Positive Distractions in Healthcare Environments

Survey of Positive Distractions Research in Healthcare Environments White Paper Sharon Crockett

ABSTRACT Positive distractions are most effective as a stress reducer and pain coping feature of the physical environment if they are nature‐oriented and multi‐sensory. As part of an attractive, restorative environment, positive distractions can contribute to patients’ perception of the quality of their care, to increased patient satisfaction, reduced anxiety and increased patient referrals. Ultimately, the investment of limited resources in positive distraction interventions in the physical environment must be based on scientific data about which distractions have the best therapeutic value and not on patient preferences, theories or aesthetic leanings.

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“Second only to fresh air…I should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight, is necessary for speedy recovery…I mention from experience, as quite perceptible in promoting recovery, the being able to see out of a window, instead of looking against a dead wall; the bright colours of flowers; the being able to read in bed by the light of the window close to the bed­head.

It is generally said the effect is upon the mind. Perhaps so, but it is not less so upon the body on that account…”

­­ Florence Nightingale, 1860 (cited by Weber 1996 in introduction of Rubin, Owens, & Golden 1998, viii)

Copyright 2012 Crockettstudio, LLC

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Executive Summary

Positive distractions are stress‐coping interventions in the physical environment that hold attention, elicit positive thoughts and block worrisome thoughts. The most effective positive distractions are biophilic, or nature‐oriented. Through neuroaesthetics, we are learning that the fight or flight area of the brain is most active in an anxious patient and responds favorably to representational images of nature. Visual, auditory and multi‐sensory positive distractions contribute to a restorative environment that incorporates feelings of being away, “presence” in another recognizable world, soft fascination or an ability to voluntarily focus and compatibility with the patient’s goals of healing.

Visual representations of nature reduce stress and help patients cope with pain in in‐patient recovery settings, in pre‐treatment waiting areas and in treatment rooms.

Visual positive distractions, such as static nature murals, window views to nature, aquariums and nature videos were most effective when the content was serene.

When a visual image is combined with auditory stimuli, such as classical music or nature sounds that are somewhat complex to prevent sensatory habituation, the positive distraction is even more effective in reducing anxiety and pain. Most effective are multi‐sensory positive distractions, such as virtual reality environments, which compress patients’ perception of time elapse.

A physical environment ranked as more physically attractive is associated with perceived higher quality of care and, in turn, reduced patient anxiety and greater patient referrals. Patients’ perception of the quality of care is more influenced by the attractiveness of a waiting room than by how long the patients waited. Patients’ perceptions are a better indicator of how they assess the quality of their care than their actual experiences in the waiting room. They tend to overestimate short waiting times and underestimate long (i.e., greater than 30 minutes) waiting times.

In waiting rooms judged to be physically attractive, patients tend to perceive shorter waiting times and, in turn, they feel less anxious and more satisfied overall.

The introduction of positive distractions into the physical environments of patients can contribute to attractiveness and thus to patient satisfaction.

Patient satisfaction scores may be factored into Medicare reimbursements beginning in October 2012 as part of the new healthcare legislation. It is in the interest of healthcare providers to develop patient‐centered cultures, or “brands”, that focus on the health and emotional well being of the whole patient. Positive distractions in the physical environment can help to reinforce the patient‐centered mission, thereby improving patient satisfaction and, ultimately, reimbursements, if the legislation goes into effect.

A significant percent of commercially insured and Medicare patients have indicated that they would switch to another provider if it offered a distinctive patient experience with amenities, such as those provided by positive distractions. These

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comfort‐, control‐ and amenity‐seekers often base their healthcare choices on non‐ clinical aspects of a provider, because these aspects are perhaps easier to understand than complex clinical data.

While providing amenities to patients can be more expensive than improving care outright, such amenities result in greater patient volume. The increased patient census can help to offset the costs of providing special amenities. The healthcare community must decide how it will value these amenities so that their therapeutic benefits are reflected in reimbursements.

With finite resources, healthcare providers must assess which positive distractions are most worthy of their investment. The assessment should be based on real scientific data about which interventions in the physical environment actually yield therapeutic benefits to patients and not just on theories, hunches or preferences.

Ultimately, those are the investments that will best reinforce the provider’s patient‐ centered mission and offer the overall best care for the patient.

Introduction

A variety of illuminated, brightly colored fish dart and swim back and forth through water in every‐changing patterns. We are captivated by their movement and by the textures of the rocks and greenery or corals inside the tank. Intuitively, we feel that this experience is somehow beneficial to us. What is it about the experience of watching fish in an aquarium that is so mesmerizing? Why does the rest of the world melt away as we become immersed in this natural underwater view, and how does this and other forms of distraction affect our health and well‐being?

Watching an aquarium distracts us in a positive way, and, in particular, it is a view of nature that causes us to focus. This visual and auditory positive distraction is calming, and intuitively, providers of healthcare since at least Florence Nightingale in the 19th century have posited that a positive distraction related to nature can improve the emotional and physical well being of patients. The challenge has been to understand how distraction actually works, the

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methods of distractions that are positive and how to measure their behavioral and clinical effects.

Researchers across multiple disciplines are currently tackling these questions, often with varying motivations. For instance, evolutionary biologists are interested in why we are drawn to views of nature and how the human‐animal bond works, while human ecologists are exploring how distraction generally effects a patient’s perceptions of waiting times and of overall satisfaction with the healthcare experience. Architects and interior designers are trying to understand how to incorporate the most effective nature‐oriented positive distractions into the built environment with the ultimate goal of designing supportive and restorative spaces based on real evidence. Neuroscientists are intrigued by the field of neuroaesthetics and are studying how different parts of the brain respond to different aesthetic visual stimuli. Environmental psychologists and medical practitioners wonder about how distractions related to nature can result in positive behavioral outcomes, such as reduced stress and anxiety prior to medical treatments. Lastly, healthcare researchers’ and practitioners’ focus is primarily on which distractions lead to positive clinical outcomes not just in waiting spaces prior to treatments, but also during different kinds of treatments and afterwards during recovery. Regardless of the motivation, all of the research adds important pieces to the overall puzzle of understanding positive distractions.

This White Paper will investigate the research that has been done on positive distractions in healthcare environments, revealing the various types of positive distractions, their affinity with nature, and their effectiveness in stress and anxiety reduction and in coping with pain in waiting rooms and treatment spaces. More broadly, this paper considers concepts of attractiveness of the physical environment and supportive design that incorporate positive distractions and that can help practitioners provide more patient‐centered care.

