A Qualitative Approach to Explore Audio-Visual Interaction in a Hospital Environment

Semiha Yilmazer 1 Bilkent University Department of Interior Architecture and Environmental Design, Bilkent University, Ankara Turkey

Zeynep Uğurlu 2 Bilkent University Department of Interior Architecture and Environmental Design, Bilkent University, Ankara Turkey

ABSTRACT This study presents the findings of audio and visual evaluations of a hospital environment. The re- search focused on the waiting area of an oncology polyclinic. The study aimed to get subjective re- sponses of the oncology patients via Grounded Theory and create a conceptual framework with the patients’ answers. The polyclinic’s acoustic and visual environments were identified, and LAeq lev- els were measured. Grounded Theory revealed patients’ perception of the acoustic and visual envi- ronments of the polyclinic. Semi-structured interviews were conducted with 20 voluntary patients in three of the polyclinic’s most crowded areas. The conceptual framework showed that patients were affected by both audio and visual characteristics of the polyclinic. Patients explained the polyclinic with its existing condition and preferred condition. The results revealed that patients want to hear additional relaxing sound sources such as music and nature sound rather than silence or noise, and they want to see natural elements such as water and greenery rather than plain walls.

1. INTRODUCTION

The soundscape is defined as the perceived acoustic environment within context 1 . Soundscape research first started in urban environments; however, research on indoor soundscapes started to increase recently 2 . There are many indoor soundscape studies in different contexts, such as offices 3 , museums 4 , mosques 5 , school environments 6 , dental clinics 7 , and hospital environments 8, 9 .

Hospital environments are essential as it provides treatment for patients. Therefore, the hospital should be designed to enhance patients’ relaxation 10 and well-being 11 . There is research in different parts of hospital environments, such as patient rooms or wards 12, 13 , ward corridors 14 , and emergency departments 15 . Surveys and acoustic measurements were the main evaluation methods for these studies. Only a few studies used the interview method 12 . Interviews through the Grounded Theory (GT) method can ensure learning about an environment without confronting the participants with any bias 16 . Further, the soundscape is affected by the visual environment 17 . Thus, both the sound and visual qualities should be considered for understanding perception in the environment.

Therefore, this study examines the audio-visual interaction in a hospital environment through the Grounded Theory method by patients’ perception of sound and visual environments.

1 semiha@bilkent.edu.tr

2 zeynep.ugurlu@bilkent.edu.tr

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2. METHODOLOGY

2.1. Site

The study is conducted in the oncology polyclinic of Ankara City Hospital. The hospital consists of 8 building masses (Figure 1). As every polyclinic is located similarly in the hospital, the oncology polyclinic is chosen as the study site because oncology patients are one of the most sensitive patient groups in physical and mental health. On the other hand, there is no medical equipment that produces alarm sounds in this polyclinic. This equipment is located in a different area in the hospital, and the selected area is only for waiting for the doctors and nurses. The main sound source is intelligible and unintelligible speech.

Figure 1: Oncology Polyclinic building area in Ankara City Hospital plan

The polyclinic is on the second underground floor in the oncology building. It has three adjacent spaces as A is the reception area, B is the courtyard area, and C is the corridor (Figure 2). The reception area and the courtyard area are 92 m² separately, and the corridor is 52 m². Although these three areas are in the same space, there are some differences in terms of their audio (Table 1) and visual content. The reception area has an area for receptionists as the indoor opening (Figure 3). The courtyard area has an area for the secretary as the indoor opening and a courtyard with a garden as the outdoor opening (Figure 4). Corridor has no opening (Figure 5).

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Figure 2: Ankara City Hospital Outpatient Oncology Polyclinic plan Table 1: Sound sources in the oncology polyclinic Sound sources Reception area Courtyard area Corridor

Sounds of technology HVAC, beeping (printers, computers, device for taking a turn in the queue), telephone ringing

HVAC, beeping (printers, computers), telephone ringing

HVAC, telephone ringing

Sounds of nature - - -

Sounds of human beings

Unintelligible speech (F/M), intelligible speech (F/M), coughing, footsteps, door closing, knocking, squeaking, rustling

Unintelligible speech (F/M), intelligible speech (F/M), coughing, footsteps, door closing, rattling, clunking

Unintelligible speech (F/M), intelligible speech (F/M), coughing, footsteps, door closing, rattling

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Figure 3: 360 ° photograph of the reception area

Figure 4: 360 ° photograph of the courtyard area

Figure 5: 360 ° photograph of the corridor 2.2. Data Collection and Analysis

A total of 20 patients waiting in the reception area (n=7), courtyard area (n=8), and corridor (n=5), ten male and ten female (µ age = 53.20; SD age = 13.45 years, age range 25-79) participated in the semi-structured interview. Participants were selected by convenience sampling. Eight main questions were prepared for the interview. The questions examined the perception of sound and visual environments (Table 2). These questions gave rise to other questions according to the course of the conversation, and patients also expressed their opinions in areas outside the scope of the main questions. Each interview took approximately 8-20 minutes. Ankara City Hospital Ethics Committee ethically approved the E2-21-1086 numbered research.

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Table 2: The eight main questions prepared for the semi-structured interview

1. What do you hear? 2. What do you want to hear? 3. What do you expect to hear? 4. What do you see? 5. What do you want to see? 6. What do you expect to see? 7. How do you cope with an audial or a visual factor that you do not like? 8. How do you feel in this environment?

