Research

Health Environments Research

& Design Journal
2016, Vol. 9(3) 17-30
Lighting and Nurses at ª The Author(s) 2015
Reprints and permission:
Medical–Surgical Units: sagepub.com/journalsPermissions.nav
DOI: 10.1177/1937586715603194

Impact of Lighting herd.sagepub.com

Conditions on Nurses’
Performance and Satisfaction

Khatereh Hadi, MArch1, Jennifer R. DuBose, MS1,

and Erica Ryherd, PhD2

Abstract
Objective: This study investigates the perception of nurses about their lighting environment at
medical–surgical hospital units in order to understand areas of improvement for lighting at these units.
Background: The bulk of the research about nurses and lighting is focused on nighttime nursing,
exploring the disruptions of nurses’ circadian rhythm and maintaining alertness. The understanding of
nurses’ perception about lighting and its impact on nurses’ task performance and patient examination
remains imprecise. Methods: This study used an online survey to ask a set of questions about lighting
in medical–surgical units at five key locations including centralized nurse stations, decentralized nurse
stations (DCNS), patient bedsides, patient bathrooms, and corridors from 393 survey participants. It
then explored the survey findings in more depth through conducting focus groups with eight volunteer
nurses. Results: Lighting conditions at patient besides and DCNSs were significantly less desirable for
nurses compared to other locations. A significant relationship between nurses’ access to lighting
controls (switches and dimmers) and satisfaction about the lighting environment was found. No sig-
nificant relationship was observed between the individual characteristics of nurses (such as age, years
of experience, etc.) and findings of this study. Conclusions: Thoughtful design of the lighting envi-
ronment can improve nurses’ satisfaction and perception about their working environment.

Keywords
lighting, medical–surgical unit, nurse satisfaction, nurse performance, hospital design

Introduction
Previous research about lighting in healthcare
1
environments has focused on different measures Georgia Institute of Technology, Atlanta, GA, USA
2
of performance, such as alertness, visual acuity, University of Nebraska-Lincoln, Omaha, NE, USA
and task accuracy (Buchanan, 1991; Simmons,
Corresponding Author:
2009). There have also been a number studies Jennifer R. DuBose, MS, Georgia Institute of Technology,
looking at the opportunities for using light to North Ave NW, Atlanta, GA 30332, USA.
improve working conditions for night shift Email: [email protected]
18 Health Environments Research & Design Journal 9(3)

employees and reduce disruptions in circadian sleep–wake schedule and work schedule is out
rhythm (Boivin, Boudreau, James, & Kin, 2012; of phase with the natural light/dark cycle
Costa, Gaffuri, Ghirlanda, Minors, & Waterhouse, (Alcaraz, 2009; Joseph, 2006; ‘‘Lighting Options
1995; Czeisler et al., 1990; Huang, Tsai, Chen, & by Space or Area,’’ 2013). Because night shift
Hsu, 2013; Leppamaki, Partonen, Piiroinen, workers sleep during the day, their nighttime
Haukka, & Lonnqvist, 2003; Yoon, Jeong, Kwon, environment should mimic daytime light as much
Kang, & Song, 2002). Existing studies have eval- as possible to improve cognition and alertness
uated lighting from the standpoint of how much (Thurston, 2012).
light is needed for specific performance criteria, The difference in lighting levels between work
such as the minimum intensity needed to ensure areas and patient rooms at night was also high-
accuracy in medication administration (Carayon, lighted as a problem for night shift nurses. During
2007), but limited research has been done on the night shift, the patient’s room is ideally dark
nurses’ preferences in the hospital environment. while corridors may be bright. This contrast in
Although much has been said about the negative light levels causes eye fatigue when nurses move
outcomes of improper lighting conditions in hos- back and forth between patient room and their
pital settings for nurses, little has been said about workstations passing through bright corridors
whether an improved lighting environment can (Costa et al., 1995; ‘‘Lighting Options by Space
improve nurse’s satisfaction, making it easier to or Area,’’ 2013; Miovski, 2009).
perform their patient care activities. Another issue commonly discussed is the issue
This study is an effort to explore the opinions of color rendering and its impact on the ability of
and preferences of nurses working in inpatient healthcare providers to accurately assess the
medical–surgical hospital units about lighting health of individual patients. This is particularly
in areas where they provide care to patients important in spaces, where patients are examined
and perform other tasks. It also seeks to under- and procedures are carried out, such as around the
stand the importance of lighting in different patient bed (‘‘Lighting Options by Space or
spaces and nurses’ overall satisfaction with the Area,’’ 2013; Mary Alcaraz, 2004).
lighting across all those locations. By understand- In spite of all the attention that has been paid
ing nurses’ perceptions about their current light- to the lighting for nurses’ work environment, the
ing conditions and the importance they place on literature is still lacking knowledge about the
lighting in specific locations, we believe we are actual nurses’ preferences about lighting and
able to identify priority areas for innovation. what they perceived as needed for performing
their tasks. The current study confronts this gap
This study is an effort to explore the and reflects nurses’ self-reported preferences
opinions and preferences of nurses about the lighting conditions in inpatient medi-
working in inpatient medical–surgical cal–surgical hospital units.
hospital units about lighting in areas
where they provide care to patients In spite of all the attention that has been
and perform other tasks. paid to the lighting for nurses’ work
environment, the literature is still lacking
knowledge about the actual nurses’
Background preferences about lighting and
what they perceived as needed for
The bulk of the literature about nurses and light- performing their tasks.
ing is focused on the challenges inherent in night-
time nursing. Much of this literature is targeted
at the disruption to nurses’ circadian rhythms and
maintaining alertness throughout the night shift.
Method
Nurses experience circadian phase disruptions The study was conducted between March 2014
from night shifts because the timing of their and October 2014 and included collecting input
Hadi et al. 19

