Welcome, everyone. This is Andrea Wilkerson with the Pacific Northwest National Laboratory. Thank you for joining today's webinar, Evidence Based Design for Healthcare Lighting. Where's the Evidence? Brought to you by the US Department of Energy's Solid State Lighting Program. Today's webinar is the second of a series of three webinars on health care lighting. Presenters today include me, Andrea Wilkerson, Dr. Anjali Joseph, and Dr. Robert Davis. I am a lighting research engineer at Pacific Northwest National Laboratory focusing on the evaluation of emerging lighting technologies and development of lighting system solutions supporting the Department of Energy's Solid State Lighting Program. I will be moderating today's webinar and providing a high level look at health care by the numbers.

Dr. Anjali Joseph will provide an in-depth look at research related to lighting in health care environment. She is currently the Spartanburg Regional Health System Endowed Chair in Architecture and Health Design and director of the Center for Health Facilities Design and Testing at Clemson University. Dr. Joseph is focused on using simulation and prototyping methods to research and test effectiveness of promising design solutions that may impact patient safety and high stress health care environments. She has focused her research on multi-disciplinary approaches to improving patient safety and health care through the development of tools and the environment solution. She is currently leading a multi-disciplinary project to develop a learning lab focused on improving patient safety in the operating room.

In today's presentation, Dr. Robert "Bob" Davis will take a deep dive into some of the research studies presented by Dr. Joseph from the perspective of a lighting researcher. Dr. Davis is currently a senior staff lighting engineer at Pacific Northwest National Laboratory where he directs the Gateway Program and leads Human Factor research efforts. His experience includes working in engineering and marketing at a large lamp manufacturer and leading the product development and engineering team with a luminaire manufacturer. For over 15 years, Bob taught and conducted research in lighting as a faculty member at RPI's Lighting Research Center and in the College of Engineering at the University of Colorado at Boulder. Dr. Davis has degrees in architectural engineering and a PhD in cognitive psychology.

To recap, this is the second webinar of a series. The first webinar, the Nurses' Perspective on Hospital Patient Room Lighting, is now available on the DOE SSL website in video and presentation format. You can access it by going to that DOE SSL home page and scrolling down to Webinar Archives on the right hand side of the web page. Today's webinar content, as well the upcoming webinar Tuning the Light in Senior Care, will also be made available in the same location.

As Bob discussed in the first webinar, health care is on the radar of the Department of Energy Solid State Lighting program because the health care industry is a large energy user with a considerable amount of electricity and electricity consumption attributable to lighting. The figure on the slide illustrates that, for both hospitals and outpatient health care, these are both large users in terms of energy use intensity which is BTUs per square foot. Compared to applications such as offices, education, grocery stores, only food service barely beats out hospitals.

And in our initial webinar, we discussed a survey of nurses. And part of the reason for this research was because nurses really dominate the health care profession in terms of numbers. So you can see that registered nurses, there are about 2.7 million registered nurses in the US as of May 2014. And while nurses aren't the highest paid health care professionals. They average about $70,000 per year. A little less than anesthesiologists coming in at $250,000 per year. But the 2.7 million nurses makes this a huge, huge resource that the health care industry needs to allocate and account for. Also in the nursing profession, it is expected that there will be an increase of about 16% between 2014 and 2024. And that's compared to all occupations, which there is an expected increase of 7%. And so again, it's looking at the resources that are currently being allocated to nurses and how as a lighting professional can we look at ways to increase the efficiency and quality of lighting for these health care professionals so that resources can be allocated to perhaps more critical areas.

And taking a further look at the costs associated with health care reveals how these costs translate down to individual households. So average health care spending per household in 2014 was $4,300. Consumer prices for hospital services since 1997 have tripled compared with a 50% increase in all items over the same period. And this is based on 2015 costs. The health care industry is exploring ways to try and decrease these costs including video consultations by doctors. The projected growth in video doctor consultations between 2015 and 2020 is 25%. And there's also been an investment in personalization technologies that measure and track fitness and vital signs. So think of a more advanced FitBit that's able to measure glucose levels or the amount of oxygen in the blood. And health care executives are indicating that they are realizing a return on investment in these personalization technologies. And this is 73% of health care Executives indicated that they are experiencing ROI in a recent survey.

Also in this survey health care executives indicated that they strongly agreed that, within three years, companies need to focus as much on training machines as training people. In the survey, 45% of the executives indicated strongly agree with this statement. And so it's compelling to review these numbers and consider how the lighting industry can demonstrate to the health care industry the opportunities for decreasing cost and increasing return on investment with new lighting technology and how lighting can be part of the personalization of health care as well as technology that learns and can help nurses and other health care providers to do a better job. How this will happen remains to be seen. But understanding the trends in health care with a holistic view of lighting for health care is part of the process. Today's presentation will take a step in this direction. And I'll turn it over to Dr. Davis to further explore lighting for health care.

