease for an average person

in an office building, they devised a hypothetical case wherein a highly infectious

tuberculosis patient was placed on the first floor of a ten-story office building. The

building was equipped with a ventilation system that supplied 20% outdoor air,

which is in accordance to the American society of Heating, Refrigeration and Air

 14

conditioning Engineers guidelines. No high efficiency particulate air were used or

any reduction methods. The results concluded that after eight hours of exposure,

a person on the tenth floor would have 33% risk of contracting tuberculosis.

However, it is important to note that such scenario may occur rarely in

workplaces which have a poor screening of tuberculosis positive employees.

A study of eight hospitals in Lima, Peru was conducted by Escombe et.al

(2007) to investigate the rates, determinant and effects of natural ventilation in

health care settings. Five of the hospitals were of the old-fashioned design built

before the 1950s and three were of modern designs built from1970-1990s. In

these hospitals, the 70 naturally ventilated rooms, housing the infectious patients,

were studied. These rooms included the respiratory isolation rooms, TB wards,

respiratory wards, general medical wards, outpatient consulting rooms, waiting

rooms, and emergency departments. They were then compared to the 12

mechanically ventilated negative-pressure respiratory isolation rooms built after

the year 2000. Ventilation was measured using a carbon dioxide tracer gas

technique in 368 experiments. Architectural and environmental variables were

measured. For each experiment, infection risk was estimated for TB exposure

using the Wells-Riley model of airborne infection. The studies discovered that

opening windows and doors provided median ventilation of 28 air changes/hour

(ACH), more than double that of mechanically ventilated negative-pressure

rooms ventilated at the 12 ACH recommended for high-risk areas, and 18 times

that with windows and doors closed (p < 0.001). Facilities built more than 50

years ago, characterized by large windows and high ceilings, had greater
 15

ventilation than modern naturally ventilated rooms (40 versus 17 ACH; p <

0.001). Even within the lowest quartile of wind speeds, natural ventilation

exceeded mechanical (p < 0.001). The Wells-Riley airborne infection model

predicted that in mechanically ventilated rooms 39% of susceptible individuals

would become infected following 24 hour of exposure to untreated TB patients of

infectiousness characterized in a well-documented outbreak. This infection rate

compared with 33% in modern and 11% in pre-1950 naturally ventilated facilities

with windows and doors open. Thus, the study concluded that the traditional

means of opening windows and doors would actually maximize natural ventilation

that the risk of airborne contagion is much lower and the price is much cheaper

compared to the maintenance-requiring mechanical ventilation systems. Old-

fashioned clinical areas with high ceilings and large windows provide greatest

protection. Natural ventilation costs little and is maintenance free, and is

particularly suited to limited-resource settings and tropical climates, where the

burden of TB and institutional TB transmission is highest. In settings where

respiratory isolation is difficult and climate permits, windows and doors should be

opened to reduce the risk of airborne contagion.

According to a review by Seppanen and Fisk (2004), ventilation is

necessary to remove indoor-generated pollutants from indoor air or dilute their

concentration to acceptable levels. At the same time, ventilation may also have

harmful effects on indoor air quality and climate if not properly designed,

installed, maintained and operated. Ventilation may bring indoors harmful

substances or deteriorate indoor environment. Ventilation is said to have positive

 16

impacts on health and productivity of building occupants. Good ventilation

decreases the chances of transmission especially with airborne infectious

diseases. In an office environment, a ventilation rate up to 20-25 L/s per person

seems to decrease the prevalence of SBS-symptoms. Air conditioning systems

may increase the prevalence of SBS-symptoms relative to natural ventilation if

not clean. In residential buildings the air change rate in cold climates should not

be below app. 0.5 ach. Ventilation systems may cause pressure differences over

the building envelope and bring harmful pollutants indoors.

The abovementioned studies are generalized together with the several

others conducted regarding air quality, comfort and health by the Euroven. They

gathered together different literatures and judged the findings conclusive, that

ventilation is strongly associated with comfort (perceived air quality) and health

[Sick Building Syndrome (SBS) symptoms, inflammation, infections, asthma,

allergy, short-term sick leave], and that an association between ventilation and

productivity (performance of office work) is indicated. The group also concluded

that increasing outdoor air supply rates in non-industrial environments improves

perceived air quality; that outdoor air supply rates below 25 l/s per person

increase the risk of SBS symptoms, increase short-term sick leave, and decrease

productivity among occupants of office buildings; and that ventilation rates above

0.5 air changes per hour (h-1) in homes reduce infestation of house dust mites in

Nordic countries. The group concluded additionally that the literature indicates

that in buildings with air-conditioning systems there may be an increased risk of

SBS symptoms compared with naturally or mechanically ventilated buildings, and

 17

that improper maintenance, design, and functioning of air-conditioning systems

contributes to increased prevalence of SBS symptoms.

LIGHTING

A study by Wunsh et.al (2011) was conducted to determine the effect of

window rooms on critically ill patients with subarachnoid hemorrhage admitted to

intensive care units. Seven of the ICU rooms had windows while the other five

did not. The admission to these rooms was merely based on availability. The

data was analyzed from 789 patients with subarachnoid hemorrhage from August

1997 to August 1998. Patient information was recorded prospectively at the time

of admission, and patients were followed up to 1 year to assess mortality and

functional statusm classified whether they were under the care of the ICU that

had windows or not. Results showed that of the 789 patients, 455 or 57.7%

received care in a window room while 334 or 42.3% received care in a non-

window room. The two groups were balance in terms of all patient and clinical

characteristics. It was soon found out that there was no statistical difference in

modified Rankin Scale score at hospital discharge, 3 months or 1 year (44.8%

with mRS scores of 0 to 3 with window rooms at hospital discharge versus 47.2%

with the same scores in non-window rooms at hospital discharge; adjusted odds

ratio 1.01, 95% confidence interval, 0.67 to 1.50, P-0.98; 62.7% versus 63.8% at

3 months, aOR 0.85, 95% CI 0.58 to 1.26, P=0.42; 73.6% versus 72.5% at 1

year, aOR 0.78, 95% CI 0.51 to 1.19, P=0.25). Also, there were no difference in

the secondary outcomes which included the length of mechanical ventilation,

time until the patient was able to follow commands in the ICY, need for
 18

percutaneous gastrostomy tube, ICU and hospital length of stay, nd hospital 3-

month and 1 year mortality. Thus it was revealed that the presence of a window

in an ICU room did not improve outcomes for critically ill patients with

subarachnoid hemorrhage admitted to ICU. Further studies are suggested to be

undertaken in order to ascertain if there is really a benefit derived from sunlight or

natural light for patients with acute brain injury.

