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ENVIRONMENTAL QUALITY AND HEALING ENVIRONM ENTS:
A STUDY OF FLOORING MATERIALS IN A HEALTHCARE TELEM ETR Y UNIT
A Dissertation
by
DEBRA D. HARRIS
Submitted to the Office of Graduate Studies of

Texas A&M University
in partial fulfillment of the requirements for the degree of
D O C TO R OF PHILOSOPHY
December 2000
Major Subject: Architecture
UMI Number: 9994253
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ENVIRONMENTAL QUALITY AND HEALING ENVIRONMENTS:
A STU D Y OF FLOORING MATERIALS IN A HEALTHCARE TELEM ETRY UNIT
A Dissertation
by
DEBRA D. HARRIS
Submitted to Texas A&M University

in partial fulfillment of the requirements
for the degree of
D OCTOR OF PHILOSOPHY
Approved as to style and content by:
Mardelle M. Shepley Louis G. Tasamary

(Chair of Committee)
. Bame S. Haberl
(Member) (Member)
Thomas L. McKittrick
(Head of Department)
December 2000
Major Subject: Architecture
ABSTRACT
Environmental Quality and Healing Environments: A Study of
Flooring Materials in a Healthcare Telemetry Unit. (December 2000)
Debra D. Harris, B.S., Southwest Texas State University;
M.IARC., University of Oregon
Chair of Advisory Committee: Dr. Mardelle Shepley
The purpose of this study was to investigate the impact of flooring finish
materials on the environmental quality of patient rooms and explore the
relationship of environmental quality and human response. Specifically, this
research focused on the flooring finish materials in telemetry unit patient rooms
at a regional health center.
An interdisciplinary multiple methodology was used to build a protocol for
evaluating interior finish materials. The objectives are: (a) to measure physical
criteria of the flooring finish materials for the development of an Indoor
Environmental Quality (IEQ) index; and (b) examine the IEQ index as it relates
to patient and staff perceptions, preferences, comfort, and biological responses
to their environment.
The results found that healthcare staff preferred V C T over carpet for the
flooring choice in patient rooms citing ease of maintenance as their reason.
Patients preferred carpet in their patient rooms citing comfort, slip-resistance,
and less noise as the reasons for their choice.
Healthcare staff perceived patient rooms with V C T to be more clean and
attractive, have better odor, ventilation, air movement, and fresher air. Staff
perceived rooms with carpet to be more comfortable and have less noise and
glare, fewer temperature shifts, and better temperatures. Patients perceived
patient rooms with V C T to be more clean, have better ventilation and fresher air,
but rooms with carpet to have better temperatures.
The results of the indoor environmental conditions indicated that V C T
had a higher level of glare and a higher level of bacteria in the air samples. No
significant differences were found in the levels of noise, temperature, carbon
dioxide, and total volatile organic compounds.
The study determined whether the indoor environmental conditions of the
patient rooms were consistent with patient and staff preferences, physical
comfort, biological response, and satisfaction. The specification of appropriate
flooring materials in patient room environments depends on the composition of
the material, its impact on the environmental conditions of the room, and the
comfort and satisfaction of the patients.
Additional research should focus on the materiality of flooring products,
the effect of carpet on the indoor relative humidity, and exposure to volatile
organic compounds and microorganisms.
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
had found my mentor.
It is with great gratitude that I thank my other committee members. In
addition to her experience and expertise in healthcare research, Dr. Sherry
Bame provided her unwavering support, ethics, and guidance during my pursuit
of an academic future. Dr. Louis G. Tassinary deserves many thanks for many
reasons. I appreciate his guidance and instruction on matters relating to the
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
Haberl is appreciated for his expertise and guidance in environmental building
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
notice to substitute as my Graduate Council Representative. His commitment
and dedication as an academic and educator is appreciated.
Thanks also to Dr. Donald Sweeney, who opened the door for me with an
introduction to the administration at St. Joseph Regional Health Center. A
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
systems and maintenance. In the beginning, the architecture firm of record,
Watkins Hamilton Ross, provided plans, specifications, and support for setting
up the research study. The project team included Mark Heitkamp, AIA, Amy
Bezecny, IIDA, and Mark Vaughan, AIA.
Access to the equipment needed to monitor the environmental conditions
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
Texas A&M University.
The financial support from St. Joseph Regional Health Center, the
International Interior Design Association, and the Texas A&M University
Wom en’s Faculty Network provided the necessary resources for the completion
of this project. I am deeply grateful for their support.
A special thanks goes to the participants in this study. Healthcare staff
worked around the equipment and answered my many questions. Patients
genuinely seemed to enjoy participating in the study. In addition to the
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
helping me with data collection and helping me to keep my sanity.
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
encouragement; Vannapa Pimviriyakul, a new friend who enriched my
experience at Texas A&M University; Ward Wells for providing opportunities,
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
encouragement, love, patience, and support. His editorial comments, wisdom,
and wacky ideas kept this experience lively and interesting.
TABLE OF CONTENTS
Page
ABSTRACT.......................................................................................................................... iii
ACKNOW LEDG M ENTS.................................................................................................... vi
TABLE OF CONTENTS..................................................................................................... ix
LIST OF TABLES................................................................................................................xii
LIST OF FIGURES............................................................................................................ xiii
CHAPTER
I INTRODUCTION AND LITERATURE R E V IE W ...................................................1
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
2.1 Research D esign.............................................................................87

2.1.1 Ethics................................................................................. 88
2.1.2 Research Hypotheses..................................................... 89
2.1.3 Variables........................................................................... 90
2.1.4 Setting................................................................................93
TABLE OF CONTENTS (continued)
CHAPTER Page
2.2 Patient Survey and Healthcare Staff Survey................................95

2.2.1 Participants.......................................................................96
2.2.2 Design and Procedure..................................................97
2.3 Patient Medical Chart Records....................................................101
2.4 Behavior Mapping Study.............................................................. 102
2.4.1 Participants.....................................................................103
2.4.2 Design and Procedure................................................103
2.5 Indoor Environmental Quality Index...........................................104
2.5.1 Design and Procedure................................................106
2.6 Summary...........................................................................................126
III ANALYSIS AND R E SU LTS .............................................................................. 127
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
IV DISCUSSION OF TH E RESULTS................................................................... 167
4.1 Summary of the Findings...............................................................167

4.1.1 Indoor Environmental Quality Indix............................ 167
4.1.2 Patients' Preferences and Perceptions...................... 176
4.1.3 Healthcare Staff Preferences and Perceptions..........178
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
V C O NCLUSIO NS..................................................................................................... 191

5.1 Summary of the Conclusions..........................................................191
5.2 Limitations of the Research........................................................... 192
5.3 Future Directions............................................................................. 195
REFERENCES................................................................................................................ 200
APPENDICES.................................................................................................................. 209
APPENDIX A ................................................................................................................... 210
APPENDIX B................................................................................................................... 213
APPENDIX C ................................................................................................................... 226
APPENDIX D ................................................................................................................... 228
APPENDIX E ................................................................................................................... 230
APPENDIX F.................................................................................................................... 232
APPENDIX G ...................................................................................................................234
APPENDIX H ................................................................................................................... 239
APPENDIX 1.....................................................................................................................250
APPENDIX J .................................................................................................................... 254
VITA................................................................................................................................... 256
xii
LIST OF TABLES
TABLE Page
1.1 Advantages and limitations of sheet vinyl and vinyl

composition tile...................................................................................................... 23
1.2 Human biological (or psychological) needs for

visual information...................................................................................................36
1.3 Recommended illuminance categories and illuminance

ranges for hospital patient rooms....................................................................... 38
1.4 Temperature limits for typical flooring materials, bare feet...........................63
2.1 Research hypotheses..........................................................................................89
2.2 Ataxonomy of dependent variables................................................................... 91
3.1 Flooring material properties rating comparison............................................132
3.2 Patient room interior finish specifications...................................................... 135
3.3 Lighting conditions for December 1 5 ,1 9 9 8 at 2 p.m.................................... 142
3.4 Ventilation air changes per hour for the six patient rooms............................ 146
3.5 Means and standard deviations for patient ratings of physical

attributes of their patient rooms.........................................................................160
3.6 Means and standard deviations for healthcare staff ratings

of patient rooms’ physical attributes................................................................. 163
4.1 Summary of findings............................................................................................190
LIST OF FIGURES
FIGURE Page
1.1 Example reflective surfaces............................................................................. 33
1.2 Percentage of people dissatisfied as function of vertical air temperature

differences between head and ankles, and floor temperature, degrees
Fahrenheit (ASHRAE, 1997)............................................................................. 64
2.1 Example of patient rooms with VC T and carpet flooring materials.......... 94
2.2 Flooring materials used in the study of environmental quality

in hospital patient rooms....................................................................................95
2.3 Tektronix Lumacolor II Photometer used to measure luminance

and illuminance in patient rooms.................................................................... 109
2.4 Quest Technologies Precision Integrating Sound Level Meter

used to record sound levels (dBA) in the patient rooms............................111
2.5 Alnor Velometer used to measure air flow rates in the patient rooms....115
2.6 Recordaire and lock-box used to record interval data for

temperature, relative humidity, carbon dioxide, and total
volatile organic compounds............................................................................. 117
2.7 YES-204 IAQ monitor used in controlled experiment to verify

the validity of the Recordaire monitor equipm ent...................................... 118
2.8 Controlled experiment to verify reliability for the Recordaire

monitoring equipment used for patient room IAQ interval
measurements.....................................................................................................120
2.9 Raytek ST-8 Enhanced Laser infrared thermometer used

to measure surface temperatures in patient rooms....................................122
2.10 Sample sites located on the floor and reflected ceiling p la n s ................125
3.1 Frequency of traffic in patient rooms by healthcare staff and

non-staff visitors..................................................................................................134
xiv
LIST OF FIGURES (continued)
FIG U RE Page
3.2 Healthcare staff and non-staff visitor traffic in patient room s............... 134
3.3 Patient range of age......................................................................................... 137
3.4 Patient demographics...................................................................................... 137
3.5 Healthcare staff job description..................................................................... 139
3.6 Healthcare staff demographics.......................................................................140
3.7 Reflected glare on vinyl composition tile and carpet in

patient rooms near the window.......................................................................142
3.8 Level of illuminance (incident illuminance) in patient rooms................... 143
3.9 Level of illuminance (incident illuminance) in patient rooms

categorized by flooring material.....................................................................143
3.10 Reflected glare from the floor in patient rooms........................................... 144
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).................................................. 145
3.12 Temperature boxplot showing the median and range

categorized by flooring type............................................................................147
3.13 Temperature timeline for patient rooms and outdoor conditions

3.14 Relative humidity boxplot showing the median and range

3.15 Relative humidity timeline for patient rooms and outdoor

conditions categorized by flooring type............................................................149
3.16 Inside/outside temperature and humidity displayed on

the psychrometric chart during December 14-21,1998
for patient rooms with vinyl composition tile.................................................... 150
XV
LIST OF FIGURES (continued)
FIGURE Page
3.17 Inside/outside temperature and humidity displayed on the

psychrometric chart during December 1 4 -21 ,1 9 9 8 for
patient rooms with carpet....................................................................................151
3.18 Carbon dioxide boxplot showing the median and range

3.19 Carbon dioxide timeline for patient rooms categorized by

flooring type.........................................................................................................153
3.20 Total volatile organic compounds boxplot showing the median

and range categorized by flooring type...................................................... 155
3.21 Total volatile organic compounds timeline for patient rooms

3.22 Bacteria count of colony forming units categorized by flooringtype..... 157
3.23 Bacteria count of colony forming units at each sample site

3.24 Patient preference for flooring material in their patient room.................159
3.25 Healthcare staff preference for flooring material in the patientrooms...162
3.26 Differences between the means of paired samples for healthcare

staff perceptions about flooring materials in patient rooms......................165
3.27 Average number of minutes healthcare staff and visitors spend

in patient rooms..................................................................................................166
1
CHAPTER I
IN TRO DUCTIO N AND LITERATURE REVIEW
1.1 INTRODUCTION
The purpose of this study was to investigate the impact of finish materials
on the human response and qualitative experience of an interior environment.
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.
As administrators and hospital designers strive to create facilities that support
the psychological and physical health of its inhabitants, it is imperative to
identify, specify, install, and maintain safe and sustainable products that support
places for healing.
The primary objectives of this study were: (a) to measure physical
characteristics of the flooring finish materials towards developing an Indoor
Environmental Quality (IEQ) index for flooring finish materials; and (b) examine
the flooring finish material IEQ index as it relates to patient and staff
perceptions, preferences, comfort and biological responses to their environment.
Criteria for measuring flooring materials included durability ratings, maintenance
and acoustics.
This dissertation follows the style and format of the Journal of Environment and Behavior.
2
This study focused on the changes in the environmental quality of patient
rooms based solely on flooring material selections. The investigation of
environmental quality of flooring materials within the hospital setting will provide
beneficial information to the healthcare industry, design professions, and
manufacturers of material goods. This research utilized a multifaceted
methodological design for measuring the impact of materials on the
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
physical environment in a hospital and the importance of implementing design
strategies that captures the essential experiential quality of interior architecture.
Design guidelines developed from this study provides the design professional
with improved programming criteria for creating a healthy environment, with
consideration for environmental quality, aesthetics, cost, user preference, and
satisfaction. By identifying the impact interior finish materials may have on
environmental health and the quality of the built environment, designers,
architects, and administrators can make informed decisions when specifying
appropriate materials for safe and healthy indoor environments.
Recent literature tends to focus on one variable associated with
environmental quality and its effect on human response. Any particular
3
environment is a complex system with multiple variables, each affecting and
being affected by the actions and reactions of changes within that environment.
W hile research is growing in the area of environmental quality of healthcare
architecture, there is a need for continued research.
During a search of the literature related to health facility design, it became
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
adolescents to the elderly. Previous research focusing on materials have been
produced by organizations with conflicts of interest, specifically, flooring studies
with links to the flooring industry. (Carpet and Rug Institute (CRI), 1992; Tarkett,
1997). In contrast, studies addressing issues related to indoor air quality
generally had competent research designs and were strongly supported by
professional associations committed to the research of environmental quality
(i.e., Bame & Wells, 1995; and Fanger, 1970).
After a general introduction to the objectives of the stated problem, the
literature review is divided into three general sections: 1) the complexity of
multiple end-users in healthcare facilities; 2) the quality of the physical indoor
environment of healthcare settings and its relationship to the occupants; and 3)
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
environment. Topics discussed include studies regarding healthcare facility
design and healthcare and studies focusing on patient and healthcare staff
perceptions, preferences, and assumptions. The review of this section conveys
the state of research in healthcare environmental design. Many of these studies
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
design of methodology for this research. This study used a multi-method
research design, including physical measures, to compare responses to
recorded measures of the patient room environment.
The next section, environmental quality, addresses studies pertaining to
flooring materials, lighting, acoustics, and indoor air quality. The final literature
review section discusses research theory and methodology, and indicates how
utilizing multiple methods will strengthen this research design by comparing
results within the methods (i.e., patient and healthcare survey) and between the
methods (i.e., surveys, behavioral mapping, and the indoor environmental
quality index for flooring materials).
5
1.2 HUMAN BEHAVIOR AND HEALTHCARE ENVIRONM ENTS
1.2.1 General Background
Health facilities are complex interdependent systems housed in a
multifunctional facility. Health facilities are programmed to accommodate
technological and practical requirements. Four design objectives- wayfinding,
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.
Design decisions should no longer be based solely on aesthetic criteria,
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
the healthcare setting. Davidson (1995) discusses a theory developed by
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,
continuous motion); change in one integrates a reactionary change in the other;
and the process moves toward increasing diversity and is irreversible.
Davidson (1997) adds that order and complexity are qualities of both entities
6
and through choice, harmony can be produced between the human and
environmental fields, with therapeutic results.
W hat constitutes a healthy hospital facility? It is a place contributing to
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
of life (Shepley et al., 1997). Minimally, it is a “no harm done" environment. In a
report investigating whether the built environment affects patients’ medical
outcomes (Rubin, Owens & Golden, 1997), the authors identified research
studies focusing on the effects of design elements on the healthcare
environment. Rubin, Owens, and Golden (1997) state that the design of
healthcare environments may have an effect on the occupants, supporting the
allocation of resources used to improve patient health and well-being, promote
employee efficiency, reduce employee turnover, and avoid wasteful spending.
While their report found that many of the research studies meeting their criteria
for inclusion had significant methodological flaws that weakened the validity of
their conclusions for patient outcomes, it proposes a research agenda for
identifying environmental features to be included in the scope of research and
patient groups most likely to benefit from changes in their patient environments.
The study concludes that improvements in outcomes may be available through
design interventions guided by sound scientific inquiry. Limitations of the
7
research indicate that many aspects of the healthcare environment and
numerous patient population types have not been used in this area of research.
The Rubin et al. literature review (1997) is significant to this study
because it identifies other research that focuses on the environmental conditions
in healthcare environments. The majority of studies surveyed in Rubin et al.
(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.
This research likwise focuses on one design element, flooring materials,
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
within the hospital facility are reviewed in the following sections.
1.2.2 Healthcare Staff
The designed environment can facilitate or hinder healthcare staff in the
process of care-giving. In a post-occupancy evaluation survey of a women’s
medical center, interviews and behavioral mapping methodologies were used to
complete a post-occupancy analysis and develop design guidelines for a
women’s center nursing station (Shepley, Bryant & Frohman, 1995). Twenty-two
healthcare administrators, physicians and nursing staff participated in the
8
research study. The behavioral mapping study documented periodic data to
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.
study (1995) of data collection constitute a multiple methodological research
design.
This study will utilize a multi-method research design for collecting data
from the participants including surveys, behavioral mapping, and secondary data
collection from the patient medical charts.
In a case study of intensive care unit (ICU) nursing stations (Davis, 1994),
staff retention and satisfaction were found to be influenced by the amount of
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
the staff participants included the quality of design elements pertaining to
acoustics and lighting. Additional comments suggested that space allocation for
9
personal belongings for staff was a factor in their job satisfaction. Statistical
analysis was not conducted on the data collected, which compromises the
validity of the conclusions.
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
specific questions about individual elements within the interior environment.
Jules Horton (1997) states that people under stress react more strongly
to environmental variables so healthcare facility design should strive to satisfy
the often contradictory needs of multiple users of the space. Healthcare
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
groups as functional needs (appropriate space, equipment, and proximities
related to the effectiveness of their task performance); and perceptual needs
(data from the environment that creates the sensation of an experience). The
complexity of a space that accommodates multiple end-users with varying needs
suggest the importance of the environment as an indicator of quality within a
healthcare institution.
10
Common themes in studies focusing on staff issues in healthcare
environments focus on satisfaction with their workspace. By understanding the
issues effecting staff satisfaction, administration can employ a strategic plan for
staff retention and productivity. These studies addressed physical requirements
including space allocation, maintenance, functionality of the space, and
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
that can affect stress and fatigue.
Research limited to the physical environment may not take into
consideration other variables affecting staff moral and satisfaction. In healthcare
delivery, change and complexity are constants; these factors often create
confounding and contradictory scenarios for healthcare professionals. While
healthcare delivery is not a brick and mortar problem, it is part of the
environmental complex and has an effect on the perception of staff. Regardless
of the external variables, the design of the healthcare environment should
support the delivery of healthcare services.
This study employes uses multi-methods, similar to the post-occupancy
evaluation of the women's medical center (Shepley, Bryant & Frohman, 1995).
11
In addition to the data collection of human interaction with the environment,
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
physical environment can be a source of stress, impeding the patients' abilities
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
esteem); 3) environmental demands (i.e. control of one’s environment or lack of
control, issues related to the effort, energy and resources required to interact
with the environment); and 4) information deprivation (i.e. isolation, deficit of
contrasts that provide tension and challenge).
The experience of hospitalization is a source of psychological stress for
most patients, regardless of the nature of the illness. The interior design of
healthcare facilities can contribute to a more effective, satisfying experience for
12
patients, if healthcare and design professionals focus on the physical,
psychological, social and spiritual needs of the patient (Orr, 1993).
In a study investigating how patients are disturbed by hospital noise, Topf
(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
male postoperative patients in a large metropolitan Veterans Administration
hospital over an eight month period. Each participant completed a survey
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
volunteers with an average age of 35 in a simulated hospital environment. Noise
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
polysonmograph equipment and self-reports. These volunteers were not
patients, limiting the generaiizability of the results.
13
Bame (1993) conducted a study on dialysis treatment room design
focusing on four features: 1) noise, 2) light, 3) temperature, and 4) spatial
arrangement and privacy. Fifty-five facilities participated in the study. Two
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
below recommended standards in a majority of the facilities. Patients and staff
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.
Temperature levels in the treatment rooms tended to be cooler than
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
greater compliance by the patient in following treatment plans, and reduce
fatigue, burnout and dissatisfaction in staff. If the design of the treatment
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
equipment) are often contradictory considerations in flooring material decisions
(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
significantly related to falling were identified: 1) the season (September through
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
assistive ambulatory devices; 2) taking certain medications; and 3) cognitive
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.
In another study, (Willmott, 1986) fifty-eight elderly hospital patients were
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
15
walking on carpet. This study demonstrates that the criteria for flooring
selections should include user preferences in addition to cost and maintenance
factors when selecting floor materials for elderly and infirm patients.
In Topfs study (1985), there was no mention of physical measures (i.e.
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
physical measures of the environment and the dependent patient population.
This is an important example of applied research in that it respects the multifacit
nature of the healthcare environment. The use of physical measures (i.e.
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
effect thermal comfort and indoor air quality.
This research study intends to identify the design elements effecting
patient comfort and satisfaction by considering the variables affecting thermal
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
research, supporting or refuting self-reported measures from the survey data.
16
1.3 ENVIRONM ENTAL QUALITY
This section discusses the environmental elements relating to this
research study. Environmental quality is the totality of many singular elements in
an environment. Often, a change in one element will have an effect on one or
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
discusses flooring materials and the impact on environmental health, global
environmental concerns, material composition, maintenance, and life-cycle costs
of flooring materials.
Flooring materials were selected as the independent variable for this
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
treatments cover more area, flooring is exposed to a complex set of
environmental factors - foot traffic, spills, exposure to the sun, consideration of a
range of acoustic properties, and contamination from organic and chemical
sources. As a finish material, it is often considered the most important
specification in the interior design scheme. Flooring choices create an
17
opportunity to expand a color palette and specify a product that is conducive to
the type of activities and purpose of the building.
1.3.1 Flooring Materials
Environmental Health
Flooring material selection is concerned with a range of issues related to
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
for specification in healthcare facilities. In hard surface flooring, choices include
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,
with various construction, design, and performance standards. Each type of
flooring offers a different aesthetic appeal with advantages and disadvantages in
maintenance (Coffin, 1993).
Environmental factors associated with flooring are indoor air quality,
acoustic properties, lighting and reflected light, and physical comfort. Malven
(1990) defines the seven threats to user well-being: 1) mechanical - injury from
falls; 2) chemical - exposure to harmful substances resulting in superficial
irritation, internal irritation, allergic reaction or toxic effects; 3) emotional -
exposure to environmental “stressors”; 4) organic - injury resulting from
18
exposure to harmful organisms; 5) thermal threats - comfort, exposure to the
elements; 6) electrical threats - accidental grounding; and 7) physiological
threats - sensory stress. Each of these factors are potential threats to the health
and well-being of the occupants in healthcare facilities. Threats of this nature
should be considered when specifying flooring materials.
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
surroundings, access to social support, and access to positive distractions.
Determining the functional needs and psychological objectives associated with
each area of the hospital, appropriate flooring selections and maintenance
program can ensure a long-term contribution to an attractive and safe
environment (Coffin, 1993).
Community and Global Environmental Concerns
Making appropriate choices as a design professional is fundamental to
the building of healthy communities. The design of the built environment impacts
those who occupy the space, the surrounding community, and the global
environment. Materials and finishes can be rated for environmental sensitivity
based on the following criteria (LeClair & Rousseau, 1992):
1. production - sustainable or renewable resources, factory energy
efficiency, recycling, and low emissions plant operations;
19
2. packing and shipping - recycled, recyclable packaging or indigenous
material procurement and minimum transport energy;
3. installation and use - minimum installation hazards, low-toxic
emissions in use, durability, and simple nontoxic maintenance;
4. resource recovery - reusable, salvageable and recyclable; and
5. social responsibility - fair business practices, along with research and
education programs.
While there are authors attempting to document a constructive plan for
the rating and specification of interior finish materials that limit the impact on the
environment in commercial and residential buildings, it is clear that the research
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
collection tool. Criteria was based on their expectations for environmentally-
aware materials and it was successful in generally defining and meeting their
objectives.
Radke (1997), a specialist in the carpet industry, addresses the issues
relating to the use of carpet in health facilities and patient environments.
However, the text does not include other flooring choices that are considered
appropriate for hospitals and other health facilities. Fuston & Nadel’s (1997)
20
chapter on creating nontoxic health-enhancing environments is a good
introduction to the issues, but not substantial in creating a method for
application.
Material Composition
Excepting aesthetics, flooring material choices in healthcare facilities are
typically determined by performance, maintenance, and flammability (Standley,
1987). However, it is important to consider other environmental factors in
determining appropriate finish selections. For example, biological contaminants
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
environmental quality factors include health and safety factors (biological
control, flame resistance, electrostatic propensity, and slip resistance),
environmental factors (acoustics, comfort, ambience, and wheeled vehicle
mobility), and wear life of the flooring (durability, appearance retention,
maintenance) (Weinhold, 1988).
An elastic or resilient property in a flooring material is used to define a
family of products that includes cork, linoleum, sheet rubber, sheet vinyl, and
vinyl composition tile (VCT). This product family is manufactured by 1) mixing
various resins, fibers, plasticizers, and fillers; 2) forming them under heat and
21
pressure into sheet goods; and 3) cutting into tile shapes, if applicable. (Ballast,
1992). Typically, an adhesive is used to bond the flooring to the subfloor
(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
processing. Cork is considered to be a durable material with good thermal and
acoustic properties; it is shock-resistant, dissipates static electricity and is
nonconductive (LeClair& Rousseau, 1992).
Linoleum is a composition material made from natural, renewable
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
flammability. It is flexible, nonconductive, non-static, and extremely durable
(LeClair & Rousseau, 1992).
Newly manufactured rubber is a synthetic petroleum product and by
existing industry practices, causes air and water pollution (LeClair & Rousseau,
1992). Rubber made from recycled materials (shredded post-consumer sources
such as tires), has two environmental benefits over new rubber: 1) it is utilizing
an already manufactured material which lessens the additional processing; and
2) it reduces the waste of discarded tires. Rubber is very resilient, shock
absorbing and sound-deadening. However, it is highly flammable and produces
22
a continuous off-gassing which produces an unpleasant nonhazardous odor
(LeClair & Rousseau, 1992).
Vinyl is manufactured from petroleum and is available in sheet goods or
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
environmental and toxic health impacts (LeClair & Rousseau, 1992).
Vinyl composition tile (VCT) is composed of the same ingredients as
sheet vinyl with the addition of mineral fibers and may possibly include asbestos
(Weinhold, 1988). Asbestos is considered safe when encapsulated within the tile
as long as the tile is properly handled. Environmental concerns in the
manufacturing process are driving manufacturers to seek nontoxic alternatives
in the manufacture of V C T and sheet vinyl (Weinhold, 1988).
Resilient flooring materials as a general rule are installed with a flooring
adhesive. Linoleum sheets, laid dry, without adhesives, would be a notable
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
23
welding may produce hazardous fumes, especially in vinyl installation (LeClair &
Rousseau, 1992).
In spite of ecological concerns, vinyl continues to be a popular
specification for health care facilities. Sheet vinyl and V C T similarities and
differences have been summarized, and performance carefully considered in
T a b le ! 1.
Qualifying factors for flooring specifications differ based on the activity
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
same requirements and therefore, V C T or carpet are often specified based on
the criteria for selection such as cost or comfort.
Table 1.1
Advantages and Limitations of Sheet Vinyl and Vinyl Composition Tile (adapted from Weinhold,
1988).
SHEET VINYL VINYL COMPOSITION TILE

