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1 UNDERSTANDING THE EF FECT OF THE PHYSICAL ENVIRONMENT ON THE VETERINARY CAREGIVER ACTION: CASE STUDY O F A SMALL ANIMAL VETERIN ARY CARE FACILITY By ANUPRITA ARUN SALKAR A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER IN INTERIOR DESIGN UNIVERSITY OF FLORIDA 2012
2 2012 Anuprita Arun Salkar
3 To my dearest f ather, Arun Vithal Salkar (1955 2011)
4 A CKNOWLEDGMENTS I would like to take this opportunity to express my gratitude to the people who have contributed to the completion of my thesis. First and foremost, I would like to thank my committee chair and graduate advisor, Dr. Maruja Torres Antonini, for all the enco uragement, support and guidance rendered to me during my course of study. She is not only an outstanding mentor, but also an equally wonderful person. I would also like to thank my co chair, Prof. Candy Carmel Gilfilen for her dedication, invaluable knowle dge base and timely feedback to perfect this project. Special thanks goes to the medical director and staff members of my research setting for their time and cooperation. I am forever indebted to my father, the late Arun Vithal Salkar, who has been my gua rdian angel all my life. My deepest love and gratitude goes to him for giving me the hope I have made him proud. I would also like to thank my mom, Amol Arun Sal kar, my sister, Mansi Arun Salkar and my grandmother, the late Surekha Salkar for their unconditional love, support and encouragement. Finally, I would like to thank my life partner Nikhil Goenka for being there for me in all my good and bad times. It was his immense love and faith that gave me the strength to go on. Words cannot express my love and gratitude for him.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURES ................................ ................................ ................................ .......... 9 LIST OF ABBREVIATIONS ................................ ................................ ........................... 11 ABSTRACT ................................ ................................ ................................ ................... 12 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 14 Physica l Environment of the Workplace ................................ ................................ .. 15 Stress and the Veterinary Caregiver ................................ ................................ ....... 17 Research Purpose and Question ................................ ................................ ............ 21 2 LITERATURE REVIEW ................................ ................................ .......................... 23 The Notion of Stress ................................ ................................ ............................... 23 Environmental Stressors ................................ ................................ ......................... 24 Noise Control ................................ ................................ ................................ .... 26 Lighting ................................ ................................ ................................ ............. 31 Indoor Air Quality ................................ ................................ .............................. 33 Ergonomic s and Layout ................................ ................................ .................... 38 Psychological Stressors ................................ ................................ ................... 45 Occupational Stressors ................................ ................................ .................... 48 Risks associated with animal patients ................................ ........................ 49 Physical strain of the work and the work environment ............................... 50 Mechanisms of injury ................................ ................................ ................. 50 Chemical and biological hazards ................................ ............................... 51 Implications of the Literature ................................ ................................ ................... 53 Summary of Literature Review ................................ ................................ ................ 56 3 METHODOLOGY ................................ ................................ ................................ ... 58 Case Study Research Strategy ................................ ................................ ............... 58 Case Selection ................................ ................................ ................................ ........ 59 Research Setting ................................ ................................ ................................ .... 61 Research Participants ................................ ................................ ............................. 62 Research Instruments ................................ ................................ ............................. 64 Research Procedure ................................ ................................ ............................... 67 Personal Interviews with Participan ts ................................ ............................... 68 Observations ................................ ................................ ................................ .... 69
6 Methods of Analysis ................................ ................................ ................................ 70 Limitations ................................ ................................ ................................ ............... 71 Summary of Research Methodology ................................ ................................ ....... 72 4 FINDINGS ................................ ................................ ................................ ............... 73 Observation Findings ................................ ................................ .............................. 73 Existing Conditions: Ambient ................................ ................................ ............ 73 Ergonomics and Layout ................................ ................................ .................... 73 Noise ................................ ................................ ................................ ................ 84 Indoor Air Quality ................................ ................................ .............................. 86 Lighting ................................ ................................ ................................ ............. 87 Personal Interview Findings ................................ ................................ .................... 91 Facility Staff ................................ ................................ ................................ ...... 91 Noise ................................ ................................ ................................ ................ 92 Indoor Air Quality ................................ ................................ .............................. 94 Lighting ................................ ................................ ................................ ............. 95 Ergonomics and Layout ................................ ................................ .................... 96 Effect of Occupational Stressors on Stress Levels ................................ ........... 98 Frequency of Stress Caused by Environmental Stressors ............................... 99 Intensity of Stress Caused by Stressors ................................ ......................... 100 Effect of Str essors on Satisfaction Levels ................................ ...................... 101 Stakeholder Feedback ................................ ................................ ................... 103 Summary of Findings ................................ ................................ ............................ 105 Noise ................................ ................................ ................................ .............. 105 Indoor Air Quality ................................ ................................ ............................ 106 Ergonomics and Layout ................................ ................................ .................. 106 Occupational Stress ................................ ................................ ....................... 106 Conclusion of Findings ................................ ................................ ................... 107 5 DISCUSSION ................................ ................................ ................................ ....... 109 Effect of the Physical Setting on Caregiver Stress and Satisfaction Levels .......... 109 Environmental Stressors ................................ ................................ ....................... 110 Noise ................................ ................................ ................................ .............. 111 Design Recommendations for Improved Noise Control ................................ .. 118 Ind oor Air Quality ................................ ................................ ............................ 119 Design Recommendations for Improved Indoor Air Quality ............................ 123 Ergonomics and Layout ................................ ................................ .................. 123 Design Recommendations for Improved Ergonomics and Layout .................. 127 Occupational Stressors ................................ ................................ ......................... 128 Design Recommendations to Minimize the Impact of Occupational Stressors ................................ ................................ ................................ ..... 130 Psychological Stressors ................................ ................................ ........................ 131 Merits to the Design and its Contribution to Ameliorate Caregiver Stress ............ 132 Lighting ................................ ................................ ................................ ........... 133 Materials and Finishes ................................ ................................ ................... 135
7 Recommendations for Future Research ................................ ............................... 139 Conclusion of Discussion ................................ ................................ ...................... 140 APPENDIX A INSTITUTIONAL REVIEW BOARD PERMISSION ................................ ............... 143 B INFORMED CONSEN T FORM 1 ................................ ................................ .......... 144 C INFORMED CONSENT FORM 2 ................................ ................................ .......... 145 D PERSONAL INTERVIEW QUESTIONS SAMPLE ................................ ................ 146 LIST OF REFERENCES ................................ ................................ ............................. 153 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 161
8 LIST OF TABLES Table page 3 1 Description of the facilities ................................ ................................ .................. 60 3 2 Demographics of the participants. ................................ ................................ ...... 63 4 1 Triangulation of the d ata ................................ ................................ ................... 107
9 LIST OF FIGURES Figure page 3 1 Veter inary caregiver stressor framework. ................................ ........................... 65 4 1 Floor plan of the veterinary facility ................................ ................................ ...... 74 4 2 reception area ................................ ................................ ................................ .... 75 4 3 Grooming area and the kennel. ................................ ................................ ......... 77 4 4 Exterior faade of the facility. ................................ ................................ ............. 78 4 5 Treatment area. ................................ ................................ ................................ 79 4 6 ................................ ................ 80 4 7 Examples of decorative features and personalization ................................ ........ 81 4 8 ................................ ...................... 82 4 9 I ntensive Care Unit (ICU) in the treatment area. ................................ ................. 83 4 10 Examination room, the laboratory and the adjacent corridors separated by doors. ................................ ................................ ................................ ................ 84 4 11 Imaging department. ................................ ................................ .......................... 85 4 12 Public areas mounted with ceiling fans to as sist ventilation. ............................. 86 4 13 Transparent windows provide natural lighting to recept ion and waiting area. .... 87 4 14 Technician work area and pantry. ................................ ................................ ...... 88 4 15 Examination room and laboratory. ................................ ................................ ..... 89 4 16 Surgery room and kennel. ................................ ................................ ................. 90 4 17 Distribution of responses for environmental stressors ................................ ........ 91 4 18 Distribution of responses for noise as a stressor ................................ ................ 93 4 19 Distribution of responses for indoor air quality as a stressor. ............................. 94 4 20 Distribution of responses for lighti ng as a stressor. ................................ ............ 96 4 21 Distribution of responses for ergonomics and layout as a stressor. .................... 97
10 4 22 Frequency of stress caused by the treatment of environmental stressors (n=14). ................................ ................................ ................................ ................ 99 4 23 Intensity of stress caused by environmental stressors response review (n=14). ................................ ................................ ................................ .............. 100 4 24 Intensity of stress caused by occupational stressors response review (n=14). 101 4 25 Satisfaction levels with the treatment of environmental & occupational stressors affecting work response review (n=14). ................................ ............ 102 4 26 Satisfaction levels with the treatment of ergonomic conditions response review (n=14). ................................ ................................ ................................ ... 102 5 1 Significant environmental stressors affecting the veterinary caregivers. .......... 110
11 LIST OF ABBREVIATION S AAHA American Animal Hospital Association ASHRAE American Society of Heating, Refrigeration, and Air conditioning Engineers AVMA American Veterinary Medical Associ ation CT Computed Technology EPA Environmental Protection Agency ICU Intensive Care Unit IRB Institutional Review Board MRI Magnetic Resonance Imaging NCIDQ National Council for Interior Design Qualification NIH National Institutes of Health NRC Noise Reduction Coefficient OSHA Occupational Health and Safety SAD Seasonal Affective Disorder SBS Sick Building Syndrome TWA Time Weight Average VOC Volatile Organic Compound
12 Abstract of Thesis Presented to the Graduate School of the University of Florid a in Partial Fulfillment of the Requirements for the Degree of Master of Interior Design UNDERSTANDING THE EFFECT OF THE PHYSICAL ENVIRONMENT ON THE SMALL ANIMAL VETERINARY CARE FACILITY By Anuprita Arun Salkar August 2012 Chair: Maruja Torres Antonini Cochair: Candy Carmel Gilfilen Major: Interior Design Although there have been t echnological advancement in services of veterinary facilities, there is concern that their design fails to prioritize the requirements of veterinary caregivers. Further, despite the acknowledged importance of the effects of the physical environment on workers, to date no directly relevan t research is available for the effects of the physical env ironment on veterinary caregivers. This study was therefore conducted to examine the impact of the physical environment on the The rese arch used a case study strategy that included personal interviews, resea The case study location was selected on the p remise that it was an optimal setting du e to the numerous design awards and its American Animal Hospital Association accreditation. The objective of the study was to understand how, if at all, the physical setting of the facility responded to caregiver stres s and satisfaction levels and if the merits of the facili design contribute to ameliorating caregiver stress.
13 The findings revealed that to varying extents, environmental stressors impacted the veterinary care giver staff. The caregivers indicated high satisfaction with the marginally affected by noise, indoor air quality, privacy, visual access, activity and safety req uiremen ts. However, lighting and e rgonomics and layout did not illustrate an effect Based on these conclusions, it appears that the design of the facility can positively impact stress and satisfaction levels of caregivers to promote their well being, thus making it an exemplary model for the design of small animal veterinary facilities.
14 CHAPTER 1 INTRODUCTION The first veterinary care facility in the United States was built in the 1800s as a small laboratory with a few stalls for animals. From its humble b eginnings to the state of the art facilities that are available today, there have been many innovations in the technology and services offered by vete rinary care facilities. tend to offer the features comparable to those avail able to human patients, including specialized services such as magnetic resonance imaging (MRI), computed technology (CT) scans, o r intensive care unit s (ICU), as well as surgical and dental rooms, laboratories, pharmacies, pet resort and spas, kennels, ki tty condos, grooming facilities, and activity parks. However, the availability of technologically advanced equipment does not guarant ee good facility design. In some cases, the requirements of the veterinary caregivers are not given sufficient consideratio n during the pre design phase of the facility, and thus are not reflected in the design. Recent developments and advances in the veterinary profession are in part the result of an evolution of the human animal bond, which is considered the motivating forc e for the greater demand for veterinary care (Mitchener and Ogilvie, 2002). Pets are no longer kept for primarily utilitarian purpose, but are considered by many to play an integral rol e in their personal lives. P ets are often considered cherished members of the family and are referred to as children in many of those families. In some instances, the bond between the owner and the pet becomes so strong that pets become essential for the survival of their owners by providing both physical and emotional suppor t (Mitchener and Ogilvie, 2002). company, solace and even assistance when necessary.
15 Veterinary caregivers are acknowledged as the professionals with the greatest knowledge of animal health and care and are trusted by the public with decisions concerning animals, including their welfare (Seigford et al., 2005). According to the AVMA, anima l welfare is assessed in terms of how an animal is coping with the conditions in which it lives. An animal is in a good state of welfare if it is healthy, comfortable, well nourished, safe, able to express innate behavior, and if it is not suffering from u npleasant states such as pain, fear and distress (AVMA). In addition, good animal welfare requires disease prevention and appropriate medical treatment. In response to the human animal bond, veterinary caregivers today place emphasis on acknowledging and appreciating the bond between owners and their pets. Not only does this require attention to the medical needs of the animal patient, but also necessitates providing empathy to, and supporting the emotional needs of the owner (Mitchener and Ogilvie, 2002). However, before veterinarians can provide animal welfare and client services, they must themselves be provided with a favorable physical environment at their workplace. According to Ulrich (1991), good health care cannot be administered without healthcare professionals, but factors such as job stress and burnout can impair both the physical and psychological health of the staff. The work of a veterinary caregiver is characterized by low control and high responsibility a problem that can be aggravated by po orly designed environments Physical Environment of the Workplace According to United States Environmenta l Protection Agency (EPA), on average, Americans spend 90 percent or more of their time indoors. Furthermore, research shows that the interior environm ent itself can influence human behavior. The field of environmental psychology assumes that a dynamic and reciprocal relationship exists
16 between individuals and groups and the environment in wh ich they work (Frumkin, 2005). Researchers are increasingly fin ding links between employee health and the physical environment of the workplace. In addition, there is evidence that the physical environment in the workplace affects both job performance and job satisfaction (Vischer, 2007) Stressors in the work environ ment affect employee performance adversely when they are high intensity or prolonged and increase task complexity Further, the conflict between the demand placed on the workers and the control they have over the physical environment is by definition stres s generating (Vischer, 2007). According to Lambert and Lambert (2008), workplace stress can be best described as the physical and emotional outcomes that occur when there is a disparity between the demands of the job and the amount of control the individua l has in meeting those demands. Environmental comfort or the opposite of stress, comprises three hierarchically related categories: physical, functional and psychological. Physical comfort includes satisfaction of basic human needs such as safety, hygien e and accessibility, which are met in the building environment through applying current building codes and standards to architectural design and construction decision making. Functional comfort is defined of work related tasks and activities. Psychological comfort results from feeling s of belonging and control over the workspace ( Vischer, 2007) Functionally uncomfortably workspaces draw energy out of the worker and affect work performance and as such are conducive to stress Depending on the ir occupation, workers are affected to varying extents by environmental, psychological and occupational stressors. E nvironmental stressors
17 include noise level, lighting, temperature and layout and ergonomics. A supportive, positive and effective work environment encourages work performance. The difference between a supp ortive and an unsupportive work place is the degree to which occupants can conserv e their e nergy for the tasks, as opposed to expending it to cope with adverse environmental conditions ( Vischer, 2007) According to Chang et al. (2006), coping with workplace stressors is the process of constantly changing cognitive and behavioral effects to manage external and/or internal demands that are appraised as taxing or exceed ing the resources of the workers Every workspace can be defined as providing more or less support to people performing specific tasks and activities that in turn have speci fic environmental requirements. The more support workers receive for their tasks, the more comfortable the workspace. Spaces providing less support are appraised as uncomfortable by users, requiring them to perform coping activities to solve their environm ental problems, and are therefore more stressful (Vischer, 2007) Although the importance of a well designed and supportive physical environment is consistently acknowledged in the interior design field, few studies have been conducted to specifically unde rstand the environment of a veterinary care facility. Furthermore, no study focusing on the effect of the physical environment on veterinary caregivers is apparent in the literature. Stress and the Veterinary Caregiver A study conducted by Smith et al. (2009) on Australian veterinarians found that after ten years of practice, work stress was the most important concern. According to Kahn and Nutter (2005), any event which may produce feelings of failure, helplessness, gu ilt, frustration, anger or sorrow is a pote ntial cause of stress, and these emotions may be experienced on a regular basis throughout the working day of the veterinary
18 caregiver According to H eath (2008), veterinarians struggle with the conflict between t heir affinity for animals and the demanding nature of their professional work. The work environment in a veterinary facility is one of continuous hard physical and mental work, wit h most practicing veterinary caregivers working an average 56 hours a week ( Jeyaretnam and Jones 2000 ). Caregivers experience stress and burnout because their work is characterized by low control and high responsibility; a problem that can be aggravated by poorly designed environments (Ulrich, 1991). Despite this fact, and effor ts by the American Veterinary Medical Association (AVMA) and American Animal Hospital Association (AAHA) to address professional issues confronting veterinary caregivers including the mental and physical health needs of its professionals, only a few studie s have specifically looked at stress and satisfaction levels among veterinary caregivers Further, little to none has conducted a detailed analysis of the various stressors present in the physical environment of small animal veterinary facilities (Heath, 2008) Hence, there is a need to assess the relationship between the physical environment of veterinary facilities and stress and satisfaction levels of veterinary caregivers. A satisfactory physical envi ronment at the workplace may imply improved productivity caregiver satisfaction and better care for animals. According to Mitchener and Ogilvie (2002), stress has been found to impact the veterinary caregiver. In a study conducted by Reijula et al. (2003) on levels of stress in Finnish veterinarians, it was found that work was perceived as the most significant cause of stress by 65% of the respondents Additionally, in Heath on Australian veterinarians, 66% respondents said that they felt significant and regular stress at their workplace (2008) Further, a study conducted by McArthur et al. (2007) revealed that
19 not only are veterinarians under a sign ificant amount of stress, but also experience elevated levels of anxiety Besides depression, reports have highlighted the reality of burnout and suicide within the practice of veterinary medicine. study, 40% of the veterinarians reported moderate levels of work related burno ut. Overall, 10% of the veterinarians experienced a significant amount of work related fatigue or exhaustion. Problematic professional outcomes such as these have been associated with veterinary fati gue overwork and stress According to Bartram and Baldwi n (2008), o n the basis of proportional mortality ratios in England and Wales, Scotland, Norway, Australia and similar estimates in USA, veterinary professionals appear to be at a particular high risk, around four times more likely to die of a suicide than the general population and around twice as likely than other health care professionals Whether widespread or not, these claims remain alarming. According to Smith et al. (2009), learning to cope with stress remains a critical area of veterinary practice. Further, veterinary practice is extremely varied with many different challenges presented to every member of the veterinary healthcare team, often on an hour to hour basis (Mitchener and Ogilvie, 2002). Veterinarians may have to deliver news about an unex pected pet loss after major surgery or an accident. They may also have to make Regardless of the specific news, these types of communication have been identified as so me of the most difficult and challenging aspects of the veterinary profession (Leonard and Ptacek, 2004) Australian veterinarian study was evidence of a relationship between stress and working in small animal
20 practice, particularly not having enough time per patient (2009) In Germany, stress was more common among veterinarians working in small animal practice, than those working in large animal or mixed practice Similarly, 2003 study exha ustion was most common among veterinarians working among small animals, as compared to mixed practice. According to Nienhaus et al. (2005), the risk of occupational stressors is higher for veterinary caregivers than for general health practitioners The ve working relationship with their animal patients is the main reason they are exposed to numerous unique risks (Reijula et al. 1992). Apart from a higher incidence of musculoskeletal injuries among nurses, human health professionals do not have high rates for occupational injuries due to physical causes. However, v eterinarians are at higher risk because they pull, push and lift animals, some of which are very heavy (Nienhaus et al., 2005). Additionally, these professionals could be at a gre at risk from exposure to heavy, uncooperative or aggressive animals, X ray radiation, stress and chemicals such as anesthetics, pesticides, vaccines, disinfectants and drugs (Fritschi and Soest, 2004) ent was considered very high by 54% of the female veterinarians and 66% of the male veterinarians. Further, this study found that about every third veterinarian had previously endured a work related ac cident within the previous year. According to Reijula e t al (1992), veterinary caregivers are often involved in hazardous situations, and that there is a great need to improve the physical environment at their workplace These findings prompt an investigation to understand the various stressors present in vet erinary facilities and their effect on the veterinary caregivers.
21 Research Purpose and Question The objective of this study is to identify the effect of the design features and levels by performing a case study of a representative small animal veterinary care fac ility. The premise of this study is that the constituents of the physical environment have a direct impact on the stress and satisfaction levels of workers; and more specifically, that this is also true within the context of veterinary care. For the purpo se of this research, the term veterinary care facility will be used to refer to any types of veterinary care setting. The naming of a veterinary care facility is regulated differently in each state based on their veterinary practice rules and regulations. The guidelines from the AVMA are the national standard and designate veterinary facilities based on the scope of the services that are provided to patients. According to AVMA a veterinary hospital, clinic, or center can be defined as a facility in which th e practice conducted includes the confinement as well as the treatment of animal patients. The term veterinary clinic applies to those that only provide outpatient care. In contrast, a veterinary hospital provides full services and hospitalization. A veter inary medical center is similar to a hospital but the name is typically applied to those facilities that also provide specialist services and have advanced capabilities The case study will explore elements of the physical environment variables and their perceived impact on the stress and satisfaction of the small animal veterinary care facility staff. The stressor framework will comprise environmental stressors constituted by noise, lighting, indoor air quality and ergonomics and layout, psychological str essors, and occupational stressors. The study attempts to answer the following research
22 question: How, if at all, do design considerations impact the stress and satisfaction levels of the veterinary caregivers in a small animal veterinary care facility?
