The Sky Factory, LC
A White Paper

Scientific Research and Sky Image Ceilings
by Bill Witherspoon and Mark Petrick

Contents
Executive summary………………..……..…….…..……. 2
Hypothesis………..……………………………….………...…… 3
Background…….………………………………………..…..….. 3
Pictures vs. illusion…………………...........… 3
Light and the illusion of sky….…...… 6
Nature as the subject of illusion….. 7
The relaxation response….……….…...… 9
Pilot research on SkyCeilings™ ……….….…… 9
Suggestions for future research…….…..…… 11
Request for cooperation………………….…...……. 12
Relevant research studies…………….….……….. 13
Contact information…………………………………… 20

The Sky Factory, LC

Scientific Research and Sky Image Ceilings

Executive summary
The Sky Factory designs, manufactures and sells sky image ceilings(SkyCeilings™) which it believes create functional illusions of real sky.
Observations, testimonials, pilot studies, and related research indicate that thesesky image ceilings have the ability to produce a physiological relaxation responsein observers, to change subjective experiences of space in interior environments
and to produce certain beneficial effects. The Sky Factory wishes to engage incooperative scientific research to better understand possible mechanisms ofaction and benefits.

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Hypothesis
Sky Factory sky image ceilings have an influence on people who view and spend
time in environments where they are installed. We believe that they trigger thesame psycho-physiological relaxation response as an experience of real sky. We
also believe that they modify peoples’ subjective experience of vertical space.
Consequently, we believe that they contribute beneficial effects in healthcare,
workplace, hospitality and residential environments. It is our belief that Sky
Factory sky image ceilings achieve these beneficial results by producing an
illusion of sky so realistic that people experience and automatically respond as if
they were being exposed to actual sky.

Background
Pictures vs. Illusion
Pictures are experienced as what they are, visual representations of somethingelse. Illusions are perceived as something other than what they are.
A simple way of understanding how we know things is:• We experience a thing or event through one, or more, of our senses.
• Our mind deals with this raw information via the processes of cognition• Cognition results in a perception – thoughts and/or feelings that identify
the experience and our response to it.
Cognition is a complex and incompletely understood process that includes
mental activity shaped by millions of years of human evolution, along with the
influences of our conditioning, knowledge and memories acquired since birth.
Cognition functions to create a true and useful picture of reality.
Pictures (pretty or beautiful) may be pleasing, attractive or interesting to an
observer. Such images are photographic or painterly and are representative or
abstract. Those that are representative provide sufficient information so thatthey recognizably correspond to previously experienced sensory inputs.
Illusions have an added dimension, they too provide information whichreferences prior experience, however, they result in misperceptions or mistakes in
the perception of the observer. They may be experienced as something else or asreal but are typically surprising or misleading. Illusions are generally considered
to be remarkable events, but are so only in relationship to what is accepted as
normal, or unremarkable.1
1

According to Prof. Michael Bach, “Optical phenomena bring to light particular good adaptationsof our visual system to standard viewing situations. These adaptations are ‘hard-wired’ in ourbrains, and thus under some artificial manipulations can cause inappropriate interpretations of
the visual scene. As Purkinje put it: ‘Illusions of the senses tell us the truth about perception.”
Excerpted from: http://www.michaelbach.de/ot/

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Deliberate illusions are generally intended to trick the eye and/or confuse theprocess of cognition. Cognition, an important aspect of the process of knowing,is based on the activity of a complex arrangement of habits which are establishedand maintained by previous experience and are expressions of the mind’s
fundamental neural pathways. Basically, habits of perception function as
efficient generalized solutions to the interpretation and perception of the large
amount of data provided by the senses. However, efficiency gained throughgeneralization may be accomplished at the expense of accuracy – hence themisperceptions of illusion.
There are many sorts of illusions. Magical illusions quickly come to mind, forexample, a magician saws through the lady in the box. In spite of an intellect thatknows better the eye and the mind of the observer are convinced, the pulse rises
and younger or less sophisticated observers may even experience temporary
emotional distress – followed by relief and wonder when she emerges intact.
Magicians or illusionists understand our habits of perception and how tomanipulate those habits and do so to produce a desired perception or experiencethat does not correspond to the actual or ‘true’ reality.
Looking at a photograph of the magician sawing the lady in half has little impact
on our physiology, psychology or emotions. However, being led through theillusion by a master magician is a different matter. This is because a true illusion
fully engages the interconnected functions of physiology, psychology andemotion in the same way that an actual or authentic event would.
Sky Factory sky image ceilings are crafted to create as convincing an illusion ofsky as possible. Over 20 design parameters are carefully monitored to insure
sensory support for what is actually an erroneous perception of real sky.2
That these illusions are effective is now well documented by dozens oftestimonials and anecdotes and by the direct observation of thousands of prone
and seated observers of SkyCeilings.3 The observations of physiological andpsychological change in prone observers of SkyCeilings are of interest withreference to healthcare. Prone observers commonly report, or are observed toexperience, spontaneous slowing of breath rate, relaxation of musculatureincluding spontaneous smiling, marked psychological relaxation, reduction in
2

Some of the more obvious of these parameters are discussed in Bill Witherspoon’s paper,
Awareness Engagement Technology: Healing with Nature, presented at the AIA Academy on
Healthcare Design October 28, 2004, Omni Shoreham Hotel, Washington, D.C.
3

In addition to the normal feedback received from clients by an alert and questioning marketer,
The Sky Factory operates a mobile showroom (SkyMobile) which includes a healthcare recliner
situated beneath an 8’x6’ elliptical SkyCeiling. Thousands of architects, designers and healthcare
professionals have observed SkyCeilings from this vantage point and have reported theirexperience – both spontaneously and in response to questions. Virtually everyone experiences thesky as having a three-dimensional quality and roughly one third of observers’ report that theclouds appear to be moving. These misperceptions serve to indicate that the mind is engaged in
an illusion.

