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The Effect of Lighting on the Caregivers' Satisfaction in a Neonatal Intensive Care Unit

Permanent Link: http://ufdc.ufl.edu/UFE0045139/00001

Material Information

Title: The Effect of Lighting on the Caregivers' Satisfaction in a Neonatal Intensive Care Unit
Physical Description: 1 online resource (160 p.)
Language: english
Creator: Mozaffarian, Rozita
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: care -- caregivers -- design -- lighting -- neonatal -- satisfaction -- unit
Interior Design -- Dissertations, Academic -- UF
Genre: Interior Design thesis, M.I.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The concept of healing environment in healthcare has been of great importance in the past few years. One of the departments of hospitals that can greatly benefit from this theory is NICU. Newborns and caregivers are in a tense and critical situation and providing a soothing and at the same time practical environment for them has a great impact on both the healing of newborns and caregivers’ health and job performance. One of the design aspects that can contribute to achieve this goal is lighting; especially in NICU, lighting has great importance since the level of lighting needed by newborns is different than that by caregivers(Dalke et al., 2005). This study is a case study of the NICU department in Shands Hospital at the University of Florida and focuses on caregivers’ lighting satisfaction in NICU as well as providing a comparison of the existing lighting condition of Shands NICU and the IESNA lighting recommendations. A total of 96 doctors,nurses and parents randomly participated in this study. They were given a questionnaire that asked for their demographic questions, their tasks and their satisfaction level with different aspects of lighting in Shands NICU. The aspects of lighting quality were majorly categorized as general lighting, task lighting, natural lighting and controllability. The participants were also asked to volunteer in an interview and 10 people in each group participated in it. The results show different levels of satisfaction based on groups’ demographic, their tasks and the aspect of lighting quality being evaluated. The major difference was between nurses and family members; this could be mainly because of the difference in their age and tasks. The results also show that following the recommended standards does not necessarily guarantee caregivers’ satisfaction. This study recommends some improvements in the IESNA recommended standards. For example, some of the recommendations by IESNA are too general and need to be proposed more in depth and details based on each group of caregivers, their tasks and demographics. Results also show that Shands NICU lighting needs some improvements such as focusing more on the quality of task lighting so that the general lighting is used only for navigation and minimal levels of facial recognition. This way the problem of newborns needing dim light for their circadian rhythm and caregivers needing bright light because of their tasks, can be solved. The issues of controllability and direct light exposure to the newborns’ eyes are very importance in Shands NICU. Further researches could expand the number of case studies in order to come up with a more detailed recommendation for NICU lighting design and also to be able to generalize the results for all NICU’s. Also, the issue of effects of environmental factors on job satisfaction can be looked at in more details in future studies. The impact of natural lighting on caregivers stress and satisfaction can be also studied more in depth by choosing a healthcare environment that relies on natural lighting more than Shands NICU.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Rozita Mozaffarian.
Thesis: Thesis (M.I.D.)--University of Florida, 2012.
Local: Adviser: Park, Nam-Kyu.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0045139:00001

Permanent Link: http://ufdc.ufl.edu/UFE0045139/00001

Material Information

Title: The Effect of Lighting on the Caregivers' Satisfaction in a Neonatal Intensive Care Unit
Physical Description: 1 online resource (160 p.)
Language: english
Creator: Mozaffarian, Rozita
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: care -- caregivers -- design -- lighting -- neonatal -- satisfaction -- unit
Interior Design -- Dissertations, Academic -- UF
Genre: Interior Design thesis, M.I.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The concept of healing environment in healthcare has been of great importance in the past few years. One of the departments of hospitals that can greatly benefit from this theory is NICU. Newborns and caregivers are in a tense and critical situation and providing a soothing and at the same time practical environment for them has a great impact on both the healing of newborns and caregivers’ health and job performance. One of the design aspects that can contribute to achieve this goal is lighting; especially in NICU, lighting has great importance since the level of lighting needed by newborns is different than that by caregivers(Dalke et al., 2005). This study is a case study of the NICU department in Shands Hospital at the University of Florida and focuses on caregivers’ lighting satisfaction in NICU as well as providing a comparison of the existing lighting condition of Shands NICU and the IESNA lighting recommendations. A total of 96 doctors,nurses and parents randomly participated in this study. They were given a questionnaire that asked for their demographic questions, their tasks and their satisfaction level with different aspects of lighting in Shands NICU. The aspects of lighting quality were majorly categorized as general lighting, task lighting, natural lighting and controllability. The participants were also asked to volunteer in an interview and 10 people in each group participated in it. The results show different levels of satisfaction based on groups’ demographic, their tasks and the aspect of lighting quality being evaluated. The major difference was between nurses and family members; this could be mainly because of the difference in their age and tasks. The results also show that following the recommended standards does not necessarily guarantee caregivers’ satisfaction. This study recommends some improvements in the IESNA recommended standards. For example, some of the recommendations by IESNA are too general and need to be proposed more in depth and details based on each group of caregivers, their tasks and demographics. Results also show that Shands NICU lighting needs some improvements such as focusing more on the quality of task lighting so that the general lighting is used only for navigation and minimal levels of facial recognition. This way the problem of newborns needing dim light for their circadian rhythm and caregivers needing bright light because of their tasks, can be solved. The issues of controllability and direct light exposure to the newborns’ eyes are very importance in Shands NICU. Further researches could expand the number of case studies in order to come up with a more detailed recommendation for NICU lighting design and also to be able to generalize the results for all NICU’s. Also, the issue of effects of environmental factors on job satisfaction can be looked at in more details in future studies. The impact of natural lighting on caregivers stress and satisfaction can be also studied more in depth by choosing a healthcare environment that relies on natural lighting more than Shands NICU.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Rozita Mozaffarian.
Thesis: Thesis (M.I.D.)--University of Florida, 2012.
Local: Adviser: Park, Nam-Kyu.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0045139:00001


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1 THE EFFECT OF LIGHTING ON THE CAREGIVERS SATISFACTION IN A NEONATAL INTENSIVE CARE UNIT By ROZITA MOZAFFARIAN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREM ENTS FOR THE MASTER OF INTERIOR DESIGN UNIVERSITY OF FLORIDA 2012

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2 2012 Rozita Mozaffarian

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3 To my Mom Nahid, my Dad, Mohammad and my Sisters, Romina & Roya Mozaffarian

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4 ACKNOWLEDGMENTS I would like to thank my thesis chair, Dr. Na m Kyu Park for her support, encouragement and guidance throughout this process. She was not only my advisor but my mentor. This journey wouldnt be possible without her believing in me I would also like to thank Professor Jason Meneely, my committee member for his insightful comments and suggestions. Graduating would not be possible without these professors understanding and faith in my abilities. A special thanks to Dr. Margaret Portillo, the chair of the department of interior design, for her support and assist in completing my study; and also Professor Candy Carmel Gilfillan for her support in this path. I would like to express my special thanks to Shands NICU staff and family; specially Dr. Sandra Sullivan who was my first contact at Shands Hospital and made it possible for me to use Shands NICU as a case study for my research, Mrs. Elizabeth Talaga who tremendously supported me throughout my data collection in Shands NICU, Mr. George Magee who had an important role in obtaining demographical information about Shands NICU staff and family and reaching out to the caregivers for data collection, and Dr. David Burchfield for his support in my data collection. I extend my thanks to Shands Hospital at the University of Florida for allowing me to collect infor mation about the lighting design of their interior environment especially Mr. Bradley Pollitt, the Vice President of Facilities in Shands, for providing necessary documents about Shands NICU and for his insights. Also I wanted to thank the Department of i nterior Design at University of Florida for accommodations to the Interior Design students, great studios that were my second home for few years and providing graduate students office which had a great role in my

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5 ability to finish my thesis; and special t hanks to the Interior Design Office Manager, Ms. Vicky Traylor for her great help and support. F inally thanks to anyone in the D epartment of Interior Design who somehow supports students and make their lives easier. Special thanks to Dr. Chini for his time and support and always being there for me when I needed him; and Mr. Fred Vyverburg for believing in me and giving me my first job in the field of design even before I start the Interior Design program. Also, I want to thank future doctors, Johnny Wu and Nima Afshar Mohajer for helping me with using SPSS for data analysis. Finally, my deepest gratitude goes to my family and those true friends of mine who somehow supported me in my journey of completing graduate education. My Mom, Nahid, who always encouraged me to put education as my priority and did everything possible to make this goal possible and easy for me; m y Dad, Mohammad, whose priority was always the success and comfort of his children. This wouldnt be possible without you two. My sisters, Romina who was one of the initial encouragements for my changing majors to Interior Design and has always supported me with her insight and resources and Roya who has always initiated in providing me with great information in the field of Interior Design. I woul dnt be even close to where I am if it wasnt for my family.

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6 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 LIST OF TABLES .......................................................................................................... 10 LIST OF FIGURES ........................................................................................................ 11 LIST OF ABBREVIATIONS ........................................................................................... 13 ABSTRACT ................................................................................................................... 14 CHAPTER 1 INTRODUCTION .................................................................................................... 16 Research Purpose .................................................................................................. 19 Research Questions ............................................................................................... 20 Summary ................................................................................................................ 20 Definition of Terms .................................................................................................. 21 2 LITERATURE REVIEW .......................................................................................... 22 Healthcare Design .................................................................................................. 22 Neonatal Intensive Care Unit Design ...................................................................... 23 Lighting Design in NICU .......................................................................................... 24 IESNA Lighting Recommendations ......................................................................... 33 General Lighting vs. Task Lighting ................................................................... 33 Color Rendering Quality ................................................................................... 34 Circadia n Rhythm vs. Vision ............................................................................. 34 Day Shift vs. Night Shift .................................................................................... 35 Control, Glare, Shadow and Vertical Surfaces ................................................. 37 Conclusion .............................................................................................................. 37 3 RESEARCH METHODS ......................................................................................... 38 Study Design .......................................................................................................... 38 Case Selection Criteria ........................................................................................... 38 Setting ..................................................................................................................... 39 NICU II .............................................................................................................. 42 Newborn Care Area II ................................................................................ 42 Support Areas in NICU II: .......................................................................... 45 NICU III ............................................................................................................. 45 Newborn Care Area ................................................................................... 45 Support Areas in NICU III .......................................................................... 52 Participants ............................................................................................................. 56

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7 Research Instruments ............................................................................................. 57 Observation ...................................................................................................... 57 Documentation ................................................................................................. 57 Survey .............................................................................................................. 58 Interview ........................................................................................................... 60 Pilot Study ............................................................................................................... 60 Sampling and Data Coll ection ................................................................................. 61 Informed Consent ...................................................................................... 61 Observation and Documentation ................................................................ 62 S urvey ........................................................................................................ 62 Interview ..................................................................................................... 63 Data Analysis .......................................................................................................... 63 Problems and Limitations ........................................................................................ 63 4 RESULTS ............................................................................................................... 65 Characteristics of the Participants .......................................................................... 65 Compariso n of the Observation and Documentation Findings (Existing Conditions of Shands NICU) with the IESNA Recommended Standards ............ 68 Newborn Care Areas ........................................................................................ 68 NICU II: ...................................................................................................... 68 NICU III ...................................................................................................... 68 Support Areas .................................................................................................. 73 Support areas in NICU II ............................................................................ 73 Support areas in NICU III ........................................................................... 74 Summary of Observation and Documentation Findings ................................... 75 Survey Findings ...................................................................................................... 75 Lighting Satisfaction Analysis by Groups ......................................................... 76 Doctors satisfaction w ith newborn care areas ........................................... 76 Doctors satisfaction with support areas ..................................................... 77 Summary .................................................................................................... 77 Nurses Satisfaction with newborn care areas ........................................... 78 Nurses satisfaction with support areas ...................................................... 79 Summary .................................................................................................... 80 Families satisfaction with newborn care areas .......................................... 81 Families satisfaction with support areas .................................................... 81 Summary .................................................................................................... 81 Comparison of Caregivers Satisfaction ........................................................... 82 Interview Findings ................................................................................................... 91 General Lighting ............................................................................................... 92 Task Lighting and Natural Lighting ................................................................... 93 Controllability .................................................................................................... 93 5 DISCUSSION ......................................................................................................... 94 Research Question OneTo What Extent, If Any, Does Shands NICU Existing Lighting Condition, Meet The IESNA Recommended Standards? ....................... 94

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8 General Lighting ............................................................................................... 94 Task Lighting .................................................................................................... 99 Natural Lighting .............................................................................................. 100 Controllability .................................................................................................. 101 Research Question TwoHow Satisfied Are the Caregivers from the Existing Shands NICU Lighting Conditions? ................................................................... 103 What are the Visual Tasks that Each Group of Caregivers Do While Spending Time in NICU? ............................................................................. 103 What Is Caregivers Satisfaction Lev el With The General And Task Lighting? ...................................................................................................... 104 What Is Caregivers Satisfaction Level with the Natural Lighting? .................. 112 What Is Caregiv ers Satisfaction Level With Lighting Controllability? ............. 114 Conclusion and Further Research ........................................................................ 115 APPENDIX A IRB APPROVAL ................................................................................................... 118 B CONSENT FORM ................................................................................................. 119 C RESEARCH AND INFORMATION PRIVACY AT THE UNIVERSITY OF FLORIDA CERTIFICATION .................................................................................. 120 D CONFIDENTIALITY STATEMENT ....................................................................... 121 E SURVEY INSTRUMENT 1 (DOCTORS, NURSE PRACTITIONERS & RESIDENTS) ........................................................................................................ 122 F SURVEY INSTRUMENT 2 (NURSES, RESPIRATORY THERAPISTS & TRANSPORT TEAM) ............................................................................................ 126 G SURVEY INSTRUMENT 3 (PARENTS AND FAMILIES) ...................................... 129 H INTERVIEW INSTRUMENT 1 (DOCTORS, NURSE PRACTITIONERS & RESIDENTS) ........................................................................................................ 133 I INTERVIEW INSTRUMENT 2 (NURSES, RESPIRATORY THERAPISTS & TRANSPORT TEAM) ............................................................................................ 134 J INTERVIEW INSTRUMENT 3 (PARENTS AND FAMILY) .................................... 135 K PARTICIPANTS COMMENTS ............................................................................. 136 L FREQUENCY FOR PARTICI PANTS LIGHTING SATISFACTION IN INTERVIEW .......................................................................................................... 153 LIST OF REFERENCES ............................................................................................. 155

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9 BIOGRAPHICAL SKETCH .......................................................................................... 160

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10 LI ST OF TABLES Table page 2 1 Sample of IESNA lighting recommendations for NICU ....................................... 36 4 1 Characteristics of the staff part icipants ............................................................... 66 4 2 Characteristics of the family participants ............................................................ 67 4 3 Comparison of Shands existing general lighting in NICU to IESN A recommended standards .................................................................................... 70 4 4 Comparison of Shands existing general lighting in NICU support areas to IESNA recommended standards ........................................................................ 72 4 5 Comparison of Shands existing task lighting in NICU to IESNA recommended standards .................................................................................... 73 4 6 Comparison of Shands existing natural lighting in NICU to IESNA recommended standards .................................................................................... 73 4 7 Mean (M) and Standard Deviation (SD) scores for caregivers satisfaction ........ 84 4 8 Mean (M) and Standard Deviation (SD) scores for staffs level of satisfaction with light supporting their tasks in their used spaces .......................................... 87 4 9 Mean (M) and Standard Deviation (SD) scores for families level of satisfaction with light supporti ng their tasks in their used spaces ....................... 87 4 10 Mean (M) and Standard Deviation (SD) scores for staffs level of satisfaction with light control .................................................................................................. 88 4 11 Mean (M) and Standard Deviation (SD) scores for families level of satisfaction with light control ............................................................................... 88 4 12 Frequency for participants comments on lighting dissatisfaction in surveys ...... 89 4 13 Mean and standard deviation for lighting satisfaction (Post HOC test) ............... 90 4 14 Mean and standard deviation fo r lighting satisfaction (ANOVA test) .................. 91 K 1 Caregivers Comments in Surveys ................................................................... 151 L 1 Frequency for participants lighting satisfaction in interview ............................. 153

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11 LIST OF FIGURES Figure page 3 1 Shands NICU ceiling/lighting plan ...................................................................... 41 3 2 Shands NICU floor plan (zoning diagram) .......................................................... 41 3 3 Shands NICU furniture and equipment plan ....................................................... 42 3 4 The isle along NICU II ........................................................................................ 43 3 5 NICU II general lighting ...................................................................................... 43 3 6 NICU II ceiling plan ............................................................................................. 44 3 7 NICU II floor plan ................................................................................................ 44 3 8 Newborn care area III floor plan ......................................................................... 46 3 9 Newborn care area III floor plan ......................................................................... 46 3 10 Typical bed spaces in NICU III ........................................................................... 47 3 11 Typical bed spaces in NICU III ........................................................................... 47 3 12 Typical general lighting for bed spaces in NICU III ............................................. 48 3 13 Emergency lights (spot light) .............................................................................. 49 3 14 Warmer with task light ........................................................................................ 50 3 15 Old task lights ..................................................................................................... 50 3 16 New task lights (girrafe) ...................................................................................... 51 3 17 Gener al lighting in hallways ................................................................................ 53 3 18 Lighting in oncall room ...................................................................................... 54 3 19 Lighting in the lobby (waiting room) .................................................................... 55 3 20 Lighting in pump room ........................................................................................ 55 4 1 A bed space with no general or task lighting ...................................................... 69 4 2 T ask area with no general or task lighting .......................................................... 71 4 3 Covering isolates with sheets to prevent direct light exposure to babies eyes .. 71

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12 4 4 Frequency of usage for spaces used by doctors group (showed in percentage) ........................................................................................................ 78 4 5 Frequency of usage for spaces used by nurses group (showed in percentage) ........................................................................................................ 80 4 6 Frequency of usage for spaces used by family group (in percentage) ............. 82 4 7 Frequency of visual tasks done by staff (showed in percentage) ....................... 83 4 8 Frequency of tasks done by families (showed in percentage) ............................ 84 4 9 Comparison of the means of level of light quality satisfaction for all three groups of caregivers ........................................................................................... 86 4 10 The frequency of caregivers usage of the controllable lighting features they have access to. ................................................................................................... 86

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13 LIST OF ABBREVIATI ONS CRI Color Rendering Index IESNA Illuminating Engineering Society of North America IRB Institutional Review Board LED Light Emitting Diode NICU Neonatal Intensive Care Unit PICU Pediatric Intensive Care Unit

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14 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Req uirements for the Master of Interior Design Degree THE EFFECT OF LIGHTING ON THE CAREGIVERS SATISFACTION IN A NEONATAL INTENSIVE CARE UNIT By Rozita Mozaffarian D ecember 2012 Chair: Nam Kyu Park Major: Interior Design The concept of healing environment in healthcare has been of great importance in the past few years. One of the departments of hospitals that can greatly benefit from this theory is NICU. Newborns and caregivers are in a tense and critical situation and providing a soothing and at the same time practical environment for them has a great impact on both the healing of newborns and caregivers health and job performance. One of the design aspects that can contribute to achieve this goal is lighting; especially in NICU, lighting has great importance since the level of lighting needed by newborns is different than that by caregivers (Dalke et al., 2005) This study is a cas e study of the NICU department in Shands Hospital at the University of Florida and focuses on caregivers lighting satisfaction in NICU as well as providing a comparison of the existing lighting condition of Shands NICU and the IESNA lighting recommendations. A total o f 96 doctors, nurses and families randomly participated in this study. They were given a questionnaire that asked for their demographic questions their tasks and their satisfaction level with different aspects of lighting in Shands NICU. The aspects of lighting quality were majorly categorized as

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15 general lighting, task lighting, natural lighting and controllability. The participants were also asked to volunteer in an interview and 10 people in each group participated in it. The results show different levels of satisfaction based on groups demographic, their tasks and the aspect of lighting quality being evaluated. The major difference was between nurses and family members ; this co uld be mainly because of the difference in their age and tasks. The results also show that following the recommended standards does not necessarily guarantee caregivers satisfaction This study recommends some improvements in the IESNA recommended standards. For example, some of the recommendations by IESNA are too general and need to be proposed more in depth and details based on each group of caregivers, their tasks and demographics. Results also show that Shands NICU lighting needs some improvements such as focusing more on the quality of task lighting so that the general lighting is used only for navigation and minimal levels of facial recognition. This way the problem of newborns needing dim light for their circadian rhythm and caregivers needing bright light because of their tasks, can be solved. The issues of controllability and direct light exposure to the newborns eyes are very importance in Shands NICU. Further researches could expand the number of case studies in order to come up with a more detailed recommendation for NICU lighting design and also to be able to generalize the results for all NICUs. Also, the issue of effects of environmental factors on job satisfaction can be looked at in more details in future studies. The impact of natural lighting on caregivers stress and satisfaction can be also studied more in depth by choosing a healthcare environment that relies on natural lighting more than Shands NICU.