Intersection of Distraction and Nature

Nature is a recurrent theme in the majority of the research that has been done about distractions. Why do concepts of positive distraction and nature intersect so often?

It’s helpful first to understand some basic concepts about distraction.

While the definition of a distraction is a diversion of attention, one way of defining a positive distraction is within the context of stress. A 1984 study by R.S. Lazarus and S. Folkman looked at stress as being a situation in which a person perceives that the environment is taxing and threatens his or her well‐being and that there are insufficient resources to cope (Gougeon 2008, 14; Schneider & Hood 2007, 3). A positive distraction can then be thought of as “an

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environmental feature that elicits positive feelings and holds attention without taxing or stressing the individual, thereby blocking worrisome thoughts” (Ulrich 1981, summarized by Ulrich 1991, 102; Pati 2009, 8). It “offer[s] patients a means of mitigating stress” (Pukszta, 2010) by permitting them to focus their emotions.

“Distraction is an emotion‐coping strategy because it diverts the focus of attention away from unpleasant stimuli by manipulating the environment” (Schneider & Hood 2007, 3). The result is a reduction in stress because not only does the patient perceive the environment to be less threatening, but also feels that there are now resources available to cope with the challenging environment.

Positive distractions can work in treatment contexts and in waiting contexts, which will be discussed more later on. “Distraction therapy” is already being used expressly for the purpose of helping patients cope during difficult treatments, such as burn care and blood drawings (Diette, Lechtzin, Haponik, Devrotes & Rubin 2003, 942). In waiting rooms, studies increasingly show that a positive distraction helps to focus the attention of stressed‐out waiting patients (Pati, Nanda, Waggener 2010).

Commonly seen types of “distractions” are flat screen televisions in waiting rooms, aquariums, artwork on walls, sculptures, interesting floor and ceiling patterns, reading material, refreshments, indoor views, outdoor views, patient‐education materials and music (Becker & Douglass 2008, 130). A blaring television or a very abstract sculpture or even incessant piped in music or just a popular radio station are not necessarily “positive distractions” in that they do not necessarily “elicit positive feelings”, hold one’s attention and block “worrisome thoughts”.

Humans, as it turns out, have particular distraction preferences. Nature is a universal preference. The “biophilia hypothesis”, first posited by Harvard biologist, E.O.Wilson, is the idea that humans are genetically hardwired to be receptive to life and lifelike processes (Kahn 1997, 1). This means that as a result of millions of years of evolution and cultural conditioning, humans universally gravitate and respond favorably to trees, plants and water because those elements indicate survival. The hypothesis is that merely views of natural elements results in reduced stress, because we’re viewing an environment that has been nurturing and non‐ threatening to humans over the course of our evolution. These natural elements are restorative to us, because they can help us recover from stress (Gougeon 2008, 23).

The biophilia hypothesis also extends to the human‐animal bond, as is seen in the positive interactions between autistic children or the aged, who have chronic brain syndrome, and small animals (Kahn 1997, 8).

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Whether or not biophilia can be proven or not, preference studies consistently show that patients have thematic preferences related to nature. A 2008 study of British children’s preferences by Coad & Coad (Pati, Nanda, Waggener 2010) indicated the “myth of Disney”. Most children in the study favored water, nature and beach/sea themes over cartoon and fantasy character themes and preferred blues and greens.

This result suggests that the children in the study would be receptive to the aquatic themes of an aquarium. In another study in 2006 of pediatric patients by Eisen, it was again revealed that regardless of age or gender, the children preferred nature art.

These results hold even among adult patients. In a 2007 study by Nanda, Hathorn, and Newman of patient art preferences, patients significantly preferred paintings of landscapes, flowers and water over critically acclaimed paintings by artists such as Van Gogh and Chagall (Ulrich, Zimring, Zhu, DuBose, Seo, Choi, Quan, Joseph 2008, 32). In fact, the most preferred painting was of a simple waterfall and vegetation and was representational rather than abstracted. Patients did not favor even slightly abstracted art. Roger Ulrich, PhD. found out through interviews with psychiatric patients that they rejected “emotionally challenging” works of abstract art (1991).

In the burgeoning field of neuroaesthetics, through brain scans researchers are beginning to understand how the brain perceives art while in healthcare settings.

The part of the brain that makes aesthetic judgments is in the front of the brain, which is not the part of a patient’s brain that is most active while waiting for medical treatment or during treatment. It is the back part of the brain, or the “fight or flight” part of the brain, that is most active and that most effects the perception of art while a patient is in a healthcare setting.

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This idea from the field of neuroaesthetics can help explain the results of the various preferences studies. The fight or flight part of the brain responds favorably to non‐ challenging, representational art containing themes that are immediately recognizable as being about life and lifelike processes. By contrast, abstract art agitates the fight or flight response, possibly because the front part of the brain that would have the better capacity of judging such art is underactive in a healthcare setting (Nanda 2012). Abstract art may represent a form of distraction that is not particularly positive. The biophilia hypothesis that looks to evolution may relate, in this case, to how our brains have evolved to perceive and respond to environmental stimuli. These findings from neuroscience combined with the philosophy of aesthetics help to confirm some intuitive ideas we have about why nature themes work well in health care settings.

Interestingly, research shows that humans don’t just respond positively to nature, they also respond more favorably to built environments that feature water, trees and various vegetation more so than to built environments that do not have such features (Kahn 1997, 3). This finding bolsters efforts by architects and designers to integrate nature into the built environment to create restorative and healing spaces.

It helps to delve a bit more deeply into what a restorative environment is, because positive distractions that relate to nature can be an essential part of such an environment. Restoration involves clearing the mind, recovery of directed attention, soft fascination” (i.e., voluntarily paying attention to something) and self‐ reflection (Gougeon 2008, 25). Nature is apparently well suited to fostering

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restoration. Research in 1989 by Kaplan & Kaplan on how we recover from stress through restoration indicates five essential features of a restorative environment:

1. A Feeling of Being Away. For patients waiting for treatment or in the midst of treatment, nature can take them “away”.

2. “Extent”. Extent is the feeling of “presence”, or the feeling of being perceptually in another non‐abstract and comprehensible world, almost in a virtual reality sense. Nature is easily comprehensible for a sick patient and can stimulate an immersive feeling of being present in a different world.

3. Fascination. The soft fascination already discussed above allows a patient to focus voluntarily on nature while still allowing his or her mind to wander to other pleasing thoughts, providing a distraction from stress or pain.

