Master's Design Project by Kayla Ross

Optimizing the Dental Office Environment to Minimize Stress

Kayla Ross

Optimizing the Dental Office Environment to Minimize Stress By Kayla Ross A non-thesis project document submitted in partial fulfillment of the requirements for the degree of MASTER OF ARTS IN INTERIOR DESIGN Matt Melcher M. Arch., Committee Chair Kathleen Ryan M.A., Committee Member Ann Oâ&#x20AC;&#x2122;Kelley Wetmore M.S.D.H., Committee Member WASHINGTON STATE UNIVERSITY Department of Interior Design 2013

Acknowledgments First and foremost, I would like to thank my parents for giving me their unyielding encouragement and support to reach my dreams. I also want to thank Zack, for his dedicated partnership in life, helping me with all of my struggles and celebrating with me all of my achievements. In addition, I would like to express my deepest gratitude to my committee chair, Matt Melcher, and committee members Kathleen Ryan and Ann Oâ&#x20AC;&#x2122;Kelley Wetmore who have continually conveyed dedication to research and scholarship. I also would like to take this opportunity to thank all the faculty members of the Interior Design program, as well as everyone else who has lent a helping hand during this endeavor.

Supportive Design, Attention Restoration Theory, Biophilic Design

Table of Contents Research

ABSTRACT (2) INTRODUCTION (5)

Research Questions Objective Justification

REVIEW OF THE LITERATURE (08) Stress and Anxiety Supportive Design Biophilic Design Attention Restoration Theory Summary

METHODOLOGY (14)

Participant Selection Open–ended Interviews Case Studies Data Collection Researcher’s Role Data Analysis Limitations

PROJECT PROPOSAL (20) Design Strategies Site Next Steps

Design

PROGRAMMING (25) I

Project Goal Theory Properties & Attributes Adjacency Matrix Laws & Codes

SITE (30)

Existing Interior Existing Interior

Design Concept Color Scheme Floor Plan Dental Office Exterior Waiting Area Design Operatory Room Design Consultation Room Design Employee Break Room Design

BIRCH TREE DENTAL (35)

REFLECTION (50) IMPLICATIONS FOR FUTURE RESEARCH (50)

Appendices

APPENDIX 1: REFERENCES (53) APPENDIX 2: GLOSSARY OF TERMS (55) APPENDIX 3: CASE STUDY QUESTIONS (55) APPENDIX 4: IRB INFORMATION (56) APPENDIX 5: INTERVIEW QUESTIONS (57) APPENDIX 6: EXISTING FLOOR PLAN (58)

Abstract Purpose: The research project examines how the physical characteristics of the dental office environment can be optimized to reduce stress and

anxiety. Numerous bodies of literature provide evidence there is clearly a need to improve the dental office physical environment due to high levels of stress in both the members of the dental team and patients. There are a number of empirical studies that show increasing contact with nature in the work environment is a practical and straightforward way to decrease stress. Supportive design facilitates coping with stress by incorporating features that help reduce stress while eliminating features that elevate stress. Biophilic design incorporates nature into the built environment to create a place that promotes positive emotional experiences and alleviates stress. Attention Restoration Theory also plays a role in reducing stress because contact with natural elements can restore mental fatigue that may contribute to stress. There is much consistent evidence that focuses on supportive design, biophilic design, and Attention Restoration Theory in the workplace or healthcare setting; however, there is no research on how these theories can be linked to optimize the dental office.

Methodology: A two phase study was conducted. Phase I consisted of open-ended interviews with the dental team. Phase II includes case studies of three dental offices. Intended Result: The findings from the literature review, interviews, and case studies are utilized in an interior design project of a dental office. It concentrates on using design strategies derived from supportive design, biophilic design, and Attention Restoration Theory.

Supportive Design, Attention Restoration Theory, Biophilic Design

Research INTRODUCTION REVIEW OF THE LITERATURE METHODOLOGY PROPOSAL

Introduction Empirical research suggests many dental patients experience significant amounts of emotional stress. In fact, 20%-30% of the population dislikes going to the dentist and seeks dental treatment only in the case of emergencies (De Jongh, Aartman & Brand 2003). This can lead to poor oral health. For the dental team, the demands of their jobs contribute to negative health effects (Lang, 2007; Myers & Myers, 2004). These demands can lead to high levels of stress and mental fatigue (Myers & Myers, 2004). There is a great need to reduce this stress in the dental office environment. The dental office should promote an environment that is supportive in fostering the ability to cope with stress. The theory of supportive design proposes that our ability to cope with stress can be maximized if environmental features that elevate stress are eliminated while other environmental features that reduce stress are emphasized (Ulrich, 1997). Biophilic design and Attention Restoration Theory support the same notion of reducing stress but propose incorporating natural elements into the built environment have the ability to do so. Biophilic design looks at how contact with nature within the built environment can derive alleviation from stress and lead to positive experiences (Kellert, Heerwagen, & Mador, 2011). Similarly, Attention Restoration Theory explains that people prefer restorative environments that are natural because their mental fatigue (which can lead to stress) will be restored faster in environments with involuntary attention, as natural environments most often provide (Kaplan, 2001). How can the dental office be optimized to minimize stress for both the patients and dental team? The purpose of this study is to develop an understanding of the relationship between the connection between natural elements in the dental office environment and minimizing stress. This paper discusses the influences the physical and natural environments have on reducing

stress. Supportive design, Attention Restoration Theory, and biophilic design are combined to make up the framework for this study and also inform sub research questions. RQ1: How can supportive design be used to minimize stress for the patients and dental team in the dental office environment? RQ2: How can Attention Restoration Theory be used to minimize stress for the patients and dental team in the dental office environment? RQ3: How can biophilic design be used to minimize stress for the patients and dental team in the dental office environment?

BIOPHILIC DESIGN

ATTENTION RESTORATION THEORY Dental Office DENTAL OFFICE EnvironmentTO OPTIMIZED Optimized MINIMIZE forSTRESS Stress

SUPPORTIVE DESIGN

Figure 1.1: The diagram visually displays the relationship between Supportive Design, Biophilic Design and Attention Restoration Theory.

Objective The amount of research to date on reducing stress in a dental office environment is limited; however there is a large body of relevant research regarding how stress can be mitigated through supportive design,

biophilic design, and Attention Restoration Theory. The primary objective of this study is to examine how the dental office physical environment can be altered to minimize stress. This is addressed through a review of supporting literature. The theories proposed are intended to help increase understanding of minimizing stress for both the patients and dental team in relation to the physical environment. Literature reviews along with interviews with dental team members and case studies of dental offices yield further direction for incorporating stress-reducing elements into the physical environment. The overall intended outcome of this study is to demonstrate how to optimize the physical design of the dental office to minimize stress. In doing so, the information gathered may further support the application of these theories. The dental office is a significant investment of the dentistâ&#x20AC;&#x2122;s time and money. The design of the dental office should be thoughtfully analyzed. In the stressful profession of dentistry, appropriately designed dental offices can offer many significant benefits and can contribute greatly to the success of the dental practice (Unthank & True, 1999). Effectively designed dental office interiors have the capacity to not only minimize stress but create a positive experience. Another major objective of this study is to provide designers and oral healthcare providers guidelines that govern the design of dental offices. These guidelines are derived from supportive design, biophilic design, and Attention Restoration Theory and may be considered when remodeling or designing a new dental office. Following these design guidelines has potential to yield optimum results in reducing stress.

Justification Studies suggest that there is a great need to reduce negative stress-related health problems related to the practice of dentistry, many of which can cause detrimental psychological and physical effects. This stress may not only affect the dental team but may also negatively affect the quality of care of patients. There is a significant amount of research

that focuses on how the dental team and patients are affected by stress. Thus, there is a great need for research on how the dental office can alleviate this stress in all users. Dentists Dentists are highly subject to job related stress. Often dentists are confined to spaces that are approximately seven by nine feet for nearly the entire work day (Lang, 2007). They must perform very meticulous work in a small area, which can take a mental and physical toll. When stress leads to an individual experiencing emotional exhaustion in the workplace, burnout can occur (Gorter, 2005). Many physical symptoms are related to burnout but mental fatigue is the most prominent. Stress that occurs in the dental office environment can explain nearly half of the overall stress in a dentistâ&#x20AC;&#x2122;s life (Myers & Myers, 2004) this may lead to psychological and physical negative health effects. According to research reported in dental literature, 32% of dentists experience psychiatric symptoms, while in comparison the general population was only at 17.8% (Lang, 2007). It has also been reported that dentists have alarmingly high incidences of emotional illness, ranking dentists third in the nation. Stress-related physical symptoms have also been associated with dentistsâ&#x20AC;&#x2122; stress, including symptoms of headaches, feeling tense, and having difficulty sleeping (Myers & Myers, 2004). Also, it is evident that dentists suffer from coronary disease and high blood pressure 25% greater than the general population (Lang, 2007). Among all these stress-related physical symptoms, cardiovascular disease has proven to be the greatest threat, causing the most deaths of dentists. In addition, dentists are recognized to have high incidences of suicide (Stack, 1996). In a study controlling for socio-demographic factors among dentists, dentists still had significantly higher risks of suicide which indicates that occupation stress may be the cause. These studies suggest that stress can take a psychological and physical toll on dentists and there is a great need to reduce stress in the dental office.

Supportive Design, Attention Restoration Theory, Biophilic Design

Dental Hygienists Dental hygienists also experience high amounts of stress as they share the same general work setting as dentists (Lang, Gilpin, & Gilpin, 1990). Research suggests that dental hygienists experience relatively high stress-related psychological symptoms. In fact, dental hygienists showed more stress-related physical symptoms than the national norm. In a survey measuring stress-related physical symptoms in dental hygienists findings indicated that in eight out of the nine dimensions regarding stress, dental hygienists had significantly higher scores than the normative sample (Lang, Gilpin, & Gilpin, 1990). These dimensions included global severity, positive symptom distress, positive symptom total, somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility paranoid ideation and psychoticism. Phobic ideation did not differ significantly from the normative mean however. Time management was the primary source of stress because dental hygienists often experience tight schedules that allow little flexibility. Other stressors included patient resistance, concern with equipment, and safety of self and patient. Dental hygienists also are subject to experiencing burn out (Gorter, 2005). This can cause them to maintain a distance from their patients and treat them as a case, rather than a human being. In a study measuring stress in dental hygienists, 15% reported mental exhaustion which as previously stated is a primary symptom of burnout. Also, research showed that 16% of dental hygienists reported chronic headaches and 13% experienced anxiety. Patients There have been significant improvements in the practice of dentistry in technological advancements (Klages, Sadjadi, Loek, Rust, & Wenrbein, 2008) and an increase in knowledge about ways to reduce fear of dentistry (Armfield, 2010). Still, evidence has shown that high levels of dental fear have not significantly decreased (Armfield, 2010). This fear of going to the dentist can lead to dental avoidance and poor oral health.