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anxiety levels, increased sense of well being and refreshed alertness(physiological correlates of the relaxation response, discussed later).
Further, based on conversations with clients, staff operating MRI and otherdiagnostic radiological procedures routinely are able to schedule more patients
per day after installation of SkyCeilings and attribute this to reduced body
movement in more relaxed and less anxious patients. Prone observers commonlycompare their experience to those of their childhood, lying under a tree andlooking up into a beautiful sky. Some liken the experience to that of theirpersonal meditation practice.
Prone or captive observers of sky image ceilings experience these illusions largely
through their frontal (central) vision and, considering their vision is directed
only toward the ceiling; have little choice about where their visual attention is
directed. In such cases, (assuming optimal size and placement) the sky image
ceiling typically occupies the observer’s entire field of frontal vision (and some
portion of the peripheral vision as well) and the patterns of clouds andvegetation become visual elements, the exploration of which is the subject of theobserver’s attention.
In other environments (typically non-healthcare), where the observer may beseated or standing beneath a sky image ceiling, their attention, and consequently
their frontal vision, is typically directed elsewhere, toward some other activity. Insuch a case the sky image ceiling is experienced primarily through peripheral
vision.4 However, because peripheral vision serves as our security or safetysystem, it appears that the constant stimulation of sky overhead, communicates
important information about the condition of our physical environment that inturn triggers further erroneous or misperceptions.
Observers in a highly confined, windowless conference room space that includes
a SkyCeiling typically respond to the illusion with surprise and even shock thatinstead of the space eliciting discomfort and claustrophobia, their experience is

4Peripheral vision is good at detecting motion (a feature of rod cells), and is relatively strong atnight or in the dark, when the lack of color cues and lighting makes cone cells far less useful.
The distinctions between central (frontal) and peripheral vision are reflected in subtle
physiological and anatomical differences in the visual cortex. Different visual areas contribute to
the processing of visual information coming from different parts of the visual field, and acomplex of visual areas located along the banks of the interhemispheric fissure (a deep groovethat separates the two brain hemispheres) has been linked to peripheral vision. It has beensuggested that these areas are important for fast reactions to visual stimuli in the periphery, andmonitoring body position relative to gravity
Excerpted from Wikipedia article on Peripheral Vision,
http://en.wikipedia.org/wiki/Peripheral_vision

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characteristic of the ease and comfort of an outdoor space.5 These peripheral only
subjective reports are so consistent (nearly all observers) and strongly stated(includes confirmed claustrophobics) that they suggest the investigation ofdifferent routes of cognition stemming from the different frontal and peripheralvisual inputs to the cognitive process may provide access to an important avenue
for better understanding of the mechanisms involved in the psycho-physiologicalimpact of such illusions and the associated brain functions.
Light and the Illusion of Sky
Arguably, light is one of the two dominant experiences of sky, the other being
the more abstract experience of space. Sky-light (i.e. light coming from the sky)
has two essential components – the light itself which is a combination of
wavelength and intensity and the ‘information’ carried by that light, namely
color which corresponds to time of day, atmospheric conditions associated withweather or man made influences such as pollution, and image (principally, cloud
patterns).
Day light depravation results, for some, in the seasonal affective disorder
syndrome (SAD). While not yet conclusive, research indicates that SAD can betreated with artificial light6 – where color temperature (Kelvin), intensity andtreatment time (as related to circadian rhythms) are relevant factors. From thisresearch, and direct experience using light of different color temperatures andcolor rendering indices (CRI), it appears that illusions of sky can best be createdusing artificial light in the 6500K range. This, we suggest is due to the mind’s
inability to clearly distinguish between 6500K high CRI artificial light and true
mid-day light from the sky.
5

The SkyMobile also contains a 7.5 ft. x 12 ft x 9 ft. high conference space and conference-table
above which is a 4 ft. x 6 ft. SkyCeiling installed so as to uniformly stimulate the peripheral visionof those seated at the table.
6

