Nature! Small steps that can make a big difference

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1 Guest Editors Column Nature! Small steps that can make a big difference Health Environments Research &DesignJournal 2016, Vol. 9(2) 6-10 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalspermissions.nav DOI: / herd.sagepub.com William C. Sullivan, PhD 1 and Rachel Kaplan, PhD 2 Healthcare design is incredibly complicated. The contexts range widely, the technical details are endless, and regulations and professional standards are imposing. Creating healthcare settings that meet these many constraints is complex and demanding. But healthcare design needs to address even more challenges. Healthcare settings must also promote the wellbeing of the great diversity of individuals who use these settings. As such they would also: Enhance the users capacity to think clearly and listen with care; Reduce the stress they are feeling; Support their inclination to reflect on their situation and plan for the future. At first glance, designing such a setting may seem beyond the reach of most facilities. How can you address the diversity of motivations people have for seeking care? Some come in with prevention on their minds while others are facing a major life event (e.g., having a baby, learning of a serious diagnosis) and still others entail the constantly changing vicissitudes of longterm care. Then there are the needs of the professionals who spend their days working in healthcare settings. On top of all the existing requirements, adding the notion that the design of such settings might also help people think clearly, listen with care, feel less stress, and reflect may seem an unreasonable request. Wouldn t it be wonderful if there were some design feature that could produce all of these benefits! There just may be. There is mounting evidence that exposure to nature may provide that key factor. Places that include visual or physical access to trees, flowers, water, and daylight have been shown to have a wide range of physical and psychological benefits. Consider some recent findings. Compared to seeing scenes of an urban setting without vegetation, viewing scenes of a green space or a forest significantly reduces the stress people feel (Brown, Barton, & Gladwell, 2013; Jiang, Chang, & Sullivan, 2014). Individuals who were randomly assigned to look at images of green settings, as opposed to those assigned to see built or geometric scenes, scored significantly higher on standard tests of attention (Berto, 2005). In the paragraphs that follow, we consider what might promote such findings, examine additional recent results regarding the benefit of exposure to nature on wellbeing and pose some suggestions for designers and researchers of healthcare settings to consider. Two pathways connecting exposure to nature and wellbeing There are certainly several pathways through which exposure to nature impact wellbeing (Kuo, 1 Professor and Head of Landscape Architecture, University of Illinois in Urbana-Champaign, Urbana, IL, USA 2 Samuel T. Dana Professor of Environment and Behavior, School of Natural Resources and Environment, University of Michigan, MI, USA Corresponding Author: William C. Sullivan, PhD, 611 E. Taft Drive, 101 Temple Buell Hall, Champaign, IL wcsulliv@illinois.edu

