Preliminary Development of Items for a Nurses' Physical Environmental Stress Scale

RESEARCH PURPOSE

This study aimed to develop a preliminary Nurses' Physical Environmental Stress Scale (NPESS) that explores the relationships between the physical environment in the intensive care unit (ICU) and work-related stress among ICU nurses.

BACKGROUND

Working within the healthcare field is stressful and comes with a high level of responsibility for nurses, especially ICU nurses. The ICU work environment is associated with risk factors such as excessive workload, increased expectations, and long working hours that can lead to burnout among nurses. There is some evidence that environmental design has the potential to prevent or mitigate work-related stress; however, an adequate assessment tool to identify physical environmental stressors or supports for moderating stress is lacking.

METHODS

To develop the preliminary environmental assessment tool, an exploratory sequential methodology was used. The approach consisted of three distinct phases, including (a) a qualitative content analysis of existing focus group data, (b) a qualitative content analysis of pertinent literature related to environmental assessment tools in a healthcare context, and (c) the development and refinement of the NPESS assessment tool. Tool refinement was based on interviews with ICU nurses.

RESULTS

The resulting NPESS tool was comprised of seven sections (sounds, lighting, smells, staff respite spaces, staff workspaces, patient rooms, and aesthetic qualities) containing a total of and 81 items that address factors that were identified as potential moderators of environmental stress in ICU settings.

CONCLUSIONS

The resulting NPESS assessment tool provides a feasible approach for evaluating ICU settings to identify possible improvements to reduce stress among nurses. Future research will be conducted to assess the validity and reliability of the final tool by distributing it to a larger sample of ICU nurses.

Developing Resilient Community Spaces in Healthcare Facilities: An Exploratory Study of a Public Health Crisis

OBJECTIVES

This exploratory study aimed to investigate the impact of the COVID-19 pandemic on the design of healthcare facilities, particularly those featuring communal spaces. It sought to identify strategies that were implemented, learned, or recognized when adapting to the limitations imposed by protective measures during the pandemic.

BACKGROUND

Third places are social gathering places outside of home and work. Over time, these community-centric places evolved from free-standing getaways to more integrated niches in diverse contexts including healthcare. Their numerous advantages for users include enhancing community bonds and collaboration among healthcare workers. The onset of the COVID-19 pandemic resulted in a need to rethink the design of such spaces to make them more adaptable and resilient.

METHODS

An exploratory qualitative study was conducted through in-depth semi-structured interviews with sixteen practitioners involved in healthcare architecture and design projects during the pandemic. Data were analyzed using a thematic analysis approach.

RESULTS

Findings indicate that the design of shared spaces in healthcare facilities for pandemic-like situations requires a special focus on modifiability and multifunctionality, achievable through strategies such as the use of movable, unconnected, and rearrangeable furniture or partitions that could swiftly change the function of a space. Other strategies include the capacity for compartmentalization of spaces, fostering indoor-outdoor connections, integrating advanced technology, and implementing effective infection control measures. Detailed emergent themes and examples of experienced constraints are discussed.

CONCLUSIONS

Insights gained from our findings can be applied to new and ongoing healthcare design projects to ensure resiliency during normal and pandemic conditions.

Adapting to Change: A Systematic Literature Review of Environmental Flexibility in Emergency Departments

PURPOSE

This study aimed to offer a comprehensive analysis of distinct design strategies identified, evaluated, or discussed in the existing literature that promote environmental flexibility in the context of emergency departments (EDs).

BACKGROUND

EDs are subject to constant changes caused by several factors, including seasonal disease trends, the emergence of new technologies, and surges resulting from local or global disasters, such as mass casualty incidents or pandemics. Thus, integrating flexibility into ED design becomes crucial to effectively addressing these evolving needs.

METHODS

A systematic search was conducted in four databases: CINAHL, MEDLINE, PubMed, and ScienceDirect, in addition to a hand search. A two-stage review process was employed to determine the final list of included articles based on the inclusion criteria. Included studies were evaluated for quality, and findings were categorized using a hybrid deductive and inductive coding approach.

RESULTS

From the initial yield of 900 records, 22 studies met the inclusion criteria and were included in the final full-text review. The identified design strategies were organized into five categories: modifiability (n = 13 articles), versatility (n = 8 articles), tolerance (n = 6 articles), convertibility (n = 4 articles), and scalability (n = 7 articles). Specific design strategies under each category are reported in detail.