Ulrich and Zimring, et al, present the case that “several studies strongly support that bright
light—both natural and artificial—can improve health outcomes such as depression, agitation,
sleep, circadian rest-activity rhythms, as well as length of stay in demented patients and persons
with seasonal affective disorders (SAD). At least eleven strong studies suggest that bright light iseffective in reducing depression among patients with bipolar disorder or SAD.” They also
enumerate studies that show that: exposure to morning light is more effective than exposure toevening light in reducing depression; that exposure to bright morning light has been shown to
reduce agitation among elderly patients with dementia; that exposure to bright light improves
sleep and circadian rhythms; that patients in brightly lit rooms have a shorter length of staycompared to patients in dull rooms; that patients exposed to an increased intensity of sunlight
experienced less perceived stress, less pain, took less analgesic medication and had less pain
medication costs.
The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime
Opportunity – Roger Ulrich*, Xiaobo Quan, Center for Health Systems and Design, College ofArchitecture, Texas A&M University; Craig Zimring*, Anjali Joseph, Ruchi Choudhary, Collegeof Architecture, Georgia Institute of Technology, published by The Center for Health Design,
September 2004, Funded by the Robert Wood Johnson Foundation.
http://www.healthdesign.org/research/reports/pdfs/role_physical_env.pdf

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Of further interest is recent research that has demonstrated inner retinal
photoreceptors sensors in the eye other than rods and cones which appear tohave peak sensitivity in blue wavelengths. These melanopsin photoreceptors arelinked to a wide range of non visual light-mitigated responses such as circadiancycles, hormone secretion and regulation of rest and activity cycles. As a matterof aesthetic policy all Sky Factory images include a significant percentage of blue
sky with elements such as trees and clouds composed so as to direct attention tothese blue fields7 .
Nature as the Subject of Illusion8
In predicting or eliciting a desired response, content is important. Human beings
respond differently to different content. In a healthcare context, nature is anadvantageous subject because it’s universal accessibility and its ability togenerate an influence consistent with the healing process.9
7Since 2002, Philips Electronics has been involved in many research projects at the Universities ofJefferson (USA), Surrey (UK), Monash (Australia), Eindhoven and Groningen (NL) to study theeffects of lamps with an increased blue light content. These tests and other field trials have driven
the introduction of new lighting products that contain an optimized amount of high-wavelength
blue light to maximize the effect on the third receptor. The third receptor allows for the so-called
non-visual, biological effects of light. All humans need these effects for general well-being andadjustment of their 24 hour rest-activity pattern. The general conclusions of the research supports
the hypotheses that the high-wavelength blue light positively effects workers alleviation of
fatigue, improved energy, concentration and self-reported work performance and productivity.
http://www.lighting.philips.com/gl_en/activiva_club/sci_research_1_activiva_explained.php?
main=special_section_activiva&parent=19487263063&id=&lang=en
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In healthcare, The Sky Factory recommends and generally uses “wild” natural images as
opposed to “manicured” or “controlled” images of nature. Images of unmodified nature tend to
be more expressive of the mechanics and laws by which nature operates while images thatexhibit human intervention (such as gardens) are expressive of precisely that – humanintervention. These criteria applied to choice of image are consistent with the underlying
philosophy of western medicine as stated by Hippocrates in 400 BC, “Natural forces within us are
the true healers of disease.” “Only Nature heals if given the opportunity to do so.”
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There is a substantial body of research beginning with Roger Ulrich’s landmark 1984 study,
View through a window may influence recovery from surgery (Science, 224, 42-421), that supports
the use of images of nature as adjuncts to healing protocols, and as important elements in thedesign of healthcare architecture. The meta-study, The Role of the Physical Environment in the
Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity (cited above), reviews over 600
studies related to improving the physical environment in hospitals and includes reviews of alarge body of research that shows that viewing nature or images of nature: has stress-reducing or
restorative benefits such as positive emotional and physiological changes; that stressful ornegative emotions such as fear or anger diminish while levels of pleasant feelings increase; thatviewing nature produces stress recovery quickly evident in physiological changes, for instance, inblood pressure and heart activity; can serve as positive distractions for patients; can help reduce
the use of pain medications.
In Healing Spaces: Elements of Environmental Design That Make an Impact on Health (THEJOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE, Volume 10, Supplement
1, 2004, pp. S-71–S-83 © Mary Ann Liebert, Inc.), authors Schweitzer, Gilpin, and Frampton cite
numerous studies that confirm the benefits of views to nature, actual or artificial, as beneficial not

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As a natural subject, for the crafting of an architectural illusion the sky has
several features to recommend it.
•

Sky is the largest and most pervasive experience of nature experienced byhumans.

•

Evolution beneath a blue sky has left its mark in ourphysiology/cognition: for example as the impressionists discovered, blue
(cool) colors recede in space and red (warm) colors press forward (had weevolved under a red sky it is likely that traffic stop lights would be green).
Blue light receptors seem to be critical to the regulation of a wide range ofphysiological and psychological functions.

•

Further, an illusionary sky in a ceiling (unlike a landscape picture on thewall) is consistent with basic laws of nature such as gravity and is not sitespecific as is a landscape. (Interestingly, even though wall-oriented, a rowof virtual clerestory windows which cannot reference horizon and do notreference unfamiliar vegetation appear to have a significant capacity togenerate illusion).

•

Finally, whatever other aspects of nature; mountains, deserts or oceansthat individuals may be partial toward, it seems that we universally
appreciate the sky as an expression of natural beauty and inspiration.

only to healing outcomes of patients, but to the general satisfaction and productivity of office
workers. Their meta-study points to the need for, among other recommendations, views to nature
as an important aspect of architectural design in the service of creating ‘healing spaces.’