4. Compatibility. This means that a restorative environment is supportive of the healing goals of the patients in the space. In effect, as best described by Kaplan & Kaplan, “may the wind be always at your back” (Gougeon 2008, 25‐ 27; Mazer 2010, 3) Nature is compatible with the healing goals of patients, because it can do no harm, but has the potential of doing much good.

Nature as a Positive Visual Distraction: Treatment Spaces

While the biophilia hypothesis, patient preferences and findings from neuroaesthetics about how the brain perceives nature art in a healthcare setting are all interesting, ultimately the concern is whether nature as a positive distraction can reduce stress and anxiety and help patients cope with pain. Most research done to date has focused on visual forms of nature without sound, and the form used derives from the space. So, for instance, researchers such as Ulrich have focused on window views to nature.

Some researchers have tested nature‐themed wall murals and paintings, nature still photographs, flat screens showing nature photography slide slows and ambient nature art and even aquariums in waiting rooms. Other researchers have mounted nature‐ themed murals on the ceilings of treatment spaces.

Through his groundbreaking 1984 study of hospitalized patients recovering from gall bladder surgery, Ulrich discovered that something as simple as making sure that hospital rooms have windows with views to nature can yield health benefits.

Ulrich compared a control group of recovering patients who had prolonged views of a brick wall to another group of recovering patients who had views of a small stand of trees. The patients that had views to nature not only had shorter hospital stays and fewer negative comments in nurses’ notes, but they also had fewer post‐ operative complications. Furthermore, the patients who had prolonged views of the

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brick wall required stronger painkillers than the patients who had nature views, who required less potent painkillers. These are findings that have real implications for a hospital’s bottom line and for the well being of its patients.

The results of the Ulrich study of post‐ operative patients are compelling, especially since the only difference between the two groups of patients was that one group viewed nature and the other didn’t. The emphasis here is first on nature as a visual positive distraction without accompanying sound, since being out in nature is a multi‐sensory experience that cannot be readily replicated in a waiting room or treatment setting.

Do nature images, which are a form of mediated nature, have parity with actual nature? Since most of the studies to date have used visual representations of nature as positive distractions that can create restorative environments, there is apparently some parity. The human brain can perceive visual stimuli in the form of simulated nature images, and through recall and memory recreate the multi‐sensory experience of being out in nature. The result is a positive distraction and a time for focus away from stress and pain to reflect (Mazer 2010, 3).

There are challenges to using mediated forms of nature, such as murals and nature photography or slideshows shown on flat screens. If the visual representation of nature is too static, then visual habituation can set in if exposure to it is prolonged, such as in a waiting room or hospital room. The patient can become de‐sensitized to a static nature image (i.e., a wall or ceiling mural) as compared to a view of real nature. The de‐sensitization can diminish the stress reductive effects of the image.

Even a repetitive set of images (i.e., in the form of a slideshow) during a prolonged period of time can lead to visual habituation. If the patient also does not feel that they can control or change the set of scrolling images, this feeling of lack of control in and of itself can feel stressful and become, thus, counterproductive (Mazer 2010, 6).

These ideas suggest that designers, architects and practitioners should devise strategies for how to introduce visual representations of nature into a space depending on how long a patient will be in the space. In waiting spaces time spent can range from as brief as five minutes to as long as two hours, for instance. The challenge is to balance the goal of fostering stress reduction through the attention‐ holding effect of a visual nature distraction against the risk of aggravating stress as a result of patients’ feelings of de‐sensitization and habituation during a more prolonged wait. A hospital room where a patient may be recovering during a long period of time following surgery, requires more variable, dynamic positive

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distractions, like a window view of a real nature scene and, if medically possible, physical interaction with small animals and other human beings.

Another challenge of using representational forms of nature is that the nature subject matter could arouse stress rather than reduce it. For instance, a 1990 study on the effects of ceiling mounted pictures on stressed patients on gurneys in a pre‐ surgical holding room found that arousing nature pictures, such as images of sailboarders or of zebras gazing at the observer, were not effective at lowering blood pressure.

Arousing Nature Image Serene Nature Image

The most effective images in reducing stress as measured by blood pressure were primarily those involving water and nature and could subjectively be described as “serene” (Coss 1990, summarized in Kahn 1997, 6).

The studies that have revealed measurable improvement in stress, anxiety and pain management in connection to the use of visual nature representations as positive distractions in waiting and treatment spaces are diverse and fairly conclusive. They measure stress and anxiety through a combination of patient self‐reporting and readings of systolic blood pressure, pulse and heart rate. The studies that focus on coping with pain also use patient self‐reporting, augmented by data about the extent and potency of the usage of pain medication, especially patient‐controlled sedation doses.

A two‐year Swedish study of the effects of nature images on post‐operative open heart surgery ICU patients showed that patients who viewed nature images experienced less anxiety after surgery than patients who saw no images or who saw abstract images. Since these patients received heart pumps, which can cause cognitive impairment and temporary brain injury in 50 to 60 percent of patients, the study was also interested in the effects of the nature images on post‐operative cognition and brain function. The results indicate that the exposure to visual stimulation contributed to enhanced visual/perceptual cognition as compared to those patients that did not view such images (Ulrich 1991).

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View of Nature Images ‐ ICU Patients  Less Post‐Surgery Anxiety View of Nature Video ‐ Burn Patients  Less Pain & Anxiety Guided Nature Imagery ‐ Cancer Patients  Less Discomfort

In addition to the Ulrich study on window views to nature, another study found that bedridden heart surgical patients who had pictures of a view of trees and water in their sightlines required less strong dosages of pain medicine than patients who had no pictures or who could view only an abstract image (Ulrich, Lunden, & Eltinge, 1993; Ulrich et al. 2008, 23). Severe burn patients experiencing a great amount of pain were exposed to a videotape of nature scenes of waterfalls, flowers, ocean and forests during the changing of their dressings as part of another study (Miller, Hickman, & Lemasters 1992; Ulrich et al. 2008, 23‐24). The result was significantly reduced pain intensity and anxiety. Guided imagery of nature scenes helped reduce discomfort of women with early‐stage breast cancer in a study by Kolcaba & Fox in 1999 (Schneider & Hood 2007, 3)

Nature as a Positive Visual Distraction: Waiting Spaces

Studies have shown that nature as positive visual distractions in waiting spaces have significant calming effects (Pati, 2010). In Pati’s research on positive distractions in pediatric waiting rooms, calm behavior increased significantly and both fine and gross behavior decreased significantly when positive distractions, namely aquariums and ambient art, were present in the environment.

