To Examine the Effect of a View of Nature on Patient's Stress and Anxiety
Condition: Stress; Anxiety
MeSH terms: Anxiety Disorders
Study type: Observational

Summary: 
      -  Rationale: Recently, research that demonstrates a clear relationship between the built
           healthcare environment and the health and wellbeing of patients has come available.
           Patients in a CT scan suite are usually anxious. The environment has been shown to lower
           stress; a painting or piece of art for example, can capture and hold attention and
           thereby lower negative thoughts and evoke positive emotions. Sights of nature have
           demonstrated to be especially effective in recuperating from stress, presumably because
           the human brain has evolved in a natural environment. The current study will investigate
           the effects of exposure to nature in the CT scan suite. A SkyCeiling, a large, slightly
           illuminated, photographic illusion of a real sky view is placed above the CT scan. The
           main hypothesis of this study is that a sky view will lead to a lower level of anxiety
           in the CT scan suite.

        -  Objective: The primary objective of this study is to examine the effect of a view of
           nature on a patient's stress and anxiety. Secondary objectives are to study the effects
           of a view of nature on a patient's environmental appraisals of the CT suite,
           satisfaction with the provided service, and trust in the healthcare provider.
    

Detailed description: 
      1. INTRODUCTION AND RATIONALE

           The importance and the potential benefits of well-designed healthcare facilities have
           been widely acknowledged and recent research clearly demonstrates the relationship
           between the built healthcare environment and patients' health and well-being (Dijkstra,
           2009).

           Encounters with healthcare situations are generally characterized by fear, anxiety,
           stress, and uncertainty (Mitchell, 2003; Pearson, Maddern, & Fitridge, 2005). Looking at
           most environments in which these encounters take place, one might rightfully ask how
           well these healthcare environments satisfy the psychological needs of patients.

           In order to create more beneficial environments, environmental stimuli can be added to
           (or removed from) the environment to influence the patient in a positive manner. The
           environment may elicit positive feelings, hold attention and interest, and block or
           reduce negative thoughts, for example, by the presence of art or a view from a window
           (R. S. Ulrich, 1984). The purpose of the present study is to improve patients'
           well-being by adding positive elements to existing healthcare environments, such as
           pictures of nature.

           Stress is an important factor in healthcare situations and stress reactions can be
           considered a clinical problem since they often result in negative or worsened medical
           outcomes (Malkin, 2008). Previous studies (Volicer & Volicer, 1978), for example, found
           that hospital stress was correlated with changes in heart rate and blood pressure. Other
           studies showed that psychological stress impairs wound healing in patients (Christian,
           Graham, Padgett, Glaser, & Kiecolt-Glaser, 2006; Kiecolt-Glaser, Marucha, Malarkey,
           Mercado, & Glaser, 1995). Elbrecht and colleagues (Elbrecht et al., 2004) studied the
           effects of perceived stress and cortisol levels on wound healing and demonstrated a
           considerable negative effect of stress.

           Rabin (2004 in Malkin 2008; personal communication 2008) proposed that pleasant
           healthcare environments are those that are perceived by the brain as calming, meaning
           that the stress reactive areas of the brain decrease their activity with a resultant
           decrease in the concentration of cortisol and norepinephrine in the blood. This results
           in patients experiencing less pain, having more restful sleep, less anger, less muscle
           tension, and a lower risk of stroke. Furthermore, Kaplan and Kaplan (R. Kaplan & Kaplan,
           1989) state that "the nervous system seems to be structured in such a way that pleasure
           and pain tend to inhibit each other". A more pleasant healthcare environment could,
           therefore, result in less stress and anxiety in patients and this should lead to better
           health and increased feelings of well-being. When speaking about a more pleasant
           healthcare environment, a wide variety of environmental characteristics come to mind.
           Variables such as indoor plants and music could help create environments that generate
           positive feelings and, as a consequence, reduce negative outcomes.

           Nonpharmacological anti-anxiety interventions The advantage of using environmental
           interventions to lower anxiety is that these kind of interventions do not carry any risk
           and are not time consuming. Several studies have examined various methods of anxiety
           reduction in healthcare environments. For example, research has demonstrated the
           beneficial effects of scents on anxiety and mood in dental patients (Lehrner,
           Eckersberger, Walla, Poetsch, & Deecke, 2000; Lehrner, Marwinski, Lehr, Johren, &
           Deecke, 2005) Furthermore, music therapy has successfully been applied to reduce pain
           and anxiety in patients undergoing various medical procedures, such as children with
           cancer undergoing lumbar puncture (Thanh Nhan, Nilsson, Hellström, & Bengtson, 2010) and
           women during caesarian delivery (Chang & Chen, 2005). Sunlight appeared to have
           beneficial effects on perceived stress (Walch et al., 2005). A recent study (Park &
           Mattson, 2009) demonstrated that indoor plants in a hospital room can have therapeutic
           value and serve as a noninvasive and effective complementary medicine for surgical
           patients. Esthetic enhancements can thus provide unobtrusive and inexpensive stress and
           anxiety management methods. In this study we propose nature as an anti-anxiety
           intervention, which possibly has an even stronger effect on anxiety then scent, daylight
           or music.