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The Relaxation Response10

The relaxation response, the opposite of the fight or flight response, is triggeredby a wide range of relaxation and meditative techniques including contemplative
experiences of nature. It is characterized by the following physiologicalcorrelates:• Metabolic rate decreases• Heart beats slower and muscles relax• Breathing becomes slower• Blood pressure decreases• Levels of nitric oxide are increased• Brain wave patterns change in specific ways
The relaxation response is widely considered to be an antidote for stress and an
important element in maintaining stable health as well as creating conditions
supportive of the healing process.

Pilot Research on Sky Factory SkyCeilings
1. Pilot study performed at Westminster College, Salt Lake City, Utah in 2005
Management students undertook a pilot study at a local business todetermine how strongly the Sky Factory SkyTiles influence employee’s
overall satisfaction in relation to other important aspects of satisfaction, as
well as how they affected employee’s perceived productivity andcommitment to the organization.
The study concluded that The Sky Factory can and should claim in theirmarketing campaigns that Sky Factory SkyTiles contribute to employee’s
perceived productivity and improved the attitude of employee’s, as well as
increased employee’s commitment to the organization.

2. Impact of perspective and geometry in creating illusory sky image ceilinginstallations: an informal study carried out by The Sky Factory (BillWitherspoon)
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The term relaxation response was coined by Herbert Benson, M.D. based on his research with Dr.
Robert Keith Wallace on practitioners of transcendental meditation. They found that several
physiological indicators of stress were changed by the practice of meditation – proving to be aneffective alleviator of the deleterious effects of stress. Benson went on to characterize theuniversal components of a practice to systematically produce the relaxation response andpromote its practice. Dr. Benson is currently Director Emeritus of the Benson-Henry Institute for
Mind Body Medicine and the Mind/Body Medical Institute Associate Professor of Medicine,
Harvard Medical School. Based on hundreds of studies undertaken over the past four decades by
Benson and others, the characteristics and benefits of the relaxation response are well understoodand accepted.

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Hypothesis: Habits of perception related to viewing the sky are highly refined,
responsive to subtle cues and independent of intellectual discrimination.
Successful illusion relies on proper stimulation of such perceptual habits.
Background• A sky image with clouds was photographed with a near-normal lens on a 6
x12 cm transparency. The enlarged displayed portion of the image was a 1:3
aspect ratio segment which corresponded to a 2’x 6’ceiling opening. One endof the displayed image recorded the zenith and the other end of the image
recorded information about 40 degrees above the horizon – the entire
displayed information spanned about 50 degrees of sky. This photographic
view corresponded closely to what would actually be seen if a 2’x 6’ holewere cut in an eight-foot ceiling and the observer were prone (about 20”
above the floor) with the head positioned directly beneath one end of theceiling image. The ceiling image was not back-lit but rather was an opaque
image lit by ambient light.
• About two feet at each end of the image, recorded a portion of cumulus whitecloud, while the middle two feet were of uniform open blue sky. Because of
the geometry of the photography, one end of the image showed white cloud
as seen from the perspective of looking straight up and therefore displayed
only the bottom of the cloud. At the other end of the image, the bottom of thecloud was visible (obliquely) but also the view included the side of the cloud.
Phase 1• Thirteen observers were placed prone on a chiropractor’s adjustment tabledirectly and symmetrically beneath the 2’x 6’ ceiling mounted sky image.
• The observers’ first viewings were with their feet beneath the zenith – inother words oriented incorrectly.
• All observers were pleased with the image, commented on its novelty, andindicated that it was a ‘good idea’.
Phase 2
• In the second phase of the experiment which followed immediately, theimage was installed correctly, i.e. with the head of the observer beneath thezenith. The change was not immediately obvious because of the symmetricalmasses of white cloud at each end of the ceiling image.
• In all thirteen cases, the experience was reported as being considerably
different, with many of the observers puzzled by what had caused the change.
Only two people noticed that the image had been rotated 180 degrees.
• All participants expressed their changed experience in terms of a greater
perception of space or depth, and increased realism.
• Each observer indicated that something significant had changed in theirsubjective experience as well. They became quieter, were more absorbed in
the experience, looked longer, and described a more prominent subjective
inner experience.

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Most related this illusion to the childhood experience of lying on their backand looking up into the sky. In some cases, the experience was likened to theinner experience of peacefulness that occurs in meditation.
After the second viewing, the prevailing remarks shifted from discussion of
the idea of a sky image ceiling to that of the experience of a sky image ceiling

