AJN, American Journal of Nursing:
September 2009 - Volume 109 - Issue 9 - pp 65-67
doi: 10.1097/01.NAJ.0000360316.54373.0d
Patients First
Ensuring Quieter Hospital Environments
Montague, Kimberly N. AIA, NCARB, LEED AP; Blietz, Connie M. MBA, BSN,
NE-BC, RN; Kachur, Mandy PE, INCE, Bd.Cert.
Author Information
Kimberly N. Montague is the director of design consultation at Planetree in Derby, CT. Connie
M. Blietz is the chief nurse executive at Alegent Health's Mercy Hospital in Council Bluffs, IA.
Mandy Kachur is a senior consultant at Acoustics By Design, Inc., in Ann Arbor, MI.
Contact author: Kimberly N. Montague, kmontague@planetree.org.
Patients First is coordinated by Susan B. Frampton, PhD: sframpton@planetree.org. The authors
acknowledge Sara Guastello at Planetree for her assistance in reviewing and revising the article.
Abstract
This is the fourth in a series of articles from Planetree, an international nonprofit organization
founded in 1978 that's "committed to improving medical care from the patient's perspective." For
more information, go to www.planetree.org.
Patients often complain about the amount and level of noise they hear during hospitalization. The
near-constant din created by equipment, hallway traffic, and conversation results in a less-than-
restful experience for many. And the effects can be detrimental; studies in adult patients have
linked excessive noise to sleep disturbance1, 2 and increased blood pressure, heart rate, and
stress.3 Excessive noise and inadequate sound isolation can interfere with patients' auditory or
"speech" privacy-which by law hospitals and other health care facilities must safeguard. (Oral
communication about a patient's health information is protected under the Health Insurance
Portability and Accountability Act of 1996.4) When patients aren't assured of such privacy, they
can be reluctant to fully disclose their conditions and concerns. One study of ED patients found
that curtain partitions provided inadequate speech privacy, causing a few patients to withhold
portions of their history.5
It's significant that the Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey (www.hcahpsonline.org/surveyinstrument.aspx), which measures patients'
perceptions of hospitalization, includes a noise-related question: "During this hospital stay, how
often was the area around your room quiet at night?" In results published on the Department of
Health and Human Services' Hospital Compare Web site (www.hospitalcompare.hhs.gov), just
56% of patients nationwide who were discharged from July 1, 2007 through June 30, 2008
reported that their room was "always" quiet at night, a finding that suggests there is marked room
for improvement. Such data have significant financial implications as well. Under a proposed
"value-based purchasing program" that will link payment to hospital performance, the Centers
for Medicare and Medicaid Services has recommended including the HCAHPS survey as one
performance measure.6
Nurses and other health care staff are also adversely affected by high noise levels. According to
one literature review, such levels have been associated with increased stress and annoyance,
fatigue, emotional exhaustion, and burnout.7 And excessive noise can interfere with staff
communication, increasing the likelihood of error.7
Guidelines set by the World Health Organization (WHO) for background noise in patient rooms
recommend that average sound levels not exceed 35 dBA during the day and 30 dBA at night,
and that maximum transient levels not exceed 40 dBA.8 These sound levels are on the order of
sounds produced by a breeze blowing through trees at five to 10 miles per hour. Other resources
commonly used by engineers make similar recommendations for sound levels in hospitals.9, 10
Yet one literature review found that these maximums are often exceeded, frequently peaking at
85 dBA and higher7-a level roughly equivalent to that produced by heavy traffic on a highway
heard from a distance of 25 feet. And researchers who analyzed data gathered at various
hospitals between 1960 and 2005 identified "a trend of increasing noise levels during daytime
and nighttime hours," with most sound levels 20 to 40 dBA higher than those recommended in
the WHO guidelines.11
Sources of noise on an inpatient unit include the movement of people and equipment;
conversations of staff, patients, and visitors; sounds from patients in distress; medical equipment;
other devices such as telephones, computer printers, and televisions; the public address system;
and the hospital ventilation system.12, 13 A facility's architectural design can also play a role. For
example, a unit with long corridors and distances between patient rooms and the nurses' station
might encourage staff to hold "microconferences" in the hallways.13
Although many factors contribute to noise in hospitals, the effects of some can, and should, be
mitigated.
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ONE HOSPITAL'S INITIATIVE
In 2000 Alegent Health's Mercy Hospital in Council Bluffs, Iowa, began a major renovation and
expansion initiative. (One of us, CMB, has worked there since 1998.) The first area to undergo
renovation was the combined medical-surgical and pediatric unit on the third floor; its design and
furnishings had been unchanged since the hospital was built in 1971. The goal was to create a
calm, healing environment with reduced noise levels.
The original 44-bed unit had three wings radiating from a central nurses' station where patient
charts were located; the unit secretaries were also stationed there. Nurses, physicians, and other
providers often gathered in this central area, which frequently resulted in high levels of activity
and noise.
During the planning stage of the unit's renovation, hospital staff and community members were
invited to share their ideas. To improve patient privacy, the group agreed that semiprivate rooms
should be converted to private ones. The nursing staff, seeking to improve workflow efficiency
and increase nurses' proximity to patients, recommended having a nurses' station on each of the
unit's three wings. Although this model was likely to increase renovation costs and complicate
nursing assignments, it was accepted. Other design changes aimed at reducing unit noise
included adding carpeting in the hallways, creating open kitchenettes on each wing for patient
and family use, and adding family areas with seating, telephones, and a television to patient
rooms (a curtain can be drawn when the patient wants privacy). Spaces dedicated to family use
help to reduce noise levels in other areas. The use of indirect lighting in hallways and soothing
colors on walls also contributes to a more serene environment.
