David Lawrence / Prime Images, Inc.

BY BARBARA LYONS STEWART, AIA, EDAC, M.Arch

Designers and clients enjoy selecting artwork. Imagination and creativity are finally given free reign when the art selection committee decides what will be best for their building and community. But can we be too innovative when selecting art? Could we be compromising patient and staff health because we view artwork differently than they do?

According to environmental psychologists, the answer might be “yes.”

Along with the basic knowledge we acquire, we seem to learn a ‘way of seeing’ that is characteristic of our chosen profession … Architects see form, light, and color, where the rest of us see walls, floors, and doors … The very same everyday buildings are judged differently based on social class, sex, age, mood, and educational level. (ref 1)

We know artists look at the world differently. They turn the mundane into the sublime by transforming everyday objects into intriguing images. Similarly, design professionals apply their training and experience to create edgy and unique buildings, often selecting art with the same philosophy. But healing has nothing to do with what appeals to the 21st century design mind—and everything to do with human instinct.

Neuroscientists say we are hardwired to respond to features including color, landscape views, light, fire, and garden. Roger Ulrich’s constantly quoted 1984 study confirmed the significance of landscape views when it showed that patients who viewed trees through their windows recovered sooner and required less pain medication than patients facing a brick wall. (ref 2)

Later studies confirmed that stress-reduction can foster better clinical outcomes: A study by Miller, Hickman & Lemasters in 1992 revealed that when patients suffering intense pain because of severe burns viewed a videotape of a nature scene (forest, flowers, ocean, and waterfall), their anxiety and pain intensity reduced significantly. (ref 2)

And later studies by Ulrich in 1999, and by Parsons & Hartig in 2000, indicated: Strong evidence that even fairly brief encounters with real or simulated nature settings can elicit significant recovery from stress within three minutes to five minutes at most. (ref 2)

Artwork can create a simulated nature setting, but not every nature image will reduce stress, such as:

• Leaves in a geometric composition;

• Plaster tree branches applied to a wall; or

• Abstract images of sky or water.

Images like these have been described as healing art, even though every evidence-based design study I’ve found has proven that only viewing representational landscape scenes measurably decreases heart rate, blood pressure, and pain while improving mood.

Professor Irving Biederman at the University of Southern California has found that when people view scenes that are universally preferred - a beautiful vista, a sunset, a grove of trees—the nerve cells in that opiate-rich pathway become active. It is as if … your own brain gives you a morphine high! (ref 3)

One art trend consists of enlarging natural forms like flowers. These contribute to the nature-based design themes people find so appealing but create a missed opportunity in patient, exam, waiting, and procedure rooms where stress and pain reduction is a goal.

Which do you find more relaxing?

A. Sitting on a deck looking out over a lawn at a lake, forest, or mountain range?

B. Sticking your face in a plant?

Restorative (stress-reducing) images can be photographs, paintings, watercolors, drawings, backlit light fixtures, video images, etc., but include a foreground, middle, and distant views. That is what our eyes see when we glance out of a window or go for a walk. Neuroscientists have proven that three different parts of our brains perceive close, medium range, and distant objects. We activate all three by unconsciously scanning the horizon for things that stand out, zooming in on anything that grabs our attention. (ref 3)

Evolutionary psychologists say that our brains haven’t changed much since our ancestors walked out of Africa 100,000 years ago to populate the rest of the world. (ref 4) Some believe that when people were injured in the wilderness, focusing calmly on an open landscape allowed them to anticipate danger, decide whether to fight or flee, and survive. Staring at a close object left them vulnerable on all sides.

Environmental psychologists describe our instinctive positive responses to wide landscape views as the Savannah Theory or the Prospect and Refuge Theory. We feel most comfortable in a protected place (refuge) with wide visibility (prospect). For example, 4,000-year-old Feng Shui’s Commanding Position carries this concept into site planning, building layout, and furniture placement. The Neanderthals typically located their caves on mountainsides overlooking a valley in this defensive position. Along with inheriting our ancestors’ DNA, we seemingly inherited their defensive and self-calming instincts.

We are all Stone-agers living in the fast lane. (ref 4)

Restorative scenes make us feel that life is safe and easy:

• A spring, summer, or early autumn scene with green trees and plants (Instinctively means food, water, and shelter are plentiful);

• A wide daytime view with sun and a blue sky (Instinctively means good weather for hunting and gathering with the ability to see predators);

• A scene with signs of humans in the foreground (Instinctively means this is a safe place).