M ranagss Advantages
1) good abrasion resistance I) good abrasion resistance
2) very good resilience 2) resistant to adds, alkalis, oils and grease
3) add, alkali, oil and grease resistance 3) easy installation and flexible application
4) excellent moisture resistance 4) initial cost is relatively inexpensive
5) easy installation and flexible application
6) dear bright colors
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)
24
Carpet flooring for commercial use is typically made of synthetic fibers
from petroleum sources or natural fibers made from wool. Synthetic fibers are
made on continuous looms, bonding a fiber to a backing with a latex glue
(LeClair & Rousseau, 1992). These materials are not renewable or
biodegradable, and off gassing emissions of new materials can effect the indoor
air quality. Proper specification for use extends the life and performance of
carpeting. Through research and development, carpet has evolved to meet
health and safety criteria and provide acoustic, comfort, and aesthetic qualities.
It is slip resistant, and has excellent durability and appearance retention.
Maintenance procedures, if followed, assist in achieving a longer wear life
(Weinhold, 1988). Disadvantages include control of maintenance procedures,
soiling from dry, wet or oily sources, repair and replacement, and initial cost.
The changes in materials and manufacturing processes indicate that
more research is needed to support or contradict the findings of previous work.
The latest revision of the Center for Disease Control guidelines for protecting
healthcare workers from infectious disease states (Garner & Favero, 1985):
There is no epidemiological evidence to show that carpets
influence the nosocomial infection rate in hospitals. Carpets,
however, may contain much higher levels of microbial
contamination than hard surface flooring and can be difficult
25
to keep clean in areas of heavy soiling or spillage; therefore,
appropriate cleaning and maintenance procedures are
indicated (p. 18).
In one carpeting evaluation study, the researchers (Anderson e ta l, 1982)
found that carpets do become heavily contaminated but did not find statistically
significant differences in infection rates between patients in carpeted room and
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
floor cleaning procedures.
Detractors of carpet installations state that the environmental impact is
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 &
Rousseau text (1992) attempts to articulate the advantages and limitations of a
variety of building and finish materials in reference to environmentally-aware
choices.
26
Maintenance
In one study, a typical manufacturers’ recommended 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
of V C T requires daily care, washing, and polishing and stripping (Weinhold,
1988). In many healthcare facilities, the standard maintenance procedure is to
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
removed by stripping (Linttell & Roth, 1994).
In addition to the reflectivity, waxing vinyl flooring makes the floor more
slippery, and shows traffic patterns. Many hospital facilities do not follow the
recommended maintenance program in favor of waxing because: 1) the
perception of “shiny is clean"; 2) contracted services determine their own
procedures, using their own products; 3) janitorial equipment and supply
companies encourage a wax program; and 4) since VCT has exposed seams,
current thought is that wax provides a sealed floor.
Advances in technology have made carpet a viable alternative to resilient
and hard surface floorings by developing methods for soil and stain resistance
(IIDA, 1995). It is imperative that a planned schedule of cleaning procedures be
employed to keep the carpet investment looking good and providing excellent
27
performance (Radke, 1997). Minimum maintenance recommendation from the
Carpet and Rug institute (CRI) suggests that high traffic areas be vacuumed
daily, medium traffic areas should be vacuumed twice weekly and light traffic
areas should be vacuumed once a week (Radke, 1997). Dupont (1997)
recommends a dual-motor vacuum as the type of machine needed to thoroughly
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
single-motor commercial vacuum. The use of a vacuum cleaner with a high
efficiency particulate air filter (HEPA) will restrict dirt and particle dust from
blowing back into the room (IIDA, 1995).
Long term maintenance procedures should specify the use of water
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
then vacuumed. Two shampoo methods can be used during scheduled
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
28
detergent solution and water. The most typical cleaning method used in
hospitals is the bonnet pad machine. In this procedure, a solution of detergent
and water is sprayed onto the carpet. A rotating absorbent pad agitates the
carpet tufts and collects soil (Dupont, 1997).
Proper and consistent maintenance of any flooring material prolongs its
life and maintains its appearance. The life of the materials chosen for healthcare
environments are reliant upon the maintenance program and its execution.
Hospitals often have contractual agreements with cleaning companies to provide
a managed maintenance program. W hile hiring outside service providers may
be a effective strategy, it may be beneficial to have operational procedures
supervised by a specialist charged with environmental quality management and
informed by physical samples of the air, materials, equipment and building
systems (Haberl, 1997).
Cost Analysis
Life cycle costing is defined as a method of calculating the total cost of a
material or component, including its maintenance and replacement costs over
the life of a building. Recently, this definition has been expanded to include
methods of qualifying ecological costs (LeClair & Rousseau, 1992). Ecological
cost is an assessment of the effects of an action on the environment and all
living things. Examples of such costs are: 1) resource depletion; 2) air, water
29
and solid waste pollution; and 3) disturbance of habitats (LeClair & Rousseau,
1992).
In the Carpet Specifier’s Handbook (Carpet and Rug Institute, 1992),
studies were compiled that compared carpet and other flooring materials. The
cost considerations included material cost, installation, and maintenance costs
on an annual and twenty-year basis (Weinhold, 1987). In comparing carpet and
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.
According to these studies, maintenance costs were defined as: 1) cleaning
labor; 2) purchase cost of cleaning equipment; 3) expendable supplies; and 4)
equipment maintenance (CRI, 1992).
Weinhold (1987) states that most comparison studies are conducted by
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
30
maintenance of hospital flooring and the comparison does not include carpet as
a flooring material. According to Linttell and Roth (1993), it is difficult to
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
discrepancy between the manufactures’ recommendation for VC T maintenance
protocol and the protocol used by many hospitals.
Carpet has a higher initial cost for the product which can be offset by a
lower financial outlay in terms of maintenance, labor, time, and equipment. In
cost comparisons of maintenance of V C T and carpet, on an annual basis and in
a fifteen year comparison, carpet was consistently lower (CRI, 1992). This
compilation of studies included initial costs of materials, installation, cleaning
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
cleaning equipment (CRI, 1992).
Value is not necessarily the same as cost when it comes to choosing
appropriate flooring materials in a healthcare facility. Specifiers of flooring
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.
Qualities of carpet include a nonslip surface, cushioning, acoustic benefits, and
31
regarding thermal comfort, a potential for higher surface temperatures. VC T
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
high as well. Regardless of the flooring material choice, maintenance plays a
large role in the longevity, appearance, and the added quality to the facility.
How does the designer decide the appropriate material choice for a
particular type of space? Research on finish materials has typically concentrated
on durability, maintenance protocols, and environmental conditions such as
acoustical quality, light reflectance, and comfort. The body of knowledge needed
in making choices between one kind of material and another is complex. An
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
determines the expected end result.
Many studies on flooring materials are conducted by industry-interested
parties, leaving a question of objectivity. These studies have focused on
durability, life-cycle costs, and maintenance. Costs associated with flooring are
hard to calculate, again rendering the available literature either flawed or
suspect. Maintenance protocols are on record in healthcare facility management
offices and procedure manuals are available from the manufacturer, yet the
management of ongoing maintenance is difficult to document.
32
This research will use a timeline for comparing two flooring materials
focusing on physical properties, maintenance, costs, and environmental impact
on lighting, acoustics, and air quality within the study site.
1.3.2 Lighting
The standards for lighting measurement procedures, calibration, and use
of equipment are maintained by national standardizing laboratories (IESNA,
1993). The Lighting Handbook, edited by the Illuminating Engineering Society of
North America (IESNA), provides detailed explanations of protocols for the
measurement, documentation and analysis of lighting (IESNA, 1993).
According to IESNA (1993), studies that have focused on illuminance and
luminance typically combine the use of a photometer as the physical
measurement instrument and subjective surveys to measure participant
responses to the environment. The quantity of light, or illuminance levels, are
measured by footcandles (Egan, 1983). Afootcandle is defined as a unit of
illuminance, a luminous incident upon a surface (Trost, 1999). When a meter is
used to measure luminance, it is measuring the number of lumens per unit area
diffusely leaving a surface (ASHRAE, 1997).
Reflectance is the percentage of incident light that is reflected from a
surface, with the remainder absorbed, transmitted, or both (Egan, 1983).
33
Surfaces that are “matte” or rough, diffuse the reflected light in multiple
directions, lowering the incidence of reflected glare (Egan, 1983). Polished or
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
create a situation for a higher incidence of reflected glare (Egan, 1983). Of
course, there are exceptions to this rule. Light reflectance of surface materials
plays an important role in determining the level of artificial lighting needed to
make a room bright enough for its intended use. Surfaces with light colors tend
M ans (or diffuse) Glossy (or specular)
Brick, rough Aluminum, polished

Concrete Enamel paint
Flat paint, low gloss Glass
Limestone Marble, polished
Plaster, white Plastics, polished
Plastics, low gloss (ABS, M F , PVC) Stainless steel
Sandstone Terrazzo
Wood, unfinished Tin
Wood, oiled
Specular
reflection
Rough surface Polished surface

(where t i ' i r )
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).
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
level of illumination and stronger contrast to reach optimal visual performance
(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,
1983). Visual information that is inadequate or inaccurate, such as levels of
light that do not meet the need of the activity or reflected glare, can be
distracting and possibly dangerous (Lam, 1977).
35
Lighting for visual information that satisfies human survival, protection
and sustenance requirements affect the perceived comfort level within one’s
environment (Lam, 1977). Defined areas of informational needs include:
1. orientation,
2. security,
3. time,
4. weather,
5. the presence of other living things,
6. territory,
7. opportunities for relaxation and stimulation, and
8. places of refuge.
These categories provide information in regard to basic human needs (food,
water, and shelter), environmental conditions, spatial boundaries, and the
presence of danger (Lam, 1977). Table 1.2 represents basic human biological
needs for visual information in regard to the built environment.
The design of health facilities, with multiple end-users performing a
variety of activities, requires special attention to meeting the objectives of
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
36
Table 1.2___________________________________________________________
Human Biological (or Psychological) Needs for Visual Information (Egan, 1983).
The table below presents basic human biological (or psychological)

needs for visual information along with example lighting objectives.
Visual information fo r Examples and lighting conditions
Physical orientation and location 1. Level horizontal lines of reference (e.g.,

moldings, wainscots, expansion joints)
2. Emphasis on dangerous edges in stairs and
corridors
3. Clear definition of circulation intersections
Physical security 1. Light gradients to complement structure

(e.g., scallops of light coordinated with wall
panels)
2. Clearly visible egress routes with well-lighted
exit signs
Relaxation 1. Nonuniform lighting layouts with control of

glare
2. Emphasis on walls rather than overhead
lighting
3. Interesting visual rest centers (e.g., illumi
nated sculpture, paintings, plants) as occu
pants periodically scan environment
Time orientation Awareness of day-night cycle through dear

windows and skylights
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
Definition of personal territory 1. Task-ambient lighting such as torcheres and

furniture-integrated fixtures
2. Large ceiling coffers or columns in open
plans
housekeeping personnel. Each of these users have specific activities that
require different illuminance levels (IESNA, 1995).
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
37
a high color-rendering index (CRI). The color-rendering index is a number
obtained by comparing light sources to standard reference sources by
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
the patient’s appearance (IESNA, 1995). Lighting should be located at each
patient bed and the floor area so the nurse can observe the patient and
monitoring equipment during the night (IESNA, 1995). Examining patients
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
the nuisance of shadows (IESNA, 1995). IESNA (1995) defines examination
lights as luminaires used for minor medical procedures in areas other than the
operation room.
Activities associated with a patient’s use of light include reading, visiting,
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
the use of lighting by an individual (IESNA, 1995). Lighting levels for
housekeeping services must be sufficient to see dirt, which requires oblique
lighting over horizontal surfaces (IESNA, 1995). Table 1.3 shows the
38
recommended illuminance categories and activities in patient rooms for target
lighting levels.
In 1991, a study of 55 dialysis facilities (Bame & Douglass, 1994)
measured architectural design characteristics of the outpatient treatment
environment for adult, chronic hemodialysis patients. Lighting levels were
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.
Recommendations for the design of this particular type of facility included
Table 1.3
Recommended illuminance categories and illuminance ranges for hospital patient rooms
(Adapted from IESNA,1995, pp. 4- 6).
AREA ACTIVITY IESNA ILLUMINANCE REFERENCE RANGE OF ILLUMINANCES