Suggestions for Future Research
Below are some of the research ideas we and others have proposed. The Sky
Factory is happy to consider all relevant research possibilities.
Basic physiological research
1. Do sky image ceilings elicit a physiological response identical orsimilar to those that characterize the relaxation response?
2. fMRI studies to determine areas of brain associated with:a. Experience of illusion vs reality
b. Function of frontal (central) vision vs. peripheral vision incognition and perception
Use of sky image ceilings in healthcare environments (Outcome-related)
1. Modification of self-administered pain medication
2. Modification of hospital stay duration
3. Modification of anxiety levels prior to administration of anesthesia
4. Modification of surgical outcomes and healing times
5. Modification of diagnostic and therapeutic radiological suite
utilization
a. MRI
b. Linear Accelerator
c. PET/CT
d. Other
6. Changes in patient comfort and attitudes (these have been done in thecontext of patient satisfaction surveys and sky image ceilings figure
importantly in patient responses)
7. Changes in staff attitudes, comfort and efficiency
8. Use of programmable sky image ceilings in healthcare. [Inprogrammable systems, light levels can ‘rise’ and ‘set’ with the sun(including color changes if desired) and do so according to the sun’sseasonal changes. In this way we feel a sky image ceiling may
contribute to the maintenance or reestablishment of circadianrhythms.]a. ICU - circadian rhythm reestablishment and maintenanceb. Nurse Station – reversal of circadian rhythms to promote nighttime alertness
9. Use of sky image ceilings in the workplacea. Productivity
b. Absenteeism
c. Job satisfaction

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d. Attitudes toward management
10. Use of sky image ceilings in retail establishments
a. Modification of time spent by customers in areas influenced by
sky image ceilings
b. Modification of spending patterns

Request for Cooperation
The Sky Factory believes that there are valuable opportunities for research in thearea of illusory sky image ceilings. We believe that such research would help toestablish the validity of our products but we also believe that such research could
reveal understandings that will be valuable to the entire architectural and designcommunity. For example: investigation of illusion, as applied to architecture andinterior design, may hold great promise for the future of these disciplines.
Further, there is the distinct possibility that basic physiological and brain studies
involving illusory sky image ceilings could add to our understanding of how
mind and body function and interact with the environment.
We respectfully request that those who find interesting notions in this paper
contact us for further discussion. We also request those who identify flaws in ourideas and/or expressions contact us to aid in increasing the correctness andclarity of our thinking and understandings.

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Relevant Research Studies
Excerpts and citations from:The Role of the Physical Environment in the Hospital of the 21st Century: A
Once-in-a-Lifetime Opportunity
Roger Ulrich*, Xiaobo Quan, Center for Health Systems and Design, College ofArchitecture, Texas A&M University, Craig Zimring*, Anjali Joseph, Ruchi
Choudhary, College of Architecture, Georgia Institute of Technology* Co-principal investigators and corresponding authors: Roger Ulrich, Ph.D.:
ulrich@archone.tamu.edu;
Craig Zimring, Ph.D.: craig.zimring@arch.gatech.edu.
Report to The Center for Health Design for the Designing the 21st Century
Hospital Project. This project is funded by the Robert Wood Johnson Foundation.
September 2004
Provide Nature and Positive Distraction
Positive distractions refer to a small set of environmental features or conditions
that have been found by research to effectively reduce stress. Distractions can
include certain types of music, companion animals such as dogs or cats, laughteror comedy, certain art, and especially nature (Ulrich, 1991). The focus here is on
the last, nature. (There is an additional large research literature on music, but thisis not covered in this review.)
As background relevant to assessing the credibility of nature findings inhealthcare environments, it should be mentioned that many studies of
populations other than hospital patients have produced strong evidence thateven fairly brief encounters with real or simulated nature settings can elicit
significant recovery from stress within three minutes to five minutes at most(Parsons & Hartig, 2000; Ulrich, 1999). Investigators have consistently reported
that stress-reducing or restorative benefits of simply viewing nature aremanifested as a constellation of positive emotional and physiological changes.
Stressful or negative emotions such as fear or anger diminish while levels ofpleasant feelings increase. Laboratory and clinical studies have shown thatviewing nature produces stress recovery quickly evident in physiologicalchanges, for instance, in blood pressure and heart activity (Ulrich, 1991). By
comparison, considerable research has demonstrated that looking at built scenes
lacking nature (rooms, buildings, and parking lots) is significantly less effective
in fostering restoration and may worsen stress.
Questionnaire studies have found that bedridden patients assign especially highpreference to having a hospital window view of nature (Verderber, 1986).
Mounting research is providing convincing evidence that visual exposure tonature improves outcomes such as stress and pain. For example, a study in a
Swedish hospital found that heart-surgery patients in ICUs who were assigned apicture with a landscape scene with trees and water reported less anxiety/stress