23 C HAPTER 2 LITERATURE REVIEW This chapter presents the literature review pertaining to the purpose of the study. The key issue in the study, stress in the workplace, is an environmental behavior issue that may be applicable to any work and healthcare environ ment Hence, the initial part of the chapter not only presents the current literature that is available on the various stressors present in the physical environment of the veterinary settings, but also complementary environmental behavior concepts that may bear upon the issue at the core of the study. The second part of the chapter illustrates and summarizes the implications of such literature on the study. The Notion of Stress Healthcare workers, by the very nature of their work, have both unique and comm on health hazards in their work environment. Many of these hazards are obvious, while others are difficult to recognize and include physical as well as psychological risks, and stress induced disorders (Charney, 2009). Authors have argued that reactivity t o aversive physical characteristics of the environment involves relationship between stress, stressors, personal control and health outcomes (Topf, 2000; Rashid and and physiological response to the perception of demand and challenge (Ongori and Agolla, 2008). Stress is the subjective (i.e., psychological/felt) and/or physiological arousal that occurs when one is unable to exert personal control over a stressor. Stresso rs are events with the capacity to cause stress, which include major personal and cataclysmic events (Topf, 2000). They can be characterized as acute and time limited, chronic, or intermittent; as single events or multifactorial; and as mild,
24 moderate, or serious (William et al., 2005). Workplace stressors are present in general workplace and healthcare settings, including those dedicated to animal care. The literature review focuses on the following three types of work related stressors that are prevalent in veterinary healthcare settings: (1) environmental stressors (2) psychological stressors and (3) occupational stressors. Environmental (also called ambient) stressors are background conditions, passing largely unnoticed unless they interfere with some i mportant goal or directly threaten health. They can also be described as chronic, negatively valued aversive aspects of the physical environment. The degree of intensity, duration, controllability and predictability of specific ambient stressors are believ ed to affect their capacity to cause stress (Topf, 2000). Psychological stress occurs when an individual perceives that environmental demands tax or exceed his/her adaptive capacity (Cohen, 2007). Occupational stressors can be defined as a relationship bet ween the person and the environment that is appraised by the person as taxing and endangering his or her well being (Gardner and Fletcher, 2009). Environmental Stressors According to Gifford (2007), the work environment can be considered not only as a col lection of physical stimuli (noise, light, temperature, etc), but also as a physical structure (size, furniture, hallways, etc). A good workplace design begins with the knowledge of employee environmen t relations. W ork outcomes fall into four major categor ies which include performance, feelings, health and stress and social behavior (2007) A conceptual framework developed by Rashid and Zimring (2008) links the in door environment and stress. This framework groups the physical environment variables into two categories: indoor environmental variables and interior design
25 variables. Indoor environmental variables relate to the different condi tions of indoor air and include noise, lighting, ambient temperature and air quality; whereas interi or design variables a re all conditions that define an interior environment and include the use of space, furniture, fixtures and equipment, finishing materials, color, artwork and natural views. Interactions among some of these variables may occur, thus contributing to the lev el of stress. Any negative environmental effects of these variables are treated as immediate outcome variables. variables with somewhat direct associations with stress may be affect ed when individual needs are constrained by environmental features. However, it should be noted that any negative effect on an immediate individual outcome does not automatically result in on one or more immediate outcomes depends on his/her coping skills. The effectiveness of their coping the context within which stress occurs. Time may be an addit ional factor determining the potency of environmental stressors. In some contexts, people may simply get used to a stressor if exposed to it for an extended period. In other contexts, a mild stressor may have a major effect if an individual is exposed to i t for an extended period (Rashid and Zimring, 2008). Research shows that a sense of control is an important factor influencing stress levels and wellness. A consistent finding in stress research has been that if the individual has a sense of control with respect to a potential stressor, the negative effects of the stressor are markedly reduced or even eliminated (Ulrich, 2000) Control refers to
26 do to them. Research i ndicates that people who feel they have some control over their environmental circumstances deal better with stress and have better health than persons who lack a sense of control (Ulrich, 2000) In addition, loss of control is an important problem for hea lthcare employees because their jobs often combine an overload of demanding responsibilities with low decision latitude or authority. Poorly designed, unsupportive healthcare environments further undermine control. Healthcare design characteristics that en hance feelings of control, therefore, should tend to mitigate stress and improve other outcomes (Ulrich, 2000). In many cases, the physical environment may trigger processes leading to stress by the ways in which it affects individual and/or workplace nee ds (Rashid and Zimring, 2008) stress and job satisfaction. According to Topf (2000), reactivity to aversive physical characteristics of the environment involves relationships be tween stressors, stress, person al control, and health outcomes. Based on the theoretical framework by Rashid and Zimring (2008), t he environmental stressors reviewed in this body of literature include noise control, lighting, indoor air quality and ergonom ics and layout. Noise C ontrol Noise is o ften defined as unwanted sound, or a ccording to Field and Solie (2007), as sounds that are harsh and unplea sant. Noise is also recognized as an environmental pollutant, which causes workplace disruption and has imp lications for chronic mental and physical health. Noise can stimulate the pituitary gland and the sympathetic nervous system, which produces endocrine and sympathetic effects commonly seen in response to a stressful situation ( Choiniere, 2010) There is ov erwhelming evidence
27 from laboratory experiments that the presence of uncontrollable noise can significantly impair cognitive performance (Passchier Vermeer and Passchier, 2000). With reference to healthcare settings, in 1979, the US Environmental Protecti on levels not exceed 45 dB during the day and 35 dB at night noting that noise exceeding these levels could produce serious physical and ps ychological stress (EPA, 1979). Regard ing task performance, it is reported that exposure to noise may lead to decrements in task performance or highly variable performance (Rashid and Zimring, 2008). However, according to Bowden and Wang (2006), individual reactions to a particular noise are v ery subjective. Because of the subjective nature of noise perception, quantifying noise and determining appropriate levels that will satisfy the majority of occupants is a difficult process. A second issue to consider is that of sustained noise. Continuous exposure to noise is reported to have adverse physiological and psychological effects on workers (Prashant and Shridhar, 2008). O ccupational S afety and H ealth A dministration (OSHA) standards require a hearing protection program when workers are exposed to noise levels above 85 dB based on an eight hour time weight average (TWA). The TWA is a method of calculating the danger based on the intensity of the noise and duration of exposur e, e.g., the louder the noise; the shorter its exposure is permitted ( Seibert, 2011). According to OSHA the sound levels should not exceed 90 dB during an 8 hour work period. For sound levels above 90 dB, reductions in exposure time are required, within a limit of 15 minutes of exposure per day to sound level of 115 dB. A further
28 aspect of the Act is that no impulsive or impact noise should exceed 140 dB (Field and Solie, 2007). Also, noise abatement in excessively noisy work areas is required. If a workpl ace is deemed excessively noisy, workers must be provided with safety equipment and required to use it (Field and Solie, 2007). Considerable support exists for the contention that hospital sounds are ambient stressors and that noise in healthcare settings creates additional stress for patients and workers alike (Rashid and Zimring, 2008). However, according to Applebaum, Fowler and Fiedler (2010), researchers have examined the effects of noise on patients, and comparatively few studies are available for the caregiver staff. Studies show that hospital noise is amongst the top complaints of healthcare professionals (MacLeod et al., 2007). According to Choiniere, the body responds to noise in much the same way as it responds to stress, which over time can impa ir health. However, the hospital is a work setting where noise levels exceed the EPA noise level recommendations (2010). There is evidence that high noise levels adversely affect caregivers. Such levels have been associated with increased stress and annoy ance, fatigue, emotional exhaustion and burnout. Further, increased feelings of noise related stress and burnout can lead to an increase in employee turnover (Appleba um, Fowler and Fiedler, 2010). In addition, a ccording to Schweitzer et al. (2004), correla tions between noise and increased frequency of headaches and symptoms of burnout in caregivers have been made. Evidence shows that improving noise control and introducing positive background noise during and after the building process can reduce stress for the caregivers, along with the clients and patients.
29 Studies show that veterinary practices are not typically noise free (Moser, 2010). Acoustical environments are often given little consideration in veterinary facilities (Turner et al., 2007). Although it will vary from one breed to another, as well as from one animal to another, noise levels from a barking dog can reach 80 dB 90 dB. Noise levels in the kennels typically range from 95 dB 115 dB measured at the center of the room (Seibert, 2011). Unsurpr isingly, according to Jeyaretnam & Jones (2000), hearing loss has been widely reported in the veterinary profession. Barking dogs have been estimated often to cause sound pressures up to 105 dB and might prove a problem both to the veterinary caregiver sta ff and the neighboring residents (2000) Additionally, noise from dryers and clippers in a grooming area in veterinary facilities can also present a hazard. Depending on the size of the room, the number of dryers and clippers in use, and the texture on th e walls, noise levels can get up to 100 dB (Seibert, 2011). According to Turner et al. (2007), it is extremely important to minimize excessive noise resulting from daily maintenance in veterinary facilities. The noise p roduced by motors and equipment shoul d be minimized using architectural and noise abatement techniques. According to Gilchrist et al. (2003), the three basic strategies for sound attenuation or sound mitigation include (a) noise/ source control, (b) path control and (c) receptor control Noise /Source control. Controlling a noise at the source is the most effective method of eliminating noise. The advantage of controlling noise at its source is that it reduces noise emissions in all directions and not just al ong a single path (Gilchrist et al 2003).
30 Path control. Although sound control strategies are effective, they are insufficient in many cases in reducing the noise to acceptable levels. Thus a second mitigation strategy would be to control the noise along the transmission path. Noise barrie rs can provide a substantial reduction in noise levels (Gilchrist et. al, 2003). As noise is transmitted through air, a common strategy for noise path control entails the introduction of barriers that can section off and seal spaces from one another. Opera ble doors often serve this purpose. Receptor control. This strategy of controlling the noise at the receptor tends to be the most difficult and costly mitigation technique, as the critical receptor may be human precision equipment that is sensitive to low levels of ambient noise (Gilchrist et. al, 2003). H owever, it is important for designers to consider both the functional relationships and acoustical compatibility between spaces. Sound barrier partitions can be designed to achieve noise control, but at greater cost and complexity. Therefore the least costly and most effective noise control is intelligent planning (Evans and Philbin (2000). Moreover, d oors and windows are often the weaker components of partitions. Where attenuation is required for speech privacy, up to 30 dB of attenuation can be ac hieved with laminate glass a quarter inch or greater thickness, or doors with acoustic head, jamb, and threshold seals (Evans and Philbin, 2000). One of the simplest ways to drive errant background noise in vet erinary facilities is to use suspended acoustical tiles with a higher noise reduction coefficient (Moser, 2010). A study conducted by Blomkvist et al. (2005), found that by replacing traditional
31 ceiling tiles with acoustical tiles, the caregiver staff work ing in the unit experienced less stress and felt less irritable than the staff that did not have acoustical tiles in their unit. Lower noise levels were linked with a number of positive effects on healthcare staff, including reduced perceived work demands increased workplace social support, improved quality of care for patients and better speech intelligibility. These positive outcomes for the healthcare staff have the potential to increase caregiver satisfaction with the workplace ( Applebaum, Fowler and Fiedler, 2010). Therefore, it may be implied that lower noise levels will improve task performance and contribute to reducing the stress and increasing satisfaction levels in veterinary caregivers. Lighting Most healthcare settings are lit by a combination of daylight entering through windows (natural light) and electric light sources (artificial light) ( Applebaum, Fowler and Fiedler, 2010). The electrical light sources include cool white fluorescent, incandescent energy efficient fluorescent, and full spectrum fluorescent lighting. Different wavelengths or spectral distributions of light have different effects on the human body. Most electric light sources lack the spectral distribution needed for complete biolog ical functions, although full spectrum fluorescent lighting does come close to that of natural light (Edward and Torcellini, 2002) There are few empirical studies that have examined the impact of light, artificial or natural, on mood or task performance in healthcare settings. Constant exposure to artificial light, in particular fluorescent tube light is commonly mentioned by caregivers as one of the most draining aspects of work ( Applebaum, Fowler and Fiedler, 2010). According to Schweitzer et al. (2004) the differences between natural and artificial light
32 are significant, including levels of illuminance, uniformity, diffusion of light, color and amount of ultraviolet radiation. One study of 141 health caregivers in Turkey found that caregivers exposed to natural daylight for at least 3 hours a day experienced less stress and were more satisfied at work (Applebaum, Fowler and Fiedler, 2010). Furthermore, looking out at natural light can improve health outcomes in caregivers. According to Edward and Torce llini (2002), daylight provides a better lighting environment than artificial lighting. The majority of building occupants prefer a daylit environment because sunlight consists of a balanced spectrum of color, and also has the highest levels of light neede d for different functions (2002). Additionally, researchers from the Center for Health Design confirm from previous research that the most obvious effect of light on humans is that of enabling vision and performance of visual tasks (Applebaum, Fowler and F iedler, 2010). According to Applebaum, Fowler and Fiedler (2010) the nature of the task, as well as the amount, spectrum, and distribution of the light, determines the level of performance that is achieved. Performance on visual tasks improves as light l evels increase. Studies have shown that caregivers with access to natural light are more productive and have higher job satisfaction levels. Additionally, approximately 86% of the respondents preferred having sunshine in their office year round as opposed to only one season of the year or not at all (Rashid and Zimring, 2008). Further, questionnaire studies across a variety of workp laces have shown that staff members prefer window views of spaces illuminated by sunshine (Ulrich, 2000). In addition, occupant s in dalylit office buildings repor ted an increase in general well being. Specific benefits include better health, increased productivity, and lower
33 fatigue levels. Studies show that the proper use of daylighting decreases the occurrence of headaches, Seas onal Affective Disorder (SAD) and eyestrain (Edwards and by minimizing the dependence on artificial illumination According to Mayhoub and Carter (2010), daylight ing sources such as windows provide contact with the exterior and can influence physiological responses to improve health conditions in working environments. Well designed daylighting will deliver copious amounts of light, without either discomfort or disa bility glare, free from strong shadows and reflections (Boyce et al., 2003). However, the benefits of daylighting can only be realized if it is implemented correctly. Improper use of dayligting can reduce productivity and increase employee absenteeism due to the possibility of extremely high lighting levels, excessive glare, and high temperatures (Edwards and Torcellini, 2002). Studies conducted by Moser (2010), indicate positively that a sunlit, well ventilated environment reduce d stress and increase d prod uctivity and performance in veterinary facility settings. According to Wesley et al (2011), the use of natural lighting will also improve the energy efficiency of the veterinary facility. Indoor Air Q uality According to the American Society of Heating, Re frigeration, and Air conditioning are no known contaminants at harmful concentrations as determined by cognizant authorities and with which a substantial majority (80% or more) of the people exposed
34 components of IAQ reviewed are as follows: Climate control and ventilation. According to Occupational Safety and Health Administration (OSHA), the factors affecting indoor air quality (IAQ) include poor ventilation, poor temperature control, high or low humidity, or other activities in or near the building that can affect the flow of air into the building. Sometimes specific contaminants like mold, cleaning supplies, pesticides, or airborne chemicals may also cause poor IAQ (OSHA, 2010). Often indoor air contains more pollutants and at higher concen trations than outside air (Schweitzer et al., 2004). In a study conducted by Reijula and Sundman Digert (2004) on the extent of indoor air problems in office environments in Finland, the most common environmental problems were dr (34%) and dust or dirt (25%). In this study, the most common environmental problems that occurred occasionally were swings in room temperature (53%), too low temperature (5 1%), too high temperature (48%) and unpleasant odors (46%). According to Schweitzer et al. (2004), the proponents of building energy efficiency argue that natural ventilation can increase energy efficiency in buildings as well as improve indoor environmental conditions. In a U.K study conducted by Raja et al. (2001), on the thermal comfo rt of workers in naturally ventilated buildings, it was found that building occupants use windows extensively. Additionally, allowing cross ventilation helps to lower the indoor temperature. The study also found that occupants who have greater access to IA Q controls (e.g. those close to a window) reported less discomfort than those who had less access (e.g. away from the wi ndow). Further, n atural ventilation from operable
35 windows can play an important role in controlling the IAQ and temperature in summer by helping aid air movement (2001). A strategy for good indoor air quality is to develop ventilation practices that support operable windows, where appropriate. Operable windows avail the occupant of external ambient smells, breezes, and all the sensory stim uli of an open environment. Employees rate windows with a view of a natural setting as very desirable. Additionally, employees with a window view of nature report less stress, better health status, and higher job satisfaction (Schweitzer et al., 2004). Acc ording to Rediich (1997), problems associated with indoor environments are one of the most common environmental health issues faced by caregivers. Research shows that poor IAQ in buildings can decrease productivity (Wyon, 2004). Successfully dealing with t he environment of the spaces would require the designer to consider all the factors that affect this phenomenon. The most recent standards from the U.S. Green Building Council stress improving indoor air quality (Moser, 2010). Several studies in health car e setting have linked air quality and infection rates to the types of air filter, directions of airflow, air pressure, air change rates, humidity, and ventilation system cleaning and maintenance regimes (Rashid and Zimring, 2008). According to Portner and Johnson (2010), it is important to address issues such as odor and humidity control and heating and cooling system efficiency. Infection control must be a factor in the design; air contamination is likely the most significant risk. Sensitive treatment area s should be ventilated so that the room air pressure is higher than the corridor air pressure. This ensures that air moves from clean to less clean areas thereby keeping airborne infectious particles from entering the sensitive areas.
36 Studies show that si ck building syndrome (SBS) is generally high in healthcare facilities and that work stress and lack of control are among the predictors of SBS in hospitals (2008). SBS is used to describe situations in which building occupants experience acute health risks and comfort effects that appear limited to time spent in a building, but where no other specific illness or cause can be identified (EPA, 1979). Studies show a relation between ventilation and SBS. In air conditioned buildings, low ventilation rates may b e associated with statistically significant worsening in perceived air quality outcomes (Rashid and Zimring, 2008). According to Butala and Muhic (2007), in order to decrease SBS related symptoms and improve the perceived air quality and productivity in of fices, ventilation rates must be increased with regards to standards. The prevalence of SBS related symptoms is lower in naturally ventilated buildings. Several studies in healthcare setting have linked air quality and infection rates to the types of air f ilter, direction of airflow, air pressure, humidity, and ventilation system cleaning and maintenance regimes (Rashid and Zimring, 2008). According to the survey conducted by Reijula et al. (2003) on the health and work environment of Finnish veterinarians, every third veterinary caregiver reported the presence of hazardous gases in the indoor air. Hence it is important that the exposure to anesthetic gases be considered in planning the ventilation of the workspace, and that an effort be made t the veterinarians inhaled irritating amounts of gases at work, and 39% reported exposure to gases and dust (2003). According to Spengler and Chen (2000), the three control strategies to improve the IAQ in a building are (1) source elimination, (2) local source control and (3) dilution
37 of the indoor contaminants by ventilation. Source elimination is the most effective and least expensive method to improve IAQ. Source elimination may be ach ieved through environmental parameter control, such as temperature and relative humidity. The building material characteristic ideal for better IAQ include durability, hard smooth surfaces, non toxic materials, low Volatile Organic Compound (VOC) emissions low moisture content, low moisture absorptivity, and low toxic chemical and fiber content. The local source control technique limits pollutant transport with in a building by use of exhaust systems. Finally, the third control strategy is dilution of indo or contaminants by ventilation, defined by American Society of Heating, Refrigeration, and Air by natural or mechanical means to or from any space (Spengler and Chen, 2000). According to Splenger and Chen (2000), ventilation systems are used to maintain a good thermal comfort level and acceptable IAQ, at a reasonable cost. By design, the ventilation should be sufficient to dilute the contaminant sources so that their concentra tion will be below the thresholds. There are two ways to achieve ventilation in a building: natural ventilation or mechanical ventilation. Compared to mechanical ventilation systems, natural ventilation systems consume little energy, require little mainten ance, have low first costs, and are environmentally friendly (Spengler and Chen, 2000). Odor. The perception of smell is dominated by pleasant or unpleasant dimensions. Just as pleasant smells contribute to a sense of well being and health, malodors have t he ability to produce a response that can be most unpleasant and even possibly harmful. Odors are on a continuum and can be viewed as a range or levels,
38 such as no odor to highly odiferous, but these are not clearly defined ( Applebaum, Fowler and Fiedler, 2010). According to Sander (2010), odor symbolizes inadequate care and lack of professional concern. The most significant source of odor in veterinary facilities is from the excreta and ur ine of animals. Odor can affect mood and thus stress because of the overlap of the olfactory and emotional systems in the brain. Furthermore, odors are often perceived as indicators of airborne pollutants (Jacobson et al., 2003). Numerous studies have found that offensive odors yield unpleasant psychological reactions (Fr umkin, 2005). According to Mroczek et al. (2005), air quality has been linked to stress in the workplace. The quality of air is a concern for employees and is rated as one of the most important factors in the work environment. Poor air quality can result in dissatisfaction with the workplace environment. In addition, studies also reveal that problems associated with the indoor environments are one of the most important environmental health issues caregivers face ( Rediich, 1997). Ergonomics and L ayout Acco rding to OSHA (2010), ergonomic disorders can be defined as range of health ailments arising from repeated stress to the body. These disorders may affect the musculoskeletal, nervous, or neurovascular systems. They typically strike workers involved in repe titious tasks, or those whose jobs require heavy lifting or awkward postures (2010). Healthcare professionals are under increasing pressure to work more efficiently with fewer resources. This stressful situation can be made worse by physical discomfort at the workplace (Springer, 2007). Adapting workplaces to fit workers and the work they perform is a fundamental principle of ergonomics. Highly supportive workplaces are high performance workplaces and are designed to optimize
39 performance of the tasks and su pport the work behaviors of the staff. Research evidences over the past 25 years consistently shows an average of 12% improvement in performance when a comprehensive approach to ergonomics is applied to the workplace (2007). Work environment and ergonomic s. According to Springer (2007), the workplace should be designed to adapt to workers. Workers may be able to accommodate poor design and hostile environments, but adaptation takes a toll on users, causing decreased performance and fatigue. Appropriately a daptive equipment and environments relieve strain on the workers by reducing their need to adapt to shortcomings in the workplace (2007). Providing ergonomically correct work surfaces, heights, and access for staff can reduce injuries and therefore lessen stress and risk for the caregiver staff. The work of a veterinary caregiver has often been understood as either mainly office work or purely clinical work ( Reijula et al., 2003) However, the work of a veterinary caregiver often involves physically strenuous phases that especially strain the surveyed veterinarians work bent over or in improper back postures. In addition, 15% of the surveyed veterinarians worked with one or both arms above shoulder level for over one hour daily. These percentages point out the significant physical loading apparent within veterinary work. The increased risk of mu sculoskeletal problems and the importance of its prevention are accentuated on the basis of the Finnish study by Reijula et al. (2003). In this study, 67% of the veterinarians suggested that their work environment and
40 ergonomics needed improvement. The erg onomic principles and occupational physiotherapy that have been applied to physically straining work tasks in other professions including human healthcare need to be applied also to veterinary caregivers. Spatial relationship. According to Portner and Joh nson (2010), in order to provide for an interior environment that meets program objectives, the designer should examine data on spatial allocations, functional adjacencies, user requirements, staffing projections, flexibility requirements, redundancy requi rements, security requirements, architectural finishes, fixed equipment needs and circulation of personnel, material, animals and waste. This data serves to prepare functional diagrams and adjacency flow chart s that lead to the design of spaces optimally s The arrangement of critical adjacencies will greatly impact the quality of life of the animals, the caretakers and the veterinarians. Appropriate adjacency planning will modify interference from noise and vibrations, economiz e circulation routes and maintain the appropriate degree of cleanliness of the facility. The zones in the facility may be divided into four categories: public zones, transitional zones, specific pathogen free zones and contaminated zones. In addition, it is crucial to identify the variety of species that the facility should be expected to accommodate over time, the temperature and humidity range that each species can tolerate and the degree of flexibility and adaptability required within the facility to ac commodate different species (Portner and Johnson, 2010). Facilities that house dogs may have outdoor runs for enrichment of the animals. Further, the animal facility should be flexible and adaptable to accommodate
41 changes in function and protocols without having to make major changes to the facility (NIH, 2003). Materials and finishes. Acc ording to Portner and Johnson (2010), operation rooms require a higher degree of infection control than other areas. The design of the operating rooms should limit foot t raffic in the adjacent areas. Windows in the operating rooms should never be opened and any operable windows should be fitted with insect screen. Isolation rooms should be designed with an anteroom. This also limits the movement of air from the isolation r oom to the general population. Special attention should be paid to providing convenient hand washing stations in all the clinical areas of the facility. Further, the choice of flooring material depends on the area of the facility. Floor in the clinical are as should be easy to clean. This requires that the surface be relatively smooth, non porous, water resistant and not physically affected by germicidal solutions. (Portner and Johnson, 2010). An effective flooring material for veterinary facilities should be durable, easily cleaned, resilient, slip resistant, nonabsorbent to liquids and odors, homogenous, resistant to microbial growth (Gates, 2004). According to NIH (2003) guidelines, the factors to be considered while selecting the flooring include wearing surface durability, joints (in seams and at wall intersections), slip resistance, urine resistance, stain resistance, scratch resistance, comfort underfoot, reparability, life cycle, color selection, and substrate requirements. In addition, the floors sho uld also be smooth, moisture proof and resistant to the effects of high temperature water, and detergent cleaning, as well as chemicals used in treatment rooms and continuous movement of cages and equipment.
