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The Impact of Daylighting in Hospital Architecture and its Effect on the Efficiency and Productivity of Staff Workers

Talal Osama Bader 160733268 ARC3060 Dissertation Studies Year: 2019-2020 BA Architecture

A C K N O W L E D G E M E N T S

First of all, I would like to thank my family for all the love and support they have blessed me with. You guys have always been there for me in my ups and downs and pushed me to do my best in life and achieve my goals. I really would like to thank the American Mission Hospital group for providing me with the opportunity to undertake this dissertation project with all the information and access I needed.

I owe sincere thanks to my dissertation tutor, Neveen Hamza, that helped and guided me throughout the journey towards this final paper. Your energy to always have the time and effort to help me improve the dissertation research was remarkable, and without it, I wouldn’t achieve this final output. Finally, To all my friends and colleagues that were also in this journey with me, thank you so much for making me enjoy the process and show me nothing but positivity and love!

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While the provision of windows in hospital patient rooms is regulated by code in most countries, daylight design in staff rooms is overlooked and often results in healthcare professionals spending the majority of their working hours in artificially lit spaces. The absence of daylight exposure plays a major role in staff behavior, efficiency, and work quality, and it may also contribute to medical error.

This dissertation aims to investigate the impact of daylight design on hospital staff performance through the case-of two hospitals in Bahrain, a country where investment in medical care and, surprisingly, medical error are both on the rise.

The study interlinks primary and secondary research on daylighting and staff performance through quantitative, qualitative and ethnographic methods.

For quantitative data, daylight LUX levels were measured in specific medical staff rooms along with window configurations to determine the quality of window design and illuminance. Qualitative research consisted of survey data from medical staff collected by questionnaire, interviews with medical staff, and observations of staff circulation in the case study hospitals.

Research and case-study analysis show that daylighting was the most important factor contributing to staff comfort and that it has a significant impact on the mental and physical well-being for medical staff members. The results show a correlation between daylighting and staff performance, and, proves that the lack of window design and daylight implementation in staff rooms may negatively affect staff efficiency and performance. Several design suggestions are proposed using VELUX software to enhance the quality of daylight in both hospitals and to expand general knowledge for hospital daylighting design.

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Table of Contents

Abstract 7 Introduction

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Methodology

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4) Post-Occupancy Evaluation

5) Introduction to Case study

Literature Review: 1) Setting the Scene of Hospitalization in Bahrain

1.1 - Population and Geography of Bahrain 1.2 - Medical Care in Bahrain 1.3 - History of American Mission Hospital and its Architecture

4.1 – Purpose-Built Hospital Architecture 4.2 - Improvements and Benefits for Hospitalization

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6.1 - Lux Reading Analysis 6.2 - Window Design Configuration Analysis

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6) Daylight Design Analysis 15 15 16

2) Daylighting Design in Hospital Architecture

2.1 - Daylighting Implementation in Hospital Architecture 19

2.2 – Building Form and Orientation 20

2.3 – Window Design Configuration 22

2.3.1 – Window Size 22

2.3.2 – Window Shape 24

2.3.3 – Window Pattern 24

2.3.4 – Window Position 24

2.4 – Hospital Shading Systems Design

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7) Study of Staff Perception & Behaviour

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7.1 - Staff Movement Study 7.2 - Staff Interviews 7.3 - Questionnaire Study

8) Design Suggestions

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9) Conclusion and Recommendations

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2.5 - Artificial Lighting vs. Natural Daylight. 28

3) Daylighting Effects on Human Health

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3.1 - Physiological & Psychological Impacts on Human Behaviour 31 3.2 - Daylighting Effects on Staff Efficiency and Productivity 32 3.3 – Staff Perception in Work Environment 33

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“L

ight is of decisive importance in experiencing architecture. The same room can be made to give very different spatial impressions by the simple expedient of changing the size and location of its openings.” - Steen Eiler Rasmussen

Introduction

Hospitals are among the most complex buildings to design, both in terms of their programmatic needs and code requirements. Underlying that complexity, however, should always be a simple goal: to create a therapeutic atmosphere that promotes patient care and the ability of medical staff to work well. Environmental controls constitute the most important factors at a designer’s disposal when trying to achieve such an atmosphere, and daylighting is foremost among them (Boubekri, 2014, p.2). Daylight plays a major role in the quality of an occupant’s health, visual perception, and their psychological and physiological state in all environments, especially indoors. (Schweitzer, et al., 2004, p. 75) It is also an age-old architectural element that is used as a language of communication and source of interpreting space through revealing its form, texture and colour. (Baker & Steemers, 2002, p. 4) Rapid early-twentieth-century developments in building technology such as electric air-conditioning and fluorescent

lighting enabled architects to design deeper buildings without the use of daylight.

(Baker, et al., 1993, p. 1) Artificial lighting can cause extreme negative impacts on a building’s occupants including high stress levels, depression, and exhaustion—all health problems associated with Sick Building Syndrome. (Tregenza & Wilson, 2011, p.

6) Moreover, the reliance of modern buildings on artificial light is compounded by the fact that people now spend more than 80% of their time indoors. (Boubekri, 2008, p. 7) While the provision of windows in hospital patient rooms is regulated by code in most countries, daylight design in staff rooms is overlooked and often results in healthcare professionals spending the majority of their working hours in artificially lit spaces. The absence of daylight exposure plays a major role in staff behavior, efficiency, and work quality, and it may also contribute to medical error (Guenther & Vittori, 2013, p. 352).

This dissertation aims to investigate the impact of daylight design on the productivity and efficiency of hospital staff workers through qualitative and quantitative analysis of a refurbished and newer purpose-built hospital in Bahrain, a country where investment in medical care and medical error are both on the rise. (fig.1) It provides an analysis of the amount of daylight and quality of illuminance in staff 11

rooms according to lux measurement-taking and window design configuration. It also studies the physical and psychological effects of daylighting on staff behaviour and performance. The research topic was chosen to stir the public focus on creating a healing therapeutic environments for the medical staff as they work on demanding and visually sensitive tasks that keep themselves, patients, and the public safe.

M e t h o d o l o g y An observational case study has been conducted in two American Mission Hospital branches located in Bahrain, within an arid climate.

Both primary and secondary research are interlinked using quantitative and qualitative research methods. For the quantitative data, daylight LUX levels were measured in specific medical staff rooms and the study of window configurations determining the quality of window design and illuminance entering through the spaces.

A structured system questionnaire was designed and given to the medical staff members, including on nurses and doctors. The questionnaire consists of questions driven from the literature review about the behavioral aspect of daylighting, as well as other environmental and spatial factors that 12

are corelated to the impact of daylighting.

Qualitative open-ended interviews were conducted with medical staff, to understand the significance of daylight and its relationship to enhancing work patterns and practices. An ethnographic method was conducted as an observational study of staff movement and circulation in hospital spaces to understand the relationship between the staff and their time-duration and amount of exposure to daylight in staff areas.

Design suggestions were conducted using a daylighting visualizer software (VELUX) to enhance the quality of daylight for occupants in current hospital buildings and also future buildings with similar functions.

Aim

Research Objectives

To measure the amount of daylight and analyze window design configurations to determine the quality of daylight in staff spaces.

To understand the effect of daylighting on the physical and psychological state of staff behavior.

To investigate the impact of daylight on the productivity and efficiency of hospital staff

To analyze the relationship between staff movement and their exposure to daylight in staff areas.

To develop software simulated design suggestions to enhance daylight quality and exposure of staff room

To establish qualitative and quantitate studies to understand different perceptions of staff members in their individual workspaces in relation to daylight.

Figure 1 - Research Aim and Objectives

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1.1.

Population and Geography of Bahrain

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Literature Review:

Setting the Scene of Hospitalization in Bahrain

Bahrain, also known as the “Pearl of the Persian Gulf,” is an archipelago of 40 islands located in the Western shores of the Arabian Gulf. The population of Bahrain is 1.64 million people, and about 80% of the population lives on the main island, where the capital, Manama, is located (Fig.2). It has a dense urban population, ranking as the 7th most densely populated country in the world (Bahrain.bh, 2019).

Bahrain is located on a desert plain with an arid climate of hot summers with midday average temperatures of 38-45°C, mild winters with midday average temperatures of 16-21°C, and rainfall only reaching 80mm per year (ClimatestoTravel, 2019).

1.2.

Medical Care in Bahrain Healthcare has become one of Bahrain’s major priorities. Governmental-led initiatives like “Health for All” in the early 1990s have made comprehensive health services available to all citizens and residents (moh.gov, 2018). According to the Health Improvement Strategy of Bahrain (20152018), 8,000 cases were served daily by primary healthcare, implying that the Ministry of Health provides approximately 25% of its services to the kingdom’s population (moh. gov, 2018, p. 6). The number of healthcare facilities and registered healthcare professionals has increased significantly in the past 7 years, and the World Health Organization estimates that the healthcare market has grown from an estimated 1.1 billion dollars in 2015 to 2 billion dollars in 2020, which more than tripled the average

Figure 2 - Bahrain Map

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medical care to inhabitant ratio from 0.92 to 2.8 per 1000 people (Export.gov, 2019).

Alongside such growth and investment in Bahrain’s hospitals there has been a concerning trend: medical error is now the most common cause of death after car accidents and chronic diseases. According to the National Health Regulatory Authority, 42 severe medical errors have been spotted in 2018 alone. (NHRA, 2018).

It suggests that Bahrain’s overall healthcare industry is improving quantitatively rather than qualitatively. The president of the Bahrain Medical Society, Mohammed Rafie, has called for improving health institutions and hospitals and for ensuring better designed working environments (Gulf Daily News, 2017). In light of this disturbing trend in medical error, the relationship between design of hospitals environments and medical staff performance warrants further investigation.