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Scientific Research and Sky Image Ceilingsand needed fewer strong doses of pain drugs than a control group assigned no
pictures (Ulrich, 1991). Another group of patients assigned an abstract picture,
however, had worsened outcomes compared to the control group. Ulrich (1984)
found that patients recovering from abdominal surgery recovered faster, had
better emotional well-being, and required fewer strong pain medications if they
had bedside windows with a nature view (looking out onto trees) than if theirwindows looked out onto a brick wall.
Recently, strong studies using experimental designs have produced additional
convincing evidence that viewing nature reduces patient pain as well as stress.
These investigations also support the interpretation that nature serves as apositive distraction (Ulrich, 1991) that reduces stress and diverts patients fromfocusing on their pain or distress. A randomized prospective investigation foundthat adult patients undergoing a painful bronchoscopy procedure reported lesspain if they were assigned to look at a ceiling mounted nature scene rather than acontrol condition consisting of a blank ceiling (Diette, Lechtzin, Haponik,
Devrotes, & Rubin, 2003). Another controlled experiment that used volunteers ina hospital assessed the effect on pain of viewing a soundless nature videotape incontrast to a static blank screen (Tse, Ng, Chung, & Wong, 2002). Subjects who
watched the nature scenes evidenced a higher threshold for detecting pain andhad substantially greater pain tolerance. Two studies of female cancer patients
have shown that taking a virtual reality nature walk while in bed or a hospitalroom (through a forest with bird sounds) reduced anxiety and symptomatic
distress (Schneider, S. M., Prince-Paul, Allen, Silverman, & Talaba, 2004).
Research on patients suffering intense pain because of severe burns found that
exposing patients to a videotape of scenic nature (forest, flowers, ocean,waterfalls) during burn dressing changes significantly reduced both anxiety andpain intensity (Miller, Hickman, & Lemasters, 1992).
The possibility that nature can improve outcomes even in patients with late-stage
dementia, including Alzheimer’s disease, has received some support from aquasi experimental study that found reduced levels of agitated aggressive
behavior associated with a shower bath when recorded nature sounds (birds,
babbling brook) and color pictures were present (Whall et al., 1997). A wellcontrolled study of blood donors in a waiting room found that blood pressure
and pulse were lower on days when a wall mounted television displayed anature videotape, compared to days with continuous daytime television
programs (Ulrich, Simons, & Miles, 2003). More research is needed to identify
conditions under which television can either be a stress-reducing positive
distraction or a stressor in hospitals.
Art in healthcare environments: A small number of studies on art in hospitals
have yielded findings parallel to those from nature research. Results suggest aconsistent pattern wherein the great majority of patients respond positively torepresentational nature art, but many react negatively to chaotic abstract art(Ulrich & Gilpin, 2003). For example, Carpman & Grant (1993) studied thepreferences of 300 randomly selected inpatients and concluded that the patients
consistently preferred nature images but disliked abstract art. Although nature
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pictures and other emotionally appropriate art elicit positive reactions, there isalso evidence that inappropriate art styles or image subject matter can increasestress and worsen other outcomes (Ulrich, 1991). It should not be expected that
all art is suitable for high-stress healthcare spaces, as art varies enormously insubject matter and style, and much art is emotionally challenging or provocative.
The pitfalls of displaying emotionally challenging art in healthcare environments
are revealed by a study of psychiatric patients (Ulrich, 1991). The unit was
extensively furnished with a diverse collection of wall-mounted paintings andprints. Interviews with patients indicated strongly negative reactions to artworks
that were ambiguous, surreal, or could be interpreted in multiple ways. The
same patients, however, reported having positive feelings and associations withrespect to nature paintings and prints.
Diette, G. B., Lechtzin, N., Haponik, E., Devrotes, A., & Rubin, H. R. (2003).
Distraction therapy with nature sights and sounds reduces pain during flexible
bronchoscopy: A complementary approach to routine analgesia. Chest, 123(3),941-948.
Leather, P., Pyrgas, M., Beale, D., & Lawrence, C. (1998). Windows in theworkplace: Sunlight, view, and occupational stress. Environment & Behavior,
30(6), 739-762.
Ulrich, R. S. (1984). View through a window may influence recovery fromsurgery. Science, 224(4647), 420-421.
Ulrich, R. S. (1991). Effects of interior design on wellness: Theory and recent
scientific research. Journal of Health Care Interior Design, 3(1), 97-109.
Ulrich, R. S. (1999). Effects of gardens on health outcomes: Theory and research.
In C. Cooper Marcus & M. Barnes (Eds.), Healing Gardens (pp. 27-86). New
York: Wiley.
Ulrich, R. S., & Gilpin, L. (2003). Healing arts: Nutrition for the soul. In S. B.
Frampton, L. Gilpin & P. Charmel (Eds.), Putting patients first: Designing andpracticing patient-centered care (pp. 117-146). San Francisco: Jossey-Bass.
Ulrich, R. S., Lawson, B., & Martinez, M. (2003). Exploring the patient
environment: An NHS estates workshop. London: The Stationery Office.
Ulrich, R. S., Lunden, O., & Eltinge, J. L. (1993). Effects of exposure to nature andabstract pictures on patients recovering from heart surgery. Paper presented at
the thirty-third meeting of the Society for Psychophysiological Research, RottachEgern, Germany. Abstract in Psychophysiology, 30(Suppl. 1), 7.
Ulrich, R. S., Simons, R. F., Losito, B. D., Fiorito, E., Miles, M. A., & Zelson, M.
(1991). Stress recovery during exposure to natural and urban environments.
Journal of Environmental Psychology, 11(2): 201-230.