In a study measuring dental fears as well as perceptions of going to the dentist and dental experiences, results indicated that patients experience fear at the dental office because they perceive the situation as being unpredictable, uncontrollable, disgusting and/or dangerous (Armfield, 2010). Thus, their perception of going to the dentist plays an important role in determining their level of anxiety and fear rather than their actual experiences. Patients who experience dental anxiety also exhibit great concerns about upcoming dental procedures and display distrust in the dental team. Anxious dental patients may also be affected by mental fatigue due to an accumulation of stress generated from the dental treatment with other stressors outside of the dental office. In many patients experiencing dental anxiety, stress was so severe that they experience numerous symptoms that are related to posttraumatic stress disorder (PTSD) (De Jongh, Aartman & Brand, 2003). PTSD is usually related to disasters, assaults or accidents. However, certain dental treatments can be very painful, causing physical injury and psychological discomfort so much that patients fear they are being threatened. Many of these patients with severe dental anxiety who have upcoming dental appointments experience intrusive memories that may lead to avoiding dental treatments. There are many factors that cause this stress and anxiety in a dental office environment but no research has yet addressed how supportive design, biophilic design and Attention Restoration Theory can contribute to reducing this stress. An understanding of how to incorporate design strategies derived from these theories can lead to a better understand how it can directly affect dental patients and dentists. The information gathered from this research may prove useful in changing the face of dentistry. It may not only minimize stress and anxiety but also create a more positive experience of going to the dentist.

Review of the Literature The dental office should be more than satisfactory in terms of providing a patient dental service. The environments should be supportive of its users by fostering the ability to cope with stress that is closely related to the field of dentistry. There is a great deal of research that yields credible evidence on how the role of design can create environments that can mitigate stress. High priority should be given to how the environment will affect the stress levels of the patients and dental team when designing the dental office.

Stress and Anxiety Stress is the process in which an individual responds to environmental forces, referred to as stressors that threaten their wellbeing (Evans & Cohen, 1984). As shown in Figure 1.2, a person will cognitively appraise the situation as a threat and will react to it both psychologically and physically. If an individual perceives a threat, stress reactions trigger an adaption mechanism, known as the fight-or-flight response (Grahn, & Stigsdotter, 2010). These stress reactions are both

Figure 1.2: The diagram visually displays the process of stress. When a stressful situation occurs, an individual cognitively appraises the situation to see if it is a threat and then will react to it with either stress or coping resources (Evans & Cohen, 1984).

natural and necessary and the body reacts by increasing in blood pressure, sweat gland production, adrenaline, and muscle tension. In today’s modern life, rarely do we need to fight or flee when we perceive threats; instead we experience this as stress. Anxiety is a response to stress that is induced when an individual apprehends the anticipation of a future threat (Sarason, 1984). This threat may be actual or perceived. In fact, many anxious people cannot specify the cause of their reaction. People who experience anxiety associated it with feelings of worry or being tense. It can interfere with a person’s ability to perform tasks and may even become debilitating in an individual’s daily life. The physical environment can influence how an individual recovers from stress (Ulrich, Simons, Losito, Fiorito, Miles, & Zelson, 1991). Certain physical characteristics of an environment are capable of hindering a person’s adaptive resources, while others can foster them (Evans & Cohen, 1984). For stress to occur, environmental demands must exceed an individual’s coping capabilities. A person is constantly adapting to their surroundings and is able to tolerate these environmental demands for a short period of time but coping with these stressors requires a lot of effort and may be cognitively fatiguing.

Supportive Design The theory of supportive design facilitates coping with stress by eliminating environmental features that are stressful and emphasizing features that have stress reducing influences (Ulrich, 1997). The idea of supportive design has been studied in healthcare settings, most typically hospital environments. It is justified to propose that dental office environments will likely support stress relief if they are designed to use best practices in dental office design, eliminate environmental stressor, foster a sense of control, provide access to social support, and provide access to positive distractions (as shown in Figure 1.3).

Supportive Design, Attention Restoration Theory, Biophilic Design

Figure 1.3: The diagram visually displays the properties of Supportive Design Theory.

Best Practices Healthcare facility design is particularly likely to have a meaningful impact on patients because they already arrive under considerable amounts of stress (Berry, Parker, Coile, Hamilton, O’Neill, & Sadler, 2004). A well planned dental office has potential to provide immediate and positive impacts in mitigating stress in both patients and the dental team. Using best practices in dental office design will communicate the quality of the service the dental office is providing for the patients (Unthank, 1999). The design features of the waiting room inform patients about the value the dental office places on their comfort (Leather, Beale, Santos, Watts, & Lee, 2003). How the waiting room, looks and feels, has the ability to reduce stress and anxiety experienced by patients prior to dental treatment. Best practices around this issue include patients not being able to see private areas (Unthank, & True 2010). Operatory rooms should not be visible from the waiting area. The front of the dental office should be open enough to greet patient while allowing privacy for the staff to manage their administrative duties. The business area should be discrete so that patients discussing finances or treatment options have privacy. Many patients entering the treatment room will experience their blood pressure elevating, muscles constricting and stress levels rising (Malkin, 2005). If interventions are in place to reduce this stress, it may

be possible to change this perception. Best practices around this issue include orienting the patients toward a window to a view of nature when entering the treatment room and during the procedure (Unthank, 1997). This will direct the patient’s attention outward through a window and not allow the patients to face the corridor or other patients. The dental team spends a great amount of time in the operatory rooms so they must be very well planned to minimize stress (Unthank, 1997). When all treatment rooms are designed and equipped identically, the dentist doesn’t have to rely on one room for long procedures because he knows exactly where everything is, each room is the same as the next. This will allow greater scheduling flexibility. Also, circulation space is a primary concern in dental office design. There must be adequate access for the dental team to move around the patient’s chair in the operatory room. Furthermore, the degree of privacy between the operatory rooms varies with the each practitioner and with the procedure type, but if privacy is important, solid walls between the rooms may be appropriate. Elimination of Environmental Stressors Elements in the built environment have the ability to elevate stress levels (Heerwagen, Heaubach, Montgomery, & Weimer, 1995). Eliminating those that are associated with stress can support an individual’s ability to cope. These environmental stressors can include noise and crowding (Evans, & Cohen, 1984). Exposure to noise that is loud and unpredictable has shown to elevate blood pressure, and increase heart rate and skin conductance which are symptoms of the body trying to cope with stress. A person can experience crowding when their need for space exceeds their accessibility of space. In other words, when there are too many people in a room. This can cause a person to experience negative effects of tension, anxiety and stress. The absence of these stressors may promote relief from stress but may not eliminate it completely (Heerwagen, Heaubach, Montgomery, & Weimer, 1995). Features that have the ability to mitigate stress including access to social support, sense of control, and access to positive distractions may also be required.

Access to Social Support Patients derive stress-reducing benefits from contact with family or friends who are supportive, even if the contact is for a short period of time (Ulrich, 1997). The design of the dental office can either facilitate or hinder social support (Berry, Parker, Coile, Hamilton, O’Neill, & Sadler, 2004). Furniture arrangements and layouts of the room can affect the level of social interaction. Promoting social interaction must not conflict with providing access to privacy. Sense of Control Research from hospital settings has shown that a sense of control over the environment is directly related to stress (Berry, Parker, Coile, Hamilton, O’Neill, & Sadler, 2004). If a patient feels they lost a sense of control of the situation, then stress may emerge. It is important for the design of the environment to minimize the feeling of loss of control. If patients feel that they have a sense of control, stress may be reduced or eliminated. Offering dental patients options and choices allows them to feel more in control if they perceive the situation as threatening (Malkin, 2005). Amenities such as DVDs, televisions, and headphones can help by allowing patients to control the volume, choose a movie, TV show, or song, or choose a channel/station. Access to Positive Distractions Stimulation levels must be moderate for positive distractions to aid reducing stress levels (Berry, Parker, Coile, Hamilton, O’Neill, & Sadler, 2004). If stimulation levels in an environment are too high an individual can experience overload, but if stimulation levels are too low, a person can experience sensory deprivation (Evans & Cohen, 1984). Stress can occur on either end, a middle level of stimulation is optimal. Distractions that are positive can elicit positive feelings and can effectively hold one’s attention allowing them to no longer become preoccupied with worrisome thoughts (Ulrich, 1997).

Natural elements are particularly effective in distracting patients from stress and anxiety. Recovery from stress is significantly faster and more complete in environments with natural elements (Ulrich, Simons, Losito, Fiorito, Miles, & Zelson, 1991). This is because encounters with natural environments are perceived as nonthreatening and will influence a greater recovery from stress. Many scholars believe that humans have an inclination to positively respond to natural environments due to our ancestor’s needs for survival (Grinde & Patil, 2009). During the course of human evolution, it was crucial for human beings to survive in settings with natural content where plants served as a resource for food and shelter. Because humanity evolved in response to natural conditions and stimuli, it is still essential for humans to be in contact with nature for maturation and functional development (Kallert, Heerwagen, Mador, 2008).