CONCLUSIONS

Our findings suggest that most flexibility design solutions are based on anecdotal evidence or descriptive studies, which carry less weight in terms of reliable support for conclusions. Therefore, more studies employing quantitative, relational, or causal designs are recommended.

Coping and Caregiving: Leveraging Environmental Design to Moderate Stress Among Healthcare Workers in the Emergency Department Setting

BACKGROUND

Due to exposure to overwhelming work stressors, approximately half of emergency department (ED) physicians and nurses experience burnout, leading to lower productivity, lower quality of care, higher risk of medical errors, higher rates of absenteeism, and eventually turnover. Growing evidence suggests that the physical environment can be leveraged to support healthcare workers' well-being.

OBJECTIVES

This study aimed to identify (1) self-care behaviors that healthcare workers engage in to help them cope with job-related stress, (2) where they engage in those behaviors, (3) attributes of the built environment that may support coping behaviors.

METHODS

A mixed-methods study was conducted in three EDs, using online questionnaires (n = 85) and interviews (n = 20).

RESULTS

Job-related stress was derived from interruptions, workload and inability to take breaks, insufficient workspace, lack of privacy, unpredictability of EDs, and security concerns. Talking with a colleague, getting something to eat or drink, listening to music, and taking a walk were considered destressing activities. The bathroom was considered a place for destressing by the majority of participants, followed by outside areas, physician-only areas, and care team stations. Supportive environmental features included sufficient workspace, maximized privacy, reduced noise and clutter, controlled temperature and lighting, spaces for decompressing, spaces for documentation, close-by breakrooms with enough eating space and massage chairs, chairs with back support, standing desks, food options, and convenient bathrooms.

CONCLUSIONS

Design decisions play an important role in supporting stress reduction among healthcare workers. This study provides several strategies to achieve this aim.

From Stressful to Mindful: Reactions to a Proposed Emergency Department Design for Enhancing Mindfulness and Stress Reduction Among Healthcare Clinical Staff

OBJECTIVES

This study explored design solutions that can help clinicians manage work-related stress, pursue mindful work, and practice relaxation and coping strategies.

BACKGROUND

Clinicians are experiencing burnout at increasingly higher rates, leading to compromised patient care. While self-care and stress management strategies are shown to be effective in healthcare settings, little is known about how the design of healthcare settings can facilitate these strategies.

METHODS

Using findings of a preceding study by the authors, a virtual walk-through video of a design proposal for a free-standing emergency department was built. Feedback data were collected from clinicians in 10 in-depth interviews, and emerging themes were identified using qualitative content analysis.

RESULTS

Our findings suggest that work environments that reflect intentional efforts to meet clinicians' needs for stress management can enhance their feeling of being valued and sense of professional worth. Clinicians are more likely to step away from work if there are multiple spaces for bio breaks and rest breaks. Primary break rooms are preferred to be close to patient care areas, but respite/escape spaces are preferred to be distant and private from patient care areas. Participants endorsed the provision of at least one staff bathroom large enough for extra seating and one outdoor respite space. Multiple workspaces should allow the completion of various tasks with adjustable levels of privacy.

CONCLUSIONS

We suggest special attention to non-institutional aesthetics, providing choice and control, increasing flexibility, promoting privacy for focused work, maximizing access to daylight and outdoors, and providing opportunities for grief support.

Using Space Syntax Analysis to Measure Patient Aggression Risk

OBJECTIVES

The present study investigates whether space syntax offers appropriate tools for identifying risks of aggression, interventional opportunities, and environmental design strategies to reduce the risk of Type II violence in emergency departments.

BACKGROUND

Although healthcare workers are a relatively small percentage of the U.S. workforce, they sustain almost 75% of workplace assaults. Poor environmental design has been identified as an antecedent to aggression by patients and/or their companions.

METHOD

Guided by Rational Choice Theory, Lifestyle Exposure Theory, Routine Activity Theory, and Crime Prevention through Environmental Design (CPTED), the study uses five visibility graph analysis (VGA) measures: visibility, control, controllability, mean visual depth, and occlusivity. Three U.S. hospital-based emergency departments were selected. First, a VGA was performed on all three layouts. A second VGA was performed after excluding unconnected spaces, and a third was performed on key patient and staff areas. Last, a fourth VGA was conducted after performing physical modifications to the three departments.