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Ulrich, R. S., Simons, R. F., & Miles, M. A. (2003). Effects of environmental
simulations and television on blood donor stress. Journal of Architectural &Planning Research, 20(1), 38-47.
Excerpts and citations from:
Healing Spaces: Elements of Environmental Design That Make an Impact on
Health, MARC SCHWEITZER, M.Arch.,1 LAURA GILPIN, M.F.A., R.N.,2 andSUSAN FRAMPTON, Ph.D.3, THE JOURNAL OF ALTERNATIVE ANDCOMPLEMENTARY MEDICINE
Volume 10, Supplement 1, 2004, pp. S-71–S-83 © Mary Ann Liebert, Inc.
Viewing nature
Ulrich’s “Theory of Supportive Healthcare Design” includes a design guideline
to “Provide Access to Nature and other Positive Distractions.”74 A working
definition of “positive distractions” is “environmental-social conditions marked
by a capacity to improve mood and effectively promote restoration fromstress.”75–77 Ulrich pays particular attention to views of nature in his research, but
identifies comedy or laughter, caring or smiling human faces, music, andcompanion animals as others.19,76
Both workers and patients rate having a window as very desirable, preferablywith a view of a natural setting.76 Furthermore, studies of students and office
workers on behalf of the California Energy Commission’s Public Interest Energy
Research program find that for both groups an “ample and pleasant view”
improved performance.60,78 Employees with a window view of nature report lessstress, better health status, and higher job satisfaction.79 Studies on hospital
inpatients have concentrated on critical or intensive care units. Such studies havelinked the lack of windows with high rates of anxiety, depression anddelirium.80,81 A view of nature has been correlated with shorter postoperative
hospital stays, higher satisfaction with nursing care, and decreased use of potent
analgesics in cholecystectomy patients compared to patients with obstructed
views.82
Ulrich postulates that the lack of a window may act negatively by reducing
positive stimulation and aggravating the negative effects of sensory deprivation,
particularly in a clinical environment with such conditions as repetitive soundsof respirators.75 In addition, he has found that views of nature can reduce anxiety
and pain and have a restorative effect on patients as well as staff (e.g., mood
improvement, lower blood pressure, and reduced heart rates). He postulates
an evolutionary theory predisposing humans to find scenes of nature
restorative.19
Office workers with access to natural light and views of greenery are moreproductive and have higher job satisfaction.83 National Aeronautics and Space
Administration studies have found that a sense of perceptual distance andexpansiveness, either with distant views, internal view corridors with interesting
focal points, or even the design of vertical surfaces, promote “cognitive
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tranquility,” which aids mental functioning.84 Providing patients, families andstaff with access to nature by providing indoor and outdoor gardens, views ofnature through windows, and artwork of nature scenes can relieve stress.19 In
one study, surgical patients in postoperative units with no windows to theoutside developed twice as many cases of postoperative delirium during a 72hour period as those with windows.85 In addition, patients in units without
windows developed more symptoms of depression.
Citations from the preceding excerpt
19. Ulrich R, Gilpin L. Healing arts—nutrition for the soul. In: Charmel PM,
Frampton SB, Gilpin L, eds. Putting Patients First—Designing and Practicing
Patient–Centered Care. San Francisco: Jossey-Bass, 2003; 117–146.
60. Heschong L. Windows and Classrooms. Fair Oaks, CA: Heschong MahoneGroup. 2003.
74. Ulrich R. Effects of healthcare environmental design on medical outcomes. In:
Design & Health—The Therapeutic Benefits of Design. Proceedings of 2ndInternational Congress on Design and Health. Karolinska Institute Stockholm,
Sweden, June 2000: 49–59.
75. Ulrich RS. Effects of health facility interior design on wellness: Theory andrecent scientific research. J Health Care Des 1991; 3:97–109. Reprinted in
Marberry SO, ed. Innovations in Healthcare Design. New York: Van Nostrand
Reinhold, 1995.
76. Ulrich RS. Effects of gardens on health outcomes: Theory and research. In:
Marcus CC, Barnes M, eds. Healing Gardens: Therapeutic Benefits and Design
Recommendations. New York: John Wiley & Sons, 1999:27–86.
77. Ulrich RS. Evidence based environmental design for improving medical
outcomes. Proceedings of the Healing by Design: Building for Health Care in the
21st Century Conference. Montreal, Quebec, Canada, March 1–10, 2000.
78. Heschong L., Windows and Offices. Fair Oaks, CA:
Heschong Mahone Group, 2003.
79. Leather P, Pyrgas M, Beale D, Lawrence C. Windows in the workplace:
Sunlight, view, and occupational stress. Environ Behav 1997; 30: 739–762.
80. Keep PJ, James J, Inman M. Windows in the intensive therapy unit.
Anesthesia 1980; 35:257–262.
81. Parker DL, Hodge JR. Delirium in a coronary care unit. JAMA 1967; 201:702–
703.
82. Ulrich RS. Benefits of nature: View from a hospital bed. Science
1984: 224: 420–421.
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83. Clay RA. Green is good for you. Monitor on Psychology. 2001; 32: 1–16.
84. Heerwagen JH, Johnson JA, Brothers P, Little R, Rosenfeld
A. Energy Effectiveness and the Ecology of Work: Links to Productivity and
Well-Being, 1998. Online document at:
www.sustainableportland.org/grn_rethink_heerwagen_5-9-03.pdf
85. Wilson LM. Intensive care delirium: The effect of outside deprivation in awindowless unit. Arch Intern Med 1972; 130: 225–226.
Excerpts from:How Design Impacts Wellness
R.S. Ulrich. “How Design Impacts Wellness.” Healthcare Forum Journal(September-October, 1992)
ABSTRACT: In research on patient anxiety in a dental fears clinic, patients felt
less stressed when a large mural depicting a natural scene was hung on a wall of
the waiting room, in contrast to when the wall was blank.
Link:
http://www.scenicflorida.org/lscwellness.html
Positive distractions
Striking scientific evidence regarding negative human consequences of poor
design has emerged from studies of patients exposed to sensory deprivation –the lack of positive environmental distractions – in health facilities. Research on
intensive-care units has shown that windowlessness appears to aggravate thedeleterious effects of low levels of environmental stimulation such as unvarying
lighting and the repetitive sounds of respirators and other equipment.
The concept of a positive distraction implies that certain types of environmental
features are especially effective in reducing patient stress and promoting
wellness. A positive distraction is an element that produces positive feelings,
effortlessly hold attention and interest, and therefore may block or reduce
worrisome thoughts. A growing number of studies indicate that the effects ofpositive distractions also involve desirable physiological changes such as
reduced blood pressure.
The most effective positive distractions are mainly elements that have been
important to humans throughout a million years of evolution: (1) natureelements such as trees, plants, and water; (2) happy, laughing, or caring humanfaces; (3) benign animals such as pets.
Nature is restorative
Over the last decade, scientific studies of nonpatient groups such as university
students have shown that for stressed individuals, restorative influences of18

