Naturally, the daily wear and tear on flooring caused by heavy equipment, hospital beds, wheelchairs, and a high volume of foot traffic, makes durability a top priority. However, it is also important to consider patient-centred requirements and emerging design trends when selecting flooring options for healthcare facilities.
If specified carefully, flooring has the potential to ease anxiety through thoughtful and inclusive design,1 guiding patients, visitors, and staff through the hospital’s labyrinth of corridors and wards, and providing the essentials of safety, infection control, and sustainability.
By appreciating the importance of hospital flooring and its role in healthcare settings, we can work to create an environment that is calming, informative and safe. This in turn mentally reinforces vitality, contributing to better patient health outcomes as well as other benefits such as an enhanced visitor experience and staff productivity.
There are five key themes that can influence how design affects patient wellbeing.
Biophilic design
Biophilic design is based on what is known as the biophilia hypothesis: “[the] idea that humans possess an innate tendency to seek connections with nature and other forms of life.” (Encyclopædia Britannica)
In simple terms, research has shown that spending time in nature is extremely beneficial for one’s mental wellbeing and emotional health. Considering the amount of time people now spend indoors, biophilic design harnesses the benefits of being in and around nature to create healthier indoor environments.
When applied to a healthcare setting, this design concept has been shown to have a particularly supportive effect. Incorporating the natural environment into the design of a hospital or healthcare facility is believed to benefit the patient recovery experience. In fact, a wide range of studies have reported exposure to nature can reduce stress, lower blood pressure, provide pain relief, improve illness recovery, accelerate healing, enhance staff morale and performance, and lead to fewer conflicts between patients and staff.2
There are several ways to apply biophilic design into hospital and healthcare settings:
- Adding indoor plants and greenery to a space.
- Using architectonic features such as fittings, accessories, and wood effect flooring.
- The use of natural materials and ample light to create the sense of being at one with nature.
- Mindfully use natural effects like wood and stone, grass, moss, and water, using digitally printed flooring, where it is appropriate to the application.
- Consider materials that are sustainable, do not release VOCs (volatile organic compounds) and have suitable acoustic qualities to support the use of the space.
- Use a natural colour palette for your scheme.
Where circumstances do not lend themselves to the inclusion of natural features, designers are challenged to think creatively for solutions. A rigorous cleaning regime, for example, may limit material choices, or an inner-city location may exclude the possibility for green views, although art depicting natural scenery can still evoke a similar sense of calm. Just as wood-effect flooring can closely mimic the real thing.
Inclusive environments
Walking into a hospital setting can be a daunting experience for any patient, as well as for family and friends visiting. For those who are neurodiverse or living with dementia, it can be unsettling, which is why creating inclusive environments can contribute to more positive inpatient stays and outpatient visits.
Sensory, mobility, or cognitive impairments (or sometimes a combination of all three) can have a serious impact on the way people experience care facilities. Functioning, behaviour, independence and, ultimately, quality of life can all be compromised, but appropriately designed environments — including the correct specification of floor coverings — can help keep them safe.
Currently, there are around 900,000 people living with dementia in the UK, a figure that is projected to rise to 1.6 million people by 2040.3 Dementia is an umbrella term that covers a range of conditions that affect the brain, with each of the different types of dementia having different sets of symptoms and effects. This can include issues with memory, thinking, reasoning, language, movement, and motor control. Dementia can also affect perception, so people may have problems seeing things in three dimensions and judging distances.
In collaboration with the Dementia Services Design Centre (DSDC), Forbo has developed a portfolio of solutions that work with their set of guidelines to ensure that everyone can navigate a building safely:
- It is recommended that a difference of 30 degrees in Light Reflectance Values (LRV) is achieved between surfaces — such as floors, walls, and doors.
- Adjoining floor areas must be similar tonally to prevent the perception of a step that is not there and could cause a fall. Flooring LRVs should be within eight degrees of each other (although less is better).
- The transition strips between flooring should also match the tones of both flooring surfaces, with an ideal difference of no more than three degrees of LRV. Greater tonal difference can again create the illusion of a change in floor height.
- For flooring, a matt finish with a simple, plain design is recommended. Flecked, striped, or patterned effects or flooring that incorporates a logo should be avoided as these can cause confusion and hallucinations. Also, glossy or sparkly flooring could be perceived as a wet surface.
Acoustics
Providing an environment with minimal noise is essential in healthcare facilities. Noise in such buildings can have a variety of sources including alarms, machines, wheeled traffic (moving beds, wheelchairs, and carts), HVAC systems and people. This noise can be harmful if it causes increased levels of stress or disturbs rest and sleep of the patients.