42 Portner and Johnson propose that the floors in clinical areas should be monolithic (seamless). It is important to avoid a completely smooth surface; although ideal for infection control, it can create a serious slippery hazard for clients and caregivers when wet, and some dogs may have difficulty walki ng on it. The wall base should be selected with infection control in mind (2010). Additionally Portner and Johnson (2010) suggest that the use of floor drains in kennels and grooming areas is controversial. Drains provide the opportunity to wash an area wi th large volumes of water and disinfectant or even high pressure washers. However, drains provide a potential site for bacteria colonization that can be difficult to eliminate. If floor drains are used, they must be disinfected routinely. Further, wall fi nishes also depend on the area of the facility. As in other healthcare settings, textile or fabric walls should be avoided, except in the administrative areas. In clinical areas where walls are likely to be soiled, the finish should be washable. In sensiti ve areas of the hospital e.g., isolation units, surgical suites, oncology wards, etc, wall finishes should be free of fissures, open joints, or crevices t hat could harbor dirt particles. In addition, the walls should not only be capable of withstanding the impact of cages, carts, and racks, but also provide a smooth and moisture resistant surface (2010). In the opinion of Portner and Joh n son (2010), ceilings are less likely to be directly contaminated with infectious body fluids than walls or floors. F or the ceiling, acoustical ceiling tile is an affordable and reasonable selection in most areas of the facility. Ceiling selection in operating rooms is of great concern because particulate matter from the ceiling can drift into open body cavities. Acousti cal ceiling tile has crevices that can trap
43 dust and harbor bacteria or mould. It is also not washable, and it crumbles when handled. However, the greatest danger with acoustical ceiling tile occurs when the tile gets wet, which allows mold or bacteria to thrive. Hence, the acoustical ceiling tile should be immediately replaced if they get wet. (Jeyaretnam, Jones and Phillips, 2000) It is therefore advisable to install a hard ceiling that is smooth and washable in operating rooms (Portner and Johnson 2010) Introduction of nature and decorative features. Providing healthcare staff with access to nature by providing indoor and outdoor gardens, views of nature through windows, and artwork of nature scenes can relieve stress. Buildings with natural characteris tics and visual features, including daylight, nature views and indoor plants, are more highly preferred by occupants ( Schweitzer et al., 2004 ). Indoor plants have also been shown to increase work efficiency and attentiveness as well as decreasing perceived stress, and lowering blood pressure. Design that encourages positive interactions among staff, such as gardens and lounges, could also promote greater job satisfaction ( Schweitzer et al., 2004 ). In a study conducted by Mroczek et al. (2005), the staff was impacted positively by the various design features, which included views of nature, and artwork. According to Moser (2010), the view has to be of a substance like a tree, a park, a garden, or some form of nature. I f it is not possible to provide veterina ry staff members with lush views, attempts should be made to bring the outside in by adding skylights in bird room or aquariums and to bring greenery indoors for the staff to enjoy. If an elaborate garden is not possible due to space constraints, a small Z en garden with
44 decorative rocks and a few strategically placed plants in a small walled in alcove can achieve the same effect (2010). Privacy consideration. Privacy can be defined as the regulation of interaction between the self and others and/ or environ mental stimuli (Kupritz, 1998). Privacy identity by creating personal boundaries. Visual and acoustical barriers may accommodate privacy by allowing an individual to main tain psychological boundaries. inside the workplace without being overheard. Visual privacy can be defined as isolation from unwanted observations. Visual and acoustical re gulation of privacy helps to maintain an optimal level of social contact that people need; dissatisfaction occurs from being in situation that deviate from what a person considers optimal (1998). Environmental control is applied specifically to the physi cal office work workspace. Control of the work environment can have positive effects on worker health and effectiveness. Environmental control was found to contribute directly to workplace satisfaction and performance and indirectly to stress. If an individual can exert control over the physical environment and has the knowledge to increase his/her perception of enclosure and privacy, this suggests that environmental control can mediate the stress experienced by the workers (Huang, 2004). According to Vetich (2011), t he ability to control environmental inputs is an important moderator of environmental stress. When cts of stressors are diminished.
45 In this context it has become a critical concern for interior designers to design spaces that are not only creative, functional, and technically sound but also facilitate the physically strenuous work performed by the vete rinarian and the caregiver staff. Psychological Stressors Good health care cannot be administered without healthcare professionals, but factors such as job stress and burnout can impair both the physical and psychological health of the staff. Caregivers experience stress and burnout because their work is characte rized by low control and high responsibility; a problem that can be aggravated by poorly designed environments (Ulrich, 1991). By knowing the stress factors to which caregivers are susceptible, an interior designer can begin to understand the needs and pre ferences of the caregivers and incorporate these as design considerations. Ulrich (1991) suggests that scientific research can be useful in informing the intuition, sensitivity, and creativity of designers and thereby can help to create psychologically sup portive healthcare environments. Healthcare worker burnout can be defined as a syndrome of physical exhaustion including a negative self concept, negative job attitude, and loss of concern and feeling for patients. According to Piko (2006), burnout is a type of prolonged response to chron ic job related stressors. Burnout affects both the physical and mental health of the caregivers. An emerging trend is escalating where a growing number of animal caregivers, negatively wrought by emotional events at work, fall victim to a condition known a s compassion fatigue. This is defined as the synergistic effect of primary traumatic stress, secondary traumatic stress and burnout. Secondary traumatic stress includes intrusive and avoidance symptoms. Avoidance symptoms are expressed when people begin to numb themselves, withdraw from activity that was previously
46 pleasurable, shut down or face troubled relationships. Such symptoms can lead to greater anxiety and can cause physical ailments (i.e., gastrointestinal or chronic pain, fatigue ). Burnout can cau se fatigue and exhaustion, even depersonalization (Davis, 2003). Burnout and compassion fatigue can be emotionally devastating, resulting in impaired performance that makes the goal of quality patient care almost impossible to accomplish (Keidel, 2002). In order to make appropriate decisions the designers should be informed about how these factors can affect stress levels in the caregivers. Veterinary medicine is recognized as one of the most caring of all professions. It has been proposed that the veterin caregivers in human healthcare (Mitchener and Ogilvie, 2002). Further research suggests that veterinarians are likel y at a great risk to experience this condition as a result of the nature of work, the circumstances at the workplace and the human animal bond, which is considered to be the motivating force for the work done by the caregivers (Mitchener and Ogilvie, 2002) McArthur (2010), states that just like regular healthcare professionals, veterinarians are required to work long and often unpredictable hours. Stress in veterinarians is associated with the ordering of drugs, staff supervision, public relations, profes sional working hours, and heavy responsibilities. While most veterinarians manage these stressors adequately, there is an ongoing problem of suicide, drug addiction, and burnout in the profession (Lessenger, 2006, p. 276). Further, veterinary practice is extremely varied with many different challenges presented to every member of the veterinary healthcare team, often on an hour to hour
47 basis. For example, each day a single caregiver must be prepared to deal with the delights of new puppy visits, as well as the stresses resulting from the emotional concerns of death, euthanasia, and financial capabilities of the pet owner, which may accompany advanced pet care (Mitchener and Ogilvie, 2002,p.308). In addition, as a profession, veterinarians are exposed to dea th frequently. It has been estimated that veterinarians experience patient loss and death five times more than general medical practitioners (Mitchener and Ogilvie, 2002). According to Lee (2009), as a population caregivers exhibit high rates of depression anxiety, and other indices of mental ill health. under 65 years of age, 73% of the veterinarians (71% of women and 77% of men) reported being rather or very stressed. Str ess was reported by two thirds of the veterinarians in the survey. There were differences in work related burnout among the veterinarians based on the sex, age and assigned tasks. Stress was experienced most by women in the age group of 45 54 years, and am ong men in the age group of 25 34 years. Work was perceived as the most significant cause of stress by 65% of the respondents as opposed to family matters by 14%, and the economic situation by 13%. xhaustion was most common among veterinarians working with small animals, equine veterinarians, clinical veterinarians, and private practitioners. The veterinarians reported accidents, serious work related fatigue, and working in cold temperatures as the major hazards in the ir work. Overall, 10% of the veterinarians experienced a significant amount of work related fatigue or exhausti on, and 42% moderate exhaustion ( Reijula et al., 2003).
48 In the study conducted by Piko (2006), it was found that burnout, particularly emotional exhaustion, was strongly related to job dissatisfaction. In a study conducted by Hansez et al., (2008) to measure burnout in Belgian veterinarians, it was found that 15% of the veterinarians reported a very high level of emotional exhaustion. Other studie s showed that veterinarians work for 44 56 hours in an average week (Smeltzer, 2009). Veterinarians were seen to be highly dedicated professionals, who are motivated by work and therefore on call to deal with emergency cases (BLS, 2008). These statistics h ighlight the stress pertinent to the job of a veterinary caregiver. Additionally, it has recently been demonstrated that the veterinary profession in England and Wales has one of the highest incidences of suicide among all occupations (Mellanby et al., 20 10). A similar increase in mortality by suicide has also been reported among veterinarians in several other countries, including the USA, Norway and Australia (Miller and Beaumont 1995). These studies suggest a clear and urgent need for the veterinary prof ession to develop strategies aimed at improving the mental health of veterinarian staff (Mellanby et al., 2010). Occupational Stressors The National Institute for Occupational safety defines occupational stress as the harmful physical and emotional respons es that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker (Choiniere, 2010). According to Ongori and Agolla (2008), occupational stress is a discrepancy between work related demands (stressors) and indi vidual capacities to fulfill these demands. The risk of occupational stressors is higher for veterinary caregivers than for general health practitioners (Nienhaus et al., 2005). The nature of activities undertaken by veterinarians exposes them to many occu pational hazards including risks associated
49 with animals, physical strain, injuries and chemical and biological hazards (Scuffham et al., 2009). Risks associated with animal patients is the main reason they are exposed to numerous unique risks. Studies indicate that veterinary caregivers are often involved in hazardous situations, and that there is a great need to improve the physical environment at their workplace (Reijula et al., 19 92). The number of occupational illnesses and injuries veterinarians suffer is high. According to Jeyaretnam & Jones (2000), apart from a high incidence of musculoskeletal injuries amongst nurses, human hea l th professionals do not have high rates for occup ational injuries due to physical causes. Veterinarians are at risk because they pull, push and lift animals, some of which are very heavy. study (2003), the risk of an accident was considered very high by 54% of the female veterinarians and 66% of the male veterinarians. Further, this study found that about every third veterinarian had endured a work related accident within the previous year (2003). Veterinarians and caregivers are in close contact with animals of different families, gen era, and species. It is quite common for veterinarians to receive bites, scratches, crush injuries, and lower back injuries from these animals. Many of these animals may be large, unwieldy, and uncooperative during examination or treatment; therefore unexp ected hazardous situation may occur when treating the patient or when carrying out a complex procedure (Reijula, 2003). However, the animal causing the accident depends on the size of veterinary practice. Though larger animals may cause great harm, the ris k also exists in small animal facilities (Nienhaus, 2005).
50 A 1988 study on AVMA members in Minnesota and Wisconsin showed than 65% of veterinarians suffered a major animal related injury in last 12 months (Landercasper et al., 1988). A recent survey of ve terinarians from Minnesota and Wisconsin showed that 92.3 % and 81.0% respectively reported being bitten by dogs and cats (Drobatz and Smith, 2003). The study also found that there are from 80 to 115 bit e wounds reported each year, although many bites may g o unreported (Drobatz and Smith, 2003). Other findings further illustrate the hazards associated to veterinary care. According to injury in Australian veterinarian staff, i t was found that 71% veterinarians had suffered work related injuries over the past 10 years. The injuries were related to animal bites, equipment or instruments, lifting of heavy dogs, and chemical and biological exposures. Finally a study conducted by S pringer (2005) to assess the occupational hazards on German veterinarians revealed that bites and scratches were the most frequent injuries caused by animals (48%). Physical strain of the work and the work environment e than 30% of veterinarians work in improper postures creating back strain and injury (2003). In addition, 67% of veterinarians said they need improvements in the physical work environment. Further, the physical load of work, and difficult work posture oft en lead to musculoskeletal problems (Reijula et al., 2003). I ncreasing fatigue results in carelessness, especially in young doctors without substantial on the job safety experience. Mecha nisms of i njury For the most part physical injury resulting from these factors can be put into two categories: animal attack and non attack situations. The injuries that are sustained due
51 to attack by animals include animal kick, animal bite being c rushed by an animal s ustaining a scratch, and other injuries like goring, head butting or being run over. In the past year (2000). The injuries in veterinarians that are not directly rela ted to an animal attack include those sustained by lifting large and heavy animals, those endured while restraining the animals, or by the awkward postures required for performing procedures found that the large an imal practitioner experienced a greater rate of trauma than small animal practitioners total number of injuries reported, 17% were estimated to req uire outside medical the 12 months prior to the study, 35% of the veterinarians had a work related injury (2003). The other types of treatment required for the injur ies were sutures, repair of found that the veterinarians reported accidents, serious work related fatigue, and working in cold temperatures as the major hazards at their work The NIH (2003) guidelines state the specifications for the medical equipment should include a requirement that whenever possible, sharp edges that may cause injury should be avoided. In addition, the location, height, and weight of wall mounted cages should be considered in order to minimize hazards associated with lifting them Chemical and biological h azards Many of the hazards that veterinarians face are obvious while others are difficult to recognize and include physical risk factors such a s communicable diseases, exposure
52 to chemical and biological toxins, carcinogens, ionizing and non ionizing radiation and ergonomic/ human factor hazards, as well as psychological risks, and stress induced disorders. Modern veterinary medicine exposes prof essionals to a variety of chemicals necessary for safe and sanitary practice. Many of these agents can be toxic in the wrong dose (Jeyaretnam & Jones, 2000). The common culprits are disinfectants, analgesics, anesthetic gases, therapeutic agents, hormones and X rays Further, a study by Jeyaretn am, Jones, and Phillips found that exposure to ionizing radiation for veterinarians were potentially high. Exposure to radiation may pass unnoticed due to lack of physical sensation and the delay in the onset of symp toms from damaging effects. In addition, the risk is increased when the radiographic equipment is old, thus potentially causing harmful exposure (2000). contact with irritant chem icals and agents that cause varieties of dermatoses, allergies, allergic respiratory and reproductive problems. Allergens and zoonotic disease (diseases caused by infectious agents that can be transmitted between animals and humans) are a concern. The comm on exposures are allergens like dander, latex and zoonotic infections (Jeyaretnam & Jones, 2000). Zoonotic infections are the infections that can be transmitted from animals to humans. According to Lessenger (2006), many zoonotic diseases in veterinarians are self diagnosed and treated. Nonzoonotic diseases in veterinarians include coccidioidomycosis, a fungal infection affecting the respiratory system, and malaria, a highly tropical bacterial disease. In addition, veterinarians are at risk for infections f rom mishandled biological materials in laboratories. In addition, veterinary caregivers may be exposed to anestheti c gases,
53 pharmaceutical agents and disinfectants which may lead to toxic and chromosomal effects on the caregivers. According to Portner and Johnson (2010), animals that need isolation must be separated from the rest of the population through the use of barrier precautions and/or isolation protocols. This isolates the patient from the veterinary staff, limiting contamination of hands and clothing and the potential spread of pathogens to other patients or hospital areas. Footbaths are commonly used in veterinary isolation protocols. Lastly, veterinarians are also at a risk for infections from mishandled biological mate rials in laboratories. (Lessenger, 2006). Implications of the Literature Designing spaces without concern for end user risks the possibi lity that the space cannot thoroughly serve their needs. In this context, designing functional spaces to ir technical, physiologic al and psychological needs are very important issue s for the desi gner. The interior design y to establish a sense of attachment, belonging and personal control by meeting their needs as comforta bly and efficiently as possible. This theory for human healthcare facilities is also applicable to veterinary hospitals, as it implies that good design for human caregivers may also have favorable implications for the caregivers of the pets, their owners and even for the animal patients (Kopec, 2006). Accordin g to National Council for Interior Design Qualification (NCIDQ), interior design involves the application of creative and technical solutions within a structure to achieve a built interior environment. These solutions are functional, enhance the quality of life and culture of the occupants and are aesthetically attractive D esigners must
54 assume the responsibility of ensuring that the occupants for whom they create environments can maintain optimum health (Kopec, 2006) Incidents of injury and illness often result from the human environment relationship simply be cause the environment is a causa l factor. Both the physical and physiological health of occ upants is affected by the implemented design (Kopec, 2006). The physical environment, occupational health and safety of the users in this case, of veterinary caregivers are important considerations for a good design. The design of the facility should be both functional and workable. It should also be aesthetically ple asing to caregivers since they spend most of their time working in the facility. Simple design considerations such as masking noise, increasing sunlight, and improving the airflow can lead to better and faster healing, higher productivity and more relaxati on for those under stress (Moser, 2010). Design should do more than produce health facilities that are satisfactory in terms of functional efficiency and codes. Hence, a nother important goal of the designer should However, t he amount of research to date on psychologically supportive health design is limited (Ulrich, 1991). As previously mentioned, w hen the caregiver staff experience considerable stress, this can in several ways adversely affect the patient wellness. If health facilities are to be successful in delivering high quality care, it is critically important to attract and retain high quality health personnel. To promote wellness, healthcare facilities should be designed to foster coping with stress and facilitate access or exposure to physical features that have stress reducing influences (Ulrich, 1991).
