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DOI: 10.1177/0013916503254777

2003 35: 842Environment and BehaviorPhil Leather, Diane Beale, Angeli Santos, Janine Watts and Laura Lee

Outcomes of Environmental Appraisal of Different Hospital Waiting Areas

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10.1177/0013916503254777ARTICLEENVIRONMENT AND BEHAVIOR / November 2003Leather et al. / STRESS AND AROUSAL IN HOSPITAL WAITING AREAS

OUTCOMES OF ENVIRONMENTALAPPRAISAL OF DIFFERENTHOSPITAL WAITING AREAS

PHIL LEATHER is a senior lecturer in applied social psychology and assistantdirector of the Institute of Work, Health, & Organisations (I-WHO), University ofNottingham. He is chair of the Social and Environmental Psychology Research Groupand director of the M.Sc. in Occupational Psychology. He graduated from the Univer-sity of Lancaster where he completed a B.A. in English (with behavior in organiza-tions as his minor), an M.A. in organizational psychology, and a Ph.D. in theDepartment of Behaviour in Organisations. Dr. Leather's interests in the environmen-tal psychology of workplaces and organizational settings concern the way in whichindividual cognition, affect, well-being, and behavior are influenced by design char-acteristics of the physical environment. He is responsible for the delivery of an envi-ronmental psychology and design module and has supervised a range of M.Sc.dissertations in the area.

DIANE BEALE is the Institute Senior Research Fellow in Applied Psychology at theI-WHO, University of Nottingham. She is a member of the Social and EnvironmentalPsychology Research Group, Director of the M.Sc. in Psychological ResearchMethods, and Convenor of the M.Phil./Ph.D. Program. Dr. Beale completed an M.A.in natural sciences (chemistry) at Oxford University and an M.Sc. in information sci-ence at the University of Sheffield. She completed her Ph.D. in applied psychology atthe University of Nottingham investigating work-related violence. Her research inter-ests encompass psychosocial aspects of healthcare and other workplaces, includingthe effects of the physical environment on interpersonal interactions.

ANGELI SANTOS is a research associate at the I-WHO, University of Nottingham,and a member the Social and Environmental Psychology Research Group. She has aB.Sc. in psychology from the Ateneo de Manila University in the Philippines and anM.Sc. in occupational health psychology at the University of Nottingham. She is near-ing completion of her Ph.D. in applied psychology at Nottingham on “Individual andSocial Moderators of the Consequences of Work-Related Violence in the Police.” Shealso teaches for the environmental psychology and design module on areas to do withsupportive hospital design, office design, and environmental stress and is currentlymanaging a research project on the evaluation of the use of the performing arts ininforming hospital design.

842

ENVIRONMENT AND BEHAVIOR, Vol. 35 No. 6, November 2003 842-869DOI: 10.1177/0013916503254777© 2003 Sage Publications



JANINE WATTS graduated with a bachelor’s degree from the School of Psychologyat the University of Nottingham. She now works as a chartered clinical psychologistat the Institute of Psychiatry, King’s College, London. While in Nottingham, she wasan active researcher in the area of environmental design and took part in a number ofstudies to do with environmental design in hospitals around the United Kingdom.

LAURA LEE graduated with an M.Phil. in the area of environmental psychologyfrom the School of Psychology at the University of Nottingham. She now works as aprison psychologist for Her Majesty’s Young Offenders Institute in Lancaster, UnitedKingdom. Current research interests include the design of the physical environmentas a way of influencing the behavior of young offenders.

ABSTRACT: This article evaluates the intuitively informed interior design changesmade to a United Kingdom neurology outpatient waiting area following relocation toan alternative building. Thisnouveauenvironment is compared with the moretradi-tionalwaiting area used before the relocation. The two waiting areas are compared interms of their effects on the environmental appraisals, self-reported stress andarousal, satisfaction ratings, and pulse readings of 145 outpatients. The equivalenceof the outpatient samples attending each clinic is demonstrated in terms of their com-mon demographic characteristics and their similar health profiles. The results provideconvergent evidence that the nouveau waiting area is associated with more positiveenvironmental appraisals, improved mood, altered physiological state, and greaterreported satisfaction. These findings provide support for the concept of a therapeutichospital environment.