Despite the insignificance of the light factor in subarachnoid hemorrhage

patients, it is quite different for Dementia patients. Marum RJ (2008) performed a

research on the symptomatic treatment of dementia. It was described that the

effects of long-term daily treatment with whole-day bright light in elderly patients

with dementia, with or without the addition of melatonin (2.5 mg daily), on

cognition, mood, behavioral symptoms, activities of daily living and sleep. The

study concluded that light has a most benefit in improving some of the cognitive

and non-cognitive symptoms of dementia. Increasing light intensity in the living

rooms of patients with dementia is an easy step and cheap intervention with

possible effects on at least some patients.

In 2007, Stevens et.al conducted a study on the impact of architectural

design upon the environmental sound and light exposure of neonates who

require intensive care. The main objective of the study was to evaluate the

differences in environmental sound, illumination and physiological parameters in

the Boekelheide Neonatal Intensive Care Unit (BNICU), which was designed to

comply with current recommendations and standards, as compared with a

conventional neonatal intensive care unit (CNICU). The results of the study
 19

showed that median sound levels in the unoccupied BNICU (37.6 dBA) were

lower than the CNICU (42.1 dBA, P<0.001). Median levels of minimum (6.4 vs

48.4 lux, P<0.05) and maximum illumination (357 vs 402 lux, P<0.05) were lower

in the BNICU. A group of six neonates delivered at 32 weeks gestation showed

significantly less periodic breathing (14 vs 21%) and awake time (17.6 vs 29.3%)

in the BNICU as compared to the CNICU. Such data lead to the conclusion that

light and sound were both significantly reduced in the BNICU. Care in the BNICU

was associated with improved physiological parameters.

James Watt of Royal Science Medicine in his article on The Ventilation,

Heating and Lighting of Hospital Wards said that much importance is being

attributed to the effect of sunlight to health and on such diseases such as

tuberculosis and rickets. The supply of artificial lights should not be niggardly.

General ward lighting, by reflection from the ceiling, can be made quite

satisfactory when carefully arranged but wall lighting is preferred. Electric light

should be supplied Electric light should be supplied over each bed by a wall

bracket and a shaded lamp, with the switch accessible to the patient. Such a light

at a height of approximately 6 ft. from the floor, and of not less power than 25

watts, will provide for comfortable reading by the patient, and for nursing

attention and treatment by the staff, without glare affecting other patients. In two

hospitals known to me, these bracket lights -have their broad base detachable

from a flat hook on the wall, thus providing all the advantages of a movable side-

light for examining throats or eyes or skin rashes. They have, however, the

disadvantages of dangling flexes, collecting dust, and it is more usual to prefer a

 20

fixed wall light over each bed and, between each pair of beds, a point into which

to plug a side-light. Dr. Gordon Pugh, of Queen Mary's Hospital, Carshalton,

recommends a less expensive alternative, by which the interval between

windows is wide enough to take two beds. One wall bracket light with a spherical

white glass shade is shared between the two beds. The light is thus oblique, and

does not cause glare to a recumbent patient. With a system of lights over bed

heads, very few central lights are needed for general illumination in large wards,

perhaps one over a sterilizer table or drug cupboard and one over a fireplace for

the use of ambulant patients. A shaded light must be provided over the nurse's

table and one or two ceiling lights with inverted shades as night lights. The

switches for the latter should be separated from the other switches to prevent

bright lights being switched on in mistake at night.

Illumination from electric lighting in the built environment is quite different

from solar radiation in intensity, spectral content, and timing during the 24-hour

daily period. Stevens and Rea (2008) conducted a study regarding the light in the

built environment: potential role of circadian disruption in endocrine disruption

and breast cancer. The study revealed that Electric lighting in the built

environment is generally more than sufficient for visual performance, but may be

inappropriate for the maintenance of normal neuroendocrine rhythms in humans;

e.g., insufficient during the day and too much at night. Lighting standards and

engineering stress visual performance, whereas circadian function is not

currently emphasized. The molecular biological research on the circadian clock

and on mechanisms of photo-transduction makes it clear that light for vision and
 21

light for circadian function are not identical systems. In particular, if electric

lighting as currently employed contributes to `circadian disruption' it may be an

important cause of `endocrine disruption' and thereby contribute to a high risk of

breast cancer in industrialized societies.

In 2003, Ancoli-Israel et.al tried to find out if what mechanism is behind

how increased light exposure consolidates sleep and strengthens circadian

rhythm in severe Alzheimer disease patients. Sleep in the nursing home

environment is extremely fragmented, possibly in part as a result of decreased

light exposure. This study examined the effect of light on sleep and circadian

activity rhythms in patients with probable or possible Alzheimer's disease.

Results showed that both morning and evening bright light resulted in more

consolidated sleep at night, as measured with wrist actigraphy. Evening light also

increased the quality of the circadian activity rhythm, as measured by a 5-

parameter extended cosine model (amplitude, acrophase, nadir, slope of the

curve, and relative width of the peak and trough). Increasing light exposure

throughout the day and evening is likely to have the most beneficial effect on

sleep and on circadian rhythms in patients with dementia. It would behoove

nursing homes to consider increasing ambient light in multipurpose rooms where

patients often spend much of their days.