data from nurses through an electronic survey and Table 1. Nurses’ Individual Characteristics.
focus group discussions. Responses to the survey
What is your age? 30 or under 14.1%
together with in-depth discussions in focus groups 31–50 36.8%
helped the authors to understand nurses’ perspec- Over 50 49.1%
tives about lighting in medical–surgical units. What is your gender? Female 94.9%
Male 5.1%
Do you wear Yes, I always wear 65.6%
Survey prescription glasses either glasses or
or contact lenses? contact lenses
Survey Design Yes, I sometimes wear 16.5%
glasses or contact
The survey was designed by authors based on pre- lenses
viously conducted lighting surveys (Abbaszadeh, No, I never wear 17.8%
Zagreus, Lehrer, & Huizenga, 2006; Dianat, Sed- either
ghi, Bagherzade, Jafarabadi, & Stedmon, 2013; Do you have any of the Glaucoma 1.0%
Houser, Tiller, Bernecker, & Mistrick, 2002; following issues Cataracts 4.6%
Hua, Oswald, & Yang, 2011; Juslen, Wouters, which may affect Macular degeneration 0.5%
your vision? Select Retinopathy 0.3%
& Tenner, 2007; Konis, 2013; Moore, Carter, & all that apply
Slater, 2003; Veitch & Newsham, 2000; Wright,
Hill, Cook, & Bright, 1999), industry scanning,
and a literature review. In designing the survey, responses. The survey also included several
an effort was put toward simplifying the survey multiple-choice questions and one open-ended
to ensure an adequate response rate balanced with question at the end of the survey about any other
sufficient details in the questions to cover a range lighting issues that participants might have in their
of issues. A description of the research plan for working environment. The survey evaluated the
the survey was approved by the institutional overall satisfaction with the lighting, overall
review board (IRB). amount of lighting, disturbing lighting conditions
The survey was developed using Survey Mon- (glare, shadows, and flickering), access to light
key (SurveyMonkey Inc., Palo Alto, California, controls, importance of having lighting controls,
USA), which is an online survey and question- and ease of using available light controls across all
naire tool to conduct surveys. The survey focused the five locations. The quality and quantity of
on five key locations in the medical–surgical lighting available at nights in patient rooms and
units, where lighting conditions are likely to vary corridors were also asked at the end of the survey.
and have impact on nurses: central nurse stations This survey only asked for nurses’ perceptions
(CNS), decentralized nurse stations (DCNS), about lighting, and no data were collected about
patient bedsides (PBS), patient bathrooms (PBR), the types of bulbs used nor were any objective
and corridors. The survey questions were organized metrics collected about the physical environments,
by these five locations, including a standard set of such as the lighting level or locations.
questions about each location. The survey also
recorded demographic data by asking a few ques-
tions to determine the typical shift worked, age, Survey Participants
experience, and presence of any eye pathologies To reach a broad group of nurses from hospitals
that could interfere with vision and might explain across the country, the authors contacted over 20
some variations in perception of lighting in the unit different associations and nursing groups to ask
(see Table 1). Considering the importance of the for their help distributing the survey. The Nur-
nighttime lighting for nurses, a set of questions spe- sing Institute for Healthcare Design and another
cific to the lighting conditions at night were asked large national nurse’s organization assisted with
as well. distributing the survey request by sending an
The survey questions were designed in a e-mail to their members informing them of the
5-point Likert-type scale format to organize opportunity. The survey was open from July
20 Health Environments Research & Design Journal 9(3)

23, 2014, to August 15, 2014. During that time, At the end of the survey questions, the partici-
393 people responded to the survey. Because the pants were asked if they were willing to partic-
survey did not ask respondents to identify the ipate in focus group discussions. To maintain
name of the hospital where they work, it is not anonymity, those who showed interest were
possible to know the number of different hospi- directed to another webpage to enter their con-
tals represented by this sample. tact information. The authors contacted the
The respondents were all nurses working in 100 people through e-mail, who had expressed
medical–surgical units with a close to even split interest in providing additional feedback. The
between registered nurses and certified medical– e-mail included a link to a website with the
surgical registered nurses. More than 60% of the informed consent verbiage, a list of various
respondents have worked in their current medi- times for focus groups, and the offer of a gift
cal–surgical unit for 6 or more years, with only card. Eight different sessions were offered at a
5% reporting tenure in their current unit as less variety of times, and the number of participants
than a year, suggesting that these nurses have a on any one call was limited to no more than
good degree of familiarity with the conditions five. Eight nurses participated in the focus
on their unit. Regarding the total medical–surgical group discussions, all women.
unit experience, about 80% of nurses have worked The focus groups were conducted by confer-
for 6 years or more in a medical–surgical unit dur- ence call using a semi-structured interview proto-
ing their entire career and only 0.5% have worked col. The discussions in the focus groups were
in a medical–surgical unit less than a year during organized around three major topics: lighting to
their entire career. While a majority of the respon- support tasks at the PBS, lighting to support tasks
dents work mostly during day shift (65%), there at DCNSs, and lighting transitions throughout the
was a large enough sample of night shift nurses day. Focus group participants were identified by
(25%) to allow for significant findings when com- first name only and were asked what shift they
paring the different opinions of the two shifts. worked (day or night) but were not asked to pro-
vide any other identifying information such as the
name of the hospital. From those interviewed,
Survey Data Analysis four were working day shift and four working
The analysis of the survey data was carried out night shift. The calls were recorded and tran-
using SPSS software version 21. All of the data scribed to ensure all comments were captured.
from the survey were tested for normality using
Kolmogorov–Smirnov and Shapiro–Wilk tests
and found to be nonparametric. The nonpara- Results
metric Mann–Whitney test was used to look for
Subjects’ Judgment on Lighting Across
differences in the rank positions of the lighting
scores when comparing two different groups
Different Locations
(e.g., night shift nurses vs. day shift nurses). The Overall satisfaction about lighting. The survey results
nonparametric Wilcoxon signed-ranks test was showed that nurses in different hospitals have
used for testing differences between the lighting similar degrees of satisfaction with the lighting
scores of groups when comparing results across in specific locations. The authors hypothesized
different locations in the medical–surgical units that some locations on the medical–surgical unit
(Field, 2013; Field & Hole, 2002). In comparing have better lighting than others and that this holds
study variables, p values < .05 were considered true across different hospitals covered by the sur-
statistically significant. vey. To test this hypothesis, the average degree of
agreement that nurses’ reported when asked if
they were satisfied overall with the lighting in
Focus Group Discussions each of the five locations targeted by the survey
A detailed protocol for the focus groups was were compared. The averages for each location
developed and received approval from the IRB. were compared against the average for all of the
Hadi et al. 21