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16 CHAPTER 1 INTRODUCTION For the past decade, reducing environmental impacts has been the goal of healthcare industry; they pursue this goal by engaging in a transformation of design, construction, and operational practices Today, Hospitals and healthcare environment represent an essential societal function with the fundamental goal of c aring for and healing the sick (Guenther et al., 2006). Recent r eviews and books (e.g. Devlin & Arneill, 2003; Verderber & Fine, 2000) have documented the evolution of the health care environment and the role that physical design may play in health and well being. What is of fundamental importance in this, is that the physical environment might be considered either as a source of stress or as a source of coping resources. Study has frequently found that physical and psychological elements interact in their effect on well being (Leather et al., 1998). The concept of heal ing environments suggests that the physical environment of the healthcare settings can affect the healing process and patients feelings of well being in a positive way. However, conclusive evidence in scrutinizing the effects of specific environmental sti muli is still very limited and difficult to generalize (Dijkstra et al., 2006). Study shows (Dijkstra, 2006) that physical environmental stimuli that turn healthcare facilities into healing environments is being challenged; also, the focus on healthcare is more as a curing machine for medical conditions, rather than as an environment to promote wellness for the individual (Arnell & Devlin, 2002). The framework proposed by Rashid & Zimring ( 2008) groups the physical environmental variables into two categories: indoor environmental variables and interior design variables. Indoor environmental variables include noise, lighting, ambient

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17 temperature, and air quality, whereas interior design variables include the use of space, furniture, fixtures and equipment, finishing materials, color, artwork, natural views, and environmental graphics. Previous investigations suggested that not enough evidence and research exist in the area of lighting. The existence of very old and limited research articles, such as that by M ehrabian and Russell (1974) or Dijkstra and colleagues (2006), indicate the need for the evaluation of the importance of features like lighting. Lighting has been of a great importance in healthcare environment since color and lighting can have an impact on peoples perceptions and responses to the environment and also affect patient recovery rates, improving the quality and overall experience of patients, staff and visitors. According to Kenner and Lott (2007), one section of hospitals that requires spec ific attention to its lighting is Neonatal Intensive Care Unit (NICU). NICU is defined as intensive care unit designed for premature and ill newborn babies, by Med Term website. Based on March of Dimes, approximately 3,000,000 babies are born each year in the United States and 543,000 of them, or 1 in 8, are born prematurely. This figure is growing fast due to rapid growth of population of the United States which has been about 1.1 % each year since the year 2000 (U.S. Census website: http://quickfacts.census.gov/ ); therefore the need for NICU continues to increase as well as the number of parents and family members who use spaces in NICU. Along with that the need for more caregivers such as doctors and nurses increases. On the other hand, the challenge of maintaining staff effectiveness will be increasingly important as the number of nurses is decreasing and the aging population is increasing (Ulrich et al., 2008). Jobs by nurses, physicians, and other healthcare workers often include direct

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18 patient care, critical communications, charting, accessing technology and information, and other tasks. A lot of these tasks are visual tasks that need proper lighting and need a level of lighting that is di fferent than that by caregivers (Carlson et al., 2006). Newborns need lowe r lighting level but the doctors and nurses need a higher level of illumination for their tasks. So, the lighting needs in NICU are almost bipolar (Ulrich et al., 2008); therefore, l ighting design is of a great importance in NICU design and lighting matters are not only related to newborns wellbeing but also the caregivers wellbeing and ability to work well as well as the family of the newborns. Also, changes are needed in NICU (Car lson et al., 2006) to keep caregivers satisfied. Newborns are the center point of the NICU and that is why most researches have studied the needs of the newborns and how to design NICU to improve the environment for them but we need satisfied and healthy c aregivers to take care of the babies; therefore it is time to focus on the caregivers as much as newborns and make changes in NICU design to meet their needs. A growing body of evidence on the developmentally appropriate healing environment for neonates al so suggests that changes are needed in NICU design. One good reason for this, suggested by Ulrich and colleagues (2008) is that the growth in the number of premature babies causes problems like admitting more babies than their bed spaces and not having adequate lighting for each baby which can often increase staff anxiety and reduce effective care delivery. So even though the job requirements and volume has changed for the caregivers, many hospitals have not been redesigned. There have been recommended standards for NICU design on different aspects including lighting by Illumination Engineering Society of North America (IESNA), but hospitals are rarely able to follow

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19 these standards (Dalke et al., 2005). The Consensus Committee to Develop Recommended Standar ds for NICU Design has developed recommended lighting standards for the NICU, based on IESNA standards. Although there have been s tudies about lighting needs of newborns in NICU, not enough study has been done to focus on the caregivers need. Study shows lighting in NICU is often poorly maintained, concentrating only on basic requirements for task illumination resulting in a poor visual environment for caregivers (Dalke et al., 2005). Therefore, this study seeks to explore the effect of lighting as an env ironmental stimulus on c aregivers satisfaction in NICU, in order to help them have a higher satisfaction and better job performance. Research Purpose Little is known about the effects of lighting on caregivers satisfaction; also, a few bodies of evidence are available that studied about the adequate lighting required for caregivers as well as newborns. We are still in an evolutionary phase of NICU design because the optimal lighting environment has not yet been defined (White, 2000). The purpose of this study is to investigate the existing lighting conditions in Shands NICU as a case study and to compare it with the IESNA lighting recommendations for NICU; also, to measure the caregivers satisfaction with this lighting condition. Based on Rea (2004), the word caregivers include doctors, nurses a nd families of newborns and that is what this word is used for in this study. Lighting perceptions are how lighting is perceived along dimensions of lighting quality: brightness and color of light. Lighting prefer ence is defined as people favoring one lighting condition over another (Rea, 2000). Lighting satisfaction is how caregivers are satisfied with the lighting conditions including illumination, direction of light type of

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20 lighting and their level of control a nd adjustment of light etc Control is defined as control of illumination and adjusting ability across the recommended range of lighting levels This study results in finding out the weaknesses and strengths of Shands lighting design as a case study in or der to suggest some practical guidance to designers responsible for the lighting in the NICU and eventually an optimum lighting environment for this hospital and other NICUs for improvement. Research Questions 1. To what extent, if any, does Shands NICU existing lighting condition, meet the IESNA r ecommended standards? 2. How satisfied are the caregivers from the existing Shands NICU lighting conditions ? 2.1. What are the visual tasks they do while spending time in NICU? 2.2. What is their satisfaction level with the general lighting? 2.3. What is their satisfaction level with the task lighting? 2.4. What is their satisfaction level with the natural lighting? 2.5. What is their satisfaction level with lighting controllability? Summary The concept of healing environment in healthc are has been of great importance in the past few years. One of the departments of hospitals that can greatly benefit from this theory is NICU. Newborns and caregivers are in a tense and critical situation and providing a soothing and at the same time pract ical environment for them has a great impact on both the healing of newborns and caregivers and the practicality of staff. One of the design aspects that can contribute to achieve this goal is lighting; especially in NICU, lighting has great importance since the level of lighting needed by newborns is different than that by caregivers (Dalke et al., 2005); This can cause a conflict between keeping the light at a level that is not harmful to the newborns and at the same time is enough for caregivers to do their job. Previous studies have mostly

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21 focused on the optimum level of lighting for newborns and not the caregivers. This study researches the existing lighting condition of Shands Hospital in Gainesville, FL and compares that to the recommended standards provided by IESNA. It also measures the level of satisfaction of the caregivers from the existing lighting condition. Definition of Terms LUX: Measuring unit for the amount of light that falls on a surface within a onefoot radius of the source (Winchip, 2008) Diurnal lighting cycles: 24hour, day night cycles with brighter lighting for a portion of the 24hour period (usually at least 12 hours), and dimmer lighting for the remainder of the 24hour period (White, 2000) Z eitgeber : O r a time giver is a st imulus that sets the circadian clock (White, 2000). Visual performance: T he speed and accuracy of processing visual information (White, 2000)

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22 CHAPTER 2 LITERATURE REVIEW This chapter reviews the literature containing studies about these topics: 1) Healthcare Design, 2) Neonatal Intensive Care Unit Design and 3) Lighting Design in NICU and Caregivers Satisfaction. This section is followed by explaining IESNA lighting recommendations which include: comparison of recommended general lighting versus t ask lighting, color rendering and luminaire and the lighting level needed for circadian rhythm versus vision, lighting at dayshift versus night shift, lighting control, glare and shadow, and vertical surfaces and artwork. This information is provided to familiarize the reader with these recommendations since they will be used several times in this study. The IESNA recommendations were mainly obtained from the summary of recommended standards provided by White (2007) but it was also compared with the Lightin g handbook by Rea (2000) to find further details. Healthcare Design Health care leaders are continually trying ways to improve their care services, become financially feasible, and retain quality caregivers. These goals seem impossible in todays competiti ve environment. The incorporation of a healing environment into the health care setting not only improves clinical care and outcomes, it also optimizes staff satisfaction, morale and retention (Altimier, 2004). At the same time, a major growth in hospital construction is occurring in the United States and several other countries. The U.S. healthcare system is facing the challenge of the need to replace old 1970s hospitals, population shifts, the graying of the Baby Boom generation, and the introduction of new medical technologies (Jones, 2007).

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23 Some of the most important findings relating the environment to human health and wellbeing come from studies in environmental psychology and healthcare environment research. For instance, the degree of environmental fit and the ability of the environment to provide beneficial elements are highly related to the occurrences of physiological symptoms (Parsons et al., 1998). The evidence indicates that well designed physical settings play an important role in making hosp itals safer and more healing for patients, and better plac es for staff to work (Ulrich et al 2008) It has been shown that views of nature, natural light, soothing colors, therapeutic sounds, and the interaction of family members can enhance healing. These elements must be balanced with staff needs when designing critic al care environments (Altimier, 2004). Neonatal Intensive Care Unit Design The global literature shows that the Intensive Care Unit (ICU) is a stressful place, where patients experience physical and psychological discomfort due to the environment characteristics, characterized by a large amount of equipment, professionals and procedures that interrupted the circadian cycle, hindering the patients' sleep and welfare ( Rosa et al., 2010). Int ensive care units built for newborn infants are a relatively new type of hospital unit. About 30 years ago, most neonatal i ntensiv e care u nits were located in converted patient rooms. These converted spaces were rooms along a hallway; their only modificati on was the elimination of walls to create units. It was not until the late 1970s and 1980s that NICUs designed and built only for caring for critically sick neonates became common (Floyd, 2005). The NICU is described in the literature as part of a hospit al that admits newborns in need of critical care or serious medical attention at birth. Approximately 10 to 15 % of newborns require this type of care and are admitted to a NICU where advanced

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24 technology and healthcare professionals provide these fragile i nfants with the specialized care they need. Some NICUs also give intermediate or continuing care for less critical infants that are also in need of specialized nursing care (Neonatal Intensive Care Unit, 2009). A few studies found out that environmental factors important in NICU include noise, light, and single versus multi bed patient rooms; they documented the importance of light in modulating circadian rhythms and thereby improving the adjustment to night shift work among staff but not enough studies hav e been done on caregivers satisfaction of lighting in NICU (Harris et al., 2006). Lighting Design in NICU Defining good lighting requires understanding that lighting is not only important for the infants in the NICU but also plays significant roles for adults in the NICU (Rea, 2004). First, lighting supports visual processes (e.g., acuity, color vision, visual performance). Second, lighting affects circadian regulation (e.g., alertness, sleeping, and hormone production). Finally, lighting communicates a m essage to professional staff as well as families about the level of care and sophistication provided by the hospital (Rea, 2004). Healthcare providers, especially nurses, experience a high level of work stress (Jayaratne & Chess, 1984; Pines & Maslach, 1978; Siefert et al., 1991; Tummers et al., 2001). Studies indicate that satisfaction and stress have a direct correlation to employee burnout and a decision to leave the job (Barrett & Yates, 2002; Pines & Maslach, 1978; Topf & Dillon, 1988). Despite a large number of evidence on the negative impact of stress and satisfaction on healthcare workers, especially ICU nurses, relatively few studies have examined how the physical environment contributes to caregivers str ess

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25 and satisfaction (Ulrich et al., 2008) Caregivers are defined as both medical staff and families by Rea (2004). As Maslow suggested in his Hierarchy of needs pyramid, when the physiological needs of an individual is met and the individual feels safe and important by the people in charge of hi s environment, then he has more confidence in the jobs he is performing; so by thoughtfully addressing all three roles of lighting mentioned above, the lighted environment in the NICU can support the productivity and wellbeing of the professional staff, th e health and safety of patients, as well as the profitability of the NICU. Although there is considerable evidence on the negative effects of dissatisfaction on healthcare workers, relatively few studies have examined how the physical environment contributes to staff satisfaction. Several descriptive studies on staff stress have assessed the possible effects of the characteristics of intensive care environments, such as blinking lights, alarms, and equipment noise (Corr, 2000; Donchin & Seagull, 2002; Dyson, 1999). A review paper by Corr (2000) identified the healthcare physical environment as one of the causes of work dissatisfaction, along with the job itself and the organization. Several studies of nonhealthcare workplaces such as commercial offices hav e found that environmental factors associated with stress include noise, crowding, poor ambient conditions (light, air quality, and temperature), and lack of control over the environment such as lighting (Baum et al., 1981; Evans & Cohen, 1987). However, l ittle research has evaluated the impact of these various environmental factors on staff satisfaction in healthcare settings. We gather most of what we know about the world around us through our eyes and the visual system (Schuman, 2002) and several studies have documented the

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26 importance of light in reducing depression, modulating circadian rhythms, and improving sleep quality (Ulrich et al. 2008). Healthcare environment studies indicate that such psychological responses could elicit additional physiologic al disorders (Ulrich et al., 2004); such as helping to adjust to night shift work among staff by controlling the body s circadian system (Baehr et al., 1999) Three studies show that providing cycled lighting (reduced light levels in the night) in neonatal intensive care units results in improved sleep and weight gain among preterm newborns (Blackburn & Patteson, 1991; Mann et al., 1986; Miller et al., 1995). In one study (Miller et al., 1995), 41 preterm newborns in structurally identical critical care uni ts were provided either cycled or noncycled lighting (constant light levels during the day and night) during a lengthy hospital stay. Compared to newborns in the noncycled lighting condition, newborns assigned to the cycled lighting condition had a great er rate of weight gain, were able to be fed orally sooner, spent fewer days on the ventilator and on phototherapy, and displayed enhanced motor coordination. Based on this study, it doesnt seem very practical to use sheets to provide cycled lighting for n ewborns. On the other hand the importance of proper lighting for newborns in NICU has been proved several times. One study looked at intensive care babies admitted into the control or experimental environment immediately after birth, and manipulated only the lighting environment, with sound levels the same in both rooms. They showed that weight gain, length of stay, and scores on the Brazelton motor cluster, were improved at the time of discharge for the group cared for in the room where lighting levels were reduced at night (White, 2000). Continuous darkness, such as the fetus would ordinarily experience in

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27 utero isnt the optimal lighting environment for premature newborns because it is known that the fetus is ordinarily exposed to diurnal lighting cycles of a number of maternal hormones and activity, which could act as a zeitgeber to synchronize its own developing diurnal cycles of hormones and activities. When the maternal zeitgeber is removed, it may be advantageous to the premature newborn to have an e xternal zeitgeber available (Miller et al., 1995). These studies talk about the effect of lighting on the newborns circadian rhythm but as we know lighting has effects on the caregivers circadian rhythm as well and it is especially important for the night shift staff Light has two effects on the circadian system: acute effects and phaseshifting effects Acute effects can be shown after exposure to light during the circadian dark phase, which is nighttime for those people entrained to a wakeduringthe day/ sleepduringthenight life style. Brain activity, cognitive performance, body temperature, and subjective feelings of alertness all increase slightly after exposure to light of the right intensity and spectrum at night (Iwata et al. 1997) Figueiro and colleagues showed positive acute effects on night shift nurses who were exposed to bright white light (2500 LUX on the task plane) during their break periods. Depending on the time of exposure the circadian clock can be advanced, leading to earlier rise times from sleep, or delayed, leading to later rise times from sleep, in the next sleep cycle. Humans are a diurnal species, genetically programmed for sleep at night, and it is very difficult and unnatural for us to invert this process. Humans are also a social species and despite the importance of ones profession, we naturally desire gregarious relationships with our families and friends who are almost always awake during the day and asleep at night (Crowley et. al., 2003). Consequently, it is unusual to find a night shift health care

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28 professional whose circadian clock is not following the normal wakeduring theday/sleepduringthenight cycle, at least for the first few night shift periods. Obviously, this disparity between lifestyle and circadian phas e makes sleeping and waking difficult for the night shift personnel (Ulrich, 2008). Circadian light exposure from daylight during the morning serves as the primary entrainment stimulus for day shift personnel. Daylight during the day from windows and clere stories in the NICU and low light levels from incandescent lamps at home during the evening are normal, practical, and recommended light exposures for day shift personnel. Important to consider in these recommendations are the findings from animal studies that the circadian system is more concerned with the relative light levels between night and day than with the absolute levels. Extrapolating from these animal studies, dim light levels may be seen by the human circadian system as night if the dayt ime light levels are very high, whereas that same light level may be seen as day if the nighttime light levels are very low. An attempt has been made to consider both systems in these recommendations (Horowitz et al., 2001). Lighting makes an impression on people, consciously if one is a designer or an architect and subconsciously if the person is a health care professional or a parent. These impressions are formed at two levels, perceptual and psychological. At the perceptual level people prefer bright spaces that show variety in the light distribution. Because humans walk erect and their retinas are oriented vertically, the brightness of walls, ceilings, faces, and objects are extremely important for conveying a perception of brightness in the NICU (Boivin & James, 2002). Some direct lighting luminaires, designed to provide maximum illumination on horizontal surfaces while minimizing the

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29 brightness of the luminaires (to avoid reflections in computer screens), produce dark walls and ceilings and can leav e faces and threedimensional objects in shadow. These luminaires, despite their claims for energy efficiency, are usually not suited for the NICU because so much of the work and interactions with people in the NICU are not associated with headdown work on horizontal surfaces or with intensive computer use. In addition to brightness, it is important that lighting provide some luminous highlights in the space (Leppamaki et al., 2003). At the psychological level, lighting can convey different associations and evoke different behaviors. Naturally, associations are formed between the relaxing home environment and the warm, incandescent table lights, whereas very different associations can be formed between the stressful and anxiety producing office or hospital environments and the cool, fluorescent lighting in the ceiling. Many spaces within the NICU are designed to provide a warm, inviting atmosphere for anxious parents by using color, soft objects, rocking chairs, and family pictures. Yet all too often, inexpensive, fluorescent direct luminaires are found in these same spaces. Without question they provide good visibility at a modest cost, but the message these fixtures send to parents is probably not the one intended (Boivin & James, 2002). One study with 87 female night shift nur ses examined whether repeated, brief exposure (4x 20 minutes) to bright light (over 5,000 LUX) during night shifts improved their wellbeing during and after night work (Leppamaki et al. 2003). Results showed that light significantly lessened the caregivers anxiety associated with night shift work, in both summer and winter. Bright light (over 2,500 LUX) is used for the treatment of seasonal affective disorder in winter (Partonen & Lonnqvist, 1998). A recent study by Partonen and Lonnqvist (1998) found that bright light exposure has a positive effect on

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30 mood even in healthy people. Another study found that staff with more than three hours of daylight exposure during their shift had higher job satisfaction and less stress than staf f with less daylight exposure. However, the findings are complicated by the factor of types of nursing activities: nurses from ICUs, EDs, or ORs were mostly exposed to daylight for less than 3 hours, while nurses from inpatient units mostly had an exposure of more than 3 hours. More research is needed to understand the impact of natural light on staff stress (Alimoglu & Donmez, 2005). Jobs by nurses, physicians, and other healthcare workers often include direct patient care, critical communications, charti ng, accessing technology and information, and other tasks. Many hospitals have not been redesigned, although jobs have been changed, and as a result, hospital environments often increase staff anxiety and reduce effective care delivery. The challenge of maintaining staff effectiveness will be increasingly important as the number of nurses is decreasing and the aging population is increasing. While much research in the hospital setting has been about patients, there is a growing and convincing body of evidence suggesting that improved hospital design can make the jobs of staff easier. Lighting levels may have an impact on staff effectiveness, but relevant studies are still limited (Ulrich et al., 2008). There have been studies in manufacturing showing a posi tive effect of higher lighting levels on the speed of production (Juslen et al., 2007). However, none of that was specifically related to healthcare environments. A small pilot study was conducted in a nursing home to evaluate the usefulness of providing LED lighting triggered by motion sensors for nighttime lighting. The 17 staff members in the study reported that they found these lights convenient and useful for conducting nighttime rounds without

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31 disturbing residents sleep (Taylor, 2005). There are several studies that have evaluated the effect of bright light (2,500 LUX ) and set sleep schedules on staff working the night shift (Horowitz et al., 2001). These studies report that the most significant positive effect is seen only when these factors are used in combination (Ulrich et al., 2008). Also the fact that mature adults need more light to perform routine tasks plays an important role in lighting design for caregivers (Schuman, 2002), since Lomperski (1997) indicates that as individuals age, their lens es develop a yellow coloration which causes a loss in sensitivity to both light and color and this effects the ability to read. Therefore, in a lifeanddeath situation, it is sound practice to provide relatively high light levels from white light sources. Excellent care will hardly happen with unsatisfied hospital staff. Job satisfaction is known to be influenced by many nonphysical working conditions, such as autonomy (O Rourke et al., 2000), compensation (Best & Thurston, 2006), and performance (Douglas et al., 1996). Lack of support from the physical environment can make already stressful working conditions worse (Ulrich et al 2008). Investments in the environment to increase staff satisfaction could potentially reduce the cost of staff turnover, whic h can cost more than $62,100 per nurse replaced. However, not many studies have examined the effects of environmental factors on job satisfaction (Jones, 2004). Mrockzek and colleagues (2005) conducted a residence survey of staff working in a newly constr ucted facility and found that natural light in the new facility had the most positive environmental impact on work life, followed by live music in the atrium. Another study by Alimoglu & Donmez (2005) found that staff with more than 3 hours of daylight exposure during their shift had higher job satisfaction than staff with less

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32 daylight exposure. However, the findings are complicated by the types of nursing act ivities performed by each group. In addition, new healthcare facilities might not increase job sat isfaction if they are not carefully designed. In a study comparing an old and a new ward in a mental healthcare facility ( Tyson et al., 2002) concluded that the new ward resulted in no increase in job satisfaction, probably because of the isolation of nurs es caused by the larger space and separated observation wings, and understaffing in the new acute ward and the fact that the new design did not change the amount of daylight they were receiving. Therefore, site planning and the orientation of healthcare fa cilities should be carefully designed to ensure enough daylight and avoid situations where some buildings block light for others. Larger windows in patient rooms not only provide natural light, but they also have the potential benefit of offering views of nature and should be considered in the design process. The amount and timing of light in healthcare settings should be suitable for the activities that take place in them. In general, sufficient lighting is beneficial to both patients and staff. Bright lighting is preferred in areas where staff performs critical tasks such as medication dispensing. Caregivers are rewarded for efficiency, technical skills, and measurable results, while their concern, attentiveness, and human engagement go unnoticed within their professional organizations and institutions (P hillip Benner from Georgetown University) Although considerations of the perceptual and the psychological effects of lighting are the least scientific, they are, perhaps the most important to hospital administrators. Thoughtful attention to these issues will help to minimize the anxiety experienced by health care professionals and by the parents in the NICU for a relatively modest investment (Ulrich et al., 2008). The IESNA Lighting Handbook is a good

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33 r eference for exploring how lighting can communicate a caring environment to health care professionals and to visitors and parents. IESNA Lighting Recommendations For nearly 100 years the Illuminating Engineering Society of North America (IESNA), North Ame ricas lighting technical society, has been providing consensus based lighting recommendations to support visualization in health care environments (White, 2006). These recommendations have been predicated on the assumption that health care professionals need high light levels and good color rendering to see the critical visual tasks they perform in hospitals. A great deal of research has shown that visual acuity, color perception, and visual performance improve with higher light levels (White, 2007). Whi te (2007) mentions that although the IESNA has always informally recognized the importance of lighting criteria other than light level and color rendering, formal recognition of other lighting cri teria has appeared only in the IESNA Lighti ng Handbook writt en by Rea (2000) T hat is the version used in this study as the reference and the following are recommendations for good lighting in the NICU obtained from this reference. General Lighting vs. Task Lighting Provide layers of light from different types of l uminaires. For general, general lighting provide no more than 500 LUX. For task areas provide local lighting up to 1000 LUX with tight optical control that prevents glare at other locations. The light source and procedure lighting for infant areas should be separated. The general lighting in newborn care area should be adjustable between 10600 LUX and should pay attention to the color rendering index of the light. There should not be any direct view of electric light

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34 source or the sun in this area, so that the newborns dont have a direct line of sight to the fixture. None of the newborns should be too close to windows and the windows should have an easily controlled shading device. Custom LED luminaires (kmax = 470 nm) should be acquired that provide blue light, over 30 LUX at the eye in the evening, and wear yellow tinted glasses in the morning. Minimize daylight exposure during the day (phase shifting effect). Color Rendering Quality Provide good color rendering lamps with a color rendering index of at least 80. It is required to install luminaires that connote this desired effect. As recently as 2000, the IESNA recommended that good color rendering lamps (CRI > 80) provide 1000 LUX on critical visual tasks fo und in health care environments. It is now know n that light levels this high are never needed throughout the facility; they are only needed in specific task areas associated with critical care for the infant (Rea, 2000). Circadian Rhythm vs. Vision Impact of light on human circadian system should be c onsidered very carefully in conjunction with authorities on the topic of circadian regulation. Although light entering the eye provides both visual and circadian information, the characteristics of the light important to these two systems is radically diff erent. Consequently, good lighting for circadian regulation is quite different than good lighting for vision. Significantly higher light levels of white light are required to stimulate the circadian system than the visual system. Light levels adequate for good vision can be onetenth of those needed to stimulate the circadian system effectively. The circadian system is tuned to a different part of the electromagnetic spectrum than the visual system. Whereas the visual system is maximally sensitive to middle wavelengths (555 nm: yellow green) light, the circadian

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35 system is maximally sensitive to short wa velengths (450 nm: blue) light ( White, 2007). As almost all commercially available light sources are tuned to maximize visual response, there are few electric light sources suitable for circadian regulation, unless very bright white lights (at least 10 times that normally found in the NICU) are used. Importantly, Figueiro and colleagues showed that much lower light levels from blue LEDs (30 LUX of 470 nm at the eye) could be used to stimulate the circadian system. Although the visual system is essentially equally sensitive to light throughout the 24hour day, the circadian system responds to light differently over the course of the solar day. Depending on the ti me of day or night, the circadian system can be more or less sensitive to light, and that light can either advance or delay the timing of the biologic clock. The visual system is very fast in its response to light, on the order of a few milliseconds, where as the circadian system may require several minutes to respond to light. These fundamental differences in the response characteristics of the visual and the circadian systems to light significantly complicate recommendations for good lighting for the circa dian system. And unlike recommendations for good lighting for vision, there are no formal consensus based recommendations available for good lighting for the circadian system from the IESNA or from any other body. Day Shift vs. Night Shift IESNA recommends that the lighting in night shift should Keep health care professionals awake and productive by applying light of different intensities, spectra, and timing in addition to those important for good vision. Also provide bright white illumination (2500 LUX ) o n task surfaces in break rooms, but shield the light source from glare (acute effect).For day shift, provide access to daylight to help entrain

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36 circadian rhythms to the solar day, particularly in the morning; and provide opaque blinds or shades, not tinted windows, to minimize glare from sunlight. Table 21.Sample of IESNA lighting recommendations for NICU Sample of IESNA Recommendations Newborn Care Area General Lighting: 1 0 600 LUX Separate source of general light and task light. No direct view of the electric light source (including procedure lighting) Fixture, easy to clean No glare Stay awakedifferent intensities, timing Create an inviting and productive environment for parents and staff. Task Lighting: 1000 LUX (min) at the plane of the infant bed Separate procedure lighting for EACH infant bed Temporary increases in illumination necessary to evaluate a baby or to perform a procedure should be possible without increasing lighting levels for other babies in the same room. Adjustable in intensity, field size and direction Natural Lighting: No direct view of the sun to the newborns Be situated at least 2 feet (0.6 meter) away from any part of an infant's bed to minimize radiant heat loss. Be equipped with shading devices that are neutral color or opaque to minimize color distortion from transmitted light. Controllability: Control of illumination and adjusting ability multiple light switches AND a master switch for immediate darkening of the room Dimmers Support Areas 15 minute/shift exposure to W hite light: 30 0 50 0 LUX Where public area meets Newborn care area: Separate light sources, Independent switches Highlight artwork and architectural features.