Thank you, Andrea. And thank you, everyone, for attending. At the Department of Energy and Pacific Northwest National Lab, we take a broad view of lighting for health care. Andrea mentioned that the energy use in health care facilities in the US is a major national energy user. That's one reason that it comes on the radar screen for us certainly. In the current days, we've had a lot of discussion about the non-visual effects of light, the effect of light on circadian rhythms. There certainly is a lot of activity in that area. To be honest, that's not a focus of our work necessarily. There are other folks who are doing really great work in that. The Lighting Research Center, Thomas Jefferson University, Harvard Medical. Lots of people with good medical backgrounds looking at that. We're certainly staying aware of that.

But what we want to sort of take the focus on today is looking at health care facilities very broadly and the lighting in health care facilities. And specifically on some of the visual aspects of lighting. I think with the focus on non-visual effects, it's easy to sort of lose sight if you will of the fact that lighting does a lot of different things in health care facilities. And you want to understand what those effects are. As Andrea mentioned, there's a lot of new technology, these personalization technologies that allow us to sort of track and measure people's responses in new ways that we never could before. There's also a lot of advancement obviously in lighting technology and lighting measurement.

And so these three bullets on the slide here, the bottom three bullets are the things we're going to focus on in the webinar today. That is, when we think about lighting for health care facilities, what do we know about lighting's effect on task performance in terms of visibility, in terms of the stress levels that can be created for workers in health care facilities? The second topic will be what about lighting and perceptions? How does lighting and interior design affect things like people's mood, agitation levels? Just the general trend of trying to move away from the institutional environments of the past into things that are more pleasant spaces for people to be in. Many of our health care facilities in the US are quite old and were built under different times. And getting those sort of updated to today's standards is an interesting question and how lighting can be part of that. And then thirdly from the visual aspect of lighting, lighting is an important part of safety in health care facilities. Safety from the standpoint of people making errors while working. Certainly with seniors, risks of falls. Or with anyone who has an injury moving around the hospital or a health care facility.

And so the three bullets-- the task performance, perceptions, and safety-- are what we're going to focus on in the next 45 minutes or so. And the question is really is there evidence that exists now? What evidence can help us provide lighting to better address these needs? And also sort of what further evidence do we need? What can we do in the future to better understand these things and to help our design of health care facilities from an evidence based design standpoint?

The way this project got kicked off, because of our sort of growing interest in the health care application, we came across a literature review that Dr. Joseph had done 10 years ago now in August 2006. I show the document on the right of the slide. Professor Joseph before joining Clemson was the Director of Research for the Center for Health Design. She completed a really excellent literature review back in 2006 on the impact of light on outcomes in health care settings. One of the things that impressed us about that literature was how broad it was, that it really tried to address all these different aspects of lighting in health care facilities.

And it looked at a very broad view of the literature. Not just that lighting publications that us folks here on the DOE team know. We know Leukos, the Journal of the Illuminating Engineering Society very well. We know Lighting Research and Technology. But a lot of the other journals where people were publishing relevant research are beyond our normal daily operation. And so we collaborated with Professor Joseph in her position as Clemson now to sort of update over the last 10 years. What's new in the literature? Are there design recommendations that can come out of this? And what can we glean from the current literature to see what needs to happen in terms of future research?

So that was the impetus behind it. This slide is just sort of showing of the overall outline of the document that Professor Joseph and her team at Clemson have been working on. And number two there on the list there on the slide is really the primary focus of the content of the document that we're working on. And that is the impacts of light. Now in the literature review, we are looking at both the visual and the non-visual impact of light. So we're not certainly disregarding the non-visual impacts. That's a big part of what's happening in lighting research today. But I have that sort of grayed out on this slide because today we're just going to focus in on these visual impacts and then also talk a little bit about the design implications.

And so the way we've structured this is Dr. Joseph and I will sort of be bouncing back and forth through those three topics that I mentioned. She's going to give you a big picture view of different things they've seen in the literature as they've gone through it. Not enough time to go into the details of each study. And then what we decided was I would on each topic just pick a few of those studies and focus in a little bit more, give you a little bit more background about the people doing the work, what they found, and also sort of focus on here's what they found. What could we learn in future research that could even help with that? So that's sort of the process. We'll be looking back and forth. And at this point, I'll turn things over to Dr. Joseph to tell you a bit more about the literature review and then jump in on the task performance things. Anjali?

Thank you, Bob, for that great introduction. I think you set it up really well to explain why we need to look at lighting in health care for many different reasons. You know, energy consumption is the highest in health care. The nurses and staff are working for many long hours. And often the lighting in their environment is not well designed to support them. And of course, the patients that spend their time in these environments. How do we design it to be more healing? So I'm excited to be a part of this study. And it's been great collaborating with PNNL and the DOE. So we appreciate the support for this project. As Bob mentioned, this study does build upon some work I did 10 years ago. It seems like it was yesterday. But it was a long time ago that we put this together. And this was a great opportunity for us to see how has the field advanced since then, what are the new areas that we've seen covered in the last 10 years that were not addressed in 2006.

But we essentially focused on the same domain. We looked at health care environments and long term care environments. And the focus of the research was an article that specifically focused on lighting in our daily life as an environmental variable. And we looked at article that had a health outcome. So if it was a study that was primarily the simulation of the lighting environment without looking at a specific outcome, then we probably did not include those in our literature review. And we really focused on articles that were published in peer reviewed journals. And we looked at articles that were published after 2000. We looked between 2000 and 2006 in case there were any articles that we had missed in the previous literature review. Bob, if we can move on.