Attention Restoration Theory Attention Restoration Theory (ART) explains how nature can minimize stress (Kaplan, 1995). Others have supported his original research through their evidence in connecting stress and directed attention in context of human environment relationships. According to ART, people must exert a great amount of effort to resist distraction when completing a task which can lead to direction attention fatigue (Kaplan, 1995). This may result in a person having increased irritability, and an increase in errors when concentrating on tasks (Van Der Berg, Hartig, & Staats, 2007). It can further lead to a person experiencing stress (Bringslimark, Hartig, & Patil, 2007). Thus, Attention Restoration Theory also plays a role in reducing stress. According to Kaplan, ART proposes an explanation for why people prefer restorative environments (Kaplan, 2001). It suggests that attention will be restored faster if a person experiences involuntary attention which is drawn by stimuli that does not deplete resources, as directed attention does. This involuntary attention can also help a person in resisting distractions and allow a person to be selective in what they

Supportive Design, Attention Restoration Theory, Biophilic Design

focus on. The concept of a “restorative environment” or a “restorative experience” refers to a setting that provides opportunities to recover from directed attention fatigue (Kaplan, 1995). When a person experiences restoration, they are able to gain a heightened capacity to reflect on issues of importance (Herzog, Maguire, & Nebel, 2003). Restoration can occur in both the natural and built environment, and both have different restorative potentials in regards to a person’s needs to cope (Grinde & Patil, 2009). However, ART explains that more restorative qualities can be found in environments incorporating nature because they provide effortless attention that offers an opportunity to restore mental capacity. As shown in Figure 1.5, ART hypothesizes there are four properties that aid in providing a restorative environment-being away, extent, fascination and compatibility (Kaplan, 1995). Environments that incorporate nature are likely to meet each of these properties.

viewing the environment in a new way or a change in a person’s gaze (Kaplan, 2001). Extent Extent relates to a setting that has distance to a boundary (Kaplan, 2001). For extent to occur, a setting needs to have rich and coherent content to see, experience, and think about. In doing so, a person will no longer focus on directed attention and will be restored from mental fatigue (Kaplan, 1995). People often describe this experience as being in “a whole other world”. Natural environments provide many opportunities for extent because they provide a scope for continued exploration (Van Der Berg, Hartig, & Staats, 2007.) Fascination People experience fascination when settings or objects are able to attract and hold a person’s involuntary attention (Van Der Berg, Hartig, & Staats, 2007). Nature encompasses soft fascination which holds a person’s attention effortlessly and leaves opportunities for reflection (Kaplan, 1995). Hard fascination on the other hand, is characterized by settings that may be so fascinating that it does not allow one to reflect (Van Der Berg, Hartig, & Staats, 2007) such as watching auto racing (Kaplan, 1995). Settings with hard fascination are not restorative.

Figure 1.5: The diagram visually displays the properties of Attention Restoration Theory.

Being Away Being away refers to settings where a person feels free from directed attention (Kaplan, 1995). In fact, people often use the term “getting away” to describe this restorative experience. Achieving the feeling of being away does not need to be a physical transformation but rather a conceptual transformation. This may be accomplished by

Compatibility Environments are compatible when they supports a person’s purpose and activities (Kaplan, 1995). In a compatible environment, a person should be able to carry out their task with no struggle. An environment can become incompatible when it requires a great amount of directed attention (Herzog, Maguire, & Nebel, 2003). Natural environments are considered highly compatible due to their ability to provide effortless attention (Kaplan, 1995). In fact, many people functioning in a natural environment expend less effort than when

environment, even though they are familiar with it.

Biophilic Design This notion of humans connecting with nature otherwise known as “biophilia” was pioneered in the 1980’s by an American biologist, Edward O. Wilson (Wilson, 1984). The term biophilia stems from the Greek roots meaning love of life. Wilson describes biophilia as humans having a natural affiliation to other living organisms because we have an “innate tendency to focus on life and lifelike processes”(Wilson, 1984, p.1). This human connection with nature can be achieved through the design of the built environment (Kellert, Heerwagen, & Mador, 2008). Biophilic design enhances and restores the benefits that are derived from incorporating nature into the built environment. Nature influences a person’s mind subconsciously, even if they consciously don’t realize the visual presence of nature (Grinde & Patil, 2009). In other words, if a person is unaware of a natural object, their brain still recognizes it. In the absence of natural elements, as the urban built environment often is, the brain may register environments to be unnatural and potentially threatening. This may lead to a person experiencing the flight or fight response (Grahn, & Stigsdotter, 2010) and as previously mentioned can result in experiencing stress. Even though humans now live in an age where they spend most of their lives within the built environment cut off from almost all contact with nature, even a brief exposure to natural elements can be beneficial (Grinde & Patil, 2009). Biophilic design incorporates nature into the built environment to create a place that promotes positive experiences and relief from stress. Attributes of biophilic design that provide stress reducing benefits include but are not limited to window views to nature, natural light, simulated nature, natural materials, and indoor plants (Figure 1.4). These attributes serve as a way to achieve the goals of being away, extent, fascination and compatibility that Attention Restoration Theory proposes.

Figure 1.4: The diagram visually displays the attributes of Biophilic Design.

Window Views to Nature Window views to nature are very influential in mitigating stress (Kaplan, 2001). The views of natural settings have the ability to draw a person’s attention because minimal effort is required. Though short lived, views of nature provide opportunities for a micro-restorative experience. The dental team may experience the restorative effects of window views to nature from repeated opportunities. Accumulating these microrestorative experiences may lead to a reduction in stress levels. “The glimpse of the world beyond afforded by the window view can quickly transport one elsewhere in mind if not in body” (Kaplan, 2001 p.511). The stress reducing qualities of natural scenes depends on the content of what is being seen. Landscape design needs to be considered from the perspective of the user looking outward from the windows (Chang, & Chen, 2005). Spatial openness and green vegetation are most preferred over most modern synthetic elements such as concrete (Ulrich, 1993). Natural Light Windows provide a view to the outside world, as well as allow daylight to penetrate inside. Research has shown natural light is also associated with mitigating stress (Alimoglu, & Donez, 2005). A study

Supportive Design, Attention Restoration Theory, Biophilic Design

investigating if exposure to daylight in work settings could be correlated with job burnout found that at least three hours of daylight exposure a day caused less stress and higher satisfaction among the workers. The study concluded that daylight may be effective in reducing job burnout (Alimoglu, & Donez, 2005) which the dental team is often prone to experiencing (Jeswin, & Madhusudhan, 2011. Gorter, 2005). Exposure to natural light has also shown to decrease depression and anxiety (Grahn, & Stigsdotter, 2003). Simulated Nature Contact with nature can be beneficial whether it is real or simulated. Viewing simulated nature such as paintings, photographs, slides, videos or computer displays that have nature content can be restorative (Felsten, 2009). Natural murals in indoor settings may provide a person who is fatigued with opportunities for restoration when there are no views of nature present or the space is limited in restorative potential. In a study measuring where college students would like to take a break on a college campus, participants were instructed to imagine their selves cognitively fatigued. They then rated the perceived restorativeness of indoor campus settings that either had no views of nature, some views of nature but with built structures and views of simulated nature depicted as large nature murals. The findings suggest that settings with views of dramatic, wall-sized nature murals were rated significantly higher on the four properties of Attention Restoration Theory than with settings with no views of green space. They even rated higher than settings with window views that included green space with built structures present. Nature can also be simulated within interiors by mimicking motifs found in the natural world (Kellert, Heerwagen, & Mador, 2008). These representations of forms, shapes and patterns are often of plants, tress, animals and shells. This ornamentation or decoration may be represented literally or only vaguely represent nature. The most successful simulation of natural features occurs when it possesses features that are in response to environmental process. Fractal patterns found in nature have shown to have a positive effect on holding peopleâ&#x20AC;&#x2122;s attention and

inducing a response of relaxation (Hagerhall, C., Laike, T., Richard, T., Kuller, M., Kuller, R., Martin, T., 2008). Fractal patterning occurs when natural processes determine the forms and patterns of natural organisms (Heerwagen, 2003). For example, growth patterns are very noticeable in leaves with branching angles, and seashells with spiraling shapes. Because of this fractal growth process, natural shapes are sinuous and flowing, they are rarely characteristic of straight lines and right angles (Heerwagen, 2003). Biophilic design also encompasses natural features that incorporate the essence of nature without making exact replicas of forms and visual patterns (Heerwagen, & Hase, 2001). This can be achieved by designing with organic shapes and forms representational of the natural world, they resist straight lines and right angles that are characteristic of the built environment. Nature can also be simulated through aroma as odors can influence peopleâ&#x20AC;&#x2122;s emotional states (Lehrner, Marwinski, Lehr, Johren, & Deecke, 2005). Lehrener et al. stimulated dental patients with ambient odors of either lavender or orange in a dental office. Results showed that patients who were exposed to orange or lavender odors experienced less anxiety, a more positive mood, and were calmer. Natural Materials Research indicates people prefer natural materials over those that are artificial, even when artificial ones are of exact copies (Kellert, Heerwagen, & Mador, 2008). This is likely due to the incapability of artificial material to reveal the natural process of aging through time. This progression evokes a positive response through familiarity and satisfaction. Materiality also provides a visual connection with nature as well as a sensual experience (Heerwagen, 2003). For example, a deep wood grain on an object may fascinate an individual and they may explore the reason why through touch. Indoor Plants

Incorporating plants, even artificial ones into the interior

Conclusion Based on the reviewed literature, it is apparent there is a strong relationship between supportive design, Attention Restoration Theory, and biophilic design (Figure 1.6). Many studies have connected these theories to stress in the hospital settings, but there is gap in the research of how all three can be used to mitigate stress in an environment. The dental office creates a unique opportunity to explore these relationships due to the stressful nature of dentistry. The design of the dental office needs to support coping from stress, whether the concern is for patients or for the dental team. It is crucial for designers and oral healthcare providers to have a better understanding of the elements that contribute to mitigating stress. Practicing this research has the potential to greatly improve the way the dental office is perceived. A deeper understanding of how dental offices currently use each of these theories to reduce stress will be gained through interviews with various dental team members, as well as case studies.

SUPPORTIVE DESIGN

POSITIVE DISTRACTIONS

NATURAL MATERIALS

SIMULATED NATURE

INDOOR PLANTS

NATURAL LIGHT

BIOPHILIC DESIGN

WINDOW VIEWS

environment is an effective way to minimize stress (Chang, & Chen, 2005). Indoor plants are commonly cited in literature as attracting attention without effort and evoking positive emotions (Bringslimark, Hartig, & Patil, 2007). This interrupts the stress process and promotes recovery from the inability to concentrate. Indoor plants are less effective in their benefits to promote restoration if a person has only moderate restoration needs. In contrast, the effects are greater if a person has higher levels of stress (Chang, & Chen, 2005). Research also suggests that the stress reducing effects of indoor plants are derived from the perceived attractiveness of the space (Dijkstra, Pieterse, & Pruyn, 2008). Visual stimuli that is deemed aesthetic gives pleasure to the mind (Grinde & Patil, 2009). The presence of plants is found to be aesthetically pleasing and releases tension. Also, live plants provide non-visual benefits in making a space more attractive which include fragrance, improving acoustics, improving humidity, and purifying the air.

ART PROPERTIES BEING AWAY EXTENT FASCINATION COMPATIBILITY

Figure 1.6: The diagram visually displays Attention Restoration properties as goals and biophilic design and positive distractions in supportive design as a way to achieve those goals.