Keywords: hospitals; environmental appraisal; stress; arousal

SOURCES OF STRESS IN THE HOSPITAL ENVIRONMENT

For many patients and visitors, the hospital is a strange and alien envi-ronment (Carver, 1990; Veitch & Arkkelin, 1995; Zimring, Carpman, &Michelson, 1987). As Carver (1990) described it,

Leather et al. / STRESS AND AROUSAL IN HOSPITAL WAITING AREAS 843

AUTHORS’ NOTE: The authors would like to thank David Stevens and LeslieMorrison for their involvement in establishing the study that this article is based onand Fehmidah Munir for her help in the early stages of data gathering. This studyforms part of a program of ongoing research into the impact of the hospital environ-ment on staff, patient, and visitor attitudes, perceptions, and well-being undertaken bythe Institute of Work, Health, and Organisations. Address correspondence to Dr. PhilLeather, Institute of Work, Health, and Organisations, University of Nottingham, Unit8, William Lee Buildings, Nottingham Science & Technology Park, University Boule-vard, Nottingham NG 7 2RQ, United Kingdom; e-mail: [email protected].



Being admitted to a modern hospital can be like entering an alien spacecraft.The atmosphere can be intimidating and unfamiliar . . . there is often. . . a con-fusing array of doors, corridors, and color-coded signs-enveloped in a tall,intimidating structure appearing . . . like an oversized air conditioning unit.(p. 86)

Veitch and Arkkelin (1995) suggested that the mere mention of the wordhos-pital conjures up “thoughts of long sterile hallways, stainless steel utensils,banks of life-monitoring equipment, people in white uniforms rushing to andfro, specialized rooms for specialized functions, wheelchairs lined up at ele-vators, and the smell of rubbing alcohol and disinfectant” (pp. 291-292).

The unfamiliarity and strangeness characteristic of the hospital environ-ment may generate strong negative emotions—often, those associated withsuffering and death (Brown, 1961). At the very least, hospitals are perceivedas strange, frightening, and fearful places that stimulate feelings of threat andvulnerability (Brown, 1961; Carpman, Grant, & Simmons, 1984; Leventhal,Nerenz, & Leventhal, 1982). Leventhal et al. (1982) added that the environ-mental sterility characteristic of the modern medical setting can contribute tothe experience of patient dehumanization. As Olsen (1978) explained, hospi-tal designs often communicate a uniform message that people are “sick anddependent and should behave in an accordingly passive manner” (p. 7). Inessence, patients and visitors pick up on design cues (e.g., bedside pri-vacy, medical equipment, location of nursing stations) that influence self-perception, help define sick-role behavior, and provide information about thehospital’s humaneness and competence as an institution (Zimring et al.,1987).

Shumaker and Reizenstein (1982) identified this negative symbolicmeaning as being one of the principal ways in which the physical environ-ment of the hospital can contribute to levels of stress. Stress, defined as animbalance between perceived demands and perceived coping resources(Cox, 1978; Lazarus, 1966; Lazarus & Launier, 1978; Selye, 1976), offers avaluable heuristic to help explain how the physical features of any environ-ment can influence human health and well-being (Evans, 2000; Evans &McCoy, 1998; Ulrich, 1991). Evans (2001) noted, in this respect, that thephysical environment might contribute to stress in three distinct ways: (a) byacting as a stressor that directly loads or pressures the system, for example,where crowding creates excessive stimulation; (b) by damaging or ameliorat-ing coping resources, for example, where chronic noise leads to learned help-lessness (Glass & Singer, 1972); and (c) by eliciting coping strategies that, inturn, lead to poor health, for example, where noisy working conditions areassociated with increased substance abuse.

844 ENVIRONMENT AND BEHAVIOR / November 2003



What is of fundamental importance in this is the idea that the physical en-vironment might be conceptualized either as a source of stress or as a sourceof coping resources. Physical and psychosocial elements have frequentlybeen found to interact in their effect on well-being (Evans, Johansson, &Carrere, 1994; Evans & Lepore, 1992; Leather, Pyrgas, Beale, & Lawrence,1998). This opens up the possibility that, although the physical characteris-tics of an environment might not be stressful in themselves, they neverthelessmight act to exacerbate or attenuate the negative impact of some co-occurringpsychosocial stress. Investigators (e.g. Ulrich, 1991) have applied this to thehospital setting. This article also tests this proposition, namely, that differ-ently designed hospital outpatient waiting areas might accentuate or alleviatethe stress known to accompany a visit to the hospital for a medical consulta-tion (Ulrich, 1991).