1.3 History of American Mission Hospital and its Architecture The American Mission Hospital in Manama was the first modern hospital established in the Arabian Gulf region, and it was founded in 1903 by American Missionaries James Cantine and Samuel Zwermer (Fig.3) (AMH, 2019). After the hospitals grand opening in 16

1903, it treated the citizens of Bahrain but also attracted visitors from the greater region, treating approximately 100 patients daily in 1924 (Fig.4) (Clarke, 1993, pp. 32,65).

The main materials used for the construction of the building were stone from a semi-coral formation broken out of the sea and limestone mixed with cement. The roof and staircases of the building were made of mud because of its cooling properties in the hot climate. Verandas, 3.5 metres wide, enveloped the building with sunshades on the eastern and western elevations (Clarke, 1993, pp. 32,65). Abdulmajeed, the current head of the engineering department, stated that “until this present day, we are maintaining the building’s structure as the sea salt inside the walls is coming through the plaster and pushing the paint out and we are also trying to straighten any curvy old wall, as it was built handmade.” In the 1950s, the hospital’s reputation declined due to a lack of financial support. The interiors were poorly maintained, and the exterior looked more like a warehouse than a prestigious medical center (Fig.5). The hospital underwent a major refurbishment in 1983 by the architects John Counsell and Nick Devenny to enhance the patient wards, remodel the building interiors, and uplift the façade (Fig.6) (Clarke, 1993, pp. 32,65).

Throughout the 2000s, three additional purpose-built hospitals have been con-

structed under the American Mission brand, including the Saar town branch analyzed below, to serve the country and take the load off the main iconic headquarters (Clarke, 1993, pp. 220,243).

Figure 3 - James Cantine (left-side) and Samuel Zwemer (right-side)

Figure 4 - Ward Room at the Hospital in 1907

Figure 5 - ‘Warehouse’ Façade Appearance in 1970s

Figure 6 - New Hospital Extension and Refurbishment Concept of Architects

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2.1 Daylighting Implementation in Hospital Architecture

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Daylighting Design in Hospital Architecture

The manipulation and appreciation of light is a key aspect of architectural design.

Daylighting provides functionality, safety, and dynamism through illumination and warmth (Ander, 2003, p. 23). Ralph Hopkinson once stated in his book The Ergonomics of Lighting that “vision is the primary sense through which we experience architecture, and light is the medium that reveals space, form, texture and colour to our eyes.” In hospital architecture, it is vital to create a healing environment with appropriate physical characteristics for often uncomfortable or anxious patients (Ulrich, 1997, p. 97).

It has been argued that the physical environment of hospitals is the primary element that impacts staff well-being, as it can foster the reduction of environmental stressors through connection to nature, access to positive distraction, increase of social support, and control over physical-social surroundings (Lyendo, et al., 2016, p. 175). With a strategic implementation of daylighting in hospital design, these factors can be achieved.

Daylighting design in hospital architecture was pioneered by Florence Nightingale, “the mother of modern-nursing,” who created a humanist architectural approach

that influenced 19th century hospital design (Burpee, 2008, p. 1). Her approach incorporated strategically placed windows at regular intervals to provide patients with adequate daylighting and views as well as circulation of fresh air between blocks for cross-ventilation (Figs.7-8).

Nightingale’s ward concept advocated the pavilion system through an arrangement of separate ward units, and she specified that one large window providing direct sunlight and fresh air should be provided for every two beds (Fig.9-10) (Nightingale, 1888). Nightingale’s influence on hospital design was recognized and used for over a hundred years (Richardson, 2010).

Daylighting, as a structuring element in hospital design, is important as it accentuates and enhances the perception of occupant space, path selection, spatial comprehension, and occupant wayfinding.

It also provides a sense of openness and spaciousness in rooms through its colour rendering and light penetration properties (Boubekri, 2008, p. 96). Health-facility architects consider hospital design to be a complex task and are required to follow numerous specialized requirements and regulations. With so many explicit require-

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ments, architects tend to pay less attention to the main aim of creating a healing environment. For instance, it has been documented that daylight is not commonly prioritized for staff rooms in modern hospitals (Schweitzer, et al., 2004, p. 10). This has a harmful effect on not only staff members, but also the patients they are treating. In order to create or maintain a pleasant and sustainable hospital environment, an architect must meet the various illuminance requirements demanded for each therapeutic area. The nursing and clinical staff have duties that include clinical examinations, dressing wounds, and other basic tasks, which require specified light levels for safe and accurate performance (Ralph, 2019, p.

8). There are optimum lighting conditions for staff performance and one aim of hospital design is to provide them for occupant safety. Medical staff do not perform opti-

per unit area (Roy, 2019). Hospital rooms have different LUX requirements depending on the activity taking place. However, the most ideal specification is around 500800 LUX for clinical areas—any area where a patient is treated privately by medical staff. These include consultation rooms, treatment rooms, and ward units where observation of the patient’s skin, eyes, or tissue colour is highly significant (Ralph, 2019). LUX levels in that range provide adequate levels of lighting for staff to efficiently and comfortably perform their tasks.

mally under unwanted, uncontrolled, or inadequate light (Hopkinson, 1970, p. 17).

Lighting preferences are subjective and vary with age, gender, and the time of the year. However, the older the building occupant and more intricate the activity is, the more lighting is needed; hence, providing sufficient daylight spaces until evening time is important (The European Commission , 1994, p. 1). Daylight in spaces is measured using a unit called LUX, the amount of luminous flux (perceived light)

healing environment (fig.11) (Tregenza & Wilson, 2011, p. 22). Hence, it also has has a major impact on the experience of staff and patients (Phillips, 2000, p. 27).

The amount of daylight a building receives varies based on geographic location, the form of the building, and its immediate surroundings (i.e. reflectivity and obstruction of adjacent buildings) (The European Commission , 1994, p. 2). As opposed to environments with overcast skies, clear and sunny places require more complex build-

2.2.

Building Form & Orientation

Figure 7 - Section Drawing of Nightingale Ward Window and Spatial Layout Design

Figure 8 - Nightingale Ward Plan Drawing (St.Thomas Hospital)

Building orientation influences the design of windows and shading devices, as it shapes views and daylighting, which are crucial qualities of a

Figure 9 - Internal render of Nightingale window, ventilation and daylighting strategy.

Figure 10 - External render showing cross-wind ventilation strategy of Nightingale pavilion hospital.

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ing envelope design because the sun angle substantially varies throughout the day and year (Baker & Steemers, 2002, p. 45). For example, Bahrain’s azimuth sun position is situated at 255.05°, meaning Bahrain receives high sun angles throughout most of the year (Figs.12-13) (Hoffmann, 2019).

Building form is also important, especially since buildings with deeper plans—like hospitals—have limited daylight possibilities, which can affect staff members working in the interior for lengthy periods of time (Robinson & Selkowitz , 2013, p. 21).

2.3.

Window Design Configuration In addition to sky conditions, factors that influence the quality, spread, and depth of daylight in a building’s interiors in-

Figure 11- Building Orientation and Sun Solstice

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cludes window size, shape, position, pattern, and view (Baker & Steemers, 2002, p. 63). Common issues in side-lit spaces in work environments are that daylight distribution is not uniform across space.

Window design configuration is primarily concerned with creating an appropriate luminous environment on a horizontal work-plane (Razon, 2017, p. 3).

2.3.1 - Window Size

Figure 12- Azimuth Angle and Sun Position of Bahrain

As a rule of thumb, a room can be adequately daylit for a depth equal to twice the floor to the top of the window opening height (Fig.14) (Baker & Steemers, 2002, p. 64). However, window size also influences thermal comfort, shading effectiveness, and glare in adjacent areas, meaning larger windows require more control. The appropriate window size should be based on the required internal illuminance of the

Figure 13 - Sun Direction of Manama Branch (top) and Saar Branch (bottom) site plan.

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natural cross-ventilation and improving room atmosphere (CIBSE, 2014, p. 43).

Figure 14: Window Size Rule of Thumb

particular activity the staff is undertaking (Robinson & Selkowitz , 2013, p. 18).

2.3.2 - Window Shape Window shapes mainly affect the depth of daylight in rooms. Tall windows provide the deepest daylight penetration; however, they are more likely to create potentially discomforting shadow patches throughout spaces. Horizontal shapes in large spaces and square shapes in small spaces are seen to be the easiest way to provide efficient anti-glare daylighting with a more even

Figure 15: Illumination Contours of One and Two Windows in a Room

light distribution than vertically shaped windows (Vogiatzi, et al., 2000, p. 11).

and providing occupants with a view of the horizon and foreground (Vogiatzi, et al., 2000, p. 11). However, it is essential to consider the proximity and direction of furniture layout and placement within a room in relation to the window position as the occupants’ activities may be affected by shadows, heavy contrasts, and glare (fig.16-17) (Robinson & Selkowitz , 2013, p. 24). The placement of views should be carefully considered, as research states that staff members prefer views with

2.3.3 - Window Pattern Window patterns offer advantages such as the improvement of the uniformity of daylighting by increasing the area of sky visible from deprived areas (Fig.15) (Boubekri, 2008, p. 113). Patterns can also greatly reduce glare by increasing the luminance of daylight surrounding the window. Lastly, they can affect staff comfort by providing 24

Figure 16 - Optimum Layout Arrangement in Relation to Window Views

2.3.4 - Window Position

Window position affects a room’s daylight illumination and distribution. Glazing located high in the wall is most efficient at letting in daylight into deeper parts of the plan. The optimum location of windows is the center of the wall, improving the overall illumination of the workplace

Figure 17 - Types of Glare and their Effects.

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changing activities that capture interest instead of a static view. (Ulrich, 2001, p.52).

2.4.

Hospital Shading Systems Design Windows suffer from unwanted solar heat gain, glare, and harsh daylight contrasts, which affect staff morale and productivity (Baker & Steemers, 2002, p. 109). Solar shading aims to provide solutions to these issues without reducing daylight. The most commonly used shading systems are overhangs, louvres, light shelves, solar films, and blinds. Solar shading is a highly sustainable and cost-effective solution as comfort can be accomplished at zero cooling energy consumption, cutting daytime light and cooling costs ( Mandalaki & Tsoutsos, 2019, p. 8). It is common on a sunny day in staff rooms to see the blinds completely drawn and artificial lights turned on because of lack of attention to daylight design.