RESULTS

Statistical analysis revealed significant differences in VGA measures not only between different layouts but also between the original and modified layouts. Specifically, small changes created by architectural features can affect visual access and exposure as measured by space syntax. Alcove-style spaces in key staff areas are also associated with limited visual control of the local environment. Typically, in smaller zones, central staff workstations afford better control of patient spaces.

CONCLUSION

This study shows that space syntax analysis is a useful tool for identifying risks of aggression in hospital spaces and for identifying interventional opportunities.

Toward Building Surge Capacity: Potentially Effective Spatial Configurations in Emergency Departments

BACKGROUND

Emergency departments (EDs) have been struggling with overcrowding issues for years. Some spatial configurations have been proposed to improve ED performance in facing overcrowding. Despite similarities with mass casualty incidents (MCIs), when demand for care exceeds the capacity, little is documented about the application of the proposed configurations during MCIs to improve surge capacity.

OBJECTIVES

We aimed to explore the potential of spatial configurations that have been proposed to handle ED overcrowding in daily operations so as to improve surge capacity during MCIs.

METHODS

Using an online Likert-scale survey, 11 spatial design strategies were rated by ED care teams in terms of their potential to improve surge capacity during MCIs.

RESULTS

Responses from 72 participants revealed that establishing an in-house lab was perceived as the most potential strategy, followed by rapid care area, internal waiting rooms, and in-house imaging. In contrast, separate entrance and exit doors, as well as decentralized nurse stations, were perceived as the least potential strategies but also exhibited the most variance in response. Respondents' comments implied that their choice of in-house ancillary services was primarily to improve communication and to reduce turnaround time and risk of errors. Their choice of rapid care and internal waiting areas related to improved flexibility.

CONCLUSIONS

Understanding clinicians' perspectives on potentially effective spatial configurations aids in implementing balanced strategies to better equip EDs to handle overcrowding in daily operations and manage surges during MCIs.

The use of virtual reality to modify and personalize interior home features in Parkinson's disease

As the second most common progressive neurodegenerative disorder with increased prevalence in the aging population, Parkinson's disease (PD) affects more than 10 million individuals worldwide with approximately 60,000 new cases occurring each year only in the US. While daily living abilities deteriorate in people with PD, they spend a significant amount of time in their homes. Unfortunately, most existing guidelines for home modification design reflect a standardized, singular plan. This study aimed to demonstrate the feasibility of using a virtual reality (VR) system for persons with PD to virtually walk through different home modifications and to adapt and personalize interior features. A sample of 15 participants with idiopathic PD and 24 healthy adults ambulated on a pressure mat, while using a VR headset and hand controller. Both groups envisioned walking through a virtual doorway from a simulated bedroom into its attached bathroom. Design features for the intervention included doorway width and door-frame color. Each participant was randomly assigned to one of three intervention conditions: (1) standard design, (2) enhanced design, and (3) co-design. The codesign module allowed participants to manipulate design features using a hand controller. We recorded 4 movement variables. Participants completed three questionnaires assessing anxiety, system usability, and satisfaction. Healthy control adults revealed no differences in movement or subjective assessment between the three intervention conditions. However, there were significant differences in the PD group between co-design and the other conditions. The changes were appreciated in the baseline measures of gait distance and strikes as well as in the composite gait component score. This study showed that using VR as a participatory design tool for persons with PD is safe and feasible. Additionally, the self-determination of interior design conditions may possibly affect movement performance measures and merits additional controlled trials.

The Impact of the Built Environment on Patient Falls in Hospital Rooms: An Integrative Review

OBJECTIVES

The aims of this study were to identify and evaluate scientific evidence examining the impact of the built environment on patient falls in hospital rooms.

METHODS

An integrative review (IR) with a systematic literature search was performed using the patient, intervention, comparison, outcome framework. We searched CINAHL, PsychINFO, PubMED, and Web of Science databases. The search included peer-reviewed studies from 1990 to 2017 written in English. An additional hand search was also conducted. Selected articles were reviewed and rated based on a hierarchical categorization, comprising six evidence levels, developed by the American Association of Critical-Care Nurses and adapted for evidence-based design systematic literature reviews.

RESULTS

After a multitiered process, 30 articles met the selection criteria. Thematic areas were created based on the examined elements of the physical environment including patient room configuration and available space, bathroom configuration, bathtub and shower, door, bed height and bed rail, flooring, floor mats, patient chair, lighting, toilet, handrail, grab bars, intravenous pole, sink, ceiling lift, and wheelchair and walking aids. Findings of studies on each element are discussed in detail.