In general, less restless behavior resulted from the introduction of positive nature distractions in pediatric waiting rooms in the study.

A 1999 study showed that in adult waiting rooms, any distraction – even distractions that were not nature‐oriented ‐‐ helped to reduce stress and anxiety, because it both allowed waiting patients to have a choice of things to do and kept them occupied (Hosking & Haggard, summarized by Ulrich 1991, 130). Other studies emphasize that not all distractions are equal, however, and those that direct focus and attention to nature have more significant effects on waiting patients’ stress, anxiety and pain than those that don’t. Thinking logically, the inpatient studies on positive nature distraction probably apply well to waiting spaces and outpatient clinics, as long as adjustments are made to the nature‐oriented distraction so that it fits the goals of waiting patients, emphasizing shorter duration exposure.

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For instance, in a 2003 study by Ulrich, Simons, & Miles, blood donors who watched a wall‐mounted television on days that a nature videotape was playing had lower systolic blood pressure and lower pulse readings than on days when the television provided continuous daytime television programming (Ulrich, Quan, Zimring, Joseph, Choudhary, 2004, 22). In another study, (Heerwagen 1990, summarized by Kahn 1997, 6 and Ulrich 1991, 103)) patients waiting in a dental clinic who saw a large mural of an open landscape reported feeling less stressed than patients who waited on days when the mural was not on the wall.

Ulrich recommends, where possible, that waiting spaces provide for the same window views to nature that he determined were beneficial to control the pain of post‐operative hospitalized patients. He posits that waiting patients concerned with pain would benefit as much as in‐patients, especially given that a variety of studies have revealed a reduction in sympathetic nervous system activity and other measures of stress within as little as three minutes of exposure to nature as a distraction (Ulrich, et al. 2008, 31).

Nature as a Positive Auditory Distraction: Treatment and Waiting Spaces

Being out in nature is, of course, multisensory and involves not just seeing but also hearing sounds, even subtle ones like the blowing of slight breeze. The sounds are rarely constant and can be transporting. Much of the research is showing that while nature images alone can be effective positive distractions, when combined with sounds, they become even more powerful. For instance, in a 2009 study of pediatric waiting room positive distractions, ambient art with sound and an aquarium with sound attracted the most attention of young patients in cardiac care and dental clinic waiting rooms (Pati et al. 2010). The addition of sound makes the visual nature imagery even more immersive, thereby contributing even more to stress reduction and coping with pain.

The same challenges related to mediated representational nature images applies to nature sounds. Simulated or recorded nature sounds can seem repetitive to the human ear (Mazer 2010, 6). The problem of auditory habituation can occur if the nature sounds persist for a long duration. A patient becomes de‐sensitized to them and their effectiveness diminishes or, paradoxically, causes more stress if the patient cannot turn off or change the sound. They are more effective for a short‐

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term treatment or short wait time. For example, the sound of running or bubbling water like that of an aquarium or soothing music that incorporates the sound of ocean waves and running streams can tap into our biophilic inclinations and harness our positive memories related to water during a brief waiting period at a dentist’s office (Schwartz 2012, 1).

Some of these same principles can apply to music.

Music that is accessible and complex enough, however, can be an effective positive distraction and can even mask other, noxious sounds, enhancing relaxation (Mazer 2010, 7). For instance, an interesting study of nature distraction for colonoscopy patients (Lee 2004) found that nature scene distraction was only effective at pain reduction and did not reduce patients’ self‐administered sedation. When classical music was added, however, the combination of visual nature stimulation and auditory distraction lowered patients’ intake of self‐administered sedatives during colonoscopy (Ulrich et al. 2008, 23). Similarly, in the case of the research done on burn patients, during their burn dressings the addition of music to the nature videotape that they watched further lessened pain and anxiety (Ulrich et al. 2008, 23). Another study by Ezzone, Baker, Rosselet, and Terepka (1998) found that music distraction reduced the extent of nausea and vomiting in chemotherapy patients prior to bone marrow transplants. Finally, two studies showed that music contributed to less reported anxiety and improved satisfaction of patients undergoing endoscopic procedures (Palakanis, DeNobile, Sweeney, et al. 1994 and Bamton & Draper 1997, summarized by Diette, Lechtzin, Haponik Devrotes, & Rubin 2003, 946).

Positive Visual and Auditory Distractions Combined

Being outdoors in nature is the ultimate multi‐sensory positive distraction, and access to gardens is shown to be beneficial to both the health and well being of patients at hospitals and at assisted living facilities. Being outdoors, however, is not typically possible when waiting to see a doctor or dentist or while undergoing medical treatment. Indoor mediated nature experiences are quieter and highly appropriate, as we’ve seen so far, for patients who are waiting or undergoing treatments.

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Multi‐sensory positive distractions are by far the most attention holding, compared to visual distractions or auditory distractions alone (Pati 2010). According to the Pati pediatric waiting room research, a still slideshow was the least effective at drawing attention of the children who were waiting with their parents. In particular, the study showed that multi‐sensory positive distractions were most effective in the dental clinic waiting room. The other waiting room observed in the study was in a pediatric cardiac care clinic. Notably, while multi‐sensory positive distractions held the children’s attention the most, these forms of distractions did not necessarily translate into calmer behavior. This research has not been conducted with an adult patient population, which could yield different results.

Just as the addition of classical music to nature imagery as positive distractions enhanced pain control during colonoscopy, the option to listen to a continuous tape of nature sounds (e.g., water in a stream and birds chirping) through headphones during a painful bronchoscopy also yielded positive results. The bronchoscopy patients already could view a ceiling mounted mural of a mountain stream in a spring meadow.

Laura Rothenberg Bronchoscopy‐Endoscopy Center, NY Presbyterian Hospital

The addition of nature sounds that they could turn on or off or adjust the volume of enhanced pain control and patients’ ability to breathe. The combination of visual and auditory nature distraction had no effect, however, on reduction of anxiety (Diette, et al. 2003, 945).

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Perhaps the closest we can come to replicating the experience of being out in nature is through virtual reality (“VR”) distraction. VR environments create “presence”, that crucial element of a restorative environment that makes a patient perceive that he or she is immersed in another, though recognizable, world. Presence in VR occurs when the patient is able to voluntarily focus or be distracted. Ulrich states that nature distractions are more immersive and thus more effective if sound and visual stimuli are combined, as they are in VR (Ulrich et al. 2008, 23), though VR goes even further by making the environment interactive.