Overhangs obstruct sun angles, and are appropriate for South facing façades. They can be attached to existing façades and do not hinder windows or exterior views (Fig.18) (Baker & Steemers, 2002, p. 114).

Light shelves divide windows into a lower part that serves as a viewpoint for occupants and an upper part that redi26

rects daylight deeper into a room. A lightshelf works best in sunlight conditions as it provides shade while reducing glare (Fig.19) ( Kontadakis , et al., 2017, p. 24).

In temperate climates, solar films, known as tinted screens, can be used to lower daylight intensity in rooms. However, solar films may not be functional, especially disregarding orientation, as they may reduce useful visible daylight transmittance and make a room look gloomy (BRE, 2015, p. 29).

Louvres provide a flexible shading system that can be used externally or internally in different arrangements. Louvres are designed to block unwanted glare and redirect daylight deeper into the building.

Horizontal louvres are an effective method for blocking high summer angles in southern facades, while vertical louvres are advantageous in east and west façades (Fig.20) (Gherri, 2015, p. 69). Louvres can be fixed or movable depending on daylight levels. Shading devices will not perform ideally if placed internally because of absorbed radiation (Ander, 2003, p. 10).

However, internal shading raises the topic of occupant control. Research states that control over lighting environment can boost staff performance up to 30-40% by providing freedom of people’s control over

their own space (Baker & Steemers, 2002, p. 122). Hospital staff spend most of their time indoors, where they have little choice of choosing where they can work. Some job requirements have varying environmental preferences that could not be permitted, such as daylighting (Chaudhury, 2007, p.

9). Therefore, providing spaces with internal shutters and blinds could enable people to tolerate a wider range of environmental conditions, at least temporarily, with different comfort relations between individuals and work requirements. For instance, some people may want sunlight present the entire day and others may think it hinders their job performance, so occupant control offers a solution for both parties.

Figure 18 - Overhang Shading Device

Figure 20 - Vertical and Horizontal External Louvres

Figure 19 - Lightshelf Shading Device

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2.5.

Daylight vs. Artificial Light Despite the design conflicts, differences and characteristics between artificial lighting and daylighting in hospital architecture, both are always working together and contributing to a given scheme (fig.21) (Tregenza & Wilson, 2011, p. 94). In hospital buildings, daylighting should be the main source of illuminance from morning time until sunset. If artificial light is to be used, it should only supplement daylight by maintaining the required task illuminance of contrasted and unlit spaces (CIBSE, 2014, p. 60).

Modern light-emitting diodes (LEDs) can closely mimic the distribution and light exposure of daylight ( Mottier, 2010, p. 233).

It has been argued that the role of artificial light is greater in hospital architecture because it makes it easier for designers to specify lighting in deeper plans and reduce risk in the design stage. Providing electric lighting in hospital spaces has an advantage over daylighting because it gives designers the ability to adjust and calibrate the angle, intensity, movement, and distribution of light in hospital spaces. Studies have reported that the tolerance of visual discomfort tends to be higher from daylighting exposure and glare than from electric lighting (Boubekri, 2008, p. 101).

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However, daylight contains all of the wavelengths of the visible spectrum and provides the best colour rendering of any type of light, which improves medical staff’s ability to observe intricate details (Chaudhury, 2007, p. 31). Unlike artificial lighting’s static properties, daylight modulates and changes over the course of a day adding a sense of openness, spaciousness, and orientation in spaces. It also comforts hospital occupants in stressful environments (Phillips, 2000, p. 25). This factor plays a major role in the psychological and physiological state of staff in therapeutic environments.

Figure 21 - Corelation Between Daylight and Electric Light

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3.1.

Physiological & Psychological Impacts on Human Behavior

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Daylighting Effects on Human Health

Daylighting in architecture is more than just the implementation of generic standards and light levels for different spaces; it is also an important factor that affects the psychological and physiological health of occupants. Campbell et al. (1988) has stated that light is the most important environmental input in the human body after food. Numerous studies show that daylight has numerous effects on the mind and body including regulation of sleep-wake rhythms, increased task visibility and productivity, and reduced depression, irritability, and exhaustion. These behavioral factors are affected through neuro-hormonal changes such as the secretion of melatonin, a hormone that is the main stimu-

synchronized with daylight (Fig.22). If circadian rhythms do not match workday rhythms—common among healthcare staff—workers may start to feel exhausted, unproductive, and/or drowsy. For example, circadian rhythms keep most people awake and alert during the day and sleepy at night, which can result in fatigue and even complete inability to perform tasks during night shifts. This is caused by the photic energy in the human retina that directs circadian rhythms, causing decreased blood pressure and decreased heartrate (Tregenza & Wilson, 2011, p. 6).

Another important factor affected by daylighting is human mood. An individual’s mood is altered and revitalized in relation to neuroendocrine changes, such as changes in melatonin, serotonin, and dopamine linked to light intensity and

lus of alertness and sleepiness. Research color temperature (Boubekri, 2008, p. 93). has shown that sunlight’s ultraviolet rays affect human health by increasing protein metabolism, stimulating white blood cell production, and increasing the release of endorphins, which promote emotional well-being (Lyendo, et al., 2016, p. 178).

One of the most important effects of daylighting on human behavior is its relationship to the circadian system, which is an internal 24-hour biological clock that is

Figure 22 - Circadian Rhythm

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Daylight has been found to be a more sufficient form of environmental lighting than artificial lighting in enhancing task alertness and cognitive performance. It provides high-intensity blue light at 400-500nm in the morning, then smoothly transitions to orange light at 600-700nm at sunset with minimal blue light intensity. These light wavelengths positively correspond to the 460-500nm of an effective circadian response. Moreover, occupants will be stuck in “biological darkness,” when exposed to artificial light for long periods, which is not appropriate for the human body’s natural state (Alimoglu & Donmez, 2004, p. 550).

3.2.

Daylighting Effects on Staff Efficiency and Productivity The optimization of the physical environmental conditions of hospital spaces, specifically staff rooms, is the key element to providing an alert, productive, and high-performing workforce . A strategic environmental design consisting of restorative qualities that are supportive of sensitive tasks could help healthcare professionals work more effectively. On the contrary, working environments that are dark, tedious, and monotone with no attention to help healthcare professionals achieve their peak state of alertness and performance can 32

cause staff members to struggle with staying awake and productive (Joseph, 2006, p. 3). Because patient rooms are regulated by code in most countries, attention toward window placement and design in staff rooms is overlooked and results in healthcare professionals spending the majority of their working days in artificially lit spaces.

This absence of sunlight exposure plays a major role in their behavioral state and task alertness (Guenther & Vittori, 2013, p. 352).

healthcare professionals impacts both the quality of care delivered to patients and the personal lives of workers themselves (Alimoglu & Donmez, 2004, p. 449).

al., 2016, p. 175). These psychological factors underline the importance of daylighting and the need for better and more widespread implementation in hospital spaces.

3.3.

Staff Perception in Work Environment

It has been estimated that 44,000 Americans die in hospitals due to preventable medical errors each year, which is among the leading causes of death above AIDS, breast cancer, and automobile accidents.

The Institute of Medicine stated in its landmark quality report that “the frustration levels of both patients and clinicians have probably never been higher. Yet the prob-

Daylighting may arguably be the most important environmental factor affecting healthcare professionals because it impacts thermal comfort and ventilation in addition to lighting conditions. Among all the environmental factors that improve staff perception of the quality of their work life, the availability of daylight triggered the highest positive response among hospital staff members (CIBSE, 2014, p. 11).

It is evident in research that healthcare professionals working in non-stimulating windowless spaces benefit from viewing a change of external scenery, even if only for a few minutes. There is strong evidence that even three to five minute encounters with

lems remain. Healthcare today harms too frequently and routinely fails to deliver its potential benefits” (Ulrich, 2004, p. 2).

Poorly designed staff spaces within hospitals are physically and psychologically intense and can add to staff stress, errors, and burnouts.

According to Herbert Freudenberger, burnout is “known to be a prolonged psychological response to chronic emotional and interpersonal stressors on the job, and is a common problem in caregiving and medical treatment.” Burnout among

nature settings can significantly help staff members recover from stress ( Zadeh & Shepley, 2014, p. 37). Viewing a stimulating change of scenery can prevent emotions of fear or stress among caregivers while increasing positive feelings, which cause quick responses in blood pressure and heart activity. Ulrich found that patients that are recovering from surgery recovered faster, had a more positive well-being, and less pain medication costs if they had bedside windows with a view of nature (Lyendo, et

der, and health state—and homeostatic response—which is the universal response to universal environment stimuli such as deficiencies of thermal comfort, air quality, lighting, and water (Lowenthal, 1967, pp. 42-43).

In the same built environment, all occupants may have varying perceptions.

As such, work performance varies among individuals in a given environment (Tuan, 1974, p. 5). For example, several staff members may have eye defects that prevent them from experiencing the full

Attitude and perception shape each individual’s experience of their surroundings, allowing them to visualize the world in their own distinctive ways. Perception influences one’s reactions, cognition, judgements, preferences, and affective responses ( Ward, et al., 2010, p. 73).

Perception is measured with two main factors: adaptation levels—which is based on an individual’s complex environment, past experiences, culture, personality, age, gen-

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range of colours that most people see, which will affect the way they work and perceive certain spaces ( Blake & Sekuler , 2005, p. 5). Further, age plays an important role, as vision and hearing levels among elderly people is weaker than younger individuals. Moreover, depending upon a person’s cultural background, they might find a room very hot and want to open a window at a time when another wants to put on a coat (Tuan, 1974, p. 5).