Central to this idea is the degree of congruence or fit between individualneeds and environmental resources and affordabilities. Importantly, in thisrespect, research identifies clear disparities between hospital user groups inthe extent to which their environmental needs are recognized and prioritized.The typical hierarchy places clinical and medical needs first, inpatients sec-ond, outpatients third, and visitors last (see, for example, Zimring et al.,1987). To differing degrees, patients and visitors are all expected to adjust toan unknown environment in which much is new and alien to them (Shumaker& Reizenstein, 1982). As Leventhal et al. (1982) concluded, attending clinicsfor medical treatment often involves a loss of control over many aspects ofdaily life including control over the physical environment. Thus, the stressassociated with the hospital visit is not confined solely to the worry and anxi-ety known to accompany physical illness (Cohen & Lazarus, 1979). In addi-tion, it can derive both directly from the adaptation needed to actively engagewith a strange and alien environment (Shumaker & Reizenstein, 1982) andindirectly from the depleted coping resources that are thereby left to deal withany physical illness or complaint.

Physical discomfort is a further mechanism by which the hospital envi-ronment can be a potential contributor to stress (Steele, 1973). Conversely, acomfortably designed environment may at least partially mitigate the stressof a hospital visit (Zimring et al., 1987) by way of design features that meetpatient needs for bodily comfort (Shumaker & Reizenstein, 1982).

THERAPEUTIC HEALTH CARE ENVIRONMENTS

The potential for what is often termed thetherapeutic dimensionin hospi-tal design has a long history (e.g., Kirkbride, 1854) and continues to be afocus for contemporary research (Canter & Canter, 1979; Cumming &




Cumming, 1964; Moran, Anderson, & Paoli, 1990; Sommer & DeWar,1963). The 1986 Ottawa Charter (Ottawa Conference, 1986) identified thecreation of “supportive environments” as necessary for effective health care.The Michigan Patient and Visitor Participation (PVP) Project saw theremoval of the stress inherent in the clinical environment as being fundamen-tal to the needs of hospital users (Carpman, 1983; Reizenstein & Grant,1982).

Moran (1990) pointed out that, as a bare minimum, “healthy environ-ments” should “at least lack attributes which are associated with dis-ease”(p. 6). Similarly, Carver (1990) suggested that the design of hospitals needsto portray “a nurturing, non-threatening environment. . . to help put people atease” (p. 90). Evidence does indeed suggest that people respond positively toattractive environments that connote caring intent (Campbell, 1979). Forexample, changes in decor, furnishings, and furniture arrangement have beenfound to increase social interaction and decrease anxiety in hospital settings(Bakos, Bozic, Chapin, & Neuman, 1980; Hiatt, 1981; Holahan & Saegert,1973; Sommer & Ross, 1958). The value of an attractive environment isthought to lie in its ability to distract attention (Baum & Davis, 1976) withnatural environments, in particular, allowing recovery from mental fatigue(Kaplan & Kaplan, 1989). These examples demonstrate that environmentalfeatures may facilitate or enhance patient behavior and contribute to the gen-eration of a healthy environment (Canter & Canter, 1979; Moran, 1990).

Color (hue), for example, has been found to moderate both subjective andphysiological indexes of patient well-being. Schauss (1979) attributed a ten-sion-relieving effect to a specific shade of pink, whereas Brown (1974)reported that pulse rate changed in response to different hues thereby sub-stantiating the claim that color can induce emotional states. Generally, coolcolors (green and blue) have been found to have a relaxing effect by decreas-ing the pulse rate, whereas warm colors (red and some pinks) tend to induceboth physiological arousal by increasing the pulse rate and a tendency forattention to be directed outwards into the environment (Birren, 1979). Birren(1979) argued against the use of the color white in hospitals, because, in com-bination with artificial (fluorescent) lighting, it can cause “distressing glare”sometimes linked with headaches and eyestrain.

The value of a pleasantly designed healthcare environment should not beunderplayed. Reizenstein (1976) found that it facilitated self-disclosure byclients to hospital social workers. Bobrow and Thomas (1990) found thatdoctors were keen to develop a pleasant environment as a means to increasethe efficiency and quality of their work. Perhaps most impressively, Ulrich(1984) found shorter postoperative stays and decreased analgesic use in




hospitalized patients whose windows looked out on a natural scene ratherthan an urban view.