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37 Control, Glare, Shadow and Vertical Surfaces It is recommended to include dimming and switching lighting controls for flexibility and energy efficiency. It is important to note that the role of switching (and dimming) to accommodate the variety of tasks performed in the NICU at different times has always been recognized as important in the IESNA lighting recommendations (White, 2007b). Define the geometries between the light source, the task, and the observer. Control the optical distribution of the luminaires; luminaire optics should always hide a direct view of the light source from normal viewing positions to avoid shadows on work surfaces and faces and to anticipate reflected glare from incubators and visual displays (e.g. computer monitors). Use matte, highreflectance surfaces to scatter light throughout the space and to diffuse reflected images from light sources. Light vertical surfaces to provide brightness in the space. Highlight artwork and architectural features (Overall feeling about the space they work in). Conclusion The review of literature shows that even though there are many studies about NICU, a few of them study the environmental design aspect of the NICU Lighting is very important in NICU because the level of light needed by newborns is different than that by caregivers. The studies about lighting design in NICU mostly focus on the lighting needs for newborns and not the caregivers lighting needs and satisfaction. T hese gaps in literature show a need of studying the lighting design in NICU, focusing on caregivers satisfaction; a type of study that links hospital physical environm ents with healthcare outcomes.

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38 CHAPTER 3 RESEARCH METHODS Study Design This study is a Case study which is an approach to studying a social phenomenon through analysis of an individual case as well as Cross Sectional Study or one that collects data only (Kumar, 2005). This study is a combination of quantitative and qualitative methods that employ the use of a closed and open ended Questionnaire as well as interview and observation. To gather an indepth understanding of caregivers satisfaction on lighting conditions in NICU at Shands, the study employed the qualitative method including indepth interview and observation techniques. Case Selection Criteria Shands Hospital at University of Florida, which is one of the top 50 hospitals in 8 specialties wa s built in 1958 (Shands hospita l website : https://ufandshands.org ) and contains two NIC U u nits; NICU II & III. NICU II is less intensive and admits newborns in less critical conditions, whereas NICU III is more intensive. Ac cording to Shands facilities man agement NICU II has not been renovated since 1999 but NIC U III was renovated around 2005 ( Obtained from Shands facilities management). When visiting the Shands NICU it was realized even though this building is among the semi modern hospitals; it still ne eds improvements in its environmental design and specifically in lighting design. They generally had to use a sheet over the newborns in order to make the level of lighting needed for their growth and to prevent the direct exposure of bright general lighting into newborns eyes. In other areas of Shands N ICU like NICU II the level of general lighting was too low for the caregivers to do the necessary procedures. The term medical procedures in Shands NICU, in

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39 general, means tasks like pulling out or putting in IVs, putting in tubes and checking the babies for Jaundice. Studies suggest that the general lighting level in the NICU be sufficiently bright so that nurses can do their work comfortably and accurately. Babies can be protected from lighting levels t hat might be optimal for nurses performance by covering their eyes or incubators. Nurses should also have access to a bright light source (light shower) of at least 2500 LUX ( about 250 foot candles) in their lounge or work area for at least 15 minutes at the start and middle of their shift, if they find it useful (White, 2000). There were some sections of the Shands NICU, like the staff lounge that didnt have natural lighting at all. Study shows that adequate and appropriate exposure to natural light is critical for health and well being of patients as well as staff in healthcare settings. A combination of daylight and electric light can be the optimum solution to this problem Finally, some of the lights in Shands NICU were not useful and could be used in other places. These facts and observations plus the convenient location of Shands hospital, made it a proper site for this research. It also shows the need of a lighting quality evaluation in Shands NICU. Setting The study is done in the NICU of Shands Healthcare Center at the University of Florida in Gainesvil le, FL. The NICU consists of a level 3 nursery (NICU III) as well as a level 2 nursery (NICU II). The NICU III is a 22 bed unit that provides tertiary care to newborns within the State of Florida and areas of South Georgia, based on diagnosis and availability of resources. The NICU II is an inpatient sister unit to NICU III and has a bed capacity of 30. Both units operate twenty four hours a day. According to Shands building documents obtained from the facilities management NICU department was

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40 built in 1984; NICU II has not been renovated since 1999 but NICU III was renovated around 2005. Admissions for both units are routinely taken from labor and delivery, referrin g hospitals, and newborn nursery. Patients are transferred between the NICU II and III based on patient acuity. NICU III is focused on the stabilization and critical care needs of the neonate and the family. NICU II focuses on the intermediate or recovery phase of the care needs of the neonate. The NICU II and III are both located on the 3rd floor adjacent to the Labor and Delivery areas as well as the post partum area. All patient newborn care areas are equipped with newborn care area monitors, with alarms, which have the capabilities of monitoring heart rate, respiratory rate, blood pressure, and oxygen saturation levels. There is an intercom system in place that provides for newborn care area communication. Bed spaces are equipped with an emergency alarm to the clerical areas. In the event of an emergency each bed space in NICU II is equipped with a Code Blue alarm that connects directly to NICU III. This system connects NICU III with II and newborn nursery and in the event of its activation requires the response of the Neonatal Team. Newborns in NICU II that are in bassinets are banded with security devices. When the devices are detached, they will provide alarms and door lock down. In addition there is camera surveillance that monitors the primary entrance to NICU II. Available support services for Neonatal patients include: Pharmacy, Respiratory Therapy, Physical Therapy, Occupational Therapy, Nutrition Services, as well as Patient and Family services (Shands Hospital website: http://nursing.jobs.ufandshands.org). Shands NICU is m ade of three major areas: Newborn care areas, Offices and Support

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41 Areas (Public Areas). This study just focus es on the Newborn care areas and support areas. These are the areas mainly used by doctors and nurses. Figure 3 1. Shands NICU ceiling /lighting plan Figure 3 2. Shands NICU floor plan (zoning diagram)

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42 Figure 3 3 Shands NICU furniture and equipment plan In order to better understand the organizatio n of Shands NICU, this space will be further explained based on the information obtained by the r esearchers observation. In these explanations, the two NICUs (NICU II and III) are divided into two major areas: the newborn care area and the support areas. Then each area will be explained based on the aspects of lighting quality. NICU II Newborn Care Area II This area has an isle in the middle that all monitors are scattered on it and is used as a charting area for nurse s (Figure 34) The beds are placed on both sides of this isle, and also along the windows. There are recessed lights along this is le that are used as both general light and task light (Figure 35). The general lighting includes the same Fluorescent lights in NICU III but the difference is that these lights are located on a straight line and a dimmer switch turns on every other light ( Figure 35).

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43 Figure 3 4 The isle along NICU II Figure 35 NICU II general lighting

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44 Figure 3 6 NICU II ceiling plan Figure 37 NICU II floor plan

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45 Support Areas in NICU II: The storage (called the garage) is to store supplies and equipment It is very lit by few sets of fluorescent lights. Family room is a space that parents can stay in and rest and its general consists of a set of 2 by 2 fluorescent lights. The handwashing area has one covered line ar florescent for illumination. NICU III Ne wborn Care Area This area consists of one open area in the middle and two isolation rooms. The total number of bed spaces designated for this area is 22, including the isolation rooms. The open area consists of 3 semi private bed spaces in the corner (have three glass walls and a curtain) but there is no priority for the newborns to be located there. Eight of the bed spaces are by the windows. Newborns are either in a bassinette or an isolate. The difference between them is that isolates are closed on top and are for babies in more critical conditions. The space in the middle has one main nurse station and some scattered computers on the countertops that serve as a nurse corner for charting and documentation. There is also transport team desk in the hallway of this section. The x ray viewing desk is in this hallway across from the transport team desk. The medication room and the physicians room are located in this area as well which will be explained further when explaining the support areas in NICU III. P hysicians room is called a fish tank because two of the walls of this room are glass walls that allow this room to benefit from the general lighting of the newborn care area.

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46 Figure 38. Newborn care area III floor plan Figure 39 Newborn care area III floor plan

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47 Figue 310. Typical bed spaces in NICU III Figue 311. Typical bed spaces in NICU III Where the monitors are typically placed; Switches are behind the monitors (Figures 3 11)

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48 General lighting: There is a repeated pattern of general lighting on top of each bed space, shown in Figure 312; as shown in this picture, the general lighting for each bed space consists of recessed lights that are controlled by dimmers. Each dimmer switch controls two of the recessed. There are also three spot lights that are used for emergency and are controlled by an on/off switch; direction of these emergency lights can be adjusted but the problem is they are up on the ceiling and a person should climb up a chair in order to adjust them (Figure 313) There are two center points in this area that have some of the bed spaces around them. These center points illuminate its surrounding by an indirect light ( Figure 416). Figur e 312 Typical general lighting for bed spaces in NICU III

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49 Figue 313. Emergency lights (spot light) Task Lighting: The pattern of task lighting is not consistent for each bed. Some of the old isolates have a heater that has a light installed in it; this light is used as task lighting that is not adjustable and has o nly two levels of illuminations (figure 314). Some of the old isolates also have another task light that is flexible but because of its weight and built, is hard to move (Figure 315). The new isolates, on the hand, have a task lighting called the Giraffe. This task lights are built in a way that are very easy to move and adjust. They have three lev els of illumination which makes it much easier for caregivers to adjust the illumination based on their needs (Figure 316).

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50 Figue 314. Warmer with task light Figue 315. Old task lights

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51 Figue 316. New task lights (girrafe) Natural lighting : T he natural light ing affects the general lighting for this area especially for the bed spaces next to the window. The NICU windows structure has a n overhang that prevents direct sun light entering the unit. The blinders are closed most of the time and very few caregivers use the natural light for their tasks. Isolation r ooms : Isolation rooms are for the babies who are in a fragile state who need to be away from public. Their general and task lighting pattern are the same as the main section of the newborn c are area. The advantage in these rooms is that the space is only for one newborn so staff and family can control the lighting without the hesitation of weather they ar e bothering other newborns. There are glass sliding doors for each of these rooms that sl ightly help them to benefit from the general lighting in the main section of the newborn care area. Semiprivate bed spaces and b ed spaces n ext to w indows : These are the areas that are partially closed on the sides by glass walls. They have the same general and

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52 task lighting pattern as described in the main section of the newborn care area. The walls are white paint except the wall behind the bed space which is light blue. Eight designated bed spaces by the windows. The reason some of the babies are located next to the windows is just because that space was available; but a newborn is not located next to the window if he is too young or not in a very critical condi tion since they need an environment that is more similar to the womb. Support Areas in NICU III Nurse stations staff l ounge and h allways : There is one main nurse station in NICU III that has its own general lighting on top of the desk; but nurses mostly use the counters by the beds as their station for charting. These are the spaces where the monit ors are located at. Some of the monitors face the windows and some have their back to the windows. Staff lounge has seating for 10 people. General lighting in this area is a combination of linear fluorescent and recessed compact fluorescent light. There is also an indirect fl uorescent lighting on the walls. There is separate general lighting for the kitchen area. Transport team desk, x ray viewing station, physicians room (fish tank): Transport team desk is located in the hallway of NICU III; they basicall y use the hallway general lighting for their tasks. X ray viewing station is located in the same hallway acros s from the transport team desk. Physicians room has two glass walls, one toward the hallway and the other toward the main newborn care area; that s why it is called a Fish Tank. This room gets a part of its general illumination from the newborn care area and the glass walls make it easier for the users to have a view of the newborn care area.

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53 A B C D Figur e 317. General lighting in hallways A ) NICU III hallway B ) NICU II hallway. C ) NICU III hallway D ) NICU III offices hallway. On Call/ sleep rooms and multipurpose room (Frans room): Oncall rooms are used by d octors and attendees who w ork at night shift. As you can see in Figure 318, the general lighting consists of a set of 2 by 2 covered linear florescent light s. There is a night light next to the bed and a fluorescent light on top of the hand washing sink. Multipurpose room has seat s for 6 people and is used for resting and privacy purposes. The general light here is a set of 2 by 2 linear fluorescent lights; there are two lamps there that can be used either as task light or a more soothing general light.

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54 A B C Figur e 318 Lighting in oncall room A ) General lighting. B ) Side lamp. C ) Sink lamp. Lobby (waiting room) pump room (breast feeding room) and conference room: Lobby has seats for about 17 people. As shown in Figure 319, t he general light ing consists of recessed compact fluorescent lights. There is an architectural feature in the mid dle of the ceiling in that simulates a skylight and illuminates the room by artificial lights. This helps to create the feeling of having natural lighting there. There are three adjustable spot lights for the artworks and a wall sconce. The pump room has two privat e areas for pumping (Figure 320); each area has its own general lighting that consists of recessed fluorescent light. There is a linear fluorescent lamp o n top of the sink. There is no task lighting in the pump room The general lighting in conference room is 2 sets of 2 by 2 linear fluorescent lighting which are controlled by dimmers

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55 A B C D Figur e 3 19. Lighting in the lobby (waiting room). A ) Wall sconse. B ) General lighting. C ) Skylight D ) Spot lights. A B Figur e 320. Lighting in pump room. A ) Pumping space lighting. B ) Sink lighting

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56 Participants An application and authorization form was submitted to the University of Floridas Institutional Review Board (IRB) for research involving human subjects prior to the start of the screening and selection of participants ( Appendix A). The other requirement was Research and Information Privacy at the University of Florida cer tification ( Appendix C ), followed by completing the Confidentiality Statement ( Appendix D ). NICU III has one nurse per two patients, including the charge nurse whereas NICU II has one nurse per 3 or 4 patients (Retrieved from Shands hospital website: http://nursing.jobs.ufandshands.org). A charge nurse is designated for each shift. Unit clerical coverage is also available 24 hours a day for each unit. The NICUs are under the medical direction of a Neonatologist, a Nurse Manager, 2 Clinical Coordinators, and an Administrative Assistant which are assigned on day shift five days a week. The Team Coordinators provide off shift and on weekends administrative assistance. The staffing plans for the Registered Nurse are consistent for all shifts. The study population is comprised of 96 caregivers, including doctors, r esidents, nurses practitioners, nurses, respiratory t h erapists, t ran sport t eam, & parents and family of the pati ents. The participants were divided into three groups: 1Doctors group that include: doctors, residents and nurse practitioners; 2Nurses group, includes: nurses, r espiratory therapists and transport t eam; and finally 3Families g roup that includes: parents and f amily of the patients. According to the information obtained from Shands NICU management, t here are 65 doctors including r esidents, 14 nurse practitioners, 125 nurses, 23 respiratory staff, 9 transport team members; therefore, there are 79 people in group one (d octors) and 157 people in group two (n urses) There are 700 to 750 newborns admitted to Shands NICU

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57 annually. There were 60 newborns admitted at the time of research. The 96 participants included 20 participants in doctors group, 42 partic ipants in n urses group and 34 participants in Families group; which gave a good turnout of about +/ 30 % participants per group. Out of all the participants willing to take part in an interview, 10 in each group were chosen randomly; so there were 30 people interviewed in total. Research Instruments The research instruments used for this study are: Observation, Documentation, Survey and Interview. These instruments were all approved by IRB after the pilot study and prior to starting the data collection. Observation Field notes were taken from all areas of NICU II and III. Notes included the demographic of the users of different spaces at the time of observation, focal points and visual attractions, observing the level of control and ease of access user s have with switches and lighting levels, the overall mood of the space at the time of observation, materials used in the space, if there is any natural lighting in that space and if yes, is it possible to control the level of natural lighting in that spac e and finally if the level of lighting in that space is enough for way finding and security. The information gathered was used to illustrate the possible factors that influence each participants behavior and explore whether their location within the unit affected their satisfaction. The methods of observation were obtained from Sommer & Sommer ( 2002). Documentation The information documented in each space includes: Type of lighting in that space (Ambient, Task, Natural, Emergency, Exit), the type of lamp used for each of these and if it is easy to replace, the illumination level (Foot Candle which then was

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58 converted to LUX ) for ambient and task lighting in each space. The method of gathering information during documentation and organizing the data was obtai ned from Winchip (2008). Survey There are three gr oups of survey made for the three groups of participants mentioned earlier (doctors, nurses and families). The surveys for doctors and nurses were webbased and created using http://www.SurveyMonkey.com. Since the number of participants in online survey was very few, the researcher handed out most of the surveys to collect the desirable amount of data. The survey for parents was handed out to them in person. All of the surveys are contained of three sections ; the demographic question, a chart containing a series of questions to find out the most used space by the participant and the tasks they do while in that space, as well as measuring their level of satisfaction with the lighting level and controllability in those spaces. The last part has supporting questions for the second part containing e valuation of the participants satisfaction level with general lighting, task lighting, natural lighting, visual comfort and controllability. The survey for doctors and nurses all contain 7 questions in the demographics section and 7 questions in the last section (Appendix E and F). The survey for families contains 6 questions in the demographic section and 8 questions in the l ast section (Appendix G ). Each section of t he survey is explained below in more details: First section: This section contains the demographic questions. It asks the participants about their gender, age, their title or relationship to the patient, what shift s they work at and how much time they spend in the NICU. The age categorization in this section is based on the relation between age and eyesight level reported by Julie Moller

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59 (2008). The shift, length of work in Shands NICU and number of hours worked in a week are all categorized based on the information obtained from the management and administration in the NICU center; the length of newborns stay in NICU has been obtained from the same source. Demographic questions were asked to determine the relationship of the study variables and participant s information to exclude extraneous variables including age & visual impairment related to age, the length of stay in NICU and previous NICU experiences. Second section: This section asks the participants about the spaces they mostly use, the length of ti me they spend there, the tasks they do while spending time in those areas and their level of satisfaction with the lighting in these areas as well as how much the lighting level of these areas support their tasks. The time table for the length of stay in a space per week is obtained from the information provided by Shands NICU management and administration. The visual tasks mentioned in this section were based on the observation done by the researcher prior to conducting the survey. The scale is based on t he 7point likert scale ranging from 3 as being strongly disagree to +3 as being strongly agreed. Third section: In this section the main objective was to assess user satisfaction. The questions include asking participants satisfaction of the major lighting issues mentioned by IESNA recommendations such as natural lighting, general lighting, task lighting and controllability and were on a sevenpoint rating scale ranging from 1 meaning Very Satisfied to 7 meaning Very Dissatisfied. The last quest ion in this section asks the participants if they are willing to participate in an indepth interview.

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60 Interview Interview questions were also designed based on each group of participants ( doctors, nurses and parents). These questions get into more in depth evaluation of caregivers satisfaction with the existing lighti ng conditions in Shands NICU (Appendix H, I and J). Similar to the survey, interview questions ask about satisfaction of lighting levels, control, night shift vs. day shift, newborns lighti ng need vs. caregivers need and the conflict it can cause and finally their satisfaction and suggestion on all the support areas they use. The interview form for doctors and nurses contain 10 questions and the one for parents has 5 questions. The researcher attempt was to interview participants at the space mostly used by them and at the shift they usually work at. Pilot Study Prior to sending the research instruments to IRB to obtain approval, a pilot study was done to assure the accuracy and clearness of survey and interview questions and also to detect any defects such as issues with wording or terminology, and to check the experimental procedures timing and sequencing. The pi lot study was administered to 15 caregivers in the Pediatric Intensive Care U nit (PICU) at Shands Hospital. There were 5 participants of each category of car egivers (doctors, n urses and f amilies ). This department was used because the researcher would not lose any participants in the NICU departm ent and also this department had the closest am bient to the NICU. All fifteen of the participants took an average of 15 to 20 minutes on the survey and 10 to 15 minutes for the interview after which they were asked if anything was confusing or anything about the survey or the experience could be improved. Pilot study participants made some useful suggestions

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61 on the survey wording which were then employed in that instrument. Participants did not express any confusion or difficulty with the interview questions and no changes were made for that c ontent. Sampling and Data Collection Based on Kumar (2005), random sampling is when each element in the sample population has an equal and independent chance of selection in the sample. Selection of the qualified participant in this research employs a random sampling in which staff and families randomly volunteered to participate in a questionnaire. At the end of the questionnaire, they were all asked if they could participate in an indepth interview, so they randomly volunteered for that. The data collec tion was done in three weeks in December of 2011. Based on Ulrich and colleagues (2008), the typical length of stay in NICU for newborns is 3 weeks; therefore the data collection was designed to be done in 3 weeks so that there was a higher possibility of observing all stages of a newborns stay in NICU The researcher had to obtain a badge to enter the NICU s The badge was received from the Shands Facilities Development m anagement by providing identification and referral from the Nursing Council in Shands Informed Consent Participants were presented with an informed consent form to obtain their written permission to complete the study. The form also informed them that study posed no risks to participants and they could withdraw at any time. The participants were given the opportunity to consider all options and ask questions about the process. Their signature was required; however, it was not associated with the participants name.

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62 Observation and Documentation To obtain the maximum data as far as different lighting levels and caregivers behavior, the observation and documentation were done in four different shifts: 2am to 6am, 6am to 11am, 12pm to 5pm and 8pm to 12am. This division of time was based on the suggestions made by nurses in a meeting with Shands NICU Nursing Council. Their rational behind this was that this division provides the researcher with the most variety of data. The primary observation of NICU also helped the researcher to arrange this time division based on the level of artificial lighting used in different times of the day and the level of natural lighting. In order to make the process easier and more organized for the researcher, each NICU was divided into two segments: Newborn care area and support a reas (Figure 32). The researcher observed caregivers behavior such as how often they change the lighting level, how much control they have over this change, how accessible the lighting switches are, what spaces they mostly use and its relationship to the lighting level. A Light meter was used to document the illumination level of different spaces at different time frames mentioned above. The type of lamps and their locations were documented. Survey An e mail was sent to all the 65 doctors, 14 nurse practitioners, 125 nurses, 23 respirat ory staff and 9 transport tram members, with a link to the survey ; since only a few of them participated in the online survey, the researcher approach them in person randomly and handed out the surveys. Parents were approached in person too. When it seemed proper to approach a family member, the researcher asked for a few minutes of their time and explained what the researc h is about and asked if they were willing to fill

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63 out a survey. At the end of the survey, the participants had the option of choosing i f they wanted to participate in an in depth interview. The information was not in any form attached to the survey in order to keep the surveys anonymous. Interview The participants, who decide to take part in an Interview, were contacted by the researcher with the information they provided. This information was either email address or their phone number All the interviews were taken place in the space used by the participant and also in the shift they usually work For example, a nurse who worked in the night shift only was given the survey and was interviewed during the night shift; and also in the newborn care area in which she spent most of her time in. A recorder was used to record the interview after asking for the participants permission. The averag e length of each interview was about 15 minutes. The interviews were then linked to the related survey by a code. Data Analysis The data was obtained through observations and documentations surveys and interviews which were then analyzed. The survey was analyzed, using SPSS software. The interviews were analyzed using content analysis The observation and documentations were organized and then compared to the IESNA recommended standards. Problems and Limitations The limitations of this study can be the method of study design ( case s tudy ) since this approach rests on the assumption that the case being studied is typical of cases of NICU in hospitals so that, through intensive analysis, generalizations will be made from the result of this study to other c ases. The other limitation can be the number of

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64 participants as well as the possibility of the findings only being generalized to cities of similar size and climate. Another Limitation is the fact that the documentation was specific to that moment of coll ecting data and could change at any moment by turning a light on or off. Even though the documented illumination levels were averaged, they would still be different if collected at a different time frame. It is important to mention that f or night shift per sonnel, who are still trying to lead a normal wakeduringtheday/sleepduringthenight lifestyle, it is much more difficult to make truly satisfactory recommendations. I f the night shift person wants to maintain a normal lifestyle, caffeine and bright white light during the night shift will provide some mitigation of the effects of a body that wants to sleep.