2 Sullivan and Kaplan ). Here, we focus on two: Stress Reduction Theory (SRT) and Attention Restoration Theory (ART). Stress Reduction Theory (SRT) postulates that contact with some kinds of natural settings will reduce the time it takes to recover from a stressful event (Bratman, Hamilton, Daily, 2012; Ulrich, Simons, Losito, Fiorito, Miles, & Zelson, 1991). The notion here is that humans, and our ancestors, have spent 99.9 percent or our time on earth living in tremendously close contact with nature. Indeed, until recently, each of our ancestors participated in, what can be called from today s perspective, a life-long camping trip (Orians, 1986). SRT proposes that, given the impact such settings had on shaping our survival as a species, we are predisposed to resonate with natural surroundings, experience positive emotions, and decrease negative feelings or stress when we occupy more natural places. The idea here is that through contact with natural places our brains produce a relatively fast emotional reaction at a subconscious level that can be measured through physiological pathways. In the last decade, scholars have measured physiological responses associated with various kinds of landscapes and have generally found that, in urban areas, the higher the level of vegetation, the greater the stress reduction (Alvarsson, Wiens, & Nilsson, 2010; Beil & Hanes, 2013; Lee, Park, Tsunetsugu, Kagawa, & Miyazaki, 2009; Roe et al., 2013; Ward Thompson et al., 2012). In a recent study, 160 individuals participated in an experiment designed to measure the impact of increasing densities of street trees on the speed with which people recover from a stressful experience (Jiang, Li, Larsen, & Sullivan, 2014). Participants engaged in some stress-inducing activities (e.g., making a five-minute speech, performing a subtraction exercise out loud, with no aids, in front of others while being videoed). They were then randomly assigned to watch one of ten three-dimensional videos of street scenes that varied in the density of tree cover (from 2% to 62%). Participants completed a questionnaire at three points in the experiment. Analysis revealed a positive, linear association between the density of urban street trees and self-reported stress recovery. That is, the greater the density of the street trees, the faster they recovered from the stressful experience. It is clear that being in or simply viewing a green space can help people recover from stressful experiences. But people who use healthcare settings, or who work within them are not only subject to stress, many are also mentally fatigued. To what extent does exposure to nature reduce mental fatigue? As we shall see, a great deal. Mental fatigue is a state with which you are likely familiar. It occurs after a period of focused attention and can leave you feeling worn out, depleted, and yearning for a break. It can also leave you feeling irritable and distracted. You may have experienced mental fatigue after a prolonged meeting, near the end of an intense week, after preparing an important proposal or reviewing a set of proposals. Healthcare workers, given their intense schedules and the complexity of the problems they seek to solve, are subject to mental fatigue on a daily basis. And learning that you have a serious medical condition is likely to result in mental fatigue too (Cimprich & Ronis, 2003). Attention Restoration Theory (ART) postulates that contact with nature helps people recover from mental fatigue. In order to pay attention to something, we must block out distractions from the things going on around us and from the thoughts that are constantly swirling around in our heads. The mechanism in our brains that blocks these distraction fatigues with use and after a while, it becomes increasingly hard to focus, make decisions, and remain at ease. But, according to ART, having a view to a setting that contains natural elements (e.g., trees, flowers, water), or actually being in such a space for even just a few minutes, can restore your capacity to focus because it provides the mechanism necessary to block distractions an opportunity to rest and restore (S. Kaplan, 1995, Kaplan, Kaplan, & Ryan, 1998). An extensive body of empirical evidence has accumulated in support of ART: exposure to green settings consistently boosts a person s capacity to pay attention. The findings come from green settings such as forests (Park, Tsunetsugu, Kasetani, Kagawa, & Miyazaki, 2010), rural areas (Roe & Aspinall, 2011), community parks (Fuller, Irvine, Devine-Wright, Warren, & Gaston, 2007),

3 8 Health Environments Research & Design Journal 9(2) schools (Matsuoka, 2010), neighborhoods (Rappe & Kivela, 2005), and laboratory settings (Berto, 2005). Studies have demonstrated links between green spaces and higher performance on attentional tasks in public housing residents, AIDS caregivers, cancer patients, college students, prairie restoration volunteers, and employees of large organizations (for an overview, see Sullivan, 2015). One of the challenges associated with being a patient, or loved-one of a patient, is the tendency to ruminate on one s situation. Rumination is a maladaptive pattern of repeatedly engaging in a thought. It is associated with heightened risk for depression and other mental illnesses. But a recent study found that a walk in a natural setting decreases both self-reported rumination and neural activity associated with rumination, whereas a walk in an urban setting had no such effects (Bratman, Hamilton, Hahn, Daily, & Gross, 2015). There is reason to believe that exposure to natural elements may help people reflect on their situation andplanforthefuture(kaplan,2001). Thus far we have seen that exposure to nature via a view through a window or by being in a green space helps people recover from stressful experiences and mental fatigue significantly faster than if they had not had such exposure to nature. What are the implications for these findings for healthcare settings? Implications for healthcare settings It is easy to imagine dozens of situations in which healthcare workers, patients, or family members feel stress or mental fatigue. Such situations are ideal places for a nature intervention: Infusion centers where patients receive chemotherapy or other kinds of infusions Dialysis centers Surgical waiting areas Staff break areas Clinical staff workstations Admitting areas where people are not only checked into a facility, but also must provide detailed information about their insurance providers and what can seem like endless other details. What is surprising about this list is that, except for the clinical staff workstations, these places typically already have an intervention that has been provided with anxious people in mind. This intervention is intended to distract people from the troubles they face. The problem is this distraction television may exacerbate rather than reduce stress and mental fatigue (Kaplan & Berman, 2010). Instead of providing televisions in these spaces, the research evidence demonstrates that a nature intervention would be significantly more beneficial. Such an intervention could take the form of: A view from a window to a green setting that includes some combination of trees, flowers, and water; An aquarium with live fish; A video of wonderful or even typical nature scenes, from faraway places or even places that are near the healthcare facility; An accessible patio or roof garden that allows people to sit in a green space for a few minutes; A vase with some flowers or some potted plants; Pictures of natural areas. Looking ahead It is indeed wonderful that there is a design feature nature that has produced so many health benefits; benefits that are especially necessary in healthcare settings. It is also reassuring that there is such a wealth of evidence-based research substantiating these benefits. In the context of creating healthcare settings promoting wellbeing there is further good news. Unlike many design features, this one lends itself to many readily available adaptations. The notion of small experiments (Kaplan, 1996; Kaplan et al., 1998) is particularly appropriate in considering how you might find more opportunities to connect people in healthcare settings to nature. Small experiments are manageable interventions that permit exploring hunches and testing ideas. They can sharpen intuition (Hamilton, 2014) and they focus on local