Chemotherapy treatments can last several hours and thus require a more interactive and less passive positive distraction than can be provided even by combining nature imagery and sound or music (Schneider & Hood 2007, 4). Virtual reality provides just the kind of immersive distraction that can engage all of a chemotherapy patient’s senses for a long period of time.

In a 2007 study, a group of adults receiving chemotherapy treatment for a range of different types of cancers was given head‐mounted devices that project images and sounds to create a computer‐generated environment. Another group did not use VR and could read, talk to others or watch TV. The study was trying to find out if there was any reduction of symptom distress immediately after chemotherapy and/or 48 hours later. Patients could select from four VR scenarios: deep sea diving, walking through an art museum exploring ancient worlds or solving a mystery related to the Titanic. Patients were allowed to change scenarios at will.

The VR experience altered the patients’ perception of time, with most under‐ estimating the durations of their treatments by, on average 11 minutes. There was no reduction in symptom distress, however, either immediately following therapy or after 48 hours as compared to the control group of patients. Nevertheless, the use of VR significantly compressed the patients’ perceived duration of their treatments, making them more tolerable (Schneider & Hood 2007, 9‐10) and proving that the VR did distract them. The relative inexpensiveness of the equipment ‐‐ $5‐$10 cost per patient per VR session – makes this distraction intervention cost‐effective.

Interestingly, the study found that when a patient used VR during her initial treatment, she experienced lower anxiety as compared to the control group during

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its second chemotherapy treatment. This result indicates that VR may be most effective as a positive distraction during the initial treatment when coping skills are weakest and that its effectiveness may diminish with repeated use as a distraction.

On the other hand, the timing of its use could become a tool in helping chemotherapy patients develop the coping skills they need. Another finding was that patients who reported “higher levels of presence in the virtual environment” also had lower levels of fatigue and anxiety post‐treatment. While symptom distress did not decrease following the use of VR, fatigue and anxiety did decrease. A decrease in fatigue and anxiety can help moderate the other more specific symptoms related to chemotherapy such as nausea, vomiting, anorexia and insomnia.

Other research involving VR showed that both children and women cancer patients undergoing outpatient chemotherapy did report reduced symptom distress (Schneider, Prince‐Paul, Allen, Silverman, & Talaba, 2004, summarized by Schneider & Hood 2007, 5). Compared to the Nintendo 64 flat screen video games, VR was superior in controlling pain during dressing changes of burn patients in a 2000 study by Hoffman, Patterson, & Carrougher (Schneider & Hood 2007, 5). Even in a subsequent study when VR was used repeatedly, the reduction in pain did not diminish with repeated exposure to this form of distraction, indicating that it was not simply the novelty of the experience that caused the pain control. The most fascinating study showed that not only does VR significantly reduce pain‐related brain activity, but that VR also actually changes the way that patients interpret pain signals, as evidenced from magnetic resonance images of patients’ brains (Hoffman 2004, summarized by Schneider & Hood 2007, 5).

Attractiveness and Positive Distractions in the Waiting Room: Achieving Overall Patient Satisfaction

While some of the research on positive distractions in healthcare spaces has involved waiting rooms, the vast majority has focused on in‐patient and treatment settings. Logically, though, much of this in‐patient positive distraction research can be sensitively applied to waiting room environments, especially since patients in these environments are frequently under stress or in pain. Waiting rooms can be dreary and stressful if they are not aesthetically pleasing and, as we have seen in studies presented so far, devoid of any nature‐themed positive distractions.

Patients also generally don’t like to be kept waiting for appointments, but often must, as healthcare providers attend to other patients. How does their experience in the waiting room effect their perception of the quality of their care, of the nature

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of their waiting experience and their perception of how long they are waiting? And do these perceptions influence each another?

The waiting room is a patient’s first “stop” in their healthcare journey and offers many opportunities for creating positive first impressions. It also presents many risks for setting the wrong tone. One important point is that patient perception is even more important than the patient’s objective, or actual, experience. Keeping this point in mind, a practitioner can make interventions to modify the waiting room environment to positively influence both patient perceptions and actual levels of patient stress and anxiety. The goal of providing a favorable waiting experience for patients while reducing patient stress and anxiety aligns closely with a practitioner’s other more practical goal of achieving good medical outcomes while maintaining or increasing market share and reinforcing the practice’s “brand” or culture. The overarching goal is achieving patient satisfaction through patient‐ centered care.

Patient‐centered care is meaningful to the bottom line, because beginning in October of 2012 Medicare will begin using patient satisfaction scores to determine part of the reimbursements to healthcare providers. Given that as a result of the new healthcare reform legislation, government reimbursements will be tied not just to clinical outcomes but also to patient satisfaction, it is more than imperative that we understand how the outpatient (and inpatient) physical environment influences patient satisfaction.

A study of six clinical outpatient services at Weill Cornell Medical College in New York took a look at the attractiveness of each area to determine how it effects patients’ perceptions of their care and of their waiting times (Becker & Douglass 2006). This was one of the first studies that focused on the outpatient services waiting experience rather than on in‐patient care. These were the study’s most crucial findings:

1. The higher a space was ranked in attractiveness, the higher the patient perceived the quality of medical care and the greater the reduction in anxiety reported by the patient.

2. Physical attractiveness of the waiting rooms had a greater influence on patients’ perceptions of quality of care and anxiety than did the actual time they spent waiting for care.

3. “Patient perceptions of quality and anxiety relief, feeling cared for as a person, and recommending the office to others were higher in more attractive physical environments.” (Becker & Douglass 2006, 3) 4. “…the attractiveness of the physical environment influences the patient’s perception of quality, and ….the perception of care quality then reduces the patient’s anxiety level. “ (Becker & Douglass 2006, 3)

The waiting areas judged to be the most attractive were the top‐ranked Jay Monahan Center for Gastrointestinal Health, which has a “spa aesthetic”, colorful

Survey of Positive Distractions Research in Healthcare Environments 19

contemporary furniture and artwork and is the newest of the six facilities and the Iris Cantor Women’s Health Center, which has pastel colors, modern furniture and artwork by contemporary female artists. The waiting areas judged to be the least attractive were older, tended to have either dark woods or furniture of synthetic materials, neutral wall colors and minimal decoration.