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65 CHAPTER 4 RESULTS This chapter presents the results of data collected from both Neonatal Intensive Care Units (NICUs) It starts with the charact eristics of the participants and answers to questions like what the most used spaces by each category of participants are and what are their visual tasks while being in those spaces. It follows by three sections: o bservation and d ocumentations findings and comparing them with the IESNA standards; survey f indings and interview f indings Characteristics of the Participants For the purpose of this study, the caregivers are divided into two major groups: staff and f amily. Staff includes two major groups: doctors and nurses whereas f amily include s newborns parents and relatives A total of 96 adult subjects volunteered in this study There w ere 20 in the doctors group (doctors, nurse practitioners and r esidents), 42 in the n urses group (nurses, respiratory therapists and transport t eam), and 34 in the family group (parents and relatives). Table 41 presents the frequency distribution of the general characteristics of the staff and Table 42 presents f amily As shown in both Tables 41 and 42, females were much more than males in all groups. D octors and families were mostly 18 to 35 years old versus nurses who were between 46 to 55 years old. No one was above 65 years old. Dayshift is different for each group; for doctors it is 6:30 AM to 5:30 PM, for n urse s it is from 7 AM to 7 PM. Night shift is also different for each group. Doctors night shift starts from 5:30 PM and can be as long as till 6:30 AM the next morning whereas for nurses it starts from 7:00 PM to 7:00 AM. Families can stay in NICU all day and night with the exception of half an hour in between each shift for nurses and doctors to do the needed procedures; so f amily can stay in NICU from 7:30 AM to 7 PM and from 7:30 PM to 7:00 AM. Procedures done by

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66 doctors and nurses in Shands NICU, in general means tasks like pulling out or putting in IVs, putting in tubes and checking the babies for Jaundice and needed. Results show that families are mostly present in NICU during the day but there is a small difference between the number of people who s tay in NICU during the day and the ones who stay there during both day and night. And finally the results show that doctors and nurses mostly work both shifts. Table 41. Characteristics of the staff participants Characteristics Doctors (N=20) Nurses (N=42 ) Total (N=96) N % N % N Gender Male Female 3 17 15.00 85.00 2 40 4.76 95.23 5 57 Age 1835 Years 3645 Years 4655 Years 56 65 Years 8 4 4 4 40.00 2 0.00 20.00 20.00 10 6 15 11 23.80 14.28 35.71 26.19 18 10 19 15 Shift Day Night Both 7 2 11 35.00 10.00 55.00 4 14 24 57.14 38.10 4.76 11 16 35 Worked At Shands Less Than A Year 1 5 Years 5 10 Years More Than 10 Yrs 3 3 6 8 15.00 15.00 30.00 40.00 1 5 9 27 2.38 11.90 21.42 64.28 4 8 15 35 Another NICU Yes No 14 6 70.00 30.00 16 26 38.09 61.90 30 32 Work Hrs/Week Less Than 12 Hrs 1324 Hrs 2536 Hrs 3748 Hrs More Than 48 Hrs 1 4 2 8 5 5.00 20.00 10.00 40.00 25.00 3 25 12 2 7.14 59.52 28.57 4.76 4 29 14 10 5

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67 Results (Table 41) showed that most doctors (8 of them, 40 % ) and nurses (27 of them, 64.28 % ) have worked in Shands NICU for more than 10 years Most doctor s (14 of them, 70 % ) have worked in another NICU. Doctors spend more time in NICU (37 to 48 hours) than nurses who mostly spend 25 to 36 hours there. Table 42. Characteristics of the family participants Characteristics Family (N=34) N % Gender Ma le Female 8 26 23.52 76.47 Age 1835 Years 3645 Years 4655 Years 5665 Years Above 65 Years 28 2 1 3 82.35 5.88 2.94 8.82 Shift Day Night Both 17 1 16 50.00 2.94 47.06 Newborn In NICU Less Than A Week 1 3 Weeks More Than 3 Weeks 8 6 20 23.52 17.64 11.76 To summarize demographic results, it can be concluded that most staff have worked in Shands NICU for more than 10 years, most of them havent worked in another NICU and most of them work in NICU, between 25 to 36 hours per week (Table 4 1); most of the newborns have been in Shands NICU for less than a week (Table 42); and overall, females are much more than males among all caregivers, most of the caregivers ar e between 18 to 35 years of age (except nurses) and most of them are present in NICU during both shifts.

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68 Comparison of the Observation and Documentation Findings (Existing Conditions of Shands NICU) with the IESNA Recommended Standards In this section the results of observations and documentations will be explained based on the two main sections of NICUs (newborn care areas and support areas). These findings will be categorized based on the lighting issues such as general lighting, task lighting, natural lighting and controllability A majo r part of the observations was explained in chapter 3 for a better understanding of the Shands NICU setting; o nly the important issues observed will be explained in the following section. These results will also be compared to the IESNA recommended standards. Newborn Care Areas NICU II : This area has an isle in the middle that all monitors are scattered on it Nurses use this counter as their charting station (Figure 34) There are no task lights on this counter but there are recessed general lightings on top of it that is used for task lighting as well (Figure 35). The beds are placed on both sides of this isle, plus along the windows (figure 37) The general lighting includes the same f luorescent lights in NICU III b ut the difference is that these lights are located on a straight line and a dimmer switch turns on every other light. The average illumination here during the day time was 7 0 LUX and it was 30 LUX during the night time. The illumination level along the win dows was 111. 6 LUX during the day. This recommendation for the general lighting is 1 0 to 600 LUX. Task illumination level was about 1900 LUX compared to IESNA recommendation which is 2000 LUX. NICU III This area is for babies with more critical conditions than NICU II. This area consists of one open area in the middle and two isolation rooms. The total number of bed spaces designated for this area is 22, including the isolation rooms; but it was

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69 observed that some babies were located in a space that was not meant to be a bed space due to not having any more enough space; these spaces may not have any general lighting or task lighting for the baby ( Figure 41 ). The open area consists of 3 semi private bed spaces in the corner and 8 bed spaces by the windows. Newborns are either in a bassinette or an isolate. The difference between them is that isolates are closed on top and are for babies in more critical conditions. Figure 41 A bed space with no general or task lighting General lighting: The general lig hting in the main open area consists of four recessed lighting which is controlled by dimmers. There is a repeated pattern of general lighting on top of each bed space ( Figure 312) ; t here is one dimmer switch that controls two of the recessed lights and t he other two each has its own dimmer switch. There are also three spot lights that are called emergency lights and have only one on and off switch; these spot lights, called emergency lights, are adjustable but the problem is they are up on the ceiling and a person should climb up a chair in order to adjust them ( Figure 313). These lights are supposed to be just for emergencies while caregivers are doing some procedures but it was observed that sometime the task illumination is

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70 either not enough or not eas y to adjust so caregivers have to use these emergency lights for their daily visual tasks ; sometimes they leave them on, wasting energy and creating too much heat There are two architectural columns in the newborn care area III that illuminate the area by an indirect lighting. These two columns are the anchor for the designated bed spaces in NICU III newborn care area. Table 43 Comparison of S hands existing general lighting in NICU to IESNA recommended standards IESNA Recommendations Existing Condition Newborn Care Area 10 600 LUX NICU II Da ytime: 6 9 8 LUX NICU II Night time: 3 0 LUX NICU III Daytime: 7 3 LUX NICU III Night time: 8 5 LUX Separate source of general light and task light. Done No direct view of the electric light source (including procedure lighting) Direct light is an issue Solution: a small sheet on head or isolate Fixture, easy to clean No No glare It is an issue Stay awake different intensities, timing Nurses complained about low level of lighting specially in N ICU II that makes them sleepy Create an inviting and productive environment for parents and staff. Results dont show a high level of satisfaction of the ambiance of the NICU. It was observed that one nurse was trying to look at the color of PH paper and she had to move to find a lit space; she had a hard time to read it because there was no general or task light in this space (Figure 43). The other nurse was doing a procedure on one of the newborns, while there was a cover on top of the isolate and the task light was shining on that; she wanted to prevent the direct light exposure to the babys eyes and the fact that the task illumination was too much for the baby, she had to

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71 compromise it with covering the isolate. The newborn in by the window and the blinders are open so the nurse is using some of the natural light for her procedure (Figure 42). The other observation shows that one baby was under the Bilirubin light and had blindfolds on (Figure 42) Figure 42 Task area with no general or task lighting A B Figure 43 Covering isolates with sheets to prevent direct l ight exposure to babies eyes A ) NICU III. B ) NICU II.

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72 Table 44. Comparison of Shands existing general lighting in NICU support areas to IESNA recommended standards I ESNA Recommendation for Support Areas Existing Condition 15 minute/shift exposure to White light: 30 0 50 0 LUX Lounge: All Fluorescent Daytime: 260 LUX Night time: 140 LUX Where support area meets Newborn care area: Separate light sources, Independent switches Done Highlight artwork and architectural features. Done, in the waiting room Task Lighting: The pattern of task lighting is not consistent for each bed. Some of the old isolates have a heater that has a light installed in it; this light is used as task lighting that is not adjustable and has o nl y two levels of illuminations (F igure 314). Some of the old isolates also have another task light that is flexible but because of its weight and built, is hard to move (Figure 315). The new isol ates, on the hand, have a task lighting called the Giraffe. They have three levels of illumination and very easy to move and adjust (Figure 316). It was observed that nurses and doctors had to constantly adjust their position on top of the newborn to av oid shadow. The illumination level for task lights was between 1200 to 1900 LUX which is even more than the recommended illumination level. Natural lighting : The natural light has some effect on the general lighting for this area especially for the beds ne xt to the window which will be explained below. The blinders are closed most of the time and very few caregivers use the natural light for their tasks. It was observed that a nurse was doing a procedure on a baby next to the window but the blinders were cl osed; she did not use the natural light for her procedure. Also based on the information obtained from nurses, there is no priority as to which baby is positioned next to the window; it is just the matter of available space. There is

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73 restriction only for babies who are in very critical and fragile condition; they need an environment that is very similar to the womb and are not positioned next to the window. Table 45 Comparison of Shands existing task lighting in NICU to IESNA recommended standards IESNA Recommendations Existing Condition Newborn Care Area 100 0 LUX (min) at the plane of the infant bed 120 0 190 0 LUX depending on the task light Separate procedure lighting for EACH infant bed Some newborns are not in a space designed as a bed space so dont have any lighting and have to borrow from other newborn care area s Temporary increases in illumination necessary to evaluate a baby or to perform a procedure should be possible without increasing lighting levels for other babies in the same room. Possible for new isolates (with Giraffes) Old ones only two illumination levels. Table 46 Comparison of Shands existing natural lighting in NICU to IESNA recommended standards IESNA Recommendations Existing Condition Newborn Care Area No direct v iew of the sun to the newborns This barely happens to the babies next to the windows and it is controllable. Be situated at least 2 feet (0.6 meter) away from any part of an infant's bed to minimize radiant heat loss. This was applied in Shands NICU Be equipped with shading devices that are neutral color or opaque to minimize color distortion from transmitted light. Done S upport Areas Support areas in NICU II The Storage (t he Garage) family room and hand washing area: The storage is to store su pplies and equipment It is very lit by f ew sets of fluorescent lights. There are

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74 two recliner sofas in the family room that parents can stay in and rest. The general lighting consists of a set of 2 by 2 fluorescent lights. Hand washing area in NICU II is similar to NICU III and has one linear florescent for illumination which is c overed and illuminates up to 718 LUX w hen the surrounding is about 275 LUX IESNA recommends 300 500 LUX for the surrounding while the task can go up to 1500 LUX. Support areas in NICU III Nurse s tations, staff lounge and hallways: There is one main nurse station in NICU III; but nurses mostly use the counters by the beds as their station for charting. These are the spaces where the monitors are located at. Some of the monitors fac e the windows and some have their back to the windows. Staff lounge has seating for 10 people. General lighting in this area is a combination of linear fluorescent and recessed compact fluorescent light. There is also an indirect fluorescent lighting on the walls. Transport t eam desk x ray viewing station, physicians room (fish tank) : Transport team desk is located in the hallway of NICU III; they basically use the hallway general lighting for their tasks. X ray viewing station is located in the same hall way across from the transport team desk. Physicians room has two glass walls, one toward the hallway and the other toward the main newborn care area; thats why it is called a Fish Tank. This room gets a part of its general illumination from the newborn care area. On Call/sleep rooms and multipurpose room (Frans room): Oncall rooms are used by doctors and attendees who work at night shift. T he general lighting consists of a set of 2 by 2 covered linear florescent lights. There is a night light next to the bed and a fluorescent light on top of the hand washing sink (Figure 318) Multipurpose room has seats for 6 people and is used for resting and privacy purposes. The general light here

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75 is a set of 2 by 2 linear fluorescent lights; there are two lamps there that can be used either as task light or a more soothing general light. Lobby (waiting room), pump room (breast feeding room) and conference room : Lobby has seats for about 17 people. The general lighting consists of recessed compact fluorescent lights. There is an architectural feature in the middle of the ceiling in that simulates a skylight and illuminates the room by artificial lights. This helps to create the feeling of having natural lighting there. There are three adjustable spot lights for the artworks and a wall sconce (Figure 319) The pump room has two private areas for pumping (Figure 320); each area has its own general lighting that consists of recessed fluorescent light. There is a linear fluorescent lamp o n top of the sink. There is no task lighting in the pump room The general lighting in conference room is 2 sets of 2 by 2 linear fluorescent lighting which are controlled by dimmers Summary of Observation and Documentation Findings The average general lighting level in both NICUs falls within the lower level of IESNA recommended standards. The average level of general light in NICU II is lower than NICU III especially at night. The task light illumination level is higher than the recommended standards but its level of flexibility i s an issue. The caregivers information about light switch placement and figuring out which switch controls which light, is not enough. Switch placements also need improvement since some of them are hidden behind the monitors. Support areas mostly meet the recommended standards; but the type of lighting in spaces like the staff lounge or the conference room is not suitable for the visual task and type of ambient needed for that space. Survey Findings In this section, survey finding s f or each group of parti cipants (doctors, nurses, and families ) will be described. There were 20 participants in the doctors group, 42 in

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76 n urses group and 34 in f amily group. These results show the frequency of use for different spaces ( Figures 44 through 46 ), visual tasks done in ea ch groups most used space ( Figures 47 and 48 ) and lighting satisfaction as far as how much the lighting supports their vi sual tasks in these spaces ( Tables 48 and 49 ), how much control they have over lighting there ( Tables 410 and 411) and ov erall lighting quality satisfaction ( Table 47) In the following part of this section, the researcher compares the survey results among al l three groups of participants. The last part is a summary of all the findings from surveys. Lighting Satisfaction An alysis by Groups Doctor s satisfaction with newborn care areas Based on Table 47, doctors are mostly satisfied with the level of information they have about the controllable features to adjust the light in newborn care area. These features are shown in Fi gure 410 ; based on this figure, doctors mostly use light switches A very small number of doctors claimed that they either dont use any of the control features to adjust the light or they dont change the lighting at all Comparison of the level of doctors satisfaction with lighting control in the newborn care area II (Mean=4.09) and III (Mean=4.25) verses their level of satisfaction with the information they have to adjust the light (Mean= 5.2), shows they are more satisfied with their level of informat ion than actually being able to control the light. General lighting and visual comfort are the second most satis factory aspects of lighting for doctors So, in summary d octors are most satisfied with their level of information about where the features for controlling light is and they are least satisfied with the natural lighting. There are 25% of the doctors who spend less than 5 hours per week in newborn care area II; whereas 30% of them spend 5 to 10 hours there ( Figure 44 ). The tasks done by doctors in this area are reading in general, reading labels, viewing x rays, and

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77 writing using computers and performing procedures on the patients. The task Reading was divided into two task s, the reading in general and reading the labels. The reason is that labels are in smaller fonts and harder to read and the researcher wanted to make sure the participants evaluation of the visual comfort is done as detailed as possible. The mean of their satisfaction with the level that lighting supports their tasks in this area, is 4.09 ( Based on the 7 point Likert Scale, 1=very dissatisfied, 7= very s atisfied ) and the mean of their satisfaction with the level of control they have here, is 4.09 (Based on the same Likert scale). There are 15% of the doctors who spend less than 5 hours per week in newborn care area in NICU III; 20 % spend 5 to 10 hours, 5 % spend 11 to 25 hours, 10 % spend 26 to 35 hours and finally 10 % spend more than 35 hours per week in newborn care area II I. Their tasks are the same as newborn care area II and their satisfaction of lighting support for these tasks has a mean of 4.5. Their level of satisfaction with lighting control has a mean of 4.25. Doctors satisfaction with support areas Physicians room is one of the offices in NICU III. There are 5% of d octors who spend less than 5 hours in this space and 25% spend 5 to 10 hours per week. Visual tasks are reading, working on the computers and writing. The mean of their satisfaction with lighting support here is 5 and this number for controllability is 3.83. Summary Figure 44 shows that the most used spaces for doctors are newborn care area II and III. They may use other spaces for a longer period of time in different occasions but if both factors are combined ( number of users and the length of use) th ese two areas w ill be the most used spaces by doctors.

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78 Based on Figure 45, the visual task d octors mostly do while in the two newborn care areas (their mostly used spaces) is using computers and the one done least by them is reading labels. Doctors are m ostly satisfied with the level that light supports their visual tasks in offices in NICU III followed by offices in NIC U II and then physicians room and least satisfied with the newborn care areas (they are less satisfied with newborn care II compared to III) This group is mostly satisfied with the level of lighting control they have in office III followed by newbor n care area III and then II; so betw een the two most used areas by doctors, newborn care area III has slightly better lighting adjustment cont rollability, in their opinion. Figure 44 Frequency of usage for spaces used by doctors group (showed in percentage) Nurses Satisfaction with newborn care areas Table 47 shows that nurses are mostly satisfied with the level of information they have about the controllable features in their most used spaces. Nurses mostly use light switches to control the light and use desk lamps the least ( Figure 410).

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79 Comparison of the level of satisfaction with control that nurses hav e in the newborn care area II (Mean=4.3) and III (Mean=4.48) verses their level of satisfaction with the information they have to adjust the light (Mean= 5.41), shows they are more satisfied with their level of information than actually being able to contr ol the light. So, in summary n urses are most satisfied with their level of information about where the f eatures for controlling light are and they are least satisfied with the natural lighting. About 14 % of the nurses use newborn care area for less than 5 hours per week whereas 5 % use for 5 to 10 hours, about 24 % use for 11 to 25 hours, about 14 % for 26 to 35 hours and 17 % for more than 35 hours per week. Tasks done in these areas are reading in general, reading labels, viewing x rays, writing, using c omputers and applying procedures. The mean satisfaction level for how much the lighting quality in this area supports these visual tasks is 3.58 among nurses; this number for their satisfaction level with the controllability over lighting is 4.3. Five % of the nurses use this area for less than 5 hours, 7 % for 5 to 10 hours, 33 % for 11 to 25 hours, 17 % for 26 to 35 hours and 12 % for more than 35 hours. Tasks are the same as Newborn care area II. The mean for lighting support satisfaction is 3.77 and it is 4.48 for controllability satisfaction. Nurses satisfaction with support areas There is one main nurse station in NICU III and several scattered ones throughout both newborn care area II and III. About 12 % of the nurses spend less than 5 hours here, 9. 5 % spend 5 to 10 hours and about 2 % for 11 to 25 hours per week. Tasks done are this area are reading in general, sometimes reading labels and of course using computers. The satisfaction mean for lighting support in this area is 5.1 and it is 4.5 for controllability. The transport team desk is located in NICU III and used by transport team who are a part of the nurses group in this research. About 5 % of

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80 transport t eam spends less than 5 hours in this area and about 7 % spend 11 to 25 hours per week her e. The tasks done here are the same as offices. The mean for lighting support satisfaction is 5.57 and it is 5.75 for controllability. Figure 45. Frequency of usage for spaces used by nurses group (showed in percentage) Sum mary The most spaces used by nurses group are the two n ewborn care areas as clearly shown in Figure 42 As described for doctors, even though nurses may use other spaces than newborn care areas for a longer period of time, but if both factors are combined, the number of users and the length of use, these two areas w ill be the most used spaces by nurses. Based on Figure 47 the visual task n urses mostly do while in the two newborn care areas (their mostly used spaces) is using computers and the task they least do is viewing x rays. Nurses are mostly satisfied with the level that light supports their visual tasks in transport team desk. They are least satisfied with the newborn care areas, especially newborn care area II. Nurses group is mostly satisfied with the level of

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81 lighting control they have in transport team desk and t he least in offices in NICU II; so between the two most used areas by nurses, newborn care area III has slightly better lighting controllability, in their opinion (Figure 410). Famil ies satisfaction with newborn care areas In general families reported that they use light switches among all the light controllability features; the frequency in which they use the switches somehow is less than doctors and nurses. There are some family members that reported no lighting control at all (figure 410) Families are mostly satisfied with the visual task and general lighting in their mostly us ed spaces (newborn care areas). As shown in Figure 48, family members spend most of their time in newborn care areas performing tasks like changing diaper, reading, writing and using the computers; but the task mostly done by them is changing diapers. Mean of f amily satisfaction of the lighting support for their visual tasks in newborn care areas is 5.75 and it is 4.31 for controllability. Families satisfaction with support areas Family Room is a room designated for parents and family to rest in or stay overnight. There are two family rooms in Shands NICU, one in NICU II, called Frans r oom and the other one in NICU III. About 6 % of f amily members spend less than 5 hours in these areas and the same number of people spends 11 to 25 hours in this a rea. Visual tasks done by f amilies, here are reading, writing and using computers. The mean for f amily satisfact ion with the level of lighting support for their visual tasks is 4; this number for lighting controllability is 3.5. Summary There are 38.22 % of the f amily members who use Newborn care area II and 61.74 % use Newborn care area III for more than 35 hours per week; 11.76 % uses

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82 family r oom for maximum of 11 to 25 hours ( Figur e 44). This result shows that families mostly use the two newborn care areas. Based on Figure 46 the most done task by this group is changing babies diaper. Families are mostly sati sfied with the level that light supports their visual tasks and also controllability, mostly in newborn care area II; they are least satisfied with the family rooms. This group is mostly satisfied with the level of lighting control they have in newborn car e area II; family rooms are in the last place. Figure 46 Frequency of usage for spaces used by family group (in percentage) Comparison of Caregivers Satisfaction Findings from survey showed that most used spaces for doc tors, nurses and families are the two newborn care areas in NICU II and III. So as mentioned earlier the satisfaction levels that are not specified to a certain space in analysis are basically for the participants most used space; t heir opinion about comm on areas was evaluated in the interview questions and was analyzed further, using content analysis.