A study was conducted by Joonho Choi et.al (2004) egarding the effects

of daylight on patient outcome in a healthcare facility. This study investigates

how indoor daylight environments affect patient Average Length of Stay (ALOS),

by evaluating and analyzing daylight levels in patient rooms in comparison to

 22

their ALOS. The patient ALOS data were taken at one general hospital in Inchon,

Korea and the other in Bryan, Texas, U.S.A.; physical, environmental and day-

lighting conditions were assessed at each building site. The gathered data were

analyzed using SPSS statistical package to determine the trends in patient′s

length of stay in hospital wards with 95% and 90% statistical significances. The

data were categorized based on the orientation of a patient room and were

compared between different orientations and types of patient rooms in the same

ward of each hospital. Selected hospital wards were classified based on their

orientations and types of patient rooms. The other variables considered in the

study were: the differences in day-lighting environments (illuminance, luminance

ration, daylight factor, diversity and uniformity of illuminance), and physical

environment properties of the patient rooms of each hospital, and how these

affected patient ALOS in both locations (Inchon and Bryan). To analyze the day-

lighting environment, on-site measurements, RADIANCE simulations and

physical scale model measurements were conducted. This study also

investigated patient feelings and opinions, and their preferences in day-lighting

environments with the questionnaire survey. Through this study, three

hypotheses were tested and was evidence for the following conclusions. First,

there may be a positive relationship between indoor daylight environments and

ALOS. Second, seasonal weather differences cause different indoor day-lighting

levels and may influence the length of patient hospitalization. Third, overall

patient satisfaction and reactions to patient rooms may be related with indoor

daylight environments. More controllable shading devices, naturally lighted

 23

indoor environments, and glare prevention create positive outcomes for patient

ALOS and visual comfort. To increase the validity and confidence about the

positive effects of daylight on human physiological conditions, further studies are

necessary which provide more samples, facilities and other variables.

CLEANLINESS

One of the most important factors in preserving health is cleanliness.

According to Irvin Tristen (2010), a hospital is a place where people come to be

treated and cured, not to be introduced to a whole new set of diseases. More

evidence is emerging about the importance of cleanliness in hospitals and its

impact on preventing infection. Novel biocides, antimicrobial coatings and

equipment are available, many of which have not been assessed against patient

outcome. Cleaning practices should be tailored to clinical risk, given the wide-

ranging surfaces, equipment and building design. There is confusion between

nursing and domestic personnel over the allocation of cleaning responsibilities

and neither may receive sufficient training and/or time to complete their duties.

Since less labourious practices for dirt removal are always attractive, there is a

danger that traditional cleaning methods are forgotten or ignored. Few studies

have examined detergent-based regimens or modelled these against infection

risk for different patient categories. Fear of infection encourages the use of

powerful disinfectants for the elimination of real or imagined pathogens in

hospitals. Not only do these agents offer false assurance against contamination,

their disinfection potential cannot be achieved without the prior removal of

organic soil. Detergent-based cleaning is cheaper than using disinfectants and

 24

much less toxic. Hospital cleaning in the 21st century deserves further

investigation for routine and outbreak practices.

According to Patel (2004), there has been a lot of literatures in recent

years about the lack of environmental cleanliness in hospitals. The House of

Lords Select Committee (1998) talked about falling standards in hospital cleaning

and, more recently, the government acknowledged in The NHS Plan

(Department of Health, 2000) that hospitals were unacceptably dirty. Such

comments may affect people's perceptions of hospitals and, rather than

regarding them as safe environments that promote healing, they may be viewed

as dangerous places that might cause vulnerable patients greater harm. While it

is known that about 10 per cent of hospital inpatients have a nosocomial infection

at any one time (Emmerson et al, 1996), there is uncertainty about whether there

is a sound evidence base to support the theory that dirty hospitals cause

infection.

There is a growing recognition of the relationship between the effective

cleaning of hospitals and long-term care facilities and the health and safety of

both patients and staff. The national Canadian Nosocomial Infection Surveillance

Program (CNISP) “in the past 5 years has documented a significant increase in

the number of patients colonized or infected with MRSA.” A Welsh study

evaluating hospital cleaning regimes and standards argues that there is “no

doubt that environmental surfaces can act as a source of pathogens which can

give rise to nosocomial [hospital-acquired] infections”.

 25

Revised hospital infection control guidelines highlight the importance of

high standards of ward cleaning to stop the spread of methicillin-resistant

Staphylococcus aureus. British infection control doctors argue that instead of

attempting to apply limited MRSA control measures, which are impossible to

achieve, infection control has a duty to press for investment in cleaning. For

example, Rampling et al. found that despite aggressively applied infection control

measures, a 21-month outbreak of infection/colonization with MRSA on a male

surgical ward in Dorchester could not be controlled.Increasing the cleaning hours

to almost double the usual level and allocating responsibility for the cleaning of

ward medical equipment finally terminated the outbreak. Environmental surveys

found that “radiators, medical equipment and furniture were the most frequently

contaminated sites”. The cleaning time was increased from 66.5 hours to 123.5

hours per week on the 37-bed ward, with an emphasis on dust control and

vacuuming. Additionally, radiators and ventilation grills were cleaned every 6

months. The study concludes that a dusty ward is an important source of MRSA

infection for surgical patients and that “a high standard of hygiene should be an

absolute requirement in hospitals. In the long term, cost-cutting on cleaning

services is neither cost-effective nor common sense.” Similarly, an outbreak of

MRSA in a Scottish surgical unit was attributed to sub-optimal cleaning (one

cleaner for two hours daily). “The outbreak, involving fourteen patients was

halted by the institution of a major cleaning programme in all areas of the unit

and improvements in the ward fabric.” Scottish Drs. Corcoran and Kirkwood

argue that resources should be more effectively directed on “areas of more

 26

fundamental importance, including education, cleaning and the improvement and

maintenance of ward fabric”, rather than being diverted to controlling MRSA

outbreaks. Also inreferrence to general cleaning, a seven-year study by Zafar et

al. examined the incidence of hospital-acquired infections in an American

hospital. The study concluded that “there was a sustained decrease in

nosocomial C. difficile, when cleaning was included as a major part of an

aggressive infection control program.”

But despite the connection between cleanliness and infection control,

there are studies that prove otherwise. Green et.al (2006), conducted a study

that tried to establish the relationship between cleanliness and methicillin-

resistant staphylococcus aureus bacteremia rates. Publicly available data for all

National Health Service hospitals in England were used to examine whether

there is a link between hospital cleanliness and rates of methicillin-resistant

Staphylococcus aureus (MRSA) bacteremia. It was not possible to demonstrate a

consistent relationship between hospital cleanliness, as measured by weighted

Patient Environment Action Team (PEAT) scores, and the incidence of MRSA

bacteremia. The large sizes of the data sets make it unlikely that a true

correlation was missed. While a high standard of hospital cleanliness is a

worthwhile goal, it is not helpful to repeatedly link MRSA control measures with

improvements in standards of environmental cleanliness.