All of these measures appear to have contributed to a quieter environment, and patients and
families have reacted favorably. Since the renovation the unit's noise-reduction efforts continue
to be effective, as evidenced by the hospital's most recent HCAHPS survey results, which were
markedly above the national average. Among patients hospitalized between July 1, 2007 and
June 30, 2008, 65% of Mercy Hospital patients reported that the area around their rooms was
"always" quiet at night, compared with 56% of patients nationwide.
Inventive ways to address staff concerns have also been found. For example, the carpeted
hallways make moving patients and equipment and cleaning more difficult. So the hospital
purchased motorized beds for the unit and is equipping each patient room with a computer to
eliminate the need for a computer cart. A new carpet design permits individual tiles to be
removed, which allows for easier cleaning.
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STRATEGIES FOR REDUCING NOISE
As Mercy Hospital's renovation of the medical-surgical unit shows, informed architectural
design can markedly reduce ambient noise levels. Effective strategies include selecting
appropriate sound-blocking and sound-absorbing materials during construction, locating noisy
equipment and high-traffic areas away from patient rooms, and purchasing and using quieter
equipment when that's an option. For example, during new construction or major renovation,
staggering patient room doorways along a corridor, or placing each room's bathroom between the
head of the bed and the corridor, can reduce the amount of room-to-room sound transfer and
enhance speech privacy. Using transparent materials for sound barriers between common areas
and patient rooms allows staff to see patients while reducing sound transfer. The use of carpeting
and acoustically absorbent ceiling tiles in hallways helps to reduce sound propagation.
The Green Guide for Health Care, a resource for best practices in sustainable design for health
care settings, has a technical brief outlining these and other strategies (http://bit.ly/JE8eu). The
brief interprets the Interim Sound and Vibration Design Guidelines for Hospital and Healthcare
Facilities (http://bit.ly/gitNV). These interim guidelines will be incorporated into the Guidelines
for Hospital and Health Care Facilities (forthcoming in 2010 from the American Society for
Healthcare Engineering), a definitive resource that's accepted as code or reference (in whole or in
part) in more than 40 states and by seven federal agencies. (For more information, write to
info@fgiguidelines.org.)
Electronic strategies might include moving television speakers closer to the listener to minimize
disturbance to others and equipping staff with personal pagers to minimize public address system
use. At Johns Hopkins Hospital in Baltimore, Maryland, after staff on a pediatric ICU were given
personal pagers, overhead pages decreased from one at least every five minutes to one or two per
hour.11
Some sounds, such as equipment alarms and signals, cannot be eliminated. To minimize such
disturbances, introducing white noise through a sound-masking system-consisting of a central
electronic controller and several emitters (speakers)-can be helpful. This constant, low-level
background sound fills in the gaps between louder, intermittent noises, making them less
noticeable. The system should be located in patient rooms but not in corridors or at nurses'
stations, where the additional sound could interfere with monitoring. One study found that the
use of white noise increased subjects' arousal threshold during sleep.14 (Patients on ototoxic
drugs should not be exposed to white noise; indeed, they should be assigned the quietest rooms
available.)
Behavioral and administrative measures to reduce noise should also be considered. At Saint
Marys Hospital in Rochester, Minnesota, such measures have included conducting shift-change
reports behind closed doors, changing IV bags before the alarm sounded, muffling the pump
speaker when programming changes, and restocking supplies during the evening rather than at
night.15
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7. Joseph A, Ulrich R. Sound control for improved outcomes in healthcare settings. Concord,
CA: Center for Health Design; 2007 Jan. Issue paper #4.
http://www.healthdesign.org/research/reports/documents/CHD_Issue_Paper4.pdf.
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8. Berglund B, et al. Guideline values. In: Berglund B, et al., editors. Guidelines for community
noise. Geneva, Switzerland: World Health Organization; 1999. p. 55-65.
http://www.who.int/docstore/peh/noise/Comnoise-4.pdf.
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9. American Society of Heating Refrigerating and Air-Conditioning Engineers. Chapter 47.
Sound and vibration control. In: ASHRAE handbook-HVAC applications. Atlanta; 2007. p. 34.
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10. Beranek LL. Application of NCB noise criterion curves. Noise Control Engineering Journal
1989;33(2):45-56.
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11. Busch-Vishniac IJ, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am
2005;118(6):3629-45.
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12. Bayo MV, et al. Noise levels in an urban hospital and workers' subjective responses. Arch
Environ Health 1995;50(3):247-51.
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13. Shepley M, Davies K. Nursing unit configuration and its relationship to noise and nurse
walking behavior: an AIDS/HIV unit case study. Washington, DC: AIA Academy of
Architecture for Health; 2005.
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14. Stanchina ML, et al. The influence of white noise on sleep in subjects exposed to ICU noise.
Sleep Med 2005;6(5):423-8.
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15. Cmiel CA, et al. Noise control: a nursing team's approach to sleep promotion. Am J Nurs
2004;104(2):40-8.
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