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83 Figures 47 and 48 show the frequency of visual tasks done by caregivers in Shands NICU. The way questions were asked in the survey, gave the participant the chance to individually choose the task they do in each of the spaces, therefore one task could be chosen more than once by one participant; this caused the high percentiles in so me of the results. Doctors and nurses use the computers more than any other task. Changing babies diapers is the visual task mostly done by f amilies while present in their newborns bed space ( Figure 48 ). Figure 47 Frequency of visual tasks done by staff (showed in percent age) Table 47 and Figure 4 9 go hand in hand to show the mean of the caregivers satisfaction from the aspects of lighting quality mentioned above. The evaluation for this question in survey was based on a 7point Likert scale. In this scale, number 1 means not satisfied at al l or better said, very dissatisfied and 7 means very satisfied. The Standard Deviation (SD) was calculated to show the variety of the replies that resulted in these means. As shown, staff (doctors, nurses) is most satisfied with the level of information they have of where the switches are; on the other hand this is the aspect

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84 that family are least satisfied with. Families are the most satisfied with the general lighting, among caregivers. Nurses on the hand are the least satisfied. Staff are least satisfied with the natural lighting. Figure 48 Frequency of tasks done by families (showed in percent age) Table 47 Mean (M) and Standard Deviation (SD) scores for caregivers satisfaction Doctors (N=20) Nurses (N=42) Family (N=34 ) M* SD M SD M SD General Lighting Satisfaction 4.55 1.39 3.59 1.77 5.3 1.34 Task (1) Task Light Satisfaction (2) Task Performance 3.83 4.10 1.34 0.71 3.45 3.57 1.90 1.79 5.03 4.85 1.2 1.09 Natural Lighting Satisfaction 3.35 2.01 3 1.82 5 1.53 Visual Comfort 4.5 1.43 3.95 1.86 5.32 1.41 Information About Controllable Features 5.2 1.83 5.41 2.08 4.06 2.11 *M= Based on the 7 point Likert Scale, 1=Very Dissatisfied, 7= Very Satisfied In order to better analyze the caregivers level of inform ation for lighting control and adjustment, one of the questions in the survey was about what controllable features they have access to and use. The results are summarized in Figure 410. The available

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85 features in both Shands NICUs were observed and they w ere light switch, under cabinet light, desk lamp, window blinder, light dimmer and night light. Obviously each caregiver doesnt have access to all of these and some of them dont try to adjust any of the features around them so the researcher gave them the None option in the questionnaire; families have the highest percentage for not changing the lighting in the bed space. The most used features by all caregivers are obviously the light switches followed by light dimmers. As mentioned above, caregivers level of satisfaction with how much lighting supports their task performance, and their control over the lighting in their used spaces was asked twice in the questionnaires. Tables 48 through 411 show the mean of caregivers satisfaction level with these two aspects; the difference is that this time, it is analyzed for all the spaces the caregivers use and not only for their most frequent used space. These tables give out useful details like caregivers level of satisfaction of each of the newborn care areas separately (newborn care area in NICU II and the one in NICU III), instead of a combined result. Families were analyzed separately because the spaces they use are very different than the ones used by staff. Nurses are mostly satisfied with the control lability of the light features at nurse stations (both the main nurse stations and the scattered ones around NICU II and III) and transport team desk (the desk used by the transport team who are a part of the n urse group) ; both doctors and nurses are least satisfied with the newborn care areas whereas families are most satisfied with them. Between the two newborn care areas, NICU II is less desirable among doctors and nurses but more desirable among families (Tables 48 and 49)

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86 Figure 49 Comparison of the means of level of light quality satisfaction for all three groups of caregivers Figure 410 The frequency of caregivers usage of the controllable lighting features they have access to.

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87 Table 48 Mean (M) and Standard D eviation (SD) scores for staffs level of satisfaction with light supporting their tasks in their used spaces Spaces Doctors (N=20) Nurses (N=42) M* SD M SD Newborn Care Area I I 4.09 1.88 3.58 1.91 Newborn Care Area I II 4.5 1.5 3.77 1.91 Office I I 5.5 0.5 4.86 1.96 Office I II 6.5 0.5 4.5 1.77 Physicians Room 5 0.82 Nurse Station 5.1 1.58 Transport Team 5.57 1.09 Control Charting Front Desk *M= Based on the 7 point Likert Scale, 1=Very Dissatisf ied, 7= Very Satisfied Table 49 Mean (M) and Standard Deviation (SD) scores for families level of satisfaction with light supporting their tasks in their used spaces Spaces Family (N=34) M* S D Newborn Care Area II 6.08 1.25 Newborn Care Area III 5.75 1.48 Frans Room 4 3 Family Room I II 4 3 *M= Based on the 7 point Likert Scale, 1=Very Dissatisfied, 7= Very Satisfied As far as the c ontrol over lighting, doctors are most satis fied with offices in NICU III, n urses with the transport team desk and the nurse stations and families with n ewborn care areas. Doctors and nurses are more satisfied with the level of control they have in n ewborn care area III than n ewborn care area II ; and this result reverses for f amily. Some of the questions in the survey gave the participant the option to explain their answers further. These comments were analyzed using content analysis and the result of their replies is summarized in Appendix K, Table K 2. Table 412 shows the frequency of participants comments for each category of questions. All the written comments were about their dissatisfaction with the related category and no positive

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88 comment about their satisfaction was written. Doctors mostly talked about their job performance; one of the doctors (D1) said: Spot lighting is often insufficient for procedures (Appendix K). Nurses talked about their dissatisfaction with natural lighting, general lighting and task lighting. Family mostly talked about general lighting; even though natural lighting seems to be an important matter for them as well. One of the family members (P1) said: I think they could use a little more sunlight. It is good for the baby (Appendix K). Table 410. Mean (M) and Standard Deviation (SD) scores for staffs level of satisfaction with ligh t control Spaces Doctors (N=20) Nurses (N=42) M* S D M S D Newborn Care Area I I 4.09 1.44 4.3 1.61 Newborn Care Area III 4.25 1.23 4.48 1.70 Office I I 3.5 0.5 3.71 2.12 Office I II 5.25 0.83 4.5 2.36 Physicians Room 3.83 2.27 Nurse Station 4.5 1.75 Transport Team 5.75 1.09 Control Charting Front Desk *M= Based on the 7 point Likert Scale, 1=Very Dissatisfied, 7= Very Satisfied Table 411. Mean (M) and Standard Deviation (SD) scores for families level of satisfaction with light c ontrol Spaces Family (N=34) M* SD Newborn Care Area I I 4.38 2.27 Newborn Care Area III 4.31 2.05 Frans Room 3 2 Family Room I II 4 3 *M= Based on the 7 point Likert Scale, 1=Very Dissatisfied, 7= Very Satisfied

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89 Table 412. Frequency for participants comments on lighting dissatisfaction in surveys Themes Doctors ( N =10) Nurses ( N =10) Family ( N =34) General Lighting 2 17 4 Task Lighting 2 16 1 Task Performance 3 6 1 Natural Lighting 2 18 3 Visual Comfort 2 7 1 Controllability N/C* 1 2 *N/C=No Comments A oneway ANOVA was used to test for satisfaction differences among the three caregivers group for lighting conditions at NICUs (Table 413) Post Hoc test HSD (Honestly Significant Differences) tests were conducted when signi ficant one way ANOVE results were obtained (Table 414). This test shows that the difference between the satisfaction levels of the three groups of caregivers is significant for all the lighting aspects except their level of information of the light control features. In order to better understand the significance of difference between each group of caregivers specifically, the result of Post Hoc test is shown in Table 414. Based on these results, there is a significant different between the level of satisfaction for nurses versus families. This difference is true for all the aspects of lighting such as general lighting, task lighting, natural lighting, job performance and visual comfort. The results of this study shows that families and nurses have the most difference in their lighting satisfaction since their visual tasks are different and their level of responsibilities and the level they need to change the lighting in NICU is very different. Post Hoc results show that this difference is significant. The results obtained from the Post Hoc test reinforce the results of this study.

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90 Table 413. Mean and standard deviation for lighting satisfaction (Post HOC test) Dependent Variable (I) type (J) type Mean Difference (I J) Std. Error Sig. Info rmation Doc tor Nurse .252 .549 .647 Families .79 0 .624 .209 Nurse Doctor .252 .549 .647 Families 1.043 .531 .053 Families Doctor .790 .624 .209 Nurse 1.043 .531 .053 Natural Doctor Nurse .350 .495 .482 Families 1.83 .563 .002 Nurse Doct or .350 495 .482 Families 2.181 .480 .000 Families Doctor 1.831 .563 .002 Nurse 2.181 .480 .000 General Doctor Nurse .954 .432 .030 Families .677 .491 .172 Nurse Doctor .954 .432 .030 Families 1.632 .41 8 .000 Families Docto r .677 .491 .172 Nurse 1.632 .418 .000 Task Doctor Nurse .397 .432 .360 Families 1.377 .491 .006 Nurse Doctor .397 .432 .360 Families 1.774 .418 .000 Families Doctor 1.377 .491 .006 Nurse 1.774 .418 .000 Job Perf ormance Doctor Nurse .528 .388 .177 Families 1.081 .441 .016 Nurse Doctor .528 .388 .177 Families 1.610 .376 .000 Families Doctor 1.081 .441 .016 Nurse 1.610 .376 .000 Visual Comfort Doctor Nurse .547 .449 .227 Families 1.181 .511 .023 Nurs e Doctor .547 .449 .227 Families 1.729 .435 .000 Families Doctor 1.181 .511 .023 Nurse 1.729 .435 .000

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91 Table 414. Mean and standard deviation for lighting satisfaction (ANOVA test) N Mean Std. Deviation F Sig Info rmation Doctor 20 5.20 1.88 1.944 .150 Nurse 42 5.45 1.91 Families 22 4.40 2.32 Total 84 5.11 2.04 Natural Doctor 20 3.35 2.05 10.682 .000 Nurse 42 3.00 1.8 4 Families 22 5.18 1.53 Total 84 3.65 2.02 General Doctor 20 4.55 1.43 8.067 .001 Nurs e 42 3.59 1.79 Families 22 5.22 1.26 Total 84 4.25 1.72 Task Doctor 20 3.85 1.26 9.129 .000 Nurse 42 3.45 1.92 Families 22 5.22 1.02 Total 84 4.01 1.73 JobPerf Doctor 20 4.10 .71 9.173 .000 Nurse 42 3.57 1. 80 Families 22 5.18 1.00 Total 84 4.11 1.56 Visua l Doctor 20 4.50 1.46 7.895 .001 Nurse 42 3.95 1.88 Families 22 5.68 1.28 Interview Findings In this section, interview findings will be described based on lighting factors ( g eneral lighting, task lighting, natural lighting and controllability). There were 10 people participating from each group. Questions in interviews covered issues of lighting such as frequency of caregivers satisfaction of daytime lighting, nighttime lighting, lighting factors in general, newborn focused factors and the overall general lighting condition of the support areas used by each group ( Appendix H, I and J ) Each groups comments and suggestions have also been gathered from the interviews and will be talked about in each s ection (Appendix K).

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92 General Lighting Families talked about general lighting illumination more than the other two groups; all the groups were mostly unsatis fied with this factor as well as other aspects of general lighting. This result is the same as general lighti ng satisfactory report at nighttime with the difference that doctors and families mostly talked about it. Doctors and nurses were mostly unsatisfied with the glare, shadow and contrast; they were satisfied with the visual comfort in NICU III than NICU II; families did not mention anything about this factor. As far as preventing direct light exposure to the newborns eyes, all the groups that mentioned this were mostly satisfied with the way they cover newborns eyes or isolates; there was one iss ue that ca me up by one of the d octors, he mentioned that he didnt like the sheets; they hindered what he was doing and that it might fall down and get contaminated. When the same question was asked of a nurse and was mentioned that one of the doctors does not like this way of preventing direct light, she mentioned that this was an affordable and convenient way and if for any reason the cover they use got contaminated, for example fell on the floor, they immediately sent them to the laundry room; with the exception t hat if the cover was prov ided by the family members. All the groups were unsatisfied of the level that light was individualized for each newborns bed space. All the groups were mostly satisfied with the public areas they use. In general doctors were more unsatisfied with the general lighting in both daytime and night time; also with the lighting factors and factors that relate to the newborns comfort. The number of doctors who are satisfied with the glare issues in newborn care areas is the same as the ones who are not satisfied. On the other hand, doctors are mostly satisfied with th e general lighting in the support areas; the only exceptions are the conference room and the Call room.

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93 Among the lighting factors, glare, shadow and controllability most bot hers the nurses; followed by the placement and accessibility of the light switches. Nurses who talked about the public areas were mostly satisfied with the general lighting and visual comfort there. Family me mbers were mostly unsatisfied with the general l ighting in both day and night time; all the ones who talked about lighting factors in general and newborn focused factors, were unsatisfied. Task Lighting and Natural Lighting Task lighting was more toward unsatisfactory as well; mostly doctors and nurses menti oned the issues of task lighting. Overall n urses were more satisfied with the task lighting in their mostly used spaces (the newborn care areas) than the general lighting there; and more satisfied with NICU III visual comfort level than II. Families opinion of the task lighting was more toward satisfactory. Natural lighting was mentioned by all the groups and they were mostly unsatisfied. Controllability The issue of controllability was mentioned by all the groups; doctors were mostly satisfied. Switch placements were not easily accessible for the doctors and nurses. One f amily member talked about this who was not satisfied as well. The only aspect of lighting doctors are more satisfied with than being unsatisfied is controllability and the way ther e is to prevent direct light exposure to the newborns eyes.

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94 CHAPTER 5 DISCUSSION The purpose of this study is to investigate the existing lighting conditions in Shands NICU as a case study and to compare it with the IESNA lighting recommendations for NICU ; also, to measure the Shands NICU ca regivers satisfaction with the existing lighting condition. Based on Rea (2004), the caregivers in t his study include doctors, nurses and families of newborns. This chapter is organized to discuss each research question. In order to do this clearly, the aspects of lighting have been divided into four categories : general lighting, task lighting, natural lighting and controllability of lighting. The general and task l ight are combined for discussion because the existing l ighting condition of Shands NICU sometimes forces caregivers to use the general lighting f or their task s; for example nurses need to be able to read the charts while they are moving from one newborn care area to another or sometimes they just use the gener al light to perform minor procedures. The term medical procedures in Shands NICU, in general means tasks like pulling out or putting in IVs, putting in tubes and checking the babies for Jaundice. Research Question OneTo What E xtent If Any, Does Sha nds NICU Existing Lighting Condition, Meet The IESNA Recommended Standards? General Lighting Findings show that the level of general illumination in NICU II and III falls within the lower level of the recommended illumination range by IESNA. Recommended r ange by IESNA is 10 to 600 LUX; results show that the existing general lighting in Shands NICU is 69. 8 LUX for NICU II during daytime and 30 LUX during the nighttime whereas it is 73 LUX for NICU III during daytime and 85 LUX during nighttime. As mentioned above, the average illumination in NICU II was lower than NICU III, especially at night. Based on Rea (2004), lighting supports visual processes such as acuity, color vision

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95 and visual performance so having adequate level of lighting in NICU is important for caregivers specially staff w ho have to perform visual tasks such as procedures. One of the IESNA recommendations mentions that there shouldnt be any direct view of the electric light sourc e (Rea, 2000). IESNA does not clarify if this recommendation is specifically for newborns or caregivers; but findings of this study show that this matter was majorly an issue to the newborns. The general lighting could bother the babies eyes because there was no control on the direction and distribution of the general lighting To prevent this problem, the caregivers were using sheets draped over the babies eyes or the isolate. It was not expected that caregivers would be satisfied with this method because it does not seem like a professional approach to solving the problem of direct light exposure i nto babys eyes. It was expected that caregivers would desire to look for a better solution for this matter; but the results show that most of the doctors and nurses are actually satisfied with this method (4 doctors out o f 7 and 7 nurses out of 9 who talked about this issue). One doctor mentioned this method hindered his job performance and his other concern was that if these sheets get contaminated by; for example falling on the floor and it was dangerous for the babies health. This concern was brought into two nurses attention; they both mentioned that if a sheet fell down, it would imm ediately go to the dirty hold unless the sheet is brought by family members Regardless of satisfaction of the caregivers with having a sheet draped over the babies isolate s, this method is not the best solution as a design view point We may have to look into furniture design exclusively for NICU to solve this issue. For example, an individual bed can be designed in a way that has its ow n adjustable task and general light carried with it or it can have its own canopy to shield the light to the babies eyes.

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96 There are some IESNA recommendations that are not met by Shands NICU; for example, the light fixtures are not easily accessible to be cleaned and can cause changes in lighting quality and discomfort for caregivers health. One of the staff mentioned that the light on top of the front desk has not been cleaned for ages and they can actually see the difference it makes on the level of il lumination. The solution can be either to have more accessible general lighting or to maintain the lights in a better fashion. Preventing glare is another recommendation by IESNA. In Shands NICU, glare is majorly caused by general lighting, task lighting and slightly by natural lighting. This is related to the direction of the light and its controllability. If caregivers were able to control the direction of light, they could avoid glare and problems caused by it more easily. Some of the IESNA recommendati ons are too general and need more details and elaboration in order to be useful. For example, IESNA recommends creating an inviting and productive environment for parents and staff ( White, 2007) but does not explain what inviting and productive environment mean s. Rea (2004) mentioned that lighting communicates a message to professional staff, as well as parents and visitors, about the level of care and sophistication provided by the hospital. So, t his matter can cover a lot of details as far as what is invi ting and productive for each of the groups of caregivers based on their tasks, needs and time of day they are in NICU. These details need to be mentioned in IESNA recommendations. The IESNA recommends that the general lighting should have different intensities at different times ( White, 2007) General lighting in Shands has dim mer s for the recessed down lights which can be adjusted according to the users needs. The problem is that adjusting the lighting on top of one bed space can affect other one next t o it This can cause discomfort for other babies especially if the newborn is not in a

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97 designated bed space due to higher volume of admitted babies to newborn care area; therefore some of the babies occupy the same illumination zone and if one bed space needs to increase or decrease the illumination level, the other one will be affected by it. So the general lighting level is dimmable but the illumination zone needs to be flexible If the illumination zone is flexible, the caregiver can just move the general light to one bed space and use it specifically for that newborn without bothering the newborns around it. The best solution is to rely on task lighting instead of general lighting. If the general lighting is only used for navigation and minimal levels of facial recognition, then there is no need to adjust the general lighting. Instead, the task light covers the illumination needed for visual tasks. This is another indication that IESNA recommendations are too general and need to investigate different aspects of each recommendation; they also need to propose the recommendations based on different situations and environments in different NICUs. Another example to support this argument is that IESNA recommends general lighting to have different intensities but it doesnt mention that it has to be controllable too. If the light is not easily adjustable, caregivers will face problems such as glare, exposure of direct light to the babies eyes, etc. The findings indicate that one of the problems night shift nurses had, was the low level of general lighting in NICUs, especially in NICU II; this made night shift nurses sleepy and they also couldnt perform their visual tasks easily. White (2000) recommends that bright lighting is preferred in areas where staff performs critical tasks such as medication dispensing. The IESNA also recommends lighting at night should be lit enough to keep nurses awake ( White, 2007) On the other hand babies need less general lighting at night for their circadian rhythm. So, the lev el of lighting needed by caregivers to perform their tasks at night time is different than the level of lighting

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98 needed by newborns. Findings also showed that even though there are two main nurse stations in Shands NICU, most nurses do the majority of thei r charting on the monitors located on the counters by newborns newborn care area; also based on nurses comments, it is hard for nurses and doctors to read the charts while walking toward a bed space, so they have to look for a lit space and this frustrates them. Studies indicate that satisfaction and stress have a direct correlation to employee burnout and a decision to leave the job (Barrett & Yates, 2002). One might suggest installing task lighting for each charting station next to the newborn care areas. This does not solve the issue with general lighting since we will be using task lighting to solve a general lighting issue. A better solution could be to change the general lighting to a level that is enough for navigational purposes and routine visual t asks like reading and using the computer and instead, focusing on making task lighting more accessible and controllable. Also, it is necessary for IESNA to narrow down its recommendations for general lighting ( The IESNA recommendation for general lighting is 10 to 6 00 LUX ) One suggestion for these general lighting recommendations is to change this range to minimal illumination level for navigational purposes and instead have more specific and detailed task lighting requirements. IESNA recommends that staf f should be exposed to either natural light or white light (300500 LUX) at least 15 minutes a day ( White, 2007) This is important for staffs circadian rhythm and their vitamin D intake (Rea, 2004) Shands staff doesnt have this opportunity unless they stand by the windows and have the blinds open; this doesnt happen often because they dont want to bother the babies with the direct sun exposure and also the windows are not easily accessible since newborns beds are placed next to the windows. Accessing windows is even harder in NICU II because there is a counter right by the windows and there are monitors and charting materials on it. Besides, the

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99 newborn care area is designed to primarily suit the newborns need and natural light exposure for staff is not necessarily a main design aspect of this area. So, staff should be able to obtain the natural light somewhere other than the newborn care area. The best place to accommodate white light for staff is the staff lounge. Study shows that staff exposure to bright light (5000 LUX for about 15 minutes) lessened the caregivers anxiety associated with night shift work (Leppamaki et al., 2003). The most economical source for white lighting is full spectrum fluorescent light and this can be suggested for Shands NICU lounge area. White light is especially useful for the nightshift staff since it stimulates their body to stay awake and be more alert; this can be recommended for NICU lounges in general and is not specific to Shands NICU. Another aspect that needs t o be considered in NICU lounges in general is that lounge should be a place for relaxation and comfort. Even though white light is necessary for the staff, it might be necessary to have another type of lighting that creates a soothing and relaxing environm ent; for example indirect lighting. A n economical solution is to provide a type of white light that can be easily adjusted to an indirect light. The day shift staff may benefit from the indirect light more than night shift because dayshift staff are already stimulated by the natural light and the higher level of illumination in the newborn care areas and need a more soothing environment in lounge to relax in; on the other hand night shift staff can benefit from the direct white light for their circadian rhy thm and gaining back their alertness. Therefore, NICU lounge general lighting can be designed in a way that accommodates both types of lighting at the same time Task Lighting The task light illumination level almost meets the standards recommendation but illumination level is not the only aspect of task light that is important for task

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100 performance. One of the task lighting issues in Shands NICU is the difference between the task lighting for the new isolates compared to the old isolates; as shown in the r esults, the task lighting in the old isolates is hard to manage and adjust. The task lighting of the new isolates called the giraffe is flexible and easy to manage; they can be adjusted for different intensities It is ideal to replace all the NICU beds with the a new design that can provide both the general and task lighting individually for that bed; this might not be economical for all the NICUs, therefore another recommendation can be to remodel the existing beds by replacing their task lighting with a more flexible ones such as the Giraffes in Shands NICU; they are flexible and very easily to handle and control, based on caregivers feedback. Results show that an increase in specific locations of task lighting for newborn care area and for families is needed in Shands NICU. For example, providing a task light specific to the chair used by family members by the bed could invite the families to change the level of illumination based on their needs without asking for permission. Also task lighting needs to be installed where the nurses and doctors do the charting by the bed spaces. This is usually done on the counter next to the bed space. Natural Lighting The IESNA recommends that there should not be any direct view of the sun to the newborns eyes ( Wh ite, 2007) This is not of much concern in Shands NICU because windows are designed in a way that there is an exterior overhang which prevents direct exposure of natural light into the newborn care areas; the blinds are also closed most of the time and nur ses can open them by preference. H aving accessible blinds is a useful way of controlling natural lighting in Shands NICU. Another IESNA recommendation is that babies are situated at least 2 feet away from the windows and this is done in Shands NICU (Rea, 2000)

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101 Even though Shands NICU does not rely on natural lighting, there could still be areas that simulate natural lighting just to provide a more natural ambiance. Horowitz and colleagues (2001) recommended that daylight from windows is normal, practical, and recommended light exposures for day shift personnel. One recommendation to fill in the lack of natural lighting in Shands NICU was mentioned earlier and was the white light and indirect light in the lounge; the other recommendation can be a desi gn in the ceiling that simulates a skylight. This is done in Shands NICU waiting room and can be a good model for the rest of the NICU. It was also recommended by one of the nur ses who used to work in NICU of another hospital ; she mentioned that the other NICU d esigned the ceiling of the newborn care area in a dome shape that simulated a very large skylight. They integrated lights in the ceiling in a way that represented stars at night and natural light during the day. LED lamps can very well be used for this pur pose. Natural light should be incorporated into lighting design in Shands NICU not only because it is beneficial to patients and staff, but also because it is light delivered at no cost and in a form that most people prefer (Joseph, 2006). Controllability Results of this study show that there are some controllability issues in Shands NICU. For example, controlling the direction of the general lighting or the level of task lighting is not easy in Shands NICU according to the caregivers. IESNA recommends that there must be control of illumination and adjusting ability ( White, 2007) but does not talk about each specific type of lighting and also how each group of caregivers need different level s of controllability based on their tasks. For example the results show that nurses need the most controllability of lighting versus the families who need the least. This goes back to their visual tasks Nursing care is focused on the assessment, diagnosis, planning, treatment and evaluation of patients requiring acute care. Nursing

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102 interventions in both units address alterations in the physiological function of the neonate and alterations in the family processes. The job description of nurses identifies the population served, equipment utilized, skills performed, and clin ical parameters as well as putting in tubes or pulling out IVs They are the ones who prepare ev erything for the procedures. Each nurse has the authority and accountability for decision making and total care for assigned patients for a shift as opposed to 24 hours responsibility. The nursing staff is committed to patient advocacy and innovative patient care. Families on the other hand either prefer not to change the lighting or they dont need to since their task s mostly do not require a high level of illumination; if they want the illumination level to be changed, they prefer to ask the nurses to do so. This explains the fact that nurses talked about their need of controllability much more than families in the interviews The suggestion is that IESNA inves tigates these kinds of details to make its recommendations more specific and related to each group of caregivers. Another IESNA recommendation is that there must be multiple light switches and a master switch for immediate darkening of the room ( White, 2007) This is done in Shands NICU but the problem is that switches are usually hidden behind the monitors and not easily accessi ble for the caregivers. Mostly nurses know about the switch placement but it is hard for them to figure out which switch controls which light or which way the dim mer s should be turned to change the illumination level. Families have the least informati on of the switch placement. They did not complain about this matter s ince they prefer to have the nurses adjust the light for them. The placement of switches and informing the caregivers of their placement and the proper way of using the switches is something that was not considered in the IESNA recommendations.