Jay Monahan Center for Gastrointestinal Health‐ Reception

The Weill Cornell study’s findings mean that patients do pay attention to their physical environment in a waiting space, and that they then perceive the quality of the care they receive based on how attractive the space is. Then, when they perceive that they are receiving good quality care, as a result of the cues sent to them by the attractive environment, they feel less anxious and are more likely to recommend the office to other patients. There is thus a causal relationship between attractiveness of the waiting room, the perception of good quality care and the reduction of patient anxiety.

Survey of Positive Distractions Research in Healthcare Environments 20

Recommendations to Other Patients

Attractive Waiting Room

Reduction in Anxiety

Perception of High Quality of Care

The results of the Cornell study re‐confirm the results of an earlier and slightly different, though relevant, study by Arnell and Devlin (2002, summarized by Becker & Douglass 2008, 129). That earlier study found that subjects who looked at photographs of waiting rooms that they judged as being attractive also perceived that the quality of care provided by the office to be high. While helpful, the study’s limitations were that actual patients were not used and the subjects only looked at photographs rather than assess actual physical spaces. Clearly, the Cornell study is the more definitive of the two, though the Arnell and Devlin research results clearly were accurate.

Why do patients perceive higher quality care in more attractive spaces and thus, in turn, experience reduced anxiety? An interesting older study (Maslow and Mintz 1956) showed that people are perceived “more positively in beautiful rooms than in ugly rooms” (Becker and Douglass 2008, 129). This suggests that patients who assess the waiting room as being more attractive also perceive more positively the staff that cares for them. In turn, patients perceive good quality care and feel less anxious.

The connection between attractiveness of the physical environment and perception of care quality and of staff quality indicates that design interventions in waiting rooms, such as integrating positive distractions into the design, can both convey a healthcare provider’s brand values while contributing to lowered patient stress. “…[The] physical environment…can convey different messages…landscape pictures, plants and comfortable chairs can convey positive messages, while sparsely

Survey of Positive Distractions Research in Healthcare Environments 21

decorated and run‐down environments can convey negative values” (Edvardsson, Sandman, & Rasmussen 2006, summarized by Mazer 2010, 2).

Waiting Times and Positive Distractions in the Waiting Room: Achieving Overall Patient Satisfaction

Another influence on patients’ perception of the quality of care is the waiting time.

The total waiting time consists of the pre‐process period from entry to the time a patient goes to the examination room, the in‐process period between entering and leaving the examination room and the post‐process period from leaving the examination room to completing all paperwork to leave the facility. Here we are focusing on the pre‐process waiting period.

The Weill Cornell study found that patients who perceived that they waited less than five minutes also perceived their care as being of higher quality and the environment as reducing their anxiety than patients who perceived that they waited more than 30 minutes (Becker and Douglass 2008, 134). This was the case in all six waiting rooms included in the study. A 2004 study (Miceli and Wolosin, summarized by Ulrich 1991, 130) found that “longer waiting times were negatively correlated with overall satisfaction.” This study also determined, however, that good communication between staff and patients could help mitigate the negative correlation. A 2007 online survey by McKinsey & Co. (Grote, Newman, & Sutaria) of 1000 U.S. patients with either Medicare or commercial health insurance found that, among the commercially insured patients, 75% would switch to another facility if it conducted scheduled appointments on time (i.e., within 30 minutes or compensated with a gift certificate for a lengthy wait).

The combination of a physically attractive waiting room and a short waiting time is the essence of patient‐centered care, because the result is a less‐stressed patient who perceives that his or her care is of high quality. Since short pre‐process waiting times are not always feasible, a well‐designed waiting room with effective positive distractions can make up for the longer wait time and possibly even lack of communication with staff, so long as the wait does not exceed 30 minutes. In fact, the Weill Cornell study found that “patients in more attractive environments perceived shorter waiting times than did patients in less attractive environments” (Becker and Douglass 2006, 4).

Survey of Positive Distractions Research in Healthcare Environments 22

Attractive Physical Environment (Including Effective Use of Positive Distractions)

SHORTER PERCEIVED WAITING TIME

Perceived Higher Quality of Care, Reduced Anxiety & Greater Patient Satisfaction

Most interestingly, though, is what the study found out about the relationship between perceived waiting times and actual waiting times. Not only does perceived waiting time not equate to actual waiting time, research shows that the perceived waiting time is actually a better indicator of patient satisfaction than actual waiting time (Thompson et al., summarized by Pati et al. 2010).

A 2005 study (De Man et al., summarized by Becker & Douglass 2008, 130) of nuclear medicine patients showed that they significantly underestimated their actual pre‐process waiting times. This is somewhat consistent with the findings of the Weill Cornell study, which detected a more subtle relationship of actual to perceived waiting times. The Weill Cornell study did find that patients who waited more than 30 minutes tended to underestimate their actual waiting times, just as in the 2005 study. But, the study also showed that patients who waited less than 5 minutes tended to overestimate their actual waiting times.

The key point is that, medical practices can do things to improve patients’ perceptions of time so that they perceive a shorter waiting time and thus perceive higher quality care and experience stress reduction. Influencing patients’ perceptions of time is more useful than reducing their actual waiting times, since patients tend to overestimate even short waiting times.

This is not to say that clinicians should not strive to deliver care as efficiently as they can to reduce lengthy waiting times. As the McKinsey survey showed, commercially insured patients are willing to switch to other providers who keep timely appointments.

We have seen, however, that time elapse compression can occur in treatment environments when a positive distraction is used effectively, such as in the case of the chemotherapy patients who lost track of time while using virtual reality systems. Creative and sensitive architects, designers and healthcare providers should be able to identify those nature‐oriented positive distractions that can be adapted to be restorative in waiting spaces. These should be features in the

Survey of Positive Distractions Research in Healthcare Environments 23

environment that take patients “away”, give them an opportunity to feel “extent” or “presence”, “soft fascination” (i.e., voluntary focus) and that are compatible with their goals of being healed. Perhaps the more immersive, multi‐sensory positive distractions, such as aquariums and ambient art with sound are effective and more appropriate substitutes for virtual reality in waiting rooms, as the 2008 Pati study on pediatric waiting rooms found.

Positive Distractions and Patient­Centered Care: Attracting Patients and Reinforcement of Brand

Since reimbursement by government healthcare insurance payers is set to be determined in part by patient satisfaction scores (i.e., Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS) beginning in October 2012, healthcare providers have an incentive to think about the amenities they offer in their waiting rooms as a way of conveying their values to patients and reinforcing their culture, or “brand” as one that is patient‐centered. A patient‐centered culture focuses on clinical outcomes, of course, but it is also concerned with the patient experience. Providers can re‐think their values as being those related to caring for the whole person – their emotions and feelings as well as their physical well‐being.