Methodology The purpose of this study is to explore how the dental office environment can be altered to mitigate stress. The strategy of inquiry is a qualitative approach. The data was collected in two phases. The first phase consisted of collecting data from open-ended interviews. Before the interviews were conducted, the study was submitted to the International Review Board (IRB) to protect the rights and welfare of the participants. The Washington State University Office of Research Assurances determined that the study satisfies the criteria for exempt research and assigned the study an IRB#12786. In the second phase of the research, data was collected from case studies of dental offices. Participant Selection Participants included dental team members. They were recruited by the researcher based on the following criteria: the dental office in which they worked had attributes of biophilic design or their company philosophy was related to reducing stress for their patients. These interviews were conducted with one dentist and dental hygienist from

Supportive Design, Attention Restoration Theory, Biophilic Design

each of the three dental offices. In total, six participants were interviewed for the study. The site of a dental office environment was important because it is the type of space being studied. A participant’s experience in the environment of study is relevant to their perception of the place so it is crucial that the interview was completed at the work site. Phase I Prior to the case studies, interviews were conducted with each of the six participants. Open-ended interview questions allowed the participants to answer the questions in-depth. The face-to-face interviews were held at the dental office of each participant. The purpose of these interviews was to gain a richer insight of the ways in which dental offices are designed to mitigate stress for their patients and dental team. Participants were encouraged to provide any information they felt would be appropriate to the study (See Appendix: 3 for interview questions). Phase II Case studies were conducted at each of the three dental offices where the interviews took place in order to gain additional insight. The case studies gathered information related to the three theories that made up the framework of the literature review: supportive design theory, Attention Restoration Theory, and biophilic design. (See Appendix: 4 for case study questions). Data Collection After collecting data from interviews and case studies, the data was organized to allow for an accurate analysis and interpretation of the data. A general sense of the information was obtained by reviewing the data repeatedly and reflecting on the overall meaning, looking at what general ideas the participants said. A detailed analysis with a coding process was used by organizing the information into segments of text to build a coherent justification for themes. To ensure validity,

triangulation of the data was employed. Themes were then established based on converging perspectives of participants and were chronicled. In addition clarification of the researcher bias is articulated under the heading “Researcher’s Role”. Researcher’s Role Because the nature of qualitative research in phase two is interpretive, it is important to discuss issues that may shape the interpretations of the data collected. As the primary researcher, my personal experience of going to dental offices as a patient has been negative which has shaped my interest in the topic of this study. This has led to constructing this study and the desire to reduce stress in the dental office environment. However, I will still make an effort to remain neutral in interpreting the data. Data Analysis The results are presented in a descriptive narrative form to convey the findings. Descriptions of the interview’s perspectives and case studies will communicate a holistic picture of the themes that emerged. To protect the anonymity of the participants; the names have been disassociated from the responses during the coding and recording process. Pseudonyms have been assigned instead to protect the individuals and places of case studies. In addition, no other identifying information was collected. In Phase I of the research an open-ended interview was conducted with three dentists and three dental hygienists. Responses to the questions yielded interesting results. Similar themes emerged throughout the questions regarding how forces shape the design of the dental office. As you can see in Figure 1.6, regarding how the dental office design impacts function the most common answers among the participants was that the operatory room needs to have enough space to easily move around the patient chair and that everything needs to be conveniently accessible and within reach so that the dental team does

Forces that Shape the Design

Number of Participants

5 4

What Doesn't Work Well

5 4 3 2 1

3 2

s stic Aco u

Acc

es wit sibilit hin y rea & Ste ch riliz atio n-c lea n/d irty Ste clo rilizat se io to n & ope l rato ab Erg ry ono mic furn itur e

Participant Answers

Figure 1.7: All participants mentioned the function of the sterilization room and proximity of the sterilization room to the lab and operatory rooms as a force that drove the shape of the dental office design. The majority of participants also answered that accessibility and items within reach as well as ergonomic furniture were also important in shaping the design.

Ch ang i uno ng ro Ch rga om eck niz ed in/o /lac ut co k n fus of priv ing acy

In terms of what works well and doesn’t work well of the physical organization of the space, Figure 1.8 describes a common theme among the dentist’s answers was a consultation room allowed for the dentists to talk to patients about treatment options and is in good proximity to both the waiting area and the operatory rooms. A few of the dentists mentioned they had a problem with their reception area, and suggested that they would change the shape of it so the patient knows exactly where to check in and out. Two of the dental hygienists also expressed that the room where they change and keep their scrubs was unorganized. Both would suggest this problem could be resolved if it was more like a walkin closet with shelves and cubbies for each person.

Number of Participants

not need to get out of their chair during the treatment. This was also a common answer in terms of ergonomics. In addition nearly all the participants mentioned that furniture in the operatory rooms needs to be ergonomic by being able to adjust. Another common theme found among all six participants included how their dental office was designed for standard precaution for infection control. A sterilization room is located within close proximity to the operatory rooms and has a clean side and a dirty side so that instruments are not contaminated. A common theme also emerged in how the dental office is designed to impact efficiency for all participants stated that the sterilization room and lab are centrally located to the operatory rooms so that the dental team doesn’t have to walk far. In addition, half of the participants responded that acoustics plays a major role in the design of the operatory room. The other three participants mentioned that daylight, accessibility and simplicity were a force that shaped the design of the operatory rooms.

Participant Answers

Figure 1.8: Participants mentioned that the changing room check in/out area doesn’t work well.

Figure 1.9 identifies in terms of what works well in regards to the culture of the dental office, all three dental hygienists stated that staff interacts frequently during their meetings; while all three dentists stated that the reception desk faces the patients so they are able to talk to the patients and form a relationship. In regards to

Supportive Design, Attention Restoration Theory, Biophilic Design

What Works Well

Dental Office Philosophies

5 4 3 2 1

P abl atien ts e/ stre to be ss free Po siti ve exp erie nce Pa tien hom ts fe el e like

4 3 2

Sta

ff in dur terac ing ts me often etin gs Re cep fac tion es d pat esk ien for Con t talk sulta tion ing to r pat oom ien ts

com

Participant Answers

Figure 1.9: Half of the participants mentioned what works well in the dental office is the staff interacts often during meetings, the receptionist desk faces patients, and that the consultation room works well for talking to patients about finances and treatment options.

All three dental offices had similar philosophies because they wanted their patients to be comfortable/stress free. In regards to why this philosophy guides their decision-making, Figure 1.10 shows all six participants responded with the same notion of wanting to make the patient have a positive experience of going to the dentist. All participants stated they support their philosophy by trying to make the patient feel as comfortable as possible. Half of the participants stated they did this by making the office feel home-like and not a typical

fort

Number of Participants

dental office by having pictures hung on the wall, wallpaper, a fireplace, and/or large comfortable seating in the waiting area.

Number of Participants

what doesnâ&#x20AC;&#x2122;t work well between patient and staff interactions, another common theme that was also noted as a problem is the physical organization of the dental office. Trying to check out at the front desk can be confusing for there is not a designated area for the patient to talk about financial issues in privacy. They suggested making it better by creating a space in the reception area where it is obvious that the patient check out there and make it feel comfortable to talk about insurance and methods of payment.

Participant Answers

Figure 1.10: All participants expressed their offices philosophy was that they wanted their patients to be comfortable and stress free as well as have a positive experience and half tried to make their patients feel like they were at home.

Questions in regards to what features in their dental office helped alleviate stress and anxiety for patients varied greatly among dental hygienists. In Figure 1.11, Dental Hygienist 1 stated that they provided pictures of their personal life in the operatory rooms for conversation starters so they can feel more comfortable and can build a relationship. Dental Hygienist 2 on the other hand stated that they provided a squeeze ball for anxious dental patients to relieve stress. Over half of the participants also mentioned they provided windows views in the operatory. Several of the dentists repeated that they have features that make the patient feel like home through either wallpaper, a fireplace, a kidâ&#x20AC;&#x2122;s area, or comfortable furniture. Dentist 2 replied that when patients walk into the operatory room, all the equipment and instruments are behind them so they donâ&#x20AC;&#x2122;t get stressed out right when they enter. Responses to what features in their dental office helped alleviate stress and anxiety for their staff also were similar in that half

the participants replied that providing updated software and equipment reduces stress among the staff for they become less frustrated. Another common theme found from most participants included providing break rooms for the staff. 6

Features that help Alleviate Stress & Anxiety

provide a sense of control for their patients by allowing patients to control the volume and music that they listen to on the headphones. All three dentists on the other hand responded that they provide a sense of control for their patients by telling the patients to raise their hand to let them know when to stop during the treatment. 6 5

Number of Participants

How the Dental Offices Foster Coping with Stress

3 2 1

4 3 2

P ope atien rato t c ha ry roo ir Pro m vid ing am for eniti pat es ien t Dis t r win act dow w vie ith ws Co n t vol um rol th e & rough mu sic

Eq ui pat pmen ien t t i is b n ope ehind rato ry Bre ak for room sta Up ff dat ed s & o equ ftwa ipm re Ho ent me -lik e fea ture s

Pi per cture son s o f al life Sq uee ze bal l Win dow s vie ws

Participant Answers Participant Answers

Figure 1.11: Participants answers varied greatly regarding the features that alleviate stress and anxiety, however most participants expressed that they provide break rooms for the staff.

Figure 1.12, illustrates responses to how their dental office fosters coping with stress. All participants responded that they provide access to social support for their patients by either having a chair in the operatory room for visitors to come in and comfort the patient or having space for a chair if one was needed. Also providing amenities to distract patients was a common theme found among all participants, though the amenities each participant listed their dental office provided varied. Amenities various participants mentioned consist of headphones, massage pads on the chairs, hand wax with gloves, eye masks, warm neck pillows, and coffee and tea in the waiting area. Furthermore to distract patients from stress and anxiety, half of the participants replied that the windows views were present. All three dental hygienists replied that they

Figure 1.12: All the participants mentioned that they foster coping with stress through providing a patient chair and amenities for the patients, while half said they distract patients with window views and provide control though the volume and music.

In Phase II of the research, a case study was conducted at the three dental offices where the participants were interviewed. Photographs documenting the case studies can be seen in Figure 1.13. Common themes emerged in regards to best practices of dental office design. It was noted that in all three dental offices, reception desks were oriented to face the waiting area and patient chairs in the operatory room were orientated to face the window. In addition, proximity was nearly the same in each dental office, with the waiting room, reception and restroom within close distance to each other. The lab and sterilization room are also centralized to the operatory rooms. Other common themes were revealed regarding the operatory room; included two ceiling mounted fluorescent 2x4 light

Supportive Design, Attention Restoration Theory, Biophilic Design

fixtures above the patient chair and easily cleanable and durable materials on surfaces. __Case Study 1

Waiting Area

Reception Area

Operatory Room

Sterilization Room

__Case Study 2

Waiting Area

Reception Area

Operatory Room

Sterilization Room

__Case Study 3

When observing biophilic design attributes in each of the case studies, it was noted that each dental office had operatory window views to nature. However, the amount of nature content the view contained greatly varied. Case Study 1 in Figure 1.13, contained views with various bushes and trees that were situated in front of a rock wall and behind a large parking lot. On the east side of the building however, window views to nature are extremely limited with only a large bush in front of a hotel lobby. Case study 2, on the other hand, contained vast views of the rolling hills of the Palouse with large windows that expanded nearly the whole length of the operatory wall. Case study 3 also has expansive windows with a view of a wooden fence that is in very close proximity with shrubs in front of it and tress behind it. __Operatory Window Views

Palouse View Dental

Peterson Dental

Pullman Smiles N.