Yeah. So this is how we've organized the literature. So in any literature review, we get the articles and then get a [INAUDIBLE] to see what are some common themes that emerged. And the three key areas that we identified that had to do with the visual effects of light in health care settings included task performance, perception of quality of satisfaction, and then looking at the area of the impact of light on safety. And in that, we found three main categories that were of interest. Impact of light on falls. Impact on staff safety and staff health. And the impact on errors, then again getting back to patient safety. So those were sort of the three areas.

And the lighting and task performance is the most core for any kind of lighting practice that you might do. Even as the designer or a product manufacturer at a very basic level, light should promote visibility and your ability to perform your tasks adequately. Bob, onto the next slide. So light is essential for vision. And we know in health care, in addition to all characteristics covered, is that the workforce in health care is getting order. More than half of the nursing staff is 50 years and older. And the average age of registered nurses is about 47 years. So we have a progressively older workforce. The patients are also older. A lot of the patients who are coming into health care settings, especially in-patient settings, are elderly. And I'm including the other patients. So the need for appropriate lighting to perform tasks, for healing all need to be considered significantly in a health care environment. We also know that performance in visual tasks gets better as lighting levels improve. And so there is a big need to design lighting in hospitals for the visual ergonomics, both for the patients as well as the staff.

I'm going to present very quick snippets from some of the studies that we've found. And as Bob eluded, we are writing this up as the initial brief that should to be available from the Department of Energy pretty soon. We're also planning to write this up as a journal manuscript which will have a lot more of the details for the individual studies. And if anyone is interested, we can give you additional information on any of these as they we move along. So there are a decent amount of studies that talk about the relationship between illuminance levels and fatigue or stress. A few studies have looked at shift work-- so nurses who are working late at night.

And they found that with illuminance levels reduced, there was more eye fatigue. And that makes sense. And often the big light conditions for people who are working at night were not suitable for the kind of work that nurses often have to do. And that's a bit of a challenge. Because along with providing environments that are patient-centered where patients can sleep undisturbed through the night. But at the same time, nurses need adequate lighting for some of the critical tasks that they have to perform-- whether it's providing medication, taking vital signs for patients, making sure the patients are doing all right. So there is a bit of a back and forth on that. So that's got to balance for us. Because the staff will stress when there isn't enough light for them to perform the tasks that they need to do. And inadequate light has a negative effect on staff work performance.

Bob, moving on. We've also found several studies that show that having low levels of light can contribute quite a bit to worker stress. A few studies that have looked at operating room environments, they've been interesting for us. Because it makes sense. But the kind of lighting that you're talking about here is very high intensity focused lighting that allows you to clearly discriminate between the cavities where you have to perform surgery. And there were a lot of studies that showed that surgeons were-- and nurses and medical teams-- were under a lot of stress in this environment. And having inadequate lighting or lighting that didn't work well contributed to stress.

Other studies have shown that nurses working in cancer care environments felt exhaustion and burnout when they worked in windowless environments. And unfortunately, that's all too common in health care. You can spend the whole day in the hospital without seeing daylight. And that can be very stressful. Some studies have looked at the impact of exposure to bright lights. And when we say bright light, it's usually like a light box rather than a lighting fixture or natural light. But even that kind of exposure, almost like a treatment, can help to reduce stress and burnout.

That's good. Thanks, Anjali. And before I move on from this slide, I think it's a good opportunity just to mention for those of you who aren't familiar with Professor Anjali's work, I mentioned it in her intro. But she's leading a major national effort right now looking at the design of operating rooms. And so lighting is a part of that. But there are many other aspects, too. So I just wanted to highlight that.

What I want to do now is take a little deeper dive in a couple of these papers that were mentioned. And even as I transition here, I'll just remind those of you attending the webinar today to feel free to be entering questions as we go. Andrea is going to be monitoring those and kind of lining up a Q and A at the end. We are going to wait till the end since we just have an hour to answer questions. But if you have any questions on each topic as we go, don't wait till the end. Please go ahead and type those in. And we'll get ready to be getting you answers for those.

As I sort of looked critically at some of these papers, one thing I want to highlight is how quickly things are changing. Some of the papers are a decade or more old. And so when we look at them today, we can think, well, you know it would've been nice if they'd done this or that, if they'd have measured this. And the truth is that a lot of the things we're able to do in research today just weren't possible when some of these papers were done. So we don't mean to be unfairly critical certainly. But really take a look to the future and say, well, what would we want to know in the future?

I thought some of you attending would be interested, too, to learn a bit more about some of the journals and the people who are doing this. So the first of the three papers I've picked out on task performance to highlight for the webinars is one from Morghen, et al in 2009 that talked about illuminance levels and stress. You can see here it's from the Journal of Occupational Medicine and Toxicology. Like I mentioned, there's a lot of other journals other than the lighting journals that most of us are familiar with. And these researchers are from Italy, from a University Hospital in Italy. So they are sort of medical academics. And they're really interested in the effects of the work environment in hospitals on the nurses and the doctors working there. So this is part of that research.