CONCLUSIONS

Some environmental elements have not been examined in past relational or causal studies, and the level of evidence for the examined attributes is not high enough to gain robust confidence in healthcare design decision-making. Because of the low level of evidence for several environmental elements, conclusions must be taken with caution. More studies using quantitative, relational, or causal designs are recommended to develop actionable interventions on patient falls in hospital rooms.

Physical Design Factors Contributing to Patient Falls

OBJECTIVES

The aim of this study was to identify physical design elements that contribute to potential falls in patient rooms.

METHODS

An exploratory, physical simulation-based approach was adopted for the study. Twenty-seven subjects, older than 70 years (11 male and 16 female subjects), conducted scripted tasks in a mockup of a patient bathroom and clinician zone. Activities were captured using motion-capture technology and video recording. After biomechanical data processing, video clips associated with potential fall moments were extracted and then examined and coded by a group of registered nurses and health care designers. Exploratory analyses of the coded data were conducted followed by a series of multivariate analyses using regression models.

RESULTS

In multivariate models with all personal, environmental, and postural variables, only the postural variables demonstrated statistical significance-turning, grabbing, pushing, and pulling in the bathroom and pushing and pulling in the clinician zone. The physical elements/attributes associated with the offending postures include bathroom configuration, intravenous pole, door, toilet seat height, flush, grab bars, over-bed table, and patient chair.

CONCLUSIONS

Postural changes, during interactions with the physical environment, constitute the source of most fall events. Physical design must include simultaneous examination of postural changes in day-to-day activities in patient rooms and bathrooms. Among discussed testable recommendations in the article, the followings design strategies should be considered: (a) designing bathrooms to reduce turning as much as possible and (b) designing to avoid motions that involve 2 or more of the offending postures, such as turning and grabbing or grabbing and pulling, and so on.

In the Moment: Fostering Mindfulness and Reducing Stressors in the Healthcare Workplace

While healthcare design research has primarily focused on patient outcomes, there is a growing recognition that environmental interventions could do more by promoting the overall quality of care, and this requires expanding the focus to the health and well-being of those who deliver care to patients. Healthcare professionals are under high levels of stress, leading to burnout, job dissatisfaction, and poor patient care. Among other tools, mindfulness is recommended as a way of decreasing stress and helping workers function at higher levels. This article aims to identify potential environmental strategies for reducing work-related stressors and facilitating mindfulness in healthcare settings. By examining existing evidence on workplace mindfulness and stress-reducing design strategies, we highlight the power of the physical environment in not only alleviating stressful conditions but intentionally encouraging a mindful perspective. Strategies like minimizing distractions or avoiding overstimulation in the healthcare environment can be more effective if implemented along with the provision of designated spaces for mindfulness-based programs. Future research may explore optimal methods and hospital workers' preferences for environments that support mindfulness and stress management. The long-term goal of all these efforts is to enhance healthcare professionals' well-being, reignite their professional enthusiasm, and help them be resilient in times of stress.

Data-Driven Design Strategies to Address Crowding and Boarding in an Emergency Department: A Discrete-Event Simulation Study

OBJECTIVE

To address prolonged lengths of stay (LOS) in a Level 1 trauma center, we examined the impact of implementing two data-driven strategies with a focus on the physical environment.

BACKGROUND

Crowding in emergency departments (EDs) is a widely reported problem leading to increased service times and patients leaving without being seen.

METHODS

Using ED historical data and expert estimates, we created a discrete-event simulation model. We analyzed the likely impact of initiating care and boarding patients in the hallway (hallway care) instead of the exam rooms and adding a dedicated triage space for patients who arrive by emergency medical services (EMS triage) to decrease hallway congestion. The scenarios were compared in terms of LOS, time spent in exam rooms and hallway spaces, service time, blocked time, and utilization rate.

RESULTS

The hallway care scenario resulted in significantly lower LOS and exam room time only for EMS patients but when implemented along with the EMS triage scenario, a significantly lower LOS and exam room time was observed for all patients (EMS and walk-in). The combination of two simulated scenarios resulted in significant improvements in other flow metrics as well.

CONCLUSIONS

Our findings discourage boarding of admitted patients in ED exam rooms. If space limitations require that admitted patients be placed in ED hallways, designers and planners should consider enabling hallway spaces with features recommended in this article. Alternative locations for boarding should be prioritized in or out of the ED. Our findings also encourage establishing a triage area dedicated to EMS patients in the ED.