Pullman Smiles S.

Figure 1.14: Window views in the operatory room of each of the three case studies.

Waiting Area

Reception Area

Operatory Room

Sterilization Room

Figure 1.13: Documented photographs of case studies

In addition, both case studies 2 and 3 had window views to nature in the waiting area while case study 1 only had clear story windows. All three case studies also were well lit with daylight in the operatory rooms and the waiting areas. In addition, all three case studies had only few indoor plants present. Natural material was present but was most prominently found in the wood doors, trim, cabinetry and furniture in all three of the case studies. Very little simulated nature was also present. Each dental office had few pictures with nature content in hallways while only case study 1 and 2 had pictures of nature content, as well as nature inspired motifs on fabric in the waiting areas. Other forms of nature

that took place the dental office was found in case study 2, windows that opened to allow in fresh air and case study 3, an electric fireplace in the waiting area. When observing Attention Restoration Theory properties in the three dental offices, common themes also emerged. A sense of being away was noted in all three case studies due to the nature content of the window views except in the east side of the building in case study 1 for it faced a hotel lobby. Both case study 1 and 2 were recorded to display extent through their window views for the view has sufficient scope but case study 3 was lacking extent for a large fence was within an approximately 15 foot distance from the window and did not allow one to see much distance. It was noted both case study 1 and 3 provided relatively the same amount of fascination through few plants, pictures with nature content and wood materials of throughout the space. Case study 2 also incorporated these but in addition had statues of animals in the waiting room and in niches in the hallway that captured and held attention. Furthermore, both case study 1 and 3 were noted to not be compatible with reducing stress due to their few elements of nature dispersed throughout the building. On the other hand, case study 2 was noted a compatible environment with the goal of reducing stress, for it has significantly more elements of nature but was also noted that it was not optimized to its fullest potential. Limitations of the Study Certain limitations exist in the study though the researcher has tried to consider every aspect of the study. It is limited in that it captures the perceptions of a small number of people within three dental offices. Also, the study is limited to general dental offices and does not capture the perceptions of other fields within dentistry; therefore it does not represent the broader experience of the dental team. Despite these limitations, the data gathered from this study, still has significant implications in understanding how to mitigate stress in patients and the dental team.

Project Proposal Based on the findings from the literature review and analysis from the interviews and case studies, important design considerations emerge. These considerations will guide the intended Master’s design project. Data gathered in regards to supportive design, Attention Restoration Theory, and biophilic design will aid in creating design guidelines for the built environment. The framework of the study is broken down into goals that will be achieved in the design project. With each goal, strategies are presented that specify how to achieve those goals. Design Goals 1. • • • • 2. • • • • 3. • •

Reduce environmental features that are stressful and emphasize features that have stress reducing influences. Provide breaks rooms for the dental team and an area for a patient to achieve access to social support. Provide opportunities for patient’s choice to attain a sense of control over the environment. Eliminate environmental stressors. Include architectural and/or objects as positive distractions. Design using best practices in dental office design. Operatory rooms should have privacy related to the waiting area. Provide adequate space in the waiting room to greet patient while allowing for privacy. Design all treatment rooms identically in terms of equipment and storage so the dental team can know exactly where everything is from one room to the next. Provide adequate circulation around the patient chair in the operatory room. Develop a design that promotes restoration. Promote a sense of being away by incorporating opportunities that allow relief from directed attention. Orient the patient chair toward the window in the operatory

Supportive Design, Attention Restoration Theory, Biophilic Design

room. • Provide extent through restorative qualities found in the natural and built environment by framing or layering the interior spaces with a foreground, middle ground, and background so that there is perception of depth. • Provide fascination through access to natural materials, natural forms, indoors plants and simulated nature. • Design the dental office environment to be compatible in minimizing stress for both the patients and dental team. Site An existing dental office in Pullman, Washington will be used as the location of the proposed design project. The building is currently being occupied by two dentists and staff. The dental office is in a high traffic location within the town and serves the local community, as well as college students. The building was chosen as the project site due to its location and aesthetic of a typical dental office. It is in close proximity to other buildings and is limited in natural elements.

Figure 1.16: Exterior of existing dental office.

Patient Views

Figure 1.15: Proximity map of the dental office.

The current dental office does utilize views to nature but these views are not fully maximized. The patient looking outward from the operatory room has views of grass and trees as well as a parking lot and urban built environments. On the south side of the dental office the patient directly looks into the lobby of a hotel. The only nature that exists

is a small amount of plants and the wood siding on the building. Due to this, the blinds on the windows are most often shut and only let in daylight from the top. In effect, patients then face the blinds and do not have the opportunity to mitigate their stress through windows views. __Operatory Window Views

North _Chair View

North_Standing View

North_Exterior View

South_Chair View

South_Standing View

South_Exterior View

West_Chair View

West_Standing View

West_Exterior View

Figure 1.17: Operatory window views.

Although there has been a great stride in knowledge and technological advancements in regards to reducing stress in the dental office, the benefits of these three theories accrued through implementing design strategies may also be advantageous. These strategies will be applied in the next phase of the project. This research may likely be effective in creating a greater awareness among healthcare providers and designers of the need to give high priority to reducing stress through the design of the dental office environment. It also may be effective in changing patientâ&#x20AC;&#x2122;s negative perception of the dental office.

Supportive Design, Attention Restoration Theory, Biophilic Design

Design PROGRAM SITE CONCEPT BIRCH TREE DENTAL REFLECTION IMPLICATIONS FOR FUTURE RESEARCH

Project Goal

Adjacency Matrix

W ait i Re ng ce Ro Re ptio om str n Co oom Are a ns u O lta p e ti r o St ato n R er ry o o La iliza Ro m b tio om n s O Ro ffi om ce Br ea C h k Ro an om St gin or g a R X- ge oom ra y

To optimize the dental office environment by implementing supportive design, Attention Restoration Theory and biophilic design in order to minimize stress and anxiety for patients and the dental team. The design project will also serve as a prototype for healthcare providers.

Theory Properties & Attributes Waiting Room Reception Area Restroom Consultation Room Operatory Rooms Sterilization Room Lab Office Break Room Changing Room Storage X-ray

Not Adjacent Close Adjacency Adjacent

Project Program After observing numerous case studies, particular spaces within the dental office that are stated below will be most focused on in the design project due to their poor design and most use.

SPACE

FUNCTIONS

DESIGN STRATEGY

DETAILS

Positive distractions, sense of control, social support, Indoor plants, natural light, natural eliminate environmental stressors (Ulrich, 1997), window materials, simulated nature, (Wilson, views (Wilson, 1984), extent, fascination, being away, 1984), options and choices, reduce noise & crowding (Ulrich, 1997) compatibility, layer interior space (Kaplan, 1995)

Waiting Area

Socializing, seating, waiting

Reception Area

Employee-patient interaction, Positive distractions, social support (Ulrich, 1997), Indoor plants, natural materials, fascination, being away, compatibility (Wilson, 1984), provide simulated nature, natural forms in clerical work adequate space in the waiting room to greet patient while the architecture (Wilson, 1984), allowing for privacy (anonymous, in discussion with author)

Operatory Room

Patient receiving dental treatment, dental team performing treatment

Consultation Room

Dentist-patient interaction, meetings with employees

Positive distractions, sense of control, social support, eliminate environmental stressors, (Ulrich, 1997), extent, fasination, being away, compatibility, (Wilson, 1984), privacy (Unthank & True, 2010), orient the patient chair toward the window, design all treatment rooms identically in terms of equipment and storage, provide adequate circulation around the patient chair (Unthank, 1997) Positive distractions, social support, eliminate environmental stressors (Ulrich, 1997), fascination, being away, compatibility (Kaplan, 1995)

Window views, indoor plants, natural light, natural materials, simulated nature (Wilson, 1984), reduce noise & crowding, options and choices, visitor chair as social support (Ulrich, 1997), Indoor plants, natural materials, simulated nature (Wilson, 1984), furniure grouped for social support (Berry, et. al. 2004)

Break Room

Socializing, resting, storage, food prep

Positive distractions, social support, eliminate Window views, indoor plants, environmental stressors (Ulrich, 1997), extent, fascination, natural light, natural materials, simulated nature (Wilson, 1984), reduce being away, compatibility (Kaplan, 1995) noise & crowding (Ulrich, 1997)

Changing Room

Clothes and personal item storage, washing and drying clothes

Compatibility (Kaplan, 1995), eliminate environmental of stressors (Ulrich, 1997)

Natural materials, simulated nature (Wilson, 1984), storage for clothing (anonymous, in discussion with author)

Birch Tree Dental

Laws & Codes All dental offices must comply with federal and state laws relating to privacy (HIPAA), environmental hazards (OSHA), safety (WISHA), building codes (IBC), and accessibility for people with disabilities (ADA). Below are regulations that state how to comply with the requirements of all applicable laws as they relate to the design of the dental office.