And in this particular study, they had 134 doctors and nurses who participated from three different hospitals in Italy. And when they report their study, I always sort of look at how do they describe the stimulus that people are responding to in terms of the lighting metrics that we all use and then how do they describe the response. What is it about the people and the response that they're measuring? So you know, how is the stimulus and response characterized? And in this paper from 2009, they sort of place the illuminance into three large categories. So you can see less than 700 lux or think roughly 70 foot-candles. And then a mid-range of 700 to 1500 lux. And then those that were in lighting that was greater than 1500 lux.

And basically they saw that there was a relationship between how people reporting their level of stress and the illuminance level, that the people who are working under the over 1,500 lux reported less stress than those who were at the under 700 lux. So that's sort of an interesting finding from a lighting standpoint. When I look at their documentation of the stimulus, we see that they gave illuminance in these ranges. We don't know a lot about how the illuminance might have varied within that range or not even a lot about where they measured it. Was it uniform? Other metrics. But at least we know the illuminance levels. And they also report the CCTs and the CRIs. So some color metric. Today we know we really want to get full SPDs. Back then, you know CCT and CRI were what we reported. And so in looking to the future, we would say let's look more broadly at some of the stimulus measures.

The other thing I thought was really interesting in this paper was that they reported that they also tried to measure things other than lighting. Right? That's pretty important. And they found that things like people's family conditions and their working conditions had much bigger influences on their stress levels than lighting. They did find a significant effect with lighting. But I think it's good for us to all acknowledge that sometimes no matter how good the lighting is, there are other factors that are going to cause some of the results that we're looking at in research.

The second paper I'll mention is this one by Mahmood et al in 2012 on lighting and errors. These are folks from a couple of Canadian universities. The team that did this work published in the International Journal of Health Care Quality Assurance. And their background or their research is that one person was in a gerontology research program. Another in pediatrics. So kind of interesting spanning the age ranges. And also a psychologist on this research team. And they're really looking at overall factors in the environment and how that can affect errors and job satisfaction. Now broad look at a lot of different factors. And as Anjali mentioned, they found a really high percentage of the nursing staff that highlighted adequate lighting. It's one of the top things they need to avoid errors.

And so it's sort of like we talked about in the first webinar when we did the nurse survey of some nurses here in Portland, Oregon. I think that this type of study really shows that nurses do think a lot about lighting, about whether the lighting is adequate or poor, about how much that affects their performance. In this case, the measurement of performance was really strictly the nurse's impressions of their performance. It was a survey based research program.

The researchers mentioned that they tried to sort of compare things to records of actual errors that were made. But they didn't have access to all the records. So they felt that because they had incomplete records, they weren't able to link it directly to performance measures. It was mostly a survey of what things the nurses feel like affected it. And because it was a survey of a lot of people, they weren't actually in the spaces documenting what it was about lighting. So for me, the evidence is that the nurses consider lighting a very important part. We need a lot more about what aspects of lighting can contribute to that.

And then the third one that I'll highlight that Anjali mentioned is a study which actually comes from the School of Public Health in Iran, from an occupational health department. Researchers in Iran studied night shift workers. There's a lot of discussion in our industry about what do we do with people working third shift in many applications-- including health care applications-- and the different needs that the caregivers have than patients might have during the third shift. This paper is in the International Journal of Occupational Hygiene. And it's kind of an interesting study. They looked at over a 15 day period, kind of as a control condition, people working under normal lighting during third shift. Normal lighting was defined as 150 lux. And then for 15 days, they had them experience a very high level of light, 2000 lux, at the eye-- they mentioned that this was measured at the eye-- for 30 minutes during their shift. And that light was described as a 6,400 Kelvin compact fluorescent system.

And they found that during those 15 days when they had this 30 minutes of bright light exposure, their perceptions of stress and-- there is an instrument they use to measure what they call burnout syndrome, a survey instrument-- that those both were reduced. But there are other things listed here. Anxiety symptoms, social functioning, depression that the bright light exposure did not significantly affect. It wasn't a lot of people. So when we look at it critically, we say well, it was 15 nurses working third shift. Again it was all based on self-report. When Andrea mentioned the personalization technologies today, I think what we would hope in future research is that we can start to document some of the physiological measures that might relate to stress just to be able to see how these things are actually affecting people in terms of some of those physiological measures.

And again we don't know a lot about the lighting configuration other than what I mentioned in those first couple of bullets. We don't really know if there was a potential glare under this bright light. Exactly how that was administered. But kind of an interesting thought of how we can use lighting during the third shift. There may be certainly important non-visual things but also this impact that it could help third shift workers in their overall stress levels while they're working the third shift. So that's our look at task performance. Again, feel free to be entering questions as we move onto the second topic. And I'll turn it back to Anjali for lighting and perceptions.

Thanks, Bob. And as you were speaking, it brought again to my mind one of the challenges with some of the literature that we've been finding is that often there isn't a lighting engineer or a lighting expert on the scene. These are often conducted by clinical people or a psychologist. And while they will focus a lot on understanding the impact on the health care outcomes, they're not as equipped to measure or define the environmental variables related to lighting. And that really is a gap that we need to address. We need to work more collaboratively to clearly define more of those measures so that we know how we can be sort of intervene as far as the building management is concerned.