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103 Research Question TwoHow Satisfied Are the Caregivers from the Existing Shands NICU Lighting Conditions? This question embeds more specific questions such as: What are the visual tasks caregivers perform in Shands NICU? What is their satisfaction level with the general lighting? What is their satisfaction level with the task lighting? What is their satisfaction le vel with the natural lighting? And what is their satisfaction level with lighting controllability? As we mentioned in the introduction, the discussion for answering questions 2 1 and 22 has been combined since gener al lighting in Shands NICU is used for task performance as well as general illumination. What a re t he Visual Tasks t hat Each Group of Car egivers Do While Spending Time i n NICU? Results show that doctors and nurses mostly work on computers. For doctors us ing computers is followed by viewing x rays, performing procedures and reading, in that order; w hereas for nurses, it is reading, performing procedures and writing. Families reported that the visual task they mostly engage with while by their babys newborn care area, is changing the diaper followed by reading, writing and using the computers. What is important here is the difference between doctors and nurses visual tasks compared to families. Lighting quality is more critical for doctors and nurses tasks than families. Nurses deal with lighting changes the most since they do some procedures themselves and have to prepare everything including lighting levels and directions for procedures done by doctors Nurses are also asked by families to change the i llumination levels (based on families interview results). Families on the other hand either do not need to change the light or prefer not to; this way they avoid the possibility of bothering staff and other babies

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104 What Is Caregivers Satisfaction Level With The General And Task Lighting? Among three groups, families were the most satisfied with the general lighting. This could be because according to the families, they prefer a dim lighting for the babies comfort and also for bonding with the baby. One of the parents mentioned that she preferred dim light because the harsh fluorescent light takes away from the intimacy needed for bonding with the baby. So, even though the level of general lighting in both NICU II and III are in a lower range of the IESNA recommendations, parents prefer it that way; one of the can be the fact that fa milies tasks are not relied on illumination level as much as doctors and nurses tasks. It is possible that if the general lighting was a soft and soothing light, parents would prefer higher level of illumination since a couple of parents said that they needed more light but softer light so it is not harsh for the babys eyes. Individualized lighting for families can change the atmosphere and mood of that space by providing intimacy and privacy. Jeannette Price findings in her thesis study show that privacy is one of the important issues in NICU for the parents and family members, especially when the mother is breast feeding the newborn. We can recommend achieving privacy by li ghting design based on our findings If we design individualized lighting for each bed space in a way that is controlled by dimmers and easily controlled by families, they can change the lighting level in their space based on t he level of privacy they need. An example of this could be installing a task light by each seat next to the bed side, in a way that can be easily controlled by parents. Nurses on the other hand are the least satisfied with general lighting. As mentioned earlier, nurses are the ones w ho deal with the lighting issues more than other groups. This could be the reason they are least satisfied and they are the ones who talked about the issues of general lighting more than the other two groups. One nurse said I wish I could turn more lights on without bothering babies and other staff.

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105 This could be accomplished at the task level if more effective task lighting were employed at all task locations in the newborn care area. A few other nurses mentioned that they noticed their eyesight had changed due to low level of illumination. They explained that the contrast between monitors and the surrounding general lighting hurts their eyes in a way that they cannot look at the monitors for long. Juslen and colleagues (2007) showed a positive effect of higher lighting levels on the speed of production for nurses tasks. Results also show that nurses are mostly unsatisfied with the distribution of the general as well as the illumination level. This means that they are not satisfied with how much of their task surface is covered by illuminated; also the illumination is not uniform This is an indication that nurses use the general lighting for some of their task performances such as reading on monitors, reading charts, feeding the baby, changing the baby and some procedures. So the existing general lighting in Shands NICU is not only important for the ambiance in the newborn care area in Shands but also for task performance. It is necessary to have a uniform distribution of both general and task light for vi sual tasks; this is one of the aspects that contributes to caregivers visual comfort. A better solution to this problem would be to design the lighting in a way that general lighting is o nly for navigation purposes; therefore enough task lighting should be provided for the visual task specially the ones performed by nurses. Distribution of light is one of the issues that are not mentioned in IESNA recommendations. This shows another gap in the standard recommendations. IESNA could have considered different aspects of general lighting such as distribution and talked about each of them and recommended standards specifically for each of the lighting attributes. This gap in IESNA recommendation can generate the illusion that all the problems related to general lighting is related to illumination level and that the

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106 caregivers dissatisfaction with general lighting is only related to illumination level; but this studys results show that this conclusion can be incorrect and that dissatis faction can be related to issues other than illumination level ( such as distribution) The issue of aging eyes is of a great importance. Schuman ( 2002) talked about the fact that the nurses average age is increasing in healthcare environment and that they need more light to perform routine tasks Ulrich and his colleagues (2008) also mentioned that the challenge of maintaining staff effectiveness will be increasingly important as the number of nurses is decreasing and the aging population is increasing. The results of this study a lso showed that nurses average age is higher than doctors and family members, in addition to that, nurses deal with changing the light level s more than the other two groups; so general light level is very critical for them. Some nurses mentioned this problem, one of them said: as you get older you need more light for things like visualizing monitors from across the room ; s o it is necessary that Shands NICU pay more attention to the nurses lighting requirements in their design. It is necessary that Shands NICU evaluates the visual tasks for nurses and provide adequate lighting for their tasks by providing strategically located task lighting in order to be able to keep the general lighting at the minimum level needed for navigation. This method of design w ill provide a suitable general lighting for newborns comfort and circadian rhythm as well as prov iding adequate task lighting for caregivers tasks. A large number of nurses and doctors talked about glare, shadow and contrast, caused by the direction of the general lighting. This is especially important when they are doing procedures on the babies. One nurse mentioned that Sometimes there is a glare from the overheads onto the isolates that make it difficult to see the patient clearly. They also menti oned glare from the monitors. This is another indication of the need to move the main lighting layer down to the task level. The problem is that

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107 caregivers cannot adjust the general lights in the NICU even though they are adjustable; the reason is that they are on the ceiling and hard to reach. It is necessary that Shands NICU make s a use of having adjustable recessed lights; without them being accessible, their adjustability doesnt make a difference. One suggestion for preventing glare from the monitors i s to use OLED lamps in the monitors. OLED lamps have been approved by the FDA to be used for monitors in the healthcare; s ome of their advantages are wider viewing angles and improved brightness and better power efficiency; they are an indirect light sourc e so they dont cause direct glare. Their cost is not low now but will decrease in the near future (Obtained from www.Wikipedia.org ) The pattern of nurses being least satisfied and families the most satisfied, is s een in the flexibility and adjustability issues of lighting too. Again, this can be related to the difference between nurses and families visual tasks as well as their lighting preferences. Even though families had the highest level of satisfaction wi th the lighting in Shands NICU, some of them mentioned the glare from isolates bothering them while trying to look at the baby. We also have the issue of lighting level needed by night shift staff. The results show that the illumination level in both NICU II and III are very low at night compared to the recommended standards (An average of 30 LUX in NICU II and 85 LUX in NICU III compared to the recommended 106 00 LUX ). One doctor mentioned that he had to use a flashlight to pull the IVs from one babys vein. This issue is at the level of task lighting not general lighting. If the doctor had adequate task lighting, the level of general illumination would not be very important. This issue is even more serious in NICU II since the level of lighting is generally lower than NICU III. As previous studies suggest (Leppamaki et al., 2003), repeated and brief exposure (4x 20 minutes) to bright light (over 5,000 LUX) during night shifts improves the well being of night shift staff during and after night work. Barrett a nd Yates (2002) showed that satisfaction and stress have

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108 a direct correlation to employee well being. So, considering issues like staff exposure to bright light can have a noticeable effect on increasing the staff satisf action and as a result, improving th eir job performance. This can be provided in staff lounge especially for night time since staff might be tired and sleepy. Creating an interesting environment by lighting might stimulate their brain and increase their alertness. Study done by Taylor (2005) showed an increase in staff satisfaction by using LED lighting triggered by motion sensors for nighttime lighting. They found these lights convenient and useful for conducting nighttime rounds without disturbing residents sleep. Also Ulrich and colleagues (2008) mentioned that bright light exposure has a positive effect on mood even in healthy people. Families on the other hand are relatively more satisfied with the lighting in NICU II than doctors and nurses, which can be related to preferring dim light for their babies instead of the bright, direct fluorescent light and having a more intimate environment to bond with the baby. Research done by Ulrich and colleagues (2008) showed that babies need to be exposed to lower levels of illumination during the ni ght in order to trick their circadian rhythm into a night mode; so dim light is healthier for babies circadian rhythm and their well being during the night. It is important to have a space where the lighting design creates a soothing environment for caregivers to relax in. Shands NICU has family rooms that family members can stay in to rest and relax especially if they are spending the night in Shands NICU. Some nurses suggested using indirect lighting for this purpose. Ulrich (2008) suggests that lighting from indirect luminaires alone can create an uninteresting space. A little sparkle, color, and highlighting of objects in the space can create an interesting, pleasing environment. Wall sconces integrated into the architecture and accent lighting for ill uminating photographs and artwork will enhance the appeal of the

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109 space significantly. Even colored light, used in combination with whitelight illumination, can provide an environment that is interesting, pleasing, and memorable. There are also rooms calle d Call rooms for nurses and doctors who work at night shift. Based on caregivers feedback, only one room called the multipurpose room ( Frans room ) in NICU III has the soothing environment provided by night lights and proper type of light ing. According to caregivers this room has the incandescent light that is more soothing for the users; the others use the fluorescent lighting. One of the reasons healthcare environments use mostly fluorescent light is for the purpose of saving energy as well as econom ic matters The problem with this is that usually having a soothing general lighting as well as proper lighting (as far as spectrum and color rendering) for visual tasks are sacrificed for saving energy and money. As mentioned earlier, what can be done to compromise between both saving energy and providing an inviting environment for caregivers is to use full spectrum fluorescent lamps with high level of CRI or to use LED lamps. Shands in particular, can decrease the illumination level in storage room (Gar age) and supply room. The lights in these spaces are always on; Shands can also use energy saving bulbs for these areas as well as other areas in Shands. Sensors could also be used in spaces like storage and supply room but based on staff comments, this m ight not make a noticeable difference in energy saving since the traffic is high in these two areas, specially the storage that is used as a passage between NICU II and III. The color quality of lighting in Shands was another unsatisfactory aspect of light ing in NICU. The caregivers dissatisfaction is related to the ambiance created by the general lighting and also their job performance. Two of the doctors mentioned that it is hard for them to distinguish babys skin color for diagnosing Jaundice. Jaundice is common between newborns especially the premature newborns and needs to be

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110 diagnosed immediately for treatment. This important issue is currently dealt with at both general and task lighting level in Shands NICU, meaning doctors and nurses use both general and task light to diagnose jaundice. One suggestion could be to provide proper task lighting with high Color Rendering Index (CRI) so that staff doesnt have to use the general light for critical task like this. This way, the general light can remain at the suitable level for newborns while doctors and nurses are performing their tasks. This can be provided with both fluorescent and incandescent light as long as it has a proper CRI. Parents also mentioned that fluorescent lights [with low CRI] take away from the intimate ambience with their child as well as it being too harsh for their babies. Studies show that there is a direct association between the relaxing home environment and the warm incandescent lights (Ulrich et al 2008). One suggestion could be to install a task light for to the seat by the newborn care area. This approach also sends a message that family is free to control and adjust this task light without asking permission. Some direct lighting luminaires, designed to provide maximum illum ination on horizontal surfaces while minimizing the brightness of the luminaires (to avoid reflections in computer screens), produce dark walls and ceilings and can leave faces and threedimensional objects in shadow. These luminaires, despite their claims for energy efficiency, are usually not suited for the NICU because the work and interactions with people in the NICU are not only associated with headdown work on horizontal surfaces or with intensive computer use, i t also includes staff interaction among themselves or with families It was observed that sometimes nurses and doctors meet by the newborn care area to discuss a babys evaluation; all these interactions need proper lighting at the horizontal level as well as vertical. This issue of causing shadow by direct illumination of horizontal surfaces can add to the problem of diagnosing

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111 jaundice as well. It might be necessary to have indirect lighting for general lights and some adjustable direct lights for task purposes. The flexible general lighting can be adjusted to indirect lighting when it is not needed for task performance. Even though, the level of task illumination in Shands NICU almost meets the recommended standards (Task illumination levels vary between 1200 to 1900 LUX, compared to recomm ended 1000 LUX by IESNA), the satisfaction with task lighting has the same pattern as the general lighting, nurses are the least satisfied (mean=3.45) and families are the most satisfied (mean= 5.03) but the overall caregivers satisfaction with task lighti ng is higher than the general lighting. There are still some issues that are important to mention; for example quite a few of the staff mentioned the new task light feature called as Giraffe (the giraffes) versus the old ones. Caregivers emphasize that t he giraffe light fixtures make their tasks much easier due to flexibility and different light intensities. There are problems with glare, shadow and contrast can be also related to task light. One doctor mentioned, In the Unit [NICU II and III newborn c are area] some of the bright procedure lights are not adjustable, so if the baby's bed is not in the designated bed space, the lights are not directed at the bed and it causes shadows. When a baby is in a space that was not originally designed as a bed space, they either dont have any general or task lighting which means in order to lit the space for visual task and procedures, they have to borrow task lights from other beds; or they might have only the fixed task lighting that reflects directly into the babys eyes and causes discomfort. This dislocation also causes shadow and glare and makes it hard for caregivers to work on the babies. Having individualized task lighting that is flexible and has adjustable intensity is strongly recommended for NICUs in general since task

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112 lighting is used for critical procedures and diagnosis on babies. Once again these results support an argument for diminishing general lighting and amplifying task lighting. Caregivers addressed their preference about task lighting duri ng the interview. For example one f amily member suggested using a screen or shade to prevent direct light exposure to the babies eyes. This shield or screen needs to be flexible and easily removable from the isolate for the cycled lighting intake that babies need for their circadian rhythm. A nurse mentioned to have more flexible task lights: If all of them could be like the giraffes [the new task lighting features], it would be great. Another suggestion was to have more than one type of adjustable task lighting, so they have more option to control the task lighting. It can be suggested that instead of having several task lights with varieties, there can be one task light that has t he enough flexibility and intensities that covers all the illumination levels needed for all groups of caregivers. What Is Caregivers Satisfaction Level with the Natural Lighting? Newborn care areas are the only spaces in both NICUs that get some natural lighting from the south facing windows. Families have the highest satisf action of natural light ing and nurses have the lowest among all three groups of newborn care area users; the same pattern as general lighting and task lighting. Some nurses mentioned glare caused by natural lighting. Nurses work on the monitors in newbor n care area for a long time and change the condition of natural lighting by opening or closing the window blinders, so the issue of controlling the natural lighting is more critical for them compared to other caregivers. This might be the reason that nurses talked about natural lighting in the interviews more than other groups of caregivers. H aving windows is not only important for receiving natural light but also providing good view to the outside and important for regulating the circadian system. Windows pr ovide occupants with visual

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113 information about the outside environment (Ulrich, 2008) However, windows can also be sources of visual discomfort and disability, especially when direct sunlight penetrates in. Glare from sunlight can be extremely uncomfortabl e and can make electronic display completely unreadable. Therefore, providing flexible, occluding treatments to windows to limit all types of glare is essential. Tinting the windows will not accomplish the desired effects because daylight and sunlight are so bright that even dark window tints cannot prevent disabling or uncomfortable glare. One study by Mrockzek and colleagues ( 2005) shows that providing natural ligh ting h as the most positive environmental impact on work life. Another study found that staff with more than 3 hours of daylight exposure during their shift had higher job satisfaction than staff with less daylight exposure. It was observed that the windows in Shands NICU had an exterior overhang which provided shading effects and prevented direc t lighting entering the newborn care area. The advantage of this design is preventing direct sun shining on the babies but it also means that caregivers need another source of natural lighting since the amount of natural lighting in newborn care area shoul d be adjusted based on babies needs because of their critical state. One of the ways to compromise this bipolar need of natural lighting is by creating spaces for caregivers that either have natural light or a type of lighting that simulated natural light ing; for example designing staff lounge, as discussed earlier, could be a beneficial design to staff health and satisfaction. A combination of daylight and electric light is the ideal lighting design for NICUs in general because natural light is light del ivered at no cost and in a form that most people prefer (Joseph, 2006). It is important to mention that according to some doctors and nurses, the reason that some babies are located next to the windows, is just because that space was open. Although, if a baby is in a very fragile state, it is preferred to be placed further from the

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114 windows since they need a darker environment for their healing, that resembles the womb. What Is Caregivers Satisfaction Level With Lighting Controllability? The controllabilit y of general lighting and the caregivers knowledge of switch placement is an important aspect of lighting. Doctors reported that they mostly deal with light switches when it comes to controlling light whereas nurses deal with both switches and window blin ders. These two groups have about the same level of satisfaction with the level of information they have about where the switches are and how to control them. Even though this is not a low number for these two groups in survey results, the interview shows that a lot of doctors and nurses are not satisfied. The difference between survey and interview results for this matter could be because the participants did not understand the question well while filling out the surveys or since they have the opportunity to discuss their answers more in depth, they expressed their opinion more clearly and accurately. Also, since the interview is done after the participants fill out the survey, the survey questions could make them realize the aspects of lighting they never thought about; so we may be able to conclude that the replies to the interview questions were more premeditated. One of the doctors said: a lot of the switches are behind the beds and hard to reach, one nurse said: Switches are not in a place that is easily reachable, or we dont know which is for which light. The caregivers who had problems with the placement of switches suggested that they should be placed in a more visible place and also be labeled so they dont have to try different switches and turn unwanted lights on and off and bother the babies and people around them in order to figure out the right switch. Changing the monitors position might help with another problem brought up by caregivers and that is: the monitors are placed too up high (o n the countertop).One of the nurses suggested

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115 putting general lighting on tracks so they can be adjustable but to make sure the height is accessible to the caregivers. But the best solution could be eliminating the need to control the general illumination and focusing on more accessible and adjustable task lighting for doctors and nurses. Families results on the other hand, show that they barely change the lighting level and use the switches. This could be because they are not provided with proper informa tion about controlling the light in their babys space and they are also not comfortable with changing the lighting. One parent said that each time they need to change something about lighting; they need to ask the staff so they prefer not to bother them. They also mentioned that they dont change anything because they dont need to. Survey results show that Families have a distinguished lower level of information about the controllable features. This supports the fact that f amily members do not change the light condition in their babys newborn care area. Another question in the survey asked about the level of satisfaction of controllability of light in each of the newborn care areas. Doctors, nurses and f amilies, all had close satisfaction level for this m atter. The high light of these results is that doctors and n urses had a slightly higher satisfaction with NICU III than NICU II whereas this was reverse for families. This issue could be solved by providing a task light for the families in each bed space. Conclusion and Further Research In conclusion, the level of satisfaction among caregivers varies based on all the lighting variables, their demographics, the space they use mostly, and the shift they work in. Shands NICU follows some of the recommended standards but not all. Following the exact recommended standards does not always affect the caregivers satisfaction since for example, the general lighting level of newborn care areas in Shands NICU is in the recommended range by IESNA but the level of satis faction with

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116 general lighting in this area is not high. This shows that there are other aspects of light such as direction and distribution that IESNA needs to consider as well as the level of illumination. Also, the task done by each group of caregivers effects their lighting needs; results show that the major reason of the difference between nurses satisfaction and families satisfaction of lighting quality is the difference between their visual tasks. These are indications for highly suggesting IESNA to i nvestigate the lighting needs of each group of caregivers based on their visual task prior to recommending standards. Most recommendations by IESNA are generally addressed and do not distinguish which group of caregivers they are talking about. Another as pect of IESNA recommendations that needs consideration is that ranges of desirable illumination level provided by IESNA are too wide and need to be narrowed down. For example it is suggested that the general lighting illum ination level be between 10 to 600 LUX. This is a very wide range and is not useful for distinguishing a proper light level for NICUs in general IESNA does not indicate if this range shows the range of illumination provided by dimmers or just by the step dimmers In general, this study s upports the previous studies as far as lighting design in NICU. As mentioned earlier, we suggest that NICUs in general use the general lighting only for navigation and minimal levels of facial recognition; therefore it is preferred the general lighting is not adjustable. Then all controllability can live at the task level which solves many of these general illumination issues. This suggestion can be provided by IESNA for general NICU lighting design. It might be necessary for Shands NICU to consider more accessible and easily adjustable task lighting that has variable illumination intensity. The new task lighting fixtures in Shands (giraffes) can be a good model for task lighting in NICUs in general. Bed design can be one of the suggestions for NICUs; for example have beds with

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117 canopies to prevent direct light exposure to the babies eyes instead of using sheets on the isolates or having individualized general and task lighting attached to each bed for better control and adjustability. An economical soluti on is to renovate the existing beds by replacing the old task lights with new ones like the Giraffes. It is also necessary for all NICUs to integrate natural light in the common areas used by staff such as staff lounge; if int egrating natural lighting i s not possible then use of adjustable white light in a way that can be adjusted into soothing or stimulating (based on night shift and day shift needs) is necessary Switch placements in Shands are not easily accessible and visible and caregivers are not properly informed about them. Further researches could expand the number of case studies in order to come up with a more detailed recommendation for NICU lighting design and also to be able to generalize the results for all NICUs. Literature also mentions that there are not many studies that have examined the effects of environmental factors on job satisfaction (Douglas et al., 1996). This issue can be looked at in more details in future studies. Also the impact of natural lighting on caregivers stress and satisfaction can be studied more in depth (Ulrich, 2008). So, one suggestion for further studies is to choose a healthcare environment that relies on natural lighting more than Shands NICU.