Investigating the Impact of Healthcare Environmental Design on Staff Security: A Systematic Review

Objective:

To systematically review the literature regarding the role of the physical environment in preventing or mitigating aggressive behavior toward healthcare professionals in acute care, outpatient, and psychiatric/behavioral health facilities.

Background:

Globally, the incidence of violence against healthcare professionals is alarming. Poor environmental design has been identified as a risk factor of violence toward employees. The design of the physical setting in which healthcare is provided may moderate the incidence and severity of violence against healthcare workers.

Methods:

We conducted electronic database searches of PubMed and CINAHL through November 2018.

Result:

Findings were organized according to four categories identified in the literature regarding crime prevention through environmental design (CPTED) including natural surveillance, access control, territoriality, and other CPTED elements. Fifteen studies (published between 1991 and 2017) met the inclusion criteria. Of the 15 studies, 4 incorporated environmental interventions. In the 11 remaining studies, physical environment attributes (i.e., layout, location, ambient conditions, equipment) were among the factors affecting violent incidents and staff security. Most study settings were hospital-based (11, with 10 of those specifically focused on emergency departments), followed by behavioral health facilities (4 studies). Design-focused recommendations, such as providing a second door in a triage room and a sub-waiting area inside the treatment zone, were summarized according to CPTED categories.

Conclusion:

This review suggests that the physical environment in healthcare facilities may affect the incidence of violence by patients or visitors against staff. Further research is needed to identify environmental design strategies that may protect the safety of healthcare professionals.

Design Strategies to Improve Emergency Departments' Performance During Mass Casualty Incidents: A Survey of Caregivers

OBJECTIVES

To identify effective facility design strategies to improve the performance of healthcare providers and patient flow during mass casualty incidents (MCIs) in emergency departments.

BACKGROUND

Emergency departments (EDs) are the first line of medical care in MCIs. While operational surge management plans are well described in literature, physical design strategies to improve performance and patient flow during disasters are discussed scarcely.

METHOD

An online questionnaire was sent to EDs' caregivers nationwide asking them to rate the effectiveness of nine physical design strategies, discussed in the literature, to improve caregivers' performance and patient flow during MCIs. Assessed strategies were about providing expandable departments and care areas, alternate care facilities for the least sick to maximize care areas for critical patients, care areas from nonemergency units, increased number of decontamination units, dedicated isolation units, within-hospital and close emergency operation centers, and within-hospital media areas.

RESULTS

All suggested strategies were rated as effective. The most effective and agreed-upon solution was identified as maximizing the care area for critical patients by establishing an alternate care facility with separate entrance and exit doors from the emergency department for the least critical patients. The least effective and agreed-upon strategy was identified as locating a media unit within the hospital outside of the ED.

CONCLUSIONS

Caregivers who work in EDs consider design strategies to be effective in surge management during disasters. Designers can consider implementing identified strategies in designing new emergency departments or expansion and renovation projects.

Safer chairs for elderly patients: design evaluation using electromyography and force measurement

A vast majority of patient fall events in hospitals involve the elderly. In inpatient care settings, despite the risk of fall, patients are encouraged to leave their bed, move around their room, and sit on their chair to progress in their healing. Despite the vital role of patient chair design in improving recovery, few studies have examined the ergonomic requirements of safe patient chairs. This study examined the impact of manipulating horizontal and vertical positions of armrests in a test chair on required physical effort during Stand-to-Sit-to-Stand (St-Si-St) transitions among 15 elderly women. Physical effort was measured using: (1) surface electromyography (sEMG); (2) force measurement by load cells; (3) video recording. Findings showed non-linear patterns of change in required physical effort due to changes in armrests' height and distance. It was also found that minimum effort is associated with armrests higher and farther apart than those in typical patient chairs. Practitioner Summary: Safe chairs are essential for inpatient recovery, yet their ergonomic features are not investigated. Impact of changes in chair armrests on required physical effort was examined using electromyography, force measurement and video recording. Armrests higher and farther apart than those in typical patient chairs may be safer for elderly patients.

Delivering Rural Health in a Changing Health Model: A Qualitative Study Involving Four Hospitals

OBJECTIVES

An exploratory examination of rural hospital staff experiences to determine whether the physical state of rural healthcare facilities influence the healthcare experience and perception of care quality.