Whether respondents agree that they are sasfied overall with the lighng at the
specified locaon
60%

50%

40%

30%

20%

10%

0%
Centralized Nurse Decentralized Nurse Paent Bedside Paent Bathroom Corridor
Staon Staon
Strongly Disagree Disagree Neither Disagree Nor Agree Agree Strongly Agree

Figure 1. Nurses’ overall satisfaction with lighting condition.

other locations, and each combination of pairs about the quantity of light for different locations
was compared to determine if the difference on the medical–surgical units, that is, they would
between the ratings was significant and repre- agree that some locations are typically dark and
sented a real difference in opinion or if the differ- others tend to be bright. To test this hypothesis,
ence was within the margin of error. nurses were asked to rate the overall amount of
Based on the Wilcoxon signed-ranks test light at each of the five locations from ‘‘too little’’
results, the lighting at the DCNSs and PBSs are up to ‘‘too much’’ light. The Wilcoxon signed-
the most problematic lighting conditions, that is, ranks test was used to compare the ranks of light-
the locations with the least satisfaction. There are ing for each location. Based on the results, PBSs
significantly more nurses satisfied with the light- were ranked significantly darker by nurses com-
ing at the centralized nurse stations (p < .0001), pared to the CNSs, PBRs, and corridors (p <
PBRs (p < .0001), and corridors (p < .0001) than .0001). The amount of light at PBSs and DCNSs
those satisfied with the lighting at the DCNSs. are both perceived as having too little light and
The magnitude of the difference across locations are ranked equally by nurses. PBRs are also
can be seen in Figure 1. ranked significantly darker compared to other
The overall satisfaction ranks at the DCNSs are locations with the exception of the PBS that is
not significantly different from the PBSs, which ranked even darker (p < .0001).
also have a low satisfaction rank. More nurses are To summarize, the results show that PBSs and
satisfied with the lighting at the centralized nurse PBRs are considered as locations with the least
stations (p < .0001), PBRs (p < .0001), and corridors amount of light available. Equally ranked with
(p < .0001) than with the lighting at the PBSs. PBSs DCNSs are also considered to be dark.
Centralized nurse stations and PBRs, identi- Figure 2 shows that at DCNSs and PBSs, the
fied with almost identical satisfaction ranks, have percentage of nurses who rate the overall amount
significantly more nurses satisfied with their of lighting as ‘‘just right amount’’ is below 40%.
lighting conditions compared to other locations, It indicates that more than half of the nurses
which identifies these two locations as ‘‘least pro- believe that the amount of lighting at these two
blematic’’ across the range of hospitals surveyed. locations is not ‘‘just right.’’ The PBSs and
DCNSs, as mentioned earlier, are the places
The perceived quantity of lighting. The authors where nurses report the least satisfaction. It is
hypothesized that, even at different hospitals, possible that divergence of the light intensity
nurses would generally have shared perceptions from the right amount required for nurses’ task
22 Health Environments Research & Design Journal 9(3)

Percentage of nurses who rated the overall amount of lighng as 'Just right
amount' at each locaon
60%

50%

40%

30%

20%

10%

0%
Centralized Nurse Decentralized Paent Bedside Paent Bathroom Corridor
Staon Nurse Staon

Figure 2. Nurses’ rating on whether lighting is just the right amount.

performance to darker ranges is one of the Table 2. Availability of Lighting Controls at Different
sources of dissatisfaction about the lighting at Locations.
these PBSs and DCNSs.
Access to Lighting Controls Yes (%) No (%)

The importance of lighting. More meaningful per- Central nurse stations 74.3 25.7
Decentralized nurse stations 56.5 43.5
haps than the quantity of and satisfaction with
Patient bedsides 89.3 10.7
lighting is the importance that lighting in specific Patient bathrooms 86 14
locations plays in the minds of nurses. The Corridors 63.9 36.1
authors speculated that lighting conditions at
some locations on the medical–surgical units are
considered to be more important than others. To while medical–surgical nurses in a range
test this hypothesis, the average degree of agree- of hospitals feel that lighting at the patient
ment that nurses’ report when asked if the light- bedside is the most important lighting in
ing experience was important to them in each of their unit, they tend to be least satisfied
the five locations targeted by the survey were with the available lighting and frequently
compared using the Wilcoxon signed-ranks test.
report that there is too little lighting
Based on the results, only lighting at the PBSs
available there.
was ranked significantly more important than all
other locations (p < .0001). None of the other
comparisons of perceived importance yielded a
significant difference. Although PBSs showed Availability of lighting controls. Availability of light-
to be considered significantly more important than ing controls, either for turning lights on and off or
other locations, as stated earlier, they had lower for dimming the lights, gives the nurses a measure
satisfaction rates and were perceived darker com- of control over their environment by allowing
pared to other locations. To summarize, while them to adjust the light to meet their needs. The
medical–surgical nurses in a range of hospitals feel survey asked the question of whether or not
that lighting at the patient bedside is the most nurses have control of lighting at each of the five
important lighting in their unit, they tend to be spaces (see Table 2). The survey did not specify a
least satisfied with the available lighting and fre- definition for the controls (e.g., dimmer or
quently report that there is too little lighting avail- switches), so the responses represented any light-
able there. ing controls. Based on the responses, DCNSs and
Hadi et al. 23