Sleep is an important part of recovery and general wellbeing for anyone. Research has shown that despite the need for rest and recovery during acute illness, hospitalisation is a period of acute sleep deprivation for older adults due to environmental factors. Sleep loss in hospital is associated with worse health outcomes and non-pharmacological interventions have shown promise in improving sleep loss.4
Research by acoustical engineers at John Hopkins University found that noise in hospitals has significantly increased since the 1960s; average daytime hospital sound levels have risen from 57 to 72 dB, while average night-time levels have increased from 42 to 60 dB.5 All these levels exceed the World Health Organization’s (WHO) recommendation of 35 dB upper limit for sound levels in patient rooms.
As such, creating a comfortable acoustic environment can play an important role in supporting safety, health, and wellbeing for all occupants. In recognition of the effect noise can have on individuals, manufacturers are constantly striving to develop innovative acoustic products to meet customer demand and regulatory requirements.
Building elements such as acoustic ceilings, partitions, and flooring can all offer significant contributions to noise reduction. In fact, floor coverings can help in two ways: impact sound reduction (noise generated by traffic contacting the floor surface that is transmitted through the floor to rooms below) and reducing in-room impact noise. In specifying acoustic products, it is important that they not only meet the sound reducing objectives but also the functional and design requirements.
There are many floor coverings available on the market for healthcare buildings that meet these various considerations, but one of the most popular choices is vinyl, thanks to the fresh and striking colour tones and performance characteristics.
Understanding the relevant building codes and healthcare regulations regarding flooring materials will ensure compliance and that all safety and healthcare standards are met. It is also worth conducting acoustic testing or consulting with flooring experts to assess the suitability of various flooring materials for your specific healthcare facility. This can help identify potential acoustic issues and guide the decision-making process.
Paying attention to the installation method and subfloor preparation to minimise noise transmission between floors will also ensure the acoustic performance of the flooring.
Health first
Some might say these are givens in a hospital setting, but the right flooring can impact heavily on each of these areas.
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n Infection control
One of the key priorities for all hospitals is to ensure that patients, visitors, and staff are protected from the risk of healthcare-associated infections caused by bacteria (germs), which should be in accordance with the requirements set out in The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance.
When it comes to infection control, there is no better way than to start from the flooring up. In fact, there are floor coverings available on the market that have been proven to inherently inhibit the growth and spread of infections such as MRSA, norovirus, E. coli and C. difficile — helping to contribute to a healthier and more hygienic environment in any area of a hospital.
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n Indoor air quality
Another way to keep contaminants out of a healthcare setting is through the right ventilation strategy, but as there are many sources of pollutants a more holistic approach must be taken to ensure patients and other building occupants can breathe easy.
Indoor air quality (IAQ) encompasses a wide variety of factors including temperature, humidity, presence of chemicals and other contaminants, such as indoor allergens. Poor air quality has been directly linked to health conditions such as asthma, chronic obstructive pulmonary disease (COPD) and lung cancer, as well as an increased risk of cardiovascular diseases.6 Therefore, maintaining a good IAQ is especially important in healthcare environments, where people are more vulnerable to its effects.
A particular concern is Volatile Organic Compounds (VOCs). VOCs are a group of chemicals that evaporate at room temperature and, as such, contribute to indoor air pollution.7 VOCs are emitted by many wall and floor coverings, furniture, and appliances throughout their lifespan, and the negative health effects of these chemicals are well documented.8
There are a wide range of interior products available that have low VOCs and other emissions. It is also worth looking for floor coverings and other materials that have achieved the Allergy UK ‘Seal of Approval’, which provides independent certification of products proven to reduce or remove allergens from the indoor environment.
Safety flooring
In 2023/24 there were 26.2 million attendances to A&E, a significant increase in comparison to previous years.9 With this in mind, it is important to keep all those recovering, visiting, or working in a hospital safe from hazards, such as slips and trips. In fact, with hospitals being very busy places, the floors are exposed to all types of contaminants. As such, maintaining a high level of slip resistance is key to patient and staff safety — and this is where specifying appropriately graded slip resistant flooring can make a significant difference.
When specifying safety flooring, it can be useful to understand the testing methods used to grade the products, to help identify the correct solution.
First up is the Pendulum Test, recommended by the Health and Safety Executive (HSE) to assess the slip resistance of floor surfaces. A pendulum test is conducted by a swinging arm that sweeps over a flooring surface. One side of this arm is a rubber slider, which strikes and passes along the floor from a predetermined distance. Once the arm strikes the floor, friction will cause it to slow down. Where the arm finishes following the swing will indicate a value with a pointer and this is your pendulum test value (PTV). The test can assess slip resistance in both dry and contaminated conditions and measures the coefficient of friction of a floor surface to provide a slip potential classification. The UK Slip Resistance Group and HSE guidelines demonstrate that a PTV of zero to 24 indicates high slip potential, a PTV of 24 to 35 signifies moderate slip potential, and a PTV of 36 or higher is classified as low slip risk.