This proves that occupant perception affects job requirements and constraints, as well as environmental control. Daylighting may be designed to take advantage of these conscious and subconscious processes among hospital staff in order to influence emotions, decision making, and cooperation.

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04

Post Occupancy Evaluation

4.1.

Purpose-Built Hospital Architecture Post-Occupancy Evaluation (POE) is the process of assessing a building’s performance by comparing and understanding its design objectives and how it meets the needs of building occupants to gain foresight for future designs (RIBA, 2016). The goal of POE, also known as evidence-based design, is to integrate cultural diversity as well as psychological and social considerations in building design. POE provides useful evidence about the positive and negative aspects of older buildings from occupants’ perspectives, illuminating what works and what does not in terms of design and building performance (Hadjri & Crozier, 2009, p. 27).

4.2.

Improvements and Benefits for Hospitalization POE provides a method to rethink hospital design by improving spaces that reduce staff and patient stress and fatigue, increase productivity in delivering care, and improve overall healthcare quality outcomes. These elements can be achieved by emphasizing strategic opportunities to influence the design of healthcare facilities and tailor work environments ac36

cordingly (Phillips & Meilink, 2013, p. 4).

POE’s are conducted by systematic questionnaires to evaluate the occupant’s attitudes toward design and use, which helps to identify the problems of daylighting systems and controls alongside other factors in a given building. The evaluation is also conducted using computer-aided simulations that compare current building models with newer improved versions in order to evaluate design solutions for occupant comfort and energy savings in buildings ( Löfberg & Hygge , 1999, pp. 12,15).

Analysis: The POE method was used to design the Saar Branch American Mission and address the design issues of the older American Mission Hospital in Manama. The head of the engineering department, Abdul Majeed, said in an interview that “The main aspects we wanted to implement were an attractive façade that represents a welcoming hospital image, open-plan infrastructure, wider corridors for improved circulation, a large courtyard to implement greenery and to raise glazing to surface area ratios to bring in more natural light.“ However, the fact that the building conducted a POE, does not mean that it has solved all problems. It may have improved in certain areas and lacked complete attention to others, for example, the focus on staff areas within the hospital.

05

Introduction to Case Study

Figure 23 - Methodology Research Plan

Table: Staffroom area to hospital area ratio

MANAMA

SAAR

Total medical staff room area (m²)

1398

1536

Overall hospital area (m²)

4500

2500

1398/4500 = 0.31 (31%)

1536/2500 = 0.61 (61%)

672 519 205

382.28 408 90 (courtyard floor)

Ground floor

672/4500 = 0.15 (15%)

382.28/2500= 0.15 (15%)

First floor

519/4500 = 0.11 (11%)

408/2500 = 0.16 (16%)

205/4500 = 0.04 (4%)

90/2500 = 0.03 (3%)

Total-staffroom to hospital-building area ratio Ground floor staffroom area (m²) First floor staffroom area (m²) Second floor staffroom area (m²)

Floor-wise

provide new daylighting solutions based on research findings. To conduct a more comprehensive approach, it would be important to analyse staff situated in different environments and conditions with contrasting daylight illumination and job requirements.

Therefore, this case study analyses two well-illuminated staff rooms ranging from 500 to 800 LUX, two over-illuminated staff rooms ranging above 800 LUX, and three poor-illuminated staff rooms ranging from 0 to around 400 LUX in each hospital. These

staff rooms were carefully chosen after an onsite study of 12 different rooms across the two hospitals (shown in appendix).

staffroom area to total hospital-building area ratio

This observational case study was conducted in two American Mission Hospital buildings. (fig.23) The Manama Branch in Bahrain’s capital, which was the first modern hospital built in the Middle East, and the Saar Branch, which opened in 2016 and is located in a suburban town. Both hospitals consist of three floors and a main external courtyard. As shown in figure 24, the Manama branch’s total floor area is 2500m² with 26 treatment departments and the Saar Branch’s total floor area is 1536m² with 16 service departments.

The case study analyses LUX levels and window configurations in both hospitals and integrates information collected in questionnaires and interviews with medical staff to determine daylight conditions in staff rooms and investigate their impact on medical staff behaviour and perception.

Software simulations were then used to

Second floor

Figure 24 - Staffroom Area Ratio

38

39

American Mission Hospital, Saar Branch - Built in: 2016 - Amount of Floors: 3 floors including main courtyard - Size: 2500 m² - Climate: Arid

Figure 25

40

Figure 26

41

American Mission Hospital, Manama Branch - Established in: 1888 - Built in: 1903 - Amount of Floors: 3 floors - Size: 2700 m² + 1800 m² (New Extension) - Climate: Arid

Figure 28

42

43

Category 1 - High-Illuminated Staff Rooms (500-800 Lux)

Category 2 - Over-Illuminated Staff Rooms (800 - Above Lux)

Room A

Room C

Room Department: Dental Office Hospital: Sar Branch

Room Department: Gynaecologist Office Hospital: Sar Branch

Figure 35 Figure 31

Figure 32

Room D

Room B

Room Department: Pediatrics Office Hospital: Sar Branch

Room Department: Dental Nurse Office Hospital: Manama Branch

Figure 33

44

Figure 34

Figure 36

45

Category 3 - Low-Illuminated Staff Rooms (0-400 Lux)

Room E

Room Department: Gynaecologist Office Hospital: Manama Branch

06

Figure 37

Room F

Room Department: ENT Office Hospital: Manama Branch

46

Figure 38

Figure 39

Daylight Design Analysis

ter, and line graphs representing daylight starting at the window and ending at the farthest point in the room. Measurements were taken at 9AM, 2PM, and 5:30PM in bright sunny conditions from July to August with artificial lights switched off in staff rooms. In both hospitals, staff rooms have been grouped under three categories corresponding how daylight in the current room scheme measures against required levels.

Category 1 High-illuminated Staff Rooms

Window (1) Dental, Sar 800 700

Illumination Level (LUX)

LUX measurements of staff rooms were achieved using a standard LUX meter. The results are shown in grid plans, with daylight levels measured in every square me-

hours. Artificial lighting will be needed at sunset, as the daylight levels drop to an average of 277 LUX in the same area.

Room B is separated into two spaces by a wall, which creates different light levels in each part. The left side is provided with illumination from two windows throughout the entire day with an ideal average of 582 LUX in the task focus area where the seats are situated in (Fig.45-47); however, the right side, where nurses perform their main tasks, the daylight levels provided in this space are high enough to benefit nurses working on sensitive smaller details until sunset. However, it lacks the necessary 500 LUX level in the early morning and late afternoon with daylight levels dropping within the depth of the room yielding an average of 256 LUX (fig.48-51), requiring artificial light to be provided to the lower half of the room.

600 500 400 300 200

100 0

1

2

3

4

Distance (m) Morning Sun

Afternoon Sun

Evening Sun

Figure 43 - Window 1 Daylight Levels (Room A/Dental)

Window (2) Dental Room, Sar 800 700

Illumination Level (LUX)

6.1.

Lux Reading Analysis Background

600 500 400 300 200 100 0

1

2

3

4

Distance (m) Morning Sun

Afternoon Sun

Evening Sun

Figure 44 - Window 2 Daylight Levels (Room A/Dental)

The measurements show that the dental departments of both hospitals achieve the highest average daylight illumination of all staff rooms. In Room A, the task focus area is the dental chair, which achieves an average of 509 LUX and reaches an average of 601 LUX nearby both window areas from morning till sunset. (fig.40-42) This means that the room can be adequately lit in accordance with code regulations with daylight during daytime Figure 40 - Morning (Room A/ Dental)

48

Figure 41 - Afternoon (Room A / Dental)

Figure 42 - Sunset (Room A / Dental)

49

Window (1) Dental Nurse Office, Manama Illumination Level (LUX)

800

700 600 500 400 300 200 100 0

1

2

3

Distance (m) Morning Sunlight

Afternoon Sunlight

Evening Sunlight

Figure 48 - Window 1 Daylight Levels (Room B/Dental)

Window (2) Dental Nurse OffIce, Manama Figure 45 - Morning (Room B/Dental)

Illumination Level (LUX)

800

700 600 500 400 300 200 100 0

1

2

3

Distance (m) Morning Sunlight

Afternoon Sunlight

Evening Sunlight

Figure 49 - Window 2 Daylight Levels (Room B/Dental)

Window (3) Dental Nurse Office, Manama

Figure 46 - Afternoon (Room B/Dental)

Illumination Level (LUX)

700 600

500 400 300 200

100 0

1

2

3

4

Distance (m) Morning Sunlight

Afternoon Sunlight

Evening Sunlight

Figure 50 - Window 2 Daylight Levels (Room B/Dental)

Window (4) Dental Nurse Office, Manama Illumination (LUX)

600

500 400 300 200 100 0

1

2

3

Distance (m) Morning Sunlight

Figure 47 - Afternoon (Room B/Dental)

50

Afternoon Sunlight

Evening Sunlight

Figure 51 - Window 2 Daylight Levels (Room B/Dental)

51

Window (1) Ob/Gyn, Saar 6000

5000 4000 3000 2000

1000 0

1

2

3

4

5

Distance (m) Morning Sunlight

Afternoon Sunlight

Evening Sunlight

Figure 55 - Window 1 Daylight Levels (Room C - Ob/Gyn)

Window (2) Ob/Gyn, Saar 6000

5000 4000 3000 2000 1000 0

1

2

3

Distance (m) Figure 52 - Morning (Room C - Ob/Gyn

Morning Sunlight

Afternoon Sunlight

Evening Sunlight

Figure 56 - Window 2 Daylight Levels (Room C - Ob/Gyn)

Figure 53 - Afternoon (Room C - Ob/Gyn)

52

Illumination (LUX)

Room C and D, which are both located in the Saar Branch, are provided with daylight illuminance that exceed the lighting specification limit for required visual tasks.