OSHA The dental team may be exposed to numerous workplace hazards such as blood borne pathogens, and other chemical agents (osha.gov). Occupational Safety and Health Administration (OSHA) enforces that businesses protect their workers and reduce the number of workplace injuries, illnesses and deaths by making sure OSHA regulations are followed. The following are excerpts of OSHA standards that relate to safety in regards to designing dental offices. General requirements (walking-working surfaces) 1910.22(a)(3) To facilitate cleaning, every floor, working place, and passageway shall be kept free from protruding nails, splinters, holes, or loose boards. 1910.22(b)(1) Where mechanical handling equipment is used, sufficient safe clearances shall be allowed for aisles, at loading docks, through doorways and wherever turns or passage must be made. Aisles and passageways shall be kept clear and in good repairs, with no obstruction across or in aisles that could create a hazard. 1910.22(d)(2) It shall be unlawful to place, or cause, or permit to be placed, on any floor or roof of a building or other structure a load greater than that for which such floor or roof is approved by the building official. 1910.1200(b)(6)(iv)

Wood or wood products, including lumber which will not be processed, where the chemical manufacturer or importer can establish for flammability or combustibility (wood or wood products which have been treated with a hazardous chemical covered by this standard, and wood which may be subsequently sawed or cut, generating dust, are not exempted). General requirements-Personal Protective Equipment 1910.132(a) Application. Protective equipment, including personal protective equipment for eyes, face, head, and extremities, protective clothing, respiratory devices, and protective shields and barriers, shall be provided, used, and maintained in a sanitary and reliable condition wherever it is necessary by reason of hazards of processes or environment, chemical hazards, radiological hazards, or mechanical irritants encountered in a manner capable of causing injury or impairment in the function of any part of the body through absorption, inhalation or physical contact. 1910.132(c) Design. All personal protective equipment shall be of safe design and construction for the work to be performed. Blood Bourne Pathogens 1910.138(a) General requirements. Employers shall select and require employees to use appropriate hand protection when employees' hands are exposed to hazards such as those from skin absorption of harmful substances; severe cuts or lacerations; severe abrasions; punctures; chemical burns; thermal burns; and harmful temperature extremes. 1910.1030(d)(2)(iii) Employers shall provide hand washing facilities which are readily accessible to employees. 1910.1030(d)(2)(iv) When provision of hand washing facilities is not feasible, the employer shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands shall be

washed with soap and running water as soon as feasible. 1910.1030(d)(2)(viii) Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed. 1910.1030(d)(3)(vii) All personal protective equipment shall be removed prior to leaving the work area. 1910.1030(d)(3)(viii) When personal protective equipment is removed it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

HIPAA The Heath Insurance Portability and Accountability Act (HIPAA) sets standards for protecting patient health information (hhs. gov). Dental offices and other covered entities that have access to patient information must ensure that all the required security measures must be in place. The Security Rule The HIPAA Security Rule requires appropriate safeguards to ensure the confidentiality, integrity, and security of electronic protected health information of patients. The following are excerpts of physical safeguards that relate to the design of the dental office. ยง 164.310(a)(1) Implement policies and procedures to limit physical access to its electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed. ยง 164.310(a)(2)(ii) Implement policies and procedures to safeguard the facility and the equipment therein from unauthorized physical access, tampering, and theft.

WISHA The Washington Industrial Safety and Health Act (WISHA) protects the safety and health of employees by creating a healthy work environment (lni.wa.gov). All businesses must comply with WISHA standards and must follow requirements that are established to control the safety hazards in the workplace. The following are excerpts of safety standards that relate to the design of the dental office. General Safety and Health Standards WAC 296-24-567 The designation of refuge or safe areas for evacuation should be determined and identified in the plan. In a building divided into fire zones by fire walls, the refuge area may still be within the same building but in a different zone from where the emergency occurs. Exterior refuge or safe areas may include parking lots, open fields or streets which are located away from the site of the emergency and which provide sufficient space to accommodate the employees. Employees should be instructed to move away from the exit discharge doors of the building, and to avoid congregating close to the building where they may hamper emergency operations. WAC 296-24-75003 (3) Every skylight opening and hole shall be guarded by a standard skylight screen or a fixed standard railing on all exposed sides. WAC 296-24-75011 (1) A standard railing shall consist of top rail, intermediate rail, and posts, and shall have a vertical height of 42 inches, plus or minus 3 inches, from upper surface of top rail to floor, platform, runway, or ramp level and: (a) The top rail shall be smooth-surfaced throughout the length of the railing. (b) The intermediate rail shall be approximately halfway between the top rail and the floor, platform, runway, or ramp. (c) The ends of the rails shall not overhang the terminal posts

Birch Tree Dental

except where such overhang doesn’t constitute a projection hazard. (d) Guardrails with heights greater than 42 inches are permissible provided the extra height doesn’t create a dangerous situation for employees and that additional mid-rails were installed so that openings beneath the top rail wouldn’t permit the passage of a 19-inch or larger spherical object.

ADA The Americans with Disabilities Act (ADA) enforces standards for accessible design (ada.gov). The regulations set minimum requirements for buildings to be readily accessible to and usable for people with disabilities. The following are excerpts of ADA standards that relate to the design of the dental office. 802.1.1 Floor or Ground Surface. The floor or ground surface of wheelchair spaces shall comply with 302. Changes in level are not permitted. 802.1.2 Width. A single wheelchair space shall be 36 inches (915 mm) wide minimum. Where two adjacent wheelchair spaces are provided, each wheelchair space shall be 33 inches (840 mm) wide minimum. 802.1.3 Depth. Where a wheelchair space can be entered from the front or rear, the wheelchair space shall be 48 inches (1220 mm) deep minimum. Where a wheelchair space can be entered only from the side, the wheelchair space shall be 60 inches (1525 mm) deep minimum. 803.3 Door Swing. Doors shall not swing into the room unless a clear floor or ground space complying with 305.3 is provided beyond the arc of the door swing. 803.5 Coat Hooks and Shelves. Coat hooks provided within the room shall be located within one of the reach ranges specified in 308. Shelves shall be 40 inches (1015 mm) minimum and 48 inches (1220 mm) maximum above the finish

floor or ground.

IBC

Building codes are an essential part of designing an interior of a dental office to create a safe environment. The following are excerpts of The Codes Guidebook for Interiors (Harmon & Kennon, 2011) which states the requirements of the International Building Codes (IBC) that apply to the design of the dental office project. Business (B) Occupancy Occupant Load=53 people Type V Construction Type Clear door height is at 80” tall minimum. Door pull height is between 34”-48” tall. Clear door width is at 32” minimum. Maximum door width as part of egress is to be 4’-0”. Minimum clearances at latch side of door will vary from 0-42 inches. Corridors are to be 44” wide minimum. Two minimum exits for 1-500 person occupant loads. Unobscured paths: The exit path must be clear and unobstructed. Unless the codes or accessibility requirements specifically state that a projection is permitted, nothing may reduce the determined exit width. The expected loss of any one exit location cannot reduce the total capacity of the exit width by more than 50 percent. When two or more exits are required, the distance between two exits is at least one-half of the longest diagonal distance within the building or the building area the exits are serving. If the travel distance exceeds 75’-0” then an additional exit is necessary. Dead-end corridors must not exceed a maximum length of 20’-0”.

Site An existing dental office in Pullman, Washington serves as the new location for Birch Tree Dental. The site of the space is surrounded with a large parking lot with a busy street on the west side and a hotel on the south. There are many opportunities for fascination, extent, being away and compatibility throughout the site, though in its current state it is not being optimized to its fullest.

Birch Tree Dental

WAITING ROOM

RECEPTION AREA

CIRCULATION SPACE

OPERATORY ROOM

CIRCULATION SPACE

STERILIZATION ROOM

BREAK ROOM

The existing dental office is successful but lacks restorative and supportive properties to reduce stress and anxiety for patients and the dental team.

CHANGING ROOM

Existing Dental Office

NORTH

-Rock wall -Grass -Trees -Parking lot -Power lines -Buildings -Vehicles

EAST

-Trees -Parking lot -Buildings -Vehicles -Street lamps

SOUTH

-Hotel Lobby -Parking lot -Vehicles

WEST

-Grass -Trees -Parking lot -Busy street -Buildings -Vehicles

Birch Tree Dental

Design Concept Nature Inspired Forms

Birch Trees

Indoor Plants

Positive Distractions

Natural Materials

Inspiration pictures help visually demonstrate the design concept of Birch Tree Dental.

Color Scheme

The color scheme for Birch Tree Dental is derived from colors found in nature, most prominently that of a birch tree, moss and a tangerine.

Birch Tree Dental

birch tree dental Birch Tree Dental is an ideology to change the practice of dentistry by encompassing strategies that were derived from the findings of supportive design, Attention Restoration Theory and biophilic design. High priority is given to how the environment affects the stress levels of the patients and dental team. Birch Tree Dental serves as a prototype for an effectively designed dental office that has the capacity to not only minimize stress but create a positive experience.

DESIGN SOLUTION

4 2

The overall design of the dental office was to provide a space as people would feel in park or forest. This was achieved by eliminating all doors except ones used for security so that people move around a space without a strong feeling of enclosure (1). The patients are oriented toward a window view of nature when entering the treatment room and during the procedure (2) (Unthank, 1997). This will direct the patientâ&#x20AC;&#x2122;s attention outward for the restorative effects of nature (Kaplan, 1995). The sterilization room and lab are centrally located to the operatory rooms to allow efficiency (3). Recognizing the importance of social support (Ulrich, 1997), the visitorâ&#x20AC;&#x2122;s chair is designed to be located outside the operatory room to minimize crowding (4) (Evans, & Cohen, 1984). Extent is provided by framing or layering the interior spaces with a foreground, middle ground, and background so there is perception of depth (5). This will provide a scope for continued exploration and distract from stress (Kaplan, 2001).

Birch Tree Dental

Dental Office Exterior The entry sequence is designed to evoke calmness and reduce stress. The second the patient pulls in the site they are effortlessly attracted to it because of its restorative properties (Kaplan, 1995). The natural stone and wood exterior evokes a positive response through familiarity and satisfaction (Kellert, Heerwagen, & Mador, 2008). The landscaping is also effective in promoting restoration for stress because it provides fascination (Kaplan, 1995). The design of the exterior provides an immediate and positive impact in mitigating stress before the patient even walks through the door (Berry, Parker, Coile, Hamilton, Oâ&#x20AC;&#x2122;Neill, & Sadler, 2004).

Bird Feeders

Trellis Permeable Pavers

Birch Trees

Water Fountain

The parking lot may be perceived as an environmental stressor and is reduced by designing a stone pathway between the landscape and vehicles (Heerwagen, Heaubach, Montgomery, & Weimer, 1995). A water feature further helps extend the entry experience to the parking lot so that dental patientâ&#x20AC;&#x2122;s anxiety will decrease as they walk to the door. The variety of landscape also serves as a positive distraction from stress and anxiety (Ulrich, 1997).

Birch Tree Dental

Waiting Room The arrangement of the furniture allows social support for the dental patients (Berry, Parker, Coile, Hamilton, Oâ&#x20AC;&#x2122;Neill, & Sadler, 2004). A grouping of chairs clustered together allows those who are extroverts to talk. The lounge chairs that are oriented to the window also accommodate people who are introverted, allowing them to talk without facing one another. The design of the windows frame the view to direct the patientâ&#x20AC;&#x2122;s gaze outward, distracting them from stress (Kaplan, 2001). A trellis near the window acts as a visual filter and allows for privacy (Chang, & Chen, 2005). People also experience fascination through the terrariums because they are able to attract attention without effort and evoking positive emotions (Bringslimark, Hartig, & Patil, 2007). The birch tree murals provide a patient with opportunities for restoration when there are no views of nature present (Felsten, 2009).