55 Although links among stress, control, and wellness have been established in many studies, only a small amount of research has directly tested the extent to which specific design strategies in health facilities increase a sense of control and reduce stress (Ulrich, 1991, p.100) An empirical literature search on veterinary care facility design revealed that no detailed research is currently available that focuses on the environmental psychology of t he veterinary caregiver staff. Environmental p sychology assumes that a dyn amic relationship exists between individuals and groups and the environment, in which they live, work, play, learn, recreate and travel. It emphasizes a individuals (Frumkin, 2005) An appropria tely planned and implemented environment is generally recognized as contributing to improved animal and caregiver health (Shepherdson, Mellen, and Hutchins, 1998). The design policies and guidelines manual for veterinary facilities issued by the National I nstitute of Health Design states that the ultimate users of the facility, especially the veterinarians should be consulted during the development of program requirements and their inputs should be incorporated whenever possible (NIH, 2003). According to th ese guidelines the arrangement of critical adjacencies will greatly impact the quality of life of the animals, the caregivers and the veterinarian. In addition, the guidelines also state that that the environment should be efficient, secure, and easy to ma intain and perform animal caretaking services. To date, t here is no industry wide standard, and no general procedure to identify the variabl es that influence the effect of the design, on the veterinary caregiver staff and their daily activities. There are many theories and articles that relate the healthcare staff
56 perceptions to the design of the hospital. However, many of the guidelines for the design of human hospitals are not relevant to veterinary care facilities since the veterinary care facilities tr eat non human patients. Although the volume of research that studies the link between environment characteristics and outcomes is growing, no sound directly relevant research is available for veterinary healthcare. Further, very little is written specifica environment. According to Kopec, healthcare facilities should be designed with both patient populations and the healthcare staff members in mind because staff discord and negative at titude ca n often transfer to the patients Also, play a significant role in dictating the design considerations of the facility since a good is the focus of veterinary practice. Hence, it is evident that further research is required to with the design of veterinary care facilities. Summary of Literature Re view The purpose of the literature review was to discuss literature that is available on the various stressors affecting workers in a general workplace; healthcare and veterinary care facility. The review also examined complementary environmental behavior concepts that may bear u pon the issue at the core of this study. A well supported staff is integral to the functioning of any health care facility. There is mounting evidence that the physical work environment affects job performance, job satisfaction, employee injuries, behaviors, communication patterns, fatigue, error rates, and ph ysical and psychological stress (Applebaum, Flowler, and Fiedler, 2010). By
57 having a greater understanding of how the physical environment of the health care facili ty affects the their environment as well as how the environment may be affecting multiple levels of outcomes, designers can begin to translate research into practice and have a greater understanding of how research can be used to optimi ze the overall health care experience for everyone (Mroczek, Mikitar ian, Vieira, and Rotarius, 2005 ). The literature revealed that although a substantial amount of research is available on the stressors affecting the work environment of human caregiver fa cilities, there is no substantial research that focuses on the stressors affecting the physical environment of veterinary facilities and its caregivers. However, studies by Reiula et al. (2003) and Jeyaretn am, Jones, and Phillips (2000) are a positive step in the direction of establishing a body of literature on veterinary caregiver stress issues. Previous research specifically emphasized the absence of literature available on the stressors affecting the veterinary caregiver population. The literature r eview was necessary to highlight content and gaps in the available literature and served as a framework in establishing the need for the current study on the effect of the design considerations on the stress and satisfaction levels of the veterinary caregi ver staff.
58 CHAPTER 3 METHODOLOGY An extensive literature review of the design principles and guidelines for veterinary care facilities and their impact on the caregiver staff revealed that although the volume of research that examines the link between environmental characteristics and hea lth outcomes is growing, no sound evidence is yet available for the design of small animal facilities. Rather, the needs of such caregivers have been largely disregarded and little priority has been given to the effects of the physical environment on their stress and satisfaction levels. As indicated, the objective of this research is to put a lens on the physical environment variables and examine their perceived impact on the stress and satisfaction of the small animal veterinary care facility staff. This is accomplished through a case study of a facility considered within veterinary circles as being optimally designed; suggesting the premise for the study that such design discourages additional stress on already burdened caregivers. Case Study Research S t rategy A case study is an in depth investigation of a single instance, and represents a holistic approach to research (Sommer and Sommer, 2002). It can be defined as an in depth, multifaceted investigation, using qualitative research methods, of a single phenomenon (Feagin et al, 1991). Further, the rationale for a single case study is that it is a representative or typical case and the objective is to capture the circumstances of a commonplace situation. A case study is well suited for researching the iss ue under investigation given its ability to deal with a full variety of evidence -documents, interviews, and observations (Yin, 2009, p. 11) -in this case, direct observation of behaviors and interviews with persons involved in them. On the matter of the v alidity of
59 observations, however, the case study provides a clear advantage over other methods of investigation. Although a case study often relies on judgment exercised by the observer, the great strength of this form of research is that it does permit th e observer to assemble complementary and overlapping measures of the same phenomena which may corrobor ate the observations. Correspondence, newspaper reports, and even personal interviews with participants may be used and are used in this study to cross check and thereby validate observations as well as claims based on those observations (Feagin et al, 1991, p.19). Case Selection In consideration of selecting the facility for the research a convenience sample was generated based on the facilities that we re located within a 10 mile radius from the University of Florida campus. Eight potentially suitable facilities in the area were identified, explored and visited by the researcher to determine the viability of one facility for use toward the proposed resea rch. After exploring possible options, by comparing the focus of practice, accreditation, design merits, and services offered, the list was narrowed down to six small animal veterinary care facilities, the key features of which are illustrated in Table 3 1 Ultimately, Facility 6 was selected for the research setting on the basis that it had been purposely designed to serve as a small animal veterinary care facility, and it stood out among the others due to the numerous design awards it had won. In additio n, out of the sample, Facility 6 was the only one fully accredited by the American Animal Hospital Association (AAHA). This particular facility was ultimately chosen to test how an award winning design might respond to concerns about caregiver stress and s atisfaction levels in a veterinary setting. Other factors that contributed to the selection of the facility were
60 convenient location, size, type of practice, and wide range of technologically advanced services provided to small animals. Table 3 1. Descript ion of the facilities Facility Type of care A ccreditation and awards Services offered Facility 1 Offers canine and feline care Not an accredited AAHA member No recognized design merits Offers routine medical examination, surgical, grooming, boarding, chiropractic, acupuncture, therapeutic, ultrasound and cold laser treatment. Facility 2 Offers canine and feline care Not an accredited AAHA member No recognized design merits Offers routine medical examination, dental, grooming, boarding, and emergency case treatment. Facility 3 Offers canine and feline care Not an accredited AAHA member No recognized design merits Offers routine medical examination, vaccination, dentistry, spay and neutering, general surgery, radiology, pharmacy and laboratory services Facility 4 Offers canine and feline care Not an accredited AAHA member No recognized design merits Offers health maintenance, internal medicine, dentistry, diagnostic imaging, surgery, laser therapy, pharmacy, grooming, laboratory testing, and bo arding services. Facility 5 Offers canine and feline care Not an accredited AAHA member No recognized design merits Provides holistic veterinary care including acupuncture, traditional Chinese medical exams, and herbal medicines. Facility 6 Offers canine feline, avian, ferrets, pocket pet, rabbits, and exotic pet care Fully accredited AAHA member Awarded third party recognition of design merits Full service wellness practice and diagnostic and surgery clinic and offers a wide range of services including annual wellness programs, advanced and routine surgical and dental procedures, cardiology, alternative medicine and nutraceutical therapies, ultrasound and endoscopic procedures and diagnostic, in house laboratory and boarding.
61 As indicated, the study set out to answer the question: H ow, if at all, do design considerations impact the stress and satisfaction levels of the veterinary caregivers in a small animal veterinary care facility ? T he researcher is guided by a desire to know if given the accolades rec the design of the clinic contribute s to ameliorate the caregiver stress, which the literature suggests is commonplace in veterinary care settings and if so, what are the lessons that can be learned from this design, w hich c an then be recommended at large. Case study selection entailed a subsequent step; a pre study on the research setting identified as most desirable for the study, aimed to determine its viability for the purpose of the study. The pre study was conduc ted in the Fall of 2010 and involved a tour of the potential facility and an informal interview with the then director of the facility. The methodology for this phase of the research comprised review of literature related to the facility; observations; exa pre study co nfirmed the viability of the site and the enthusiasm of the staff members towards the study. Research Setting The study setting is an award winning small animal veterinary care facility in North Central Florida that is a fully accredited AAHA member. AAHA is the only organization that accredits veterinary practices in North America. Veterinary practices that receive accreditation are evaluated on stringent quality standards that encompass all aspects of pet care. This is a voluntary membership the goal of which is to uphold a substantially higher standard of medical care and facility resources than most states minimally
62 require. (Becoming accredited by the American Animal Hospital Association, 2012). The study facility functions as a full service, state of the art veterinary medical diagnostic, hospital surgery, radiology, clinical pathol ogy, dispensary, ward accommodation, and provision for 24 hour patient surveillance but also provides specialty services and advanced capabilities. (Goldman, personal interview, 18 th Oct, 2010). The practice was founded in 1977 and the construction of the building was completed in 1991. The facility is 494 square meters (5317 square feet) and the site includes 270 square meters (2906 square feet) as expansion space for a future wing, which has not been used to date (Goldman, personal interview, 18 th Oct, 20 10). The building is situated in an expanding complex of retail businesses, professional offices, banks, and a regional library, which is surrounded by single family residential neighborhoods. During the construction, excavation spared the trees on the sit e, especially an existing towering live oak, so that the trees would not only serve as a noise buffer for neighbors, but also as a forested walk area for boarded dogs. Research Participants The main participants of the study consisted of the veterinary doc tors, technicians, and the administrative staff of the veterinary care facility. This group of participants represents the legitimate users of the veterinary care facility and thus constitutes a purposive sample, defined as one that targets the individuals thought to be most central to the research question (Sommer and Sommer, 2002).
63 Table 3 2. Demographics of the participants Characteristics Total (N=14) n Percentage % A) Professional group Veterinary doctor Technician Administrative staff Other 5 7 2 0 35 50 15 0 B) Gender Male Female 6 8 47 53 C) Age category Less than 25 years 25 35 years 36 45 years 46 55 years 56 65 years 1 6 2 2 3 7 43 14 14 22 D) Professional experience Less than 1 year 1 < 3 years 3 < 5 years 5 < 7 years 7 <10 years More than 10 years 0 0 1 4 8 1 0 0 7 29 57 7 E) Workload per week Less than 20 hours Between 20 40 hours Between 40 60 hours More than 60 hours 1 9 4 0 7 65 29 0 At the time the study was conducted, the facility had 14 caregivers, all of whom agreed to participate in the research and hence the research sample consisted of fourteen participants. The participants ranged in age from 18 years to under 65 years. Of all the participants, six were male and eight were female. F urther, 35% of the participants consisted of veterinary doctors, 50% were technicians and 15% were experience fell in the 5 10 years range. The demographics of the p articipants are illustrated in Table 3 2.
64 Research Instruments The main data collection strategy for the study consisted of personal interviews with the participants. The interview questions were based on the theories and findings from the literature on th e various stressors that affect human healthcare and veterinary caregiver staff. The interview questions were carefully reviewed to detect any ambiguities and uncertainties. The interview questions were based on work environment on stress levels in Finnish veterinarians. The literature reveals that the stressors affecting the veterinary caregivers can be classified into environmental (ambient), occupational and psycholog ical stressors. Ambient stressors are background conditions, passing largely unnoticed unless they interfere with some important goal or directly threaten health (Evans and Cohen, 1987). A conceptual framework developed by Rashid and Zimring (2008), groups the physical environment variables into two categories: indoor environmental variables and interior design variables. Indoor environmental variables include noise, lighting, and indoor air quality (ambie nt temperature and air quality), whereas interior de sign variables include ergonomics and layout in turn constituted by use of space, furniture, fixtures and equipment, finishing materials, color, artwork, and natural views. Compared to other occupations, a with their animal patients is the main reason they are exposed to these unique risks (Reijula et al., 2003) In many cases, the physical environment may trigger processes leading to stress by the ways in which it af fects individual and/or workplace needs. Further, the physical
65 (Rashid and Zimring, 2008) According to Turnipseed (1998), burnout is a result of chronic stress. After p otentially stressful stimuli have been perceived, an individual may respond with anxiety, contributing to the development of burnout and exhaustion. Based on these factors, a theoretical framework of stressors emerged to gauge the effect of the physical e nvironment of the veterinary care facility on the veterinary 1). Figure 3 1. Veterinary caregiver stressor framework. This framework was captured in t he interview questionnaire ( Appendix A). The interv iew format entailed unstructured in depth interviews with both closed and open ended questions. In an unstructured interview the main goals are to explore all the alternatives in order to pick up information, to define areas of importance, and to allow the respondent to take the lead to a great extent (Sommer and Sommer, 2002, p. 114). STRESSORS ENVIRONMENTAL NOISE LIGHTING INDOOR AIR QUALITY ERGONOMICS & LAYOUT OCCUPATIONAL INJURY RISKS/ HAZARDS PSYCHOLOGICAL BURNOUT/ EXHAUSTION/ FATIGUE
66 An advantage of in depth interviews is that the researcher can ask key respondents about the facts of a matter as well as their opinions. In addition, using this method assu res complete freedom in the terms of the wording that can be used and the way questions are explained to the respondents (Kumar, 2005). According to McArthur (2010), open ended questions are a powerful tool to use in a consultation. They are characterized by que stioning which opens a line of i nquiry and permits full elaboration of content. This is in contrast to closed ended questioning which can shape a response and typically derives a single word answer to a specific question (2010) The interviews were conducted from August to October in 2011. The interview questionnaire entailed a series of 35 questions that were divided into the following six sections: Introduction. The participants were given a brief personal introduction by the researcher that briefed them about the purpose of the research and the findings of the stress and satisfaction. In addition, the participants were referred to the Inform ed Consent Forms. This section also included two open ended questions related to the stress experienced by the veterinary caregivers in their workplace environment. Demographics. The participants of the study were asked to classify themselves into three ca tegories based on their professional group. The demographic questions also included the following items: (1) gender, (2) age category, (3) professional/ vocational experience, (4) workload per week, (5) area/s of the veterinary care facility they worked. Environmental s tressors. This section was further divided into four sub sections on the basis of the effects of the various environmental stressors -noise, lighting, indoor
67 air quality, and ergonomics and layout -on the stress and satisfaction levels of t he veterinary caregivers. This section consisted of twelve closed and four open ended point Likert scale, with values ranging from either 1= extremely stressful to 5= not stressful; 1 = all the time/ continually to 5= never; or 1= very unsatisfied to 5= very satisfied, depending on the nature of the questions. Occupational s tressors. This section was divided into two sub sections on the effects of the various occupational stressors inc luding injury and risks/hazards on the stress and satisfaction levels of the veterinary caregivers. This section comprised four closed and two open ended questions. Psychological s tressors. This section consisted of two closed ended questions on burnout/ exhaustion/ fatigue experienced by the veterinary caregivers. The questions were based on the literature review that related the caregiver stress and burnout to poorly designed environments ( Rashid and Zimring, 2008) Miscellaneous. This section comprised o ne closed and two open ended questions to ascertain veterinary caregiver preferences related to their current workplace features. It also included a question eliciting their recommendations for the design choices/ strategies they would want included if the facility were renovated. Research Procedure Prior to contacting the participants for the study, the researcher applied for and Instit utional Review Board (IRB) ( Appendix B). As per protocol, the research was bound to Informed Consent Forms that explained the purpose of the study and regulations ( Appendix C). After IRB authorization was granted, an email was sent in July 2011 to
68 the new director of the facility, as the vete rinary care practice and facility had recently been sold. As a result, an informal meeting with the new, now current, director was scheduled. researcher enlightened him w ith the purpose and requirements of the research. The current director had recently taken charge of the facility and was equally willing to assist in the requirements of the research. He invited the researcher to visit the facility as per convenience and i nterview the caregiver staff members who were scheduled to work during those days and available for the personal interviews. The director briefed the caregiver staff members about the research, prior to the researcher meeting them for personal interviews. The director also verbally granted the researcher permission to observe and photograph of all areas of the veterinary care facility. This allowed the intended research procedure, comprised of personal interviews with the participants (veterinary caregiver behavior of the participants, to be carried out. Persona l Interviews with Participants The interviews with the participants were completed in two phases. The first phase was from July to the end of August 2011. During this time, the researcher made several visits to the veterinary care facility and spent approximately 60 hours over 15 days in the facility. Alternate participants were available on different days of the week and hence the interviews were conducted when each one of them had free time in between work duties. The researcher commenced each interview with a personal introduction and a brief discussion about the purpose of the research. During the interview, the researcher handed out a copy of the interv iew questions for their reference.
69 Participants were asked to read, sign, and date the Informed Consent Forms that explained the purpose of the study and regulations. They were therefore informed of their right to decline answering any questions that they did not wish to answer; that participation in the study was strictly voluntary; and that there were no foreseeable risks or benefits associated with participating in the study. Participants were also asked if they preferred remaining anonymous for the purp ose of the study. Each interview session lasted approximately between 30 to 45 minutes and was conducted in various areas throughout the veterinary care facility. A remaining set of interviews (n=5) that were not able to be conducted in person during any o f these periods were completed by (1) circulating copies of the interview questions to the remaining participants through the technical floor manager, assigned by the director and (2) e mailing a copy of the interview questions. The interviews were then di rectly sent to the researcher via courier by the technical floor manager. Observations The researcher visited the veterinary care facility several times during weekdays and spent an average of three to five hours during each visit. The researcher spent th e time in between interviews making observations and analyzing the design of the veterinary care facility. To evaluate the behaviors of the participants and observe the ongoing activities throughout the facility, the researcher visited the facility at diff erent times during the day and took notes. In addition, the researcher took several photographs of different areas of the interior and exterior spaces of the facility. Finally, after the interviews and observations were completed and transcribed, an email was sent to the director of the facility. An informal meeting with the director was scheduled and he was presented with a summary of the interview findings. The director
70 was offered to include his reactions or feedback, and voice any concerns that he migh t have had with the findings of the study. Methods of Analysis The data collection from the research procedure was analyzed in three steps. First the qualitative (descriptive) data from the personal interviews with the participants was analyzed. The small size of the sample was considered unsuitable for quantitative analysis beyond simple descriptive statistics. Instead, the nature of the data generated from interview transcripts lent itself to content analyses. To this end, the actual quotes from the inte rviews were transcribed into tables where they were classified as ascribed cause and effect; and (3) recommendations or suggested solutions to the perceived issues. Second, the observations made by the researcher were captured in a second table. The data from the observations was transcribed and classified into (1) perceived stressors, (2) perceived issues and (3) behavioral observations. Third, the quantitative data from the respondents was coded manually to generate descriptive statistics. This involved the distribution of responses for the different environmental stressors mentioned in the responses of the participants. This data was pre sented in pie charts portraying the distribution of responses for a single stressor, which facilitated visualizing the most significant stressors that affected the respondents. Graphs were created to show satisfaction levels with the different stressors af fecting the work of the respondents. The graphs also revealed the intensity and the frequency of stress caused by a specific stressor. A final step in the analysis consisted in comparing the two sets of data to establish concordance between the two, eventu ally triangulating the data.
71 Limitations The study acknowledges several limitations. First, despite the small sample size of the veterinary caregiver staff and the corresponding limitation for generating quantifiable data, interviews with key participants uncovered rich in depth qualitative data that added setting, the findings may not represent all veterinary care facilities. Though this limitation is inherent to all case studies, according to Yin (2009), case studies are generalizable to theoretical propositions, such as, in this case, identifying the factors underlying veterinary caregiver satisfaction with their work environment. Since the case study seeks to capt ure people as they experience their natural, everyday circumstances, it can offer a researcher empirical and theoretical gain in understanding larger social complexes of people, actions, and motives (Feagin et al, 1991). Single case study designs therefore require careful investigation of the potential case to minimize the chances of misrepresentation and to maximize the access needed to collect the case study evidence (Yin, 2009). As attempted in this study, reliability in the findings can be obtained thro ugh cross (Sommer and Sommer, 2002) to identify congruent information. Second, the data collection was largely dependent on interviews with the veterinary caregiver staff of the facility. The disadvantage of using i nterviews is that the quality of interaction between an interviewer and interviewee is likely to affect the quality of the information obtained (Kumar, 2005). Further, there is a possibility that the researcher may introduce his/her personal bias in the in terpretation of the responses. This can be bypassed by avoiding asking ambiguous or leading questions or by
72 avoiding asking questions that are based on presumptions (Kumar, 2005). Using a five point Likert scale in a majority of the interview questions red uced these possibilities. Another limitation is that six of the interviews (43% of all interviews) were not directly conducted by the researcher, but rather completed individually by the respondents. In this case, the respondents issued answers without th e benefit of the researcher present to provide assistance and/ or instructions. Hence there was a possibility that the participants may have misinterpreted the questions leading to inaccurate or biased answers. Conversely, there is also a possibility that the researcher may have misinterpreted the responses of the participants. However, according to Feagin et al (1991), the close reading of a case study data by one or two researchers has a major advantage in that there is one central place through which th e data are filtered. There is a distinct advantage to having all the information -all the contacts and interviews -in a study to go through one or two researchers. In this manner, the interpretation of the data can take on a holistic character. Summary of Research Methodology study was conducted to identify a viable case study setting. The data and literature review it entailed provided a foundation for drafting interview questions for the case study. All the required IRB protocols were followed prior to the interview with the research participants. The study was divided into four parts (1) pre study of the facility, (2) ns of the physical environment of the facility and (4) content analysis and comparison of the data. The following chapter provides information on the results of the analysis.