This results in excessive glare, which can be addressed with better daylight design. The morning daylight levels in Room C are consistently low in the morning; however, they rise dramatically in the afternoon and sunset from an average of 118 in the morning to 653 and 548 LUX in the afternoon and sunset, respectively. (fig.52-54) Moreover, the daylight levels in the task focus area surpass 1930 LUX. The worktable is positioned right in the middle of two elevations, with the window providing uncontrolled southern light directly behind the staff and low-angle western light at sunset from the large window on the right side of the room.

This glare due to excessive direct daylight creates uncomfortable and overwhelming light conditions throughout the daytime.

In contrast, Room D provides a great amount of daylight illumination throughout the day but brings in substantial amount of glare on the table and hospital bed in the afternoon and sunset, reaching up to 4750 LUX with a total average of 2637 LUX. (fig.57-59) This could significantly affect not only the staff but also patients. It may also

encourage the staff to draw the curtains during daytime and rely on artificial light

Illumination (LUX)

Category 2 - Over-Illuminated Staff Rooms

7000

Figure 54 - Sunset (Room C - Ob/Gyn)

53

Window (1) Pediatrics, Sar Illumination (LUX)

7000

Figure 57 - Morning (Room D - Pediatrics)

6000

5000 4000 3000 2000

1000 0

1

2

3

4

5

Distance (m) Morning Sunlight

Afternoon Sunlight

Evening Sunlight

Figure 60 - Window 1 Daylight Levels (Room D / Pediatrics)

Window (2) Pediatrics, Sar

Figure 58 - Afternoon (Room D - Pediatrics)

Illumination Level (LUX)

800

700 600 500 400 300 200 100 0

1

2

3

4

Distance (m) Morning Sunlight

Afternoon Sunlight

Evening Sunlight

Figure 61 - Window 2 Daylight Levels (Room D / Pediatrics)

Figure 59 - Afternoon (Room D - Pediatrics)

54

55

In the category of staff rooms with poor daylighting, room E, located in Manama branch, will be the only one analysed as the other two rooms have no windows and therefore zero LUX from daylight .

The daylight illuminance provided in Room- E is very low compared to the specified lighting requirement. The average LUX levels do not reach 500 LUX anywhere near the worktable or treatment bed even when two windows are provided on both sides. (fig.64-66) As shown in (Figs.62-63), daylight levels drop significantly two meters from the window, averaging from 226 LUX to 40 LUX in the room throughout the day.

This means that artificial light must be used at all times from morning to sunset, which may make the staff feel isolated from the outside world and less likely to take advantage of daylight benefits in other spaces, a major architecture drawback.

It has been found that: - In category 1, both staff rooms achieve the satisfied lighting requirement within 500800 LUX throughout the entire daytime.

- In category 2, daylight levels over 1000 LUX were found in several locations of the room, meaning excessive glare was found in the room affecting staff performance.

- In category 3, daylight levels in Room E were lower than the 500 LUX requirement, meaning supplementary artificial light was needed.

Figure 64 - Morning (Room E - Ob/Gyn)

Ob/Gyn (Window 1), Manama 600

500

Illumination Level (LUX)

Category 3 - Low-illuminated Staff Rooms

400 300 200

Figure 65 - Afternoon (Room E - Ob/Gyn)

100 0

1

2

3

Distance (m) Morning Sun

Afternoon Sun

Evening Sun

Figure 62 - Window 1 Daylight Levels (Room E - Ob/Gyn)

Section Summary: Illumination Level (LUX)

In this section, the LUX levels were measured to investigate whether staff rooms in both hospitals achieve the required specifications of daylight illuminance needed for visual comfort.

Ob/Gyn Window (2), Manama 600 500 400

300 200 100

0

1

2

3

Distance (m) Morning Sun

Afternoon Sun

Evening Sun

Figure 66 - Sunset (Room E - Ob/Gyn)

Figure 63 - Window 2 Daylight Levels (Room E - Ob/Gyn)

56

57

6.2.

Window Design Configuration Analysis Background: In this section, staff rooms window configuration will be analysed to determine daylight quality using a set of criteria based on established literature, including window size, position, pattern, shape, and orientation, as well as external views.

Category 1 - High-Illuminated Staff Rooms In room A, which is situated on the first floor of the hospital, the windows are facing the north and east elevations, respectively. (fig.70) The windows are perpendicular to on another, creating a uniform and balanced daylight exposure that can greatly increase luminance while reducing glare. (fig.68-69) Each window measures 2.6m x 2m windows and occupies

the full height of the wall. Since they are positioned in the centre of the room, they provide the entire room with substantial daylight illuminance. The windows overlook greenery of the surrounding suburbs, which boosts staff satisfaction.

Room B, in the Manama Branch, is situated on the third floor facing north and west. The window patterns of its partitioned spaces are different. In the left partition, windows

are side by side, while in the right, they are perpendicular, which reduces shadow contrasts. (fig. 72-74) The current windows of the left partition prioritizes light in the left corner of the space. These semi-square windows are ideal for reducing glare, however they do not succeed in lighting the other half of the room. Moreover, the windows provide views of nearby buildings, which will not positively affect staff performance.

Figure 71 - Room B Orientation in Building Form

Figure 70 - Room A Orientation in Building Form

Figure 67 - Plan of Room A Window Configuration Figure 72 - Section 1 of Room B Window Configuration

Figure 68 - Section 1 of Room A Window Configuration

58

Figure 69 - Section 2 of Room A Window Configuration

Figure 73 - Section 2 of Room B Window Configuration

Figure 74 - Plan of Room B Window Configuration

59

Category 2 - Over-Illuminated Staff Rooms Room C is located on the first floor of the hospital, with its windows facing the south and west elevations. (fig.78) Since the room has a long floor plan, the vertical shape of the window is appreciated; however, its position creates excessive glare and visual discomfort. (fig.76) The other semi-square window is also well shaped and positioned in the room, providing the staff with full views of the hospital courtyard garden; however, it does not have any shading devices to control the incoming light, which directly strikes the staff working area from the west.

Room D is located on the ground floor of the hospital, facing the north and west. (fig.79) Both window shapes occupy the entire height of the four-meter wall and measure two meters in width, which brings in abundant levels of daylight. (fig. 81-82) The staff also has great views of building’s entrance. Even though the window patterns are symmetrically perpendicular to each other and positioned in the centre, there is a substantial amount of glare from the large windows, their vertical shapes, and the lack of shading devices.

Figure 75 - Plan of Room C Window Configuration

Figure 78 - Room C Orientation in Building Form

Figure 80 - Plan of Room D Window Configuration

60

Figure 76 - Section 1 of Room C Window Configuration

Figure 77 - Section 2 of Room C Window Configuration

Figure 79 - Room D Orientation in Building Form

Figure 81 - Section 1 of Room D Window Configuration

Figure 82 - Section 2 of Room D Window Configuration

61

Category 3 - Low-Illuminated Staff Rooms Room E is situated on the ground floor of the Manama Branch, with its main window facing north. (fig.85) There are two rectangular shaped windows positioned 2.38m apart from each other in the room, one thinner than the other in width by 0.42m. (fig.83) Because both windows face north with small openings, the windows do not provide the 500 LUX target at all throughout the day. This also results from heavy framing. Heavy glass films are also applied on the windows, which not only reduces useful daylight transmittance, but also detracts from external

the size and shape of windows. Glare and external views were affected by the positioning of windows according to exterior orientation and room layout arrangement.

Figure 83 - Section of Room E Window Configuration

Figure 84 - Pln of Room E Window Configuration

Section Summary: Elements such as orientation, window design, and external views should be reviewed to ensure staff occupants work in adequate daylight conditions to maintain their health conditions. Window patterns symmetrically perpendicular to each other provided uniform daylighting when controlled. The main elements affecting the daylight exposure to the depth of staff rooms were 62

Figure 85 - Room E Orientation in Building Form

63

07

Study of Staff Perception & Behaviour

65

7.1.

Staff Movement Study Background: This section consists of an observation-based analysis using spaghetti diagrams to correlate patterns of staff movement with the amount of daylight in their surroundings. Although daylighting affects all staff in hospitals, this section focusses on doctors and nurses in their departments. The thicker the line is in the spaghetti diagram, the more dominant the movement route of the staff.

Category 1 - High-Illuminated Staff Rooms During an eight hour work shift in Room A, the doctor is mainly situated in the treatment room around the dental chair. The doctor treats his patients in the same room the entire day and spends most of his time sitting at the office desk between treatments.

His main movements outside the room were to the staff break room for a 30-minute food break and to the toilet twice a day. (fig.86) All of these locations in the dental department are accommodated with windows, which provide plenty of of daylight.

Only one nurse works in Room B. He 66

spends most of his time in his main workspace. (fig.87) The nurse would sometimes go to the consultation room to deliver dental appliances and went to the staff break room for a snack once a day. He is illuminated by daylight in all circumstances.

Figure 86 - Spaghetti Diagram of Room A Doctor Movement

Figure 87 - Spaghetti Diagram of Room B Nurse Movement

Category 2 - Over-Illuminated Staff Rooms In room D, the pediatrician mainly circulates between his consultation room to treat patients and sits in his office when there are no patients. (fig.89) He goes to the cafeteria on the other side of the hospital twice a day and eats at the small windowless room next to his office. To prevent glare, the curtains are down for most of his 8 hours of work, which highly reduces the doctor’s exposure to daylight. Apart from his office room and eating room, which do not provide adequate qualities of daylight, meaning the daylight design is likelier to negatively impact his performance.

Room C is similar, as the nurse spends most of her 8-hour shift in the staff room treating patients, visits the surrounding staff rooms, and escorts patients several times a day. (fig.88) The corridors have no windows and the blinds in the main staff room are usually down to prevent glare.

In both Room C and D window configuration changes could be made to control glare and enable safe daylight illumination to reduce the likelihood of negative impacts on staff performance.