As a pediatrician in a small group practice based in Woodcliff Lake, New Jersey said about his brand, “I’d rather have my patients read and look at the fish tank [than at a television]….That better promotes my philosophy.

(Pennachio 2003)” A provider must develop a clear “philosophy”, and to be competitive, increasingly that philosophy needs to be one of focus on patient satisfaction.

McKinsey identifies the group of patients that respond particularly well to patient‐ centered care as “comfort seekers”, “amenity seekers” and “control seekers” (Grote et al. 2007, 8). They represent 60% of the Medicare and commercially insured patients that McKinsey surveyed. These are the patients that practitioners increasingly must target and be responsive to. To do so is to have a competitive advantage compared to providers who do not offer those amenities associated with a patient‐centered care mission.

Survey of Positive Distractions Research in Healthcare Environments 24

McKinsey found that 41 percent of a patient’s decision in selecting a healthcare provider is based on the nonclinical experience and only 20 percent is based on the provider’s reputation. More than half would switch to a provider if the provider offered a distinctive patient experience (Grote et al. 2007, 3). Why these striking results? Patient amenities are easier for consumers of healthcare to understand than complex, multidimensional clinical data (Goldman, Vaiana, & Romley 2011, 2186). Perhaps this makes them easier to use as the basis of making healthcare choices.

Amenities in the waiting room are an example of information that patients can easily understand and on which they can base their healthcare decisions. Now that there is more research about which amenities are most effective in waiting rooms, and we know that the waiting experience is associated with key organizational objectives, designers and practitioners need to carefully engineer the waiting experience so that it can effectively convey patient‐centered values (Pati et al.

2010).

Aside from working with designers and architects to develop aesthetically attractive waiting rooms that include contemporary furniture, lighter woods, representational nature artwork and photography and a general “spa” aesthetic, positive distraction interventions can be added to the environment to influence patient perceptions positively and reduce stress and physical pain of waiting patients.

Pati provides further ideas that derive from findings from his study of positive distractions in pediatric waiting rooms.

Privacy. Since positive distractions give patients somewhere to focus other than on other people in the waiting room, he suggests using positive distractions to address issues of privacy and how that can help reduce stress.

Noise Reduction. He also noted, as a corollary to privacy, that since positive distractions are associated with calm behavior, he suggests using them to reduce overall ambient noise to temper chaotic periods during peak patient visits.

Layout. Since in his study one of the waiting rooms in his study was laid out so that not all of the chairs faced the distraction, which included aquariums, ambient art and still art, he suggests that through physical placement and use of sightlines and adjacencies designers and architects can help make the distractions more immersive for patients. As we have seen, the more immersive the positive distraction, the more presence the patient feels. Time compression can then ensue, resulting in a shortened perception of the waiting time.

Survey of Positive Distractions Research in Healthcare Environments 25

Biophilic Design. Lastly, since his study showed that the pediatric patients preferred nature themes (and other studies show that adults have this same preference universally), in waiting rooms where windows are typically at a premium, Pati suggests of thinking of ways, mostly already discussed, to integrate nature’s views into the design of the window‐less space: serene nature‐themed wall and ceiling murals, floor patterns, aquariums, serene representational nature art, nature photographs and tranquil nature videos. These are all possibilities that studies show can work well in waiting rooms for anxiety and pain reduction. If a space with windows with dynamic views to nature is available, certainly architects and designers should strive to designate it in their floor plans as the waiting room.

If patients are making choices on the basis of amenities, such as those provided in patient‐centered care environments, the value of those amenities is important to understand because they cost providers money to implement. Research has shown that while improvements in amenities can cost more than improvements in the quality of care, “improved amenities have a greater effect on … [patient] volume.”

(Goldman et al. 2011, 2186)

Healthcare providers who make the decision to introduce positive distractions and other elements of attractive healthcare environments to attract and retain patients while also helping to reduce their anxiety and pain want to know that the increased cost of doing so will be reflected in reimbursements. If insurers do not value these amenities, such as the provision of positive distractions in waiting rooms, as being valuable aspects of the healthcare experience, then reimbursement levels will not factor in their cost. Presumably reimbursements can still improve if both the patient volume increases and patient satisfaction scores go up even if reimbursement rates remain relatively unchanged. That increase in absolute reimbursements must still be adequate, however, to offset and, ideally, exceed the provider’s costs of upgrading the physical environment.

Survey of Positive Distractions Research in Healthcare Environments 26

One concern related to the new Patient Protection and Affordable Care Act is that Medicare is reducing growth of its reimbursements on the assumption that healthcare providers are going to be able to increase their productivity gains along with the rest of the economy. If amenities are not included in Medicare’s assessment of productivity performance, then providers who invest in them “may…suffer under the new law.” (Goldman et al. 2011, 2187) On the other hand, even if Medicare does not factor the amenities into its assessments of productivity gains made by providers, favorable patient satisfaction will begin to influence Medicare reimbursements. So, if the amenities are successful in improving patient satisfaction, reimbursements can conceivably improve as an indirect result of those improved amenities.

Recommendations

Based on the research literature, the following table summarizes some of the most common positive distractions, their key characteristics and their relationships to behavioral and clinical outcomes.

Biophilic Visual Auditory

Aquarium ✔ ✔ ✔

Multi-Sensory

✔

Reduces stress/anxiety

✔

Time elapse compressing Controls pain

Wall & Ceiling Nature Photo Mural ✔ ✔

Represent -ational Nature Art ✔ ✔

Nature Video ✔ ✔ ✔

✔

✔ ✔

✔

✔

✔

✔

NatureThemed Virtual Reality ✔ ✔ ✔ ✔

✔

✔ ✔ ✔

Changes behaviors

✔

Increases patient satisfaction

✔

✔

✔

✔

✔

✔

✔

✔

✔ ✔

✔

✔

✔ ✔

Has soft fascination or voluntary focus Adaptable to Waiting Rms Dynamic Interactive

Nature Sounds or Classical Music

✔

✔

✔ ✔ ✔

Survey of Positive Distractions Research in Healthcare Environments 27

While all of these nature‐themed positive distractions increase patient satisfaction, often because they enhance the attractiveness of the physical environment, and reduce stress and anxiety, the two stand‐outs are the aquarium and nature‐themed virtual reality. Virtual reality shares with the aquarium many of the characteristics of positive distractions that have been shown to be most effective in stress and anxiety reduction in restorative environments. They are both biophilic, multi‐ sensory and dynamic. They also both increase patient satisfaction and are anxiety‐ and stress‐reducing.