Importance of having light dimmers at different locaons

60%

50%

40%

30%

20%

10%

0%
Centralized Nurse Decentralized Paent Bedside Paent Bathroom Corridor
Staon Nurse Staon

Not at all important

BETWEEN 'not at all important' & 'somewhat important'
Somewhat important
BETWEEN 'somewhat important' & 'extremely important'
Extremely important

Figure 3. Nurses’ judgment on whether presence of light dimmers is important at different hospital locations.

corridors are the places where nurses are least centralized nurse stations (p ¼ .038), at DCNSs
likely to have access to lighting controls. (p < .0001), at PBSs (p ¼ .027), in PBRs (p ¼
The results showed that considerably fewer .004), and corridors (p ¼ .037), compared to the
nurses have access to light dimmers compared nurses who do not have access to lighting
to light switches. The survey also asked nurses controls.
to indicate importance of having switches or dim-
mers at each location regardless of whether or not Disturbing lighting conditions. The survey also col-
their current unit has them. More than half of the lected data about whether or not nurses are dis-
nurses (52%) said they consider dimmers at the turbed by lighting conditions, such as glare,
PBS to be ‘‘extremely important’’ and another shadow, and flickering. Based on the results, the
21% rate dimmers as between ‘‘somewhat impor- most common problem at the CNSs is glare.
tant’’ and ‘‘extremely important’’, (see Figure 3) About 57% of people who report any disturbing
yet only 40% of nurses report having dimmers lighting condition (glare, shadow, or flickering)
at the bedside. state that they have a problem with glare at the
As the results of the survey showed, nurses CNSs. Consistent with the general impression of
have limited access to lighting controls, espe- low lighting at the DCNSs, the most frequently
cially dimmers, on the medical–surgical units. cited disruptive condition at these locations is sha-
Another hypothesis of this study was that nurses dows (57%). Shadows are the most frequently
who have lighting controls available to them reported problem at the PBSs (63%) and PBRs
have higher satisfaction ranks about lighting. (45%) and in corridors (49%) as well.
The Mann–Whitney test was used to test this Looking across all the locations, it appears that
hypothesis. The results of this test confirmed shadows are the most problematic issue with the
this hypothesis for all of the five locations. exception of the centralized nurse stations, where
Nurses who have access to lighting controls have glare is a bigger issue. At some locations, the rate
significantly higher satisfaction scores at the of reporting flickering as a problematic issue is
24 Health Environments Research & Design Journal 9(3)

considerable (38% in PBRs and 41% in CNSs). ranks across all five locations: the CNSs, DCNSs,
However, the rate of complaints about flickering PBSs, PBRs, and corridors. The accumulative
is considerably less than complaints about glare scores of all the overall satisfaction scores from
and shadows in general. all the locations failed to find any significant dif-
ferences between day shift and night shift nurses.
Nurses’ individual characteristics and the perception Based on these tests, the hypothesis that the
of lighting. The results of this study confirm that nurses in different working shifts have different
environmental variables such as location, quan- satisfaction ranks was rejected for this sample.
tity of lighting, and availability of lighting con- Another hypothesis was that nurses in differ-
trols in the medical–surgical units can affect ent work shifts have different perceptions about
nurses’ satisfaction and perception of lighting. the amount of light at specific locations. Based
However, this study also explores the impact of on the results of the Mann–Whitney test, day shift
other intrinsic variables on the nurses’ responses nurses more commonly perceive the light as
that could possibly explain the variations in the being too little across all the locations, whereas
results. Among many others, this study looks at the night shift nurses more commonly perceive the
variation of responses based on the nurses’ working light as being too much. There are significantly
shifts, age, eye condition, and years of experience. more day shift nurses who evaluate the amount
of light as too little at the CNSs (p ¼ .001), at the
Night shift versus day shift. The first speculation PBSs (p ¼ .017), in the PBRs (p ¼ .016), and cor-
was that overall satisfaction ranks vary signifi- ridors (p < .0001), compared to night shift nurses.
cantly between day shift and night shift nurses. While there are more day shift nurses who evalu-
The survey data were split into two groups: ate the amount of light as too little at the DCNS,
responses from nurses who work mostly day compared to the night shift nurses, this difference
shifts (65%) and responses from those who work is insignificant (p ¼ .822).
mostly night shifts (25%), and the nurses who
report working both shifts were excluded from Comparisons of nurses by different age-groups.
this portion of the analysis. Once the data were Recognizing that aging eyes require more light
grouped as such, the satisfaction ranks were com- for vision, the authors speculated that the overall
pared by location for each group. Overall, the satisfaction ranks might vary significantly
comparison of satisfaction ranks between day and between nurses in different age-groups. In fact,
night shift nurses at different locations does not some studies have reported that nurses over the
show any significant differences between the two age of 40 have more difficulty performing care
groups. The trend was that at the CNSs and tasks in a given light level than do younger nurses
DCNSs, nurses who work mostly day shift are (Kamali & Abbas, 2012). To test this, the satis-
more satisfied with lighting overall compared to faction rates for each age-group were compared
nurses working mostly night shift. However, the at each location. Across all the locations, nurses
differences are not significant. At PBSs, PBRs aged 30 or under (14%) have higher satisfaction
and corridors, night shift nurses report higher ranks compared to nurses aged 31–50 (37%) and
overall satisfaction rates compared to the day nurses above 50 (49%). However, most of the dif-
shift nurses. However, the difference is only sig- ferences are not significant. Only at DCNSs, do
nificant at the PBRs, and nurses who work mostly nurses under age 30 have significantly higher
night shift are significantly more satisfied with satisfaction ranks compared to nurses aged above
lighting in the PBRs overall compared to nurses 50 (p ¼ .004). In a comparison of satisfaction
working mostly day shift (p ¼ .009). ranks between nurses aged 30 and 50 and nurses
In order to understand whether the night and over 50, nurses over 50 years have higher satis-
day shifts have different overall satisfaction rates, faction ranks at CNSs, PBSs, PBRs, and corri-
a compound variable was created combining the dors. Only at the DCNSs, do nurses between the
satisfaction values of all the locations. The com- ages of 30 and 50 have higher satisfaction ranks.
pound variable calculates the average satisfaction But, none of the differences in the overall
Hadi et al. 25