Figure 88 - Spaghetti Diagram of Room C Doctor Movement

Figure 89 - Spaghetti Diagram of Room D Doctor Movement

Category 3 (Poor-Illuminated Staff Rooms)

67

The gynecologist in Room E spends most of her eight hour shift in the consultation room. She circulates between talking to patients at her desk and treating patients on the hospital bed on the other side of the room. (fig.90) She usually visits the nearby triage and CTG rooms to collect patient documents before patient visits and goes to the toilet around twice a day. The corridors have no windows at all and the amount of daylight in the staff room at daylight peak hours is at an average of 132 LUX. Room F, which is known as the ENT department in Manama branch is situated at the end of the department’s corridor. (fig.91) The doctor spends most of her 8 hour-shift observing patients at her office desk and moving to the other side of the room with patients. The doctor circulates to escort patients and use the nearby audiology room three times a day. The staff room and corridor does not contain any windows at all.

The doctors analyzed in rooms E and F, as well as the side nurses working alongside them, are not benefitting from the important mental and physical benefits of daylighting. This is a major contributor to provide stress, depression, and exhaustion for staff that can lead to medical error. These issues must be addressed to create a healing environment for both patients and staff to cooperate successfully and healthfully.

68

Section Summary: Studying circulation patterns of staff members shows the correlation of staff work habits and staff exposure to daylight.

Despite the quality of daylight design in staff rooms, staff movement through other hospital spaces, such as corridors, may impact individual mental conditions.

7.2.

Staff Interviews Background: In order to analyse the main factors that affect hospital staff performance in relation to daylight, it is important to understand individual staff members’ perceptions and comfort in their work environments. Interviews conducted with staff members working in case study Rooms A-F emphasize the daylighting elements that staff members claim to personally affect their own job efficiency and productivity. Below, staff members are referred to the room they work in.

Category 1 - High-illuminated Staff Rooms Figure 90 - Spaghetti Diagram of Room E Doctor Movement

Figure 91 - Spaghetti Diagram of Room F Doctor Movement

Category 1 staff members work in the dental department and require similar daylighting conditions that emphasize close observation of details like colour and material. Nurse B mentioned “sometimes we need to take the tooth next to the window to visualize the shade of the tooth, and this could only happen with the sunlight’s translucency effect.” This highlights the importance of daylight for different jobs within the hospital. Doctor A and Nurse B agreed that daylight affects their productivity and

makes them feel “active,” as Doctor A stated, “I love the energy I get from daylight in work. I keep the electric lights turned off the entire daytime unless it’s needed for extra small details in treatments.” This shows that the window configurations of Room A, with large rectangular windows perpendicular to each other, positively affects Doctor A’s perception of his work environment and potentially his performance. He also mentioned that “the great advantage of having a good view outside in this room besides my personal benefit, is that it distracts younger patients from pain as they look outside.” In contrast, Nurse B stated “Manama is an old city, with these old buildings adjacent to each other, the view from this room is not benefitting me.”

This shows that the staff workers are aware of the views and their effects on the quality of the workspace. Therefore, architects should carefully consider the framing of views in hospital window design to promote staff satisfaction with their environment.

Category 2 - Over-Illuminated Staff Rooms One of the main concerns Doctors C and D have about their workspaces is excessive glare. Doctor C mentioned that “daylight is really needed during my work shift. The only problem I have, especially in the after69

noon, is that I put the curtains down the entire time because of the strong sunlight striking my face.” This is mainly caused by the high LUX levels received from the tall vertical window behind the office desk facing the South. This highlights that the oversight of staff activities by designers can result in negative impacts on staff despite good intentions to use daylight. Doctors C and D also mentioned that daylight “opens up the space,” or, as Doctor D stated, “you need windows and sunlight because it makes it more roomy and not claustrophobic.” This emphasizes how daylight can enhance a room’s overall atmosphere.

Category 3 - Low-Illuminated Staff Rooms In this category, the staff emphasized the lack of daylight entering their workspaces in relation to their work requirements. Doctor F said, “I mainly work with children that have severe distraction conditions. Placing a window in the treatment area and providing views might distract the children and refrain them from listening to me. However, placing a window at my office side would be acceptable and very helpful for me.” She mentioned that the lack of daylight she receives during work hours, especially given the small size of her room, makes her feel claustrophobic, anxious, and unmotivated.

70

She said that if her workspace was daylit, it would make her more energetic and vibrant.

7.3.

Questionnaire Study

Similarly, Doctor E, a gynaecologist, stated that “daylight isn’t convenient for us, as it may affect the private parts of patients that we are examining. However, in breaks, I would open the windows for fresh air and daylight to minimize the stress.” Doctor E and F’s comments emphasize both the correlation of daylight within their job requirements and their ability to control it.

Section Summary:

Section Summary: Staff interviews give insight into how the previously studied quantitative data relates to staff perception of their working environments. By understanding the specific preferences of workers towards daylight illuminance and window configuration, it is clear that - Staff attitudes towards daylight exposure is affected by job requirements.

- Excessive glare is a major problem towards staff comfort.

- Exposure to daylight makes staff members feel energetic and productive, where lack thereof can result in claustrophobia and stress.

Window views were highly considered and appreciated among staff

The survey was conducted from July 21st to August 28th 2019. The target sample size was 55 participants from each hospital, and 34 participants from each hospital submitted complete responses. The respondents were given to medical staff including doctors, nurses, and medical support staff, and the vast majority of respondents from both hospitals were either nurses or doctors.

The questionnaire consisted of eleven questions developed from established research regarding daylighting and corelated spatial, and environmental factors. The purpose of the questionnaire was to obtain a measure of staff member perceptions towards daylight design in their work environments.

71

Questions

Daylight - This section investigates the staff’s perception and judgements towards the daylight quality of staff rooms.

Q3: Are you satisfied with the amount of daylighting provided in staff space?

Q1: You are a: 0%

10%

20%

30%

40%

50%

60%

SAAR 2 (6%) 4. Not Answered Information Baackground - This section covers the general information of staff 5 (15%) MANAMA members in both hospitals 1 (3%) 3. Support Staff

3 (9%)

Q1: You are a: 2. Nurse 1. Doctor 4. Not Answered

0%

10%

20%

2 (6%) 0

2 1 (3%)

3. Support Staff

30%

5 (15%) 6

4

11 (32%) 40%

8

10

17 (50…

50% 14 (41%) 15 (44%) SAAR

MANAMA 14

12

16

60%

18

3 (9%)

2. Nurse

17 (50…

11 (32%)

Figure 91.c - Bar Chart of Question 3

14 (41%) 15 (44%)

1. Doctor 0

2

4

6

8

10

12

14

Q4: Are you satisfied with the presence of external window views in staff room?

16

18

70%

80%

Figure 91.a - Bar Chart of Question 1

Q2: How many hours do you spent in the particular staff room every day?

0%

10%

20%

30%

40%

50%

4 (12%) 2 (6%)

5. Not Answered 4. Up to 12 hrs

5

6 (18%)

60% SAAR MANAMA

(15%)

Q2: How many hours do you spent in the particular staff room every day?

3. Up to 8 hrs

0%

10% 20% 30% (3%) 2 (6%)4 (12%) 2 (6%) 1 (3%) 2 (6%) 6 (18%) 5 (15%) 5 10

40%

50%

1

2. Up to 6 hrs 5. Not Answered 1. Up to 4 hrs 4. Up to 12 hrs 0

60% SAAR MANAMA

15

20

15

20

Figure3.91.b Bar8Chart Up-to hrs of Question 2

1

2. Up to 6 hrs

22 (65%) 23 (68%) 70% 80%

Figure 91.d - Bar Chart of Question 4

25 22 (65%) 23 (68%)

Q5: Can you control the daylight condition by the use of screens or curtains?

(3%) 2 (6%)

1 (3%) 2 (6%)

1. Up to 4 hrs 0

5

10

25

Figure 91.e - Bar Chart of Question 5

72

73

Spatial Organization - These factors corelate with daylighting design, as it determines the

depth of daylight illuminance, the orientation of occupants facing daylight and the room/window privacy.

Q6: Are you satisfied with the size of particular staff room (is there pleasant amount of space to work or insufficient?)

Environment - These factors investigate the perception of staff towards acoustics, thermal comfort, and fresh ventilation to study their correlation towards the impact of daylight and window design.

Q9: Are you satisfied with the quality of ventilation provided from windows in staff room (bringing in fresh air and taking out stale air in building)?

Figure 91.e - Bar Chart of Question 6

Q7: Are you satisfied with the design & layout arrangement of particular staff room?

Figure 91.e - Bar Chart of Question 7

Q8: Are you satisfied with the quality of privacy in particular staff room?

Figure 91.e - Bar Chart of Question 9

Q10: Quality of thermal comfort inside building (heating and cooling)

Figure 91.e - Bar Chart of Question 10

Q11: Are you satisfied with the quality of noise levels/acoustics in particular staff room?

Figure 91.e - Bar Chart of Question 10

Figure 91.e - Bar Chart of Question 8

74

Figure 91.e - Bar Chart of Question 11

75

Summary of Findings: When asked “how many hours do you spend in a particular room every day?,� over 70% of respondents in both hospitals spent at least 8 hours a day in a particular room and nearly 20% of respondents spent at least 12 hours a day (Fig. 1.2).

This shows that the amount of daylight illuminance entering staff rooms may significantly affect their work physiology and mental health. The amount of daylight provided in staff rooms was considerably higher in Saar Branch (Fig. 1.3), whereas 44% of respondents in Manama Branch found the amount of daylight to be problematic. 56% of respondents at Manama Branch and 21% at Saar Branch found external window views to be problematic (Fig. 1.4). All respondents said they could control daylight with screens or curtains as regulated by code in Bahrain (Fig.1.5).

