Below the Surface: A Closer Look at the Impact of Flooring on Staff, Patients, and Visitors in Healthcare Environments

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by Mark Huxta

Hospitals can be a source of stress for occupants. It is ironic places intended for healing and care are often teeming with overworked front-line staff, anxious visitors, and nervous patients. Needless to say, it has never been more important to ensure healthcare employees, patients, and their loved ones feel relaxed and comfortable in hospital environments.

Designers can make healthcare spaces safer and more comfortable in a variety of ways. From controlling aromas and sound to creating community spaces that encourage relaxing interactions, there are many elements design professionals can bring to hospitals to make the patient environment more friendly, open, and welcoming.

While there are countless ways to improve the patient experience, flooring can play a major role in the overall wellness of healthcare workers. Covering the largest surface area in buildings, the right type of flooring can help address a myriad of environmental stressors.

Challenges facing the healthcare industry

The healthcare industry is facing three major challenges. The United States Census Bureau reports there are approximately 73 million baby boomers.1 By 2030, all baby boomers will be over 65 and account for one in five people in the U.S. This generation is expected to live an average of five years longer than their parents, meaning they will require additional healthcare services, potentially with greater frequency, thus overcrowding hospitals.

Providers also face rising costs and reduced reimbursements, which is creating a fiscal crisis threatening the future of healthcare. The challenges become greater when non-reimbursable costs associated with “never events” are included. Whether it is a hospital acquired infection or a patient injury from a fall, the costs associated with these types of events are wholly covered by the provider, further stressing their financial sustainability. The key to managing these challenges is balancing patient experience and outcomes with the financial sustainability of the providers.

The nursing population is also aging. The American Association of Nurse Practitioners notes the average age of nurse practitioners is 47 years old.2

An aging nurse demographic coupled with both the physical and mental stress from extended work hours has contributed to burn out and threatened staff retention. According to the American Association of Colleges of Nursing (AACN), the U.S. nursing shortage could reach 500,000 by 2025.3

Creating safer spaces with evidence-based design

According to the Center for Health Design (CHD), “the built environment is a powerful force for inpatient care.”4 When designed with intent and a focus on outcomes, healthcare settings can enable care providers to do their work more effectively with the potential to enhance patient safety.

The CHD defines evidence-based design (EBD) as “the deliberate attempt to base building decisions on the best available research evidence with the goal of improving outcomes and of continuing to monitor the success or failure for subsequent decision-making.” EBD can include visibility, paths of travel, ergonomics, acoustics, and more.

Significant strides have been made to enhance visitor and staff experience as well as patient outcomes using EBD principles. For example, increased interactions and visibility between patients and hospital staff can positively affect the healing processes. These thoughtful conversations could include carefully explaining a procedure to a patient to assuage their fears or providing a needed support system through rehabilitation of an injury. In fact, research shows patients with low levels of stress may heal up to 40 percent faster than those who display high anxiety.5

Mitigating slips, trips, and falls

While hospitals have made great strides over the years to help prevent patients from falling, they persist. A study by Johns Hopkins revealed slips and falls cost U.S. hospitals $34 billion in direct medical costs.6 At medical facilities, reducing injury from falls may lessen unbudgeted and non-reimbursable treatment charges while reducing patient pain and suffering at the same time.

The coefficient of friction (CoF) of flooring is directly tied to the slip factor. The force of impact is what affects the severity of the fall. While hospitals have taken steps to prevent slips and falls with grip rails and bed alarms, flooring can also help prevent these accidents.

The majority of flooring in hospitals is 2 to 3 mm (79 to 118-mils) thick. Even if it is resilient flooring, patients who slip and fall on a thin surface experience an impact similar to landing on concrete. Installing a thicker surface—specifically an engineered one featuring vulcanized composition rubber—can reduce force impact up to 35.5 percent compared to thinner surfaces.7

Flooring products that are evaluated according to industry protocols, including ASTM and Clegg tests, can help reduce slips and the force of impact if a fall does occur. While softer products like textiles can also minimize slips and falls, they are not ideal for healthcare environments. Resilient surfaces, such as a 7-mm (276-mil) engineered surface, featuring a heterogenous sheet vinyl or homogeneous sheet rubber fusion bonded to a vulcanized composition rubber backing, have proven to reduce force impact while still providing the same hygienic properties and sustainability as their thinner counterparts.