satisfaction scores between these two age-groups The result of the Mann–Whitney test with cumu-
are significant. lative satisfaction ranks across all the locations
Similar to the analysis done to compare day also did not show any significant differences
and night shifts, a composite variable of overall between those with and without eye conditions.
satisfaction scores across all the locations was Similarly, the authors also hypothesized that
also created to see if there are variations among nurses with eye conditions might be more dis-
different age-groups at the aggregate level. rupted by glare or shadows. To test this hypoth-
Nurses aged 30 or under have higher accumula- esis, a variable was created with the cumulative
tive satisfaction ranks compared to nurses reports of glare and shadow across all locations
between 30 and 50 and nurses over 50; however, and then split the data set into two groups, those
the differences are not significant. The least satis- reporting eye conditions compared with every-
fied group appears to be nurses between 30 and one else. A Mann–Whitney test was conducted
50 years, but this difference is not significant comparing the reported disruptions and found
either. Overall, the results of the study could not no significant difference in the rate of reported
confirm any significant differences between disruptions from glare or shadows and therefore
nurses’ satisfaction ranks in different age-groups. rejected this hypothesis. A separate analysis
A second assumption about nurses in different comparing nurses who wear corrective lenses
age-groups was that older nurses are more often to those who do not was also run and found
disrupted by glare and shadows, since this is a no significant difference in their rates of disrup-
generally reported problem for aging populations tion from glare.
(Haegerstrom-Portnoy, Scheck, & Brabyn, 1999).
A Mann–Whitney test was conducted to test this Comparisons of nurses by different years of
hypothesis by splitting the data set into three age experience. This study also hypothesized that
categories. As expected, the youngest group of nurses’ overall satisfaction ranks vary based on
nurses (30 and under) report lower overall rates the years nurses have worked in their current
of glare than the two older groups (nurses aged medical–surgical unit. Based on the survey
30–50 and nurses over 50), but neither was found results, only 1.6% have less than a year experi-
to be significant. Since the findings failed to ence, 33.8% between 1 and <6 years, 26.8%
reach significance, this hypothesis was rejected. between 6 and <11 years, and 34.8% had 11 or
A similar conclusion was drawn regarding age more years of experience in their current medi-
and disruption by shadows. cal–surgical unit. Using the accumulative scores
of all the overall satisfaction scores from all the
Comparison of nurses with different eye conditions. locations, the influence of the number of years
To investigate the effect of other possible intrinsic working in their current medical–surgical units
variables on the overall satisfaction ranks about on the overall satisfaction of nurses with lighting
lighting, the variations of satisfaction ranks at dif- was explored. The result of the Mann–Whitney
ferent locations were also compared based on two tests shows that nurses working less than a year
categories: nurses who report any eye condition in their current medical–surgical units have sig-
(i.e., glaucoma, cataracts, macular degeneration, nificantly higher satisfaction rates compared to
retinopathy, or any other conditions that could nurses who have been working in their current
affect vision and therefore the perception of light- unit for 1 to >6 years (p ¼ .041) and compared
ing) and nurses who did not report any eye issues. to nurses who have been working in their current
Based on the survey results, few respondents unit between 6 and <11 years (p ¼ .022). How-
report eye conditions such as cataracts (4.6%), ever, the difference between the satisfaction rates
glaucoma (1%), macular degeneration (0.5%), of new employees and the nurses who have been
and retinopathy (0.3%). Based on the results of the working in their current unit for 11 years or more
Mann–Whitney test, a lower satisfaction rating for is not significant. While significant differences
the lighting at DCNSs is found among nurses with between the overall satisfactions among different
eye issues, but this difference is not significant. groups according to their tenure were found, the
26 Health Environments Research & Design Journal 9(3)