73 CHAPTER 4 FINDINGS This chapter presents the results of the case study. The chapter begins with a discussion of the observational data collected by the researcher during a pre study of the facility and throug hout the course of the research. The second part of the chapter analyses the data derived from personal interview s wit h the research participants and the stakeholders of the facility. A final step leading to findings involves triangulation of the data. Observation Findings Existing Conditions: Ambient The existing conditions in the facility are described in relation to potential environmental (ambient) stressors as suggested by the literature (Applebaum, Fowler and Fiedler, 2010; Edward and Torcellini, 2000; Hunag, 2004; Kopec, 2006; Moser, 2010; Portner and Johnson, 2010; Rashid and Zimring, 2008; Redich,1997; Reiju la et al., 2003; Schweitzer et al., 2004; Springer, 2007; Topf, 2000 and Ulrich, 2000)These include ergonomics and layout, noise, indoor air quality (IAQ), and lighting Ergonomics and Layout Spatial relationship The facility is divided into five zones: pu blic, examination, t reatment, animal housing and administrative areas. The pub lic zone includes the reception as well as waiting and the retail area s As illustrated in Figures 4 1 and 4 2, t he retail area is located ne hat the clients have to pass by it after leaving the examination rooms or pick ing up their pets. The examination rooms are centrally located in a manner that they are accessible from the public areas and the laboratory by adjacent hallways that run paralle l to them.
74 Figure 4 1. Floor plan of the veterinary facility. N ot to scale ; drawn by the author based on image from Veterinary Economics, May 1993 It was observed that the treatment area is organized so that it does not have any visual access from the public areas, examination rooms and the laboratory. The administrativ e offices form the private zone and are connected to the public and treatment areas by hallways. The animal housing, which includes the kennel as well as the feline and avian wards, is located at the northwest corner (rear end) of the facility, adjacent to the treatment area ( Figure 4 1).
75 Figure 4 reception area Photograph taken by Anuprita Arun Salkar Pri vacy consideration/ Personal space The facility is divided into public, semi private, and private areas. The reception, waiting, and the retail area constitute the public areas while the examination rooms constitute the semi private areas. The private are as in the clinic are the laboratory, the treatment areas, the animal housing, and the administrative areas. is the only space that has an attached restroom. The only other restroom is located adjacent to the waiting area and was share d by the clients and staff members. It was observed that the facilit y lacks designated staff areas and/or break rooms. There is no pantry/ dining area and the staff was seen having their lunch on the examination table in the treatment area
76 Visual access It was observed that except for the public areas, most areas in the facility were not visually accessible to the clients. The treatment ar eas and the animal housing are organized in a manner that limit s visual access from the reception and waiting area la boratory and administrative areas In contrast, the researcher was able to observe that th e window in the surgery area is transparent and opens to the front faade of the building potentially enabling views from the passerby Activity requirements An overall spaciousness characterizes the clinic. The most striking feature that is noticed when entering the facility are the ample dimensions of the reception and waiting area, and t he high vaulted ceiling which adds to the sense of amplitude The number of technicians who work in the facility is higher than the number of doctors and the administrative staff. However, the laboratory area provided to the technicians does not reflect this proportion. The observer noticed that the technician staff lacks dedicated space for workstations; rather technicians were seen standing to work at the computers in the laboratory. The current laboratory has a linear layout and is tightly packed with furniture and e quipment with little or no space for adding addi tional furniture or for expansion. As illustrated in Figure 4 3a, t he grooming area in the facility features a morgue freezer, worn out tubs and paint peeling off the walls. This area appears to not have been given the same consideration as the areas that are open to the public. Further the room appears to lack sufficient storage as evidenced by the presence of makeshift cabinets Adjacent to this room is the kennel, which includes 21 indoor runs.
77 a b Figure 4 3 Grooming area and the kennel. L ayout of the grooming area (a). Washer and the dryer machine located adjacent to the runs in the kennel area (b) Photographs taken by Anuprita Arun Salkar The kennel area includes washer and dryer machines which make a lot of noise during operation ( Figure 4 3b) This noise combined with the constant barking of the dogs creates elevated sound levels resulting in the kennel being an extremely noisy place. In addition the kennel area lacks proper storage cabinets as evidenced by the presence of makeshift cabi nets The observer noticed that the facility does not have a n external run/ fenced in area for the boarded dogs as might be desirable to provide for their physical activity and for relieving themselves. Materials and finishes The materials used througho ut the clinic appear to have been chosen on two criteria, either to facilitate functional sanitation or to create a home like appearance. The exterior fac ade of the facility is made of bricks with arched and residential windows ( Figure 4 4) An arch is pla ced over the main entry. Extensive landscaping surrounds the facility It is observed that the reception and waiting area, examination rooms, treatment areas, and the animal housing are designed to be impervious to water and other liquids. This contrasts w ith the administrative areas, which are more luxurious irrespective of their waterproofing qualities.
78 Figure 4 4. Exterior faade of the facility. Photograph taken by Anuprita Arun Salkar For example, t he walls in the reception area and the laboratory are textured with semi gloss white paint. The flooring in the reception area and examination rooms is made of durable non slip tiles that are easily cleanable. The flooring in the laboratory is coved sheet rubber flooring that is an eco friendly and easily maintained material. As illustrated in Figure 4 5, t he walls in the treatment area and the kennel are made of exposed concrete block. The cells in the blocks are filled with vermiculite and extend to the roof deck to eliminate sound leakage. The flooring in the treatment area separated from the public areas by lightweight, insulated swinging doors with gaskets around all of the edges.
79 Figure 4 5. Treatment area. Ph otograph taken by Anuprita Arun Salkar The kennel area has epoxy flooring, which has a seamless and impervious membrane. The indoor runs in the kennel are made of stainless steel. The ceil ing is made of acoustical tiles. The walls in the imaging department and the surgery area are textured with semi gloss white paint and the flooring consists of coved sheet rubber flooring. The ceiling in the surgery area is made of cleanable modular acoustical tiles while the imaging area has a flat ceiling w ith semi gloss white paint The walls in the grooming area are exposed concrete block. The flooring consists of tiles that a re marked with anti slip strips.
80 As illustrated in Figure 4 6a, t he floorin carpet. The ceiling in the administrative areas is made of acoustical tiles a b Figure 4 6. office and the reception area Layout of the a ssistant doctor (a) Leash hooks under the counter and artificial vines above the reception desk (b) Photograph s taken by Anuprita Arun Salkar Color and texture The researcher was able to observe that m ost areas in the facility maintain a neutral color palette with semi gloss white paint and neutral color storage cabinets. White surfaces are emphasized in s ome areas like the laboratory with white walls and white cabinets. Additionally, t he five examination rooms have cream colored walls, with each room having a unique identifying cream color Other areas featuring a hint of color include the wall behind the reception desk which is painted with a shade of pastel blue ( Figure 4 6b) Furni shings and decorative features The furniture in the reception area includes chairs, a wooden center table and an end table. There is a coffee table for the clients at one corner of the waiting area. As illustrated in Figure 4 6b, t he front of the large re ception desk is lined with tiles for sanitary purposes and has leash hooks under the counter in order to give the clients a free hand while attending to paperwork.
81 a b c Figure 4 7. Examples of decorative features and personalization ( a,b, c) Photograph s taken by Anuprita Arun Salkar As illustrated in Figure 4 7, t he wall on one side of the reception lobby allows for personalization and is lined with pictures of the caregivers and their pets and lost and found pets The laboratory has neutral color storage cabinets that have a built in counter top with sink. Furniture is also lined up against one side of the linear wall,
82 making the space appear a little congested. The furniture in the treatment area includes neutral c olored storage cabinets, laminated counter top with a deep sink, a refrigerator, stainless steel examination tables and surgical machinery. The Intensive care unit ( ICU ) consists of 8 stainless steel cages that are lined in two tiers. The furniture in the desks with chairs, filing cabinets, neutral colored st orage cabinets, a refrigerator soft board s and few whiteboards. a b Figure 4 8 and the retail area. Furniture in the medical (a) Retail area, convex mirror seen above rear shelves (b) Photographs taken by Anuprita Arun Salkar As shown in Figure 4 8a, t he furniture in the di des k and storage cabinets, a chair and a small couch The blinds covering the window are dark brown and comple ment the wooden furniture. The furniture in the assistant chairs, a large wooden bookshelf, storage and other office equipments. As illustrated in Figure 4 8b, c onvex mirrors are placed at strategi c locations in the public areas, presumably to increase the of sight and avoid collisions. Safety requir ements Overall, most areas in the facility appear to follow the safety recommendations for veterinary facilities. However, t he observer noticed that the ICU in
83 the treatmen t area i s an open, rather than sealed area ( Figure 4 9) In addition there is a se rvice entry door in the treatment area. The technician work area is located right adjacent to the treatment area. This area is not screened from the treatment area in any manner Figure 4 9. Intensive Care Unit (ICU) in the treatment area. Photograph ta ken by Anuprita Arun Salkar The observer also noticed that due to the lack of a formal dining area, many staff members had their lunch on the operating tables in the treatment area. The original plan of the hospital shows a staff lounge adjacent to the wo rk area. However, this particular area currently functions as a multi purpose area (mostly storage) and lacks comfortable seating/ dining table for the staff members
84 Noise The one thing that is hard to miss upon entering the reception/ waiting area is the constant barking of the dogs. It was obs erved that the barking noise might get extremely loud and stressful at times. In this case, a lthough the kennel is located at the rear end of the facility, the noise generated travels to the other areas. The barking noise appears loudest in the treatment, reception/ waiting area and the faintest in the administrative Figure 4 10. Examination room, the laboratory and the adjacent corridors separated by doors Photograph taken by Anuprita Arun Salkar It was observed that there are open channels for sound to travel between the examina tion rooms, the laboratory and the adjacent corridors running parallel to them
85 Figure 4 10 illustrates the a bsence of barriers in between these areas to prevent noise migration. Figure 4 11. Imaging department. Photograph taken by Anuprita Arun Salkar The re are areas purposefully built with strategies to address noise, including dropped ceiling conditions with acoustical tiles Areas that include the se strategies are the examination rooms, treatment area, the grooming area, the administrative offices, However, as illustrated in Figure 4 11, the ceiling of the imaging departme nt, as well as the vaulted ceiling in the reception and the laboratory areas are painted with semi gloss paint which is not considered a noise containing finish.
86 The researcher was able to observe that the background or white noise in the reception and wa iting area constitutes of noise from the television set, communication devices which include phones and intercom, and other office equipment sounds In addition the sound system plays ambient music that can get extremely loud at times, especially during the aftern oon when there are fewer clients. Indoor Air Quality Figure 4 12. Public areas mounted with ceiling fans to assist ventilation. Photograph taken by Anuprita Arun Salkar The indoor air environment in most areas of the facility can be described as being well ventilated, energy efficient, sterile and odorless. The majority of the windows in the facility are non operable and the facility is centrally air conditioned with automated thermostats. The observer had the impression that almost all the sp aces in the facility
87 were sterilized and odor free. The only area that had a problem of odor was the dog kennel. Additionally, strong disinfectant smell was apparent in the ICU. However, it was apparent to the observer that t he examination rooms felt a little warmer compared to the other areas of the facility In contrast, the reception area felt extremely cold compared to most areas of the facility The public areas like the reception and waiting areas are provided with ceiling mounted fans to assist ventilation ( Figure 4 12) Lighting Figure 4 13. Transparent windows provide natural lighting to reception and waiting area Photograph taken by Anuprita Arun Salkar The facility relies extensively on daylight for illumination purposes. Artificial lighting is used to provide higher illumination levels, as demanded by specific task areas. It is
8 8 also used as accent lighting for decorative purposes. The reception, waiting and the retail service area ha ve transparent windows that allow natural sunlight to enter the interior spaces ( Figure 4 13) Nonetheless, t he reception area is artificially lit from a combination of fluorescent fixtures with translucent plastic panels and rec essed incandescent lighting Additionally, a ccent lighting highlights the walls and the artwork in the rec eption lobby and retail areas, whereas r ecessed fluorescent lighting highlights the perimeter of the high ceiling in the reception lobby. Figure 4 14. Technician work area and pantry Photograph taken by Anuprita Arun Salkar The hallways connecting the lobby to administrative areas and treatment areas are devoid of windows and are illuminated using recessed fluorescent lighting Additionally,
89 the re searcher was able to observe that a ll the five examination rooms have no windows ( Figure 4 15a). These areas compensate lack of natural illumination by having a dropped ceiling with recessed fluorescent lighting with translucent plastic panels and the use of accent lighting to highlight artwork on the sidewalls. Other areas lik e the feline and avian wards, the technician work area the storage areas do not have windows. However, as illustrated in Figure 4 14, the technician work area and pantry receives natu ral light through a translucent service entry door. a b Figure 4 15 Examination room and laboratory. Examination room devoid of windows and illuminated by artificial lighting (a). Laboratory with vaulted celing and surface mounted fluorescent ligh t fixtures (b) Photographs taken by Anuprita Arun Salkar As illustrated in Figure 4 15b, n atural lighting is provided to the laboratory by a window on one side of the wall. The laboratory has a vaulted ceiling with surface mounted fluorescent lighting fi xtures. The treatment area and the ICU also have a dropped ceiling with recessed fluorescent lighting. The treatment area has a window that provides natural lighting.
90 a b Figure 4 16 Surgery room and kennel. Surgery room illuminated using natural and artificial lighting (a) Kennel receiving diffused natural light from smoked glass bricks and artificial illumination from the recessed fluorescent fixtures (b) Photographs taken by Anuprita Arun Salkar As illustrated in Figure 4 16a, a transparent windo w in the surgery room provides general illumination through natural day lighting. High efficiency surface mounted fluorescent fixtures provide task lighting The imaging area, as a functional requirement is devoid of windows and is illuminated by surface mo unted fluorescent lighting. The grooming area also does not have any windows and is illuminated using recessed fluorescent lighting. The administrative areas include the director s and the assistant d They have transparent windows that take advantage of the natural lighting. Recessed fluorescent lights with translucent plastic panels provide task lighting. The technical staff area is located adjacent to a transparent service entry door that provides natural lighting. The task lighting consis ts of recessed fluorescent fixtures. As illustrated in Figure 4 16b, t he kennel receives diffused natural light from smoked glass block windows that are located along the length of the exterior wall at a higher level. The task lighting in the kennel is rec essed fluorescent lighting. The storage areas, feline ward,
91 non operative avian ward and the isolation area are devoid of windows and completely depend on illumination provided by recessed fluorescent fixtures. Personal Interview Findings Facility Staff Fi ndings from the personal interviews with the research participants indicate a strong relationship is perceived between the physical environment and the stress and satisfaction levels of the veterinary caregivers. Contributing factors were identified as eit her environmental (i.e. related to the physical environment characteristics and features) or occupational (related to the activities conducted therein). Specifically, environmental stressors demonstrated having a profound effect on evels. As illustrated in Figure 4 17 below, 14 participants generated a total of 67 occurrences related to environmental stress. These comprised references to noise, indoor air quality, lighting, and ergonomics and layout. Figure 4 17. Distribution of responses for environmental stressors 47% 22% 9% 22% Distribution of responses for environmental stressors, n=67 Noise Indoor Air Quality Lighting Ergonomics and Layout
92 Noise As illustrated in Figure 4 17, 31 occurrences (47%) identified noise as an environmental stressor within the facility. Of these, as shown in Figure 4 18, 13 (42%) d noise related stress to the facility conditions that facilitated noise migration. One respondent claimed: The adjacency of the dog ward to the reception area causes a lot of noise. In my opinion, clients do not wish to hear other dogs barking. The noise can also be stressful for t he pets in the reception area (veterinary technician) Another respondent asserted: stressful when we are working or trying to concentrate. However, we are supplied ear plugs, w hich help greatly (veterinary technician). related stress to the acoustical quality of the spaces in the facility. One respondent claimed: The doors between the examination room an d the laboratory are not soundproof and I have to constantly remind the laboratory staff that they can be heard in the examination room. This is not an ideal situat ion when a client is present (veterinary doctor) Another respondent stated: ers cannot have a conversation (veterinary technician) perceived noise related stress to the spatial layout or adjacencies of th e various areas in the facility. One respondent claimed: the dog ward. The dogs are in pain during recovery and bark continuously, which can (veterinary technician) Another respondent stated,
93 (veterinary technician) Figure 4 18. Distribution of responses for noise as a stressor related stress to the facility conditions that facilitated echo. One respondent claimed that t here is an echo problem due to the high ceiling in the reception and waiting area (veter inary technician). related stress to the type and volume of background music in the facility. One responded asserted: am not happy with the type of music being played in the fac ility. It can get too loud and (veterinary doctor) Another respondent stated: (veterinary doctor ) 42% 22% 13% 10% 13% Distribution of responses for noise as a stressor. Sample size n=31. Noise migration Acoustical quality of space Spatial layout/ Adjacencies Echo Type/ genre and volume of background music
94 I ndoor Air Quality As illustrated in Figure 4 17 above, out of the total number of responses related to environmental stress, 15 occurrences (22%) identified indoor air quality (IAQ) as an environmental stressor within the facility. As illustrated in Fi gure 4 19, of these, 12 related stress to the facility conditions that facilitated climate control. Figure 4 19. Distribution of responses for indoor air quality as a stressor. One respondent claimed: The air conditioning in the facility is not very good. The examination rooms are always warm and sometimes too hot. We also have clients complaining about the heat. The situation gets worse during rush hours when there are multiple people in a small area. The pant ing of the dogs al so adds on to the stress levels (veterinary technician) Another respondent claimed: been chang (veterinary technician) 80% 13% 7% Distribution of responses for indoor air quality as a stressor, n=15 Climate control Ventilation Odor
95 In add IAQ related stress to facility conditions that facilitated ventilation. One respondent claimed: examination areas do not have any windows and can g et a little claustrophobic (veterinary technician) IAQ related stress to facility conditions that facilitated odor. The respondent stated that t here is a proble m of odor due to odorous animals (veterinary doctor) Lighting As illustrated in Figure 4 17, out of the total number of responses related to environmental stressors, six occurrences (9%) identified lighting as an environmental stressor within the facility. Of these, four (68%) a related stress to the artificial lighting conditions in the facility (See Figure 4 20). One respondent claimed: (veterinary technician) Another respondent stated: (administrative staff) related stress to the natural lighting conditions in the facility. One respondent claimed: spaces have fewer windows resulting in lower levels of illumination than other areas. (veterinary technician) The findings also revealed that perceived lighting related stress to the color of the lighting in the facility. One respondent stated: white walls, white lights and white floor which adds t o the problem. However, I do like the colored (veterinary technician)
96 Figure 4 20. Distribution of responses for lighting as a stressor Ergonomics and Layout As illustrated in Figure 4 17 above, out of the total number of responses related to environmental stressors, 15 occurrences (22%) identified ergonomics and layout as an environmental stressor within the facility. Figure 4 21 below shows the breakdown of r esponses. Of these, one occurrence (7%) attributed perceived ergonomics and layout related stress to the visual access conditions in the facility. One respondent claimed: (veterinary technician) Second, one occurrence (7%) attributed perceived ergonomics and layout related stress to the facility conditions that facilitated activity requirements. The respondent claimed that the current laboratory is too small for the activities they perform. Some respondents were less overt in citing stressful workplace conditions, such as, 68% 16% 16% Distribution of responses for lighting as a stressor, n=6 Artificial lighting Natural lighting Color
97 grooming area and the kennel are extremely old and need to be renovat ed. There is need (veterinary technician) ; or that: separate recovery area for animals to wait before or after treatment since it is preferable to keep the visual contact minimum between clients and the (veterinary technician) Figure 4 21. Distribution of responses for ergonomics and layout as a stressor. Third, one occurrence (7%) attributed perceived ergonomics and layout related stress to the facility conditions that facilitated spatial relationships. The respondent claimed: The circulation and adjacencies of the different areas are unfavorable and creates an inability to observe certain work areas from other work areas. It also causes a situation where available help from th e sta ff members is hard to find ( veterinary doctor) Fourth, four occurrences (26%) attributed perceived ergonomics and layout related stress to the materials and furnishings conditions in the facility. One respondent 7% 7% 7% 26% 33% 20% Distribution of responses for ergonomics and layout as a stressor, n=15 Visual access Activity requirements Spatial relationship Materials and furnishings Privacy considerations/ Personal space Safety requirements
98 claimed: desk are a little uncomfortable and I (administrative staff) Another respondent stated: have slipped and fallen on numerous occasions. I also keep bumping my head onto (administrative staff) Fifth, five responses (33%) attributed perceived ergonomics and layout related stress to the privacy considerations or personal space in the facility. One respondent complained pla ce to eat food or sit comfortably. Most of the times, I end up eating my food on the (veterinary technician) Another respondent claimed: the clients and staff members. This is extrem ely uncomfortable since my privacy is (veterinary doctor) Finally, three responses (20%) attributed perceived ergonomics and layout related stress to the safety requirements in the facility. One respondent claimed: A laboratory wall that se parated the treatment area from the public areas was taken down recently which lead to an incident of a wild animal that got loose and entered the waiting area. This can compromise the safety of our clients and other patients (veterinary technician) Effec t of Occupational Stressors on Stress Levels Fourteen participants generated a total of six occurrences related to occupational stress. All of these (100%) attributed some perceived occupational stress to the facility conditions that facilitated risks and hazards. One respondent claimed: the major hazards include use of sensitive equipment like lasers, sterilizers, radioactive (veterinary doctor, full time)
99 Another responden t claimed: done properly. I am also concerned about the various inhalants that might be prevalent (veterinary technician ) A third respondent stated: opinion, the major hazard in the facility is the location of the radiology (veterinary doctor ) Frequency of Stress Caused by Environmental Stressors As illustrated in Figure 4 22, 64% of the respondents (n=9) said that they were occasionally stresse d by the treatment of the ambient sound levels in the facility. Approximately 21% of the respondents (n=3) felt often stressed by the treatment of the ambient sound levels in the facility Figure 4 22. Frequency of stress caused by the treatment of envir onmental stressors (n=14). In addition, 64% of the respondents (n=9) said that they were occasionally stressed by the treatment of the indoor air quality in the facility. Approximately 14% of 3 2 9 9 2 2 0 1 0 1 2 3 4 5 6 7 8 9 10 Ambient sound levels Indoor air quality Continually/ All the time Often Occasionally Rarely Never