CATEGORY WORK-PLANE
LUX FC*
General B General Lighting 50-75-100 5-7.5-10
Observation A General Lighting 20-30-50 2-3-5
Critical Examination E Illuminance on Task 500-750-1000 50-75-100
Reading D Illuminance on Task 200-300-500 20-30-50
Toilets D Illuminance on Task 200-300-500 20-30-50
*FC is abbreviated forfbotcandles.
39
consideration for the selection of materials and equipment; location and size of
window; facility maintenance and operations; and interior finish selections. The
flexibility of a lighting design which provides variations of lighting options, such
as providing task specific light and individual environmental control, may
improve the quality of the treatment environment, addressing the requirements
of comfort for the patients and task lighting for staff (Bame & Douglass, 1994).
Veitch, Hine & Gifford (1993), conducted a study focusing on the general
population’s knowledge of the technical aspects of lighting, beliefs about the
effects of lighting on people, individual preferences, and the perceived
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
understanding of the technology of lighting may be limited. The study also
revealed that the subjects had a desire for more control over lighting.
Additional lighting studies conducted in healthcare facilities include: Blackburn &
Patteson (1991); and Gifford, Hine, & Veitch (1997).
The dichotomy of the lighting needs for patients and staff in dialysis
facilities (Bame & Douglass, 1994) is not an uncommon situation. The various
end-users involved in the daily routine of providing and receiving care in a
hospital face similar conflicts. The end-users may include the patients, nurses,
specialists, physicians, and healthcare facility service staff.
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
patients and staff.
This study employs the use of an indoor environmental index to quantify
the environmental conditions and evaluate the responses from participants.
Lighting is one area addressed in the index as well as the surveys for patients
and medical staff.
1.3.3 Acoustics
Sound is a sensation induced through the ear by airwaves of varying air
pressure emerging from a vibrating source (Allen, 1995). Human response to
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
desired quiet environment; and 3) eliminate the paths of airborne or material
bome sound waves (Kilmer & Kilmer, 1992). Sound becomes noise when it is
(ASHRAE, 1997): 1) too loud, 2) unexpected, 3) uncontrolled, and 4)
41
unpleasant. Noise can also be characterized as sound that: 1) happens at the
wrong time, 2) contains pure tones, 3) contains unwanted information, 4)
suggests unpleasant experiences, or 5) is a combination of these examples.
Building materials and furnishings can affect the acoustics of a building
by: 1) sound absorption - lowering background noise levels and reducing
reverberation within a room; 2) airborne sound transmission - the ability of
partition walls and objects to resist sound waves and vibrations, thereby
reducing transmission of sound between rooms; and 3) impact sound
transmission - reducing the transmission of impact sound from one room to
another below or adjacent (Ballast, 1992).
A basic knowledge of acoustic design concepts and units of measure can
assist in determining appropriate choices in the construction and design of
interior spaces. Fundemental acoustic design concepts include noise reduction
coefficient (sound absorption within a single room), and sound transmission
class (sound transmission between rooms). The basic units of measure are
decibels (sound pressure on the human eardrum), and hertz (frequency of
sound vibration, which determines tone, high or low).
The noise reduction coefficient (NRC) is the average of a material’s
absorption coefficient at the four frequencies of 2 5 0 ,5 0 0 ,1 0 0 0 , and 2000 Hz.
Most rooms have several materials with different areas. The average absorption
42
coefficient of a room should be at least 0.20 (Ballast, 1992). To make an impact
on the acoustic quality in a room, the total absorption must be increased by at
least three times to change the reduction by 5 dB, which is noticeable (Ballast,
1992).
The sound transmission class (STC) is a single number rating used to
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
threshold of pain (DiNardi, 1997).
Sound frequency is the rate of repetition of a periodic event; frequency is
measured in cycles, or repetitions, of sound waves per second, which are
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
of a whistle (DiNardi, 1997). For measurement purposes, this range of
frequencies is divided into nine octave bands. An octave is defined as a range of
frequencies extending from one frequency to exactly double that frequency
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
narrow-band filter should be used. A common division of the frequency range is
one-third octave bands (Egan, 1988). Frequency analysis of sound is important
because human response to sound and noise control by absorption and
isolation are frequently dependent (Egan, 1988).
The instrument used for measuring sound is a sound level meter
(ASHRAE, 1997). It is an electromechanical meter which converts sound
pressure at a point to sound pressure level (ASHRAE, 1997). The sound meter
generally consists of a microphone, a preamplifier, an amplifier with an
adjustable and calibrated gain, frequency weighting filters, meter response
circuits, and an analog meter or digital readout (DiNardi, 1997).
Sound level meters record sound energy at multiple frequencies and
analyze data for level and frequency (Egan, 1988). Most sound level meters
provide filters for weighting the combined sound at all frequencies (DiNardi,
1997). T h e most common single-number measure is the A-weighted sound level
(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
44
available, classified by the American National Standards Institute (ANSI) as
Type 0 (laboratory standard); Type 1 (precision measurements in the field); and
Type 2 (general purpose) (DiNardi, 1997).
The National Institute for Occupational Safety and Health (NIOSH)
recommended exposure limit (REL) for occupational noise exposure is 85
decibels, A-weighted, as an 8-hour time-weighted average. With a forty year
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
at the 90-dBA permissible exposure limit (PEL) currently enforced by the
Occupational Safety and Health Administration (OSHA). Workers exposed to
noise levels in excess of this limit are at risk of developing material hearing
impairment, hypertension, and elevated blood pressure levels (OSHA, 1999).
According to Egan (1988), the background noise criteria for hospital patient
rooms should have an approximate range of 34 dBA to 42 dBA to support an
environment conducive to sleeping, resting, and relaxing. In contrast, Sound
Research Laboratories recommends a range of 20 dBA to 30 dBA.
Concerns about environmental noise and its adverse physical effects on
patient populations have brought attention to noise levels, noise type
(annoyance), and individual sensitivity to noise. Topf (1985) investigated
disturbance due to hospital noise with 150 postoperative patients who
45
completed a self-report survey 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.
Sensitivity to noise was found to significantly influence the level of patient
disturbance. The results from this study suggest that well-being may effect a
patient’s sensitivity to environmental stressors in addition to the stressors
themselves. The findings indicated that acoustic modifications in the design of
the hospital, furniture, and equipment should be a consideration in limiting stress
from noise (Topf, 1985).
Hospital noise, exceeding levels recommended by NIOSH, has been
cited as a factor in sleep deprivation, sensory overload, and reduced comfort
levels of patients (Griffin, Myers, Kopelke, & Walker, 1988). Noweir and al-Jiffry
(1991) found that noise levels in patient rooms significantly exceeded the
recommended standard. In their study of six hospitals, noise from equipment
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).
46
Stress is the psychological and physiological discomfort produced when
the demands of the environment exceeds one’s coping abilities. Topf (1996)
suggests altering the acoustic environment of patient areas by introducing an
alternative paging system to reduce equipment alarms and the ring of
telephones; providing private patient rooms; selecting carpet for high; traffic
areas; and designing equipment with quieter moving parts.
Noise levels in healthcare settings and its effect on the occupants is one
area of the literature that is well documented (e.g., T o p f, 1 9 8 5 ,1 9 9 4 ,1 9 9 6 ;
Bame, 1993; Bame & Wells, 1995; Bayo, Garcia, & Garcia (1995); and Gast &
Baker, 1989).
A study designed to describe the level of sound in acute patient care
areas used continuous decibel levels (dBA) and equivalent continuous sound
pressure levels (LEQ) for a period of 24 hours (Hilton, 1985). Twenty-five
patients from four intensive care and two general care units from three hospitals
in a large metropolitan area served as the sample. In addition to real-time
monitoring of the physical area, observations were made to verify sources of
sound and the participants were interviewed to determine their perceptions of
sound effects (Hilton, 1985).
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)
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
dBA in some instances (Hilton, 1985). Patient’s perceptions ranged from
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).
A study focusing on acoustical treatments associated with different noise
levels in dialysis facilities (Bame & Wells, 1995), measured the decibel level
from a sample of patient stations in 56 facilities, documented sources of noise,
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
room nor other design variables associated with the space.
Researchers (Bayo, Garcia, & Garcia, 1995) conducting a study at a
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
self-administered survey indicated that they thought it was feasible to reduce
48
noise levels in the hospital (Bayo et al., 1995).
In the design of hospital patient rooms, construction and material
selections appear to be the most practical methods for the designer to control
noise. When considering surface materials, a specification of a high NRC would
be most appropriate. If selecting a carpet, one must keep in mind that the noise
reduction bears a relationship to pile height (Weinhold, 1988). A designer must
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).
As previously mentioned, noise studies regarding healthcare
environments are well represented by published research. Some of these
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
surveys, triangulating the methods to strengthen reliability. Most of these studies
recommended strategies for eliminating or reducing sources of noise.
In the literature, there is very little mention of flooring as a variable for
noise studies. It is the intent of this study to consider the acoustical properties of
49
flooring as one factor in making appropriate choices of flooring materials for
patient rooms.
1.3.4 Indoor Environmental Quality
Indoor environmental quality is defined as the interrelated variables within
the physical setting that effects the physical, psychological, and emotional well
being of the inhabitants (Fuston & Nadel, 1997). In healthcare settings, these
environmental elements and factors center on the needs of patients, families,
and medical staff (Fuston & Nadel, 1997). Healthcare facilities are programmed
to accommodate technological and practical requirements for healthcare
delivery, ironically often with a loss of consideration for those who inhabit and
use the building (Carpman & Grant, 1993).
Seltzer (1994) claimed that indoor environmental problems cause more
widespread health problems than all the outdoor environmental problems
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
their exposure to indoor contaminants. These vulnerable populations in a health
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
(Seltzer, 1994). Hospitals provide a necessary service to assist in treating the
50
sick, but the nature of their business exposes the patients and staff to risk of
cross-contamination unless stringent environmental control measures are in
place.
A 1984 World Health Organization (W H O ) Committee report suggested
that up to 30% of new and remodeled buildings may be the subject of
complaints related to indoor air quality. Often, this condition is temporary, but
long term problems result when a building is operated or maintained in a manner
that is inconsistent with its original design or prescribed operating procedures.
Sometimes indoor air problems are the result of poor building design or
occupant activities. Common sources of indoor air pollution are: 1) construction
and finish materials, and furnishings; 2) electrical and computing equipment; 3)
cleaning and maintenance products; and 4)heating and cooling systems
(Carron, 1993). Health symptoms include nose and throat irritation, nausea,
headache, dizziness, fatigue, and sensitivity to odors.
As stated previously, the United States Environmental Protection Agency
(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;
51
projected estimates suggest 30 million tuberculosis (TB) deaths may occur over
the next decade, a high percentage of which will be attributed to the
transmission of the disease due to poor ventilation. Teachers are especially
susceptible to respiratory and other health consequences of long deferred
maintenance in aging school buildings (Nardell, 1997).
In the past ten years, a large percentage of research in commercial and
institutional buildings has focused on office environments. Studies focusing
primarily on productivity in the workplace show findings on the ill-effects and
productivity losses due to poor indoor air quality. Headaches, fatigue, itchy eyes
and respiratory distress were cited as some of the complaints from those
surveyed about their work environment (ASHRAE, 1997). The repercussions of
these symptoms were lost efficiency on the job and the possible increased use
of paid sick days.
In a healthcare setting, material selections directly relate to the health of
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
finish materials, chemical cleaning compounds used to disinfect the specified
materials, the heating, ventilation and air-conditioning (HVAC) system, and
52
microbiological contamination are cited as the most common causes of indoor
air pollution (Fuston & Nadel, 1993).
In an article describing emerging health concerns related to the indoor
environment, Danko, Eshelman and Hedge (1990), cite the environmental
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’
conclusions is to propose a framework that makes the consequences of interior
design decision-making more evident to practitioners and educators while
providing structure for future research. The integration of applied research and
practical application will be essential to creating a maximization of resources in
ensuring the health, safety, and well-being of the individual.
Many issues related to indoor air quality remain controversial. Ongoing
research about the nature of indoor air pollution and its related health effects are
providing data, though no definitive data are available to guide interpretation of
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).
The indoor environment is the collective whole of all the physical
properties in a room which effects a person’s physical state via heat loss and
53
respiration (Fanger, 1970). Indoor air quality depends on many factors, including
thermal regulation, control of pollutants, supply of acceptable air and the
removal of unacceptable air, as well as occupant’s activities and preferences
(ASHRAE, 1997). Maintaining an environment that has acceptable indoor air
quality relies on the monitoring, assessment and strategic implementation for
individual situations and building types.
In spite of the W HO and other organizations’ efforts in examining these
topics, the development of necessary design tools is impeded by an absence of
useful knowledge, theory, and practice regarding building-environment-occupant
interactions. These design tools could be helpful in creating and operating low-
pollution, energy-conserving buildings (Levin &Teichman, 1991). Designers
must achieve a proficiency beyond simple awareness of environmental health
and safety threats. Only through commitment to the issues, expanded personal
inquiry, repeated experimental applications, and gradual refinement will indoor
environmental health become an inherent part of the design professional’s
practice (Malven, 1990).
The study of indoor air in nonindustrial environments is relatively new and
many studies have inconclusive results. Ongoing research in field study
experiments and laboratory experiments offers the most promising protocol for
understanding indoor air quality and the health and comfort of the building’s
54
occupants (DiNardi, 1997).
Thermal Comfort
Thermal comfort is defined as that condition of mind which expresses
satisfaction with the thermal environment (ASHRAE, 1997). 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).
Means normally available for voluntary regulation of human thermal
comfort can be divided into passive means and active means which require the
artificial release of energy. An individual can control body temperature by
reducing or raising the level of activity and by altering clothing to accommodate
the desired effect of cooling or warming the body (Allen, 1995).
Methods for regulating thermal comfort in buildings are thermal radiation,
air temperature, humidity, air movement and the thermal properties of surfaces
contacted by the body. These five factors are interdependent; it is impossible to
change one factor without affecting the others to some extent (Allen, 1995).
While passive means of manipulating these environmental conditions, such as
natural ventilation, seem employable for most residential applications, the use of
passive means for cooling or heating the interior of an institutional building
without operational windows is limited. Many commercial and institutional
buildings rely completely on mechanical systems for thermal comfort.
55
Temperature and humidity. In patient rooms, the temperature must be
controlled between 70°-75° F, according to the guidelines for hospital and
medical facilities (AIA, 1993). In addition, the guideline suggests that a lower
temperature may be used when the patients’ comfort and medical conditions
make lower temperatures desirable. In Fanger’s study (1970), a comparison
between elderly subjects and college-age subjects showed no difference in the
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
the decreased metabolism in older adults (ASHRAE, 1997).
Relative humidity has an important effect on the interaction between the
environment and human thermal comfort. In warmer temperatures, a lower
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
56
humidity increases discomfort due to an abundance of skin moisture.
Temperature, in this case, has less an effect on comfort, since the discomfort
appears to be due to the feeling of moisture itself, and increased friction
between the skin and clothing. ASHRAE (1997) recommends that the relative
humidity level not exceed 60% on the warm side of the comfort zone.
Increasing air movement is another way to control thermal comfort. Lack
of minimal air movement can lead to complaints of stuffiness and poor indoor air
quality (DiNardi, 1997).
Computerized measurements of temperature and humidity are
technologies commonly available to the general public (Haberl, Lopez, &
Sparks, 1992). The main types of thermometers are liquid-in-glass (mercury or
alcohol), resistance temperature detectors (RTDs), thermistors, integrated circuit
temperature (IC) sensors, and thermocouples (Haberl et al., 1992). Depending
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
globe temperature (DiNardi, 1997).
A hygrometer is any instrument capable of measuring humidity. One such
instrument, a psychrometer, provides an affordable and simple method of
measuring humidity (ASHRAE, 1997). A psychrometer consists of two mercury-
in-glass thermometers, one measuring dry bulb temperature and the other
57
measuring wet bulb temperatures. The relative humidity is determined from
these measures using a psychrometric chart. Methods for precise applications
include dew point, electrolytic, electronic, and chemical hygrometers (DiNardi,
1997). The psychrometric chart is the graphic representation of the relationship
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
from the chart (DiNardi, 1997).
Ventilation. The standard for the minimum ventilation rate (ASHRAE,
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.
According to the American Industrial Hygiene Association (DiNardi,
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
58
well-designed system. Ventilation system contamination is a potential problem
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
their personal comfort (DiNardi, 1997).
W hile ASHRAE 62-1989 does provide a minimum standard for the
outside air supply per occupant, it is not always sufficient in the control of the
indoor air quality. ASHRAE 62-1989 addresses this deficiency by continuing
with a protocol for consideration of occupant activity, the types and strengths of
contaminant sources, the ventilation system distribution scheme, and the
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
buildings, motor vehicles emissions, or any other point sources of comprimised
air quality. The specification of appropriate air cleaning and filtration are needed
to reduce particulate matter and gaseous contaminants. Adequate distribution of
air to building occupants requires careful placement of the supply diffusers and
return air registers (Levin and Teichman, 1991).
Controlling for biological contamination in the ventilation system requires:
1) equipment selection to minimize the absorption of dirt and moisture that
provide a habitat for microbial colonization; 2) eliminating the use of exposed
fibrous acoustic materials inside the ductwork; and 3) sealing thermal insulation
59
from the circulating air (Levin and Teichman, 1991). In addition, new products
with antimicrobial properties are commonly being used for added protection
against the proliferation of biological contaminants. Cooling towers should be
located away from operable windows and from any area where people might be
exposed. Cooling towers have been shown to harbor several types of
pathogenic microorganisms that can cause Legionnaire's disease and other
respiratory illnesses (Allen, 1995).
Air movement affects the mechanism of exchange of convective and
evaporative heat between the human body and the environment (DiNardi,
1997). Air velocity or wind speed is measured by a velometer (Fanger, 1970). In
occupied zones, air velocities are usually small (0-100 feet per minute) but have
an effect on thermal comfort. Typically, a measure of three minutes is suitable
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
intake or outflow, at ceiling, wall or floor diffusers.
Carbon dioxide. Carbon Dioxide (C O 2 ) is related to thermal comfort as an
indicator of appropriate ventilation for indoor spaces based on actual
occupancy. ASHRAE Standard 62-1989 states that “maintaining C O 2
concentrations below 1000 parts per million (ppm) usually results in conditions
conducive to comfort and the removal of odor from human generated pollutants.”
60
Carbon dioxide demand controlled ventilation (DCV) is a process that modulates
building ventilation based on actual occupancy (Schell, 1998). Ventilation based
on actual occupancy rather than maximum occupancy can save energy while
maintaining indoor air quality (Schell, 1998). As long as outside levels of CO 2
remain at a fairly stable rate, the C O 2 concentration can provide an indication of
how outside air is being used to dilute the production of CO 2 by the occupants.
The American Society of Heating, Refrigerating and Air Conditioning Engineers
(ASHRAE) recommends a maximum level of CO 2 for “safe” buildings at 1,000
parts- per-million (ppm) (ASHRAE, 1989). Demand controlled ventilation does
not necessarily resolve air quality problems, however it can maintain the
ASHRAE ventilation rates and save energy by not over ventilating or under
ventilating for current occupancy levels (Schell, 1998).
Measurement of CO 2 criteria for the demand controlled ventilation
system has been established by ASHRAE. Sensor location and control strategy
should be selected to maintain the recommended ventilation rates based on
ASHRAE standard 62-1989. To benefit from this technology in existing buildings
with single zone systems, the sensor can be placed in the return air duct
(Schultz & Krafthefer, 1993). The control strategy should ensure that the
delivery of ventilation is responsive to changes of occupancy within the time
frame established by the standard. In addition, a strategy to control and reduce
61
buildup of contaminants that might occur during unoccupied hours in the
building should be developed (Schell, 1998).
In an evaluation of building ventilation and indoor air quality using carbon
dioxide, factors for consideration include the ventilation system configuration,
occupancy patterns, non-occupant carbon dioxide sources, time and location of
air sampling and instrumentation for concentration measurement (Persily &
Dols, 1990). Carbon dioxide does not provide information related to other
contaminant sources and is limited for indoor air quality assessment. However,
it can be useful as part of a protocol for measuring indoor air quality.
The nondispersive infrared (NDIR) sensor is the technology most widely
used for indoor air quality applications (ASHRAE, 1997). NDIR sensors
calibrated between 0 and 5000 ppm are typically accurate within 150 ppm, with
more accuracy dependent on a more narrow range (ASHRAE, 1997). These
sensors are available with direct-reading digital displays, with varying response
times (ASHRAE, 1997).
The National Institute of Standards and Technology (NIST) provides
standard reference materials for calibrating CO 2 monitors and other types of
calibrated equipment. The Environmental Protection Agency (EPA) has
guidelines for EPA monitoring of HVAC systems not to exceed recommended
levels of C O 2 . Another standard developed by NIST is for ambient air monitoring
62
of CO 2 to calibrate for stability and predictability. According to NIST, there is no
singular source for calibration standards in the United States (B. Dorko, May 14,
1998).
Surface temperature. Thermal comfort relies on the concept of thermal
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
or to cold (ASHRAE, 1997). In rooms where people are likely to be barefooted
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
capacity and high in thermal resistance (Allen, 1995). By means of conduction,
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
touch (Allen, 1995).
The radiant temperature in a room is significantly influenced by the
temperature of the floor, which is affected by the way a building is constructed
(ASHRAE, 1997). Results from previous studies conducted by Olesen in 1977
and cited in the ASHRAE Handbook (ASHRAE, 1997) investigated the
63
influence of floor temperature on feet comfort and recorded the temperature of
various flooring materials (Table 1.4). For floors occupied with normal footwear,
the flooring temperature is insignificant (ASHRAE, 1997). However, according to
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
discomfort, even if the individual generally feels thermally neutral. With
calculated estimates based on skin temperatures, Fanger (1970) cautiously
estimated temperature limits for bare feet in contact with different flooring
materials.
The research conducted by Olesen studied subjects that were in thermal
neutrality at a temperature of 77° F for sedentary and 73.5° F for standing or
walking persons. The results showed the percentage of dissatisfaction related to
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.
Typical Flooring Materials Temperature Range Comfort Range of Pain Limits