So moving onto this particular topic of lighting and perceptions, I mean that's something that we always deal with as we understand how lighting impacts us. But if we look at some of the research here-- and Bob, if you'd move to the next slide? So some interesting studies that we found related to lighting and mood or perception of the environment. So these are slightly different studies. The findings are not quite converging. But they do have some interesting points that need to be further explored. So in this first study, they looked at-- it's a simulation study. So it's not in a real environment.

But they looked at pictures of different environments with different kinds of lighting. One in which there was a brighter room. One that was not as bright. And the subjects were given a conflict of either a high stress health care situation or a low stress health care. So they would be told that you going in to visit the doctor. And you are worried about a diagnosis of cancer or something like that whereas with another one, it would be less stressful. And then you will be asked to look at these pictures and indicate how they felt in these environments and how the environment might impact the ability to pay attention to this, self-disclosed.

And in this study, they found that the brighter lit environment made the subject feel more comfortable about disclosing and how they felt in that environment. And so they added in the whole idea of how your mental state when you are in an environment, how that might impact-- in addition to-- that might affect your perception of the environment.

And the other study looked at bright light and dim light in counseling rooms. So this was an actual physical room that was simulated. And there was a simulated experience with a counselor. And they found that slightly dim light meant more pleasant environment with a more relaxed feeling in the subject. So they were more likely to self-disclose and they had a favorable impression of the interviewer. So they're slightly different in terms of the outcome. But I think the context of how you're feeling, I think that an important element that impacts also how you interact with the environment.

This was another well-conducted study that looked at spinal cord surgery recovery patients. They were randomly assigned to either the bright side of the unit or the dim side of the unit. And they looked at data that was appearing on the patients' records. And they found that patients that were on the brighter side of the unit perceived less stress, less pain. They also took less pain medication per hour. And they incurred less cost. So I think what makes this study interesting and sort of important also is the ability to link it with specific outcomes and then think about return on investment and why do we need to have a better lit environment and what some strong outcomes might be.

There are a few studies that have looked at the impact of lighting on agitation with the intention that, as light level fluctuates through the day, they might cause different kind of people to be more agitated, especially for persons with Alzheimer's disease or patients with agitation.

We found an important phenomenon that has been observed where with the changing wavelengths of light, people with Alzheimer's disease might get more agitated. So one particular study looked at that and decided to come up with a weighted solution that may help to minimize the impact of the changing angles of light during the evening hours. So they came up with a full spectrum fluorescent lighting and some kind of micro-slatted glazing that would reduce the effect of the changing sun angle. They also added in electronic controls to maintain the light intensity. This was a small study with a very small sample. But they did find a drop in disruptive behaviors when the residents were in the constant light condition compared to the control residents that were in the varying light levels. So it's a small study. But it probably needs to be a little bigger elsewhere.

Another study that highlights the importance of daylight. And in the first study where they looked at two different acute care nursing units. One that had windows in the nursing units where the staff worked. And one that did not. And they compared the nurses' behavior and some of the outcomes in the different units. And they found that, in the unit that had windows, the nurses were more alert. They were less sleepy. Less deteriorated moods. This would also mean more number of events of communication between staff compared to the windowless wards. And an interesting finding is high levels of communication and laughter which is something that they may find as well in the windowed ward as compared to the non-windowed ward.

A couple of other studies as well that have looked at exposure to daylight and found less stress and more satisfaction with work. The final study looks at an experimental room. It's an experimental environment rather than a real environment. They looked at full spectrum lighting. And they looked at different kind of spatial patterns in the room and linked that with less stress among the nurses. Moving on. OK.

There are other studies as well that have looked at the lighting and perceived staff satisfaction. Bob has alluded to the work that Dr. Mahmood and her colleagues have done. Other studies as well have shown that there is a positive relationship between lighting levels and job satisfaction. Good lighting characteristics have also been shown to be important. The source of light, light levels, light color, that's linked with employee satisfaction. A couple of studies again conducted in the operating room have shown that inadequate illumination is one of the major reasons for discomfort clearly because they cannot see what they're doing. That can [INAUDIBLE] a lot of discomfort. And the inadequate lighting was a major problem as perceived by a surgery staff and is something that really needs to be addressed in future designs.

Thanks, Anjali. Just to echo what Anjali said, I think part of our hope in presenting this information and putting together this document is to really stimulate hopefully some more collaborative efforts with research teams. As Anjali mentioned, we have a lot of sort of medical and psychological folks that have done research in the past that may not know the lighting that well. Us lighting folks don't know the medical side, right? And so to be able to combine teams and work collaboratively on things is going to be the best way to build a real strong evidence basis for future health care facility design.

So again I'll take a deeper look at a couple of these papers. And just because of my own background in cognitive psychology, that first slide Anjali showed of the couple different experiments or different projects that focused on really a counseling room situation, right? In health care facilities so often I think of the patient room as kind of the focal point. Or I'd mentioned Dr. Joseph's work in the operating room. And that's what we think of. But from the broad kind of holistic view, there's a lot of different spaces in health care facilities, all of which are very important. And in all of which there can be very difficult conversations taking place. So this study that I have up on the screen now by Okken et al I titled kind of affective experiences. This is from the Health Environment Research And Design Journal. Some of you that work in health care know that as the HERD Journal using the acronym HERD, a good journal on the environmental side of design for health care.