100 the respondents (n=2) said they were often stressed by the tr eatment of the indoor air quality in the facility. Intensity of Stress Caused by Stressors Environmental stressors As illustrated in Figure 4 23, 57% of the respondents (n=8) said that they felt moderately stressed by the noise conditions in the facility. In addition, 50% of the respondents (n=7) said that the intensity of lighting conditions in the facility was not stressful. Approximately 41% of the respondents (n=10) said that they felt moderately stressed by the indoor air quality conditions in the facility. 64% of the respondents (n=9) were minimally stressed by the treatment of the ergonomic conditions in the facility. Figure 4 23. Intensity of stress caused by environmental stressors response review (n=14). Occupational stressors Shown in Figure 4 24, approximately 71% of the respondents (n=10) said that they felt minimally stressed by the potential for injury due to workplace features in the facility and 43% (n=6) said that they felt moderately stressed by the hazards related to their w orkplace features. In addition, approximately
101 35% of the respondents said that they felt minimally stressed by the hazards related to their workplace features. Figure 4 24. Intensity of stress caused by occupational stressors response review (n=14). Ef fect of Stressors on Satisfaction Levels As illustrated in Figure 4 25, 64% of the respondents (n=9) were somewhat unsatisfied with the treatment of the ambient sound levels in the facility and found it to be a source of stress. Also, 64% of the responden ts (n=9) were satisfied with the treatment of lighting conditions in the facility. The study found that 100% (n=14) of the respondents rated daylight (natural light) to be the most satisfactory source of illumination according to the nature of tasks perfor med by them, followed by accent lighting (decorative lighting), and task lighting (functional lighting). Approximately 35% of the respondents (n=5) were somewhat unsatisfied with the treatment of indoor air quality. In addition, 43% of the respondents (n=6 ) were satisfied 0 1 0 1 2 6 10 5 2 1 0 2 4 6 8 10 12 Potential for injury Workplace hazards Extremely stressful Very stressful Moderately stressful Minimally stressful Not stressful
102 with the treatment of the indoor air quality in the facility. Finally, 64% of the respondents (n=9) were satisfied with the ergonomic conditions in the facility. Figure 4 25. Satisfaction levels with the treatment of environmental & occupational stressors affecting work response review (n=14). Figure 4 26. Satisfaction levels with the treatment of ergonomic conditions response review (n=14). 0 1 1 1 0 9 1 5 0 0 2 1 2 4 0 3 9 6 9 13 0 1 0 0 1 0 2 4 6 8 10 12 14 Acoustical conditions Lighting conditions Indoor air quality Ergonomic conditions Physical environment/ Safety conditions Very unsatisfied Somewhat unsatisfied Neutral Satisfied 4 2 3 0 8 1 2 7 4 1 1 1 8 0 0 2 2 0 1 2 3 4 5 6 7 8 9 10 Ease of circulation Ease of access to supplies Adjacencies of different departments Privacy for sensitive activities Extremely satisfied Very satisfied Moderately satisfied Minimally satisfied Not satisfied
103 Figure 4 26 shows staff satisfaction with the ergonomic conditions of the facility. Fifty seven percent of the respondents (n=8) were very satisfied with the ease of circulation in the facility. 64% of the respondents (n=9) were very satisfied with the ease of access to supplies in the facility. In addition, 50% of the respondents (n=7) were m oderately satisfied with the adjacencies of the different departments in the facility. However, 57% of the respondents (n=8) were minimally satisfied with the privacy for sensitive activities in the facility. Stakeholder Feedback The medical director of the facility was presented with the findings from the case study and personal interviews with the participants. He was asked about any concerns he might have with the findings or any feedback that he would like included in the final document. The director responded to the questions that were asked during the meeting, transcribed below. When asked for suggestions for strategies for improving the existing design of the facility, t he director revealed that the design of the veterinary f acility was a vision of the previous o wner 20 years back. In addition he believed that a major portion of the design decisions was taken by the previous owner himself, and not the architect. He commented: It is evident from the design of the facility tha t a lot of areas in the facility need better planning. I inherited a design that is not a modern one. Hence, there are certain changes that I would like to make in the existing design, although a lot of them are not feasible at this stage The director wa s of the opinion that visual and verbal access to the different areas of the facility was extremely important and the current design lacked these features. He expressed that he would like to have visual access to the examination room and the treatment area s. He stated:
104 We usually work in teams of two, and constantly need help from other caregivers during a procedure. Currently, this is extremely difficult to do since we end up having to walk a lot to escort additional caregivers. Also, there are so many hea vy doors to open whilst doing so (I feel like I have to ope n doors almost 50 times a day) Add itionally, the director revealed that he would lik e to knock down the wall of the private restroom and convert it into a staff restroom He acknowledged that he h ad made a few changes to the existing design, stating: I took down an entire wall that separated the treatment areas from the public areas. This was done for the purpose of better circulation and to avoid having to constantly open the heavy doors that separated these areas. We have also re arranged some furniture and compu ters in a few examination rooms However, there is a limit to what we can change in the curr ent design. W hen asked about his plans (if any) to address the issues of noise, indoor air quality, lighting and personal space in the facility t he director reasoned that noise was an inherent part of the veterinary care industry and there is not much he could do about the noise in the facility. He commented: The noise from the kennel does not bother me and after so many years of working in this industry, I hardly even notice it. In my opinion, our facility has much lower sound levels as compared to many others Further, the director revealed that the staff members could now change the thermo stat settings of the air conditioning as per their requirement s and he believed that this issue should not be a problem anymore. However, he acknowledged: I do agree that the staff members face a problem due to the lack of staff break areas and staff restr ooms, and I will most certainly consider it during future renovations. In addition, I am aware of the lack on a fenced in run for dogs. But the current zoning regulations prohibit us from having a fence and I do not see the regulations changing in the near future A final question asked for his opinion about the design choices/ design features that should be included in a renovated facility in the future or any improvements in the
105 design that he contemplate d in the future The director stated that first a nd foremost, he would like to have visual and auditory access to the various areas of the facility. He expressed that he would design the areas to have open visibility from the laboratory, examination areas and treatment areas. Further, he would take down the heavy solid doors and use alternate options for separating the different areas. In addition, he would want to include staff restrooms and a staff lounge. Finally, he commented that he would like to include an indoor run for the boarded dogs. Summary o f Findings The interviews revealed, and observations confirmed, that the existence of four major issues as described and illustrated in Table 4 1 below: Noise The findings from the interviews and observations confirmed a problem due to the conditions that facilitated noise migration from certain areas of the medical center including the kennel, examination rooms, treatment area and the laboratory. In addition, t he acoustical quality of the spaces in the facility was unsatisfactory and a source of stress to the caregivers. Further, the spatial layout or adjacencies of the various areas of the facility facilitated noise migration, which were claimed to contribute t stress. This included the location of the kennel and the treatment areas. Additionally, there was a problem of noise reverberation due to the high ceiling in the reception and waiting areas. Finally, the type and the volume of background musi c being played in the facility was a source of stress to the caregivers.
106 Indoor Air Quality The interviews suggested, and observations confirmed the singular facility condition that facilitated the related stress included climate con trol (air conditioning and room temperature) Ergonomics and Layout related stress included visual access, safety requirements, activity requirements and privacy conditions or p ersonal space in the facility. This finding was obtained from observations and interviews alike. Occupational Stress facilitated hazards and risks. The major concerns vo iced by the users were the use of sensitive equipment, handling certain chemicals, the hazardous inhalants that might be prevalent, and the location of the radiology room in the treatment area. On the contrary, the respondents claimed that the there is a problem of odor in the facility. However, observations suggest that most areas of the facility are sterilized and odor free. In addition, the respondents claimed that the artificial fluorescent lighting was too bright, migraine inducing and affected their eyes. However, the observations suggest that the artificial lighting is appropriate for the space, activity and task requirements. the noise from the washer and dryer machines in the kennel, combined with the constant barking of dogs results in the kennel being an extremely noisy place. In addition, the ICU in the treatment area was an open, rather than sealed area. Also,
107 there is a service entry door in the treatment area. The technician work area is located right adjacent to the treatment area. This area is not screened from t he treatment area in any manner, raising the issue of bad practice. Table 4 1 Triangulation of the d ata Type of Stressor Observations Interviews Environmental Stressors 1) Noise a) Noise migration b) Acoustical quality of the space c) Spatial layout/ Adjacencies d) Echo e) Type/ genre and volume of background music 2) Indoor Air Quality a) Climate control b) Ventilation c) Odor 3) Ergonomics and layout a) Visual access b) Activity requirements c) Spatial relationship d) Privacy consideration / Personal space e) Safety requirements f) Materials and furnishings 4) Lighting a) Artificial lighting b) Natural lighting c) Color Occupational Stressors 1) Risks/ Hazards Conclusion of Findings In sum, approximately 86% of the participants declared that they were partially satisfied with the physical conditions at their workplace. Further, the highest cited (36%)
108 workplace feature was the layout of the facility. On the contrary the acoustical conditions were the lowest cited (22%) workplace feature in the facility. Finally, when asked for suggestions about design choices or strategies that should be included in a future renovated facility, a majority of the participants (71%, n=10) declared that they would want a staff lounge, 64% (n=9) of the participants wanted a staff kitchen and dining. Further, 43% (n=6) of the participants wished for better soundproofing of the doors and spaces in the facility, 36% (n=5) wanted additional restrooms for caregivers and 36% (n=5) proposed an outdoor run for boarded dogs. Additional staff recommendations f or future renovations included better air conditioning of the facility, an additional remodeled kennel, a remodeled grooming area, separate waiting area for cats, and better adjacencies and transparency in between various departments.
109 CHAPTER 5 DIS CUSSION The objective of this research was to understand the effect of the design features satisfaction levels by performing a case study of a small animal medical center take n to be a representative case of an optimally designed facility. The findings from the literature review suggested that there is a strong relationship between the physical environment of a general workplace and its effect on the stress and satisfaction lev els of the staff. Further, the review revealed that very little is written specifically about the design requirements for the physical environment of veterinary facilities and in t. The premise of this study is therefore that the constituents of the physical environment have a direct impact on the stress and satisfaction levels of workers; and more specifically, that this is true within the context of veterinary care. This chapter analyze s and discuss es the study findings. Further, design recommendations for veterinary facilities are provided. Effect of the Physical Setting on Caregiver Stress and Satisfaction Levels The case study of the selected veterinary facility focused on the impact of environmental, occupational and psychological stressors and the extent to which they might affect the s tress and satisfaction levels of the veterinary caregivers. The study findings, in confirmation with the literature review (Applebaum, Fowler and Fiedler, 2010; Butala and Muhic, 2007; Choiniere, 2010; Edward and Torcellini, 2002; Frumkin, 2005; Jeyaretnam and Jones, 2000; Jeyaretnam, Jones and Phillips, 2000; Keidel, 2002; Lessenger, 2006; Mitchener and Ogilvie 2002; Moser, 2010; Mroczek et al.,
110 2005; Nienhaus et al., 2005; Portner and Johnson, 2010; Raja et al., 2001; Rashid and Zimring, 2008; Rediich, 1997; Schweitzer et al., 2004; Scuffham et al., 2009; Semltzer, 2009; Springer, 2007; Top, 2000; Ulrich, 2000 and Wyo n, 2004) suggested that the environmental, occupational and psychol ogical stressors have a direct/ indirect influence As stemming from the findings the most significant environmentally related issues affecting the caregivers are noise (47%) indoor air quality (22%) ergonomics and layout (22%) as well as occupational and psychological stressors. Environmental Stressors The hierarchy of the most significant environmental stressors affecting th e caregivers are illustrated in Figure 5 1. Figure 5 1. Significant environmental stressors affecting the veterinary caregivers. SIGNIFICANT ENVIRONMENTAL STRESSORS NOISE (n=31) Noise migration (42%) Acoustical quality (22%) Spatial layout (13%) Volume of music (13%) Echo (10%) INDOOR AIR QUALITY (n=15 ) Climate control (80%) ERGONOMICS & LAYOUT (n=15) Privacy (33%) Safety requirements (20%) Visual access (7%) Activity requirement (7%)
111 Noise The findings from the study revealed that out of the total number of responses related to environmental stressors with in the facility, the maximum number of occurrences (47%) identified noise as the most significant issue that contributed perceived noise related stress was significantly affected by the facility conditions that facilitated noise migration (42%). In particular, 11 responses (35%) identified the noise migration from the kennel due to the barking of dog s, as a major source of stress Miscellaneous responses stated that the location of the dog ward was not ideal since the dogs are in pain during recovery and bark constantly. The respondents perceived the noise from the kennel to be a possible cause for peak in the stress levels of staff making it difficult for them to concentrate on their tasks. Literature states that veterinary practices have the highest levels of noise amongst healthcare settings (Moser, 2010). According to the US Environmental Protection tal levels up to 45 dB are deemed comfortable for hospital work during the day (EPA, 1979). However, in the case of veterinary facilities, noise levels from multiple barking dogs can reach 115 dB in the kennel ( Seibert, 2011). Moreover, in the case of this facility, it was observed that although the dog kennel is located at the rear end (northwest corner) of the facility, the noise from the kennel migrates to the treatment area, technician work area, reception and waiting area examination rooms and the lab oratory The barking noise appears loudest in the treatment area that is located adjacent to the kennel. A reason for this may be that the sound from the barking dogs is not controlled at the source, which in this case is the kennel area According to Gil christ et
112 al. (2003), source controlling strategy is the most effective method of elimination noise since it reduces noise emissions in all directions Additionally, in the case of the facility, the noise generated by the w asher and dryer machine combines with the constant barking of dogs to further increase noise levels at the source. Literature acknowledges that dogs are noisy animals and hence sound attenuation finishes are an important consideration to avoid noise migration (NIH, 2003). In the case of this facility, the walls in the kennel are made of exposed concrete block. The cells in the blocks are filled vermiculite and extend to the roof deck to eliminate sound leakage. In addition, the doors of the kennel are insulated with gaskets around all of the edges and the ceiling is made of acoustical tiles However, despite these precautionary acoustical measures, the noise from the kennel still migrates to other areas of the facility. A reason for this may be that the finish materials in the kennel whi ch should add an additional measure of sound insulation, do not provide the protection required to contain the high noise at the levels generated in the facility An additional reason for the noise transfer may be t he absence of noise barriers between the kennel and the treatment and reception areas, which may assist in controlling the noise along its transmission path. Literature states that noise barriers can provide a substantial reduction in noise levels by resisting the flow of sound energy When a sound wave encounters a barrier, a part of the energy is transmitted through the barrier, a part of it is absorbed within the material of the barrier, while the remaining energy is reflected back towards the source (Gilchrist et al. 2003 ). Though sound attenuation can be addressed through design, behavioral issues must be considered to understand the effect of noise on the users. A ccording to a
113 conceptual framework developed by Rashid and Zimring (2008) linking the indoor environment and stress, a n ind iv of exposure to the stressors may be an additional factor in determining the perceived potency of the environmental stressor. In some contexts people may get used to a stressor if exposed to it for an extended period. I n other contexts, a mild stressor may have a major effect if an individual is exposed to it for an extended period. In the case study findings revealed that a majority of the participants acknowledged having worked in two to three veterinary facilities on an average prior to joining this facility and that they had often been subjected to high noise levels due to barking dogs In addition, two respondent s claimed that most of the staff members had been working in the facilit y for a long time and were used to the constant noise from the kennel. Moreover the findings revealed that while a majority of the participants (57%) felt moderately stressed by the noise conditions, 21% participants felt minimally stressed by the noise conditions in the facility Hence, there is a possibility that in this case, the factors of individual coping and time may have influenced the perception of stress of the respondents. As previously mentioned in Chapter 2, another consistent finding in stress research has been that if an individual has a sense of control with resp ect to a potential stressor, its negative effect is markedly reduced or even eliminated (Ul rich, 2000). F indings from the personal interviews with the medical directors of the facility revealed that neither of them felt significantly affected by the noise levels from the kennel On the contrary the caregiver staff members including the techn icians and administrative staff, declared being significantly affected by the noise migration from the kennel and att ributed it as a major cause of their stress levels. A possible reason for this may be
114 that the medical directors occupy a personal office that is an enclosed space with acoustical ceiling and wooden flooring both design features that tend to counteract so und transmission Further noise attenuation may be explained by the travel distance between the the kennel as they are located at opposite ends of the facility In addition t he directors can easily close off the door when required thus insulating themselves from the noise at will. In contrast t he caregiver staff members spend most of their time working in the laboratory located in close adjacency to the kennel Moreover, the technician area is located right adjacent to the treatment area and in proximity to the kennel Since this area is not screened from the treatment area in any manner, the caregiver staff members do not have any possi ble way to insulate themselves from the constant barkin g noise from the kennel Research indicates that people who feel they have some control over their environmental circumstances deal better with stress than persons who lack a sense of control (Ulrich, 2000) In this case, th e caregiver staff members lack c ontrol due to the absence of a designated staff area in the facility that would provide acoustical protection from the high noise levels in the facility perceived noise related stress to the spatial layout or adjacencies of the various areas in the facility. As previously mentioned, the staff work areas including the technicia n work area, treatment area the laboratory and the reception area have close adjacency to the source of noise, i.e. the kennel. Twenty nine percent of the respondents recommended changing the current location of the kennel and treatment areas and placing them further away from the reception area. According to Evans and Philbin
115 (2000), having compatible adjacencies between spaces is the least costly and the most effective method of sound mitigation. The findings from the study indicated that areas in the facility purposefully built with strategies to address noise include the examination rooms, treatment rooms, the grooming area, the administrative offices, the kennel, and the hallways. These areas ha ve dropped ceiling conditions with acoustical tiles. Additionally, the walls in the treatment area, the grooming area and the kennel are exposed concrete blocks and the cells in the se blocks are filled with sound attenuating vermiculite. In the case of the treatment area and the kennel the cells extend to the roof to reduce sound leakage. However it was observed by the respondents and confirmed by observations that despite these measures, the examination rooms, the treatment areas and the kennel failed to contain the noise levels. Furthermore, in the study, 36% of the respondents mentioned that noise frequently traveled in between adjacent examination rooms and to the laboratory and that the lack of soundproofing made it difficult for the staff members t o discuss privat e/ sensitive information without being heard by the client s This is an example of lack of speech privacy. According to Wrightson and Wrightson (1999), lack of speech privacy occurs when sensitive conversations must occur, but the spaces ava ilable allow them to be overheard. In this case, the examination rooms and the laboratory do not provide the adequate speech privacy required by the caregiver staff thus creating additional conditions for user stress Literature states that surface finishes influence the behavior of sound within an enclosed space. These must be addressed, as planning for room acoustics involves controlling sound generated within a space (Evans and Philbin, 2000). Further, sound
116 transmission through partitions between rooms can permit intrusive disturbances from adjacent rooms and also compromise speech privacy (Evans and Philbin, 2000). According to Evans and Philbin (2000), sound can be transmitted between spaces via either air borne or structural borne paths or b oth. Sound paths between adjacent spaces include do ors and partition penetrations. This may explain the observed phenomenon, as the wall finishes and doors of the examination rooms are devoid of sound absorbing materials and thus fail to control sound. In this case, noise transfer is facilitated by the respective ceramic tiles and coved sheet rubber floor finish in the examination room and the laboratory. These finishes are a functional requirement in these areas, but do not provide acoustical control. Cera mic tiles have a Noise Reduction Coefficient (NRC) of 0.0 while coved sheet rubber floor finish has a NRC of 0.05. The sound absorption coefficient indicates how much of the sound is absorbed in the actual material. Acoustically absorptive materials are ra ted by NRC, an average of absorption coefficients in the middle range of the audible spectrum of sound frequencies. The NRC value essentially identifies the amount of sound absorbed, with the remainder assumed to be reflected and scattered off the surface back into the environment (Wrightson and Wrightson, 1999). Poor acoustical quality is conducive to stress. F indings revealed that 22% of participants attributed their perceived stress levels to the acoustical quality of the space. Participants identified the kennel, the examination rooms, and the laboratory areas in the facility as needing better acoustical properties. In the case of the facility, it was observed that the doors on either sides of the examination rooms are left open at most times, except wh en a client is present in the examination room. These form open
117 channels for sound to travel between the examination rooms, the laboratory and the adjacent corridors running parallel to them. The absence of barriers facilitates sound transmission in betwee n these rooms. Another noise related issue identified by the respondents is the loud music b eing played in the facility. Twenty nine percent of the respondents mentioned that the noise levels generated by the music being played in the facility were disrup tive and interfered with the type of tasks they performed. These results support the studies conducted by exhaustion and burnout, and noise may also affect medical errors committed by staff. However, there is a possibility of a link to the individual sense of control with respect to the stressor, which in this case is the volume and type/genre of music. A few respondents mentioned they had absolutely no control over the type and volume of music being played in their workplace. The study found that the kennel area has washer and dryer machines placed adjacent to the dog runs. The interviews suggested and observations confirmed that the noise of the machin es during operation combined with the barking of the dogs created elevated sound levels in the kennel. Dog s hear high tones much better than humans. The average frequency range of a huma n is within the frequency of 20 hert z and 20,000 hert z, while the aver age frequency range of a dog is approximately 40 hertz to 60,000 hert z depending on the age and breed of the dog (Condon, 2003). According to the NIH (2002), noise levels can have a profound effect on the health and wellbeing of animals. Because sound expo sure can have variable effect on animals, noise generators (e.g., human activities and equipment) should be minimized in animal areas. Animal stress