(without surface finishing) Floor Temperature
_____________________________________________________ °F___________ Lower °F Upper °F
Pine wood 72.5 to 82° F 62-103 -63 184
Oak wood 76 to 82° F 71-95 -4 166
Linoleum 75 to 82° F 75-95 10 153
Concrete 79 to 83° F 80-94 39 130
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.______________________________________________________
64
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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
Total Volatile Organic Compounds (TVOC). Volatile organic compounds
(VOC) are air pollutants found in all nonindustrial as well as industrial indoor
environments (ASHRAE, 1997). Total volatile organic compounds (TVOC) is the
sum of all individual VOCs. Primary sources ofV O C s include automobile
exhaust, continuous emissions from building materials and furnishings, carpet,
and cleaning products (ASHRAE, 1997). Some materials may act as a sink for
emissions and then become secondary sources as they re-emit adsorbed
65
chemicals in the air (An, Zhang, & Shaw, 1999). Sink materials include carpet,
fabric, ceiling tiles, and wallboard.
Formaldehyde (HCHO) is worth mentioning as a standout VOC because
it is used in typical building products such as particle board, some adhesives,
and carpeting (ASHRAE, 1997). HCHO is a suspected carcinogen; chronic
exposure to levels above 1 ppm may cause headaches, eye irritation, sore
throat, and asthmatic reactions, to name a few (DiNardi, 1997). The Occupation
Safety and Health Administration (OSHA) has determined an eight hour
workplace exposure limit of 1 ppm (ASHRAE, 1997). The American Conference
of Governmental Industrial Hygienists (ACGIH) recommends a shortterm
exposure limit of 0.3 ppm (AIHA, 1997). ASHRAE (1997) states that the
standard short term limit of HCHO for providing a comfortable indoor
environment is 0.1 ppm.
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
specific illness or cause can be identified (EPA, 1991).
According to the American Industrial Hygiene Association (DiNardi,
66
1997), there are three basic approaches for reducing VOC levels: 1) Dilution
ventilation (increasing ventilation rates); 2) air cleaning; and 3) source
prevention or removal (selecting low emission materials; treating high emission
materials before installation). Advances in product formulation and emission
testing are leading to products claiming to be low-polluting, nontoxic, and
environmentally safe (Levin & Teichman, 1991). Manufacturers are responding
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
specifications (ASHRAE, 1997).
Biological Contamination. Bioaerosals are airborne microbiological
particulate matter derived from viruses, bacteria, fungi, pollen, mites, and their
cellular or cell mass components (ASHRAE, 1997). Bioaerosals reside in both
indoor and outdoor environments. Floors in hospitals can be reservoirs for
organisms that eventually become airborne. ASHRAE states that carpeting
appears to trap microorganisms firmly, though conditions within the carpet may
promote their survival and dissemination (ASHRAE, 1997).
Infectious diseases can be divided into three categories. The first
category consists of contagious diseases from viruses and bacteria. These are
transmitted from one person to another (DiNardi, 1997). Examples include
influenza, measles and tuberculosis.
67
The second category, virulent environmental source infections are
commonly found in wet soils enriched with bird droppings, or mechanical heating
and cooling system reservoirs, such as cooling towers. An example of a virulent
environmental source infection is Pontiac Fever (DiNardi, 1997).
The third category is opportunistic infections; sources include water
systems, natural water supplies, dry bird droppings. An example of an
opportunistic infection is Legionnaire’s disease. Currently, there are no methods
readily available for routine monitoring or sampling the air for contagious or
virulent infectious agents (DiNardi, 1997). Typically, monitoring is considered
inappropriate unless there is a reason to suspect the presence of a particular
organism (DiNardi, 1997).
Air contaminants can be measured by total number, projected area or
mass (ASHRAE, 1997). Particles are counted by capturing them in impingers,
membrane filters, impactors, or precipitators. Analysis is completed by counting
with the use of a microscope (ASHRAE, 1997). Electronic particle counters can
provide data on particle size distribution and concentration, but accuracy
depends on careful calibration, maintenance, and proper application (ASHRAE,
1997). Projected area determinations are usually made by sampling onto a filter
paper; the light transmitted or scattered is compared to a standard filter
(ASHRAE, 1997). Other materials used are membrane or glass fiber filters. To
68
determine mass, air is pulled through the filters and then compared to the mass
before sampling (ASHRAE, 1997). In addition to air sampling, other methods to
employ include observation and the collection of bulk or surface samples
(ASHRAE. 1997).
A research team from the University of Colorado at Denver conducted a
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’
perception of the comfort parameters (temperature, humidity ,dust),
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
alleviate complaints (Wormington et al, 1996). A strength of the research design
was performing the perception study in conjunction with the sampling of indoor
air.
In 1982, a research study was conducted that obtained specific microbial
and epidemiological data in a healthcare unit to determine whether microbes
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
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
association of rooms with carpet compared to rooms without carpet. More
significant was the transmission of patient organisms to the patient environment.
Not all organisms found in the carpet were airborne. Organisms associated with
hard surface flooring correlated more closely with airborne contaminants.
The results from this study (Anderson, et al., 1982) reinforce the fact that
carpets eventually become heavily contaminated with and may harbor
microorganisms. However, this study did not find statistically significant
differences in infection rates between patients in carpeted rooms compared to
patients in hard surface flooring rooms. The authors do suggest that the varying
levels of contamination in their study probably resulted from differences in floor
cleaning procedures. Recommendations from this study discusses areas that
should not have carpet. Those areas include intensive care units, nurseries,
pediatric patient care rooms, operating and delivery rooms, kitchen, laboratories,
70
autopsy rooms, and bathrooms.
Multi-method research provides understandings of the relationship
between the quantitative assessment of the environment and the perception of
the occupants. Recent studies focusing on biological contamination of indoor
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
environments, provides a strong research design applicable to other building
environments. The Wormington et al. research incorporated physical measures
with office occupant surveys that focused on the occupant’s perception of
comfort parameters. This example of multi-method research is important
because research guidelines are developed based on research precedent.
This study’s most significant influences can be found in the research of
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
its effect on the participants in the study.
This research uses methods similar to these studies to evaluate the
patient room setting and the effect of flooring materials on indoor air quality.
Physical measures include temperature, humidity, carbon dioxide and total
71
volatile organic compounds. Additional measures include air samples and
surface samples for biological contaminants. Finally, surface temperatures are
measured for consideration of its impact on patient comfort and satisfaction. A
survey administered to patients and medical staff will focus on their perception,
preferences, and satisfaction of the environment. The analysis focuses on the
interconnection of man and his environment. More precisely, the impact of the
physical environment on the occupants of patient rooms in healthcare facilities.
1.4 TH E O R Y AND METHODS
This study is a multi-method field study. The measure of the physical
environm ent, behavioral mapping, and responses from participants about their
perceptions, preferences, and satisfaction levels for patient room environments
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
applied research, and the importance of field research.
Cooperation among researchers and designers grows out of the
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
disciplines as tools for problem solving, a cooperative arrangement is created
(Zeisel, 1981). In this study, interested parties include the researcher, designer,
72
hospital administration, and the end-users - patients, medical staff, and visitors.
With the cooperation of all interested parties, a study design using qualitative
and quantitative methodologies is used to determine the impact of the treatment
on the physical space and those participating in the study.
This study utilized three specific approaches to research. First, a field
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
strength of field research is conditional on the methods for estimating 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
methods of design are used in the development of a research agenda.
Triangulation is a method of testing one source of information against
another to prove a hypothesis, reduce or eliminate alternative explanations, and
test reliability and validity of the research methodology (Fetterman, 1998). The
use of multiple methods strengthens the field research design by maximizing the
validity of the entire research endeavor (Leedy, 1993). Triangulation is the
procedure designed to reconcile qualitative and quantitative methodologies by
using elements from each to contribute to the solution of the major problem
73
(Leedy, 1993).
Finally, applied research is a method involving hypothetical predictions,
evaluation of outcomes, and organization of information to respond to the needs
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
relationship between potential health outcomes and environmental design
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
research, the researcher has the responsibility of determining statistical
significance of the study and to provide information that is transferable to
practical application.
Levin (1951) distinguished two different levels in the concept of
environment. At the first level, environment is seen in its material, geometrical
form, and defined objectively. At the second level, it is seen in its psychological
form as it exists for an individual; it is not only defined by its objective
characteristics, but also by the qualitative properties linked to an individual’s
behavior in space (Levin, 1951).
This construct for research design strengthens the study by
74
acknowledging the lack of control in field research, designing a research study
that incorporates triangulation as a method of reducing error, and producing
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
results can be applied by practitioners in solving design problems associated
with interior environments.
1.4.1 Applied Research
Applied research uses scientific methodology to develop information that
will assist in solving complex problems and is often conducted in a setting
outside of the laboratory (Boruch, 1998). Applied research focuses on
contributing to the solution of a particular problem, whereas basic research ( i.e.
controlled experiments), is intended to expand knowledge that contributes to
our understanding of how the world operates (Boruch, 1998). The nature of
applied field research makes it difficult for the researcher to eliminate competing
explanations (Boruch, 1998). For that reason, rigorous assessment of the
research design is necessary to understand the significance of the results.
Sensitivity is defined as the ability to detect a difference between the
experimental and control conditions on some outcome of interest (Lipsey, 1998).
To maximize sensitivity, one must assess the factors that determine statistical
75
power (Lipsey, 1998): 1) sample size; 2) effect size; 3) reliability; and 4) validity.
Sampling error is smaller with larger samples, which is an advantage for
statistical power. However, other factors may affect the sample size. The effect
size between the treatment and control can be adjusted to accommodate the
sample size and preferred level of alpha; a conventional method of
standardization for differences between means is used to adjust for arbitrary
units of measurement (Lipsey, 1998). A possible alternative is to raise the alpha
level and lower the effect size to maintain a consistent subject size range.
Confounding variables are a potential threat to internal validity. A strategy
for isolating the variables that may have a possible effect on the patient's level
of satisfaction or health outcomes is needed in the research design (Graziano &
Raulin, 1997). Confounding variables may impact the construct validity of the
cause.
Construct validity of the effect is the mislabeling of the outcome variable
(Reichardt & Mark, 1998). The effect size may be affected by the strength of the
treatment implemented in the experiment (Lipsey, 1990). In other words, the
effect of a patient room with carpeting may be strong enough to determine
significance on the outcome variables.
External validity is the ability to generalize the results to other subjects,
conditions, times and places (Reichardt & Mark, 1998). To make general
76
statements about the overall population based on the findings of a particular
sample, the sample must be representative of the population (Graziano &
Raulin, 1997).
Statistical conclusion validity is an aspect of sensitivity (Lipsey, 1998).
The main concern is whether the degree of uncertainty is labeled correctly. The
determination of statistical power will assist in validating the results of a study,
as well as determining the range of probability (Reichardt & Mark, 1998).
Research design factors that increase statistical power are: (1) the independent
variable (uniform application of treatment to recipients and uniform control
conditions for recipients); (2) consistency in measurement procedures; (3) the
selection of one-tailed directional tests; and (4) multiple methodologies to
increase confidence in the findings (Lipsey, 1998).
Field research is an appropriate research methodology for exploring
environmental effects on participant behavior in settings where natural events
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
compromise validity because of the experimenter’s lack of complete control
(Campbell & Stanley, 1963). Research outside of the controlled environment
may be more difficult to validate, but extend the opportunity to assess how the
77
built environment affects those experiencing the space.
1.4.2 Indoor Environmental Quality Index
Developing an indoor environmental quality index (IEQ) is a method for
assessing the quality of the interior based on industry standards. Using an
index, the researcher can consider multiple measures according to a value scale
to understand the nature of a particular environment. The most common
example of an environmental index is the effective temperature (ET). This useful
index combines temperature and humidity into a single index (ASHRAE, 1997).
Basically, regardless of a variance in temperature and humidity, if two
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
same air velocities (ASHRAE, 1997).
As a method employed in a multi-method research design, defining the
physical environment provides a base for determining environmental factors
affecting behavior, preferences, and attitudes about how that space is
experienced (Zeisel, 1981). In review of the current literature, research designs
focusing on environmental quality tend to address one aspect of the physical
space, which does not provide criteria for an environmental assessment. Many
of the studies examined for this literature review employ multiple methodologies
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).
1.4.3 Behavioral Mapping
T h e value of behavioral mapping lies in the development of a set of
principles concerning the use of space that apply to a variety of settings
(Proshansky, Ittelson, & Rivlin, 1976). Recording people’s behavior in their
environments has practical relevance for the design professions and other fields
concerned with people’s locations and movements (Sommer & Sommer, 1991).
Behavior maps may be place-centered or person-centered (Sommer & Sommer,
1991). A place-centered map shows how people arrange themselves in a
particular location; a person-centered map records people’s movements and
activities over a specific period of time (Sommer & Sommer, 1991).
Behavior mapping involves the location and time of observed behavior.
One technique of sampling is the instantaneous time-sampling, where all areas
of a setting are observed at timed intervals with little variation of time
(Proshansky et al., 1976). Continuous observations over longer periods of time
involve recording the duration of activities in a particular location (Proshansky
79
et al., 1976). Continuous observations may provide focused information that
relates to a particular problem.
Reliability of behavior mapping can be measured three ways. Split half
reliability is high when there is consistency of comparable observations; inter-
observer reliability is high when two or more observers independently report on
the same setting and there is a high consensus of reporting; and reliability for
repeated observations of the same situation at different times or repeated
observations of different but similar situations is high when a comparison of the
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.
In behavior mapping, the observation categories are designed to be directly and
easily observed and identified. According to Proshansky et al. (1976), rigorous
assessment of the validity of behavior maps is closely connected to the level of
reliability (Proshansky et al., 1976).
Behavioral mapping allows the researcher to understand the effects of
environment on psychological and social behavior. The researcher can vary the
intrusiveness in a research setting, allowing the observer to choose to be an
outsider or a participant at various levels (Zeisel, 1981). Self report methods,
such as questionnaires, do not necessarily compare to the actual actions of the
80
participants. Environmental behavior descriptions can be used to report events
and compare to self reports as a tool for the evaluation of the environmental
elements that affect relationships between participants and the environment
(Zeisel, 1981).
There are limitations to using behavioral mapping as a research tool.
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
intrusive; and generally, additional research is needed to explain the behaviors
observed (Sommer & Sommer, 1991).
1.4.4 Survey Design
The use of interviews and questionnaires to solicit information from
participants in a research study is one of the most universal tools for data
collection for research in the natural environment (Graziano & Raulin, 1997).
The purpose of survey research is to discover relationships among variables
(Graziano & Raulin, 1997). For example, in 1976 Campbell, Converse, and
Rodgers conducted a large scale survey to measure perceptions, evaluations,
and satisfactions of Americans to assess the quality of American life. Though
the researchers collected demographic data in addition to questions regarding
preferences and satisfaction, they were not primarily interested in the status of
81
the variables measured, but in the relationships among the variables (Graziano
& Raulin, 1997).
The quality of data from a survey is dependent on: 1) the size and
population representation of the sample; 2) the techniques used for collection;
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 &
Raulin, 1997). A heterogeneous sample is required when the sample needs to
represent at diverse population; a homogeneous population is one where the
members are similar to one another. If the population is homogeneous, then
smaller sample sizes may be possible (Graziano & Raulin, 1997).
Survey instruments focusing on the physical environment of healthcare
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
of various questionnaires encompassing satisfaction, well-being, preferences,
spatial organization, and the physical environment. Of those discussed, three
surveys are of particular interest.
The first survey is entitled, “Multiphasic Environmental Assessment
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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the Environmental Evaluation Questionnaire. It measures physical features in
eight distinct areas within a hospital ward. Finally, Holahan’s Physical
Environment Scales, is an instrument which measures the physical environment
by four subscales: 1) positivity-negativity; 2) stimulating-not stimulating; 3)
attractive-unattractive, and 4) cleanliness-uncleanness. Additional survey
instruments for healthcare environments are published and available for use
(e.g., Davidson, 1995; MacDonald, Sibbald, & Hoare, 1988; and Ittelson,
Proshansky, & Rivlin, 1970).
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
reliability. The main limitation of an otherwise well designed survey is the
intrusive nature of the method, which may distort the data (Zeisel, 1981).
1.4.5 Multi-method Research Design
Multiple research techniques are often needed for researchers to gather
sufficient data about different aspects of the subject or object. The use of
multiple techniques enables researchers to understand the interaction between
83
participants and the environment, linking together a complex combination of
factors influencing the experience of place (Zeisel, 1981). No single method is
completely free from threats of validity (Maxwell, 1998). According to Maxwell
(1998), the objective of the multi-method research design is to reduce the risk of
systematic distortions inherent in the use of only one methodology.
Using multiple research methods to study a problem can increase
reliability and decrease the chance of falsely constant results. Collecting
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
the others (Zeisel, 1981). Triangulation of methods to increase reliability
assumes, of course, that techniques are not biased in the same way.
A triangulation of methods and measures is designed to compensate for
the fallibility of any single method of measure and will enhance validity by
developing converging lines of evidence (Yin, 1998). Four categories for
triangulation are 1) theoretical triangulation - the use of several frames of
reference or perspectives in the analysis of the same set of data; 2) data
triangulation - the attempt to gather observations through the use of various
sampling strategies to ensure that a theory is tested in more than one way; 3)
investigator triangulation - the use of multiple observers, coders, interviewers,
and I or analysis in a particular study; and 4) methodological triangulation - the
84
use of two or more methods of data collection procedures within a single study
(Leedy, 1993).
The use of several methods to inquire about a single problem strengthens
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
later use the results to affect the physical environment. Research is an
intentional, systematic way to improve and contribute to knowledge (Zeisel,
1981). Designers can also contribute to a body of knowledge by approaching
design problems as opportunities and by making design decisions that
contribute to inquiry (Zeisel, 1981).
1.5 SUMMARY
Healthcare administrators, design professionals, and related professions
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
design professional’s interest is the knowledge to make informed decisions
85
when designing and specifying healthcare interiors. The flooring industry and
other interior material industries are striving to develop and manufacture
products that surpass the recommended guidelines for health and safety while
providing aesthetics, comfort, and durability. The literature discusses research
that has addressed all of these issues and user groups.
For this research study, participants were either assigned to a room with
vinyl composition tile or carpet. Does a change of flooring in a typical patient
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
environment assists in answering these questions.
Do patients and staff respond similarly to this environment? W hat are the
potential differences in their response? Surveys collected from the participants
(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
what is most appropriate when specifying floor materials in a typical patient
room? This dissertation attempts to answer these questions.
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
variables associated with environmental quality - acoustics,
86
reflectance of light, indoor air quality, and thermal comfort;
2. patient and staff perceptions may not correlate with the actual physical
measures of their environment; and
3. additional research is needed to understand the relationship between
environmental variables and its impact on the occupants.
This study used an interdisciplinary multi-method research design to build
a protocol for evaluating interior finish materials. Triangulation of research
methods strengthened the overall research design and assisted in eliminating
alternative explanations of the results. Research is needed in this area to
understand the materials, the physical space, the variables affecting the interior
environment, and to contribute to knowledge for practical applications.
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CHAPTER II
RESEARCH METHODOLOGY
This chapter describes the research methods used for data collection of
this study. A multi-method research design provided a rich description of the
studied phenomenon and increased confidence in the validity of the findings.
This was a comparative study of hospital patient room environments. The
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
surveys, with additional patient information from medical records; 2) behavioral
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
sampling, instrumentation, administration procedures of the surveys, and results
of pilot tests.
2.1 RESEARCH DESIGN
The use of multiple research techniques is a way of obtaining sufficient
data about the different aspects of an object being investigated. The patient and
88
healthcare staff surveys focus on preferences, satisfaction, and perceptions
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
Environmental Quality index developed in this thesis incorporated a multi
method research design for data collection pertaining to the physical space.
Data included documentation of the spaces from floor plans, building
specifications, and measures of thermal comfort and indoor air quality of each
patient room for 48 hours at 10 minute intervals. The triangulation of these
methods provides strength in the research design and enhances the validity by
compensating for any inadequacies of individual methods or measures
presented in this study.
2.1.1 Ethics
This study has been approved by the Institutional Review Board of Texas
A&M University (Appendix A) and the Institutional Review Board (Appendix A) of
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
Protection of Human Subjects of Biomedical and Behavioral Research and
dated April 1 8,1979 (Dept, of Health, Education, and Welfare, 1979).
89
2.1.2 Research Hypotheses
The effect of flooring materials on the environmental quality of the patient
room environment is the premise of this study. The use of a multi-method
research design necessitates the formation of additional hypotheses related to
each data set and the relationship between the data sets. The following
hypotheses are tentative, informed guesses (Leedy, 1993) based on the current
literature and typical hospital standards.
The premise states that there is a relationship between the independent
variable, flooring finish material, and the dependent variables related to: 1)
physical attributes (color, cleanliness, attractiveness, and window view); 2)
indoor air quality (temperature, relative humidity, ventilation, carbon dioxide,
Table 2.1__________________________________________________________________________
Research hypotheses.
Hypothesis 1: Flooring finish materials have an impact on the indoor

environmental quality of the patient rooms.
Hypothesis 2: Patients prefer carpet to vinyl composition tile (VCT)

in their patient rooms.
Hypothesis 3: Patients perceive carpet as being: 1) a contributor to poor air

quality; 2) more attractive; 3) less noisy; and 4) less clean than VCT.
Hypothesis 4: Healthcare staff prefer VCT to carpet for the flooring

in patient rooms.
Hypothesis 5: Healthcare staff perceive carpet as being: 1) a contributor to poor air

quality; 2) more attractive; 3) less noisy; and 4) less clean than VCT.
Hypothesis 6: Visitors and healthcare staff spend more time in patient rooms
with carpet compared to time spent in patient rooms with VCT.
90
levels of volatile organic compounds and bacteria); 3) sensory qualities (odor,
noise, lighting, and reflected glare); and 4) environmental controls (personal
control of temperature, lighting, and noise) of the hospital patient rooms. This
study investigated the impact that the indoor environmental conditions had on
the preferences, perceptions, and behavior of healthcare staff, patients, and
visitors. Six hypotheses address relevant concerns for the appropriate selection
of flooring materials in patient room environments (see Table 2.1).
2.1.3 Variables
The independent variable is the flooring material in the patient rooms.
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
elements of the environment experienced by the patients, staff, and visitors in
the patient rooms (Table 2.2).
Patient and staff preference of flooring material and physical attributes of
patient rooms were based on the patients’ perception of aesthetics, comfort ,and
safety (Willmot, 1986; Davis, 1994; Anderson, et at.. 1982; Garner & Favero,
1985; Weinhold, 1988), the physical and psychological benefits of the
environment (MacDonald, Sibbald, et at.; Malkin, 1992; Orr, 1993; Ulrich, 1984),
and the healthcare staff perception of aesthetics, comfort, and cleanliness
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Table 2.2
A taxonomy of dependent variables.
Category Dependent Variable Citations for Methodology Development
Preference Floor preference Orr, 1993; Willmot 1986; Davis, 1994; LeClair
& Rousseau, 1992; MacDonald, Sibbald, etal.,
1988; Malkin, 1992; Schomer, 1993; Scott,
1993
Physical attributes Color Davis, 1994; Malkin, 1992
Cleanliness Anderson et al„ 1982; Gamer & Favero. 1985;

Weinhold, 1988; Coffin, 1993; DiNardi, 1998
Attractiveness Weinhold, 1988; Davis, 1994; Orr, 1993;

Malkin. 1992
Window view Ulrich, 1984
Thermal comfort Temperature ASHRAE 62-1989; ASHRAE 62-1999;

Temperature shifts ASHRAE, 1997; Womnington, Lanning &
Air freshness Anderson, 1996; AIA 1993; Fanger, 1970;
Ventilation comfort Habert, Lopez, et at, 1992; Persily & Dols,
Air movement 1990; Schell, 1998; Schultz & Krafthefer, 1993;
Seltzer. 1994; Sieber, Schoenau, etal., 1993:
EPA, 1991
Sensory Odor Anderson, et al, 1982; ASHRAE 62-1999
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
Lighting & Egan, 1983; IES, 1995; Gifford, Hine, et al.,

Reflected glare 1997; Glass, Avery, etal., 1985; Moran, 1990
Environmental control Temperature control Saegert, 1970; Volicer& Isenberg, 1977;