Terrariums

Local Artists Feature Work

Comfort

Organic Shaped Furniture

Framing the Views

Birch Tree Dental

After Treatment birch tree dental We want to make your visit as stress free as possible. Please let us known what amenities you would like.

Please circle as many as you would like during your treatment: Music/Headphones Fresh Blanket Neck Pillow Pillow Under Knees (hip support & relaxation) Soothing Eye Pillow Lip Balm Water

Please circle as many as you would like after your treatment: Water Healthy Snack

1410 Southeast Bishop Boulevard #1s Pullman, WA 98163 birchtreedental.com tel. 509.325.7200 fax 509.322.1791

Before Treatment

Offering the patients amenities before and after the treatment makes them feel like they have a sense of control over the threatening environment (Malkin, 2005). This also will contribute to a more positive experience after the treatment so that they are not hungry after their fluoride as worn off. The amenities are prepared for them after the patient chooses and can be found in a basket in the operatory room.

Consultation/ Meeting Room The consultation room can also be used as a meeting room for the dental team. The informal seating allows the patient to feel comfortable when talking about dental treatment options. Water feature panels surround the consultation room to allow for privacy both visually (Unthank, & True 2010) and acoustically due to the constant white noise of the trickling water. The patient and dental team experience fascination through the ecospheres for they are able to attract and hold a personâ&#x20AC;&#x2122;s involuntary attention (Van Der Berg, Hartig, & Staats, 2007). The organic forms in the furniture also encompasses natural features that incorporate the essence of nature without making exact replicas of forms (Heerwagen, & Hase, 2001). This interrupts the stress process and promotes recovery from mental fatigue (Bringslimark, Hartig, & Patil, 2007).

EXISTING MEETING AREA

Informal Seating

Ecospheres

Plants Embedded in Flooring

Birch Tree Dental

Operatory Room Layering the landscape provides extent and also acts as a filtering device dependent on the conditions outside (Kaplan, 2001). Though they may be short lived, views of nature provide opportunities for a micro-restorative experience (Kaplan, 2001). Seasonal plants also allow another level of connection to nature. Various shaped glass bird feeders provide fascination to birds feeding that goes beyond the landscape experience (Grinde & Patil, 2009). A skylight in the operatory room will not only allow the natural light to be a radiant source but also mitigate stress (Alimoglu, & Donez, 2005). Natural light is a full spectrum light source and will help determine better aesthetics of dental work. Patients are also able to hear sound of rain hitting the glass which will distract them from worrisome thoughts (Ulrich, 1997). Vinyl decals of nature on the glass simulates fractal patterns (Heerwagen, 2003) and provides fascination, as well as protects the patient against glare.

Terrariums Bird Feeders

Birch Twig Wallpaper

Fractal Pattern Decals

Birch Tree Dental

Employee Break Room A lounge chair with an ottoman allows the dental team to achieve restoration as they look out the window to views of nature and shelves of terrariums (Kaplan, 1995). The expansive window views were designed to allow daylight to be the primary light source so that is would be effective in reducing job burnout (Alimoglu, & Donez, 2005), as well as decrease depression and anxiety amongst the dental team (Grahn, & Stigsdotter, 2003). The arrangement of the furniture around the table influences social support to also decrease work stress (Berry, Parker, Coile, Hamilton, O’Neill, & Sadler, 2004). The furniture’s organic forms are also able induce a response of relaxation (Kellert, Heerwagen, & Mador, 2008). Personal storage in the changing room for each of the staff members allows a sense of control over the environment (Berry, Parker, Coile, Hamilton, O’Neill, & Sadler, 2004). A bulletin board is featured to decrease anxiety through non-verbal communication.

Organic Shaped Furniture

Birch Tree Dental

Reflected Ceiling Plan The ceiling simulates nature through its organic shape (Kellert, Heerwagen, & Mador, 2008) that encourages movement of the eye and body. Skylights in the operatory room reduce the need for lighting directly above the dental chair. Other various lighting techniques were used to create a dramatic lighting effect. The wall mural in the waiting room is wall washed to direct the eye to the birch tree forest. Wall grazing is used by having a beam of light strike the wall at a narrower angle, producing shadowing that reveals and accentuates the texture of the stone wall.

Rugs with Organic Lines and Forms

Materials

Birch Forest Wall Mural Birch Wallpaper

Linen Shades

Natural Stone Wall

Walnut Flooring

Visual texture in nature is very restorative (Van Der Berg, Hartig, & Staats, 2007). The materials used are either derived from natural materials or materials that simulate nature (Kellert, Heerwagen, & Mador, 2008). Fascinating patterns can be witnessed in many of the materials. The concept of birch trees was derived from its textural interest and color contrast. The materiality provides a visual connection with nature as well as a sensual experience (Heerwagen, 2003). Deep grained woods and natural stone were chosen to provide fascination that can be explored through touch.

Cedar Wood

Vinyl Slate

Birch Tree Dental

Operatory Room

Layering the Landscape to Filter the View

Waiting Area 3

Reflection

Implications for Future Research

There are numerous bodies of literature regarding the negative health effects in dentists and dental patients. These negative health issues provide evidence that there is clearly a need to improve the dental office environment. Accumulating evidence from the three theories, interviews and case studies indicates that incorporating these design strategies may optimize an environment to reduce stress. Although this study focused of the dental environment, the theories can also be applied to other stressful arenas such as an attorney’s office, a hospital waiting room or even a residence. Not only can incorporating the design strategies promote restoration and decrease stress but it also validates for clients and employees the value placed on their overall health and satisfaction. This may be linked to dollar savings for employers or those charged with building and maintaining a space because it may result in clients returning, as well as a low turnover rate in employees. In order to greatly increase the stress reducing advantages of the theories, it is crucial to use the design strategies and goals in the initial stages of the programming and design. If the design strategies are introduced at a later stage major stress-reducing opportunities may be missed that are tied to architectural forms, the site and spatial layout of the space. Following all designs strategies should optimize any environment to minimize stress to its fullest potential. If not all design strategies can be incorporated into the built environment, it is recommended that the design strategies used should become focal points within the interior to intentionally direct a person view to it. An example of this would be to use the birch forest wallpaper, stone wall or some other biophilic material as a focal point in the space, which is strategically placed to draw attention when a person first walk’s into the room. Supportive design, Attention Restoration Theory, and biophilic design identify characteristics of an environment that are capable of fostering a person adaptive resources to cope with stress. The design strategies derived from these theories can serve as a Prototype for any setting with the goal of minimizing stress.

Case studies, interviews and review of the literature demonstrate how the dental office environment can be altered to mitigate stress however, it does not account for the environmental factors the dental patients perceive to be stressful. Future studies are needed and should be aimed to reveal the patient’s perception of the dental office environment. Improving the dental office environment has the potential to change the patient’s perception on the dental office during their visit and may also lead to a better quality of life in the days leading up to the dental treatment. Empirical data on identifying the effect of the dental office environment on dental patients and their range of dental anxiety would add to the current knowledge in the dental and interior design professions. Apart from strengthening the research, findings would add to the credibility with healthcare professionals in regards to how stress can be minimized through interior design. Interprofessional approaches are crucial in seeking to provide quality healthcare. There is a great amount of literature on Attention Restoration Theory and Biophilic Design; however the amount of research on supportive design is limited. This theory warrants more research in application to a healthcare setting. Additionally, research on the application of these theories to other stressful environments is warranted. Further research will add to best practices in designing spaces to mitigate stress for the clients, employees, and employees.

Birch Tree Dental

Appendices REFERENCES GLOSSARY OF TERMS CASE STUDY QUESTIONS IRB INFORMATION INTERVIEW QUESTIONS EXISTING FLOOR PLAN

Appendix 1: References Alimoglu, M., & Donez, L. (2005). Daylight exposure and the other predictors of burnout among nurses in a University Hospital. International Journal of Nursing Studies, 42(5), 549-555. Armfield, J. (2010). Towards a better understanding of dental anxiety and fear: Cognition vs. experiences. European Journal of Oral Service, 118, 259-264. doi:10.1111/j.1600-0722.2010.00740.x Berry, L., Parker, P., Coile, R., Hamilton, D., Oâ&#x20AC;&#x2122;Neill, D., & Sadler, B. (2004). The business case of better buildings. Frontiers of Health Services Management, 21, 3-24. Bringslimark, T., Hartig, T., & Patil, G. (2007). Psychological benefits of indoor plants in workplaces: Putting experimental results into context. HortScience, 42(3), 581-587. Chang, C., & Chen, P (2005). Human response to window views and indoor plants in the workplace. HortScience, 40(5), 1354-1359. De Jongh, A., Aartman, I. H. A., & Brand, N. (2003). Trauma-related phenomena in anxious dental patients. Community Dentistry and Oral Epidemiology, 31, 52-58. Dijkstra, K., Pieterse, M.E., & Pruyn, A. (2008). Stress-reducing effects of indoor plants in the built healthcare environment: The mediating role of perceived attractiveness. Preventive Medicine, 46, 279-283. Evans, G., & Cohen, S. (1984) Environmental Stress. In Environmental Stress (pp.571-585). New York, New York: Cambridge University press. Felsten, G. (2009). Where to take a study break on the college campus: An attention restoration theory perspective. Journal of Environ mental Psychology, 29(1), 160-167. Gorter, R. (2005). Work stress and burnout among dental hygienists. International Journal of Dental Hygiene, 3(2), 88-92. Grahn, P., & Stigsdotter, U.A. (2003) Landscape planning and stress. Urban Forestry & Urban Greening, 2(1):1-18. Grahn, P. & Stigsdotter, U. K. (2010). The relation between perceived