The next most effective positive distraction is the nature video, which has in its favor the immersive quality of a multi‐sensory experience, while lacking the interactivity of virtual reality. Representational nature art and wall and ceiling nature photo murals are next most effective, despite their static quality. Not surprisingly, nature sounds or classical music alone are the least effective as positive distractions, primarily because they represent just one sense that has not been shown in studies to provide soft fascination or a voluntary focus. Both the static visual and auditory distractions share the risk of sensory habituation, which rarely occurs with video, live nature (i.e., aquarium) or virtual reality.

Integrating any of these positive distractions into the physical environment, even the least effective ones, is ultimately better than having none at all. In a pre‐ treatment waiting space, a treatment room or post‐recovery area, nature‐oriented positive distractions have proven benefits to patients, who feel restored, more satisfied and ready to heal.

APPENDIX

Potential Healthcare, Design and Architectural Consumers of Positive Distractions

A wide range of entities has an interest in introducing positive distractions to their physical environments. Other stakeholders are advocates for patient‐centered care and would support efforts to introduce aquariums to healthcare facilities. These entities are active consumers of specialized trade media and congregate and share information through professional associations and at annual conferences. The following is a comprehensive, but by no means exhaustive, list of many of those entities and the media they consume, associations they belong to and conferences they attend that are potential outlets for reaching them.

Stakeholder Individual Practitioners, Group Practices & Outpatient Clinics

Media Outlet Dental Economics (dentaleconomics.com),

Journal of the American Medical Association

Association American Medical Association (ama‐ assn.org),

Medical Society of

Conference Pri‐Med NY (pri‐ med.com/NYC)

Annual Primary Care Conference

Survey of Positive Distractions Research in Healthcare Environments 28

Hospitals

(jamanetwork.com/journ al.aspx),

Medical Office Today (medicalofficetoday.com)

Modern Medicine (modernmedicine.com),

The New England Journal of Medicine (nejm.org).

Oncology Nurse Forum (ons.org/publications/ON F)

American Journal of Medicine (http://www.elsevier.co m/wps/find/journaldesc ription.cws_home/52504 9/description ‐ description)

DentistryIQ (dentistryiq.com)

Medical Economics (medicaleconomics.mode rnmedicine.com)

Outpatient Surgery Magazine (outpatientsurgery.net Journal of Hospital Medicine (http://onlinelibrary.wile y.com/journal/10.1002/ %28ISSN%291553‐5606)

American Journal of Cardiology (ajconline.org)

American Journal of Gastroenterology (nature.com/ajg/index.ht ml)

American Journal of Obstetrics and

the State of NY

(mssny.org) (See * below)

National Medical Association (nmanet.org)

American College of Chest Physicians (chestnet.org)

Oncology Nursing Society (ons.org )

Association for the Care of Children’s Health (acch.org)

The Healthcare Forum

Medical Society of NJ (msnj.org)

Medical Soceity of the State of NY (mssny.org)

Medical Care Long Island (nacmed.org) NJ Hospital Assoc. (njha.com)

Greater NY Hospital Association (gnyha.org)

Healthcare Association of NY State (hanys.org)

American Hospital Association (aha.org)

Healthcare Facilities Symposium & Expo

Most of the associations at left sponsor annual conferences

Survey of Positive Distractions Research in Healthcare Environments 29

Gynecology (ajog.org), American Journal of Respiratory and Critical Care Medicine (ajrccm.atsjournals.org)

American Journal of Surgery (americanjournalofsurger y.com),

National Hospital Association (nationalhospitala ssociation.org)

National Association of Public Hospitals and Health Systems (naph.org)

National Association of Children’s Hospitals (childrenshospital s.net)

Society of Hospital Medicine (hospitalmedicine. org) Hospices, American Journal of Hospice Nursing Homes Hospice and Palliative Association of & Rehabilitation Medicine America Facilities (ajh.sagepub.com) (nahc.org/hospice )

Geriatric Nursing Hospice (gnjournal.com) Foundation of

America Journal of Professional (hospicefoundatio Nursing (professionalnursing.org) n.org)

NY State Health RN Journal Facilities Assoc (rnjournal.com) (nyshfa.org)

National Rehabilitation Association (nationalrehab.or g)

American Academy of Nursing (aannet.org) Architects Architectural Record AIA New York

Most associations at left sponsor annual conferences

Healthcare

Survey of Positive Distractions Research in Healthcare Environments 30

Interior Designers

(archrecord.construction. com)

Architect Magazine (architectmagazine.com)

Architecture Week (architectureweek.com)

Architectural Review (architectural‐ review.com) Healthcare Design (healthcaredesignmagazi ne.com),

Contract Design (contractdesign.com)

Interior Design (interiordesign.net),

Metropolis (metropolismag.com),

Architectural Digest (architecturaldigest.com)

Dwell Magazine (dwell.com)

DesignNJ (designnewjersey.com)

Luxe Interiors + Design (luxesource.com/luxe‐ magazine),

Chapter (aiany.org)

Environmental Design Research Association (edra.org)

Faciilities Symposium & Expo (hcarefacilities.com)

ASID (asid.org),

IIDA (iida.org)

IDS (ids.org)

IFI (ifiworld.org)

Healthcare Design Conference (annual; http://www.healthd esign.org/chd/confe rences‐ events/healthcare‐ design)

NeoCon,(neocon.co m)

International Contemporary Furniture Fair (icff.com)

NY International Gift Fair (nyigf.com)

Architectural Digest Home Design Show (archdigesthomesho w.com),

•

•

A listing of the top 50 medical conferences in the U.S. in 2012 is compiled by the Soliant Health blog: http://blog.soliant.com/healthcare‐news/top‐50‐ medical‐conferences‐in‐2012‐by‐profession/ A listing of most of the major medical journals is compiled by JournalWatch at: http://hospital‐medicine.jwatch.org/misc/watched.dtl

Other stakeholders:

Picker Institute – pickerinstitute.org

Survey of Positive Distractions Research in Healthcare Environments 31

Purdue University’s Center for the Human‐Animal Bond – vet.purdue.edu/chab/bond.htm Center for Health Design – healthdesign.org Planetree – planetree.org AARP – aarp.org Robert Wood Johnson Foundation – rwjf.org National Institutes of Health – nih.gov Healthcare Strategy Institute – healthcarestrategy.com

Survey of Positive Distractions Research in Healthcare Environments 32

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