Bame, 1993; ASHRAE, 1997
Lighting control Bame, 1993; Egan, 1983; IES, 1995
Noise control Bame, 1993; Egan, 1988
(Davis, 1994; Coffin, 1993; Garner & Favero, 1985).
ASHRAE 62-1989 and ASHRAE 62-1999 recommend measurement,
analysis, and interpretation for thermal comfort measures. For this study, data
92
collection methods were employed based on previous studies of indoor air
quality, and flooring materials in healthcare environments (Wormington, Lanning
& 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
indoor air quality (ASHRAE 62-1989; ASHRAE 62-1999; ASHRAE 1 9 9 7 ). The
Anderson, et al. (1982) study focused on comparing resilient flooring and wool
carpet in patient rooms by conducting epidemiological and microbiological
studies. Sound levels were measured from a hand-held monitor according to
the dBA scale (Egan, 1988). Other studies provided support for the chosen
methodology (Bame & Wells, 1995; and Topf, 1 9 8 5 ,1 9 9 4 ,1 9 9 6 ).
Lighting levels and reflected levels were measured according to the
IESNA (1995) recommendations and calculated to acquire the percentage of
reflected glare (Gifford, Hine, e ta l., 1990; Moran, 1990). Egan (1983) suggests
acceptable ranges for reflected glare of floors in healthcare facilities.
Environmental control (i.e. control of the temperature with access to the
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
93
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
by industry standards (Bame, 1993; ASHRAE 62-1999; ASHRAE, 1997; IESNA,
1995; Egan, 1988).
The new patient rooms were built and completed with the specified
flooring materials on December 5 , 1 9 9 7 . Data collection began in November 3,
1998, nearly a year after installation, to lessen the probability of the Hawthorne
Effect (Krippendorff, 1986). By delaying data collection, the newly expanded
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
constructed patient rooms or the attention of the observers.
2.1.4 Setting
The setting is located within the Telemetry Unit, a step-down unit
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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Patient room with VCT Patient Room with Carpet
Figure 2.1
Example of patient rooms with VCT and carpet flooring materials.
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
(Figure 2.2). In many hospitals, V C T is considered to be the standard material
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
researcher. The carpet specification was chosen based on performance criteria
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.
chemical exposure), antimicrobial additive (a fungistat and bacteriostat for
carpets), and product construction (24 oz./sq. yd. tufted loop with thermoplastic
composite polymer backing). The pattern and color choice was selected based
on a comparison with the V C T flooring standard in regard to the existing color
palette and light reflectance value. All other finishes in both sets of patient
rooms are controlled.
2.2 PATIENT SURVEY AND HEALTHCARE STAFF SURVEY
Though there were differences in the surveys for patients and medical
staff, the methodology is very similar. Therefore, the survey methodology for
both participant groups is discussed. In addition, any variances between the
methodologies are described.
96
2.2.1 Participants
Thirty-six patients completed the survey. Participation was limited to
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.
Staff participation was limited to staff assigned to the Telemetry Unit in
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
choosing to participate. There were 90 eligible participants that were notified in
this manner. Criteria for exclusion included all employees who were not
assigned to this unit.
Each patient and staff member that met inclusion and decided to
participate were asked to sign a Statement of Informed Consent (Appendix B)
that had been approved by the Texas A&M University Institutional Review Board
and the hospital’s Institutional Review Board.
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2.2.2 Design and Procedure
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
of the patient room; 2) whether the patients or family members complain of
noise; and 3) questions regarding their work history.
Before distributing to the patients and medical staff, the questionnaires
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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open comments. This exercise assisted in the development of the final survey
instruments used for this study.
The surveys were distributed and collected daily between October 1,
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
longer working for the hospital). O f the seventy-nine remaining, forty-five
participants completed the survey. One of those participants did not complete
the questionnaire, and therefore that survey was eliminated from the total. Three
of the participants were eliminated due to an answer of “no preference" to
question number nine. This question asks for the preference of flooring material
in patient rooms and those who answered “no preference" were considered as
having no opinion or nonresponsive.
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
99
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.
The survey was provided to the patients with an abbreviated explanation
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
four open-ended. The survey was designed to take 15 minutes or less.
Patients were not randomly selected for placement in these rooms. The
healthcare staff who scheduled patient placement assigned patients to rooms
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.
The staff participants were asked to complete a survey about the 6
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
messaging system, complete the survey and place it in a box provided as
containment for the completed surveys. The second option was to pick up a
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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 survey was provided to the staff with an abbreviated explanation of
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
43 questions, 32 multiple choice, 5 open-ended, and 6 fill-in-the-blank questions
that inquired about their occupational status. As with the patient questionnaire, it
was expected that it would take 15 minutes or less to answer.
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
computer messaging system. Due to a low participation rate, a second collection
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
could effect the outcome of the study.
The healthcare staff survey asked questions about demographic data
including job title, shift assignment, age, gender, and questions about the staff
member’s work history within the profession and within this particular hospital
101
and unit.
White these surveys have not be used in previous studies, sections of
questions regarding the health of participants and rating of physical attributes
were based on a NIOSH Working Climate Questionnaire provided by Dr.
Rosemary Wormington, a professor at the University of Colorado, Denver.
2.3 PATIENT MEDICAL C HA R T RECORDS
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
according to their guidelines. The director of medical records required that
anyone gaining access to patient records must sign a confidentiality policy
agreement.
Medical chart data collected included: 1) room number; 2) admittance
date; 3} discharge date; 4) type of medical treatment; 5) date of birth; 6) gender;
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
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
admitted to the hospital, had a fall assessment form (Appendix C) prepared by
the nurse assigned to that patient. This toot was used to determine, based on a
scoring system, a risk of falling. The types of information collected in this
assessment are 1) age; 2) mental status; 3) history of falling within the past six
months; 4) impairments; and 5) medications used. On this particular form, a
score of 10 or above indicates a risk of falling.
2.4 BEHAVIORAL MAPPING STUDY
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
between November 3 ,1 9 9 8 and December 1 9 ,1 9 9 8 . Data were collected from
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.
103
Hours of observation totaled ninety.
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
determine the reliability of the measure. There were no discrepancies in the
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.
Observed participants were anonymous. Documentation did not require
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.
This was an unobtrusive procedure. A researcher sat in the corridor
104
outside of the patient rooms to document traffic patterns using a Behavioral
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
for entering or leaving, such as an emergency, scheduled procedure, reason not
evident.
The day and time of observation for each three-hour segment of the
patient rooms was randomly assigned. Statistical analysis determined whether
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
difference of time spend in patient rooms (Shepley, Bryant, et al., 1995).
2.5 IN D O O R ENVIRONMENTAL Q U A LITY INDEX
The development of the Interior Environmental Quality index (IEQ )
requires a method for building a profile of the setting. There are five primary
components to building a profile of the interior environment: 1) material
105
composition; 2) lighting; 3) acoustics; 4) thermal com fort; and 5) air quality.
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
discomfort for the occupant).
Air quality was one of the main design factors for this study. Methods of
construction and material fabrication are becoming important as issues of global
sustainability and environmental health come to the foreground. Baseline
readings of indoor air quality is one of the methods for identifying possible
environmental hazards to the respiratory tract (Nardell, 1997). Methods for
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
temperature, relative humidity, carbon dioxide, and total volatile organic
compounds. Other types of data included bacteria samples and surface
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
complexity of physical space. W hen one variable is manipulated, there is a
106
reaction and possibly a series of reactions within the environment. This
research study identified factors of flooring material choices in healthcare
settings based on interior environmental quality. The study determined whether
perception and actual measures are consistent or in conflict based on the
comparison of the IEQ index with patient and staff data, which focused on
preference, physical comfort, biological response, and overall satisfaction.
This section of the methodology focuses on the physical environment and
measures used to build the Interior Environmental Quality index. Recommended
limits for patient room environments are listed for environmental elements
included in the data collection.
Data collection of the physical environment relied on objective measures
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
evident through data collection of the patients’ records. Objective measures
include secondary data from: a) the hospital; b) the construction documents;
and c) industry sources. Primary data are measures recorded during the course
of this study and focused on environmental conditions.
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
station. Upon completion of construction, each room was photographed, in
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
nursing unit were collected. Documentation included the strategic planning
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
days for years 1997, 1 9 98,1999, and 2000.
Material composition was one factor of the indoor environmental quality
index. The specification and use of materials in hospital patient rooms are
generally concerned with performance and cost. Documentation of the
independent variable, the flooring materials used in this study, as well as the
other finishes in the patient rooms included: a) finish specifications; b) material
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
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
costs. The hospital out-sourced management for maintenance, therefore life
cycle costs were not available. Manufacturers provided data about each flooring
material: a) the content and fabrication of the material; b) packaging and
shipping; c) installation and use; d) resource recovery; and e) the companies’
statement of social responsibility. Finally, test data were collected from the
manufacturer and outside testing agencies, such as the Carpet and Rug
Institute and the American Society for Testing and Materials.
Lighting and Reflected Glare
Lighting levels and reflected glare are indicators of environmental quality.
In this study, measures were recorded for comparison to the recommended
lighting levels and reflected glare for patient rooms.
The photometer used for this study was a Tektronix LumaColor II
Photometer, Model J18 (Figure 2.3). The J18 is a digital photometer with
interchangeable sensors, providing the ability to make a variety of light
109
measurements. This photometer takes real-time measures. Two sensors were
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
range of 0.001 to 500 fc with an accuracy of 5% of reading +/- 2 counts.
Complete specifications and the performance verification procedure used to
verify that the photometer and the sensors were functioning properly can be
found in Appendix H.
In preparation for taking lighting measures in each patient room,
specifications of the two flooring materials were acquired to verify the
manufacturers’ reflectance value. Recommended illuminance ranges and
reflectance values for hospital patient rooms were documented to use as a
/ - = - - - - - - 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.
110
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
reading range between twenty and fifty foot candles.
Illuminance and luminance values were recorded on December 1 5 ,1 9 9 8
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
room described the condition of the room at the time of measurement.
Information included: 1) occupancy level; 2) number of patients assigned and
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
factors relating to noise levels.
Using the Tektronix Photometer, illuminance levels were recorded in foot-
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
recommended levels of light and reflectance values, and determine if the
111
difference of the reflected values for the flooring is significant.
Acoustics
The purpose of recording sound levels in this study is to determine
whether sound levels exceed the recommended range for noise that supports
an environment conducive to patient restoration. The recommended range for
noise in patient rooms is 34 dBA to 42 dBA (Egan, 1 9 8 8 ).
The sound meter used in data collection was a Quest Technologies
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.
112
emulates the response of the human ear and is for most industrial and
community noise environments. The octave filter is a plug-in module containing
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
2.3 and the specifications are shown in Appendix H.
A certificate of compliance and calibration was completed by the
manufacturer on April 6 ,1 9 9 5 . This certificate states that the sound meter used
in this study meets or exceeds the requirements of the American National
Standards Institute. The calibration was performed using certified laboratory
standards whose accuracies are traceable to the National institute of Standards
and Technology (NIST). In addition to the manufacturer’s calibration certificate,
an on-site calibration procedure was performed. First, a battery check was
performed. Then, the calibrator was turned on to produce 94 dB at 1 kHz. The
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).
63 Hz 125 Hz 250 Hz 500 Hz 1000 Hz 2000 Hz 4000 Hz 8000 Hz
-25 -15 -8 -3 0 +1 +1 -1
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.
In preparation for recording sound level measures in each patient room,
the NRC rating for the two flooring materials were acquired from the
manufacturers’ specifications. Real-time sound levels were recorded on
December 15, 1988 a t 2:00 in the afternoon. The time was chosen because it
was the time of day with the highest level of activity.
Sound levels were recorded using the Quest Technologies Precision
Integrating Sound Level Meter in each room for a series of three readings with
an A-weighted scale. An average for each frequency, range, and overall
average in each room was compared to the recommended range for noise
levels in hospital patient rooms.
Thermal Comfort
The indoor environmental factors that effect a person’s physical state of
thermal comfort include thermal regulation, control of pollutants, supply of fresh
air and exhaust of unacceptable air, as well as the occupant’s activities and
preferences. This section will describe data collection relating to thermal
comfort. The types of data collected include: 1) specifications of the HVAC
system; 2) measures of air supply and exhaust rates; 3) temperature; 4) relative
114
humidity; 5) carbon dioxide levels; and 6) surface temperatures. Each of these
properties are interdependent, creating an environment with a measurable level
of indoor environmental quality.
Ventilation. ASHRAE 62-1989 (1989) requires a minimum ventilation rate
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
to exhaust to the outdoors, depending on individual circumstances. In order to
assess the overall level of thermal comfort for each patient room in this study, air
supply and exhaust rates were recorded.
The instrument used to record the ventilation rates was an Alnor
Velometer (Figure 2.5). This instrument directly read average air flow rates,
either intake or outflow, at ceiling, wall or floor diffusers. Accuracy is + /- 3% of
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
velometer is at zero by manipulating the zero adjustment screw. The manifold
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.
115
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
recorded measure was multiplied by the correction factor as specified by the
manufacturer.
Temperature, relative humidity, and carbon dioxide. Comfortable
temperatures in general conditions within the United States of America usually
116
range from sixty-eight to seventy-eight degrees Fahrenheit and a 60% relative
humidity with a 36 degrees F dewpoint. For patient rooms, the AIA (1992)
recommends that temperatures range between seventy and seventy-five
degrees Fahrenheit. It is reasonable to have lower temperatures when it is
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
maintained between 30% and 60% with a dewpoint of 36 degrees F.
Carbon Dioxide (C O 2 ) is used as an indicator of appropriate ventilation
for indoor spaces based on actual occupancy. ASHRAE 62-1989 recommends a
maximum level of CO 2 at 1000 parts per million (ppm) for “safe" buildings.
Expected outdoor readings should equal approximately 360 ppm.
Outdoor weather data were downloaded from the NCDC Climate Radar
Data Inventories for College Station Easterwood Weather Station. Outdoor
Carbon Dioxide levels were downloaded on-line from the Energy Systems
Laboratory at Texas A&M University.
The instruments used for data collection of indoor temperature, relative
humidity, and CO 2 were part of a measurement system manufactured by
Engelhard Sensor Technologies (Figure 2.6). The base component is the
117
Recordaire datalogger. The Recordaire has four channels to accommodate the
carbon dioxide, temperature, and relative humidity sensors, as well as a sensor
for total volatile organic compounds, which will be discussed under the
subsection for air contaminants. The datalogger can record continuous real-time
data at specified intervals. Information can be downloaded and graphed using
software provided by the manufacturer.
The datalogger and all four sensors were calibrated and monitored by the
manufacturer, with testing completed on June 1 5 ,1 9 9 8 . The calibration was
DATA LOGGER
SAMPLING
PROBE
GRAPHING SOFTWARE RS-232 CABLE
Figure 2.6______________________________________________________________________
Recordaire and iock-box used to record interval data for temperature, relative humidity, carbon
dioxide, and total volatile organic compounds.
118
performed using certified laboratory standards whose accuracies are traceable
to the National institute of Standards and Technology (NIST). Specifications for
each sensor and the datalogger are shown in Appendix H.
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
2.7). This datalogger is manufactured by Young Environmental Systems and
records temperature, relative humidity, and carbon dioxide. Technical
specifications for this instrument is shown in Appendix H.
Figure 2.7___________________________________________________________________
YES-204 IAQ monitor used in controlled experiment to verify the validity of the Recordaire
monitor equipment.
119
The controlled experiment tested for temperature, relative humidity, CO 2 ,
and TVO C levels. The Recordaire and sensors were compared to the YES-204
IAQ Monitor, which recorded temperature, relative humidity, and CO 2 . The
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
objectives of the test, a procedure was developed to create atmospheric
changes within the box.
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
the monitoring equipment. W hile the comparison of measures showed numerical
differences, more often than not, the measures were congruent within the range
of accuracy for each sensor, according to the specifications of the equipment.
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
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
Time and treatment:

9:21 PM Base readings on Recordaire placed in test box.
9:45 PM YES-204 IAQ datalogger placed in test box for comparison.
9:46 PM Placed 1/4 c. household cleaner in test box.
9:53 PM Removed 1/4 c. household cleaner.
9:54 PM Placed paper napkin sprayed with household cleaner 14" aff. in test box.
11:10 PM Removed paper napkin sprayed with household cleaner.
11:11 PM Blew on C 02 monitor to measure expected increase in level of C02.
11:27 PM Placed 3 c. of hot water in test box.
1:40 AM Removed 3 c. of hot water from test box and stopped experiment.
Figure 2.8
Controlled experiment to verify reliability for the Recordaire monitoring equipment used for patient
room IAQ interval measurements.
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
open room environment, the TV O C level dropped.
In preparation for running the datalogger in the hospital, a secure box
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.
Surface temperature. In indoor areas where the occupants are likely to be
barefooted, comfort is dependent on the flooring temperature and flooring
material. Materials with high thermal resistance, like wood or carpeting, are
expected to be warmer than materials with low thermal resistance, such as
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
122
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
measured the surface temperature by sensing its emitted energy, reflected
energy, and transmitted energy. This energy information is collected, directed
onto a detector, and translated by a microprocessor into a temperature reading
displayed on the unit. The temperature range is -25 to 1000 degrees Fahrenheit.
This Raytek equipment is calibrated by computer by the manufacturer. Complete
specifications are shown in Appendix H.
The recorded surface temperatures in the patient rooms indicate
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.
123
occupants.
Air Contaminants
Air contaminants are foreign materials in normal air that can be classified
as: 1) particulate or gaseous; 2) organic or inorganic; 3) visible or invisible; and
4) submicroscopic, microscopic, or macroscopic; 5) toxic or harmless; and 6)
stable or unstable (ASHRAE, 1997). This study focused on biological
contaminants and total volatile organic compounds as a method of investigating
how flooring materials affect the quality of the indoor air.
Total volatile organic compounds. Indoor environments have a variety of
different compounds present on a daily basis. While an argument could be
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
EPA (1991), the accumulation of VO C s may play a role in sick building
syndrome and have adverse affects on people with chemical sensitivities.
The apparatus used for data collection was the PSI-10 datalogger, which
provided an analog signal proportional to TVOCs (Appendix H). This product
was part of the system using the Recordaire by Engelhard. The sensor was
calibrated in clean air at seventy-two degrees Fahrenheit and twenty-five
percent relative humidity.
This sensor was attached to a channel on the Engelhard datalogger used
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
determine if a change in flooring material is a significant factor in assessing
potential problems associated with TVOCs.
Biological contamination. The method of data collection used
triangulation between samples from the floor, HVAC air supply and air exhaust
vents, and the air to test for total bacteria counts.
Sampling for bacteria occurred on February 1 6 ,1 9 9 9 . Seven samples
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
aerobic plate count. The procedure required an eight-hour exposure to the
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).
126
2.6 SUM M ARY
Materials have properties that affect the amount of light absorbed or
dispersed. Its composition determines whether it absorbs or reflects sound and
establishes the acoustic value of the material. Thermal comfort is determined by
multiple factors, including temperature, relative humidity, the appropriate amount
of fresh air, air movement, and surface temperatures. The composition of a
material determines thermal resistance, defining its role in surface temperature
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
flooring materials influence the indoor environmental quality.
The triangulation of the methods, incorporating: 1) patient and healthcare
staff surveys, 2) the behavioral mapping study, and 3) the Indoor Environmental
Quality index, determine how perception, preference and satisfaction compare
to the physical space and how that space is used. The surveys show the
similarities and differences between the healthcare staff and patients; the
behavioral mapping study determines whether there was a significant difference
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
the conditions of the space and its relationship to industry standards.
127
CHAPTER III
ANALYSES A ND RESULTS
This study utilizes multiple methodologies to investigate the impact of
flooring materials on the quality of patient room environments and the
experience of patients and healthcare staff. The premise states that the
environmental conditions of the hospital patient rooms impact the preferences,
perceptions and behavior of healthcare staff, patients, and visitors. In all, there
are six hypotheses that address relevant concerns for the appropriate selection
of flooring materials in patient room environments (to review the hypothesis,
refer to Table 2.1, p. 89).
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
analysis of the environmental conditions.
128
3.1.1 Behavioral Mapping Study
The behavioral mapping study data were first analyzed qualitatively
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,
visitors, and healthcare staff. In addition, Independent Samples t-Tests were
used to compare differences in the time staff and visitors spent in the carpeted
patient rooms and the patient rooms with V C T flooring.
3.1.2 Healthcare Staff and Patient Surveys
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
verifying the accuracy of the data.
Chi-square tests were used to assess potential confounding factors. The
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
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.
Healthcare Staff Survey
No confounding factors were found during the chi-square analysis of
healthcare staff preferences. Independent Samples t-Tests were used to
determine that there were no differences between batch 1 and batch 2 of the
surveys collected. Paired Samples t-Tests were used to determine significance
of dependent variable ratings. The significance level was adjusted using the
Bonferroni to account for multiple comparisons.
Patient Survey
A two-way Analysis of Variance (ANOVA) was used to test between
subject effects of rated dependent variables . The Levene statistic tested for the
equality of group variances (i.e. homogeneity-of-variance). This test was not
dependent on the assumption of normality. The between subject factors were
floor type and bed assignment.
130
3.1.3 Indoor Environmental Quality
Each patient room was monitored for 48 hours at 30 minute intervals for
temperature, relative humidity, carbon dioxide, and total volatile organic
compounds. The data were analyzed graphically using psychometric charts,
time series line graphs, and box-whisker plots. The graphic analysis described
the environmental conditions of each patient room and illustrated any
differences between rooms with carpet and rooms with VCT.
Levels of illuminance, luminance, and sound were recorded to measure
ambient environmental qualities within the patient room. A reflectance factor (the
ratio of reflected light on a surface) was calculated to compare the flooring
materials in the patient rooms for reflected glare. Surface temperatures were
tested with a paired samples t-test and compared to recommended limits as a
factor for thermal comfort (ASHRAE, 1997). Bacteria samples were analyzed by
an independent laboratory for comparison of the bacterial colony counts in
rooms with carpet and VCT.
3.2 DESCRIPTIVE RESULTS
This section begins with a explanation of the flooring materials used in
the study (the independent variable), followed by a description of the patient
rooms. The characteristics of the participants, both patients and healthcare staff,
131
conclude this section.
3.2.1 Properties and Characteristics of the Flooring Materials
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
specs and manufactured by a leading resilient tile company. The V C T specified
for the control rooms cost $471.00 installed ($ 1 .57/sq.ft.).
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.).
A comparison designed to numerically compare the carpet and V C T used
in this study was based on Interior Finish Materials for Health Care Facilties
(Weinhold, 1988) and Environmental by Design: A Sourcebook of
Environmentally Aware Material Choices (LeClair & Rousseau, 1992). A numeric
scale was developed to rate the floor finishes for material properties using the
average of the rating scale index (1=unknown, 2=poor, 3=fair, 4=good,
5=excellent). On a rating scale of 1 to 5, the carpet rating was 3.52 and the VC T
132
Table 3.1
Flooring material properties rating comparison.
PROPERTIES CARPET TILE VINYL COMP. TILE

(specified in this study) (specified in this study)
Inherent Qualities Inherent Qualities
HEALTH & SAFETY

Slip resistance Excellent Poor
Bacteria & mold resistance
WEAR LIFE
Durability
Abrasion resistance Excellent Good
Appearance Retention
Resilience Excellent Fair
Soil Resistance Excellent Fair
Stain resistance Good Poor
Fade resistance Good Fair
Static load resistance Poor Fair
Moisture resistance Poor Good
Chemical resistance
Adds and alkalis Poor Good
Oil and grease Poor Good
Cigarette bum resistance Poor Excellent
Maintenance
Ease of maintenance Fair Fair
Cleanability Excellent Excellent
Control of Protocol Poor Poor
ENVIRONMENTAL
Dying flexibility Excellent N/A
Styling versatility Excellent Fair
Comfort underfoot Excellent Fair
Sound Absorption Excellent Poor
Sustainability
Production Poor Poor
Packing & shipping Fair Fair
Installation & use Good Fair
Resource recovery Excellent Poor
INSTALLATION
Ease of installation Excellent Excellent
Flexibility Excellent Fair
Cost
Life-cycle cost
'Undetermined at this time.
Note: Primary source is Interior Finish Materials for Health Care Facilities Ch. 2 and 3,
by Virginia Weinhold, 1988, Columbus Ohio, Charles C. Thomas. The secondary source is Environmental
by Design: A Sourcebook o f Environmentally Aware Material Choices (Vol. 1), by LeClair and Rousseau,
1992, Point Roberts, W A, Hartley & Marks, Inc.
133
rating was 2.92. Carpet rated excellent for slip resistance, soil and abrasion
resistance, and cleanability. For sustainability, carpet rated excellent for
resource recovery, good for installation and use, fair for packaging, and poor for
production. V C T rated excellent for cigarette burn resistance, cleanability and
ease of installation. It is considered to be moisture resistant, but porous. It is
chemical resistant, and has good abrasion resistance. For sustainable effort,
V C T rated fair for packing, shipping, installation, and use. The rating for
production and resource recovery was poor (see Table 3.1).
3.2.2 Description of the Patient Rooms
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
134
150 -
125 -
>
u
% mo -
© 75 -
-3 .. •
£ ■Vi 1
u_
50 -
25 - *7 ■ Visitors
□ Staff
o -
RM268 RM269 RM271 RM272 RM273 RM287

Rooms with VCT Rooms with Carpet
Figure 3.1
Frequency of traffic in patient rooms by healthcare staff and non-staff visitors.
Visitor
25% Nurse
37%
Priest
1% Doctor
Administrator J
0%
Kitchen Staff_ / '

6% Technician
House
keeping
7%
Rgure 3.2
Healthcare staff and non-staff visitor traffic in patient rooms.
135
rooms (see Figure 3.2).
The typical patient room (single or double occupancy) was approximately
275 sq.ft. (Appendix J). The patient beds in the double occupancy patient rooms
were separated by a 4 ft. wing-wall for privacy. There was a connecting
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
Patient room interior finish specifications.
Type Specification Contact
Flooring Carpet tiles Interface