Enhancing ergonomics

Ergonomics is the science of matching workspace conditions and job demands to the capabilities of workers. Incorporating effective ergonomics into the design of a product or facility can lead to avoidance of injury, increased staff satisfaction and productivity, and improved patient experience. For example, flexible furniture configurations where workers can sit, stand, and collaborate with others can yield greater productivity and wellness.

Ergonomics are critical for frontline workers. Most nurses now work long shifts and can walk anywhere from 2.4 to 5 km (4 to 8 mi) a day depending on the work environment. This can lead to a variety of injuries, including back and knee pain, bone spurs, and plantar fasciitis.

To address these challenges, flooring must strike the right balance between energy restitution and force reduction. Flooring that is too hard puts additional stress on joints, while surfaces that are too soft can contribute to fatigue and even compromise balance.

Creating a surface that enhances ergonomics begins with understanding the three phases of footfall. In the foot impact phase, the surface absorbs energy as the foot impacts the surface it deflects. Then, during the loading phase, the accumulation of stored energy strikes the middle of the foot. Captured energy is then released into the foot moving forward in the final energy restitution phase.

The key to addressing these challenges is to balance force reduction and energy restitution. Flooring must provide the ergonomic support needed to keep frontline staff comfortable during long shifts, while being durable enough to withstand heavy rolling and static loads. Vulcanized composition rubber offers a suitable balance.

Flooring that returns positive energy to the user and reduces impact can lower fatigue and stress on the body. The Agency for Healthcare Research and Quality found nurses who show less fatigue at work are not only more likely to provide better bedside care, but also their overall quality of life outside of work may be improved.8 Other benefits include reduced absenteeism, lower attrition, and improved productivity.

Evaluating hospital soundscapes

Noise is a major concern in hospitals that can lead to adverse patient outcomes due to poor sleep and increased stress levels. In fact, “quiet at night” is one of the lowest scoring categories for Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).9 With HCAHPS being the basis for reimbursements, poor acoustics may lead to loss of revenue for the provider, further compounding the financial stress on healthcare systems.

Numerous studies have been conducted to address concerns over hospital noise.10 Evidence suggests poor acoustical environments can have a negative impact on psychological and physiological reactions from both patients and staff. Reduced sleep, negative cardiovascular response, increased need for pain medication, and extended hospital stays are just a few ways noise can be detrimental to patient health.

Improvements to the sound environment, such as adding sound-absorbing materials, may positively impact staff and their perception of noise. Additionally, enhancements to the sound environment have been linked to improved patient sleep, which contributes to better outcomes. Therefore, the soundscape should be a key consideration in hospital design to support the health and safety of occupants.

Addressing acoustics

In 2019, the Journal of the Acoustical Society America (JASA) published a study that evaluated hospital soundscapes.11 This groundbreaking research expanded the scope of analysis beyond the traditional acoustics methodologies to include speech intelligibility, spectral analysis, and occurrence rates.

There are a multitude of noises in healthcare settings, many of which are directly related to flooring, such as footfalls, rolling loads, and dropped objects. In 2014, another study published by JASA measured the soundscape of an ICU where acoustic parameters were extracted from a ∼67-hour audio recording while a selected 24-hour recording was annotated offline for a source-specific analysis.12

The contribution of each noise category to the predicted loudness peaks (PLP) was found to be more uneven: staff (92 percent), alarms (six percent) and device noise (two percent). The study suggests most of the noise sources in ICUs may be associated with modifiable human factors, with footsteps being one of the top-five contributors to PLP peaks. These studies suggest a correlation between reducing floor noise to improve HCACPS.13

Reducing flooring noise helps create a sense of quiet, which can lead to a ripple effect of further mitigating sound levels. For example, lower noise levels may also encourage people to lower their voices since the space is quieter.

Testing using ASTM E3133, the Standard Test Method for Laboratory Measurement of Floor Impact Sound Radiation Using the Tapping Machine, shows floor impact-radiated sound from a variety of surfaces, including concrete, luxury vinyl tile (LVT), vinyl composition tile (VCT), vulcanized composition rubber with cork, and vinyl fusion-bonded to vulcanized composition rubber. The last two surfaces mentioned demonstrated up to a 60 percent reduction in the overall sound level. Vulcanized rubber composition flooring creates the necessary “give” that increases impact time, helps change characteristics, and reduces noise.

Flooring maintenance protocols

Most hospitals operate around the clock, and spaces like operating theaters, ICUs, and patient rooms need to be cleaned frequently. Therefore, cleaning protocols can have a significant impact on both the staff and patient experience.