118 results in loud barking and howling, which in turn may cause stress in those caring for them. According to Moser (2010), simple design considerations like masking noise can lead to high productivity and more relaxation for those under stress. M echanical and machinery noise containment is best achieved with masonry construction or de coupled, double stud drywall with multiple layers of gypsum board on each side of the wall (Evans and Philbin, 2000), which is not the case in the facility. Other noise related issues that affected the participants to some extent were facility conditions associated with adjacencies, echo, and type and volume of background music. These results are consistent with the literature that high noise levels adversely affects caregivers and have been associated with increased stress levels (Applebaum, Fowler and Fiedler, 2010). Design R ecomm endations for Improved N oise Control The f ollowing are specific as well as general design recommendations for strategies that can be adopted to minimize the impact of noise as a stressor in the facility: 1. First, i t is recommended that the k ennel area of the facility have better in room acoustics. This can be achieved by the additio n of noise control and sound absorbing materials like fabric wrapped, high density, non porous and sound absorbing wall panels An alternate option would be to use sound reduction paint on the existing walls. 2. Second, there is a need for sound isolation in the kennel. It is extremely important to avoid sound leakage from the two doors of the kennel. This can be achieved by the use of door seal kits. The seals should be of a dense an d flexible material. In addition, it is possible to increase the sound isolation ability of the existing door s separating the kennel and the treatment areas. This can be achieved by adding mass with materials like three quarter inch plywood or sheet metal applied to both the sides. 3. A third solution to minimize the noise from the kennel would be to add a second door in front of the two existing doors of the kennel. This will create a buffer space in between the kennel and the treatment area providing acoustical isolation. It is
119 recommended that this buffer space be treated with acoustical materials that aid sound absorption. 4. Further, it is recommended that the washer and dryer machines be moved to an alternate location or away from the kennel area. A dditionally, in case of future renovations to the facility, changes in the current location of the kennel will eliminate the noise migration to other areas. 5. In the case of the technician work area, it is suggested that acoustical folding partitions be used to provide sound absorption These are movable partitions and can be used as a temporary solution. However, in case of future renovations, it is recommended that the technician work area be relocated away from the treatment areas and the kennel. 6. There is a need to have better sound isolation in the examination rooms. The simplest way to achieve this would be to add an automatic swing doo r mechanism to ensure that the doors separating the examination rooms, the laboratory and the adjacent corridors remain closed at all times. In addition, it is recommended that additional soundproofing measures be applied to the existing doors. This can be done by using door seal kits and by adding three quarter inch plywood or sheet metal applied to both the sides 7. It is recommended that the laboratory area in the facility incorporate a speech privacy system to avoid the problem of noise migration to the examination room. It is also recommended that a sound reduction paint coat be used on the existing walls and acoustical window seals be used on the exterior windows of the laboratory 8. Additionally, i t is recommended to install a white noise machine to rectify the problem of background noise in the reception area. Indoor Air Q uality The results from the study indicated that out of the total number of responses related to environmental stressors, 22% of occurrences identified indoor air quality (IAQ) as an environmental stressor. The study findings revealed that 64% of the respondents were occasionally stressed by the treatmen t of the indoor air quality in the facility. Overall, 43% of the respondents were satisfied with the treatment of the indoor air quality in the facility. As previously mentioned in Chapter 2, acceptable indoor quality is the one in which 80% or more people exposed do not express dissatisfaction
120 (ASHRAE, 2001). Hence, we can conclude that the indoor air quality conditions in the facility were above acceptable standards. Despite this favorable assessment, the vast majority of occurrences citing IAQ as an en vironmental stressor (80%) attributed their perceived IAQ related stress to the facility conditions related to climate control. It was identified by 86% of the respondents that the air conditioning in the facility was not functioning effectively, resulting in varied air temperatures in different areas of the facility. Many of the respondents specifically mentioned that the examination rooms felt too warm, while the recep tion and waiting areas felt too cold. In addition, the respondents mentioned that the cl ients often complained about the warm temperatures in the examination rooms and the cold temperatures in the reception area. observations. One reason for the poor temperature control may be that the caregiver s taff members do not have access to the thermostat which is operated only by the medical director of the facility Contrary to the claims made by the latter, a few respondents (21%) believed that the thermostat settings were responsible for the varied air temperature in different rooms. Further, this is an example of the lack of control over the stressor According to Ulrich (2000), provisions of actual or perceived control over stressors usually alleviate stress. T he lack of control over the operation of the thermostat can be identified as a situation where the desire to control the stressors is important to limit the perception of the stressor. These results support previous study findings by Rashid and Zimring (2008) on
121 majority of unsolicited complaints (77%) in office buildings. Further, in a study conducted by Reijula and Sundman Digert (2004) on office environments in Finland it was found that the most common indoor air quality problems were swings in room temperature and too high or two low temperature. A n additional reason for the higher temperatures in the examination rooms may be that they are devoid of operable windows or ceiling fans to assist ventilation Literature states that operable windows allow cross ventilation that helps lower the indoor temperature. However, it was observed that a majority of th e windows in the facility are non operable including the areas with lower temperatures. Hence, it is possible that the lack of windows may not solely be responsible for the lack of thermal controllability. An alternate reason for the varying room temperatures may be a deficiency with the building s Heating, Ventilation, and Air Conditioning System ( HVAC ) or the mechanical ventilation system According to the ( EPA ) Office of Noise Abatement and Control the main purpose of HVAC system is to maintain good indoor air quality through adequate ventilation with filtration and provide thermal comfort. In this case there is a possibility that the HVAC system may require maintenance or replacement to function consistentl y. An additional reason for the cold temperatures in certain areas in the facility may be due to the air supply outlet being placed at clos e proximity to the wall. In such a case, the cold air from the outlets strikes the obstructions and bounces the cold air to the occupants causing discomfort. This phenomenon is called cold air dumping (Lin and Shum, 2008) In the case of ventilation, 13% of the occurrences attributed their perceived IAQ related stress to the facility conditions It was observed by the r esearcher that since the
122 facility was centrally air conditioned, a majority of the windows in the facility were non operable. Additionally, certain areas in the facility like the examination rooms; the technician work area, the feline and avian wards and s torage areas were devoid of windows. Although this might be a requirement in feline and avian wards to avoid the possibility of infection, literature suggests that a design choice for good indoor air quality is to develop ventilation strategies that suppor t operable windows, where appropriate. However, the examination rooms are centrally located, with no possibility of external windows. Literature states that operable windows avail the occupant of ambient smells, breezes and all the sensory stimuli of an o pen environment (Schweitzer et al., 2004). In addition, employees with a window report less stress, better health status, and higher job satisfaction. Ad ditionally, the proponents of building energy efficiency and sustainable design argue that natural vent ilation can increase energy efficiency of buildings as well as improve indoor environmental conditions (Schweitzer et al., 2004). However, it was surprising to see results of the study that only 13% of the occurrences attributed perceived stress to facilit y conditions for ventilation. Hence it is suggested that most areas in the facility are well ventilated by the mechanical ventilation system present in the facility and do not significantly contribute to the stress levels of the caregivers. The IAQ related issue that affected the least was facility conditions associated with IAQ related stress to the facility conditions related to odor. Additionally, observations by the re searcher confirmed that almost all the spaces in the facility were odor free.
123 Design Recommendations for Improved Indoor Air Quality The f ollowing are specific as well as general design recommendations for strategies that can be adopted to minimize the imp act of IAQ as a stressor in the facility: 1. First, it is recommended to regulate and maintain the air temperatures in the different areas of the facility to provide thermal comfort to the caregiver staff. This can be done by checking the existing HVAC system to ensure that it is working properly, maintained and regulated for temperature control. 2. A solution for the problem of the cold air dumping is the use of high performance diffusers. These diffuser air jets help prevent cold air downdrafts and maximize th e circulation and ventilation effectiveness. 3. It is recommended that in case of future renovations to the facility, the staff and other areas that do not require a sterile environment have operable windows to maximize the airflow and for improved circulati on Howeve r, these operable windows should be readily controlled by wi ndow treatments such as blinds to avoid the possibility of glare Ergonomics and L ayout The findings from the study indicate that out of the total number of responses related to environ mental stressors, 22% of occurrences identified ergonomics and layout as an environmental stressor within the facility. Of these, a majority of the occurrences ( 33% ) attributed their perceived ergonomic stress to the privacy consideration or personal space in the facility. The respondents stated that the facility lacked staff areas; break areas; and a pantry and dining area for the technicians and other staff members. an absence of designated staff areas in the facility. As previously noted a few caregiver staff members were seen having their lunch on the examination table in the treatment area raising issues about the privacy and safety of the staff members. This is a matter of concern since the ICU in the treatment area is an open rather than sealed area. Literature indicates that isolation rooms must
124 use barrier precautions and/ or isolation protocols to limit contamination and spread of pathogens to veterinary caregivers or other animal patients (Portner and Johnson, 2010). In a study conducted by Wright et al. (2008) on US veterinarians, it was found that most small animal practitioners reported occa sionally eating or drinking in animal handling areas, a practice that carries a high risk for transmission of pathogens. In the case of the facility, the respondents claimed that they were forced to eat their lunch on the examination tables due to the abse nce of a dining area. Moreover, the findings revealed that the original plan of the facility shows a staff a multipurpose area that is mostly used for storage. Acco rding to Vetich (2011), architectural features contribute to the development of social cohesion in work groups. Proximity facilitates social interaction; thus common areas can provide opportunities for unplanned social interactions between workers, which i n turn, foster social support, which buffers stress. Additionally, workplaces in which employees report good communication and strong social support are perceived healthier, and this in turn predicts higher job satisfaction (Vetich, 2011). In the case of t he facility, it was observed that despite the absence of a designated staff area, staff members often gathered in the treatment area and around the reception desk during non rush hours, to socialize brainstorm or Another ergonom ics and layout related issue that affected the respondents was the absence of exclusive restrooms for the staff members. It was observed that the restroom for staff members was located adjacent to the waiting area and they shared it with the clients. This is not an ideal situation since eager clients often interrupt the
125 caregiver staff, especially doctors when they are on their way to the restroom, hence compromising the privacy of the caregiver staff. These findings are in accordance with literature which states that most medical facilities reflect laudable attempts to design attractive, supportive settings for clients, but reflect little concern for the design of staff areas (Ulrich, 1992). Spaces for detachment and retreat are as important as spaces for social interaction. ely determine the physical boundaries between individuals and the spatial density of the workplace (the floor are a per person) (Vetich, 2011). Office environment research consistently reports a strong desire for privacy among employees. Privacy is largely a matter of controlling information flow: that is, one wants to regulate the degree to which others have information about oneself, and conversely the information one obtains about others (Vetich, 2011) It was observed that the treatment areas in the fac ility, which included the ICU, the imaging department, the grooming area, and the surgery area were organized in a way that they do not have any visual access from the public areas. This is necessary for restraining pets and minimizing the possibility of t he animals during/ after treatment and vice versa However, this also raised the possibility of inconvenience for the staff members si nce they have no direct visual/ verbal access to the public or the administrative areas. A respondent m entioned that the adjacencies of these areas were unfavorable since they created inability to observe certain work areas
126 from other s resulting in the caregivers having to constantly shuffle between the administrative and the treatment area throughout the day. The plan of the facility shows that the administrative and treatment areas are located at two opposite corners. A ccording to the NIH design policies and guidelines (2003), the arrangeme nt of critical adjacencies greatly impact s the quality of life of the veterinary caregivers In this case, it is necessary to have better adjacencies in between the administrative and the treatment areas, to satisfy the staff preferences and reduce the number of steps taken by them through the day. An additional observa tion that questioned the privacy of the activities in the facility was the presence of a window in the surgery area, which is not only transparent but also opens to the front faade of the building. Two respondents mentioned that the location of this windo w in the surgery area was not an ideal situation since it potentially enables views from the passerby, creating the possibility that it could interfere with the operation of the surgery area. In addition, the window creates conditions for dangerous distrac tions of the staff members while performing critical tasks and which might put the animal patients at risk. In addition, the results from the study showed that 20% of the respondents attributed their perceived ergonomics and layout related stress to the safety requirements in the facility. Twenty one percent of respondents mentioned the removal of a previous barrier in between the treatment area and the reception area as being a matter of concern. The respondents mentioned that this was a safety hazard si nce a spooked animal could get loose and easily enter the reception area, compromising the safety of staff members, clients, and other animals. However, the medical director was
127 of the opinion that the barrier was removed to achieve better adjacency betwee n the two areas. The other ergonomic conditions that minimally affected the participants were facility conditions associated with the spatial relationship and materials a nd furnishings in the facility. Spatial dimensions present additional ergonomic consid erations. The findings from the interviews and observations revealed that the number of technicians who worked in the facility was higher than the number of doctors and the administrative staff. However, the laboratory area provided to the technician staff did not reflect this proportion. A technician mentioned that the current laboratory area was too small for the activities that were performed. Beyond these implications for the caregiver staff, adjacency/ confinement issues also impact the animal populati on. It was observed that there are separate examination rooms for dogs and cats in the facility. This is helpful to avoid any stressful contact between animals, since cats can get extremely stressed in the presence of dogs. In a study conducted by McCobb e t al (2005), cats in areas of high dog exposure had higher stress levels than did cats in areas with higher noise levels. Design Recommendations for Improved Ergonomics and Layout The f ollowing are specific as well as general design recommendations for strategies that can be adopted to minimize the impact of ergonomics and layout as a stressor in the facility: 1. First it is recommended that consideration be given to an addition to the existing facility. It is suggested that the expansion space include a d esignated staff area/break room with a pantry and dining area. In addition, there should be a dedicated space for workstation s for the staff members. Finally, it is recommended to include a n enclosed conference room that can also be used as a multi purpose area for sensitive staff discussions and brainstorming.
128 2. A s econd recommendation would be to include exclusive rest r ooms for the staff members during future renovations. In addition, the laboratory space should be expanded to meet the space requirements o f the technician staff. 3. Further, the grooming area should be completely renovated by repla cing the worn out bath tubs, re painting the walls and provision for additional storage cabinets. 4. It is recommended that the future renovated facility have suitable adjacencies to minimize the physical exertion on the staff members. However, since the renovation of the facility is unpredictable in the near future, it is recommended that the existing facility include a n announcement system to reduce the need for the s taff members having to constantly shuffle between the administrative and the treatment area throughout the day. 5. I t is recommended that the transparent window in the surgery area be removed or made opaque. 6. Finally, it is recommended that the stakeholders c onsider separate waiting rooms for dogs and cats in a renovated facility. Occupational Stressors Stressors other than environmental contribute to the overall perception of stress of veterinary care employees and their satisfaction with existing facilities. In the case of occupational stressors, fourteen participants generated a total of six occurrence s related to occupational stress. All of these (100%) attributed some perceived occupational stress to the facility conditions that favored risks and hazards. However, a majority of the respondents (71%, n=10) said that they felt minimally affected by the potential for injury, due to the workplace features in the facility. The on veterinary caregivers in Finland which indicated that not only did 67% of veterinary careg ivers claim to need improvements in the physical work environment, but also 35% of the veterinary caregivers had suffered a work related injury during the 12 months prior to the study. In addition, the findings do not follow literature, which indicates tha t veterinary caregivers face many occupational hazard s and that the number of injuries
129 they suffer is also high (Reijula, 2003). A possible reason for this may be the difference in veterinary practices, regulations and settings between Finland and the USA, or in the In the case study facility, no major incidence of injury was reported by respondents and only one claimed to have slipped and fallen on rare occasions. Further observation revealed that the wet areas of the facility including the grooming area were applied anti slip strips. In addition special care was taken to apply surface markings to indicate level difference in different areas. These safety measure s ensure that the incidents of work related injuries are minimized or completely avoided. Hence, it may be concluded that the physical environment in the facility is not a significant sou rce of injury related stress for the caregivers. Additionally, the participants revealed that their injuries were mostly animal/ equipment related, and not particularly related to the environmental features in the facility. These findings are in affirmation with the literature that indicates that a h handling animal patients (Reijula, 2003). Nonetheless, t he findings from the study also revealed that 43% of the respondents felt moderately stressed by the hazards related to their workplace features. The most commonly cited hazards by the respondents were the location of the radiology room in the facility, the toxic gases that may be present in the treatment areas and radiology room, use of sensitive equipment and handling certain chemicals. This is in accordance with the literature that veterinarians are at risk of physical trauma; chemical hazards and biological threats that can harm their health; reduce their productivity and even shorten their career if not properly dealt with (Smeltzer, 2009).
130 According to Jeyaretnam & Jones (2000), many of the ha zards that veterinarians face are difficult to recognize and include physical risk factors such as communicable diseases, exposure to chemical and biological toxins, carcinogens, ionizing and non ionizing radiation and ergonomic/ human factor hazards. Furt her, modern veterinary medicine exposes professionals to a variety of chemicals necessary for safe and sanitary practice. Many of these agents can be toxic in the wrong dose. The common culprits are disinfectants, analgesics, anesthetic gases, therapeutic agents, hormones and X rays (Jeyaretnam & Jones, 2000). According to NIH (2003), the work performed in veterinary facilities involves the potential for occupational exposure to radioactive materials and other sources of ionizing and non ionizing radiation. In the case of the facility, the imaging room was separated from the treatment area by a single door. This is not an ideal situation since the radiation from the imaging equipment may be toxic to the staff members working in the treatment area. Hence it i s extremely important to minimize the exposure to radiation, and shielding of the radioactive material and equipment through good facility design. Design Recommendations to Minimize the Impact of Occupational Stressors The f ollowing are specific as well a s general design recommendations for strategies that can be adopted to minimize the impact of ergonomics and layout as a stressor in the facility: 1. The facility design should attempt to lessen the risk of injuries by focusing on prevention strategies in the design of these spaces. An option would be to change the location of the radiology room in a future renovated facility and have a buffer zone for maximum safety of the staff members. 2. In addition, it is recommended to install a toxic gas monitoring system in the treatment area and the imaging room to ensure a safe work environment for the staff members.
131 Psychological Stressors satisfaction with the veterinary care facility. H alf of the participants (50%) said that overall, they found their work to be occasionally stressful, while approximately 36% said that they found their work to be frequently stressful. Additionally, a majority of the participants (64%) said that they have occasionally experienced exhaustion or near burnout at their workplace. The results are consistent with the literature stating that veterinarians are likely at a great risk to experience fatigue and exhaustion as a result of the nature of their work, and the circumstances at the workplace (Mitchener and Ogilvie, 2002) In addition, the study findings align with the findings of the Finnish study conducted levels of stress in veterinarians under 65 years of age. 73% of the veterinarians reported being rather or very stressed However, findings from the study do not support literature that highlights the intensity of burnout experienced by veterinary caregivers. Studies conducted by Mellanby et al (2010) and Miller and Beaumont ( 1995 ) suggest the existence of a high rate of suicide in veterinarians. Other studies claim that veterinarians exhibit high rates of depression, anxiety mental ill health, and mortality by suicides (Reijula, 2 003; Mitchener and Ogilvie, 2002; Mellanby et al, 2010; Piko, 2006; and Miller and Beaumont 1995 ). On the contrary, the respondents in this study did not report any of the above symptoms associated with stress, nor nearing burnout or suicide. The findings from the study revealed that half the participants (50%) said that overall, they found their work to be occasionally stressful. Eighty six percent of the respondents said that although their
132 job would range from being moderately to occasionally stressful, it could get extremely stressful during certain occasions, especially when they had a difficult client, if there was an emergency or when they were short staffed. Moreo ver, only 36% of the respondents said that overall, they found their work to be frequen tly stres sful. In addition only 28% of the respondents admitted that they had experienced exhaustion or near burnout at their workplace. However, these respondents claimed that the reason for their burnout was due to their job demands and not related to th e physical environment of the facility. The study suggests that due to this contradiction in findings there may be the possibility that the design of the case study facility ameliorate s rather than foster the stress. An additional reason for the low levels of stress may be that the proximity of the caregivers to the animals may contribut e in relieving their stress. Twenty nine percent of the respondents revealed that working with animals were a major de stress ing aspect of their job as veterinary caregivers. Moreover, there is a possibility that additional factors like workload, job experience, professional group, better pay, administration control and organizational culture, professional satisfaction, gender, and family and social relationships, may have positively contributed to reduced stress levels and absence of burnout (Samuels et al., 2003; Kaplan, 2003; Kangas et al., 2003 and; Gormley, 2003). Merits to the Design and its Contribution to Ameliorate Care giver Stress The study findings suggested that other than the minor, correctable issues of noise control, indoor air quality privacy consideration/personal space, visual access, safety activity requirements, the design features and the physical environmen t of the facility had a positive effect on the stress and satisfaction levels of the veterinary staff.
