PART C: TESTING SOUNDSCAPE INTERVENTIONS
6.1. Soundscape intervention rationale
The soundscape interventions were derived from the conceptual model which suggested that physical and cognitive interventions may improve the perception of the soundscape (Figure 24). These interventions acknowledged the coping methods highlighted in the conceptual model to include, two physical interventions of natural sounds and steady state sound, along with a cognitive intervention in the form of information about the sounds. At this point it is important to note that the interventions were tested to improve the patient response to the CT soundscape. This direction was chosen due to the pragmatic issues of obtaining a healthcare professional sample. Moreover, the interventions developed a strong patient orientated rationale behind them discussed below.
Figure 24.Conceptual model highlighting soundscape intervention in relation to coping methods.
Sound sources, Sound level, Temporal factors
Perception and interpretation of sound: information/ stimulation/positiveor negative/necessary .
Problems associated with sound: work, privacy, sleep
Coping methods: Accept and habituate to the soundscape. Opportunities for restoration:Yesor No
Emotional-Cognitive Response ‘Relaxation’
‘Interest & Understanding’
Intervening conditions
Physical attributes of environment: space/light/temperature Job duties Behaviour Outside stimulation Patient interaction A B C D E Soundscape interventions Information (SSI) Natural sound (birdsong/water)
6.1.2. Natural sounds (NS)
Urban soundscape work has explored the effect of natural sounds on the
individual. When assessing the soundscape of two cities by Yang & Kang (2005)
interviewees were requested to classify 15 verbally described sounds into either
favourite, neither favourite nor annoying or annoying. More than 75% of participants
were favourable to water sound and birdsong. Interestingly 93% of people aged over 65
favoured birdsong, similar to the mean age of the CT ward demographic. Yang & Kang
(2005) suggest this is because as people grow older their sound preferences become
shaped by experience and the older people are the more emotion people have with the
sound environment. Yang & Kang (2005) cite (Porteous, 1996) that a soundscape is an
emotive environment not an intellectual one. Natural sound should therefore elicit a
more positive emotional response when mixed with the CT soundscape.
Guastavino (2006) used a questionnaire to investigate the sound quality of two
urban French cities. Psycholinguistic analysis of verbal descriptions showed that
positive expressions were used to describe human and natural sounds. Sounds indicating
the presence of natural elements (wind, water and natural elements) were always
appreciated, in agreement with the biophilia hypothesis – the attraction towards nature
hypothesis (Guastavino, 2006). Moreover, quiet, relaxing and tranquil environments
cannot be simply reduced to an absence of noise (Guastavino, 2006). Therefore,
providing a positive sound in a soundscape perceived as ‘noise’ should facilitate this
concept. Furthermore, gentle background music and the sounds of nature such as
waterfalls or streams, just the sound of water or birdsong, can have a very positive effect
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6.1.3. Steady state sound (SSS)
Masking sounds is potentially a way in which negative sound can be controlled
and can be defined as the presence of one sound that renders another sound undetectable
(Plack, 2005, p, 245). Loewen & Suedfeld (1992) tested the effect of masked and
unmasked office noise on arousal, stress and cognitive performance on 15 students.
Although the small sample, the notions presented in the paper are useful. Three
conditions included; office noise (at 54dB(A) and 60-66dB(A)), masked office noise
59dB(A), and no extraneous noise. The authors suggest that noise produces a decrease
in task performance, however the Yerkes-Dodson law predicts curvilinear association
between performance and arousal and suggest noise follows this. Therefore, masking
should lead to improvements, that is, the absence of sound has a detrimental impact on
performance. Loewen & Suedfeld (1992) speculated that the sound of an ocean would
not have the same effect on arousal and mood as an identical dB increase in traffic
noise. The results were captured through a number completion task, topic completion
task, Russell Mood Scale and emotional stressor questionnaire. Masked noise which was
louder than unmasked led to the highest ratings of arousal, but did not contribute to
distraction or stress and recorded the best performance on the cognitive task. They
suggest that masking qualities can be beneficial, even if it does increase ambient sound
level in general. Pertinently, presence of disruptive noise may benefit from the provision
of white noise masking and may lead to lower stress levels and distraction (Loewen &
Suedfeld, 1992). Despite the fact the white noise intervention did not significantly affect
pleasantness, masking may be beneficial to the CT soundscape, even if the ambient
Saeki et al., (2004) focused on masking speech with meaningless steady state
sound. Results showed this to be most effective noise for masking speech in the case of
speech. With lower sound levels, the SPL of meaningless steady state noise needs to be
higher. Both these examples support that steady state sound could manipulate the
emotional response to the soundscape in a positive way especially as human sounds are
a prominent source.