Pattern: Leader
Color. 1426 Performer
Carpet Adhesive Grid Set Interface
Flooring VCT Armstrong

Imperial Texture
Standard Exceton
51906 Teal
1ZVI2" Gauge 1/8T
VST Adhesive LowVOC Armstrong
Rubber Base Rubber Base Armstrong

Color Integated
Gray-Green#
Laminate Wisonart
1. Countertops 1. #4170-60 Beige Pampas
2 Mllwcrk-vertical 2 #097-60 Haze
Laminate (Doors) ARF-Plus Nevamar

#WM-1-017T Rose Renaissance
Textured
Comer Guard #866 Doeskin Acrovyn
Paint Shetwn Wiliams

1. V W Paint 1. Batitaus Buff SW1081 (LR/71%)
2 Door Frame Paint 2 Coral Sand SW1064 (LRV45%)
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).
3.2.3 Characteristics of the Patients
Thirty-six patients participated in the study by completing a survey about
perceptions, preferences, and satisfaction with their patient room. Patients were
assigned to rooms with either vinyl composition tile (44% ) or carpet (5 6 % ). Nine
of the surveys were collected from patients assigned to single-occupancy patient
rooms. Of those nine, only one patient assigned to a patient room with V C T
flooring completed the survey.
To determine whether surveys from patients assigned to single
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
only variables found to be confounding. Floor type was expected to be
significant, as this was the primary reason for excluding the surveys from
patients in single-occupancy patient rooms. The difference between the means
for external noise was significant when tested against occupancy, but was not
137
30
25
>»
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
Patient Years of Age

Figure 3.3
Patient range of age.
■ F k x x T ^ e V C T I F to cr Type Carpet
30
25
^/He Ferrde Caxascn NxvCaLcascn

PaiertGertfer F%fatFôe/Etftidty
30
25
FSsk N ttffsk Heart Related Non-Heart Related

Pdient Riskof Faffing Diagnosis
Figure 3.4
Patient demographics.
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
heart-related illness. Once a patient was situated in their room, a nurse
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
male (for additional information, refer to Figure 3.4).
3.2.4 Characteristics of the Healthcare Staff
Healthcare staff were defined as registered nurses, licensed vocational
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
patients as needed and spend limited amounts of time on the unit.
O f 91 possible participants, 12 were lost to attrition (no longer worked at
this hospital). Of the remaining 7 9 ,4 5 participants completed the survey. Four
were excluded; 3 because they had no preference for flooring material in the
139
100%
80%
:
jfrWgr-
1 f
® 40% *' vvj/.M*
20%
•;v ,:c r r .* ^
0P/o
Njsing Staff Nn-NLrsingStrff
vtbC^scnplicn
Figure 3.5
Healthcare staff job description.
patient rooms and one because the survey was incomplete. Therefore, there
was a total of 41 completed surveys from the healthcare staff participants.
Eighty-three percent of those participating in the study were nurses. Forty-
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
less. Seventy-eight percent of participants had worked at this hospital for 5
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
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+
Years Worked in Healthcare Reid Years Worked at this Hospital
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
N rrter of H u s Wbked in a Wfeek Years Wbrked in Telemetry Unit
Figure 3.6
Healthcare staff demographics.
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-
hour shift schedule, such as physical therapist or technicians. For additional
information on healthcare staff participants, refer to Figure 3.6.
3.3 HYPOTHESES RESULTS
This study focused on six hypotheses based on the differences between
flooring materials in hospital patient rooms.
3.3.1 Hypothesis 1: Environmental Conditions and Floor Type
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
patient room environment. A main consideration for the selection of flooring
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
VCT Carpet
Figure 3.7
Reflected glare on vinyl composition tile and carpet in patient rooms near the window.
Table 3.3
Lighting conditions for December 15,1998 at 2:00 pm.
Room 268 Lighting Conditions:

2’x4’ fluorescent in bathroom - on; T.V. - on; window blinds - closed

2’x4’ fluorescent at ceiling above patient bed(s) - indirect on; window blinds - open

T.V.(s) - on; window blinds - open

2’x4’ fluorescent at ceiling above patient bed(s) - on; 2’x4’ fluorescent at ceiling at entry - on;
T.V.(s) - on; window blinds - open

1) 2'x4’ fluorescent at ceiling above patient bed(s) - indirect on; window blinds - closed
Room 287 Lighting Conditions: T.V.(s) - on; window blinds - open
143
60
Patient Rooms
Figure 3.8
Level of Illuminance (incident illuminance) in patient rooms.

NOTE: Recommended levels of illuminance for reading (20-50 fc) and general activities (5-10 fc)
(Egan, 1983).
60
VCT Carpet
Flooring
Figure 3.9
Level of Illuminance (incident illuminance) in patient rooms categorized by flooring material.

NOTE: Recommended levels of illuminance for reading (20-50 fc) and general activities (5-10 fc)
(Egan, 1983).
144
illumination categorized by the flooring materials. This information is relevant for
understanding the calculated percentage of reflected glare. The recommended
range of reflected glare for flooring materials in healthcare environments is 20% -
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.
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
range for sound levels in patient room environments (Egan, 1988).
Thermal Comfort
Ventilation. Ventilation rates for hospital patient rooms require a minimum
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
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
controlled by a local pneumatic thermostat to control room temperature (not
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.
Patient Room Flooring Material Exhaust A ir Air Changes/hr
268(1,920 cu.ft.) VC T 58 CFM 1.813 A C H
269 (2,496 cu.ft.) VC T 55 C FM 1.322 ACH
271 (2,016 cu.fl.) VCT 282 C FM 8.393 ACH
272 (2,304 cu.ft.) Carpet 622 C FM 16.198 ACH
273 (2,352 cu.ft.) Carpet 718 CFM 18.316 ACH
287(2,112 cu.fl.) Carpet 60 C FM 1.705 A C H
147
affected by the choice of flooring material, but the airflow rates may have driven
down the carbon dioxide levels in the patient rooms.
Temperature and relative humidity. Temperature levels differed minimally
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
appear to be related to by the outdoor temperature. The timeline (Figure 3.13)
represents 48 hours of real-time measured data for inside and outside
temperatures. The rooms were typically warmer than the recommended
100
(/) 00-
io>
CD
a
2
3
a
>
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.
148
u_ L i.
CO
O)
(D
Q 0 D -'
£
3
2
ID
Q.
E
0)
h-
f ~ " ■- r U1----------------r ------

13m Vpm 12pm 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 Rm287
Vinyl Composition Tile Carpet
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.
Figure 3.13__________________________________________________________________
Temperature timeline for patient rooms and outdoor conditions categorized by flooring type.
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
temperatures effected by the outside temperatures. For additional information
regarding thermal comfort of each patient room, refer to Appendix I.
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
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
&
|g
E
3
X
V
>
30- <D
-Qbcfe
-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.
150
I t I 'TCTk*
j i ! !-
! ! i -r
! | ' i
002 I
: I ..***! ” ii
11
»•
II
...... r * " ..............
r........... V ‘" ! !
SO «0 ^0 mo
O r r ^ l * T m p tfM B T t ( f l
Rexam 268-Outside Conditions Room 268-Inside Conditions
oo: 3 .
I'
atmf
t -tr
I
bo «o so «o BO BO
rtmparMvr* fty b o Tiw pw airmen
Room 269-Outside Conditions Room 269-Inside Conditions
Data Not Available

.-K'
.- t —
—•4....
-TTTT^—f ---- ~
4 :— ! i
O y H O T m iir a W t ff)

NOTE: The shaded box represents the range of temperature (70-75 degree F) and humidity
(30%-60%) for hospital patient room environments. Winter range (clothing value .9), dewpoint 36
F as recommended by ASHRAE 62-1999, Ventilation for Acceptable Air Quality. Dry-bulb tem
perature range 35-95 F. Humidity ratio range 0-.03 pounds moisture/pounds dry air.
Figure 3.16_______________________________________________________________________
Inside/outside temperature and humidity displayed on the psychrometric chart during
December 14-21,1998 for patient rooms with vinyl composition tile.
« '■ ■ 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
AO AO ^0
A 0 AO
O yO ulb T i w p w w i (f)
O r r - M b T «m p«ra*ur* Jf)
-■
.< m '
: -" - i I
.... ........................J
i ..... — L ..——r—
— ............... .
i

NOTE: The shaded box represents the range of temperature (70-75 degree F) and humidity
(30%-60%) for hospital patient room environments. Winter range (clothing value .9), dewpoint 36
F as recommended by ASHRAE 62-1999, Ventilation for Acceptable Air Quality. Dry-bulb tem
perature range 35-95 F. Humidity ratio range 0-.03 pounds moisture/pounds dry air.
Figure 3.17_______________________________________________________________________
Inside/outside temperature and humidity displayed on the psychrometric chart during
December 14-21,1998 for patient rooms with carpet.
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
in room 287 caused a higher level of relative humidity (Figure 3.15).
Temperature and relative humidity data graphed on a psychrometric chart
(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.
153
relative humidity.
Carbon dioxide. There were no significant differences in the levels of
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
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: 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. Outside
carbon dioxide levels did not exceed 360 ppm.
Figure 3.19
Carbon Dioxide timeline for patient rooms categorized by flooring type.
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
means was not significant. However, neither flooring averaged a temperature
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
Total volatile organic compounds. At this time, guidelines or standards
have not been established for exposure to volatile organic compounds (TVOC)
in non-industrial indoor environments. The mean and standard deviation for
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
TVO C is associated with activities in that environment (Figure 3.21).
Surprisingly, the air exchange rate differences in the patient rooms did not effect
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.
the levels of total volatile organic compounds.
Biological (bacteria). Surface and air samples were collected for each
patient room and cultured for colony forming unit (CFU) counts. For analysis,
two events (highpoints) were excluded. The remaining samples demonstrated
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
deviation for rooms with carpet was 55.90 (33.71).
157
200
£ 150 ■
o
o
E
li.
VCT Carpet
Flooring
Figure 3.22
Bacteria count of colony forming units categorized by flooring type.
The small number of samples limit the interpretation of the bacteria
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
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.
had more bacteria colonies than the rooms with V C T .
3.3.2 Hypothesis 2: Patient Preferences
Sixt-nine percent of patients surveyed preferred carpet as their flooring
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
lower noise levels as factors that attributed to carpet in patient rooms.Though
patients assigned to rooms with V C T had a tendency to select V C T as a
preference, the majority of patients assigned to those rooms selected carpet as
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
flooring for their patient rooms cited cleanliness as their reason.
3.3.3 Hypothesis 3: Patient Perceptions
Patients perceived the rooms with V C T to be more clean, better views,
have fresher air, and better ventilation than rooms with carpet. However, the
rooms with carpet were perceived to have more comfortable temperatures.
Patients rated the physical attributes of their patient room on a scale of 1
(low) to 6 (high). The means and standard deviations are listed in Table 3.5.
Bed assignment significantly effected the patients’ rating of room
cleanliness F(1)=3.34,p<.10. The patients’ rating indicated that the patients
160
Table 3.5______________________________________________________________________
Means and standard deviations for patient ratings of physical attributes of their patient rooms.
Dependent Flooring Standard

Variable Material Mean Deviation
R oot preference VCT 1.53 .53
Carpet 1.81 .52
Color VCT 4.60 1.12
Carnet 4.75 .75
Cleanliness VCT 5.28 .91
Carpet 4.67 1.44
Attractiveness VCT 3.69 1.44
Carpet 4.42 1.31
Odor VCT 5.53 1.06
Carpet 5.17 1.03
Window view VCT 3.79 1.81
Carpet 2.92 1.93
Temperature VCT 4.47 1.60
Carpet 4.58 1.24
Temperature Shift VCT 5.21 1.05
Carpet 5.08 1.24
Air freshness VCT 5.07 .96
Carpet 4.17 1.27
Ventilation comfort VCT 5.36 .93
Carpet 4.45 1.51
Air movement VCT 5.07 1.03
Carpet 4.17 1.34
Noise (internal) VCT 4.87 1.55
Carpet 4.67 1.50
Noise (external) VCT 5.27 .96
Carpet 5.25 .97
Lighting VCT 5.60 .63
Carpet 5.55 .69
Reflected glare VCT 5.13 .99
Carpet 4.92 1.08
Temperature control VCT 3.50 2.10
Carpet 4.00 1.79
Lighting control VCT 4.57 1.74
Carpet 4.33 1.92
Noise control VCT 3.50 1.99
Carpet 3.58 1.51
Roor condition VCT 5.00 .96
Carpet 5.17 1.11
Wall condition VCT 4.21 1.37
Carpet 5.42 .67
Ceiling condition VCT 5.00 1.30
Carpet 5.58 .67
Millwork condition VCT 4.77 1.10
Carpet 5.10 1.14
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
patients in rooms with VC T.
Bed assignment significantly effected the patients’ rating of window view
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
significantly effected the rating for window view F(1)=4.35,p<.10.
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
comfortable than patients near the window.
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
effected the patients’ perception of air freshness F(1)=4.291,p<.05.
162
The floor type significantly effected the patients’ rating of ventilation
comfort F(1)=3.302,p<.10. Patients in rooms with VC T rated their level of
ventilation comfort higher than patients in rooms with carpet.
3.3.4 Hypothesis 4: Healthcare Staff Preferences
Healthcare staff preferred V C T to carpet, though 17% listed carpet as
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.
163
Table 3.6
Means and standard deviations for healthcare staff ratings of patient rooms’ physical attributes.
Dependent Variable Floor Material Mean Std. Deviation
Pair 1 Color VCT 4.53 1.04

Carpet 3.63 1.50
Pair 2 Cleanliness VCT 4.59 1.00
Carpet 2.66 1.37
Pair 3 Attractiveness VCT 4.02 1.13
Carpet 3.83 1.70
Pair 4 Odor VCT 4.88 0.95
Carpet 2.78 1.27
Pair 5 Comfort VCT 3.88 0.97
Carpet 4.43 1.43
Pair 6 Temperature VCT 3.63 1.16
Carpet 4.59 1.00
Pair 7 Temperature Shift VCT 3.82 0.91
Carpet 4.46 0.88
Pair 8 Ventilation VCT 4.56 0.75
Carpet 3.90 0.99
Pair 9 Air Freshness VCT 4.55 1.06
Carpet 2.75 1.24
Pair 10 Air Movement VCT 4.68 0.97
Carpet 3.35 0.92
Pair 11 Noise (internal) VCT 3.59 1.12
Carpet 4.78 1.11
Pair 12 Noise (external) VCT 3.56 1.27
Carpet 4.83 0.97
Pair 13 Lighting VCT 4.25 0.95
Carpet 4.25 1.13
Pair 14 Reflected Glare VCT 3.68 1.25
Carpet 5.08 1.05
Pair 15 Floor Condition VCT 3.90 1.19
Carpet 3.35 1.49
Pair 16 W all Condition VCT 3.69 1.36
Carpet 3.69 1.38
Pair 17 Ceiling Condition VCT 3.92 1.20
Carpet 3.67 1.28
Pair 18 Millwork Condition VCT 3.82 1.16
Carpet 3.45 1.29
164
3.3.5 Hypothesis 5: Healthcare Staff Perceptions
Healthcare staff rated the patient rooms with carpet and the patient rooms
with V C T on a scale of 1 (low) to 6 (high). Means and standard deviations are
listed in Table 3.6.
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
means, see Figure 3.26).
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
spent in patient rooms f(122)=2.32, p<.05. Non-staff visitors spent an average of
21 minutes and 17 seconds (SD 22:13) in patient rooms with carpet and an
165
2.5 2 1.5 1 .5 0 .5 1 1.5 2 2.5
Less glare
F H Light ng (no differei ice)
Less noise from

corridor
Less noise n roorr
Better«lir movement
Fresher air
Bet er ventilation
Fewer tempei ature s
Better tempeii ature
More connfortabl i
(Better
odor
Mon i attractive
t More
clean
Betercolo-
Carpet MCT
□ffereraes Baweentte (teens

Rgure 3.26
Differences between the means of paired samples for healthcare staff perceptions about
flooring materials in patient rooms.
166
average of 13 minutes (SD 17:30) in rooms with V C T (see Figure 3.27).
CO
<u
-4—»
3
C
VCT Carpet VCT Carpet