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118 APPENDIX A IRB APPROVAL

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119 APPENDIX B CONSENT FORM

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120 APPENDIX C RESEARCH AND INFORMATION PRIVACY AT THE UNIVERSITY OF FLORIDA CERTIFICATION

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121 APPENDIX D CONFIDENTIALITY STATEMENT

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122 APPENDIX E SURVEY INSTRUMENT 1 (DOCTORS, NURSE PRACTITIONERS & RESIDENT S) 1. Your gender? (1) Male (2) Female 2. What is your age? (1) 18 35 years (2) 36 45 years (3) 46 55 years (4) 56 65 years (5) Above 65 years 3. What is your position/ t itle: (1) Attendee (2) Resident ( 3 ) Nurse Practitioner 4. What shi ft(s) do you work at? (1) 6:30AM 5:30PM (2) Other (Please Specify): 5. Approximately how long have you worked in the Shands NICU? (1) Less than a year (2) 1 5 Years (3) 5 10 Years (4) More than 10 years 6. Have you ever worked in another NICU, other than i n Shands Hospital? (1) Yes (2) No 7. During a typical week, how many hours do you spend working in the NICU? (1) Less than 12 hours (2) 1324 hours (3) 2536 hours (4) 3748 hours (5) More than 48 hours Please go to the back of the page

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123 Which work space(s) do you spend most of your time in while working at NICU? (You can choose more than one) How many hours per week do you spend in these spaces? Which tasks do you participate in while in t hese spaces? How well the lighting in these spaces support your visual tasks? What level of control do you have over the lighting adjustment in these spaces? NICU II Office Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Newborn care area Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Readi ng (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Other (Please Specify): Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much NICU III Office Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing X rays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Newborn care area Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers /Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Physicians Room Le ss than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please s pecify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Other (Please Specify): Less than 5 hours 5 10 hours 1 1 25 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much

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1 24 1. Which of the following do you have the ability to control/ adjust in your workspace? (Check all that apply) Plea se indicate the space : ________________________ 1) Light Switch 2) Under Cabinet Light 3) Desk Lamp 4) Window Blinders 5) Light Dimmers 6) None of the above 7) Other (Please Specify): 2. How well informed do you feel about using the features you indicated above? (Choose one ): Not well very well Informed 1 2 3 4 5 6 7 informed 3. How satisfied are you with the amount of natural lighting available in your workspace? Please indica te the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please explain why: 4. How satisfied are yo u with the existing ambient/general light ing condition in your workspace? Please indicate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please explain why: 5. How satisfied are you with the existing task light ing condition in your workspace? Please indicate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please explain why: 5 1 Does your workspace lighting enhance or hinder your ability to do your job efficiently? greatly gr eatly hindered 1 2 3 4 5 6 7 enhanced Please explain why: 6. How satisfied are you with the visual comfort (i.e. glare, shadow, contrast) in your workspac e? Please indicate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please indicate why: 7. Please describe any issues you may be experiencing with your lighting that may not have been addressed above. 8. Thank you for participating in the recent survey. I would like to conduct a 30 minute interview to learn about your ideas and suggestions related to this matter.

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125 Please let me know when would be a good date and time : .. Also, please indicate your e mail address/phone number if you plan to participate in this interview: .. Thank you once again for your participation and I look forward to our I nterview! Rozita Mozaffarian University of Florida, Department of Interior Design Masters Student

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126 APPENDIX F SURVEY INSTRUMENT 2 ( NUR SES, RESPIRATORY THERAPISTS & TRANSPORT TEAM ) 1. Your gender? (1) Male (2) Female 2. What is your age? (1) 18 35 years (2) 36 45 years (3) 46 55 years (4) 56 65 years (5) Above 65 years 3. What is your position/ t itle: ( 1 ) Nurse (2) Respiratory Therapist ( 3) Transport Team 4. What shift(s) do you work at? Nurses: (1) Daytime (7AM 7PM) ( 2) Night time (7PM 7AM) (3) Evening (3PM 11PM) (4) Other (Please Specify): Respiratory Therapist and Transport Team (Please indicate your shift(s): 5. A pproximately h ow long have you worked in the Shands NICU ? (5) Less than a year (6) 1 5 Years (7) 5 10 Years (8) More than 10 years 6. Have you ever worked in another NICU, other than in Shands Hospital? (1) Yes (2) No 8. During a typical week, how many hours do you spend working in the NICU? (6) Less than 12 hours (7) 1324 hours (8) 2536 hours (9) 3748 hours (10) More than 48 hours

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127 Which work space(s) do you spend most of your time in while working at NICU? (You can choose more than one) How many hours per week do you spend in these spaces? Which tasks do you participate in while in these sp aces? How well the lighting in these spaces support your visual tasks? What level of control do you have over the lighting adjustment in these spaces? NICU II Office Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Newborn care area Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Other (Please Specify): Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medic al Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much NICU III Office Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xr ays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Nurse Station Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Newborn care area Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Transport Team Desk or other (Please Specify): Less than 5 hours 5 1 0 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Reading Medical Supply Labels Viewing Xrays Writing Using Computers/Monitors Any other activities (please specify): 3, Not a t all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much

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128 1. Which of the following do you have the ability to control/adjust in your workspace? (Check all that apply) (1) Light Switch (2) Under Cabinet Light (3) Desk Lamp (4) Window Blinders (5) Light Dimmers (6) None of the above (7) Other (Please Specify): 2 How well informed do you feel about using the features you indicated above? (Choose one): Not well very well informed 1 2 3 4 5 6 7 informed 3. How satisfied are you with amount of natural lighting available in your workspace? Please indicate th e space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please explain why: 4. How satisfied are you with the existing ambient/general lighting condition in your workspace? Please indicate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please explain why: 5. How satisfied are you with the existing task light condition in your workspace? Please indicate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please explain why: 5 1. Does your workspace lighting enhance or hinder your ability to do your job efficiently? greatly greatly hindered 1 2 3 4 5 6 7 enhanced Please indicate why: 6. How satisfied are you with the visual comfort (i.e. glare, shadow, contrast) in your workspace? Please ind icate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please indicate why: 7. Please describe any issues you may be experiencing with your lighting tha t may not have been addressed above. 8. Thank you for participating in the recent survey. I would like to conduct a 30 minute interview to learn about your ideas and suggestions related to this matter. Please let me know when would be a good date and time (preferably next week, if not the week after) Also, please indicate your e mail address/phone number if you plan to participate in this interview:

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129 APPENDIX G SURVEY INSTRUMENT 3 (PARENTS AND FAMILIES) 1. Your gender? (1) Male (2) Female 2. W hat is your age? (1) 18 35 years (2) 36 45 years (3) 46 55 years (4) 56 65 years (5) Above 65 years 3. What is your relationship to the newborn? (1) Parent (2) Family/Relative (3) Friend 4 What time of the day do you spend in NICU? (1) Day (between 7:30AM to 7PM) (2) Night (between 7:30PM to 7AM) (3) Other (Please Specify): 5. How long has your Newborn been in NICU? (1) Less than a week (2) 1 week 2 weeks (3) 2 weeks 3 weeks (4) 3 weeks 4 weeks (5) 4 weeks 5 weeks (6) 5 weeks 6 weeks (7) 6 weeks 7 w eeks (8) 7 weeks 8 weeks (9) More than 8 weeks 6 What part of NICU is your Newborn at? (1) NICU II (Please specify the space#): (2) NICU III (Please specify the space#): (3) Isolation Room

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130 Which area(s) of NICU do you spend most of your time in? (You can choose more than one) How many hours per week do you spend in these spaces? Which tasks do you participate in while in these spaces? How well the lighting in these spaces support your visual tasks? Wh at level of control do you have over the lighting adjustment in these spaces? NICU II Newborn care area Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Feeding/changing the Baby Rea ding (e.g. Charts, Books, ) Watching TV Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Rooming In Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Watching TV Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Other (Please Specify): Less t han 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Feeding/changing the Baby Reading (e.g. Charts, Books, ) Watching TV Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much NICU III Newborn care area Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Feeding/changing the Baby Reading (e.g. Charts, Books, ) Watching TV Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Rooming In Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Reading (e.g. Charts, Books, ) Watching TV Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, Very much Other (Please Specify): Less than 5 hours 5 10 hours 1125 hours 2635 hours More than 35 hours Feeding/changing the Baby Reading (e.g. Charts, Books, ) Wat ching TV Writing Using Computers/Monitors Any other activities (please specify): 3, Not at all 2 1 0 1 2 3, Very much 3, Not at all 2 1 0 1 2 3, V ery much

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131 1. Which of the following do you have the ability to control/adjust in your indicated space? (Check all that apply) Please indicate the space:_________________________ 1) Light Switch 2) Under Cabinet Light 3) Desk Lamp 4) Window Blinders 5) Light Dimmers 6) No ne of the above 7) Other (Please Specify): 2 How well informed do you feel about using the features you indicated above? (Choose one): Not well very well informed 1 2 3 4 5 6 7 informed 3 How satisfied are you with amount of natural l ighting available in your most used space ? Please indicate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please explain why: 4. How satisfied are you with the existing ambient/general lighting condition in your most used space? Please indicate the space:__ _______________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied Please explain why: 5. How satisfied are you with the existing task lighting condition availa ble in your most used space? Please indicate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied P lease explain why: Please go to the back of the page 5 1. Does your indicated space lighting enhance or hinder your ability to do your tasks efficiently? greatly greatly hindered 1 2 3 4 5 6 7 enhanced Please indicate why: 6. How satisfied are you with the visual comfort (i.e. glare, shadow, contrast) in your workspace? Please indicate the space:_________________________ Very very dissatisfied 1 2 3 4 5 6 7 satisfied If dissatisfied, please indicate why:

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132 7. Please describe any issues you may be experiencing with your l ighting that may not have been addressed above. 8. Thank you for participating in the recent survey. I would like to conduct a 30 minute interview to learn about your ideas and suggestions related to this matter. Please let me know when would be a good date and time (preferably next week, if not the week after) .. Also, please indicate your email address/phone number if you plan to participate in this interview: .. Thank you once again for your participation and I look forward to our I nterview! Rozita Mozaffarian University of Florida, Department of Interior Design Masters Student

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133 APPENDIX H INTERVIEW INSTRUMENT 1 (DOCTORS, NURSE PRACTITIONERS & RESIDENT S) 1. What do you prefer/suggest as far as general lighting in your workspace(s)? 2. How satisfied are you with the placement of light switches (especially in newborn care area)? 3. While working with computer/monitors, do you experience glare, shadow or contrast interfering? 4. For the people who work in night shift: 4.1. How does that affect you? (e.g. productivity, mood, health, welfare)? 4.2. What is your suggestion on improving lighting (ambient and task) for night shifts? 5. Does the lighting condition meet the needs of newborns at different stages of development? 6. Does increasing the illumination level of procedure lighting effect other newborns? 7. How easy/hard is it for you to work under existing procedure lighting as far as flexibility, glare, and shadow and also preventing effect on other newborns? 8. When doing procedures on babies, how do you avoid direct exposure of newborns eyes to procedure lighting? 9. How often do you use the natural lighting in NICU? 10. What is your suggestion about a better use of natural lighting that suits both the NICU newborn area as well as caregivers need? 11. How satisfied are you with the lighting in these public areas? (ambient/general, task, natural, accent, emergency lighting) NICU II: (1) Control Charting Station (2) Supply Room (3) Storage Room (Th e Garage) NICU III: (4) Staff Lounge (5) HandWashing Station (6) Isolation Room (7) X Ray Viewing Station (8) Supply Area in the Hallway (9) Multi Purpose Room (Frans Room) (10) Conference Room

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134 APPENDIX I INTERVIEW INSTRUMENT 2 (NURSES, RESPIRATORY THERAPISTS & TRANSPORT TEAM) 1. What do you prefer/suggest as far as general lighting in your workspace(s)? 2. How satisfied are you with the placement of light switches (especially in newborn care area)? 3. While working with computer/monitors, do you experience glare, shadow or contrast interfering? 4. For the people who work in night shift: 4.1. How does that affect you (e.g. productivity, mood, health, welfare)? 4.2. What is your suggestion on improving lighting (ambient and task) for night shifts? 5. Does the lighting condition meet the needs of newborns at different stages of development? 6. Does increasing the illumination level of procedure lighting effect other newborns? 7. How easy/hard is it for you to work under existing procedure lighting as far as flexibility, glare, and shadow and also preve nting effect on other newborns? 8. When doing procedures on babies, how do you avoid direct exposure of newborns eyes to procedure lighting? 9. How often do you use the natural lighting in NICU? 10. What is your suggestion about a better use of natural lighting that suits both the NICU newborn area as well as caregivers need? 11. How satisfied are you with the lighting in these public areas? (ambient/general, task, natural, accent, emergency lighting) NICU II: (1) Control Charting Station (2) Supply Room (3) Stora ge Room (The Garage) NICU III: (4) Staff Lounge (5) HandWashing Station (6) Isolation Room (7) X Ray Viewing Station (8) Multi Purpose Room (Frans Room) (9) Pump Room (10) Conference Room

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135 APPENDIX J INTERVIEW INSTRUMENT 3 (PARENTS AND FAMILY) 1. What do you prefer/suggest as far as general lighting in the space you spend most of your time in? 2. How does your indicated space lighting make you feel? 3. For the people who use NICU at night, what is your suggestion on improving lighting (ambient and task)? 4. How easy/hard is it for you to work under existing task lighting in your babys area? 5. When feeding or changing your baby, how do you avoid direct exposure of newborns eyes to the task lighting? 6. How satisfied are you with the lighting in these public areas? (ambient/general, task, natural, accent, emergency lighting) 6.1. What is your preference/suggestion for lighting in these areas?

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136 APPENDIX K PARTICIPANTS COMMENTS Participants Comments Doctors D1 Q.1: Glare from th e isolates Q.2: Giraffes have two levels Q.3: Do not like the Fluorescent Q.4: Very rarely. If the baby is grown and has been here for a long time, they might open the window to get sunlight; but that means more glare for us! Some of the blinders are closed; that is a nurse preference Q.5: The Giraffes are very adequate Q.6: Same as day b/c they rely on Artificial light only The ones under the heater get hot for us. The heater is always on. We sometimes use the emergency light for surgeries or some procedures. Q.7: I have noticed my eyesight has changed and I hear a lot of people complain about their eyesight. Now having to use the computers all the time is even worse. Q.8: I dont like the sheets, they hinder what Im doingit may fall down and get contam inated Q.9: When two beds are too close, it is hard to turn on the light without bothering the baby next door Q.10: X ray viewing station: sometimes glare and shadow depends on which direction you look at D2 Q.1: Had to use a flashlight to pull the IV Q .2: a lot of the switches are behind the beds and hard to reach If the lights bulb is burned, you cant change it; I dont know where the bulbs are. If there is a baby in that space, they dont change the bulb! Q.3: NICU II is worse than III Q.4: In the su mmer time, I like to open the blinds otherwise we dont use it. Q.5: Not enoughwe have to use emergency lights people dont turn them off Q.6: Productivity: At night we keep it dim here, towards the end of the shift, we get more tired and sleepy. Health a nd Mood: No effects I wish there were certain lights you could turn off, more for the patients. For me, it is more important that the light works properly. Q.7: there is a spot in NICU III that we weigh diapers and we check Dipsticks; often we have to walk from there to a lit space to be able to read the labels and the dipsticks Q.8&9: It depends on which light you turn on, if it is the halogen

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137 light, I turn it on for my first assessment to get a clear picture of the baby, then I turn on the dim light or t he spot light (task light), we flip it up to get an indirect light. I use it as an ambient light and it doesnt affect other babies. We flip it back down for procedures light Ivy. Q.10: Staff Lounge: Control is good here HandWashing Station: They have dim mers Frans room: It has Lamps and overhead lightingSometimes the overhead is too bright and the lamps too dim Pump Room: Needs more control too dark Suggestions: For Billie light, cover the isolates on the side. If they could have 3way lighting in Fran s Room, it would be better for having more options for controlling it. D3 Q.1: No; the monitors, I can adjust The only Glare I get is from the isolate Q.2: some switches have dimmers which is helpful Q.3: Always dim in the unit, no circadian rhythm f or babies Q.4: Blinders on and off, depends on the Nurses preference. Sometimes one baby is very sensitive to light so we cant put him next to the window. Q.5: I dont use the under cabinet lights b/c they fall far back Q.6: Nights arent as bad, no glar e from the windows, NICU III has been brighter, and they had the overhead lights on. In II, they actually had the lights on which surprised me. If all the lights are off, it is hard to assess t he baby especially if he has instauration; it is hard to figure out the color of their skin. Q.7: If you have a task light, great! But if you only have the above lights, they are good amount of light but you generally cannot use them as spot light b/c in order to move them and change the direction, you have to step on a chair. HEAT: they put out heat which is good for the baby not good for us! Q.8: They have blanket over the bassinets so they may get a little bit of light change but it is not major. Q.9: Not Major Q.10: Staff Lounge: Enough light but not enough control. Frans Room: Nice, you can adjust the light. Pump Room: Light above each station and above the sink. Suggestions: If general lights could be on a track that you could move them and adjust it to where exactly you want the light to shine. More adjustable lights in the bedsides. D4 Q.1: No paper work, all computer charting No glare from monitors and no from the isolates, all of them have an exam light and also

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138 the radio warmers have exam lights too! Its not that bad working in NICU III, the issue is i n NICU II: The bed spaces are not designed to just one space, its not like NICU III that one space ends and then the next one starts; the lighting system is not that individualized, so when you turn on the light to examine one baby, it could get the other baby blinded by the light. Q.2: only one switch for all 3 emergency lights Q.3: Very yellow, bad for diagnosing babies for jaundice Q.4: Sometimes I like them openI dont use them as task light and I close the blinds if ultrasound people are here so t hey can see the monitor better! Q.5: The warmers light directly aims babies eyes Q.6: No Q.7: Refer to Q.5 Q.8: Mostly they are already covered, if they are not, you put a blanket or a cloth on their eyes Q.9: Not Major Q.10: 1. Hard, keyboard is hard to see b/c NICUII is too dark 9. They have soft lighting there that is less harsh Suggestions: We should use the keyboards that have light switch on them, especially in NICU II D5 Q.1: Not monitors Computers are OK except where they are located, they are on the counter and it is hard to see them. I experience shadow and glare on isolates. Q.2: we have to try switches to find the right one and this bothers babies and other staff Q.3: We have quite a few spots with no general lighting Q.4: only night shif t. The only reason some babies are put next to the window is because that spot was available. Q.5: OK Q.6: 1. 12 years 2. Not really 3. No Q.7: OK Q.8: Put a cloth over their eyes or if possible to adjust the light to the spot it is needed to shineI like the covers on the isolates b/c you can shine the light only to where you want and when you turn the light on it shields it. Q.9: Not Major Q.10: 1. Good to have regular light and under cabinet light there 2&3. They are always on. Suggestions: Bring the c omputer monitors in a lower countertop so we can get a better eye view of them I wish the general light was as flexible as Task light.

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139 D6 Q.1: A little bit of glare on the computers but they are not placed properly anyways, b/c they are on the counters and hard to reach and we also need more space. Only on certain bed spots we experience shadow. Q.2: You dont know which way the dimmer should be turned Q.3: Satisfied with the ambient light b/c the dimmer switches help a lot. Q.4: None Q.5: Procedure lighting in NICU II is well lit and if we need to, we flip around the runner lights and we have the dimmer switches to make it brighter, we only have to adjust ourselves to avoid shadow. Q.6: 1.Only night shift for 26 years. 2. I am used to it, 3. more awake at night than day 4. I have fibromyalgia, thats an effect of working nights; there are studies that say working in bright light at night causes breast cancer; so a lot of us try to keep it dark at night as much as possible and we just use the general swit ches. Q.7: Refer to Q.5. Q.8: Put a cloth over their eyes ; it works Q.9: Not Major Q.10: All OK Suggestions: Have dimmers, make all isolates as giraffes (the new task lights) D7 Q.1: Sometimes on the monitor depends on the direction Hardest thing I t ry to start an I.V. when dont have a light thats right overhead or if the isolate is on the way, creates shadow. Q.2: If the baby an open crib, you can move it and adjust but if its an isolate, you cannot move it and thats when it gets hard. SWITCHES: Depends on if the baby is on an assigned bed space or we are cramped b/c when we have more babies than spaces, we have to move around the monitors to make space for babies and sometimes you have to reach behind a monitor to get to a light switch. I am awar e of the task switches but not the ambient ones! The switches dont seem to be logically placed! Q.3: Refer to Q.2. Q.4: No Just night shift Q.5: Shadow Q.6: 1.Most of my life 2. I function better at night Q.7: Refer to Q.5. Q.8: Task lighting on top of the new isolates is a spot light that you can move around; the old isolat es have the task lights that lit the

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140 whole bed so we have cover the top of the isolate with a blanket to prevent exposure of babys eyes. Q.9: Blanket is the most cost effective; it i s reasonable and easily accessible Q.10: 1. Is dim Suggestions: Change all the old task lights to an adjustable spot light add mobile lighting D8 Q.1: No glare Q.2: Hard to find light switches too many switches and lights you have to try them to find out which is which and this causes discomfort for babies and other nurses Q.3: NICU III: Ambient Is too dark; I cant read while Im walking; I physically have to move to find a lit space. NICU II: I have to use a flash light to check equipments that are plugged into the wall. Q.4: Patients by the window I love it b/c can see there and I dont need the task light as much as other spaces but for procedures like putting in a tube, I need the task light on. Q.5: Glaring Q.6: I cant see while working in night shift, I usually have to wait for the sun to come up. Q.7: Refer to Q.5. Q.8: Cover their face; in general its a good idea b/c D9 Q.1: No paper work, all computer charting No glare from monitors and no from the isolates, all of them have an ex am light and also the radio warmers have exam lights too! Its not that bad working in NICU III, the issue is in NICU II: The bed spaces are not designed to just one space, its not like NICU III that one space ends and then the next one starts; the light ing system is not that individualized, so when you turn on the light to examine one baby, it could get the other baby blinded by the light. Q.2: in NICU II I have a problem to know which switch what. I have to flip them all to find out which is the one I want Not so much in NICU III, you pretty much can tell. Q.3: Refer to above Q.4: Sometimes I like them openI dont use them as task light and I close the blinds if ultrasound people are here so they can see the monitor better! Q.5: The level of the task lighting is good but the heat of the task lighting is too much sometimes specially that your arms are covered and that makes it hotter! Q.6: No Q.7: Refer to Q.5 Q.8: Mostly they are already covered, if they are not, you put a

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141 blanket or a cloth on the ir eyes Q.9: Not Major Q.10: 1. Hard, keyboard is hard to see b/c NICUII is too dark 9. They have soft lighting there that is less harsh Q.10: All OK D10 Q.1: No; the monitors, I can adjust The only Glare I get is from the isolate Q.2: some switches have dimmers which is helpful Q.3: Always dim in the unit, no circadian rhythm for babies Q.4: Blinders on and off, depends on the Nurses preference. Sometimes one baby is very sensitive to light so we cant put him next to the window. Q.5: I dont use the under cabinet lights b/c they fall far back Q.6: Nights arent as bad, no glare from the windows, NICU III has been brighter, and they had the overhead lights on. In II, they actually had the lights on which surprised me. If all the lights are off, it is hard to assess t he baby especially if he has instauration; it is hard to figure out the color of their skin. Q.7: If you have a task light, great! But if you only have the above lights, they are good amount of light but you generally cannot use them as spo t light b/c in order to move them and change the direction, you have to step on a chair. HEAT: they put out heat which is good for the baby not good for us! Q.8: They have blanket over the bassinets so they may get a little bit of light change but it is not major. Q.9: Not Major Q.10: Staff Lounge: Enough light but not enough control. Frans Room: Nice, you can adjust the light. Pump Room: Light above each station and above the sink. Nurses N1 Q.1: Glare on Monitors. Depends on the direction of the light hits it. The ones facing the window are worst. Shadows when we have turned the light on. The contrast between the computer monitors and surrounding hurts the eyes. We sometimes turn on both task and general light, or just the task. Q.2: I wish we could tu rn more lights on and have this area lit. NICU II is worse. Q.3: Babies all have blanket over their isolates but still they keep this area very dark which makes it hard for the caregivers to work. Q.4: Very rarely. If the baby is grown and has been here f or a long time, they might open the window to get sunlight; but that means more glare for us! Some of the blinders are closed; that is a nurse preference