These folks are from the Netherlands. An engineering author and some folks who are actually in marketing communication departments at universities in the Netherlands. And it was an interesting study to read through because they really tried to look at how a space might be different for someone who is getting a good outcome-- what we'll call a low threat. Low threat means the diagnosis you're discussing with the medical professional is that there's nothing to worry about. So it's not a physical threat from a person in the room. It's the threat of getting bad news or knowing that you're going to get bad news. So high threat means you pretty much know you're going to get bad news. There's been a treatment that's been attempted. It hasn't worked.

And so these researchers wanted to look at how different might the environment be or how differently might the environment affect the person who is there to have that type of conversation. And so they varied the brightness as Anjali mentioned. In fact, I put the title of this paper on the bottom. Because I like the way they worded it. "When the world is closing in, Effects of Perceived Room Brightness and Communicated Threat During a Patient Physician Interaction." And their main finding was that when people felt like they were threatened, that they were going to get a bad diagnosis, they really liked the room to be brighter, that their perception of the brighter room was it was more spacious. And they felt more positive about the room and that they actually indicated they would be more likely to sort of disclose more information about themselves in that situation. Where when the room was dimmed, they didn't like the room as much for that type of a conversation.

So part of their-- I'll put the word "intimacy" in front as you see on the second bullet. That was part of the authors'-- we'll call it a hypothesis-- but their speculation was that when a room is dimmer, we think of that as being a more intimate thing. And that's OK if you're having a good conversation. Right? But you don't want that sort of intimacy if you're getting bad news. You sort of want to feel some space. You want some distance from the news as well as the person delivering the news. Again, you know this is a study where they were sort of creating cognitively in the subjects, the 90 participants' heads, here's the scenario. Trying to get people to imagine that you're in the situation. And this is the diagnosis you're getting. And here's the room you're in. And then doing these ratings.

And so I think it was a really interesting study to think about how the room decor, the design, the lighting can affect how people are responding and feeling in that environment. I'd love to see it repeated in some real spaces. And again that the lighting documentation is not very detailed. They were looking at pictures of a room. They weren't looking at going into an actual room. And so we want to understand what it is about the lighting. Is it the distribution of light? If we go back to some of the old lighting psychology research, is it the overall light levels? What is it? And then again, other than the rating scales, have other measures to confirm some of those things.

The kind of companion study-- and actually I did these in reverse order. Because this was the first study that looked at these things that Anjali mentioned. And these folks are environmental psychologists at several different universities in Japan. And they're looking at the interior design effect. This paper was in Environment and Behavior. And again it's 10 years ago. But in their case, they were looking at it, in a real room, this bright versus dim in a counseling room. Now the wrinkle that the Okken folks added in the more recent paper was this idea of the high threat or low threat.

So Miwa and Hanyu didn't look at the high threat or low threat. They just looked at OK, it's a counseling room. We have one room with 750 lux. We have a second room with 150 lux. And then in each of those conditions, they had a room that was very sparse with not any real decor and another room that had sort of nicer interior design and interior decor. And they found in general that people liked the dimmer room for those counseling rooms, that it gave them a more peaceful feeling and a positive impression of the interviewer.

The third bullet here again is just sort of with a 10-year-old paper, we didn't get much information about what was the color quality of the light? How was the distribution of light? In fact, they did mention the dim was described as incandescent, the bright as fluorescent. So certainly there were spectral differences. We didn't really learn any of that. So there's the overall evidence of how the room environment might affect the person in the room and their attitudes about that. But we don't know enough about the lighting to really be able to put something in the design practice.

And then sort of shifting gears. This paper that Anjali finished with is a really interesting one, too. Again in the HERD Journal. And this research team sort of caught my attention. And folks, those of you that are doing this type of research, I'd recommend trying to make contact with these folks. It's a team of folks. Someone, one of the authors is from the Georgetown School of Nursing. There's a group called Med Star Health in the DC area. They have an Institute for Innovation. And then there's also an architect interior designer from Perkins and Will on this research team. So a good combination of expertise.

And they were using a clinical simulation center, which is a place where people actually practice learning some of these medical techniques. So in this case it was a room where they could practice cardiac resuscitation on a dummy, a human patient simulator. And part of the authors' intent in this paper was to show that we can use these kind of spaces, these clinical simulation centers to do some of this research. And so two rooms. They had what they called normal finishes or control room 3,500 K fluorescent. And then again unfortunately, the lighting documentation, we would want to see more details today. They just called it full spectrum fluorescent. We don't know exactly what it was. And they also introduced color patterning as Anjali mentioned.

So they changed the lighting. And they changed the decor. And they found it made a huge difference in the stress levels and the alertness levels of the people. And this is now caregivers, not patients. The caregivers that were sort of simulating providing cardiac resuscitation, that the lighting in the room design made a big difference. And so my questions on the last bullet is just how do we sort that out for future research? How much of it was the decor? How much was the lighting? What are the spectral differences that might have caused that? Just overall some other details on the lighting. So I think really interesting bits of evidence we see from these types of studies hopefully can lead to some future studies that can get us further along.