Considering the role of spatial organization in staff performance and comfort, the vast majority of staff at Saar branch were satisfied with the sizes of their workspaces while 50% of the staff at Manama branch found the sizes of staff rooms to be problematic (Fig.1.6). A significant majority of staff at both hospitals found the design and layout of staff rooms to be beneficial (Fig.1.7). Staff members at Saar branch 76

were overwhelmingly satisfied with the level of privacy in staff rooms while Manama branch staff were split 50/50 (Fig.1.8).

The provision of fresh ventilation from windows were seen as beneficial from both hospitals. (fig.x) When asked about other environmental factors most respondents at both hospitals found the quality of thermal comfort and noise in staff areas to be beneficial or sufficient (Fig.1.9-1.11).

were insufficiently provided with windows. This questionnaire gives an insight to how doctors and nurses in both hospitals perceive their work environments and encourages the improvement of daylight design at the Manama branch.

Questionnaire Conclusions: The survey shows that daylighting factors above spatial and environmental factors contribute most to staff dissatisfaction with their work environments. Staff at the Saar branch were also more satisfied with their work environments than staff at the Manama branch due to the implementation of daylight design in workspaces. Despite the significant amount of daylight provided, daylight quality could be improved, as several staff rooms in Saar branch face problems with excessive glare. The three factors the majority of staff found most problematic in Manama branch were the implementation of daylighting, external views, and room size.

From on-site observations and the results in the questionnaire, it is shown that several staff rooms in the Manama branch 77

08

Staff Room Design Suggestions

79

Background:

Category 3 - Low-Illuminated Staff Rooms

In this section, design suggestions were conducted to enhance the workspaces of medical staff through daylighting.

These strategies are derived from the

The main problems in Room E is the poor daylight transmittance throughout the room due to small window sizes, heavy framing, uncontrolled solar films, and the low direct sunlight exposure from the north orientation. However, if two tall rectangular windows are positioned to illuminate both sides of the room as shown in (fig.9294), then the room strategy receives daylight over 500 LUX throughout the space.

analyses in the previous case study and established literature on shading devices. These should be viewed as initial steps to understand how to solve daylighting issues for similar staff rooms

Figure 93 - Room E Design Suggestion Showing Enhanced Window Configuration

Figure 92 - Design Suggestion Floor Plan Lux Indicator

80

Figure 94 - Room E Design Suggestion Perspective Lux Indicator

81

Doctor F noted that the complete lack of daylight exposure throughout her 8 hours of work in Room F makes her feel claustrophobic. Despite the staff room not being situated alongside the faรงade, placing a 1.40m x 2m rectangular window in the room attracts daylight from the windows across the corridor, providing a view to experience the transition of daylight colours and maintain a healthy circadian rhythm. (fig.95-97)

Figure 95 - Room F Plan View Showing Staff Room Relation to Nearby Corridor in the Backside.

Figure 97 - Room F Perspective View Design Suggestion Render

Figure 96 - Room F Plan View Lux Indicactor (Design Suggestion)

82

Figure 98 - Room F Perpective View Lux Indicator (Design Suggestion)

83

Category 2 - Over-Illuminated Staff Rooms Both Room C and D face excessive glare, which impacts staff comfort in these rooms and caused occupants to keep shades down during daytime. Alternative shading systems could be used to solve these issues. In Room C, the vertical window behind the office desk has been enlarged to 2m x 4m� and shifted to prevent shadow contrasts. (101-102) A light-shelf was used for the vertical window to bring light into the depth of the room while preventing excessive daylight. External vertical louvres were also installed to control low-angle glare from the West. (fig.100)

Figure 99 - Room C Floor Plan Lux Indicator (Design Suggestion)

Figure 100 - Room C External Shading Devices Used (Lightshelf + Vertical Louvers placed facing direct-sunlight side to not obstruct view)

84

Figure 101 - Room C Perspective View Lux Indicator (Design Suggestion)

Figure 102 - Room C Design Suggestion Render

85

In Room D, the room layout has been al tered so the staff has views outside while sitting at their desk. The window size near the office desk facing the Western sun has been shrunk to not exceed the required specifications, and external vertical louvres were added to control excessive glare. (fig. 102-106)

Section Summary: Daylighting issues can be solved using software simulations that meet required daylight specifications, boost productivity, and improve task visibility among staff members. To control excessive glare from affecting staff performance, shading devic-

Figure 102 - Room D Floor Plan Design Suggestion Lux Indicator

es were selected and applied based on the orientation of the staff room. Additionally, window configurations were also adjusted to enhance the amount and quality of daylight illuminance. The design suggestions provided using the Velux software may be implemented in new hospital designs to benefit from daylight so that medical error can be minimized. However, these design suggestions are brief alternatives that generate only the amount of LUX values of the suggested designs and do not determine the overall daylight quality, such as the indication of excessive glare.

Figure 104- Room E Perspective View Design Suggestion Lux Indicator

Figure 103 - Room D Extenal Vertical Louvers (placed facing direct-sunlight side to not obstruct view)

Figure 105 - Room E Design Suggestion Render

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87

09

Conclusion and Recommendations

90

The aim of this dissertation was to understand the correlation between daylighting and staff performance in hospitals. The conducted analysis showed that the amount of daylighting in staff rooms of Manama branch were indeed lower than the recommended average of illuminance needed for workspaces in hospitals. This was due to the inconsiderate window configuration design, the main element that determines the quality of daylight illuminance for staff workers on a daily basis. LUX measurements at the Saar branch showed higher daylight levels because there were more windows with larger openings. Despite the substantial amount of daylight illuminance in staff rooms at the Saar branch, the lack of glare control negatively impacted the task visibility and comfort of staff members. This would suggest that designing

To expand knowledge of the psychological and physiological effects of daylight on medical staff, data collected through questionnaires and interviews gave insight into staff members perceptions of their work environments. The questionnaire created an understanding of the correlation between daylighting and the overall environmental and spatial factors that affect it. It suggested that the majority of the staff in the Manama branch were not satisfied with the conditions of their work environments, majorly by the low exposure of daylight and unsatisfied provision of external views in staff rooms. The findings from the objectives confirm that the absence of daylight or the lack of proper control over it plays a major contribution on the disruption of staff work efficiency, productivity, and task visibility This is proven by the interviews, which elaborated on the specific perceptions of

daylighting for hospitals should allow the staff to have control over the amount of daylight they need through carefully designed window configurations.

staff members and showed that the implementation of daylight in staff work environments has significant effects on well-being and ability to complete specific tasks.

To better understand the amount of daylight staff are exposed to throughout the day, the study of staff movement showed that several staff members require more daylight in their workspaces, as they could potentially spend from six to twelve hours in rooms with poor or no daylight.

One could see the improvement of the overall environmental quality from the American Mission Hospital built in 1903 to the branch built in 2016, as the Saar branch was designed using Post Occupancy Evaluation, where psychological and physiological needs for daylight in workspace were tak-

en into account by designers. Despite the Saar branch’s superiority over the Manama branch, it still does not meet the recommended standards and qualities for creating a controlled daylit environment in all cases.

This research and the design suggestions should be used to provoke attention towards improving daylight conditions of staff workspaces in current and future hospitals and encouraging further research into the relationship between hospital architecture, medical staff performance, and rising mortality due to medical error.

91

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95

Vogiatzi, D., Peippo, K. & Lund, P., 2000. Sensitivity Analysis of Important Parameters Affecting Daylight. Solar Energy, Hut: El Sevier.

Blake, . R. & Sekuler , R., 2005. Perception. New York: McGraw-Hill Higher Education.

Boubekri, M., 2008. Daylighting, Architecture and Health. Oxford: El Sevier.

Ward, M. O., Grinstein, G. & Keim, D., 2010. Interactive Data Visualization. Natick: CRC Press.

BRE, 2015. Daylight and Shading, Watford: IHS Press.

Zadeh, R. . S. & Shepley, M. . M., 2014. The Impact of Windows and Daylight on AcuteCare Nurses’ Physiological, Psychological, and Behavioral Health, New York: Vendome Group.

Zahra, N., 2017. Bahrain probes 58 complaints of medical negligence. [Online] Available at: https://www.zawya.com/mena/en/legal/story/Bahrain_probes_58_complaints_of_medical_negligence-SNG_102463428/ [Accessed 8 9 2019].

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AMH, 2019. The Arabian Mission History. [Online] Available at: https://www.amh.org. bh/history/ [Accessed 18 7 2019].

Ander, G., 2003. Daylighting Performance and Design. New Jersey: John Wiley & Sons.

Aripin, S., 2011. Healing Architecture - Daylight in hospital design. Conference on Sustainable Building South East Asia, 5(1), pp. 173-181.

Bahrain.bh, 2019. About Bahrain. [Online] Available at: https://www.bahrain.bh/wps/portal/!ut/p/a1/jZDLDoJADEW_xQVbWhgcRncj8Q3R-ECcjUEzjhpkDKL4-aJuNPHVXZtz0tuCgAhEGp-3Ks63Oo2TWy_oojNAatnM7jG_SpD7oUM97FtO6JbA_BlAQprIB9QdumHNpgz_89EOPKvrlH4QIHLWGPmTlofYJn_6H4r_3D-WKcxAvGJvrrgD32I-gM85eiBUopf3n855uiRMgcjkWmYyM09Z [Accessed 3 9 2019].

Baker, N. & Steemers, K., 2002. Daylight Design of Buildings. London: James & James.

Baker, V. N., Fanchiotti, A. & Steemers, K., 1993. Daylighting in Architecture: A European Reference Book. New York: Taylor and Francis.

96

Burpee, H., 2008. History of Healthcare Architecture, Washington: Mahlum.

Chaudhury, H., 2007. The Effect of Environmental Design on Reducing Nursing and Medication Errors in Acute Care Setting, Vancouver: The Center for Health Design.

CIBSE, 2014. Lighting Guide 10 : Daylighting - A Guide for Designers, London: CIBSE. Clarke, A., 1993. Through the Changing Scenes of Life (1893-1993). Manama: The American Mission Hospital Society.