 27

NOISE

Noise in hospitals is a significant problem that is generally getting worse,

even in new construction. High noise levels in hospitals can potentially contribute

to stress and burnout in hospital staff, reduced the speed of patient wound

healing, And there is legitimate concern that hospital noise can negatively affect

speech communication and cause and increase number of medical errors. There

are several interesting issues that impact hospital noise. Since 1960, there has

been a clear trend for rising hospital noise levels. The situation has been

worsening steadily. Also, none of the published results show compliance with

established standards for hospital noise. For example, the World Health

Organization (WHO) suggests different noise levels during daytime and night

time that commensurate with health promotion. In addition, there is remarkably

little variation throughout the world for noise levels in different types of hospitals,

from major research facilities to smaller community hospitals. This suggests that

the problem of hospital noise is universal, and that noise control techniques

might also be expected to be applied broadly. Conventional acoustical treatments

are used sparingly in hospitals because it is believed that sound absorbing

materials with pores harbor bacteria. Instead, smooth, hard, flat are used

because they are easy to clean. Consequently, these surfaces are acoustically

reflective and serve to aggravate existing noise problems. Any acoustical

treatments in hospitals noy only face great noise abatement challenges, but must

also meet the, the most stringent hygienic standards (J. West, 2008).
 28

A study conducted by Tarahironchut (2011) on the effect of noise block

using earplugs on propofol sedation requirement during extracorporeal shock

wave lithotripsy (ESWL). The objective is to determine the effect of noise block

using earplugs on reducing propofol infusion needed to maintain a constant

bispectral index (BIS) values in patients undergoing ESWL. Fifty-eight patients

(18-65 years of age) with nephrolithiasis undergoing ESWL, having ASA physical

status I or II and have normal hearing function tested by audiometry were

enrolled in this randomized, double-blind, controlled trial. Patients were

randomized and allocated into two groups: noise blocked group (earplugs

inserted into both ears) and control group (earplugs not inserted). Sedation by

target-controlled infusion was started at 1.2 mcg/ml of propofol target

concentration was adjusted gradually by 0.2 mcg/ml every 5 minutes

intraoperaatively to achieve and maintain bispectral index (BIS) values within 75-

80% until the procedure finished. Total amount of propofol (mg), BIS values (%),

ambient noise level (dB) and patient satisfaction (1-5) were measured. Results

showed that he amount of propofol infusion needed to maintain a constant BIS

index value in patients undergoing ESWL in the noise blocked group was

significantly lower than that in the control group. Patient satisfaction was similar

in both groups. Noise diminution in ambient operating room can reduce the

amount of propofol needed to maintain light sedation during ESWL.

Noise is an environmental stressor that is known to have physiological and

psychological effects. The body responds to noise in the way it responds to

stress and overtime can impair health. Research shows that hospital noise levels
 29

exceed noise level recommendation and has the potential to increase

complications in patients. What is less known is the effect of these hospital

noises on nurses. Because nurses spend more time in hospitals over the course

of their career, they experience most of the burden from excessive occupational

noise levels. Nurses must advocate not only for a healthy work environment but

also for healing environment, for themselves as well as their patient (Nursing

Administration Quarterly, 2010).

According to Choiniere (2007), the WHO recommends that the average

background noise in hospitals should not exceed 30 dB(A) weighted in decibels,

and that peaks during night-time should be less than 40 dB(A). Noise in hospitals

and particularly in intensive care units (ICUs), frequently exceeds these values.

The United States Environment Protection Agency in fact defines noise as “any

sound that may produce an undesired physiological or psychological effect in an

individual or group.” Noise affects both staff and patients. It may impede

concentration and cognitive function. It interferes with effective communication

and may thus increase the risk of accidents. The critically ill are particularly

sensitive to the disruption of sleep by noise. Especially for the elderly and hard of

hearing, noise may hinder communication and impair understanding of their

environment. It may also potentially contribute to the abnormal thought process

and behaviour associated with ICU delirium.

Prolonged exposure to environment noise may lead to sleep deprivation,

anxiety and stress ultimately affecting patient safety. Sudden noise, such as a

dropped tray or slammed door, may cause a “startle reflex” in patients, that leads
 30

to physiological responses such as facial grimacing, muscular flexion, increased

blood pressure, higher respiratory rate, and vasoconstriction (Cmiel, et al., 2004).

Patients exposed to continuous extraneous noise can also experience altered

memory, increased agitation , less tolerance for pain, and feelings of isolation.

People who work in noisy environment for extended shifts, day in and day out,

also have similar stress-induced experience (Penny & Earl, 2004). They report

everything from exhaustion to burnout, depression, reduced efficiency,

decreased productivity and irritability expressed at home. Interfering and

distracting sounds have been shown to contribute to medical and nursing errors

and Joint Commission agrees stating that the sound environment should not

exceed the level that would prohibit clinicians from clearly understanding each

other (Julie Twiss, 2001).

LEVEL OF SATISFACTION OF PATIENTS

Hospital Environment Services is about more than just cleanliness – your

hospital’s appearance is your first opportunity to make an impression on patients

and visitors. Creating a clean safe facility builds confidence in your services and

translates into improved patient satisfaction, critical to reimbursement.

Environmental Services is an integral part of the hospital team, and its work

directly impacts not only the daily operations of the hospital, but also the most

important deliverables: satisfaction and outcomes (Crothall Healthcare, 2009).

Sridhar et al., 2005, conducted a study on patient satisfaction in 25 District

or Area Hospitals managed by the Andhra Pradesh

 31

VaidyaVidhanaParishad(APVVP). The study obtained feedback from patients

and in case the patient could not be interviewed, the attendant, using a modified

version of the Patient Satisfaction Questionnaire-III originally developed by Ware

and others. The study refers to the period from May to July, 1999. Altogether

1179 persons were interviewed, including 237 attendants, at the rate of about 40-

50 patients per hospital. Female and male patients of different ages are equitably

represented in the sample. Majority of the patients were poor and illiterate.

Results showed that overall level of patients satisfactory in APVVP was about

65% of what could be achieved. Corruption appears to be very highly prevalent

and was the top cause of dissatisfaction among patients. Other important areas

of hospital services contributing to patient dissatisfaction were poor facilities like

water supply, fans, lights, poor maintenance of toilets and lack of cleanliness,

and poor interpersonal or communication skills.

Dejene et al. conducted a study on levels of outpatient satisfaction at

selected health facilities in six regions of Ethiopia. All the three components of

investigated variables have reliability coefficients ranging from 0.57 to 0.82.