4 Sullivan and Kaplan 9 conditions. The smallness can vary with respect to budget, sample size, variations of interventions, or any other dimension of a study. Many considerations of large-scale research and the gold-standard of blind, controlled trials can be substantially relaxed. The utility of the outcome, however, depends on how we frame the study and conceptualize the measures. Consider, as an example, how to capitalize on potential benefits of the window view from a waiting room. The seating arrangements as well as the extent to which the windows are covered (e.g., blinds, curtains, not at all) can make a considerable difference. So can the content of the view (e.g., trees and other vegetation, barren parking lot). Setting up a small experiment might involve changing the window coverings over the course of several days so that the view is more or less exposed. Then you could observe people in the waiting rooms and even ask them to indicate how comfortable they find the setting. Social science researchers are often concerned about possible biases of their methodology. A small experiment, however, could be designed to take advantage of some of these! For example, asking individuals about the view from the window may sensitize them (i.e., a potential bias), but drawing their attention to the view may also be a benefit. In other words, the small experiment could be used to gain feedback while also potentially function as an intervention. Stress and mental fatigue are in abundant supply especially in healthcare settings. The opportunities for even small doses of nature in healthcare settings are also abundantly available. It is rare, however, that something that so readily lends itself to exploration can make such a large difference. We encourage healthcare design professionals and people who manage healthcare settings to act on the ideas presented here, and in this issue of HERD. Designers and managers should ensure that every person who enters a healthcare setting patients, family members, healthcare professionals has multiple exposures to nature throughout their time in the facility. Make connecting with nature a priority both in your design process and in maintaining and improving the facility. Managers can engage in a series of small experiments to test what happens as they vary the dose of nature that people are exposed to within their facilities. At its best, healthcare design meets a complex and diverse set of demands. It s time to add exposure to nature to this list multiple exposures for every individual who spends time in a healthcare facility. By doing so, you will reduce the stress and mental fatigue of those who visit healthcare facilities as well as the many individuals who live or work there. In the end, you will help create healthier places to deliver the care that people need. Acknowledgement We appreciate Marjorie LoForte, RN, for her insights on this editorial. References Alvarsson, J. J., Wiens, S., & Nilsson, M. E. (2010). Stress recovery during exposure to nature sound and environmental noise. International Journal of Environmental Research and Public Health, 7(3), Bratman, G. N., Hamilton, J. P., & Daily, G. C. (2012). The impacts of nature experience on human cognitive function and mental health. Year in Ecology and Conservation Biology, 1249, Bratman, G. N., Hamilton, J. P., Hahn, K. S., Daily, G. C., & Gross, J.J. (2015). Nature experience reduces rumination and subgenual prefrontal cortex activation. Proceedings of the National Academy of Science, 112(28), doi: /pnas Beil, K., & Hanes, D. (2013). The influence of urban natural and built environments on physiological and psychological measures of stress-a pilot study. International Journal of Environmental Research and Public Health, 10(4), Berto, R. (2005). Exposure to restorative environments helps restore the attentional capacity. Journal of Environmental Psychology, 25, doi: /j.jenvp Brown, D. K., Barton, J. L., & Gladwell, V. F. (2013). Viewing nature scenes positively affects recovery of autonomic function following acute-mental stress. Environ. Sci. Technol. 47, doi: /es305019p.

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