ClimatestoTravel, 2019. Climate - Bahrain. [Online] Available at: https://www.climatestotravel.com/climate/bahrain [Accessed 15 11 2019].

Crystal, J. & Smith, C., 2019. Bahrain. [Online] Available at: https://www.britannica.com/place/Bahrain [Accessed 1 10 2019].

Day, L., 2007. Healing Environments and the Limits of Empirical Evidence, San Fransisco: American Journal of Critical Care.

Export.gov, 2019. Healthcare Resource Guide: Bahrain. [Online] Available at: https://2016.export.gov/industry/health/healthcareresourceguide/eg_ main_124534.asp#targetText=The%20ratio%20of%20doctors%20available,of%202.8%20 per%201000%20people.

[Accessed 8 10 2019].

Gherri, B., 2015. Assessment of Daylight Performance in Buildings: Methods and Design Strategies. Boston: WI Press.

Guenther, R. & Vittori, G., 2013. Sustainable Healthcare Architecture, Hoboken: John Wiley & Sons.

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97

Hadjri , K. & Crozier, C., 2009. Post-occupancy Evaluation: Purpose, Benefits and Barriers, Belfast: s.n.

Hoffmann, T., 2019. SunCalc.Org. [Online] Available at: https://www.suncalc.org/#/26.1125,50.5966,8/2020.01.09/14:48/1/3 [Accessed 18 10 2019].

Hopkinson, R., 1970. The Ergonomics of Light. London: Macdonald & Co. Joseph, A., 2006. The Impact of Light on Outcomes in Healthcare Settings, Concord: The Center of Health Design.

Kontadakis , A., Tsangrassoulis , A., Doulos , L. & Zerefos, S., 2017. A Review of Light Shelf Designs for Daylit Environments, Volos: MDPI. LĂśfberg, . H. & Hygge , S., 1999. Post Occupancy Evaluation of Daylight in Buildings, Gavle: Centre for Built Environment.

Lowenthal, . D., 1967. Environmental Perception and Behavior. 1 ed. Chicago: Dept. of Geography, University of Chicago.

Lyendo, T., Uwajeh, P. & Ezennia, I., 2016. The Therapeutic Impacts of Environmental Design Interventions on Wellness in Clinical Settings: A Narrative Review, Nicosia: CrossMark. moh.gov, 2018. Health Improvement Strategy (2015-2018), Manama: moh.gov.

Mottier, P., 2010. LED for Lighting Applications. London: John Wiley & Sons.

Richardson, R., 2010. Florence Nightingale and Hospital Design. [Online] Available at: https://kingscollections.org/exhibitions/specialcollections/nightingale-and-hospital-design/florence-nightingale-and-hospital-design [Accessed 17 9 2019].

Robinson, A. & Selkowitz , S., 2013. Tips for Daylighting with Windows , Berkeley: Berkeley Lab. Roy, N., 2019. Daylight calculations and measurements. [Online] Available at: https://www.velux.com/deic/daylight/daylight-calculations-and-measurements [Accessed 28 6 2019].

Schweitzer, M., Gilpin, L. & Frampton, S., 2004. Healing spaces : Elements of Environmental Design that Make an Impact on Health. Journal of Alternative & Complementary Medicine, p. 10.

The European Commission , 1994. Daylighting in Buildings, Dublin: Energy Research Group.

Tregenza, P. & Wilson, M., 2011. Daylighting, Architecture and Design, New York: Routledge.

NHRA, 2018. NHRA Annual Report, Manama: NHRA.

Tuan, Y. F., 1974. Topophilia: A Study of Environmental Perception, Attitudes, and Values.

1 ed. Bergen County: Prentice Hall Inc..

Phillips, D. & Meilink, L., 2013. Post-Occupancy Evaluation: Observations on Patient Satisfaction and Staff Operations, Ballinger: s.n.

Ulrich, R., 1997. A Theory of Supportive Design for Healthcare Facilities. Journal of Healthcare Design, 9(3-7).

Phillips, D., 2000. Lighting Modern Buildings. Oxford: Architectural Press.

Ulrich, R., 2004. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity, Concord: The Center for Health Design.

Ralph, M., 2019. Lighting Guide 2: Lighting for healthcare premises, London: CIBSE. Razon, A., 2017. A Study on Window Configuration to Enhance Daylighting Performances on Working Space of an Architect’s Office in Chittagong, Vienna: International Journal of Scientific & Engineering Research.

98

RIBA, 2016. Post Occupancy Evaluation and. [Online] Available at: https://www.architecture.com/-/media/gathercontent/post-occupancy-evaluation/additional-documents/ribapoebpeprimerpdf.pdf [Accessed 18 10 2019].

Ulrich, R. S., 2001. Effects of Healthcare Environmental Design on Medical Outcomes, College Station: The International Academy for Design and Healt.

Vogiatzi, D., Peippo, K. & Lund, P., 2000. Sensitivity Analysis of Important Parameters Affecting Daylight. Solar Energy, Hut: El Sevier.

99

Ward, M. O., Grinstein, G. & Keim, D., 2010. Interactive Data Visualization. Natick: CRC Press.

Zadeh, R. . S. & Shepley, M. . M., 2014. The Impact of Windows and Daylight on AcuteCare Nurses’ Physiological, Psychological, and Behavioral Health, New York: Vendome Group.

Zahra, N., 2017. Bahrain probes 58 complaints of medical negligence. [Online] Available at: https://www.zawya.com/mena/en/legal/story/Bahrain_probes_58_complaints_of_medical_negligence-SNG_102463428/ [Accessed 8 9 2019].

List of Illustrations Title Page: Author’s Own Figure 1 - Author's Own , Diagram of Research Aim and Objectives Figure 2 - Bahrain Map, Author’s Own (Edit) – Information based from Furian, P. (2016).

Bahrain Political Map with Capital Manama.. [image] Available at: https://www.alamy. com/stock-photo-bahrain-political-map-with-capital-manama-island-country-archipelago-110339133.html [Accessed 20 Jun. 2019].

Figure 3 - James Cantine (left-side) and Samuel Zwemer (right-side) - Clarke, A., 1993.

Through the Changing Scenes of Life (1893-1993). Manama: The American Mission Hospital Society Figure 4 - Ward Room at the Hospital in 1907 - American Mission Hospital (2019).

Ward. [image] Available at: https://www.amh.org.bh/history/ [Accessed 22 Jun. 2019].

Figure 5 - ‘Warehouse’ Façade Appearance in 1970s - American Mission Hospital (2019).

Outpatient Clinic. [image] Available at: https://www.amh.org.bh/history/ [Accessed 22 Jun. 2019].

Figure 6 - New Hospital Extension and Refurbishment Concept of Architect - Clarke, A., 1993. Through the Changing Scenes of Life (1893-1993). Manama: The American Mission Hospital Society.

Figure 7 - Author's Own Figure 8 - Author's Own. Information taken from: Nazrian, M. (2011). review of different approaches to access and people circulation within health-care facilities and the application of modelling, simulation and visualisation. [image] Available at: https://www. researchgate.net/publication/321973402_A_review_of_different_approaches_to_access_and_people_circulation_within_health-care_facilities_and_the_application_of_ modelling_simulation_and_visualisation/figures?lo=1 [Accessed 18 Nov. 2019].

Figure 9 - Author's Own Figure 10 - Author's Own Figure 11 - Author's Own Figure 12 - Azimuth Graph and Sun Position Information Used to Know the Amount of Daylight that Could Enter Both Hospitals – Author’s Own – Information taken from Hoffmann, T., 2019. SunCalc.Org. [Online] Available at: https://www.suncalc.org/#/26.1125, 50.5966,8/2020.01.09/14:48/1/3 [Accessed 18 10 2019].

Figure 13-28: Author's Own Figure 29 - BHMG (2017). THE BHMG ; The American Mission Hospital. [image] Available at: https://thebhmwg.com/privatehospitals_area/manama/ [Accessed 23 Oct. 2019].

Figure 30-105: Author's Own.

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Appendix A - Staff Questionnaire Questionnaire

Questionnaire

Date:

Q11: Design & arrangement of furniture in particular staff room 1: Very beneficial

Q1: You are a: 1: Doctor

2: Nurse

3: Support staff

2: Beneficial

3: Neutral

Date:

4: Problematic

5: Very problematic

Q12: Can you control the daylight condition by the use of screens or curtains?

1: Yes

2: No

Q2: How many hours do you spent in a particular room every day?

1: Up to 4 hrs

2: Up to 6 hrs

3: Up to 8 hrs

4: Up to 12 hr

Appendix B - Research Approval

Q3: Size of particular staff room ie is there pleasant amount of space to work or insufficient?

1: Very beneficial

2: Beneficial

3: Neutral

4: Problematic

5: Very problematic

3: Neutral

4: Problematic

5: Very problematic

4: Problematic

5: Very problematic

4: Problematic

5: Very problematic

4: Problematic

5: Very problematic

Q4: Acoustic/Noise levels of Staff Area 1: Very beneficial

2: Beneficial

Q5: Amount of daylighting provided in staff space 1: Very beneficial

2: Beneficial

3: Neutral

Q6: Presence of external window views in staff room 1: Very beneficial

2: Beneficial

3: Neutral

Q7: Design & Layout Arrangement of staff room 1: Very beneficial

2: Beneficial

3: Neutral

Q8: Quality of ventilation provided from window in staff area (bringing in fresh air and taking out stale air in building)?

1: Very beneficial

2: Beneficial

3: Neutral

4: Problematic

5: Very problematic

Q9: Quality of thermal comfort inside building (heating and cooling) 1: Very beneficial

2: Beneficial

3: Neutral

4: Problematic

5: Very problematic

4: Problematic

5: Very problematic

Q10: Quality of privacy in particular staff room 1: Very beneficial

102

2: Beneficial

3: Neutral

103

Appendix C- Researched Work of Other 6 Staff Rooms

104

105

106