Results of bivariate analyses depicted that the percentage for high mean score

satisfaction with health provider’s characteristics ranged from 77.25% to 93.23%;

with service characteristics 68.64% to 86.48%; and satisfaction with cleanliness

ranged from 76.50% to 90.57%. results of multivariate analysis showed that

relatively more explanatory variables were found to be significant in influencing

cleanliness of waiting place and examination room and medical equipment.

 32

A study on Patient Satisfactory Surveys in Public Hospitals in India was

conducted by Sivalenk et al. in 2000. The objective was to identify the areas of

satisfaction and dissatisfaction in public hospitals in Andhra Pradesh, India.

Results showed that most significant areas of dissatisfaction were financial

aspects and interpersonal aspects of care. Content analysis to the open ended

question revealed that corruption appears to be very highly prevalent and was

the top cause of dissatisfaction, other areas concern were availability or supply of

drugs, poor utilities like water supply, lights, fans and poor maintenance of toilets

and lack of cleanliness in the hospital.

 33

Chapter 3

RESEARCH DESIGN AND METHODOLOGY

Chapter 3 consists of three parts: (1) Purpose of the Study and Research

Design, (2) Method, and (3) Data Analysis Procedures.

Purpose of the Study and Research Design

The main purpose of this investigation was to determine the physical

environment and level of satisfaction of patients at Sara District Hospital, in Sara,

Iloilo.

The descriptive-correlational study design was employed in this

investigation. David (2002) defines descriptive-survey research as a type of

research which answer to the questions who, what, when, where, and how. This

type of research describes a situation or a given state of affairs in terms of

specified aspects or factors.

The antecedent variables of the study were age, sex, civil status,

educational attainment and monthly family income; the independent variable was

the physical while the dependent variable was the level of patient’s satisfaction.
 34

Method

Respondents

The respondents of this study were the 37 patients admitted at Sara

District Hospital last March 7, 2012.

The convenient sampling was employed in the selection of the final

respondents of the study. According to David(2002), convenient sampling is a

non-probability sampling technique in which the investigator selects the units as

they become available.

The respondents were further classified according to age, sex, civil status,

educational attainment and monthly family income. As for age, young adult (19

years old – 39 years old), middle-aged adult (40 years old - 59 years old), and

older adult (60 years old – 79 years old);as for sex, male and female; as for civil

status, single(those who have never been married), and married(those who have

been married or widowed); as for educational attainment, elementary and below,

high school level and bachelor’s degree; as for monthly family income, lower

income (below Php 5,000 ), average income (Php 5,000 – Php 10,000), and

higher income (above Php 10, 000).

Data Gathering Instrument

Data for this investigation were gathered using a researcher-made

questionnaire.
 35

A personal data sheet was attached to the instrument to gather data on

the respondent’s name (optional), age, sex, educational attainment, and monthly

family income.

To assess the physical environment, 15- item test culled out from the

researchers’ readings was constructed.

Through a structured interview, the respondents were asked to make a

response from among the four choices by answering the item corresponding to

their responses such as: strongly agree, agree, disagree and strongly disagree.

Strongly Agree, means that the respondent is strongly in favor of the idea
conveyed.

Agree, means that the respondent is in favor of the idea conveyed.

Disagree, means that the respondent is not in favor of the idea conveyed.

Strongly Disagree, means that the respondent is strongly not in favor of

the idea conveyed.

The choices were assigned their numerical weights as follows:

Response Weight

Strongly Disagree 1

Disagree 2

Agree 3

Strongly Agree 4

To determine the level of satisfaction of the patients, 15- item test culled

out from the researchers’ readings was constructed.

 36

Through a structured interview, the respondents were asked to make a

response from among the four choices by answering the item corresponding to

their responses such as: strongly agree, agree, disagree and strongly disagree.

Strongly Agree, means that the respondent is strongly in favor of the idea

conveyed.

Agree, means that the respondent is in favor of the idea conveyed.

Disagree, means that the respondent is not in favor of the idea conveyed.

Strongly Disagree, means that the respondent is strongly not in favor of

the idea conveyed.

The choices were assigned their numerical weights as follows:

Response Weight

Strongly Disagree 1

Disagree 2

Agree 3

Strongly Agree 4

The extent of relationship was interpreted based on the scale of coefficient

of correlation and its descriptive equivalent from the guide scales by Henry

Garrett.
 37

Scale Decsription

± 0.90 – 1.0 Very High Correlation

Very Dependable Relationship

± 0.70 – 0.89 High Correlation

Marked Relationship

± 0.40 – 0.69 Moderate Correlation

Substantial Relationship

± 0.20 – 0.39 Low Correlation

Definite but Small Relationship

Less than ± 0.20 Negligible Correlation

Negligible Relationship

Procedure

A letter of permission to conduct the study was sent to the chief of hospital

thru the chief nurse of Sara District Hospital.

Before gathering the data, the respondents were informed of their

involvement in the study. The questionnaires were distributed personally by the

researchers to the respondents with the assistance of the staff nurses. The

respondents were asked for their consent to be respondents and were oriented

about the researchers and the objectives of the study. The instruments were then

gathered and checked for the completeness of data.

Then, the data were tallied, tabulated, computer processed and

interpreted.
 38

Data Analysis Procedure

The study employed the following descriptive and inferential statistics:

Frequency and Percentage were used to describe the data gathered.

Chi-square and Gamma were utilized to determine the relationship

between variables.

All statistical computations were computer-processed using the Statistical

Package for Social Sciences (SPSS) software.

Chapter 4

FINDINGS, ANALYSIS AND INTERPRETATION

Chapter Four presents the results and the findings of the study. It is

divided into two parts: (1) Descriptive Data Analysis, and (2) Inferential Data

Analysis.

Personal Characteristics

Table 1 shows the distribution of respondents according to age, sex, civil

status, academic background and family monthly income.

 39

In terms of age, there were more respondents belonging to the younger

adult (16 or 41 percent) followed by the middle-aged adult (12 or 30.8 percent)

and older adult (11 or 28.2 percent).

When group according to sex, there were more females (24 or 61.5

percent) than males (15 or 38.5 percent).

In terms of civil status, most of the respondents were married (33 or 84.6

percent) as compared to the respondents who were single (6 or 15.4 percent).