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142 Q.5: In general it is enough. The armed ones are OK. Q.6: N/A The ones under the heater get hot for us. The heater is always on. We sometimes use the emergency light for surgeries or some procedures. Q.7: I have noticed my eyesight has changed and I hear a lot of people complain about their eyesight. Now having to use the computers all the time is even w orse. Q.8: Put a blanket over other babies when they are using the Billie light for one baby Q.9: Yes, it affects other babies but not their health. If they are too young it may affect their oxidation; otherwise it may just irritate them. Q.10: X ray viewi ng station: sometimes glare and shadow depends on which direction you look at N2 Q.1: Sometimes Glare coming from isolates Q.2: Depends If you have access to the wall, it is easier. If the lights bulb is burned, you cant change it; I dont know where the bulbs are. If there is a baby in that space, they dont change the bulb! Q.3: The three halogen lights are too bright and too hot for both the caregivers and the baby. Q.4: In the summer time, I like to open the blinds otherwise we dont use it. Q.5: If the baby is not in a bed space (N Cap), you dont have task lighting or the red light so we have to turn on the Amb. Light which doesnt give enough light to do your task? Only the Billie light can be brought from other beds. Q.6: Productivity: At night we keep it dim here, towards the end of the shift, we get more tired and sleepy. Health and Mood: No effects I wish there were certain lights you could turn off, more for the patients. For me, it is more important that the light works properly. Q.7: there is a spot in NICU III that we weigh diapers and we check Dipsticks; often we have to walk from there to a lit space to be able to read the labels and the dipsticks Q.8&9: It depends on which light you turn on, if it is the halogen light, I turn it on for my first assessment to get a clear picture of the baby, then I turn on the dim light or the spot light (task light), we flip it up to get an indirect light. I use it as an ambient light and it doesnt affect other babies. We flip it back down for procedures light Ivy. Q.10: Staff Lounge: Control is good here HandWashing Station: They have dimmers Frans room: It has Lamps and overhead lighting Sometimes the

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143 overhead is too bright and the lamps too dim Pump Room: Needs more control too dark Suggestions: For Billie light, cover the isolates on the side. If they could have 3way lighting in Frans Room, it would be better for having more options for controlling it. N3 Q.1: No; the monitors, I can adjust The only Glare I get is from the isolate Q.2: NICU I II, control is easier because you can control the bedside and with the windows it is a lot nicer. NICU II is harder b/c its generally very dark, and if I turn on a light, there is someone that doesnt like it so turns it back off as soon as you turn around. SWITCHES: are not in a place that are easily reachable, or we dont know which is for which light. Q.3: There are some beds in NICU III that the light doesnt shine on the bed and is hard to assess the baby. Q.4: Blinders on and off, depends on the Nur ses preference. Sometimes one baby is very sensitive to light so we cant put him next to the window. Q.5: If you are lucky and you have a light on your bedside, you can adjust these and move around Q.6: Nights arent as bad, no glare from the windows, NI CU III has been brighter, and they had the overhead lights on. In II, they actually had the lights on which surprised me. If all the lights are off, it is hard to assess t he baby especially if he is not saturation; it is hard to figure out the color of their skin. Q.7: If you have a task light, great! But if you only have the above lights, they are good amount of light but you generally cannot use them as spot light b/c in order to move them and change the direction, you have to step on a chair. HEAT: they put out heat which is good for the baby not good for us! Q.8: They have blanket over the bassinets so they may get a little bit of light change but it is not major. Q.9: Not Major Q.10: Staff Lounge: Enough light but not enough control. Frans Room: Nice, you can adjust the light. Pump Room: Light above each station and above the sink. Suggestions: If general lights could be on a track that you could move them and adjust it to where exactly you want the light to shine. More adjustable lights in the bedsides. N4 Q.1: No paper work, all computer charting No glare from monitors and no from the isolates, all of them have an exam light and also

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144 the radio warmers have exam lights too! Its not that bad working in NICU III, the issue is in NICU II: The bed sp aces are not designed to just one space, its not like NICU III that one space ends and then the next one starts; the lighting system is not that individualized, so when you turn on the light to examine one baby, it could get the other baby blinded by the light. Q.2: in NICU II I have a problem to know which switch what. I have to flip them all to find out which is the one I want Not so much in NICU III, you pretty much can tell. Q.3: Refer to above Q.4: Sometimes I like them openI dont use them as t ask light and I close the blinds if ultrasound people are here so they can see the monitor better! Q.5: The level of the task lighting is good but the heat of the task lighting is too much sometimes specially that your arms are covered and that makes it hotter! Q.6: No Q.7: Refer to Q.5 Q.8: Mostly they are already covered, if they are not, you put a blanket or a cloth on their eyes Q.9: Not Major Q.10: 1. Hard, keyboard is hard to see b/c NICUII is too dark 9. They have soft lighting there that is less harsh Suggestions: We should use the keyboards that have light switch on them, especially in NICU II N5 Q.1: Not monitors Computers are OK except where they are located, they are on the counter and it is hard to see them. I experience shadow and glare on isolates. Q.2: Task good, General light not good Q.3: We have quite a few spots with no general lighting Q.4: only night shift. The only reason some babies are put next to the window is because that spot was available. Q.5: OK Q.6: 1. 12 years 2. Not r eally 3. No Q.7: OK Q.8: Put a cloth over their eyes or if possible to adjust the light to the spot it is needed to shineI like the covers on the isolates b/c you can shine the light only to where you want and when you turn the light on it shields it. Q.9: Not Major Q.10: 1. Good to have regular light and under cabinet light there 2&3. They are always on.

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145 Suggestions: Bring the computer monitors in a lower countertop so we can get a better eye view of them I wish the general light was as flexible as Task light. N6 Q.1: A little bit of glare on the computers but they are not placed properly anyways, b/c they are on the counters and hard to reach and we also need more space. Only on certain bed spots we experience shadow. Q.2: If the ambient lighting w ent all the way to the walls, there wouldnt be any problems with the lighting for the bed spaces that were all the way to the end of the wall; these spots are very dark Q.3: Satisfied with the ambient light b/c the dimmer switches help a lot. Q.4: None Q.5: Procedure lighting in NICU II is well lit and if we need to, we flip around the runner lights and we have the dimmer switches to make it brighter, we only have to adjust ourselves to avoid shadow. Q.6: 1.Only night shift for 26 years. 2. I am used to it 3. more awake at night than day 4. I have fibromyalgia, thats an effect of working nights; there are studies that say working in bright light at night causes breast cancer; so a lot of us try to keep it dark at night as much as possible and we just use the general switches. Q.7: Refer to Q.5. Q.8: Put a cloth over their eyes ; it works Q.9: Not Major Q.10: All OK Suggestions: Have dimmers, make all isolates as giraffes (the new task lights) N7 Q.1: Sometimes on the monitor depends on the direction Hardest thing I try to start an I.V. when dont have a light thats right overhead or if the isolate is on the way, creates shadow. Q.2: If the baby an open crib, you can move it and adjust but if its an isolate, you cannot move it and thats when it gets hard. SWITCHES: Depends on if the baby is on an assigned bed space or we are cramped b/c when we have more babies than spaces, we have to move around the monitors to make space for babies and sometimes you have to reach behind a monitor to get to a light switch. I am aware of the task switches but not the ambient ones! The switches dont seem to be logically placed! Q.3: Refer to Q.2.

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146 Q.4: No Just night shift Q.5: Shadow Q.6: 1.Most of my life 2. I function better at night Q.7: Refer to Q.5. Q.8: Task li ghting on top of the new isolates is a spot light that you can move around; the old isolates have the task light s that lit the whole bed so we have cover the top of the isolate with a blanket to prevent exposure of babys eyes. Q.9: Blanket is the most cos t effective; it is reasonable and easily accessible Q.10: 1. Is dim Suggestions: Change all the old task lights to an adjustable spot light add mobile lighting N8 Q.1: No glare Q.2: Hard to find light switches too many switches and lights you have to try them to find out which is which and this causes discomfort for babies and other nurses Q.3: NICU III: Ambient Is too dark; I cant read while Im walking; I physically have to move to find a lit space. NICU II: I have to use a flash light to check equipments that are plugged into the wall. Q.4: Patients by the window I love it b/c can see there and I dont need the task light as much as other spaces but for procedures like putting in a tube, I need the task light on. Q.5: Glaring Q.6: I cant see whi le working in night shift, I usually have to wait for the sun to come up. Q.7: Refer to Q.5. Q.8: Cover their face; in general its a good idea b/c N9 Q.1: No paper work, all computer charting No glare from monitors and no from the isolates, all of them have an exam light and also the radio warmers have exam lights too! Its not that bad working in NICU III, the issue is in NICU II: The bed spaces are not designed to just one space, its not like NICU III that one space ends and then the next one starts; the lighting system is not that individualized, so when you turn on the light to examine one baby, it could get the other baby blinded by the light. Q.2: in NICU II I have a problem to know which switch what. I have to flip them all to find out which is the one I want Not so much in NICU III, you pretty much can tell. Q.3: Refer to above Q.4: Sometimes I like them openI dont use them as task light and I close the blinds if ultrasound people are here so they can

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147 see the monitor better! Q.5: Th e level of the task lighting is good but the heat of the task lighting is too much sometimes specially that your arms are covered and that makes it hotter! Q.6: No Q.7: Refer to Q.5 Q.8: Mostly they are already covered, if they are not, you put a blanket or a cloth on their eyes Q.9: Not Major Q.10: 1. Hard, keyboard is hard to see b/c NICUII is too dark 9. They have soft lighting there that is less harsh N10 Q.1: No; the monitors, I can adjust The only Glare I get is from the isolate Q.2: some switches have dimmers which is helpful Q.3: Always dim in the unit, no circadian rhythm for babies Q.4: Blinders on and off, depends on the Nurses preference. Sometimes one baby is very sensitive to light so we cant put him next to the window. Q.5: I dont use the under cabinet lights b/c they fall far back Q.6: Nights arent as bad, no glare from the windows, NICU III has been brighter, and they had the overhead lights on. In II, they actually had the lights on which surprised me. If all the lights are off, it is hard to assess the baby especially if he is saturation; it is hard to figure out the color of their skin. Q.7: If you have a task light, great! But if you only have the above lights, they are good amount of light but you generally cannot use them as sp ot light b/c in order to move them and change the direction, you have to step on a chair. HEAT: they put out heat which is good for the baby not good for us! Q.8: They have blanket over the bassinets so they may get a little bit of light change but it is not major. Q.9: Not Major Q.10: Staff Lounge: Enough light but not enough control. Frans Room: Nice, you can adjust the light. Pump Room: Light above each station and above the sink. Families F 1 Q.1: 1.Change Diapers, feed, Crochet 2. I n III, across from window, the light in the space was OK but we couldnt see anything ahead of us so we had to turn the light on; in II, they had four lights on above the children so it was too much for the baby to sleep.

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148 3. Well if you could have a little lamp that you could turn on yourself instead of illuminating everything else around you, like at home, would be great! 4. Not enough Q.2: No Q.3: Refer to Q.1.2 Q.4: The light shines on him or I could adjust the blanket on top of the isolate to stop the l ight exposure. Q.5: 1. The light shines in from the bottom of the door Suggestions: If you could have a little lamp that you could turn on yourself instead of illuminating everything else around you, like at home, would be great! F 2 Q.1: 1 Breast feeding, bottle feeding 2. When it is on, it bothers the baby 4. No control Q.2: 1. The bright light on him was on at 4AM! 2. Put in some different lighting options Some individualized lightingBed spaces in the corner are really dark Q.3: OK Q .4: Nothing Q.5: All OK Suggestions: Put in some different lighting options Some individualized lightingBed spaces in the corner are really dark F 3 Q.1: 1. Changing 2. Too bright for the baby Not enough for task Glare 3. More lighting but s ofter 4. Not a lot of control Q.2: No Q.3: Not enough lighting level Q.4: Blanket over the isolate Q.5: 1. Havent used it Suggestions: More lighting but softer F 4 Q.1: 1. Changing 2. Not during the daytime b/c there is a window right by her; but at night the task/general light is too bright 3. Softer light 4. A little bit of control b/c its either on or off, no dimmers! SWITCHES: No idea which is which!

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149 Q.2: No Q.3: Refer to Q.1.2 Q.4: Blanket Q.5: 1. Havent used it 5. Dimmer in there is good Frans Room: Haven used it Suggestions: Softer light F 5 Q.1: 1. Changing, observe, reading 2. Very good 3. N/A 4. No control but I dont want to change it Q.2: No Q.3: Good Q.4: Nothing Q.5: 1. Havent used it F 6 Q.1: 1. Changing, feeding, giving bath, some physical therapy 2. Where he is now is good b/c he is by the window but where he was, was too dark; we had to on the light which is too bright for the baby. 3. Dimmer lights that adjust 4. Now Yes but the old space No! Q.2: At night is about the same for t he ones that are not next to the window. Q.3: Refer to Q.1.2 Q.4: Put my hands over the baby Q.5: All Good Suggestions: Dimmer lights that adjust F 7 Q.1: 1. Read to the baby 2. No, it is good 3. None 4. Its OK Q.2: Its too dark at night Q.3: OK Q.4: No thing Q.5: Lobby: could be a little bit brighter F 8 Q.1: 1. Changing, feeding 2. Sometimes when it gets too bright, it takes away from the intimacy with the baby 3. Want dimmers If we could have a curtain around each babys space and its individual l ighting, it would be great! 4. Not much Q.2: NICUII is even brighter at night

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150 Q.3: Refer to Q.1.2 Q.4: Depends on what light is on, if needed we put blanket on the isolate. Q.5: 3&5: Havent used Suggestions: Want dimmers If we could have a curtain arou nd each babys space and its individual lighting, it would be great! F 9 Q.1: 1. Changing, feeding 2. Good light We dont use the task light 3. None 4. I can ask to change the light and they do it Q.2: I really like the light at night The general light is good enough and the task when you need it is here and not too bright Q.3: Refer to Q.1.2 Q.4: Lean over him so shadow covers his face Q.5: 1: Overhead light is too bright The light behind the bed wasnt in the right place and not comfortable and too bright when on 3&6: Havent used it 5:One room has the overhead light and the other doesnt; one is too dim F 10 Q.1: 1. Just looking at the baby 2. Its fine b/c she is close to the window; but we get some glare from the isolate 3. Its adequate 4. No control; Just putting a blanket over the isolate Q.2: At night, its better b/c maybe window causes the glare It is brighter and sharper at night though Q.3: Refer to Q.1.2 Q.4: Blanket Q.5: 1,3,5: Havent used it 10: Bright enough and I am able to read

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151 Table K 1 Caregivers Comments in Surveys Doctors Nurses Families General lighting Satisfaction Sometimes shadow make procedures difficult at babys beds. Or sometimes other staffs turn on bright emergency lights when other available lighting would be OK. Too bright for the babies, or necessary for task but they forget to turn it off after their task as you get older you need more light for things like visualizing monitors from across the room and things like that Some of the bed spaces in NICU 3 have poorly placed pot lights. Not conducive to seeing the care you are providing to the patients or for procedures. NICU2 lighting is much better Need more light but softer for the babys eyes I like the pump room ambient light Task Lighting Sa tisfaction In the office it is fine. In the Unit the bright procedure lights are not adjustable, so if the bay's bed is not in the right spot, the lights are not directed at the bed causing shadows Poor lighting around each bed space Office I have no task lighting Too dark when in NICU 2 and NICU 3 is getting to be almost as bad. Hard to see what i s going on with the patient; little changes in color, etc. When the baby's bed light is on I can see well but not enough when off. Task/Job Performan ce Spot lighting is often insufficient for procedures Job efficiency: It is difficult to view patients + see subtle findings Job Efficiency: Office It is basic and not adjustable. Harsh Lighting is key to accomplishing tasks and procedures eff iciently and accurately It does not really affect my ability to do anything I need to do Doctors Nurses Families

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152 Table K 1 Continued. Natural Lighting Satisfaction None in office Physicians room is dark Office no natural lighting not enough for things li ke starting IVs and other small procedures I think they could use a little more sunlight. It is good for the baby Level of Visual Comfort If the lights are directed right it is great. When they are not it takes someone standing on a chair and redirec ting them from the ceiling. frequently I just work without the light Shadows are difficult to work with in NICU3 Bed space Sometimes there is a glare from the overheads onto the isolates that make it difficult to see the patient clearly Hard to s ee baby through glare on isolate at times Fluor. Light is harsh Level of Control N/C No control over lights in the hallways Not knowing how to control the light! No control over light

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153 APPENDIX L FREQUENCY FOR PARTICIPANTS LIGHTING SATISFACTION IN INTERVIEW Table L1. Frequency for participants lighting satisfaction in interview Themes Doctors (N=10) Nurses (N=10) Families (N=10) S A U B S U S U Daytime Lighting Condition C 1) General Lighting Illumination Color Of Light Distribution Heat 2) Task Lighting Illumination Distribution Heat 3)Natural 1 3 1 1 5 2 3 4 5 5 4 4 1 3 2 1 8 1 5 1 4 4 1 2 5 2 1 Nighttime Lighting Condition D 1) General Illumination 2) Task Illumina tion 3 6 1 1 2 5 1 1 1 6 1 Lighting Factors Glare Shadow Contrast 4 2 1 4 6 1 3 8 8 2 2 Controllability Visual Comfort NICU II NICU III Switch Placement 4 1 2 3 1 5 2 3 8 4 5 8 1 Newborn Focused Preventing Direct Light Exposure Individualized Lighting Assigned Bed Space 4 2 1 1 7 2 5 6 5 3 1

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154 Table L1. Continued. Themes Doctors (N=10) Nurses (N=10) Families (N=10) S A U B S U S U Public Areas E Supply Room Storage Room Staff Lounge HandWashing X Ray Viewing Frans Room Conference Room Hallways Restrooms Pump Room Call Room Waiting Room Family Room 6 7 6 8 4 6 3 8 8 1 2 2 4 2 9 8 5 9 3 3 4 10 10 2 1 2 1 1 2 1 1 10 7 9 10 10 7 8 2 1 1 1 a: S=Satisfied c: during the day, artificial and natural light are used b: U =Unsati sfied d: during night, only artificial light is used e: regarding overall general lighting condition and visual comfort of each area

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155 LIST OF REFERENCES Alimoglu M. K. & Donmez L. (2005). Daylight exposure and the other predictors of burnout among nurses in a university hospital. Intern ational Journal of Nursing Studi es, 42(5), 549 555. Altimier L. (2004). Healing environments: for patients and providers. Newborn and Inf ant Nursing Reviews, 4 ( 2 ), 8992. Auerbach, D. I., Buerhaus P. I., & Staiger, D. O. (2007). Better late than never: Workforce supply implications of later entry into nursing. Health Affairs, 26(1), 178 185. Baehr E., Fogg, L. F., & Eastman, C. I. (1999). Intermittent bright light and exercise to entrain human circadian rhythms to night work. American Journal of Physiology, 277, 1598 1604. Barrett, L. & Yates P. (2002). Oncology/ hematology nurses: A study of job satisfaction, burnout, and intention to leave the specialty. Australian Health Review: A Publication of the Australian Hospital Association, 25(3), 109 121. Baum A., Singer J. E., & Ba um, C. S. (1981). Stress and the environment. Journal of Social Issues, 37(1), 4 35. Beatriz R. Rodrigues ., Cunha R ., Gallani M Ceclia M ., Jayme B Moreira T & Pereira C. Gonalves C (2010). Stressors at the Intensive Care Unit: the Brazilian version of The Environmental Stressor Questionnaire. Revista da Escola de Enfermagem da USP 44(3), 627635 Best, M. F., & Thurston, N. E. (2006). Canadian public health nurses job satisfaction. Public Health Nursing, 23(3), 250 255. Blackburn, S., & Patteson, D. (1991). Effects of cycled light on activity state and cardiorespiratory function in preterm infants. Journal of Perinatal & Neonatal Nursing, 4(4), 47 54. Boivin D. & James F. (2002). Circadian adaptation to night shift work by judi cious light and darkness exposure. Journal of Biological Rhythms, 17(6), 556 567. Carlson B., Walsh S., Wergin T., Schwarzkopf K., & Ec klund, S. (2006). Challenges in design and transition to a private room model in the neonatal intensive care unit. A dvances in Neonatal Care, 6( 5 ), 270280. Corr M. (2000). Reducing occupational stress in intensive care. Nursing in Critical Care, 5(2), 76 81.

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158 Mroczek, J., Mikitarian, G., Vieira, E., & Rotrius, T. (2005). Hospital design and staff perceptions. The Health Care Manager, 24(3), 233 244. ORourke, K., Allgood, C., VanDerslice, J., & Hardy, M. A. (2000). Job satisfaction among nursing staff in a military health care facility. Military Medicine, 165(10), 757 761. Parsons, R., Tassinary, L. G., Ulrich, R. S., Hebel, M.R., & Grossman Alexander, M. (1998). The view from the road: Implications for stress recovery and immunization. Journal of Environmental Psychology, 18, 113 139. Partonen, T., & Lonnqvist, J. (1998). Seasonal affective disorder. Lancet, 352(9137), 1369 1374. Pines, A. & Maslach, C. (1978). Characteristics of staff burnout in mental health settings. Hospital & Community Psychiatry, 29(4), 233 237. Rashid, M ., & Zimring, C. (2008). A review of the empirical literature on the relationships between indoor environment and stress in health care and office settings: Problems and prospects of sharing evidence. Environment and Behavior 40(2) 151190. Rea M. (2004). Lighting for caregivers in the neonatal intensive care unit. Clin ical Perinatol 31 : 229 242. Rea, M.S (e. d.). (2000). IESNA Lighting handbook: reference and application, the (9th ed.). New York: IESNA Publications Department. Shands Hospital at the University of Florida. (2011). Retrieved May 10, 2011, from http://www.sha nds.org/ Siefert, K., Jayaratne, S., & Chess, W. A. (1991). Job satisfaction, burnout, and turnover in health care social workers. Health & Social Work, 16(3), 193 202. Sommer, R., & Sommer, B. B. (2002). A practical guide to behavioral research: Tools and techniques (5th ed.). New York: Oxford University Press. Taylor, J. (2005). Advanced lighting technologies enhance resident care. Nursing Homes: Long Term Care Management, 54(9), 36 40. Topf, M., & Dillon, E. (1988). Noiseinduced stress as a predict or of burnout in critical care nurses. Heart & Lung: The Journal of Critical Care, 17(5), 567 574. Tummers, G. E., Janssen, P. P., Landeweerd, A., & Houkes, I. (2001). A comparative study of work characteristics and reactions between general and mental health nurses: A multi sample analysis. Journal of Advanced Nursing, 36(1), 151 162.

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159 Tyson, G. A., Lambert, G., & Beattie, L. (2002). The impact of ward design on the behavior occupational satisfaction and well being of psychiatric nurses. International Jo urnal of Mental Health Nursing, 11(2), 94 102. Ulrich, R. S. (1991). Effects of interior design on wellness: Theory and recent scientific research. Journal of Health Care Interior Design, 3(1), 97109. Ulrich R S Zimring C Barch X Z. (2008). A re view of the research literature on evidencebased healthcare design. HERD 1, 61 125. Urlich, R. S., Zimring, C., Quan, X., Joseph A ., & Choudhary, R. (2004). The Role of the Physical Environment in the Hospital of the 21st Century. The Center for Health Design URL:http://www.healthdesign.org/research/reports/pdfs/ U.S. Census Bureau, state and county quick facts (2010). Retrieved April 10, 2011, from http://quickfacts.census.gov/ Verderber, S. & Fine, D. J. (2000). Healthcare architecture in an era of radical transformation. New Haven, CT: Yale University Press. White R. D (2006). Report of the Committee to establish recommended Standar ds for Newborn ICU Design. White, R. D. (2007b). Recommended standards for the newbor n ICU. Journal of Perinatology, 27, S4S19. Winchip, S. (2008). Fundamentals of Lighting. New York City: Fairchild Publications Inc.

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160 BIOGRAPHICAL SKETCH Rozita Mozaffarian was born and raised in Tehran, Iran. From the early ages she showed her talent in the art of painting. She always had the passion for art and design throughout her academic studies. She received her Bachelor of S cience in m icrobiology from Azad University in the year 2000 and moved to the U nite d States. She started working at the McKnight Brain Institute at the University of Florida as a research assistant and t hen at the school of medicine at University of California, Irvine as a lab manager She took the post baccalaureate courses for Biot echnology in these two universities. These job experiences helped her realize she needed to pursue her passion in art and design. She then took a training course in AutoCAD and was able to get an internship at an architecture firm in Gainesville, FL. She t hen applied for interior d esign program and got accepted at the University of Flori da. She will pursue a career in the field of i nt erior d esign, in the Washington DC area.