relationship is not linear or simple to explain. options available for different tasks, unmet light-
From the data collected, it is unclear why nurses ing needs, conflicts of lighting conditions
newer to a unit and those working there more than between the nurses’ task requirements and
11 years are more satisfied with lighting. patients’ comfort, and patients’ needs and feed-
Another assumption was that overall satisfac- back about the lighting and access to the light
tion rates vary based on total years of medical– controls at PBSs. The focus group discussions
surgical work experiences. Using the accumula- around the lighting at the PBSs also confirmed
tive scores of the overall satisfaction scores from the survey results that previously had shown this
all the locations, the possible explaining power of location as one of the most problematic areas
the total years of medical–surgical unit work regarding lighting:
experience on the overall satisfaction of the
nurses with unit lighting was explored. The result Lighting is definitely problematic at night in the
of the Mann–Whitney tests showed there were no patients’ room because getting a soft amount of
significant differences between the overall satis- light that is not bothersome to the patient, but
faction rates of nurses based on the years of expe- allows the nurse to adequately assess the environ-
rience (<1 year experience, 1 to <6 years, 6 to <11 ment and the patient’s condition becomes a
years, and 11 years and greater), and therefore, challenge.
this hypothesis was also rejected. So when you turn on that light bright it’s so
bright that the patient is startled a lot of the times
Focus group findings. Based on the results of the . . . they [patients] do complain because that
survey, it appears that PBSs and DCNSs are the light is really bright. It wakes you up; it really
most critical locations in medical–surgical units frightens you.
in terms of the lighting, and yet these very loca-
tions have the least satisfying lighting conditions. It appears that lighting challenges at the bedsides
In order to have a better understanding of the are more related to conflicts between nurses’ light-
lighting challenges at the PBSs and DCNSs, focus ing needs to perform their tasks and patients’ com-
group discussions were held with nurses to talk fort levels, especially at nights when patients want
about these two locations. Another topic covered to sleep. Although the overhead lights in patient
in the focus group discussions was the transition rooms are usually kept off during the day, lighting
between darkness and bright lights throughout the at PBSs is more challenging at nights when there is
day, an issue that was mentioned by many nurses no light coming in from the window. Nighttime
in the open-ended question at the end of the sur- lighting is particularly problematic because of the
vey. The discussions with nurses in the focus abrupt transition from darkness to bright lights.
group revealed that nurses are generally flexible During the day, the ambient light of the patient
and willing to work around challenges in the room environment reduces the sudden light con-
environment. They are more inclined to adjust the trast created by turning on the exam lights at the
lighting environment to the patient needs than to PBSs. At night, where the ambient lighting is dark
their personal preferences, or when unavoidable, too, turning on the light makes an intense light
simply accept the complaints from patients as just contrast that bothers patients.
a part of their job. Although results of the statis- An option for managing the light levels at the
tical analysis of the survey showed that there are PBSs is a priority lighting functionality for
variations among different nurse groups in over- nurses. Light zoning and providing light dimmers
all lighting satisfaction, no specific pattern was are desirable options that could give some level of
observed. Several other themes emerged from the control to nurses. However, nurses specifically
focus group discussions, which confirmed the state that they want dimmer switches that limit
survey findings already reported. the range that light could vary to prevent nurses
from inadvertently turning the lights up too
Lighting at PBSs. The discussions about PBSs bright. Controls also can be challenging and can
included questions about the tasks, lighting present additional cognitive burden to already
Hadi et al. 27

overworked nurses. Nurses say they would like Patients need to have access to light
more consistent and intuitive controls. controls without having to leaving their
beds, change their body positions
Being able to dim the lights instead of having them drastically, or call in the nurse to help.
on full bright. Even those on the headboard can be
kind of bright. When they’re off completely they
Lighting at DCNSs. The discussions about the
[patients] feel that it’s not enough light. Then they
turn them on and it’s too much light. That dimmer
DCNSs included questions about the different
switch would be a great option. tasks, locations, distribution, available lighting
It’s a slide dimmer switch so it’s real easy to over options, unmet lighting needs, access to lighting
brighten them in error in our haste to get in and out controls, and availability of the natural light at
. . . . If it had a wider span of settings, to make sure the DCNSs. The comments around the lighting
you don’t make it too bright for the patient’s com- at the DCNS are more difficult to interpret.
fort. I don’t know if they have stop points so you Nurses from different hospitals have different
could gauge it? definitions of DCNSs. Some refer to DCNSs as
Figuring out which switch controls which light charting areas outside of the patient room door,
and how to turn off that one and not turn on the one whereas others refer to a small charting area
that’s bright shining into the patient’s face is some- at the PBSs. Overall, nurses state that the avail-
thing that you have to do repeatedly to be able to ability of task lights, keyboard lights, and light
learn which one’s going to be able to control that. dimmers would make the charting task easier for
them at these locations:
Another important issue that emerged from the
focus group discussions was patients’ access to It would still be nice if they had light at the individ-
light controls. Patients need to have access to ual workstation where they could adjust it. You
light controls without having to leaving their know to brighten that work area. The other thing
beds, change their body positions drastically, or on the COWs [computer on wheels] themselves,
call in the nurse to help. Also, they need to know actually part of that issue could be resolved if there
which switches around their beds actually do was a lighted keyboard.
what they want to achieve. Similar to controls for
nurses, controls for patients should also be intui- Lighting transition throughout the day. The focus
tive and easy to use. group discussions about the lighting transitions
throughout the day included questions about the
The patient really needs to have a control for it adequateness of the available light in different
[overhead light] because if the nurse goes out of the times of day at different locations, acceptability
room and forgets to shut it off, the patient should of the available lighting conditions for both night
have a way that they can shut it off. shift and day shifts, availability of dimmed lights
According to the focus group discussions, too much during lights-off times, adjustability of lights in
light at night is not just a problem when the nurses common work areas, and control over the lighting
come in to check on the patients. Lighting from the conditions. A consistent theme heard from the
corridor makes it difficult to provide a dark environ- nurses is that there are no specific protocols for
ment for patients at night; however, providing a changing the lighting from ‘‘day mode’’ to ‘‘night
dark environment at night is beneficial for patients. mode’’ in medical–surgical units. Switching the
First, a bright nighttime environment does not allow lights tends to fall to overloaded nurses, and con-
patients sleep. Second, a bright ambient environ- sequently, controlling and switching light settings
ment at night disorients patients to time of day, and gets overlooked when units are busy.
third, it disrupts their circadian rhythm. At night-
time, lighting in the hallway is just so bad because I was walking through another area, another unit of
it’s so bright the patients complain about it all the the hospital, and it was probably 3 or 4 in the after-
time, but we actually can’t turn them off. And we noon and they had the nighttime hall lighting. And
can’t turn them down! I was like, did you guys intend to have it dark in
28 Health Environments Research & Design Journal 9(3)