In terms of academic background, most of the respondents were

elementary level or elementary graduates (17 or 43.6 percent) followed by high

school level or high school graduate (16 or 41 percent) and college level or

college graduate (6 or 15.4 percent).

When grouped according to family monthly income, majority of the

respondents have a family income of 5,000-10,000 monthly (19 or 48.7 percent)

followed by those respondents who have a family monthly income of below 5,000

(13 or 33.3 percent) and those who have a family income of above 10,000

monthly (7 or 17.9 percent).

Table 1. Personal Characteristics of Patients in a District Hospital

Frequency Percentage

Age

Young Adult(19-39 y.o) 16 41

Middle-aged Adult (40-59 y.o) 12 30.8

Older Adult (60-79 y.o) 11 28.2

 40

Sex

Male 15 38.5

Female 24 61.5

Civil Status

Single 6 15.4

Married 33 84.6

Educational Attainment

Elementary level/graduate 17 43.6

High School level/graduate 16 41

College level/graduate 6 15.4

Family Monthly Income

Below 5,000 13 33.3

5,000-10,000 19 48.7

Above 10,000 7 17.9

Table 2 shows the distribution of the respondents as they rated the

physical environment factors such as ventilation, lighting and noise. There was

higher percentage of respondents rated ventilation as good (61.5%) than those

who rated it as excellent (35.9%) and fair (2.6%). In terms of lighting, majority of

the respondents rated it as good (48.7%) than those who rated it as excellent

(46.2%) and fair (5.1%). On the other hand, more than half of the respondents

rated noise as excellent (61.5%) than those who rated it as good (38.5%).
 41

Table 2. Distribution of respondents according to the physical environment

such as Ventilation, Lighting and Noise

Physical Environment Frequency Percentage

Ventilation

Excellent 14 35.9

Good 24 61.5

Fair 1 2.6

Lighting

Excellent 18 46.2

Good 19 48.7

Fair 2 5.1

Noise

Excellent 24 61.5

Good 15 5.1

There were a higher percentage of respondents who rated the physical

environment as excellent (51.3%) than those who rated it as good (48.7%). The

results were revealed in Table 3.

 42

Table 3. Distribution of respondents according to environmental factors as

an entire group

Physical Environment Frequency Percentage

Excellent 20 51.3

Good 19 48.7

Table 4 shows the distribution of the respondents as they rated the level of

satisfaction such as ventilation, lighting and noise. There was higher percentage

of extremely satisfied (48.7 percent) respondents in terms of ventilation. In terms

of lighting (51.3 percent)and noise (51.3 percent), majority of the respondents

were moderately satisfied.

 43

Table 4. Distribution of respondents according to the level of satisfaction

such as Ventilation, Lighting and Noise

Level of Satisfaction Frequency Percentage

Ventilation

Extremely Satisfied 19 48.7

Moderately Satisfied 18 46.2

Satisfied 2 5.1

Lighting

Extremely Satisfied 15 38.5

Moderately Satisfied 20 51.3

Satisfied 4 10.3

Noise

Extremely Satisfied 20 51.3

Moderately Satisfied 19 48.7

There were more respondents who are moderately satisfied (48.7%) than

those who are extremely satisfied (46.2%) and satisfied (5.1%). Results were

revealed on table 5.

Table 5. Distribution of respondents according to their level of satisfaction

on the physical environment

Level of Satisfaction Frequency Percentage

 44

Extremely Satisfied 18 46.2

Moderately Satisfied 19 48.7

Satisfied 2 5.1

The results on table 6 revealed the relationship of the personal

characteristics of the respondents and the physical environment. In terms of age,

there was a higher percentage of young adult and middle-aged adult (35 percent)

who rated the physical environment as excellent than the older adults(30

percent). Meanwhile, there was a high percentage of young adult respondents

(48 percent) rated the physical environment as good than those middle-aged

adult (26 percent) and older adults (26 percent). Statistical analysis revealed a

result of .522 which is interpreted as moderate correlation. Age and physical

environment has substantial relationship.

In terms of sex, female respondents (65 percent) have a higher

percentage who rated the physical environment as excellent than male

respondents (35 percent). Meanwhile, a higher percentage of female

respondents (58 percent) than male respondents (42 percent) who rated the

physical environment as good. Statistical analysis revealed a result of .648 which

is interpreted as moderate correlation. Sex and physical environment has

substantial relationship.

In terms of civil status, there was a higher percentage of married

respondents (80 percent)than single respondents who rated physical

environment as excellent. On the other hand, there was a higher percentage of

 45

married respondents (89 percent) who rated physical environment as good than

single respondents (11 percent). Statistical analysis revealed a result of .412

which is interpreted as moderate correlation. Civil status and physical

environment factors has substantial relationship.

In terms of educational attainment, a high portion of elementary

level/graduate respondents (50 percent) rated the physical environment as

excellent than those high school level/graduate (30 percent) and college level/

graduate (20 percent). On the other hand, high school level/ graduate (53

percent) has the higher percentage of respondents who rated the physical

environment as good compare to elementary level/graduate respondents (37

percent) and college level/graduate (10 percent). Statistical analysis revealed a

result of .736 which is interpreted as high correlation. Educational attainment and

physical environment factors has marked relationship.

In terms of family monthly income, those whose family monthly income of

5,000-10,000 (40 percent)has a higher percentage of respondents who rated

physical environment as excellent than those respondents whose family monthly

income of below 5,000 (35 percent) and whose family monthly income of above

10,000 (25 percent). On the other hand, higher percentage of respondents

whose family monthly income of 5,000-10,000 (57 percent) rated the physical

environment as good than those whose FMI are below 5,000(32 percent) and

Above 10,000(11 percent). Statistical analysis revealed a result of .688 which is

interpreted as moderate correlation. Family monthly income and physical

environment factors has substantial relationship.