During the interview hours, Equivalent Continuous A-Weighted Sound Level (LAeq) measurements were taken. A sound level meter Bruel & Kjaer Hand-held Analyzer Type 2230 was used in the reception area, courtyard area, and corridor. It was placed at 150 cm height and in the middle of the spaces (Figure 2). Measurements were taken on a weekday, during the interview hours (09.00-12.00) and with 1-hour intervals as it is the most crowded time. At last, the mean values of the measurements were evaluated. The average sound levels (μLAeq) were 66.7 dB in the reception area, 64.2 dB in the courtyard area, and 60.2 dB in the corridor.

The interviews were analyzed through Grounded Theory (GT). The Grounded Theory has three steps of coding: open coding, axial coding, and selective coding (18). The interviews were finalized when the collected data reached theoretical saturation. ATLAS.ti software was used for the coding process. As the collected data was transcribed, key ideas were identified from the raw data. After, categories were formed with these key ideas, and subcategories and main categories were defined. Then, relationships were formed between the categories, and the core category was chosen. At last, a conceptual framework was formed.

3. RESULTS AND DISCUSSION

The gathered data from the grounded theory analysis is visualized in a conceptual framework (Figure 6). This conceptual framework revealed the audio-visual evaluation of the outpatient polyclinic environment by patients visiting the place with a certain frequency.

Figure 6: Conceptual framework for patients’ audio-visual perception in the polyclinic environment

3.1. Acoustic Environment & Expectation and Perception of Sound Environment

The acoustic environment presents the objective parameters of the sound environment. The acoustic environment defines how patients perceive the sound environment and what they expect from it. Patients’ perception was a little different than the actual acoustic environment. They did not perceive the sounds of footsteps, door closing, knocking, squeaking, rustling. Also, they perceive human sounds as a whole, rather than dividing them into intelligible and unintelligible speech. Most of the patients expected a quieter sound environment.

A: Normally, it is quiet here, but when you look at the current situation, there is a lot of noise. Further, perception of sound environment was related to perception of visual environment as patients perceived the polyclinic’s sound and visual environments together. For example, they saw people and heard them talking simultaneously.

3.2. Visual Environment & Expectation and Perception of Visual Environment

The visual environment presents the objective parameters of the visual environment. It categorizes the environment according to the opening types in the polyclinic space, such as an indoor opening, outdoor opening, or no opening. Similar to the acoustic environment, the visual environment defines how patients perceive the visual environment and what they expect from it. The patients perceived people, walls, garden, and furniture in the visual environment. They expected to see less crowd and places for them to rest.

B: I wish it were not this crowded. I wish I could lie down. I would like it to be an environment where patients can rest.

3.3. Intervening Factors

There were intervening factors other than the acoustic and visual environments, which affected patients’ responses to the environment. There were some emotional and spatial factors and other factors related to the appointment issues in the healthcare system. Most of the patients were emotionally desperate due to illness and compared the polyclinic and the patients with other hospitals/polyclinics or other patients. They explained some spatial factors, such as inadequacy of sitting units and poor air quality (HVAC), and mentioned other factors such as their time spent waiting in the polyclinic.

B: If there is someone in a worse situation than me, I give my turn. Chemotherapy is such a thing that it makes people very aggressive. It is something very different, and it cannot be explained.

3.4. Responses & Outcomes

Responses was the core category in this study, as many other categories were related to it. Patients’ perception of sound environment, visual environment, and other intervening factors caused positive, neutral, or negative responses. The responses to sound and visual environments were different but related to each other. Therefore, responses to sound and visual environments were grouped under positive, neutral, and negative responses. The patients mostly responded negatively to the environment. They explained the sound environment as too noisy and the visual environment as crowded and had cold, white, concrete walls.

A: Noise and lots of crowds. So busy. It would be better if it were calm...I am uncomfortable with the crowd and the intensity. I am trying to go somewhere quieter.

Patients also explained the outcomes of their responses. There were some emotional outcomes, such as feeling unhappy, distressed, and sad, and some physical outcomes, such as feeling tired, having headaches, and earaches.

B: A little disturbing. No matter how calm people are, there are buzzing sounds. Even if I go home, that sound stays in my ears.

3.5. Coping Methods/Distractions

Patients explained that in order not to experience negative outcomes, they found some coping methods/distractions. They used these coping methods to turn negative responses into neutral or positive responses. In general, patients chose to disregard and wait or leave the environment and sit in the courtyard. Others chose to pray, sleep, talk with other patients, and use the telephone.

3.6. Preferences

Positive responses from the patients defined their preferences about the sound and visual environments of the polyclinic. Some patients responded positively to the sound environment as calm, while they also preferred quiet/calm. They responded positively to the visual environment as having a garden and heart-warming paintings, while they also preferred trees, greening, flowers, and more paintings. Sound and visual environment preferences were also related as patients wanted to see and hear water elements and birds. Additionally, patients wanted to hear a certain amount of sound rather than silence or noise (3, 4, 6). Patients mostly preferred trees, greenings, and flowers in the visual environment and quiet/calm or music in the sound environment.

B: There may be a waterfall in the garden. You can sit around and listen to the sound of water.

4. CONCLUSIONS

This study showed that the sound and visual environment should be approached together as patients perceive them together. Patients’ wellbeing can be enhanced, and they can feel emotionally happier and physically stronger if the audio-visual environment of the polyclinic waiting area is designed. Further, nature elements, both in the sound and visual environments, can help the patients feel more at peace as nature contributes to a calmer hospital environment.

5. ACKNOWLEDGEMENTS

The authors would like to thank oncology polyclinic staff in Ankara City Hospital for their understanding and help during the study.

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