For example, flooring requiring the use of cleaning equipment, such as a spinning bonnet machine, can be extremely disruptive in healthcare environments. However, surfaces needing less intrusive equipment like a handheld mop can maintain cleaning protocols without negatively impacting the patient experience. Surfaces mandating a strip/wax/buff treatment also place unnecessary inconvenience and stress on hospital staff.

Replacing flooring in a healthcare environment can be extremely challenging considering the continuous operations and need to keep spaces clean and safe. Downtime and disruption due to flooring failures is simply not an option. Engineered surfaces with heat-welded seams support a sterile environment and aggressive maintenance and can withstand rolling loads of more than 454 kg (1000 lbs), such as diagnostic equipment.

Helping visitors navigate complex spaces

The stress many visitors feel when walking into a hospital can be compounded when they cannot find their destination quickly and easily. This can also place additional stress on staff when they are asked to give directions while performing their rounds.

Wayfinding can help visitors better navigate hospital spaces by using directional tools provided in the built environment. Flooring can support wayfinding in hospitals with color coding or graphics to guide traffic and designate departments.

Surfaces featuring water jet cut patterns, symbols, and logos or heat-set urethane decals can assist with wayfinding and messaging. These decals are far less expensive compared to inlays that are water jet cut. Unlike inlays, heat-set decals are not permanent. These decals have become increasingly popular since the onset of COVID-19 and the need for social distancing floor markers. Healthcare environments are also using them in physical therapy in lieu of tape and to encourage patients and visitors to use the stairs, wash hands, or practice other wellness behaviors.

Elevating the staff and patient experience

Choosing the right floor can have a tremendous impact on healthcare settings and contribute to employee retention, according to the study 2020 Vision: Working in the Future of Healthcare.14 It can lower patient stress by reducing noise levels and decreasing the risk of slips and falls. Specifying optimal flooring can enhance the overall wellness of frontline workers and reduce noise in the healing environment while minimizing recovery times and improving patient outcomes. The cumulative impact supports providers’ efforts to maintain the quality of care for patients while contributing to the financial stability of the healthcare system.

About the Author

Mark Huxta is the director of sales, health, and wellness at Ecore. An industry veteran with more than 40 years in the flooring industry, Huxta offers extensive experience and knowledge to his clients with a focus on the issues and challenges that most effect patients, residents, and providers. He was a founding board member of the Delaware Valley Green Building Council and is a member of the HealthPoint Advisory Board. He actively interacts with healthcare professionals.

Notes

1 Visit www.census.gov/library/stories/2019/12/by-2030-all-baby-boomers-will-be-age-65-or-older.html#:~:text=The%202020%20Census%20will%20provide,on%20America’s%20population%20age%20structure.%E2%80%9D&text=Born%20after%20World%20War%20II,will%20turn%2074%20next%20year.

2 Details at www.aanp.org/about/all-about-nps/np-fact-sheet#:~:text=The%20average%20age%20of%20NPs%20is%2047%20years.

3 Visit www.aacnnursing.org/news-information/nursing-shortage-resources/about#:~:text=The%20shortage%20of%20registered%20nurses,University%20School%20of%20Nursing%2C%20Dr.&text=The%20report%2C%20found%20that%20the,%25%20to%203%25%20each%20year.

4 Consult www.healthdesign.org/sites/default/files/Malkin_CH1.pdf.

5 See Note 4.

6 Visit www.johnshopkinssolutions.com/newsletters/falls-cost-u-s-hospitals-30-billion-in-direct-medical-costs.

7 Details at www.ecorecommercial.com/document/4ucgtlrf892spfu4a0im0s994q?filename=RxCollectionProductTesting_ProductSalesSheet.201906041346524371.20191112143446468.20200207154042187.pdf.

8 Visit www.ncbi.nlm.nih.gov/books/NBK2645.

9 Consult www.hcahpsonline.org/globalassets/hcahps/summary-analyses/summary-results/july-2020-public-report-october-2018-september-2019-discharges.pdf.

10 For more information, visit www.healthcaredesignmagazine.com/architecture/too-noisy-heal.

11 Visit www.asa.scitation.org/doi/10.1121/1.5090493.

12 Details at www.asa.scitation.org/doi/10.1121/1.4868367.

13 Consult www.pubmed.ncbi.nlm.nih.gov/30823810.

14 Visit www.workforceinstitute.org/wp-content/uploads/2019/12/2020-Vision-Working-in-the-Future-of-Healthcare.pdf.

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