sensory dimensions of urban green space and stress restoration. Landscape and Urban Planning, 94, 264-275. Grinde, B., & Patil, G. (2009). Biophilia: Does visual contact with nature impact health and well-being? International Journal of Environ mental Research and Public Health. 6(9), 2332-2343. Harris, N., & Crabb, L. (1978). Ergonomics. Reducing mental and physical fatigue in the dental operatory. Dental Clinics of North America, 22(3), 331-45. Harmon,S., & Kennon, K.(2013). The Codes Guidebook for Interior. Hoboken, NJ: Wiley. Herzog, T., Maguire, C., & Nebel, M. (2003). Assessing the restorative components of environments. Journal of Environmental Psychology, 23(2), 159-170. Heerwagon, J. (2003). Bio-inspired design: What can we learn from nature? Retrieved from http://biomimicry.typepad.com/bioin spire/files/BioInspire.1-01.15.03.pdf Heerwagen, J. & Hase, B. (2001). Building biophilia: Connecting people to nature in building design. Environmental Design and Construction, 30-34. Retrieved from http://treebenefits.terrasummit.com/Documents/Health/ Building%20Biophilia%20--copywrited.pdf Heerwagon, J., Heaubach, J., Montgomery, J., & Weimer, W. (1995). Environmental design, work and well-being: Managing occupational stress through changes in the workplace environment. Official Journal of the American Association of Occupational Health Nurses. 43(9), 458-68. Kaplan S. (1995). The restorative benefits of nature: Toward an integrated Framework. Journal of Environmental Psychology, 15(3), 169-182. Kaplan, S. (2001). Mediation, Restoration and the management of mental fatigue. Environment and Behavior, 33(4), 480-506. Kaplan, R. (2001). The nature of the view from home: Psychological benefits. Environment and Behavior, 33(4), 507-542. Kellert, S., Heerwagen, J., & Mador, M. (2008). Dimensions, Elements and Attributes of biophilic design. In Biophilic design: The

theory, science and practice of bringing buildings to life (pp. 3-21). Hoboken, New Jersey: John Wiley and Sons, Inc. Klages, U., Sadjadi, Z., Loek, L. D., Rust, G., & Wenrbein, H. (2008). Development of a questionnaire measuring treatment concerns in regular dental patients. Community Dentistry and Oral Epidemiology, 36, 219-227. Lang, R. (2007). Stress in dentistry: It could kill you! Journal of Canadian Dental Association, 50, 539-41. Lang, R., Gilpen, J., & Gilpen, A. (1990). Stress-related symptoms among dental hygienists. Psychological Reports, 66(3), 715-722. Leather, P., Beale, D., Santos, A., Watts, J., & Lee, L. (2003). Outcomes of Environmental Appraisal of Different Hospital Waiting Areas. Environment and Behavior, 35(6), 842-869. Lehrner, J., Marwinski, G., Lehr, S., Johren, P., & Deecke, L. (2005). Ambient odors of orange and lavender reduce anxiety and im prove mood in dental office. Physiology and Behavior, 86(1-2), 92-95. Malkin, J. (2005). Practice of Dentistry. In Medical and dental space planning: A compressive guide to design, equipment, and clinical procedures. (pp 401-402). Myers, H. L. & Myers L. B. (2004). ‘It’s difficult being a dentist’: Stress and health in the general dental practitioner. British Dental Journal, 197, 89-93. doi:10.1038/sj.bdj. 4811476 Sarason, I. (1988). Anxiety, self-preoccupation and attention. Anxiety Research, 1(1), 3-7. Stack, S. (1996). Suicide risk among dentists: A multivariate analysis. Deviant Behavior. 17(1), 107-117. Terrapin Bright Green LLC (2012). The economics of biophilia: Why designing with nature in mind makes financial sense. Retrieved from: http://edlabinc.net/documents/The20Economics20of 20Biophilia_Terrapin20Bright20Gre en202012e.pdf. Ulrich, R. (1997). Pre-symposium workshop: A theory of supportive de sign for healthcare facilities. Journal of Healthcare Design, 9, 3-7. Ulrich, R. (1993). Biophilia, biophobia and natural landscapes. In The

biophilia hypothesis (pp. 73-110). Washington D.C.: Island Press. 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, 201-230. United States Department of Health and Human Services. HIPAA Administrative Simplification Statute and Rules. Retrieved from http://www.hhs.gov Unthank, M & True, G. (1999). Interior design for dentistry. Journal of the American Dental Association, 130(11), 1586-90. Unthank, M. (1999). Design for treatment. Journal of the American Dental Association, 130(1), 1579-84. Unthank, M. (1997). Office design: Treatment area. Dentistry Today, 16(1), 89-91. Unthank, M. & True, G. (2010) Dental Office Design. Texas Dental Journal, 127(12), 1302-1304. U.S. Department of Justice. Americas with Disabilities Act. Retrieved from http://www.ada.gov U.S. Department of Labor. Occupational Safety and Health Administration. Retrieved from http://www.osha.gov Van Der Berg, A., Hartig, T, & Staats, H. (2007). Preference for nature in urbanized societies: Stress, restoration, and the pursuit of sustainability. Journal of Social Issues, 63(1), 79-96. Vanishree, R., Jeswin, J., & Madhusudhan, S. (2011). Suicide amongst dentist: Are you at risk? Journal of Oral Health Community Dentistry, 5, 160-163. Washington State Department of Labor and Industries. WISHA (the Washington Industrial Safety and Health Act of 1973). Retrieved from http://www.lni.wa.gov Wilson, E.O. (1984). Biophilia: The human bond with other species. Cambridge, Massachusetts: Harvard University Press.

Supportive Design, Attention Restoration Theory, Biophilic Design

Appendix 2: Glossary of Terms

Appendix 3: Case Study Questions

Attention Restoration Theory: Proposes that after spending time in natural environments, people experience restoration by regaining the ability to recovery from mental fatigue (Grinde & Patil, 2009).

Name of dental office: Address: Date:

Being away: Refers to settings where a person feels a sense of being away from tasks that demand directed attention (Van Der Berg, Hartig, & Staats, 2007).

Case Study: Visit dental offices regarding best practices, biophilic design and Attention Restoration Theory. What is informing these best practices?

Biophilic design: Human connection with nature can be achieved by incorporating natural elements into the design of the built environment (Kellert, Heerwagon, & Mador, 2011). Compatibility: Environments are compatible when a personâ&#x20AC;&#x2122;s purpose and activities are supported in it (Van Der Berg, Hartig, & Staats, 2007). Extent: Refers to a setting that has distance to a boundary that has enough sufficient content to engage a person and allow restoration from directed attention (Kaplan, 2001). Fascination: People experience fascination when settings or objects are able to attract and hold a personâ&#x20AC;&#x2122;s involuntary attention (Van Der Berg, Hartig, & Staats, 2007). Restorative environment: A natural or built environment which is capable of renewing a personâ&#x20AC;&#x2122;s attention resources (Herzog, Maguire, & Nebel, 2003). Stress: Stress is the process in which an individual responds to environmental forces, referred to as stressors that threaten their wellbeing (Evans & Cohen, 1984).

-Size -Proximity -Orientation -Materiality -Lighting -Spatial relationship What biophilic design attributes are present? -Window views to nature -Natural lighting -Indoor plants -Simulated nature -Natural materiality -What other forms does nature take in the dental office? What properties of Attention Restoration Theory are present? -Being away -Extent -Fascination -Compatibility

Appendix 4: IRB Information MEMORANDUM TO: Kathleen Ryan and Kayla Ross, FROM: Patrick Conner, Office of Research Assurances (3005) DATE: 10/9/2012 SUBJECT: Certification of Exemption, IRB Number 12786 Based on the Application submitted for the study titled â&#x20AC;&#x153;Optimizing the Dental Office Environment to Minimize Stress and Anxiety,â&#x20AC;? and assigned IRB # 12786, the WSU Office of Research Assurances has determined that the study satisfies the criteria for Exempt Research at 45 CFR 46.101(b)(2). This study may be conducted according to the protocol described in the Application without further review by the IRB. It is important to note that certification of exemption is NOT approval by the IRB. You may not include the statement that the WSU IRB has reviewed and approved the study for human subject participation. Remove all statements of IRB Approval and IRB contact information from study materials that will be disseminated to participants. This certification is valid only for the study protocol as it was submitted to the ORA. Studies certified as Exempt are not subject to continuing review (this Certification does not expire). If any changes are made to the study protocol, you must submit the changes to the ORA for determination that the study remains Exempt before implementing the changes (The Request for Amendment form is available online athttp:// www.irb.wsu.edu/documents/forms/rtf/Amendment_Request.rtf).

Exempt certification does NOT relieve the investigator from the responsibility of providing continuing attention to protection of human subjects participating in the study and adherence to ethical standards for research involving human participants. In accordance with WSU Business Policies and Procedures Manual (BPPM), this Certification of Exemption, a copy of the Exemption Determination Application identified by this certification and all materials related to data collection, analysis or reporting must be retained by the Principal Investigator for THREE (3) years following completion of the project (BPPM 90.01). This retention schedule does not apply to audio or visual recordings of participants, which are to be erased, deleted or otherwise destroyed once all transcripts of the recordings are completed and verified. You may view the current status or download copies of the Certified Application by going to https://myresearch.wsu.edu/IRB.aspx?HumanActivityID=36800 Washington State University is covered under Human Subjects Assurance Number FWA00002946 which is on file with the Office for Human Research Protections (OHRP). Review Type: New Review Category: Exempt Date Received: 9/23/2012 Exemption Category: 45 CFR 46.101 (b)(2) OGRD No.: N/A Funding Agency: N/A

Supportive Design, Attention Restoration Theory, Biophilic Design

Appendix 5: Interview Questions Name of dental office: Address: Date: Year opened or since last remodel: Name: Position:

-What works well in this dental office and why? -What doesn’t work well and why? -What could you suggest to make it better? These next open-ended questions relate to the philosophy of the dental office. The philosophy of your business is reflected in your mission, it is what guides your decision making. As you stated on your website, your dental office [insert the company’s philosophy here].

This interview is aimed to understand how the dental office environment can be altered to mitigate stress.

-Why do you do this? -How does this dental office environment support this?

These open-ended interview questions are in regards to the forces shaping the design of the dental office: -How does this dental office design impact function? -How does this dental office design impact standard precaution for infection control? -How does this dental office design impact efficiency? -How does this dental office design impact ergonomics? -What others forces shape the design of this dental office?

These next open-ended questions directly relate to stress and anxiety in the dental office.

These next open-ended questions are aimed to understand your opinion of what works and doesn’t work well in this dental office.

-What features in this dental office help alleviate stress and anxiety for your patients? -What features in this dental office help alleviate stress for your dental team?

The physical organization of a space refers to the layout of the dental office in terms of orientation, proximity, size, and spatial relationship. In regards to this: -What works well in this dental office and why? -What doesn’t work well and why? -What could you suggest to make it better? The culture of a business refers to the interactions between employees, as well as between customers and employees. In regards to this:

Stress is the psychological and physical way in which we respond to environmental forces called stressors that threaten our well-being. Stress can make a person feel frustrated, nervous, angry or anxious. In the presence of stress, anxiety can create feelings of worry, fear, dread and uneasiness. In regards to this:

How does this dental office foster coping with stress? -How do you provide access to social support for your patients? -How do you provide access to positive distractions for your patients? -How do you provide a sense of control for your patients?

Appendix 6: Existing Floor Plan

Supportive Design, Attention Restoration Theory, Biophilic Design