6.1.4. Sound source information (SSI)
The most novel intervention was information, derived from the interpretation of
the interview data. As discussed in detail in Chapter 4, this potentially assisted in coping
methods of accepting and habituating to the soundscape. Topf (2000) suggests personal
control is the capacity to regulate stress with a negative event, which may be
behavioural, decisional, cognitive-behavioural and pertinent here, cognitive (having
information about the stressor, reframing from the stressor, thinking about something
else). As such, it is postulated that information can facilitate this sense of personal
control. Indeed, Griffin et al., (1998) commented on the stress parents’ face in having a
child in a neonatal intensive care unit remarking because the environment is stressful,
parents should verbalise concern and, for example, nurses should clarify when alarms
are false or are unanswered. From a soundscape perspective, Axelsson et al., (2010)
state that the informational components are a substantial contributor to soundscape
perception, thus highlighting the importance to the individual of understanding the
sound environment.
Baum et al., (1981) suggest that having accurate information of what one may
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concept when considering exposure to the CT soundscape. In a sense this is emotion
focused coping (Folkman & Lazarus, 1993, Folkman, 2008). Baum et al., (1981) suggest
possible interventions utilising information include providing people with accurate
descriptions of what will happen or what they might feel or by giving them coping
strategies. For example, knowing what one may feel during a medical examination
should reduce uncertainty when symptoms are actually experienced (Baum et al., 1981).
This theory can be applied in the context of the hospital soundscape and theoretically
this should facilitate appraisal of the situation as non-threatening thus improve the
emotional-cognitive response.
There are two possible types of information. Internally focused information is
more appropriate in medical situations (for example, pain) whereas externally focused
information is effective in crowd control and noisy situations (Baum et al., 1981).
Investigating this, the authors carried out an experiment to look at the mediating
influence of information and familiarity with stressful situations. Using a crowded
situation, 12 students participants carried out tasks to find 24 items within a bookstore.
Subjects were spilt and given different information; what might happen (situational
information), emotional information, sensory based information (feel uncomfortable-
anxious, et cetera) and positive information.
The authors found familiarity effects the usefulness of information. Situational
information was more effective in reducing stress than sensory when subjects were
unfamiliar with their surroundings but familiar subjects benefitted equally. Baum et al.,
function of how well it addresses the concerns of the people in the setting. Therefore
information needs to fit the experiences of the individual.
This suggests that when patients enter the hospital ward at first it is novel.
Situational information may therefore be effective in facilitating habituating and implicit
learning to the sounds. Thus, as understanding grows the individuals’ emotional
response to the soundscape may develop more strongly as positive, via accepting.
Baum et al., (1981) cite Fuller et al., (1978) who found that routine pelvic and
breast examinations remain unpleasant after multiple experiences yet information about
the sensory aspects of the examination was associated with a reduction in distress
because information was more specific and therefore offered control. Even redundant
information can serve as a reassuring function and address the concerns that are not as
salient as others (Baum et al., 1981). Therefore, providing information that may be
obvious may be a way in creating a positive perception of a hospital soundscape. Baum
et al., (1981) acknowledges that these findings may be more uncertainty in medical
situations, something that can be considered here.
Concurring, Topf (2000) suggests that information, regarding ones condition,
can make a patient feel less stressed within the hospital environment. This is supported
by Williams & Irurita (2004) who describes a level of knowing referring to the level of
information a patient has concerning a situation or environment. The authors suggest
that patients experience feelings of reduced personal control and feeling of emotional
discomfort when experiencing a lack of relevant information within a hospital
environment. Here, Williams & Irurita (2004) are referring to information on the
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patients need the right level of information and it has been found that anxiety of patients
increases when they are provided with too many technical details. Therefore, colloquial
language to describe the soundscape was needed to provide sufficient sound source
information to individuals but not concern them
Based on this and the research by Baum et al., (1981) information was
situational, for example, detailing sound sources and associated causes, to feed the
implicit learning and therefore, habituation. Due to the complexity of sources and the
different sounds that occur it would not be possible to suggest what the sounds mean
and this could possibly increase anxiety. More broadly, understanding if this can create
a positive perception of the soundscape may also show the importance of understanding
the hospital environment, particularly for patients and visitors, in making them feel at
ease.
6.1.5. Music
Music was not used as an intervention despite its use within healthcare, often
relating the music therapy. Biley (2000) conducted a literature review focusing on using
music as a nursing intervention which led the author to conclude that the research shows
positive physiological changes meaning more confidence is placed in the psychological
value of music. Likewise, other studies have suggested the benefit music has in the
psychological wellbeing of patients (Thorgaard et al., 2004; Thorgaard et al., 2005).
Music has also been used to relax staff during the surgery although Liu & Tan (2000)
point out that this is controversial, as musical tastes differ among patients, staff, and
Importantly, music is not part of the existing soundscape whereas natural sounds
are already present to a certain degree within the environment, for example, the sound of
birds. For this reason exploring the promotion of these sounds was more relevant as they
are present within the ward soundscape, thus maintaining the context relationship of
soundscape perception. The interview data suggested that music may be met with mixed
responses as some patients suggested that it would be intrusive, concurring with Liu &
Tan (2000).
6.2. STUDY C1: SOUNDSCAPE INTERVENTIONS USING LISTENING