And then for our third topic-- and again, feel free to send questions on those first two topics, task performance and perceptions. But we'll move into our final topic on lighting and safety now. Anjali?

Thank you. Moving onto the next slide. And Bob, we have 10 minutes to go. So we will go a little bit faster. So I mentioned earlier the study by Mahmood where they did a survey of nurses to understand metrics of lighting and the perception of the environment on errors. And there's quite a few elements that have come from that where nurses say time and again that there is a need to provide adequate lighting in different kinds of spaces other than just the patients' room-- where they do their work, including the medication room, the nursing station, even the dining room. So all of these factors are really important because they do [INAUDIBLE] associated with dispensing medication or putting medication together to provide to a patient.

Another study that was conducted in a pharmacy was pretty basic. I mean from a lighting perspective. And it's actually really old. So we haven't included it in the paper. But this is one of the few studies that have looked at it so we are including it here. They increased the light level. And progressively as the light levels increased, they found that the medication dispensing errors reduced. It's one of the few studies that has looked at the connection between lighting and errors. So we included it in this presentation here.

Again there's a lot of challenges when balancing the need for patient care activities as I mentioned earlier with those trying to dispense medication and patients having to read the drug labels, color distinction. And the whole idea of creating the healing environment. There's a study that I mentioned earlier with the acute care nursing unit. We also looked among the many various outcomes and looked at medication errors. And they found a correlation between having windows in the ward and low medication errors in the windowed conditions. Moving on.

Quite a few studies-- and I'll go through this very quickly --about lighting and ergonomics are conducted in the operating room. If anyone has ever been in health care, especially in an operating room, we spent a lot time this past year observing surgeries in ORs. And usually in an OR, you know that they are very complex, cluttered environments with lots of stuff. And the surgical lights are a very big piece of it. And the nurses say time and again how they are always bumping their heads into the lights. Or they're out of reach. There are collisions. Problems with entanglement of arms, and so on. So there is a lot of need to really think about where exactly, how accessible they are, how mobile. I mean that may not be something that you may work on as a lighting designer. But that is an important ergonomic issue that probably relates to other lighting fixtures as well.

So studies have shown that luminaire positioning was responsible for a portion of interruptions of surgical tasks. And that's a big deal. Because we're looking at further [INAUDIBLE] break the flow of the surgery that may have an impact probably on patient safety and staff safety. But also on efficiency and performance of the surgery on time which has other sort of downstream effects. Then again, you have to think about that and the ergonomics cause a lot of discomfort to surgeons and other surgical team members. So some of the improvement recommendations that have been provided in some of the studies include ease of focusing, ease of moving, reducing collisions, and easy access by surgeons, residents, and nurses.

One other element that we wanted to talk about was the effect of falls among the elderly. So a lot of people have been trying to reduce falls in nursing home settings and long term care for a very long time. And it's been a very tricky challenge to solve irrespective of whatever we do. So any other dimensions that we've seen are multi-faceted. So we could then look at identifying the risks of falls for that particular patient or resident. They do a lot of environmental modifications, training of staff. But it still continues to be a problem. But some studies have looked at the fact that lighting levels can contribute to gaited stability and speed among the elderly. So a lack of light reduces impact of spatial orientation and your ability to sort of perceive your environment and the chances of falling increase.

I should mention that Mariana Figueiro and others have looked at providing lighting information that enables people to orient themselves and improve their stability when walking, including pathway lights as well as night lights that allow vertical as well as horizontal orientation, helping to do things and minimizing the impact of falls.

Thanks, Anjali. I think I'll skip one of these and go right to the things on fall risks. I think that's a big topic for many of you that work in design of health care or senior care facilities. And Anjali mentioned these two papers in the last slide she had. So just do a little bit more background on these. This Kesler paper is a team of researchers from a medical center and university in Israel in Tel Aviv and also partnered with someone from Harvard Medical. An aging expert from Harvard Medical. The Journal of Neuroengineering and Rehabilitation.

And really interesting just to see how they get at looking at gait analysis for older folks. They compared sort of two groups of people, kind of a normal ability to walk. Healthy older adults compared with those with some high level gait disorders. And compared different light levels and found out that when the lighting is much dimmer like it would be at night, both groups slowed down as Anjali mentioned. But also for the folks that had gait disorders, they became more unsteady and more variable. Again, you know it's more than 10 years ago, this paper. So the documentation of all the different lighting variables wasn't as complete as we'd like. But a critical topic.

And then kind of a similar paper. But now with folks from Lighting Research Center, we have the lighting experts reporting here, Mariana Figueiro and others at the LRC as well as some authors from the Sage Colleges in upstate New York. A similar type study where they looked at some different lighting conditions. This one, I really found interesting that they measured light at the eye at the cornea. So they're really getting the right light level. And they have an overall sort of typical hallway ambient condition of fluorescent lighting-- 650 lux-- and then just sort of plug in night lights. And then they added laser lines that could identify the path, the walking path. Almost look like what you see in the airplane. That sort of line of lights for the exit. So it didn't add any light to the eye. But it made a huge difference, it turned out, in how comfortable an older group was in walking down that hallway under a low light level.