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viewing nature scenes or elements involve a broad shift in feelings toward amore positive state and desirable changes in activity levels in different
physiological systems. These changes appear to be accompanied by sustained
attention that probably blocks or reduces worrisome thoughts.
In laboratory research, my associates and I have found that visual exposure to
everyday nature scenes produces significant recovery from stress within only
about five minutes, as indicated by reduced blood pressure and muscle tension.
In research on patient anxiety in a dental fears clinic, patients felt less stressed
when a large mural depicting a natural scene was hung on a wall of the waiting
room, in contrast to when the wall was blank. And in a study of patients about
to undergo dental surgery, visual contemplation of an aquarium with fish
reduced anxiety and discomfort, and increased scores for patient complianceduring surgery.
While such short term exposures to nature can foster impressive stress recovery,
potential wellness benefits may be greatest for patients who must spend long
periods in a confined setting. In these situations, prolonged visual contact withnature may have persistent positive effects on psychological, physiological, andpossibly behavioral components of stress that may be manifested in higher levels
of wellness and health.
I found that patients recovering from gallbladder surgery had more favorable
postoperative courses if their windows overlooked a small stand of trees rather
than a brick wall. Compared to patients with the wall view, those with thenatural window view had shorter postoperative hospital stays, elicited far fewer
negative comments (‘patient is upset’) in nurses’ notes, tended to have lower
scores for minor postsurgical complications such as persistent headache ornausea, and needed fewer doses of narcotic pain drugs.
All art is not created equal
Many health facility executives and designers apparently assume that nearly any
type of wall-mounted painting or other visual art is a positive distraction forpatients. But given that the style and content of paintings is strongly emotional,
it seems more likely that some types of art will have a positive influence on
patients, whereas others might be stressful.
In a small-scale exploratory study, I assessed effects of wall art on patients in a
psychiatric ward at a Swedish hospital. The ward was extensively decorated
with paintings and prints reflecting a wide variety of styles and subject matter.
Patients expressed positive feelings about paintings dominated by nature content(rural landscapes or vases of flowers, for example). By contrast, there were many
negative comments about abstract paintings and prints where the content was
ambiguous or completely unclear.
Patients even physically attacked a group of seven abstract paintings (they tore
the pictures from the wall and smashed the frames).
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Outi Lunden and I conducted a study in Sweden to ascertain whether exposure
to visual stimulation in intensive-care units, including views of nature, reduces
stress and has other positive effects on recovery. Patients who had undergone
open-heart surgery were randomly assigned a nature picture (dominated either
by water or trees), or one of various abstract pictures, or no picture (control
group).
Those exposed to the nature with water picture experienced less postoperative
anxiety than either the patients exposed to other types of pictures or the control
group. Patients exposed to abstract pictures had higher anxiety than patients
without any picture.
Also, four days after surgery, patients who had been exposed to any type ofvisual stimulation were able to complete a visual-perceptual functioning test
faster than patients in the control group. This latter finding is important because
it suggest that by providing early exposure to visual stimulation, it might bepossible to foster more rapid recovery from the mild brain impairment
commonly associated with heart surgery involving a heart pump.
It’s important to remember that, if visual art is to play a role in reducing stressand promoting wellness, it must be placed where it can be seen by patients. Fora patient whose condition or treatment prevents sitting up, consideration should
be given to placing a visual distraction on the ceiling in the individual’s line ofsight.

Contact Information
Mark Petrick
The Sky Factory, LC
P.O. Box 1177
Fairfield, IA 52557+1 641 472 1747 x200
markp@theskyfactory.com
www.theskyfactory.com
Bill Witherspoon
The Sky Factory, LC
P.O. Box 1177
Fairfield, IA 52557+1 641 472 1747 x202
billw@theskyfactory.com
www.theskyfactory.com© 2008 The Sky Factory, LC

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