           Nature interventions Research on restorative environments suggests that certain
           environments are capable of promoting recovery from stress. Especially natural settings
           have these restorative effects (Hartig, Book, Garvill, Olsson, & Garling, 1996).
           Considering the potential healing properties of nature (Lohr & Pearson-Mims, 2000; R. S.
           Ulrich, 1984), exposing patients to natural elements may be an effective way of reducing
           stress. A recent review concluded that viewing nature scenes may decrease pain
           perceptions by eliciting positive emotional responses and decreasing stress (Malenbaum,
           Keefe, Williams, Ulrich, & Somers, 2008).

           Ulrich et al. (R. Ulrich et al., 1991) studied the effects of exposure to nature on
           stress recovery. Participants watched a videotape that induced feelings of stress, and
           were afterwards exposed to a tape with either a natural or an urban environment. Results
           demonstrated that individuals recover sooner from stress when exposed to the former
           (natural) than the latter (urban). Lohr and Pearson-Mims (2000) studied whether the
           presence of indoor plants would increase pain tolerance. Participants were either placed
           in a room with plants, a room with non-plant objects (as visually distractive as the
           plants), or a control room (no objects). Results showed that a significantly larger
           proportion of respondents in the room with plants were able to keep their hand in the
           ice water for 5 minutes as compared to the other conditions, suggesting increased pain
           tolerance by exposure to indoor plants. They also showed that the room with plants was
           rated more positively (e.g., cheerful, calming, pleasant) than either of the control
           rooms. The results of these studies support the idea that nature may have beneficial
           effects on the health and well-being of people.

           Natural elements in the built environment have clearly shown stress-reducing properties,
           but it is still unclear which underlying mechanism causes this stress-reduction. A
           potential explanation lies in the theories by Kaplan (S. Kaplan, 1987) and Ulrich (R. S.
           Ulrich, 1983), which state that people have a tendency to prefer natural settings to
           built environments. Although these two theories have some important differences (see
           Hartig et al. (1996) for a discussion), both are based on the same evolutionary
           assumptions. The preferences for natural settings are assumed to have an evolutionary
           base; people are to some extent biologically adapted to natural as opposed to built
           environments. Secondly, it might be argued that nature may be processed more easily and
           efficiently because the brain and sensory systems evolved in natural environments
           (Wohlwill, 1983). As a result, humans have an innate tendency to pay attention and
           respond positively to natural elements (Ulrich et al., 1991). This predisposition to
           prefer natural elements to man-made objects may be the explanation of the
           stress-reducing effects of nature. It might thus be hypothesized that natural elements
           affect feelings of stress through the perceived attractiveness of an environment.

           In a laboratory experiment, Dijkstra et al. (Dijkstra, Pieterse, & Pruyn, 2008) tested
           this hypothesis and demonstrated the stress-reducing properties of indoor plants in a
           simulated hospital room. Moreover, this effect was mediated by the perceived
           attractiveness of the hospital room. The presence of indoor plants in a hospital
           resulted in participants perceiving the room as more attractive, which in turn resulted
           in less perceived stress. Considering the potential infection risks of real plants,
           Dijkstra (Dijkstra, 2009) conducted a second experiment in a figurative painting of a
           tree was added to a patient room. This second experiment re-confirmed the
           stress-reducing properties of nature, and replicated the mediating effect of perceived
           attractiveness on stress. Furthermore, stress is not only reduced by indoor plants, but
           by a painting of nature as well. An association task revealed that, next to indoor
           plants, a painting of a tree also activated the concept of nature. This suggests that a
           mere association with nature could potentially lead to beneficial effects.

           Taken together, nature interventions have shown to be beneficial in a variety of
           settings. This includes both real and simulated nature interventions. Applying such
           nature interventions in the CT scan suite might thus lead to beneficial effects in
           patients.

        2. OBJECTIVES

      This research project aims to gain insight in how the physical environment of the CT scan
      suite affects patients' health and well-being. Patients undergoing procedures in a CT scan
      suite are often anxious and frightened. Stress reactions can be considered a clinical problem
      since they often result in negative or worsened medical outcomes. Reduction in state anxiety
      may help to promote relaxation, which in turn is beneficial for a patient's sense of
      well-being.

      Primary Objective: to determine whether a skyceiling lowers stress and anxiety during
      diagnostic procedures in a CT scan suite.

      Secondary Objective(s): to determine whether a skyceiling improves environmental appraisals,
      mood, satisfaction with the provided service, time perception, and trust in the healthcare
      provider.
    

Observational model: Case-Only
Time perspective: Cross-Sectional
Sampling method: Non-Probability Sample
Study population: 
        120 Out-patients, age 18-85, who are scheduled to undergo a thorax and/or abdomen CT scan
        with intravenous contrast.
      
Keywords: Stress; Anxiety; Skyceiling; Nature