Staff Visitors
Figure 3.27
Average number of minutes healthcare staff and visitors spend in patient rooms.
167
C HAPTER IV
DISCUSSION OF TH E RESULTS
This chapter summarizes the results of this study, discusses the
relationships between the environmental conditions and participant responses,
and considers the implications of the findings.
4.1 SUM M ARY OF THE FIND IN G S
This section reviews the advantages of carpet and VC T to determine the
criteria and discuss the relative merits of both flooring materials. The summary
begins with a discussion of the Indoor Environmental Quality index, followed by
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
patients. The section concludes with a review of the indoor environmental
conditions and the impact on patients, staff, and visitors.
4.1.1 Indoor Environmental Quality Index
The Indoor Environmental Quality index is comprised of eleven factors: 1)
material composition; 2) light levels; 3) reflectance values; 4 ) sound levels; 5)
ventilation; 6) temperature; 7) relative humidity; 8) carbon dioxide; 9) surface
168
temperatures; 10) total volatile organic compounds; and 11) bacteria.
The composition and inherent properties of the flooring materials used in
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
V C T is 1) slip resistance; 2) abrasion resistance; 3) soiling resistance; 4) fading
resistance; 5) staining resistance; 6) design opportunities; 6) lower indirect
reflectance levels; and 7) the implementation of sustainable practices. V C T has
the following advantages over carpet: 1) moisture resistance; 2) static
resistance; 3) chemical resistance; 4) bum resistance; and 5) lower initial cost
for installation.
An important property of flooring material in healthcare facilities is slip
resistance. Carpet is an excellent slip resistant flooring product. VCT, typically
waxed when specified in hospitals, is not slip resistant. In a study of 58 elderly
hospital patients selected to test two flooring surfaces, the analysis
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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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
assigned to rooms with carpet. The increased number of patients designated as
at risk for falling in rooms with VC T indicated that the nursing staff perceived the
floor as a factor in determining the level of risk for their patients.
The properties of the flooring products used in this study indicate that the
carpet is resistant to the daily effects of wear while V C T is more effective in
resisting long term effects of a variety of spills. While resistance to cigarette
burns is a performance characteristic of VCT, it should not be considered in 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
consider include the costs associated with replacement, cleaning materials ,
equipment, and labor.
Maintenance
Maintenance was a controlling factor in the success or failure of patient
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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,
including this one, chose to subcontract maintenance management.
Maintenance staff were employed by the hospital and trained by the
management company. Maintenance staff were responsible for their assigned
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
Sustainability was rated based on production, packing and shipping,
installation and use, and resource recovery. The VCT was produced from
petroleum and plasticizers, which have serious environmental and health
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
an adhesive. In comparing the sustainable practices of both industries, it is clear
that there is still room for much improvement. The carpet industry, and this
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manufacturer in particular, has implemented resource recovery programs,
specifications for resource recovery, and minimized the problems associated
with installation and use by developing nontoxic adhesives and carpeting that
does not require adhesives for installation. No documentation is available that
shows the resilient flooring industry working toward more sustainable practices.
Lighting
The levels of incident illuminance was not significantly different. The
recommended range for lighting levels depends on the activities. General
activities require a range of 5 to 10 footcandles (fc) (Egan, 1983). The
recommended range for reading and other similar activities is 20 to 50
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
illuminance in rooms with V C T was 12 fc and the mean level of illuminance in
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
recommended for reading and other task-oriented activities.
Reflectance
The mean levels of indirect reflectance from the flooring materials were
significantly different. The recommended range for reflectance from flooring
materials in healthcare environments is 20% to 30% (Egan, 1983). The mean
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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
exceeded the recommended range of 34 dBA to 42 dBA (Egan, 1988).
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
remaining rooms, 271, 272, and 273, exceeded minimum ventilation
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
Temperature and relative humidity in the patient rooms did not have
significant differences. Temperature levels showed little variability in all six
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
temperature of 77.68 degrees F with a standard deviation of 1.39. The
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temperatures did not appear to be influenced by the rise and fall of outside
temperatures. W hile the recommended range of temperatures was 70 to 75
degrees F, it is noteworthy to mention that the patients assigned to these rooms
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
relative humidity was influenced by the outdoor relative humidity. However, it
appears that the influence of the outdoor relative humidity was minimized by the
use of carpet in patient rooms 272, 273, and 287.
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,
creating conditions conducive to making the patients uncomfortable and
susceptible to airborne particulates.
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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below the recommended maximum level of 1000 ppm. Events (high-points)
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
The mean levels of surface temperature were not significantly different.
While the mean for rooms with V C T and the rooms with carpet were slightly
below the recommended comfort range of 75 to 95 degrees F (AIA, 1993), the
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
significant difference, the carpeted rooms had a warmer floor surface
temperature, which correlates with the warmer room temperatures of the
carpeted patient rooms.
Total Volatile Organic Compounds
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
had been placed on the off-gassing of carpet. Based on the information
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collected about TVO C levels in the patient rooms for this study, the contribution
of the flooring materials to the levels of TVO C could not be isolated.
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,
similar to the findings of a study that obtained specific microbial and
epidemiological data in patient rooms (Anderson, Mackel, Stoler & Mallison,
1982). Caution should be used in extrapolating meaning from these data due to
the limited number of samples.
When comparing the mean and standard deviations of the samples
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
in rooms with V C T than the rooms with carpet.
These findings suggest that: 1) the ventilation system may have
influenced the level of bacteria CFU that were removed from the rooms but may
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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
have such a mechanism to reduce the number of airborne bacteria. The
Anderson et al. study (1982) reinforced that carpets become heavily
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.
4.1.2 Patients’ Preferences and Perceptions
Significant differences in the perceptions of patients included: 1)
cleanliness; 2) window view; 3) air freshness; 4) ventilation; 5) temperature.
Patients preferred carpet as the flooring material for their patient rooms. They
cited comfort, slip resistance, and lower noise levels as their reasons for
choosing carpet. Patients who selected VC T as their preference cited
cleanliness as their main reason.
Patients perceived the rooms with VCT to be cleaner, have better views,
fresher air, and better ventilation than rooms with carpet. However, the rooms
with carpet were perceived to have more comfortable temperatures. Even
though patients perceived VC T to be advantageous regarding the stated indoor
environmental quality factors, they still preferred carpet to V C T as their flooring
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material choice, indicating that comfort and the fear of falling are strong
predictors of preference for flooring material selections.
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
patients were there.
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
not supported by the data collected for this study.
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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quality in the patient rooms.
The patients’ perception of carpeted rooms having more comfortable
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).
4.1.3 Healthcare Staff Preferences and Perceptions
Significant differences in the perceptions of healthcare staff include: 1)
color; 2) cleanliness; 3) odor; 4) ventilation; 5) air freshness; 6) air movement; 7)
noise levels; 8) glare; 9) temperature; and 10) temperature shifts. Healthcare
staff preferred V C T as their flooring choice, commenting that hard surface
flooring provided easier cleaning of spills, blood, and urine.
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
comfortable temperatures, and fewer shifts in the temperature.
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
resolving problems with spills. Several incidences were observed by the
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
be properly removed as the safety threat was nonapparent.
Odor, ventilation comfort, air freshness, and air movement are indoor air
quality factors. T h e nurses’ perception of these variables being better in rooms
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
consistent comfortable temperatures in patient rooms with carpet, suggest that
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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4.1.4 Amount of Time Healthcare Staff and
Visitors Spent in Patient Rooms
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
an average of 8 patients on their shift. Patients residing in the Telemetry unit
were continuously monitored and required constant attention. It is not surprising
that the flooring material did not impact the amount of time that healthcare staff
spent with their patients.
In contrast, visitors spent significantly more time in patient rooms with
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
insight to support this observation.
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4.2 IMPLICATIONS OF TH E FINDINGS
This study utilized a synthetic fiber carpet, designed to retain its
appearance and resist abrasion, soiling, staining, and fading. The VC T has good
abrasion resistance, fair soil and fade resistance, and poor stain resistance
(Weinhold, 1988). Waxing V C T floors provides extra protection, increasing the
resistance to abrasion, soiling, and staining of the floors. However, having a
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
resistance to static, moisture, chemicals, and burns. V C T is more successful in
resisting static, moisture, chemical spills, and is excellent in resisting bums
(Weinhold, 1988). W hether the material is V C T or carpet, both require consistent
cleaning methods and appropriate maintenance procedures to insure the
longevity of the product (G am er & Favero, 1985).
Carpet has few limitations for the design of patterns and colors. In
addition, carpet is a sound-absorbing material, commonly used to enhance the
acoustic quality of the indoor environment. V C T has limited pattern designs 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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carpet flooring cushions the feet with or without a pad installed.
The manufacturing of petroleum-based carpet products shares the same
environmental and health impacts as V C T (LeClair & Rousseau, 1992).
However, the manufacturer of this carpet material has a resource recovery
program and has implemented changes to their business strategy to provide a
life cycle loop that includes recycling for their products.
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
patient rooms. Remarkably, the patient rooms were insensitive to TVOC,
possibly due to the air flowthrough the supply and exhaust.
As previously mentioned, the maintenance protocol for the installation of
V C T floors at this hospital is to apply three coats of wax, which enhances the
protective qualities while increasing the level of reflectance. Changing the
protocol to the manufacturer-recommended cleaning and maintenance would
lower the cost of maintenance and the reflectance factor, but the flooring would
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lose the protective coating provided by the wax.
The recommended range of temperature for patient rooms is 70 to 75
degrees F (AIA, 1993). The patients had control of the temperature in their
rooms and chose to maintain a temperature higher than the recommended
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
metabolism and body temperature. A lower body temperature indicates a
potential need for compensation by higher room temperatures. This finding
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
susceptible to airborne particulates (ASHRAE, 1997).
The influence of the outdoor relative humidity on the indoor relative
humidity is an indication that the rooms are not adequately conditioned to
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
indoors. The decrease of significant changes in indoor relative humidity
increases the comfort level of the occupants.
The comfort range for floor surfaces depends on the finish material.
Based on the comfort range for linoleum (Fanger, 1970), which is a resilient
material similar to vinyl composition tile, the surface temperature should be
between 75-95 degrees F to be comfortable for barefooted feet. While the
differences in flooring temperature were not significant, the higher surface
temperature in the carpeted rooms suggest that carpet may respond to room
temperatures, supporting thermal comfort conditions.
At this time, guidelines have not been established for exposure to volatile
organic compounds in nonindustrial environments. The differences in TVOC
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
introduction of other sources besides the flooring. While materials such as VC T
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
composition of the air, guidelines for exposure to TVO C levels in nonindustrial
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environments would assist in an ongoing indoor air monitoring program.
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
exposure levels of microorganisms and other particulates. The bacteria samples
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
changes per hour would benefit the indoor air quality.
The carpet appears to have acted as a sink for microorganisms. Carpet
becomes contaminated, creating an environment conducive to harboring
microorganisms. The Anderson et al. study from 1982 compared a resilient
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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the number of microorganisms in carpet flooring is the quality of proper
maintenance. During the course of this study, unoccupied rooms were rare,
leaving few opportunities for rigorous cleaning. The combined effort of
maintenance and healthcare staff could rectify the problem. If standard
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
maintenance could perform the proper cleaning protocols (similar to identifying
contaminated rooms that must be sanitized).
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
being marketed as a resilient textile flooring material. It is recyclable, durable,
and manufactured with renewable energy (solar). It is a flat weave of a synthetic
fiber attached to a high-density urethane backing with recommended cleaning
procedures similar to manufacturer recommendations for VCT. Installed in the
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
to exceed 10 years. This product is targeted toward schools and hospitals -
institutional facilities with serious maintenance and cleanliness issues.
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4.3 PRACTICAL APPLICATIONS
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
temperatures in the carpeted patient rooms.
The bacteria samples suggest that the patients’ perception of V C T as
being cleaner is supported by the study; however, the impact of the smooth
surface flooring in patient rooms adversely affect the amount of airborne
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
rooms had fewer problems with reflectance was strongly supported.
Perhaps the most dramatic finding of participant response was the
significant difference in the amount of time visitors spent in rooms with carpet
compared to the time spent in rooms with VC T. Providing comfortable
surroundings for visitors may have an effect on the physical, emotional, and
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spiritual well-being of the patients.
The flooring material specified in patient rooms should enhance the
indoor environmental quality. W hen considering factors pertaining to the IEQ, it
is essential that the maintenance and care of the flooring be controlled and
implemented.
The comparison of the properties of flooring materials rest with the
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
selecting carpet as a flooring material should be a consideration. The recent
change in industry standards regarding sustainability is an advantage to using
carpeting in patient rooms. The dramatic difference in indirect reflectance values
show carpet to have the advantage over VCT.
The advantages of VC T are influenced by the addition of multiple coats of
polished wax. Moisture resistance is a major advantage; however, the synthetic
composition of the carpet is technically moisture resistant as well. Static
resistance is not a known problem for patient room environments. Chemical
resistance is another advantage of VCT. Cigarette bums are not a known
problem in this hospital as it has a nonsmoking policy. Cost is an advantage of
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VC T, but the initial material and installation cost does not begin to consider the
long-term maintenance, materials, and labor for maintaining waxed floors.
Finally, consideration for the lack of differences in carpet and V C T floors
is just as provocative as the statistical differences. In this study, there were no
significant differences in the: 1) lighting levels; 2) sound levels; 3) temperature;
4) relative humidity; 5) surface temperatures; and the 6) total volatile organic
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
flooring materials did not influence the previously mentioned environmental
conditions indicates that these conditions should not be included in the criteria
for selecting flooring material. In other words, no differences indicate that the
performance of carpet in patient rooms is not better or worse than VCT.
The advantages of carpet revolve around complex issues of patient
preferences, perceptions of comfort, slip resistance, lower reflectance, and
sustainable practice. The advantages of V C T are based on performance with
the addition of polished wax. VC T showed no advantages for indoor
environmental quality or sustainability. This study suggests 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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or VC T is specified for patient environments, the quality o f maintenance impacts
the material composition and longevity of the flooring.
Table 4.1
Summary of findings.
DEPENDENT HEALTHCARE STAFF TELEMETRY PATIENTS VISITORS

VARIABLES
Floor Preference 17% preferred carpet 69% preferred carpet Visitors spent
Reason: comfort Reasons: comfort, slip- significantly more time
resistance, and less noise in patient rooms with
83% preferred VCT carpet than in patient
Reason: easier to dean 31% preferred VCT rooms with VCT.
Reason: deanliness
Perceptions about rooms Better color
with VCT More dean More dean
More attradive
Better odor
Better ventilation Better ventilation
Fresher air Fresher air
Better air movement
Perceptions about rooms More comfortable
with carpet Better temperatures Better temperatures
Fewer temperature shifts
Less noise in room
Less noise from corridor
Less glare
ENVIRONMENTAL EFFECT BASED ON

CONDITIONS DIFFERENCE OF
FLOORING
Glare 6 times higher in rooms
with VCT compared to
rooms with carpet
Noise No effect
Ventilation No effect
Temperature No effect
Surface temperature No effect
Relative humidity lncondusive
Carbon dioxide No effect
TVOC No effect
Bacteria Rooms with VCT had
lower floor levels; rooms
with carpet had lower air
levels
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CHAPTER V
CONCLUSIONS
5.1 SUM M ARY OF TH E CONCLUSIONS
In summary, the patient rooms did not differ significantly for
environmental factors including: 1) temperature; 2) relative humidity; 3) carbon
dioxide; 4) total volatile organic compounds; 6) illuminance; and 7) noise levels.
Temperature and relative humidity did not differ statistically, though the graphic
display of the data suggested that the outdoor relative humidity levels influenced
the indoor levels of relative humidity.
The significant difference between the reflectance value of the flooring
materials indicated that the waxed V C T flooring had a reflectance value
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
holds the bacteria out of the air.
The results of this study include signficant differences in the measures of
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some physical attributes while showing no significant differences in others.
W hile significant results are important to consider, the lack of differences in
other physical attributes should not be discounted. When selecting appropriate
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
the patient room.
The most important external factor is the most difficult to control.
Maintenance procedures can add years to the life-cycle and protection to the
flooring material. Inappropriate maintenance can contribute to the level of
contamination, undermining the inherent characteristics of the flooring. If
carpeting products or the newly introduced resilient textile flooring products are
maintained properly, either product could safely be installed in patient room
environments.
5.2 LIMITATIONS OF TH E RESEARCH
Caution must be taken in generalizing the findings from this study
because the study was limited to one hospital telemetry unit in a geographically
circumscribed area. Therefore, the findings cannot be generalized to other types
of nursing units or other hospitals. Results from this study concerning the
measurement of environmental factors and participant responses must be
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limited to the facility and participants in this study. In addition, the findings for the
patient room environments were based on difference in flooring materials. This
study used vinyl composition tile and a synthetic carpet tile. Generalizability
cannot be extended to other types of resilient flooring or carpet.
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
motivated to participate in this study, which contributed to a low response rate.
Bed assignment was identified as a confounding variable. Bed
assignment was controlled during analysis by excluding patients assigned to
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
variable, simplifying the explanation of the results.
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
complexity of indoor environments, problems in attributing causality to 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
the interpretation of the data.
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In review of the patient surveys, one obvious question failed to be asked:
“On a rating scale of 1 (not comfortable) to 6 (most comfortable), what is your
rating of comfort in your patient room?” Environmental factors were considered
when questions were developed for the survey but the overall comfort level was
never addressed. In addition, the surveys contained some confusing language
that needs to be changed before using the surveys in another study. For
instance, asking separate questions about ventilation and air movement is
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
altered to make the survey easier to understand and complete.
An additional concern related to patient and healthcare staff participants
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
ask questions. Healthcare staff appeared to be annoyed with the presence of
the equipment.
With the exception of the relative humidity sensor not recording correct
195
measurements in room 271, the equipment used to monitor the patient rooms
met calibration requirements and recorded consistent data. Deciding to measure
total bacteria CFU was a decision based on consulting with an environmental
laboratory. In retrospect, mold might have been more appropriate, especially
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
have otherwise been known.
5.3 FUTURE D IR ECTIO N S
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
properties of the materials. The comparison of resilient products would indicate
differences between the flooring types. One comparison of particular interest
would be the differences between V C T and linoleum. Another useful comparison
196
would be the differences between the specified carpet in this study and the new
textile resilient flooring product. Additional studies regarding flooring should
consider slip-resistance and recorded falls within the hospital environment.
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
microorganisms. Additional research is needed to investigate the potential for
regulating the influence of outdoor conditions on indoor environments.
Temperature levels in the patient rooms were higher than the
recommended range. The consistent temperatures above the recommended
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.
Additional research is needed to find evidence supporting a change in the
comfort range that takes into consideration a higher room temperature.
Research focusing on volatile organic compounds is needed to develop
guidelines for nonindustrial environments. Future research should focus on data
that would identify healthy limits to long term exposure to common VOC and
total volatile organic compounds.
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 sink effect in healthcare environments.
The benefits of friends and loved ones visiting a patient recuperating from
a heart-related illness is not known, but to embrace the possibility of
environmental conditions having a positive effect on the patient is reason
enough to pursue additional research on environmental design, visitors, and
patients.
The perceptions of patients and healthcare staff were similar. For
example, both groups perceived carpet to have acoustical properties that would
reduce the amount of noise and both samples perceived V C T to be cleaner.
These perceptions are rooted in our past. In spite of changes in product
development, educated people from a variety of backgrounds have similar views
that may not necessarily be correct. Additional research is needed to address
the differences between perception and environmental conditions.
The protocol for future studies should include the use of triangulation
(theory, data, investigators, and/or methodology). Ideally, the study would test
198
two patient rooms, the control and the treatment. The research design should
include physical measures of the environment. Continuous monitoring of indoor
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
questions, lessoning potential problems in analysis. Behavioral mapping of 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
environmental health and its impact on the users.
The existing body of knowledge related to this research study is
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
existence brings meaning to man’s environmental impact and the environment’s
effect on mankind. During the industrial era, technology provided new ways of
199
procuring raw materials and manufacturing goods to support a wealthy society.
In the post industrial era, society began to see the consequence of too much
consumption. As we enter a new era, we have the means through technology
and knowledge to make informed choices that will have a positive impact the
quality of our lives.
This study contributes to the body of evidence for healthcare
environmental design by focusing on interior finish materials for patient room
environments. The importance of a full understanding of flooring finish materials,
the impact on environmental quality, and the effect on the occupants increases
the designers’ knowledge and awareness of the decisions made during the
design process. Comprehension of the processes under investigation will
improve design theory, research, and practice.
200
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APPENDICES
210
APPENDIX A
APPROVAL OF INSTITUTIONAL R E V IE W BOARDS
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
TO: Debra Harris

Department of Architecture
SUBJECT: Review of Protocol Entitled, T h e Impact of Interior Finish Materials on

Environmental Quality of the Built Environment*
The above referenced protocol has been:
X Approved May 6, 1998 to May 5, 1999

Conditionally approved (see remarks below)
Tabled for future considerations
Disapproved (see remarks below)
Not Considered
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.
t . Murl Bailey, Chair

Institutional Review Board -
Human Subjects in Research
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'
July 29, 1998
TO: Debra Harris. TAMU
RE: 'Environmental Quality & Healing Environments: A Study of Flooring Materials in a

Healthcare Telemetry Unit'
The above referenced protocol and informed consent have been:
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,
Sr. Gretchen Kunz, CEO

Chair, Institutional Review Board
SGK/cn
,L Gxirii.Tico.T !’■ Cjw iu i : ; '; SYt\-
213
APPEN DIX B
C O N SE N T FORMS AND
SURVEYS (PATIENT AND STAFF)
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.
I have been given a copy of this consent form.
Signature of Participant Date
Signature of Investigator Date
Debra D. Harris, Principal Investigator

Texas A4M University
College Station, TX 77843-3137
(409) 862-2234
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.
215

INFORMED CONSENT: HOSPITAL STAFF
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.
I have been given a copy of this consent form.
Signature of Participant Date
Signature of Investigator Date
Debra D. Harris, Principal Investigator

Texas A&M University
College Station, TX 77843-3137
1409) 662-2234
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.
216
ENVIRONMENTAL DESIGN EVALUATION
ST. JOSEPH REGIONAL HEALTH CENTER TELEMETRY UNIT PATIENT ROOM
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.
Patient Room No.:
Today's Date: Time: am pm (circle)
YOUR PATIENT ROOM
1. 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
2. Why?
Please rate the following by circling the best number between 1 and 6 that best describes your
experience in your patient room.
3. Colors 1 6
BAD GOOD
Cleanliness 1 6
BAD GOOD
217
5. Attractiveness 1 2 3 4 5 6
UNATTRACTIVE VERY ATTRACTIVE
6. Odor 1 2 3 4 5 6
BAD GOOD
7. Window view (outside) 1 2 3 4 5 6
BAD GOOD
8. Temperature comfort 1 2 3 4 5 6
BAD GOOD
9. How cold it gets 1 2 3 4 5 6
TOO COLD COMFORTABLE
10. How hot it gets 1 2 3 4 5 6
TOO HOT COMFORTABLE
11. Temperature shifts 1 2 3 5 6
TOO OFTEN CONSTANT
12. Ventilation comfort 1 2 3 4 5 6
BAD GOOD
13. Air freshness 1 2 5 6
STALE AIR FRESH AIR
14. Air movement 1 2 3 4 5 6
STUFFY CIRCULATING
218
15. Noise Distractions 1 2 5 6
TOO NOISY COMFORTABLE
16. Background hospital noise 1 2 5 6
TOO NOISY COMFORTABLE
17. Electric Lighting 1 6
BAD GOOD
18. Glare from lights 1 2 3 5 6
HIGH GLARE NO GLARE
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
219
25. Counters & Cabinets 1 2 3 4 5 6
POOR EXCELLENT
26. What do you like best about your room?
27. What would you most like to change about your room?
PERSONAL HISTORY
In the past three years, have you had:
28. Migraine Headaches YES
29. Asthma YES
30. Allergies-Respiratory related (e.g. Smoke, pets, flowers YES
31. Allergies-Non-respiratory related (e.g. Food) YES
32. Allergies from insect bites YES
33. What is your occupation?
ADDRESS (optional for those requesting results at the end of this study):
Name:
Street:
City/State/Zip
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE!
220
ENVIRONMENTAL DESIGN EVALUATION:

ST. JOSEPH REGIONAL HEALTH CENTER TELEMETRY UNIT PATIENT ROOM
Telemetry Staff Questionnaire
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.
Today’s Date: Time: am pm (circle)
GENERAL INFORMATION
1. Job title:
2. Your age: <20 20-29 30-39 40-49 50-59 >60
3. Gender. MALE FEMALE
4. How long have you worked in health care? YEARS: MONTHS:
5. How long have you worked a t S t Joseph Regional Health Center?

YEARS: MONTHS:
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?
8. Which shift do you typically 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
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:
11. Colors BAD GOOD

VINYL 1 2 4 5 6
CARPET 1 2 4 5 6
12. Cleanliness BAD GOOD

VINYL 1 2 3 4 5 6
CARPET 1 2 3 4 5 6
13. Attractiveness UNATTRACTIVE VERY ATTRACTIVE

V INYL 1 2 3 4 5 6
CARPET 1 2 3 4 5 6
14. Odor BAD GOOD

VINYL 1 2 3 4 5 6
CARPET 1 2 3 4 5 6
15. Physical comfort level BAD GOOD

VINYL 1 2 3 4 5 6
CARPET 1 2 3 4 5 6
16. Temperature comfort BAD GOOD

VINYL 1 2 3 4 5 6
CARPET 1 2 3 4 5 6
222
17. How cold it gets TOO COLD COMFORTABLE
VINYL 1 2 3 4 5 S
CARPET 1 2 3 4 5 6
18. How hot it gets TOO HOT COMFORTABLE
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
19. Temperature shifts TOO OFTEN CONSTANT
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
20 . Ventilation comfort BAD GOOD

VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
21 . Air freshness STALE AIR FRESH AIR

VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
22 . Air movement STUFFY CIRCULATING
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
23. Noise Distractions TOO NOISY NOT NOISY
VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
24. Background hospital noise TOO NOISY NOT NOISY

VINYL 1 2 3 4 5 6
CARPET 1 2 3 4 5 6
223
25. Electric Lighting BAD GOOD

VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
26. Glare from lights HIGH GLARE NO GLARE

VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
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
28. Walls POOR EXCELLENT

VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
29. Ceilings POOR EXCELLENT

VINYL 1 2 3 5 6
CARPET 1 2 3 5 6
30. Counters & Cabinets 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
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
36. W hat do you like best about the patient rooms?
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
In the past three years, have you had:

39. Migraine Headaches YES NO
40. Asthma YES NO
41. Allergies-Respiratory related (e.g. Smoke, pets, flowers) YES NO
42. AlIergies-Non-respiratory related (e.g. Food) YES NO
43. Allergies from insect bites YES NO
ADDRESS (optional for those requesting results at the end of this study):
Name:
Street:
City/State/Zip
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIREI
225
October 13, 1998
Dear Cart Lintner:
I am finalizing the patient questionnaires for my dissertation study. I am collecting data

at St. Joseph Regional Health Center. I will be conducting a building analysis for environmental
quality (indoor air quality, acoustics, lighting) and will compare that with patient and staff data
on perception, comfort and preferences. I need to test" the surveys to make sure that the
questions are understandable. I am asking you to participate because you have some level of
experience with patient rooms.
Would you please fill out the survey as if you were located in this unit? The questionnaire
will have a handwritten note with the type of floor finish material in ‘your room*. After
answering the survey, please respond to the following questions:
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>,
4. Any additional comments are appreciated: [,0 0 ^ A frc O ,

l<'s O o < f r h h £ £ l A Y O 'O T
i s g > t g I hi MttJp ~ T > A r j i i l Y 6
o rra ^ l w \7i FoR. E - b a t

US-F'h'c- : r Yu'Q ''iSZP / { i O Y OTlrsEk? \tB Lp, __________________
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
409.862.2234 debra@taz.tamu.edu
226
APPENDIX C
FALL ASSESSM ENT TOOL
227
S t Joseph Regional Health Center

Bryan, Texas
FA LL ASSESSM ENT TO O L &

G U ID E L IN E S F O R U S E
Date of initial assessment_____________________ Follow up assessment

Prepared by:_________________________ Dale ___________
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.
II. MENTAL STATUS 0 10 p tx ) Onented at all tunes Q (2 p ts ) Corrfm nn at Q (4

p ts) Intermittent confusion
______________________________ or comatose________________ s i limes g (2 cts.l Head rsury________
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
VI. VISUAL IMPAIRMENT (1 p t) _____ pt*
VII. CONFINES TO CHAIR OR BED Restrains: Q y e s (3 p ts ) Q no (0 p ts ) _____ pt*-
VII). BLOOO PRESSURE le u than 80150 Q 12 p ts ) _____ pts.
DC. GAIT AND BALANCE