this hallway? And they were like, no I just hadn’t The research was not able to demonstrate any
thought about it. impact of vision problems, eye pathologies, age,
or years of service on the overall satisfaction with
Discussion lighting, the quantity of light, or complaints about
glare, shadows, or flickering. This was corrobo-
There are several compelling and significant find- rated by the interviews, and the only condition that
ings from this research effort. One consistent nurses mention as impacting the perception of
finding from the survey and focus groups is that light is migraines that cause people to be sensitive
medical–surgical nurses feel that lighting at the to light. It is possible that failure to find a signifi-
patient bed is very important but inadequate. The cant relationship is a result of the relatively small
statistical analysis comparing the responses to the sample size for the group with eye problems, or
question about importance of lighting in each of perhaps the selection of specific eye problems
the locations (CNS, DCNS, PBS, PBR, and corri- listed on the survey was not at the right level of
dor) concluded that lighting at the PBSs is the granularity to find a relationship. Future studies
only location that is ranked significantly more should continue to look for potential relationships
important than all other locations. with eye problems and issues with lighting.
Unfortunately for the nurses, while the light- These findings offer clear direction to the
ing at the PBS is considered significantly more field. The lighting conditions at the PBS are inad-
important than the other locations, it is also the equate and need to be rethought. Designers
location with the most dissatisfaction. In the sur- should give special attention to the needs of care-
vey, nurses indicate that they are dissatisfied and givers and patients when designing bedside light-
more of them rate the quantity of light at the PBS ing solutions. Facility owners need to respect the
as too little. This study explored this in more importance of this space and resist the temptation
depth in the focus group interviews and learned to cut costs by reducing controllability of lights.
that nurses do not have enough light at the bed- Lighting manufacturers need to keep developing
side to see well enough to perform some tasks. innovative solutions for inpatient rooms. While
Nurses also mention that the lights that they do the findings are instructive, this study evaluated
have at the PBS tend to be disturbing to the the subjective experience of nurses but did not
patients. The nurses state that they wish they had include objective descriptions or measures of the
the ability to turn the lights on gradually, espe- actual lighting conditions and therefore detailed
cially during the night, so as not to be startling lighting specifications are not possible. Addi-
to the patients. The survey reveals that many hos- tional research should be done combining the
pitals lack dimmer switches in the patient rooms. subjective survey with measurements of the phys-
In the interviews, the nurses also state that they ical environment to determine the qualities of
would like for the patients to have more access lighting that nurses find acceptable or unsatisfac-
to the lighting controls. In fact, controls overall tory that could support the development of more
proved to be very important to nurses. Statistical specific guidance about what works best for light-
analysis of the survey results shows that when ing this critical part of the hospital.
nurses have control over their lighting, they are
more satisfied with the lighting. This relationship
holds true in all five of the locations studied and is Implications for Practice
statistically significant.
 Improving the lighting environment for
The nurses state that they wish they had medical–surgical nurses at PBSs and
the ability to turn the lights on gradually, DCNSs can improve nurses’ satisfaction.
especially during the night, so as not to be  Providing task lights and adjustable lighting
startling to the patients. The survey options at DCNSs, providing dimmers at
reveals that many hospitals lack dimmer PBS and inside patient rooms to allow for
switches in the patient rooms. patient care activities especially during the
Hadi et al. 29