And so really a great study, well documented. And I think a clever idea that can directly lead to hopefully some products. In fact, the author suggests that the way they did it was not a commercial solution, the way they outlined the pathway. But there is certainly a need for commercial solutions. And of course, from the DOE standpoint, you know that's a great type of solution to offer a very low power, low energy night lighting system supplemented with something that sort of highlights the visibility in the parts of the space that need to be visible. We don't have to add a lot of light, add a lot of energy use in order to help people be able to reduce their fall risk to be able to move through the space. So with that, we'll move into our final concluding comments and the wrap up. And I'll go back to Anjali.

Yeah. I mean I think this was just to share that obviously lighting is very critical for human functioning. And the research continues to grow hopefully. And the idea is that lighting is essential for visual tasks. Poor lighting causes errors. There are some other elements over here which we haven't covered in this presentation. But lighting is also linked with pain and reducing depression. Clearly lighting levels that are controlled by people, especially in health care, are higher than what is provided by today's lighting standards. And that's true in long term care and health care. So exposure to light is helpful both from a staff performance as well as from a health and sleep and fall, within hospital, aspect. So it's very important to consider all of these things.

Natural light should be incorporated into lighting design. Think about both of these elements-- natural light as well as day-lighted lighting-- benefit the patients and staff. [INAUDIBLE], low cost. As with any kind of lighting, it's important to provide control in health care for the patients as well as staff to prevent glare and thermal discomfort. So that's an important element. Lighting design should be glare-free and shadow-free for the elderly. Light levels in transitional spaces need to be balanced with those in adjoining spaces. There is a need for high light levels which is often provided for visual tasks. High color quality lighting is recommended where fine color discrimination is needed. There is also a need for high exposure to bright light for stimulating the circadian rhythms. And there's adequate variation in light levels needed for the elderly to support sleep-wake patterns.

Great. Thanks, Anjali. So a lot of information. I'm going to put the last slide up. And I'll just let you read through these bullets. I think I've mentioned most of these things. We are just a few minutes from the end. But we'll try to answer a couple questions. So I'll turn it back to Andrea now for questions.

Thanks, Bob and Anjali. So a lot of the questions actually I would say-- especially initially-- were related to that characterization of the spectrum of these light sources used in the studies. So Bob, do you have any comments on that? And I think that could even tie into the last slide that you're showing.

Those are great questions. And I think that we're all-- again because of the sort of explosion of interest in the non-visual facts and our understanding about the intrinsically photosensitive retinal ganglion cells and how that all affects us differently than our visual track through the brain-- everyone is really interested in spectrum right now. The equipment to enable the measurement of SPD in the field is actually fairly new. Or at least reasonably cost equipment to do that is fairly new. And so I'm sure that most of the researchers we've talked about today didn't have that type of equipment available to them at the time.

So we just don't know. For most of the studies we've talked about, we have no details on the spectral power distribution. I would say for any of you that are doing research, please don't just measure light levels. Get a meter that allows you to measure the full spectrum. Take that out in your sites where you're doing your research. Measure at the eye. We talked several times here about getting those measurements at the location where someone's eye would be. So we really can document that. There's a lot of new variables that we can look at in terms of circadian stimulation or melonopic lux and some of the non-visual things. And you really need that full SPD to be able to do any of those. So most of the papers that are available today do not have that information.

And Anjali, this question I think is best directed towards you. In the research that you looked at, how often is it possible to gain patients' feedback?

That's a great question. I think in the studies that we looked at, many of them were [INAUDIBLE] the staff. And with the patients, more of the studies were looking at further obtaining sort of objective measures from the patients like stress levels measured objectively or pain perception. But I guess the paper section was a data update from the patient. But if you can get other objective measures such as the amount of pain medication that they use. So the studies do obtain data from patients.

But it clearly depends on the kind of population you're talking about. Some of the studies are looking at ICUs. And in that case, you really can't work with the patients directly. You're looking to get data out from the medical records and so on and so forth. So there is a variety in terms of how they've addressed that piece of it. But I do agree that we use kind of a combination of the objective data with the subjective perception data, especially as far as lighting is concerned.

And then this question really could be answered by either of you. But were the studies largely performed in the pre-LED era of lighting?

I would say yes. The adoption of LEDs, especially in health care facilities, I think has lagged behind probably other applications for obvious reasons. It tends to be a more risk averse sort of design paradigm. And trying new things has to be done very carefully. And so I think the vast majority of the studies that we've reported on today were done with fluorescent lighting and not with LED lighting. So the ability to control the spectrum and intensity that LED provides gives a lot of new opportunities in health care and I think for researchers also.

I agree. And I think there are some new solutions being developed for lighting. I had a chance to look at [inaudible] and others which are looking at LED. So now the question is whether they're going to actually start looking at the outcomes associated with that. So again, this is a comment to the lighting manufacturers out there and to the lighting engineers to think about how they can partner with the researchers out there to look at some of these issues so that we can enhance the knowledge base of that.

Thank you both. And with that, we're going to go ahead and wrap up today's webinar. Thank you for participating in the webinar brought to you by the US Department of Energy Solid State Lighting Program. We look forward to your participation in the third webinar of the health care series scheduled for October 18th. Thank you.