Q (1 D l)'A id e base o f suoport Q (1 p t) Liuchmg. swaying o r slapping gad
Q (1 p t) Loss c f balance w hin standing Q (1 p t) G a t pattern changed when w aiting through doorway
Q (1 p t) Balance pcotXems when walking Q ( I p t) Jerking o r « stsM ty when rnafcnq turns
Q (1 p t) Decrease m m uscular ccordmscon Q il p t) Use o f assistive devces (cane, 'walker, fUmeure. e tc ) ______?»
X. MEDICATIONS
Q Alcohol Anesthetic Q AntUustamme Q Anhhycettensrues Q AnttsemirefAnttepileotic

Q Seiuodlaaecmes Q Cathartics Q Diuretics Q htypoglycamc agents
Q Narcchcs Q Psychotropic* Q Sedspves Q Other (specify)
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
A score o fte n (10) o r above indicates a nek o f fa llin g :

TO TAL SCO RE _____ SIS.
COMMENTS: NS-13T
Rev. 1797
228
APPENDIX D
BEHAVIORAL MAPPING STUDY DATA FORM
BEHAVIOR MAPPING STUDY DATA FORM______________________________Ream#;

No. of beds In unit: 41 Date:
No. of beds occupied: __________________ Start Time:
No. of beds In study: 9 End Time:
No. of beds In study occupied:_____________ Observer:
Ref No Tim e In Tim e O ut Sender N » Nurse D « O odor Comments
00000 0 0 0 00 T • Technician V * Volunteer Purpose lo r visit, reason lo r leaving special
VA • V isitor Adult H • Housekeeping circum stances, em ergency, procedure, hesitates
VB ■ V isitor Age Unknown VC ■ V issor Child upon entry, etc
229
230
APPEN DIX E
TRAVEL DISTANCE BETWEEN NURSE’S STATION
AND PATIENT ROOMS
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
RM 269 42 FT. — ------------ 1

ROOM ;
RM 271 28 FT. 273
RM272 38 FT.
RM273 52 FT.
RM 287 76 FT.
NORTH
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
232
APPEN DIX F
PHOTOGRAPHS O F TH E SIX PATIENT ROOMS
233
234
APPENDIX G
ST. JOSEPH REGIONAL HEALTH CENTER PROJECTED R EVENUE TABLES
FO R TELEMETRY UNIT EXPANSION PROGRAM
235
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239
A PPEN DIX H
EQ UIPM ENT SPECIFICATIONS
240
Table 4—1: Warranted Electrical Specifications
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
Table 4-2; Typical Electrical Specifications

Pcwer Atkal-m* Dd'Tery. 7 to TOV
rti.**juif cmti it»: »EC L-flFi 1
NECA »d04
E»t»*»rvil Power Supply 1'•> ‘b VO*"
0.iU«.**y L4« 30 route
(Typical) ilEC oLPyl t) UT6fy wtir. t.icMiqM .ft jnc
RS-2-J2 t*nclu«n**,f>
Low Battery 72 V
Indicator
TEKTRO NIX
Table 4-3: Warranted Environmental Specifications
PHOTO M ETER
Characteristic 1Standard
r»*trcer.Hur*» j NcrccflMtn1; -55 C to C
| C U -55 3
|r 7'}k 5tJ i>'»J Jl'4.'
j Norv»£tar V -*7*» - ;C **:*- C
, .I*'3- -10 Cf-3 -55 -
Table 4-4: Typical Mechanical Specifications
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
Table 4 -5 : Warranted Sensor Ranges
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
241
Table 1-13: J1811 Performance Characteristics
Accuracy 5% of reading ± 2 courts (Uluminant A at lOOOcdrr2

I'ncuding ncr-lineanty) 20 ~ C to 20 ’ C, <75% relative humidity)
Spectral Response CIE pholoptc (See Figure A -l on page A-4)
Spectral Accuracy 1,' = <3% (DIN class A)
ncvcptoi n.c nt yic CoS»n€ CCTcCtcu (12C'
Table 1-14: J1811 Typical Physical Characteristics
Dimersicns Height: 1 4 .riches (35 nm)

TEKTRO NIX
(not including lens Z20 \
Width: 25 inches (63 mm)
PHOTO M ETER
Length: 2 5. inches (63 nmi
Cable ength 6teet (13m)
ILLUMINANCE HEAD
Table 1-15: J1811 Environmental Characteristics
Characteristic | Standard
'empe'ature ‘ Meets Mi Stj 2B30CE Class 3
; Nor.operalmg: - 62; C tc - 85; C
: Operating: -15 : C ID C
Humidity 143hours al 97% relative hurciiry

j ;3C;: C (c 50’ Ci
j Vcdif e l MIL Sid 288C0E
Electrostatic :mmun;p/ i Complies .vit iEC 801-2
Sectrcmagre’ic Com i Meets CISPIR 22B. FCC Class A and 7D£ Class B
j
patibility
242
QUEST TECHNO LOG IES
SOUND METER, PAGE 1 OF 3
Standards: M e e t s or e x c e e d s A N S I S I . 4-1983, T y p e 1 a n d relevant

sections of I E C 6 5 1 - 1 9 7 9 , T y p e 1(1) a n d I E C 8 0 4 - 1 9 8 5 .
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.
Printout: Wh e n used with a printer, a one page p r i n t o u t is

produced. It c o n s i s t s of th e f o l l o w i n g : Heading; W E I G H T I N G and
R E S P O N S E s e t t i n g s ; LE Q , MAX, MIN , a n d S E L l e v e l s ; R U N T I M E a n d O L
T I M E ; E X C E E D A N C E L E V E L S (dB) w i t h 1 d B r e s o l u t i o n ; a n d F i l t e r D a t a
f o r e a c h f r e q u e n c y (LEQ, MAX, M I N , a n d SEL) a l o n g w i t h t h e R U N T I M E
7L T I M E f o r e a c h f r e q u e n c y .
Hoaaa of Operation: Sound Pres su re Level ( S P L ) , M a x i m u m Level

(MAX), M i n i m u m Level (MIN), Sound Exposure Level ( S E L ) , and
E q u i v a l e n t L e v e l ( L E Q ) . P e a k L e v e l (PEAK) a n d I m p u l s e L e v e l (IMP)
can also be measured.
Minimum Measurement: Meter only; With Model QE4146 Microphone —

27 dBA. Using Linear Weighting with an O c ta ve Filter Set; See
F i g u r e 17. T h e min i m u m measurement varies depending on the filter
frequency selected.
Maximum Measurement: W i t h M o d e l Q E 4 146 M i c r o p h o n e — 120 d B with

20 d B C r e s t F a c t o r . (140 d B if m e a s u r i n g a s i n u s o i d a l s i g n a l . )
O v e r l o a d i n d i c a t i o n w i l l o c c u r if u p p e r r a n g e is e x c e e d e d .
Frequency W e i g h t i n g Networks: A, B, C, a n d L i n e a r . When using a

f i l t e r set , a n y o n e o f the w e i g h t i n g s m a y b e s e l e c t e d .
Meter Response: Slow, Fast, I m p u l s e , a n d P e a k . (The Peak onset

t i m e c o n s t a n t is l e s s t h a n 50 m i c r o s e c o n d s ) . P e a k m e a s u r e m e n t s m a y
b e m a d e i n e i t h e r A, B, C, o r L i n e a r W e i g h t i n g .
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 .
243
Q U E S T TECHNOLOGIES
S O UND METER, PAGE 2 O F 3
Meter Input: The input impedance is 1 Megohm in series with 0.1

HFD. The maximum sinusoidal input voltage is 10V RMS.
AC Output: 3.16 V RMS at full scale (60 d B ) . (3.8 V RMS maximum)

The output impedance is 3.2K ohms. Connected equipment should be
at least 10K ohms. The output can be shorted without damaging the
meter or changing the meter reading.
DC Output: 0 to 1.00V DC; 60 dB span. Each 0.167V change equals

10 dB. Connected equipment should be at least 10K ohms. The
output can be shorted without damaging the meter or changing the
meter reading.
Print Output: Serial output to printers or computers using RS-232

voltage levels. Selectable baud rates of 300, 600, 1200, or 2400.
ASCII character format.
Data Output: Output transmission of real-time digital data occv

at a rate of 16 times per second using RS-232 voltage levels.
Frequency Range: 4 Hz (-3dB) to 50 kHz (-3dB) on linear weighting,

meter only. (Subject to microphone limitations.)
Reference Range: 60 to 120 dB Range setting
Reference SPL: 94 dB
Reference Frequency: 1 kHz
Reference Direction: 0 Degree when using a Free Field Microphone.

Sound is arriving from directly in front of the microphone
diaphragm. (A Normal Line extending from the center of the
microphone diaphragm.)
Detector: True RMS
Detector Pulse Range: 63 dB
Detector Measuring Range: From 0 dB to 40 dB on the painted scale

(when measuring a signal with a 20 dB Crest Factor) . The extra 20
dB (40 to 60) on top of the measuring range produces the 20 dB
Crest Factor capability .
Primary Indicator Range / Linearity Range: 60 dB (The range as

indicated by both the dB RANGE switch and the painted 60 dB scale.)
Tested with a sinusoidal signal input.
244
Q UEST TECHNO LOG IES
SOUND METER, PAGE 3 OF 3
Level Linearity: I n s i d e the Primary I n d i c a t o r Range. It i s t e s t e d

o n the R e f e r e n c e R a n g e (60 t o 120 dB) with a sinusoidal input
signal. T o l e r a n c e is * ■ / • 0 . 7 d B r e f e r e n c e d t o 94 dB.
Overload Indication: The display annunciator (OL) indicates

o v e r l o a d o n t h e L CD.
Attenuator Accuracy: R e f e r e n c e d from the R e f er en ce Rang e a n d the

R e f e r e n c e S P L (+34 d B o n t h e p a i n t e d m e t e r s c a l e ) . w i t h i n 0.5 d3
f r o m 31.5 K z t o 8 kHz. W i t h i n 1.0 d B f r o m 20 H z t o 1 2 . 5 k Hz.
Warm-up Time: 30 seconds.
I n t e g r a t i o n T i m e (Set t l i n g Time) : 1 m i n u t e w h e n m e a s u r i n g a sho r t

impulse. 5 s e c o n d s w he n integrating a constant input signal.
'ur a e y : W i t h i n 0 . 5 d B a t 2 5 ”C; W i t h i n 1.0 d B o v e r t h e t e m p e r a t u r e

,ge o f -10-C t o + 50°C.
Temperature Range: O p e r a t i o n T e m p e r a t u r e Range: - 10°C t o ► 5 0 ,’C.

Accuracy over the O p e r a t i o n T e m p e r a t u r e is w i t h i n * / - .5 dB.
S t o r a g e T e m p e r a t u r e R a n g e ( l es s b a t t e r i e s ) : - 2 0 ‘’C t o *60"C
D o not e x c e e d t h e S t o r a g e T e m p e r a t u r e R a n g e b e c a u s e p o s s i b l e d a m a g e
to the u n i t m a y result.
Operating Humidity: O v e r a r a n g e of 30 to 90* r e l a t i v e h u m i d i t y ,

the a c c u r a c y is w i t h i n * / - 0 . 5 dB. Do not e xc ee d 95* relative
h u m i d i t y b e c a u s e p o s s i b l e d a m a g e to t h e un i t m a y result.
Effect of M a g n e t i c Fields: A m a g n e t i c f i e l d o f 1 O e r s t e d (80A/m)

at 60Hz p r o d u c e s a m a x i m u m r e a d i n g of 40 d B o n L i n e a r W e i g h t i n g .
Effect of Electrostatic Fields: Negligible as long as the

protection g r i d is k e p t o n t h e m i c r o p h o n e .
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 . )
Tripod M o u n t : A threaded insert on back of the meter accepts a

standard 1/ 4 - 2 0 tr i p o d m o u n t i n g screw.
Size: 3 . 3 x 8 . 2 x 1. 8 inches (84 x 2 0 8 x 47mm) not including the

height of the preamp.
Weight: 24 oz. (680g) including the preamp and batteries.
R eproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
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:
I — When using the LoFlow adapter to measure exhaust

volume (air movement from base to vent) above 150 CFM
(250 cubic meters/hr) multiply the reading bv 1.02 to
obtain measurement within tolerance.
2— Figure 9 can be used to determine the backpressure which
the Balometer introduces. For systems without
individually-controlled constant volume outlets, this cor
rection may be factored into the system equation if
desired.
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-iûre 1d
bottle
6H607au bdtnc i4tUOUt-"' Lu-
247
ENGLEHARD
DATA LOGGER
Relative Humidity 1058T

M e a s u re m e n t Itan e e
2 0 -9 5 % RH
A ccuracy (@ 2 5 * Q
= 5% RH
S tability
* ! % R H per year
Response T im e
10 sec
P o w er R equ irem ents
1 2 -2 8 V O C
O u tp u t (lin e a r)
0-1 V O C (10 m V/% RH)
A verage T em peratu re Range
= 0 .1 1 % R H T C
O p e ra tin g Tem peratu re Range
-4 0 * 1 29“r { -4 (r to -t-54*Q
Storage T em peratu re Range
-4 0 “ to 1 5 8 * F (-4 0 to + 7 0 rQ
C u rre n t R equirem ents (@ 1 2 V O O
I mA
D im e n s io n s (Ix W x D )
3 ' x 2“ x 1 .5 ’ ( 8 . 0 x 5 0 x 4 . 0 )
W e ig h t
3 oz. (85 gm)
W a rra n ty
18 months
Temperature Sensor 1058T

M e a s u re m e n t Range
(sensing elem ent)
-t-r*to -riitrc
Accuracy ( @ 2 5 * 0
= 1.0“C
S ta b ility (1 ,0 0 0 hrs @ 1 1 0 * 0
= 0 .0 8 “C
Response T im e (@ 1 ft/sec a ir flow )
< 1 imn
P o w e r R e q u ire m e n t
9 V O C alkaline battery
O u tp u t (lin e a r)
10 m V /*Q
Storage T em p e ra tu re Range
-4 0 * TO 1 J0 * r M 0 * To + 6 C O
C u rre n t R equirem ents (@ 9 V D Q
60 pA
D im e n s io n s (LxW xD )
4* x 2 .5* x 1 . 0 * ( 1 0 x 6 x 1 cm )
W e ig h t (w ith battery)
4 o z.
W a rra n ty
18 months
248
YO U N G ENVIRONMENTAL S Y STE M S (YES)
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
Type NCHR Neg. Temp. Thin Rim

Co-efficient Thermisor Capacitive
Range 0-5000 ppm •0 4 to 70'C 0-100%
Resolution 0 5 ppm 0.4’C @ 251C 0.4% RH
Response-lime > I min. N/A 5 min.
Warm-up Time 5 min. N/A 5 mm.
Est. Operating Ufe 15 years in air N/A N/A
249
RAYTEK
SURFACE TEM PERATURE INFRARED TH ER M O M ETER
VDFCnns Tffrrt ■mi taMtWTMM btantftMtaota ! StandM m* (MW)

Emmr fitartcMttsr mfJOBOCOntBm jMponobcotter (OSIM)
AM* AMOcomoar 4/riaoxt)an ter j UfaaoMi awter(05377/
Start/ Start)MCO
S*r ArtMMCtar ; ta m tM c trn (& $ m
Antml opvttngmgt 3»S£TCl32to120*0
rtangoopeaocnaroertt 0a5Q
CC(32a12C
TF}
ftn dstwpmtifl arncwte 0isrci32»rarF)
flagitfutisatcnarcane 0isrci32iiarP
| MftfwhumidHy 10-95%AHnonoroensq 6 u>toX X W F)
! Hmdadrtfata tOa95%* HRsnconoraaoon. aona.lasta3(TCST*!
Uhxtaoi rtoma 10-95%UR.semcanOensaoio. 9 ate30*C(36’R
Hurts(Save 10-95%HRsaracontagion, nanMXI56T)
Stnjiinpnui •25*toWCl-ty isWf) «tai tscery
Impadnaanameno •aaTtrCI-UalSffBsnpia
rwautanraora^n -25a70*C(-13aI58îsemC
atenas
Tmperaueoeacoage -2S37irC(-t3iiS8'Rarapfc
WtfghtJOimmiora 270gmt95aitt37t*t«'96mm 54it6«77n|

RswOinenscres
RaoOnensoes
| ArtiQrrwwns
9VMaw orNodbatay jm>trie, oater-asi
- ruerwoeadrwocof
i MmenBgfe
Umcntawt
I B«taryIU«(Alkafint)* MUooeH 33nfsibaatgniwt>£8(»-4iserUooets.''rnttas8(uMi]50Voacu9rtuse<i50%!

Alaoeaw rodstomooete33hns(snw * J39crccM*x»osconaser 11rcrascase*«nuse50%. U * trasfcnooanu»ST.i
i Ouagij as Catenas' Todososfnodeios33taras(semuse* recoiunripct-Vodewcomaser n noasitaserusaooSPie•wortwacao
usaoa50%aowrgoi
! krtedeUcrte’ feuslasrodetes:33hares(remecaragenonuafceHtooeiesuser 11neires(t/serutsa 50%. woecarageustseS7V

ftS ~ It li It 301
' BMrydtrfaniosMQnBufclRaidasarusap. SptcdoKRiansuatassanjem o t nact

' U M U M iiM m a K M ttia a ta a o n a a M R H O R ia tn a iy M 'M r EsKtaooresum3am sn(imm sa
’ AviaEtfflaBfaoosmw.sWitt^KCBusjirwrica.wouTwoai Esccofcapnesacsu«al aunosenoweaeo
’ uoiMa**igta«gwir>«aRttt fuefaaot&ttHcaaptt&tisw la cancansaquKoeuwnaswmk sarsowns
250
APPEN DIX I
PATIENT ROOM ENVIRONMENTAL DATA
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
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.
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
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
Note: Guidelines or standards have not been established for exposure to volatile organic compounds in
non-industrial indoor environments.
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
254
A PPEN DIX J
TYPICAL FLOOR PLAN
255
Typical Single and Double Occupancy Patient Rooms
J Single Occupancy □
v•Vf
Double Occupancy
256
VITA
Debra D. Harris
611 East 46th Street Tele: 512.453.3117

Austin, Texas 78751 E-mai: harrisdesign@mindspring.com
REGISTRATION & CERTIFICATIONS

Registered Interior Designer State of Texas No. 9153
NCIDQ Certified No. 013690
Certificate for Indoor Air Quality Testing, Texas Engineering Extension Service
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
GRANTS, FELLOWSHIPS, & AWARDS

1998 International Interior Design Association Lester Johnson Fellowship
1998 Texas A&M University Women’s Faculty Network Graduate Scholarship
1998 A Carter Manny Award Nomination, Graham Foundation
1997 St. Joseph Regional Health Center, Grant: Material Specifications for
Healthcare Interiors Impact on Environmental Health.
1997 AIA, Grant: The Impact of Design of Interiors on Productivity.
1994 American Hospital Association/American Institute of Architects Graduate
Fellowship in Health Facility Planning & Design.
1993 Institute of Business Designers Foundation/Lackawanna Leather Com
pany Professional Fellowship Award, Graduate Fellowship.
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

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INFORMATION TO USERS

The quality of this reproduction is dependent upon the quality of the

Oversize materials (e.g., maps, drawings, charts) are reproduced by

Photographs included in the original manuscript have been reproduced

Bell & Howell Information and Learning

A STUDY OF FLOORING MATERIALS IN A HEALTHCARE TELEM ETR Y UNIT

Submitted to the Office of Graduate Studies of

Major Subject: Architecture

Bell & Howell Information and Learning Company

A STU D Y OF FLOORING MATERIALS IN A HEALTHCARE TELEM ETRY UNIT

Submitted to Texas A&M University

Approved as to style and content by:

Mardelle M. Shepley Louis G. Tasamary

Major Subject: Architecture

Environmental Quality and Healing Environments: A Study of

Flooring Materials in a Healthcare Telemetry Unit. (December 2000)

Debra D. Harris, B.S., Southwest Texas State University;

M.IARC., University of Oregon

Chair of Advisory Committee: Dr. Mardelle Shepley

materials on the environmental quality of patient rooms and explore the

relationship of environmental quality and human response. Specifically, this

at a regional health center.

An interdisciplinary multiple methodology was used to build a protocol for

criteria of the flooring finish materials for the development of an Indoor

to patient and staff perceptions, preferences, comfort, and biological responses

Patients preferred carpet in their patient rooms citing comfort, slip-resistance,

and less noise as the reasons for their choice.

Healthcare staff perceived patient rooms with V C T to be more clean and

glare, fewer temperature shifts, and better temperatures. Patients perceived

but rooms with carpet to have better temperatures.

The results of the indoor environmental conditions indicated that V C T

significant differences were found in the levels of noise, temperature, carbon

dioxide, and total volatile organic compounds.

The study determined whether the indoor environmental conditions of the

comfort, biological response, and satisfaction. The specification of appropriate

flooring materials in patient room environments depends on the composition of

comfort and satisfaction of the patients.

Additional research should focus on the materiality of flooring products,

organic compounds and microorganisms.

had found my mentor.

It is with great gratitude that I thank my other committee members. In

addition to her experience and expertise in healthcare research, Dr. Sherry

reasons. I appreciate his guidance and instruction on matters relating to the

Haberl is appreciated for his expertise and guidance in environmental building

notice to substitute as my Graduate Council Representative. His commitment

and dedication as an academic and educator is appreciated.

introduction to the administration at St. Joseph Regional Health Center. A

systems and maintenance. In the beginning, the architecture firm of record,

Bezecny, IIDA, and Mark Vaughan, AIA.

Access to the equipment needed to monitor the environmental conditions

Texas A&M University.

International Interior Design Association, and the Texas A&M University

of this project. I am deeply grateful for their support.

worked around the equipment and answered my many questions. Patients

genuinely seemed to enjoy participating in the study. In addition to the

helping me with data collection and helping me to keep my sanity.

encouragement; Vannapa Pimviriyakul, a new friend who enriched my

experience at Texas A&M University; Ward Wells for providing opportunities,

encouragement, love, patience, and support. His editorial comments, wisdom,

and wacky ideas kept this experience lively and interesting.

ACKNOW LEDG M ENTS.................................................................................................... vi

LIST OF FIGURES............................................................................................................ xiii

I INTRODUCTION AND LITERATURE R E V IE W ...................................................1

2.1 Research D esign.............................................................................87