 46

Table 6. Distribution of respondents according to personal characteristics

and physical environment

Personal Characteristics Physical Environment

Excellent Good

Age F % f % Total %

Young Adult 7 35 9 48 16 41

Middle-aged Adult 7 35 5 26 12 31

Older Adult 6 30 5 26 11 28

Total 20 100 19 100 39 100

Gamma Value=.522

Sex

Male 7 35 8 42 15 38

Female 13 65 11 58 24 62

Total 20 100 19 100 39 100

Chi-square=.648

Civil Status

Single 4 20 2 11 6 15

Married 16 80 17 89 33 85

Total 20 100 19 100 39 100

Chi-square=.412

Educational Attainment

Elementary 10 50 7 37 17 44

High school 6 30 10 53 16 41
 47

College 4 20 2 10 6 15

Total 20 100 19 100 39 100

Gamma value=.736

Family monthly income

Below 5,000 7 35 6 32 13 33

5,000-10,000 8 40 11 57 19 49

Above 10,000 5 25 2 11 7 18

Total 20 100 19 100 39 100

Gamma Value=.688

The results on table 7 revealed the relationship of the personal

characteristics of the respondents and the level of satisfaction. In terms of age,

there was a higher percentage of young adult (44 percent) who rated the level of

satisfaction as extremely satisfied as compare to the middle-aged adult (39

percent) and older adults (17 percent). Meanwhile, both young adult respondents

(37 percent) and older adult respondents (37 percent) has a higher percentage

who rated the level of satisfaction as moderately satisfied than those middle-

aged adult (26 percent). Both young adult (50 percent) and older adult (50

percent) rated level of satisfaction as satisfied. Statistical analysis revealed a

result of .343 which is interpreted as low correlation. Age and level of satisfaction

has definite but small relationship.

In terms of sex, female respondents (61 percent) have a higher

percentage who rated the level of satisfaction as extremely satisfied than male
 48

respondents (39 percent). Meanwhile, a higher percentage of female

respondents (63 percent) than male respondents (37 percent) who rated the level

of satisfaction as extremely satisfied. On the other hand, both male and female

respondents (50 percent) rated level of satisfaction as satisfied. Statistical

analysis revealed a result of .935 which is interpreted as very high correlation.

Sex and level of satisfaction has very dependable relationship.

In terms of civil status, there was a higher percentage of married

respondents (83 percent)than single respondents (17 percent) who rated level of

satisfaction as extremely satisfied. On the other hand, there was a higher

percentage of married respondents (89 percent) who rated level of satisfaction as

moderately satisfied than single respondents (11 percent). Both married and

single respondents (50 percent) rated level of satisfaction as satisfied. Statistical

analysis revealed a result of .332 which is interpreted as low correlation. Civil

status and level of satisfaction has definite but small relationship.

In terms of educational attainment, a high portion of elementary

level/graduate respondents (44 percent) rated the level of satisfaction as

extremely satisfied than those high school level/graduate (39 percent) and

college level/ graduate (17 percent). On the other hand, both elementary

level/graduate and high school level/ graduate (42 percent) has the higher

percentage of respondents who rated the level of satisfaction as moderately

satisfied compared to college level/graduate (16 percent). Both elementary

level/graduate and high school level/ graduate (50 percent) rated level of

satisfaction as satisfied. Statistical analysis revealed a result of .926 which is

 49

interpreted as very high correlation. Educational attainment and level of

satisfaction has very dependable relationship.

In terms of family monthly income, those whose family monthly income of

5,000-10,000 (50 percent)has a higher percentage of respondents who rated

level of satisfaction as extremely satisfied than those respondents whose family

monthly income of below 5,000 (28 percent) and whose family monthly income of

above 10,000 (22 percent). Meanwhile, a higher percentage of respondents rated

the level of satisfaction as moderately satisfied belongs to respondents whose

family monthly income is 5,000-10,000 (53 percent) than respondents whose

family monthly income is below 5,000 (28 percent) and above 10,000 (16

percent). Respondents whose family monthly income of below 5,000 (100

percent)rated the level of satisfaction as satisfied. Statistical analysis revealed a

result of .248 which is interpreted as low correlation. Family monthly income and

level of satisfaction has definite but small relationship.

Table 7.Distribution of respondents according to personal characteristics

and level of satisfaction

Personal Level of Satisfaction

 50

Characteristics

Extremely Moderately Satisfied

Satisfied Satisfied

f % f % f % f %

Age

Young Adult 8 44 7 37 1 50 16 41

Middle-aged Adult 7 39 5 26 0 0 12 31

Older Adult 3 17 7 37 1 50 11 28

Total 18 100 19 100 2 100 39 100

Gamma Value=.343

Sex

Male 7 39 7 37 1 50 15 38

Female 11 61 12 63 1 50 24 62

Total 18 100 19 100 2 100 39 100

Chi-square=.935

Civil Status

Single 3 17 2 11 1 50 6 15

Married 15 83 17 89 1 50 33 85

Total 18 100 19 100 2 100 39 100

Chi-square=.332

Educational
Attainment

Elementary 8 44 8 42 1 50 17 44

High school 7 39 8 42 1 50 16 41

College 3 17 3 16 0 0 6 15

Total 18 100 19 100 2 100 39 100

 51

Gamma value=.926

Family monthly
income

Below 5,000 5 28 6 31 2 100 13 33

5,000-10,000 9 50 10 53 0 0 19 49

Above 10,000 4 22 3 16 0 0 7 18

Total 18 100 19 100 2 100 39 100

Gamma value=.248

Table 8 shows that a higher percentage of respondents who rated the

physical environment as excellent (75 percent) who were extremely satisfied than

those who are moderately satisfied( 25 percent). On the other hand, a high

portion of respondents who rated the physical environment as good (74 percent)

who were moderately satisfied than those who were extremely satisfied (16

percent) and satisfied (10 percent). The physical environment has negligible

correlation (.000)with the level of satisfaction.

Table 8. Distribution of respondents according to physical environment

factors and Level of Satisfaction

Level of Satisfaction Physical Environment Factors

Excellent Good Total Gamma

Value=
f % f % F % .000
Extremely Satisfied 15 75 3 16 18 46

Moderately Satisfied 5 25 14 74 19 49

Satisfied 0 0 2 10 2 5
 52

Total 20 100 19 100 39 100

Chapter 5

Summary, Conclusions, Implications, and Recommendations

Chapter Five is consists of four parts: (1) Summary of the Problem,

Method and Findings, (2) Conclusions, (3) Implications, and (4)

Recommendations.

Summary of Problems, Methods and Findings

This study aimed to determine the Physical Environment and Level of

Satisfaction of Patient’s at Sara District Hospital.

Specifically, the study sought to:

1. Describe the personal characteristics of the patients according to

(a) age, (b) sex, (c) civil status,

(d) educational attainment, and (e) monthly family income.