There is also the ‘Ramp Test’, mainly referred to as the R rating. This test is conducted by strapping a test subject — who is linked up to a safety harness — onto a ramp, which is lubricated with oil. The angle of the ramp is then raised, and the tester will take small steps backwards and forwards in boots until they slip. A computerised readout will determine the R rating based on the angle at which the slip occurred or when the tester begins to feel unsafe, which starts at R9 as a minimum standard and increases to the maximum of R13.
It is a common misconception that R10 floor coverings are extremely slip-resistant, with some people believing that the scale starts at R1, when in fact it does not. Ramp test values are also based on ex-factory testing and do not take into account changes in slip resistant properties that could occur during the working life of the floor covering. DIN51130 ramp test values should not be considered in isolation, but rather alongside the PTV as well.
Different spaces in a healthcare setting also have specific requirements. For bathroom, toilet, and changing rooms, a floor covering needs to offer outstanding slip resistance. It must cope with the demands of constant footfall, wheeled traffic, and spillages, as well as the level of cleaning required. In a bedroom, slip resistance is of course important but acoustic and patient comfort properties may also be a priority.
Every area within a hospital setting requires full assessment.
Wayfinding
Well-designed flooring can aid in guiding patients, visitors, and staff through complex hospital layouts with ease and minimal stress.
The use of colour in a healthcare environment can not only ensure that a welcoming atmosphere is created, but it can also help to define different areas of a building and assist people with wayfinding. Colour can play a big part in helping people to find their bearings, to understand the spatial layout of the hospital, to note areas that have information about key routes on the site and to recognise that they have arrived at their desired destination.
Variation in materials on the floor can create pathways and help people move around a busy space in a more organised manner. Typical routes along corridors or in large open circulation spaces can be suggested by materials and colours on walls and floors can create pathways and ‘no entry’ areas.10
Furthermore, considering the flooring from an accessibility perspective for those with limited mobility and neurodiversity eases the way finder’s path and should be barrier free. Another consideration is flooring acoustics for information areas, where people are asking for directions or spaces where patients or loved ones are receiving difficult news and it may be hard to hear for a number of different reasons.
All these factors contribute to creating a less stressful journey and can go some way to alleviating uncertainty. This makes the use of navigational flooring an important part of the healthcare setting, aiding wellbeing by reducing stress and the knock-on effect this has on the atmosphere.
Conclusion
Increasing cost pressures on the NHS and an ageing population (and infrastructure) make it an interesting time in hospital and healthcare design. Yet, with a lens on patient-centred care, commitment to Net Zero and the complex requirements of a healthcare setting, some exemplary buildings are being constructed.
Adaptable buildings, repeatable room formats, and advanced technology are all on the table, but what does the future for flooring finishes in hospital and healthcare settings look like and how can it contribute to shaping positive patient outcomes? The specification of the flooring clearly requires a holistic approach, balancing the multiple requirements of each area is crucial.
By using techniques such as biophilic design to bring the outside in or designing more inclusive environments to harmonise the senses visually and acoustically, intelligent flooring installation can contribute to a better healthcare experience.
From infection control and indoor air quality to helping users navigate the building, safely and easily, flooring is an integral part of all healthcare structures.
References
1 Bear J. Interiors that reduce patient anxiety, depression. Healthcare Design 2012; Oct 11.
2 Kellert SR, Calabrese EF. The Practice of Biophilic Design (www.biophilic-design.com).
3 Facts for the media about dementia (www.alzheimers.org.uk/about-us/news-and-media/facts-media).
4 Arora VM, Stewart N. Sleep in hospitalized older adults. Sleep Med Clin 2018; 13 (1): 127—35.
5 Rise in hospital noise poses problems for patients and staff. ScienceDaily 2005; Nov 21, (www.sciencedaily.com).
6 Air pollution at home. (www.asthmaandlung.org.uk).
7 British Coatings Federation Ltd. VOCs and air quality. (www.coatings.org.uk).
8 Public Health England. Indoor Air Quality Guidelines for selected Volatile Organic Compounds (VOCs) in the UK. (assets.publishing.service.gov.uk).
9 What’s going on with A&E waiting times? (www.kingsfund.org.uk).
10 Department of Health. Health Building Note 00-01. General design guidance for healthcare buildings. (www.england.nhs.uk).