133 Lighting A lthough a subs tantial amount of literature is available on the effect of lighting as a stressor, the study findings suggested that lighting co nditions in the facility were not perceived to impact the stress levels of the participants. O ut of the total number of responses related to environmental stressors, only nine percent identified lighting within the facility. The explanation of this finding that is, the low level of influence of lighting on the stress levels of the veterinary caregivers, is that the lighting conditions in the facility appear to be optimal The study reveal ed that the facility relies extensively on daylight for illumination purpose s Most areas in the facility have transparent windows that allow the natural light (daylight) to enter. According to Boyce et al. (2003), daylight has a greater probability of maxim izing visual performance than most forms of electric lighting because it tends to be delivered in large amounts with a spectrum that ensures excellent color rendering. In addition, daylight reduces the incidence of health problems caused by the rapid fluct uation in light output typical of electric lighting (Boyce et al.,2003). The findings from th e study revealed that 50% of respondents said that the intensity of lighting conditions in the facility was not stressful, while approximately 35% said that the l ighting condi tions were minimally stressful. A possible reason for these findings may be the observation that the daylighting in the facility appears to have be en implemented correctly. In this case, the transparent windows in the facility have blinds that allow the staff members to control the amount of daylight entering the space. This avoids the problem of excessive glare and high t emperatures associated with daylight. According to Boyce et al. (2003), windows are strongly preferred in workplaces for the daylight they deliver and the view they provide, as long as they do not cause visual or
134 thermal discomfort, or loss of privacy. Additionally, employees may respond negatively if windows are exposed directly to the sun and create bright glare patches in th e room interiors (Ulrich, 2000). ghting. In terms of most and least preferred type of lighting, all of the respondents (100%) rated dayli ght to be the most satisfactory, follow ed by task lighting. According to Edward and Torcellini (2002), daylight provides a better lighting environment than electric light sources because it most closely matches the visual response that, through evolution, humans have come to compare with all ot her lights. The human eye functions at its best when it received the full spectrum of light provided by daylight. A study conducted by Applebaum, Fowler and Fiedler (2010) found that caregivers exposed to natural daylight for at least three hours a day exp erienced less stress and were more satisfied at work Further, daylighting has also been associated with improved mood, enhanced morale, lower fatigue and reduced eyestrain ( Edward and Torcellini, 2002). The study findings revealed that 29% of the respond ents said that the bright levels of fluorescent lighting in the facility were migraine inducing and appeared too bright for the eye. The notion that artificial lighting conditions might affect workers is consistent with the literature that states that constant exposure to artificial light, in particular fluorescent tube light, is commonly mentioned by caregivers as the most draining aspect of their work (Applebaum, Fowler and Fiedler, 2010). In this facil ity, the use of artificial lighting appeared to be the highest in th e examination rooms, treatment areas and the kennel. Moreover, it was observed that although the la boratory was illuminated by daylight from the windows, it used artificial lighting to sup plement specific task
135 requirements. In addition, 36% of the respondents revealed that certain areas in the facility like the treatment area; examination rooms and kennel have few to no windows resulti ng in lower illumination levels. According to the respon dents, these areas must depend on task lighting at all hours which among other consequences may lead to higher operational costs Recent studies have shown that people who perceive their office lighting as being of higher quality rate the spa ce as more attractive, report more pleasant moo d, and show greater well being at the end of a working day. Also, l ighting conditions that improve visibility also improve task performance (Mayhoub and Carter, 2010). Additionally, several other studies prove that building occupants prefer windows that provide natural lighting and views of nature due to their positive effects on psychological and physical well being (Farley and Veitch, 2001; Ulrich, 2000; Applebaum, Fowler and Fiedler, 2010; Edward and Torcell ini, 2002). Materials and Finishes The findings from the study indicated that only 26% of the occurrences attributed their perceived ergonomics and layout related stress to the materials and furnishings in the facility. Floors. Results indicated that the flooring in the reception and examination rooms is made of non slip tiles that are easily cleanable. This is ideal since there is a possibility that a pet may urinate or otherwise engage in purposeful territorial marking while waiting in these areas. In a ddition, the flooring in the laboratory, treatment area and the adj co ved sheet rubber flooring, which is an easily maintained material. As previously mentioned, t he study findings revealed that only one respondent claimed to have slipped and fallen on certain occasions in the facility.
136 Hence, it may be concluded that the facility has an effective flooring material that does not add to the ergonomics and layout related stress. Literature states that floors are probably the mo st critical finish of a veterinary facility since they are subject to constant abuse and maintenance (Usiak, 2004). According to Portner and Johnson (2010), tile is a popular choice for reception areas, but it is important to select a non porous tile that has minimal texture because small ridges or crevices can trap dirt and bacteria. However, t ile is not a good choice for the clinical areas of the hospital because the grout filled cracks between tiles can trap bacteria (Portner and Johnson, 2010). I n the c ase of the facility, it was observed that the kennel area had epoxy flooring, which has a sea mless impervious membrane. Not only is the epoxy flooring easily cleanable and durable, but also dirt and bacteria cannot penetrate the flooring. These findings ar e consistent with the literature, which states that a better choice for clinical areas is an integral base. Poured epoxy flooring and sheet vinyl flooring both allow for continuation of the floor material up the wall, avoiding any joints that could harbor bacteria (NIH, 2003) According to Portner and Johnson (2010), floor s in clinic al areas should be easy to clean This requires that the surface to be relatively smooth, non porous, water resistant, and physically not affected by germicidal solutions. Ideal ly the floors in clinical areas should be monolithic (seamless) which appears to be the case in the facility However, i t is important to avoid a completely smooth surface; although ideal for infection control, it can create a serious slippery hazard for clients and caregivers when wet, and some dogs may have difficulty walking on it (p.E2). As previously mentioned, the flooring in wet areas of the facility including the grooming area consists of tiles that
137 are marked with anti slip strips for superior gri p. According to NIH (2003), because of frequent washing/ wetting down of surfaces, floor areas should be slightly sloped to the drain to reduce pooling of water and the probability of slips and falls. The use of floor drains was prominent in the kennel area of the facility. The respondents mentioned that the presence of the floor drains at strategic locations made it easier for them to clean the floor area of the kennel. Walls. According to Portner and Johnson (2010), wall finishes should depend on the area of the hospital A similar rationale is applied while selection the wall finishes of the different areas in the facility. The study revealed that the walls in the reception area, laboratory, imaging department and the surgery area are textur ed with semi gloss white paint. In addition, t he walls in the treatment area, the grooming area and the kennel ar e exposed concrete block with vermiculite filling Overall, walls feature continuous, smooth finishes. These findings are consistent wit h literature specifying that walls in the veterinary facility should be free from cracks, unsealed penetrations, or imperfect junctions with ceilings and floors (NIH, 2003). Further, it was observed that the wall base in the reception and waiting area, the retail area the grooming area and the kennel was made of easily cleanable tiles while that in the laboratory, treatment area and the imaging area was made of coved sheet rubber flooring Literature states that the wall base should also be selected with infection control in mind. In addition it was observed that the wall base was coved as right angled corners between the wall and the floor are difficult to clean and may lead to accumulation of bacteria. Ceiling. The study findings revealed that while t he ceiling in the examination rooms, the treatment areas, the kennel and the administrative areas in the facility were
138 made of cleanable modular acoustical tiles t he ceiling in the surgery and the imaging department was textured with semi gloss white pain t. In addition, as previously mentioned in Chapter 4, the reception area and the waiting area, retail area and the laboratory have a high vaulted ceiling with semi gloss white paint. This is consistent with literature indicating that all areas in the veter inary facility, except the administrative and reception areas require ceilings that are smooth, free of crevices and imperfect junctions with walls, and capable of withstanding scrubbing with detergents, disinfectants, and water under pressure on a frequen t basis (NIH, 2003) According to Jeyaretnam, Jones and Phillips (2000), c eiling selection in operating rooms is of great concern because particulate matter from the ceiling can drift into open body cavities. Acoustical ceiling tile has crevices that can trap dust and harbor bacteria or mo ld. Ceiling tiles are also not washable crumble when handled. It is therefore advisable to install a hard ceiling that is smooth and washable in operating rooms which is also the case in the facility Introduction of nature and decorative f eatures Observations found that the area above the reception desk had mechanical ducts, the c asing of which allowed for introduction of overhead ornamentation. In the facility, this space was used to display artificial vines for ad ditional reference to the outdoor environment. According to a study conducted by Leather et al (1998), introduction of natural environments at the workplace are advantageous to the workers because they provide an opportunity for recovery from mental fatigu e. The facility is surrounded by extensive landscaping and is designed to be very attractive to the clients. The findings from the study indicated that 57% of the
139 respondents mentioned the landscape and the access to natural views as one of the most favor able features of the facility. In addition, it was observed that staff members would often take a break from their work tasks to stroll in the landscaped area. According to Farley and Veitch (2001), the preference for natural over built views is one of th e earliest and the most consistent findings in literature. According to Moser (2010), they are concerned about patients can be reduced Recommendations for Future Research This study hopes to serve as a springboard for future research in the field of veterinary care facilities and how they influence the perceptions of caregivers with regards to stress and satisfaction. H ence a few recommendations would be suitable to initiate future research. First, it would be interesting to examine the connection between comparative studies conducted on other award winning sma ll animal veterinary facilities to further test the theoretical framework of this study. Second additiona l r esearch to compare and contrast this similar case studies conducted on large animal veterinary facilities may possibly uncover new theories. Moreover s ince none of the clients ( animal owners ) were involved in this study, a future study may focus on this group to understand the effect of physical environment of the facility on the clients. Finally since this study focused on the effect s of environmental stressors, a more detailed inquiry is su ggested to explore the effects of the occupational and psychological stressors on the caregivers. Additionally a future study may address the effect of additional stressors like psychosocial stressors not considered in this case study.
140 Conclusion of Dis cussion The primary purpose of the study was to analyze and understand the existing physical environmental conditions in the veterinary care facility and its effect on the stress and satisfaction levels of the veterinary caregiv ers. In addition, the study aimed to Association (AAHA) and other institutions that have granted numerous design awards to it, including the Veterinary Economics Design Merit Award and the Veterinary Econo mics Hospital Design Award in the Hospital of the Year competition. Further, the study also attempted to uncover any ambiguities in the design and suggests areas for improvement. The study findings clearly substantiated the premise that the constituents of the physical environment have both a direct and indirect impact on the stress and satisfaction levels of veterinary caregivers. The distribution of responses highlight the hierarchy of issues that affect the stress and satisfaction levels of the caregiver staff in the facility. The findings from the study indicate that the issues of noise control, climate control, privacy consideration/personal space, visual access, activity requirements and safety requirements were the most noteworthy stressors affecting the caregiver staff. Of these, noise was the highest cited environmental stressor in the facility with 47% of occurrences attributing their perceived stress to the noise control conditions in the facility. Further, out of the 15 occurrences related to IAQ 80% identified their perceived stress to the climate cont rol conditions in the facility, whereas out o f 15 occurrences related to ergonomics and layout related stress, 33% attributed their stress to the privacy conditions/personal space in the facility. The findings from the study imply that some of the highest cited stressors do not allow a sense of control to the caregiver
141 staff In this context, the loss of control over these stressors may positively contribute to the perception of stress. According t o Ulrich (2000), provision of actual or perceived control over stressors may alleviate stress. However, the findings from the study indicated that despite the aforementioned stressors that affected the staff members, a majority of the caregiver staff (86% ) declared that they were satisfied with the physical environment of the facility In this context, a majority of the ambient stressors present in the physical environment of the facility, including lighting, indoor air quality and ergonomic and layout con ditions, do not have a significant effect on the stress and satisfaction levels of the caregiver staff. Further, the satisfaction of the majority of the caregiver staff with the physical environment of the facility suggests that the design successfully con tributes in ameliorating the caregiver stress. Since the physical setting of our study was assumed to be an optimally designed facility, these positive findings support the premise of the study. Hence, t he results from the study can be interpreted to sugg est that the design of the facility lessens rather than adds stress to the caregivers The study findings suggest that the otes satisfaction and wellbeing, making it a model design for future veterinary faciliti es. Since the merits of the physical environment of t he facility are confirmed by these findings, the claims of the AAHA accreditation and the numerous design awards granted to the facility are well justified Further, s ince the lighting and ergonomic and layout conditions in the facility have proved to be optimal ; the following are general design strategies that can be learned from this particular design:
142 1. The facility relies extensively on daylight for illumination purpose. Most areas in the facility are illuminated by natural sunlight from no n operable transparent windows. In addition, artificial lighting from fluorescent fixtures provides higher illumination to the specific task areas while incandescent fixtures highlight the artwork in the public areas It is recommended that future facilities adopt a similar well designed system of a combination of natural and artificial lighting. In addition it is recommended to try and minimize the dependency on fluorescent lighting by incorporating daylighting sour ces such as windows whenever possible Not only will this prove to be energy efficient, but also improve heath and performance outcomes. 2. I t is important to appropriately plan the zones and critical adjacencies in the facility based on the findings of our study. In additio n, it is important to provide adaptive environments, along with ergonomically correct work surfaces, heights and access for staff. Further, it is important to pay special attention to the materials and finishes in future facilities, including the choice of flooring, walls and ceiling. T he design of the facility should include natural characteristics and visual features including daylight, nature views from transparent windows and indoor plants. 3. Finally, the findings of the study sugg est that good indoor air quality does not necessarily depend on the use of a natural ventilation system. Although, natural ventilation from operable windows is most preferred by the building occupants, a well designed and well maintained HVAC system can be as effective in maintaining an acceptable indoor air quality in future facilities. Knowle dge generated by this study may contribute to a better understanding of how the environmental conditions in veterinary care facilities can be designed to create a be tter workplace for the caregivers. The results of this study could be useful to designers; veterinary caregivers and clients when engaged in pre design considerations for designing small veterinary care facilities.
143 APPENDIX A INSTITUTIONAL REVIEW BOARD PE RMISSION
144 APPENDIX B INFORMED CONSENT FOR M 1
145 APPENDIX C INFORMED CONSENT FOR M 2
146 APPENDIX D PERSONAL INTERVIEW Q UESTIONS SAMPLE Demographic Questions: Professional group 1) Veterinary doctor 2) Technician 3) Administrative staff 4) Other Gender 1) Male 2) Female Age category 1) Less than 25 years 2) 25 35 years 3) 36 45 years 4) 46 55 years 5) 56 65 years Professional/Vocational experience 1) < 1 year 2) 1 < 3 years 3) 3 < 5 years 4) 5 < 7 years 5) 7 <10 years Workload per week 1) Less than 2 0 hours 2) Between 20 4 0 hours 3) Between 40 6 0 hours 4) More than 6 0 hours Area/s of the facility where you work Please mark in the floor plan the areas where you work, and assign an approximate percentage of weekly hours spent in e ach one
147 I ntroduction: Hello. I have read in the literature that the physical environment in a veterinary facility can have a negative effect on the stress and satisfaction levels of the caregiver staff. Statistics says that stress is pertinent to the job of a veterinary caregiv er. I want to ask you how stressful is your work (How stressful is your job really?). Is your stress, in particular, related to your workplace? (I am interested in the stress related to your working conditions) Environmental Stressors Noise A) To what e xtent, if any, is treatment of ambient sound levels in your workplace a source of stress for you? Please indicate the intensity of the stress caused by the noise conditions using a 1 5 scale: 1 extremely stressful 2 very stressful 3 moderately stressfu l 4 minimally stressful 5 not stressful B) How often, if any, is treatment of ambient sound levels in your workplace a source of stress for you? 1 all the time/ continually 2 often 3 occasionally 4 rarely 5 never C) How satisfied are you with the w ay acoustic conditions are handled in the facility? 1) very unsatisfied acoustic conditions are highly disruptive/ obstructive for my work 2) somewhat unsatisfied acoustic conditions are moderately disruptive/ obstructive for my work. 3) neutral (neither satisfied nor unsatisfied) acoustic conditions are neither disruptive/obstructive or supportive for my work 4) satisfied acoustic conditions are moderately supportive for my work 5) very satisfied acoustic conditions are highly supportive fo r my work
148 D) If applicable, what do you think makes for less than optimal acoustic conditions in your workplace? Lighting A) To what extent, if any, is the treatment of the lighting conditions in your workplace a source of stress for you? Please indicate t he intensity of the stress caused by the lighting conditions using a 1 5 scale: 1 extremely stressful 2 very stressful 3 moderately stressful 4 minimally stressful 5 not stressful B) According to the nature of tasks performed by you, rate the followin g sources of light in order of your level of satisfaction with them, beginning with the least satisfactory source: __ daylight (natural light) __ task lighting (functional lighting) __ accent lighting (decorative lighting) __ other C) How satisfied are yo u with the way lighting conditions are handled in the facility? 1) very unsatisfied lighting conditions are highly disruptive/ obstructive for my work 2) somewhat unsatisfied lighting conditions are moderately disruptive/ obstructive for my work. 3) neut ral (neither satisfied nor unsatisfied) lighting conditions are neither disruptive/obstructive or supportive for my work 4) satisfied lighting conditions are moderately supportive for my work 5) very satisfied lighting conditions are highly supportive for my work D) If applicable, what do you think makes for less than optimal lighting conditions in your workplace? Indoor Air Quality Indoor air quality can be defined as the condition or nature of air inside the building, that affects the health and well being of occupants.
149 A) To what extent, if any, is treatment of indoor air quality in your workplace a source of stress for you? Please indicate the intensity of the stress caused by the indoor air quality conditions using a 1 5 scale: 1 extremely stres sful 2 very stressful 3 moderately stressful 4 minimally stressful 5 not stressful B) How often, if any, is the treatment of indoor air quality in your workplace a source of stress for you? 1 all the time/ continually 2 often 3 occasionally 4 rar ely 5 never C) How satisfied are you with the way indoor air quality is handled in the facility? 1) very unsatisfied indoor air quality conditions are highly disruptive/ obstructive for my work 2) somewhat unsatisfied indoor air quality conditions are m oderately disruptive/ obstructive for my work. 3) neutral (neither satisfied nor unsatisfied) indoor air quality conditions are neither disruptive/obstructive or supportive for my work 4) satisfied indoor air quality conditions are moderately supportive for my work 5) very satisfied indoor air quality conditions are highly supportive for my work D) If applicable, what do you think makes for less than optimal indoor air quality in your workplace? Ergonomics & Layout the workspace conditions (layout, furnishings, and equipment ) that makes work comfortable and efficient A) How often do you perform physically strenuous tasks at work? Please describe what these tasks entail.
150 B) To what extent, if any, is the treatment of the ergonomic conditions in your workplace a source of stress for you? Please indicate the intensity of the stress caused by the ergonomic conditions using a 1 5 scale: 1 extremely stressful 2 very stressful 3 moderately stressful 4 minimally stres sful 5 not stressful C) How satisfied are you with the way that ergonomic conditions are handled in the facility? 1) very unsatisfied ergonomic conditions are highly disruptive/ obstructive for my work 2) somewhat unsatisfied ergonomic conditions are moderately disruptive/ obstructive for my work. 3) neutral (neither satisfied nor unsatisfied) ergonomic conditions are neither disruptive/obstructive or supportive for my work 4) satisfied ergonomic conditions are moderately supportive for my work 5) very satisfied ergonomic conditions are highly supportive for my work D) How would you rate your satisfaction levels with the following using a 1 5 scale (1 extremely satisfied, 2 very satisfied, 3 moderately satisfied, 4 minimally satisfied, 5 not satisfied) __ Ease of circulation in the facility __ Ease of access to supplies __ Adjacencies of the different departments __ Privacy for sensitive activities Occupational Stressors Injury A i) During the past 12 months, how often have you had an injury caused by the environmental features at your workplace? 1) never 2) rarely 3) occasionally 4) frequently 5) always
151 A ii) If applicable, p lease describe the cause and effect of this/these injury/ injuries B) To what extent, if any, is the potential fo r injury due to your workplace features a source of stress for you? Please indicate the intensity of the stress caused by this issue using a 1 5 scale: 1 extremely stressful 2 very stressful 3 moderately stressful 4 minimally stressful 5 not stressfu l C) How satisfied are you with the way the safety of the physical environment is handled in the facility? 1) very unsatisfied safety conditions are highly disruptive/ obstructive for my work 2) somewhat unsatisfied safety conditions are moderately dis ruptive/ obstructive for my work. 3) neutral (neither satisfied nor unsatisfied) safety conditions are neither disruptive/obstructive or supportive for my work 4) satisfied safety conditions are moderately supportive for my work 5) very satisfied safety conditions are highly supportive for my work Risks/ Hazards A) In your opinion, what are the major hazards in your workplace that may have a direct/ indirect effect on your stress levels/ risk of injury? B) To what extent, if any, are the hazards re lated to your workplace features a source of stress for you? Please indicate the intensity of the stress caused by these hazards using a 1 5 scale: 1 extremely stressful 2 very stressful 3 moderately stressful 4 minimally stressful 5 not stressful Psychological Stressors Burnout/ Exhaustion/ Fatigue
152 A) Overall, how stressful do you find your work? 1) never stressful 2) rarely stressful 3) occasionally stressful 4) frequently stressful 5) always stressful B) During the past 12 months, how often have experienced exhaustion or nearing burnout at your workplace? 1) never 2) rarely 3) occasionally 4) frequently 5) always Miscellaneous Satisfaction A) Overall, how satisfied are you with the physical conditions at your workplace? 1) totally uns atisfied 2) partially satisfied 3) neither satisfied nor unsatisfied 4) partially satisfied 5) very satisfied B) In your opinion, what are the workplace features that are the most favorable and unfavorable for you? Recommendations What would be your suggestions for design choices/ strategie s that should be included in a renovated facility in the future?
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161 BIOGRAPHICAL SKETCH Anuprita Arun Salkar was born and raised in India. She received her five year from University of Mumbai, India in 2006. Attesting to her interest in on animal welfare and building design, her final year thesis topic center ed on the design and developme nt of a veterinary hospital. After one and a half years of work experience as a junior architect in an architectural design firm, she moved to the United States in Fall 2008 to pursue a master s degree in interior d esign at th e University of Florida. Her research interests lead again to her thesis topic. Following the career as an architect, designer and animal welfare activist.