BACKGROUND

Rural hospitals have served as the backbone of rural communities in the United States. Over time, these facilities have witnessed enhanced expectations, expanding their scope of operations from acute care to diversified services through linked provider networks and disaster management. Simultaneously, financial challenges, increasing emphasis on safety and quality, and the Affordable Care Act have introduced new challenges for rural hospitals. Currently, there is little empirical knowledge in this domain from a facility perspective.

METHODS

An exploratory qualitative study was conducted, involving semistructured interviews of upper and mid-level administrators in four rural hospitals located in West Texas. All questions attempted to obtain the subject's knowledge, ideas, and opinions concerning the physical design of the hospitals and the hospital experience.

RESULTS

According to data on staff experiences, two classes of factors surfaced as potential influencers of hospital experience and care quality: (1) care configuration and (2) outdated building. Care configuration pertains to positioning facilities designed with inpatient care focus to a market expanding in outpatient services. Outdated buildings affect several issue including perceived provider quality and spatial accommodations for safe/efficient care and thereby also affecting the healthcare experience.

CONCLUSIONS

Physical infrastructure of rural hospitals may have important and meaningful implications for population health performance in rural America.

Making Your Instruments Work for You

Objective measures are alluring owing to the apparent robustness of data generated. However, there are numerous validity, reliability, cost, and logistics issues that can affect a study involving objective instruments. Using an ongoing study on patient chair design, this article highlights some of the important issues that an investigator must address, including repeatability, sensitivity and specificity, generalizability, integration, installation, budget, outcome, and time.

The Impact of Simulated Nature on Patient Outcomes

Objective:

To examine whether incorporation of simulated nature, in the form of ceiling mounted photographic sky compositions, influences patient outcomes.

Background:

Previous studies have shown that most forms of nature exposure have a positive influence on patients. However, earlier studies have mostly focused on wall-hung nature representations. The emergence of simulated nature products has raised the question regarding the effects of the new product on patient outcomes.

Methods:

A between-subject experimental design was adopted, where outcomes from five inpatient rooms with sky composition ceiling fixture were compared to corresponding outcomes in five identical rooms without the intervention. Data were collected from a total of 181 subjects on 11 outcomes. Independent sample tests were performed to identify differences in mean outcomes.

Result:

Significant positive outcomes were observed in environmental satisfaction and diastolic blood pressure (BP). Environmental satisfaction in the experimental group was 12.4% higher than the control group. Direction of association for diastolic BP, nausea/indigestion medication, acute stress, anxiety, pain, and environmental satisfaction were consistent with a priori hypothesis. A post hoc exploratory assessment involving patients who did not self-request additional pain and sleep medication demonstrated confirmatory directions for all outcomes except Systolic BP, and statistically significant outcomes for Acute Stress and Anxiety—Acute Stress and Anxiety levels of the experimental group subjects was 53.4% and 34.79% lower, respectively, than that of the control group subjects.

Conclusion:

Salutogenic benefits of photographic sky compositions render them better than traditional ceiling tiles and offer an alternative to other nature interventions.

Neural correlates of nature stimuli: an FMRI study

OBJECTIVE

Examine whether there are unique patterns of brain activation associated with exposure to photographic sky compositions (representing nature stimuli) as compared with other positive, negative, and neutral images.

BACKGROUND

The positive impact of nature images on health outcomes traditionally has been measured using behavioral and physiological indicators. However, there is a lack of understanding of the underlying neural mechanism that explains this positive influence.

METHODS

A combination of behavioral responses and functional magnetic resonance imaging (fMRI) technology was used to address research questions. Ten participants belonging to five age groups were subjected to short (25 seconds) exposures of 32 images while their brain activation was monitored via the BOLD response. In a separate run, participants were subjected to extended exposures (12 minutes) of a sky composition and an image of a traditional ceiling.

RESULTS

The results show that the activation patterns produced by sky compositions and positive images were quite similar as compared to negative or neutral images. However, sky compositions also produced some unique areas of activation, including those associated with spatial cognition, the expanse of space, circadian rhythm, and perceived motion. In the extended exposure condition, sky compositions tended to activate regions associated with dreaming, while traditional ceiling images activated regions that are related to face processing and potentially visual hallucinations.

CONCLUSIONS

Nature stimuli, with a combination of vegetation and sky, may produce unique beneficial effects not present in general positive stimuli.

KEYWORDS

Evidence-based design, hospital, healing environments, outcomes, patient-centered care.