2. Determine the physical environment, such as:

(a) light, (b) ventilation, and (c) noise.

 53

3. Determine the patient’s level of satisfaction regarding the physical

environment.

4. Determine if there is a significant difference between the personal

characteristics of the patients and the physical environment.

5. Determine if there is a significant difference between the physical

environment and the patient’s level of satisfaction.

6. Determine if there is a significant difference between the personal

characteristics of the patients and the level of satisfaction.

The study was conducted last March 7, 2012. The respondents of this

investigation were the 39 patients who were admitted at that time.

They were chosen through convenient sampling. The data needed for the

descriptive research were gathered utilizing a one-shot survey design, using the

researcher-made instrument through a structured interview.

The study was anchored on Environmental Theory by Florence

Nightingale. The focus of her theory was on the manipulation of the environment

as she realized that the environment had a great impact on a person’s health.

She also emphasized the need for ventilation and light in sickrooms, proper

disposal sewage, and she highlighted the benefit of good environment in

preventing illness.
 54

Based on the aforementioned problems, the following hypotheses are

advanced:

1. There is no significant difference between the personal

characteristics of the patients and the physical environment.

2. There is no significant difference between the physical environment

and the patient’s level of satisfaction.

3. There is no significant difference between the personal

characteristics of the patients and the level of satisfaction.

The descriptive statistics were frequency and percentage. The inferential

statistical tool was Chi-square and Gamma set at 0.05 level of significance which

were processed through the Statistical Package for Social Science (SPSS)

Software.

The findings of the study were the following:

1. As to personal characteristics of the patients admitted at Sara District

Hospital, it was found that most of the patients were young adults aging from 19-

39 years old, there more females than males, most were married, majority of

them reached elementary level/graduate, and most of them have a family

monthly income of 5,000Php – 10,000Php.

2. The physical environment when taken as an entire group was excellent.

In terms of ventilation and lighting, they considered it as good while in terms of

noise, they considered it as excellent. When grouped according to age, middle-

aged adults and older adults regarded physical environment as excellent while
 55

young adults regarded it as good. When grouped according to sex, females

regarded it as excellent while males regarded it as good. When grouped

according to civil status, those who are single regarded it as excellent while those

who are married regarded it as good. When grouped according to educational

attainment, both elementary levels/graduates and college levels/graduates

regarded it as excellent, while high school levels/graduates regarded it as good.

When grouped according to family monthly income, those who have an income

of below 5,000Php and above 10,000Php regarded it as excellent, while those

who have income between 5,000Php to 10,000Php regarded it as good.

3. The level of satisfaction when taken as an entire group was moderately

satisfied. In terms of ventilation and noise, they were extremely satisfied, while in

terms of lighting they were moderately satisfied. When grouped according to age,

young adults and middle-aged adults were extremely satisfied while older adults

were moderately satisfied. When grouped according to sex, females were

moderately satisfied while males regarded it as good. When grouped according

to civil status, those who are single were extremely satisfied while those who are

married were moderately satisfied. When grouped according to educational

attainment, elementary levels/graduates were,on the other hand those who are

high school level/graduates were moderately satisfied, while half of those who

are college levels/graduates were extremely satisfied and the other half were

moderately satisfied. When grouped according to family monthly income, those

who have an income of below 5,000Php and those who have 5,000Php –
 56

10,000Php were moderately satisfied while those who have income above

10,000Php were extremely satisfied.

4. There was a substantial relationship between age, sex, civil status and

family monthly income in relation to the physical environment; meanwhile, there

was a marked relationship between educational attainment and the physical

environment.

5. There was a small but definite relationship between age, civil status,

and family monthly income in relation to the level of satisfaction; meanwhile,

there was a very dependable relationship between sex and educational

attainment in relation to the level of satisfaction.

6. There was a negligible relationship between the physical environment

and level of satisfaction.

Conclusions

From the findings presented, the following conclusions were made:

1. Generally, the patients were young adults aging from 19-39 years old,

females, married, has reached elementary level/graduate, with a family monthly

income of 5,000Php – 10,000Php.

2. Most of the patients viewed the physical environment as excellent. In

terms of ventilation and lighting they considered it as good while in terms of noise

they consider it as excellent. In other words, despite of limited facilities the staff

together with the management of the hospital was able to maintain a conducive

environment in the providing quality care.

 57

3. Almost all of the patients were moderately satisfied with the physical

environment in the district hospital.

4. The respondents’ rating of the physical environment has been

considerably affected by the personal characteristics such as age, sex, civil

status and family monthly income. However, the educational attainment has

affected the rating noticeably.

5. The rating of the respondents on the level of satisfaction has been

affected minimally by the personal characteristics such as age, sex, civil status

and family monthly income. Sex and educational attainment has affected the

rating steadfastly.

6. The physical environment has insignificant effect in determining the

level of satisfaction in the district hospital.

Recommendations

Basing on the findings and conclusions drawn, the following

recommendations are advanced:

In terms of the hospital ventilation, since several of the wooden-type

windows are non-functional, repair and regular maintenance are necessary.

However it would be even better if the district hospital would change completely

the type of windows used from the wooden-type to the glass or jalousie type. The
 58

district hospital could also provide additional ceiling fans to each ward or room in

order to cover the areas with cool air.

In terms of the hospital lighting, the district hospital could provide

nightlights for each room or ward so that the main and brighter lights could be

turn off at night. The nurses could promote the exposure of the able patients to

sunlight every morning by assisting them to walk in the hallways outside; while

for bed-ridden or non-ambulatory patients, the nurses could ensure the position

of the beds facing the sunrise.

In terms of the noise in the hospital, the hallway and rooms should be

lined with more reminders and signs on observing silence. As much as possible,

it is better if only one folk or significant other is allowed to stay with the patient to

avoid unnecessary noise brought about when the patient has too many folks.

For Nursing Education, nurse educations and students must apply the

principles of Nightingale′s Environmental Theory more often as such study

proved the theory′s consistency and how simple and usually ignored amenities

like windows and ceiling fans can actually define patient satisfaction.

For other researchers who are willing to conduct the same topic in relation

to the physical environment and level of satisfaction, they could use the results of

this study as basis for their future researches and source of knowledge.

Researchers could also include other variables that not included in this

investigation. The study may be replicated at a wider coverage to allow broader

 59

generalization. To include other hospitals, and a longer time frame to the conduct

of this study.