Researchers have learned that representational art showcasing open pastoral scenes with scattered trees and meadows that are rimmed with a forest, tended gardens, and placid water are the three best sorts of images to use in healthcare environments. (ref 2)

Stephen and Rachel Kaplan, professors at the University of Michigan, noted in their 1995 study that the primary criteria for Restorative Art is that we’d prefer to be inside those scenes. (ref 5)

The most fundamental feature of a restorative place is that people have to feel that they can move into those spaces and have a wonderful experience—an image of a dark forest or a dense thicket of trees does not hold as much promise of pleasantness as a sunlit, savannah-like meadow with scattered trees. (ref 5)

In my work as a healthcare design psychology consultant to architects and healthcare organizations, throughout the design process (from site planning to art selection) I ask clients to imagine they are taking their 85-year-old grandmother or 9-year-old son into their facility. This is an effective way for design professionals to switch from a creative innovation-based perspective to a user-based perspective.

How would your 9 year old respond to an abstract leaf composition in an exam room? What about ethnic symbols and patterns? Those images wouldn’t hold his attention for more than a few seconds. He could spend a much longer time looking at this sunny beach scene imagining playing in the waves or building a sand castle. Making up stories about being inside the beach scene would engage his mind and help him ignore the big needle coming his way (the essence of a positive distraction).

Your grandmother may prefer to imagine herself leaning against the country gate, looking out onto a sunny field (an easy leap of the imagination into a safe and sweet-smelling place). Scenes that position the viewer knee-deep in a river or high weeds may be more stressful, regardless of a wonderful view.

We should also evaluate the need for restorative scenes in staff areas like break rooms, nurses' stations, offices, and on-call rooms. Staff stress affects both retention and satisfaction—major issues in healthcare today.

What about children’s art? Whimsical art? Regional art? Any image that makes us smile and feel more comfortable is positive. But studies have shown no quantifiable restorative effects for those genres.

Eisen (2006) studied the art preferences of schoolchildren and hospitalized pediatric patients across four age groups … Findings suggested that, irrespective of age or gender, the great majority … were similar in preferring nature art (such as a forest setting with lake and deer) over abstract or cartoon-like images. (ref 6)

Miro Salazar’s mural for the Kaiser Permanente Vallejo Medical Center is restorative, whimsical, and regional with water, mountains, and forest. It is easy to imagine being one of those people having a great time on a boat or in the Vallejo park. But selecting regional images of dusty farmland with old distressed barns that look like the farmers couldn’t afford paint, or went mad in 105-degree heat and sandstorms (like the regional artwork in one hospital I reviewed) will deplete, not restore, energy.

There are many places in a healthcare facility where non-restorative art may be appropriate:

• Spaces that people move through quickly like reception areas and corridors; or

• Rooms with windows overlooking green nature views.

Many design professionals believe that representational landscapes are too traditional for modern buildings. But it is our responsibility to remember that patients and staff will never view artwork through highly trained “design eyes.” According to experts, non-design professionals view art with more instinct and emotion, and less intellectual rationalization. What if someone you love enters your facility in pain someday? How important would innovative art seem then?

The words “healing art” should not be applied frivolously. Ancient wisdom and increasing quantifiable evidence show that where healing is concerned, instinctive human responses consistently trump 21st century intellectual preferences.

Unless—someday, somewhere—a healthcare facility is designed specifically for artists, art dealers, and designers, at which time all bets are off.

Barbara Lyons Stewart AIA, EDAC, M.Arch, is a healthcare design psychology consultant to architects and healthcare organizations. She has developed 18 instinct-based design principles, describing how space is unconsciously experienced from the patient/staff perspective.

References

1. Gifford, R. Environmental Psychology Principles and Practice, second edition. Allyn and Bacon,1996. 2. Ulrich, R., Quan, X., Zimring, C., Joseph, A., Choudhary, R. The Role of the Physical Environment in the Hospital of the 21st Century. Report to the Center for Health Design funded by the Robert Wood Johnson Foundation, 2004

3. Sternberg, E. M. Healing Spaces: The Science of Place and Well-Being. The Belknap Press of Harvard University, 2009.

4. Evans, D., Zarate, O. Introducing Evolutionary Psychology. Totem Books, 2000.

5. Augustin, S. Place Advantage: Applied Psychology for Interior Architecture. John Wiley & Sons, Inc., 2009.

6. Ulrich, R., Zimring, C, Zhu X., DuBose, J., Seo, H., Choi Y., Quan, X., Joseph, A. A Review of the Research Literature on Evidence-Based Healthcare Design. HERD Health Environments Research & Design Journal. Spring issue. Vendome Group, LLC, 2008.

Reprinted with permission from the February 2011 issue of HEALTHCARE DESIGN. ©2011 Vendome Group LLC. All rights reserved.