night shift and providing control over light- Carayon, P. (2007). Handbook of human factors and
ing for nurses through easy-to-use distribu- ergonomics in health care and patient safety.
ted controls and dimming can improve the Mahwah, NJ: Lawrence Erlbaum Associates.
lighting environment for nurses. Costa, G., Gaffuri, E., Ghirlanda, G., Minors, D. S., &
 Providing lighting options for patients Waterhouse, J. M. (1995). Psychophysical condi-
which can be used while prone or reclined tions and hormonal secretion in nurses on a rapidly
in bed, along with provisions for preventing rotating shift schedule and exposed to bright light
the corridor light from penetrating into during night work. Work & Stress, 9, 148–157.
patient rooms, can make the lighting envi- Czeisler, C. A., Johnson, M. P., Duffy, J. F., Brown, E.
ronment for patients more desirable. N., Ronda, J. M., & Kronauer, R. E. (1990). Expo-
sure to bright light and darkness to treat physiologic
maladaptation to night work. The New England
Acknowledgment Journal of Medicine, 322, 1253–1259.
The authors would like to thank Ms. Karyn Gayle Dianat, I., Sedghi, A., Bagherzade, J., Jafarabadi, M. A.,
from Acuity Brands Lighting, Inc., for supporting & Stedmon, A. W. (2013). Objective and subjective
this research. assessments of lighting in a hospital setting: Impli-
cations for health, safety and performance. Ergo-
Declaration of Conflicting Interests nomics, 56, 1535–1545. doi:10.1080/00140139.
The author(s) declared no potential conflicts of 2013.820845
interest with respect to the research, authorship, Field, A. (2013). Discovering statistics using IBM
and/or publication of this article. SPSS statistics (4th ed.). London, England: Sage.
Field, A., & Hole, G. J. (2002). How to design and
Funding report experiments. London, England: Sage.
The author(s) disclosed receipt of the following Haegerstrom-Portnoy, G., Scheck, M. E., & Brabyn, J.
financial support for the research, authorship, A. (1999). Seeing into old age: Vision function
and/or publication of this article: Acuity Brands, beyond acuity. Optometry and Vision Science, 76,
Inc., provided funding for this research project. 141–158. doi:10.1097/00006324-199903000-00014
Houser, K., Tiller, D., Bernecker, C., & Mistrick, R.
References (2002). The subjective response to linear fluores-
Abbaszadeh, S., Zagreus, L., Leher, D., & Huizenga, C. cent direct/indirect lighting systems. Lighting
(2006). Occupant satisfaction with indoor environ- Research and Technology, 34, 243–260.
mental quality in green buildings. Paper presented Hua, Y., Oswald, A., & Yang, X. (2011). Effectiveness
at the The eighth international conference for healthy of daylighting design and occupant visual satisfac-
buildings 2006: creating a healthy indoor environ- tion in a LEED gold laboratory building. Building
ment for people, Lisbon, Portugal, 1 January 2006. and Environment, 46, 54–64. doi:10.1016/j.buil-
Alcaraz, M. (2009, August 31). Lighting for healthcare— denv.2010.06.016
The best and the brightest. HealthNewsDigest.com. Huang, L.-B., Tsai, M.-C., Chen, C.-Y., & Hsu, S.-C.
Retrieved from http://www.healthnewsdigest.com/ (2013). The effectiveness of light/dark exposure to
news/Guest_Columnist_710/Lighting_for_Health treat insomnia in female nurses undertaking shift
care_-.shtml work during the evening/night shift. Journal of
Boivin, D. B., Boudreau, P., James, F. O., & Kin, N. M. Clinical Sleep Medicine: JCSM: Official Publica-
(2012). Photic resetting in night-shift work: Impact tion of The American Academy of Sleep Medicine,
on nurses’ sleep. Chronobiology International: The 9, 641–646. doi:10.5664/jcsm.2824
Journal of Biological & Medical Rhythm Research, Joseph, A. (2006). The impact of light on outcomes in
29, 619–628. doi:10.3109/07420528.2012.675257 healthcare settings (pp. 1–12). Concord, CA: The
Buchanan, T. L., Barker, K. N., Gibson, J. T., Jiang, B. Center for Health Design.
C., & Pearson, R. E. (1991). Illumination and errors Juslen, H., Wouters, M., & Tenner, A. (2007). Lighting
in dispensing. American Journal Of Hospital Phar- level and productivity: A field study in the electro-
macy, 48(10), 2137–2145. nics industry. Ergonomics, 50, 615–624.
30 Health Environments Research & Design Journal 9(3)

Kamali, N. J., & Abbas, M. Y. (2012). Healing envi- Moore, T., Carter, D., & Slater, A. (2003). A qualita-
ronment: Enhancing nurses’ performance through tive study of occupant controlled office lighting.
proper lighting design. Procedia—Social and Beha- Lighting Research and Technology, 35, 297–314.
vioral Sciences, 35, 205–212. doi:10.1016/j.sbspro. Simmons, D., Graves, K., & Flynn, E. A. (2009).
2012.02.080 Threading needles in the dark: the effect of the
Konis, K. (2013). Evaluating daylighting effectiveness physical work environment on nursing practice.
and occupant visual comfort in a side-lit open-plan Critical Care Nursing Quarterly, 32(2), 71–76. doi:
office building in San Francisco, California. Build- 10.1097/CNQ.0b013e3181a27d99
ing and Environment, 59, 662–677. doi:10.1016/j. Thurston, T. (2012, June 6). Making healing safe at
buildenv.2012.09.017 night. Healthcare design. Retrieved from http://
Leppamaki, S., Partonen, T., Piiroinen, P., Haukka, J., www.healthcaredesignmagazine.com/blogs/bsa-life
& Lonnqvist, J. (2003). Timed bright-light exposure structures/making-healing-safe-night
and complaints related to shift work among women. Veitch, J. A., & Newsham, G. R. (2000). Exercised
Scandinavian Journal of Work Environment and control, lighting choices, and energy use: An office
Health, 29, 22–26. simulation experiment. Journal of Environmental
Lighting Options by Space or Area. (2013). Osram Syl- Psychology, 20, 219–237. doi:10.1006/jevp.1999.
vania. Retrieved from https://www.sylvania.com/ 0169
en-us/applications/healthcare/lighting-options-by- Wright, M. S., Hill, S. L., Cook, G. K., & Bright, K.
space-or-area/Pages/nursing-stations.aspx T. (1999). The perception of lighting quality in a
Mary Alcaraz, B. H. (2004). Here’s to your health (pp. non-uniformly lit office environment. Facilities,
40–44). Philadelphia, PA: IESNA. 17, 476.
Miovski, N. (2009, July 31). Healing the nursing Yoon, I.-Y., Jeong, D.-U., Kwon, K.-B., Kang, S.-B., &
shortage with staff-friendly design. Healthcare Song, B.-G. (2002). Bright light exposure at night
design. Retrieved from http://www.healthcare and light attenuation in the morning improve adap-
designmagazine.com/article/healing-nursing-short tation of night shift workers. Sleep: Journal of Sleep
age-staff-friendly-design and Sleep Disorders Research, 25, 351–356.
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