Such findings have important implications for patient health and the qual-ity of care received. As Shumaker and Reizenstein (1982) stated, “Patientsenter hospital settings in a vulnerable state, and any stressors they encounterthat go beyond their illness can threaten them by diverting their physiologicaland psychological mechanisms from their own recovery” (p. 189).Removing such sources of stress in the hospital environment may, therefore,have beneficial effects on the process of recovery. However, Kasmar, Griffinand Mauritzen (1968) found that two contrasting visual-aesthetic settings(i.e., a beautiful and an ugly room) had no simple effects on either self-ratedmood of patients or their perceptions of the members of hospital staff.

Certainly, evidence exists to suggest that stress can generate relapse orcomplications in those who are already ill (Andrews & Tennant, 1978; Sklar& Anisman, 1981). Stress may lead to feelings of anger, frustration, and help-lessness (Cohen, 1980), which may also inhibit recovery (Seligman, 1975).Additionally, a reduction in information-processing capacity can occur fol-lowing stressful experiences (Cohen, Evans, Stokols, & Krantz, 1986).

A fundamental question being asked in attempts to identifyhealthyhealthcare environments is whether different everyday environments have differentstress-recovery capabilities (Ulrich & Simons, 1986; Ulrich et al., 1991).That is, does exposure to some environments have restorative effects, whereasexposure to others has either no effect or, worse still, a negative effect?Although Ulrich’s demonstration of the value of natural environments is par-ticularly important in this respect (Ulrich, 1981, 1984; Ulrich & Simons,1986; Ulrich et al., 1991), there is a need to continue this work in real-worldcontexts outside the laboratory.

What Ulrich’s work offers is a clear set of criteria against which the recov-ery or restorative potential of an environment can be judged. Put simply,“Restoration or recovery from stress involves numerous changes in psycho-logical states, in levels of activity in physiological systems, and often inbehaviors or functioning” (Ulrich et al., 1991, p. 202). Ulrich et al. (1991)emphasized that “recovery effects should be evident in emotional statesand physiological indicators”, the key point being that “general synchronybetween data obtained from different modes (e.g., psychological and physio-logical) would suggest true convergent validity, and justify greater confi-dence in the findings” (p. 202-203).

Despite the obvious value of systematic research on the impact of hospitaldesign choices, studies have characteristically lacked theoretical and empiri-cal content (Bell, Fisher, Baum, & Greene, 1990; Veitch & Arkkelin, 1995).Furthermore, most studies have considered only inpatients in acute care and




psychiatric settings. Research on a wider range of hospital settings is nowneeded (Zimring et al., 1987).

AFFECTIVE APPRAISAL IN WAITING AREAS

Waiting areas may play an important role in healthcare settings in reassur-ing or further distressing patients. Ingham and Spencer (1997) found that the“softening” of a dental clinic waiting area reduced worry and anxiety experi-enced by patients prior to examination or treatment. Zimring et al. (1987)pointed out that the decor and furnishings in hospital waiting areas “speak” tovisitors about the value the hospital places on their comfort. Waiting areasdesigned without consideration of user needs may communicate a negativemessage such as the patient having a low priority within the overall hospitalsystem.

This article reports the results of a comparative evaluation of two waitingareas used by outpatients at neurology clinics in a large city hospital in thewest of England. The two waiting areas, hereafter referred to as traditionaland nouveau, differed in terms of a number of aesthetic and functional attrib-utes. Essentially, the labeltraditional describes the typical design of out-patient clinics found in U.K. hospitals, whereasnouveaurefers to a deliberateattempt to create an alternative image (refer to Table 1 in Method). Basedon Russell and Snodgrass (1987), it is contended here that the person-environment relationship is largely emotional in nature with the affectivequality of a place accounting for the cumulative influence of the environmenton mood, health, and subjective well-being.

In simple terms, the impact of the physical environment derives from theindividual’s appraisal of the environment itself. Appraisal, in this sense, is theindividual’s subjective evaluation of the environment in terms of both thequality of features present and how the environment fits the person’s needs.This conceptualization is in line with an appraisal model of emotion(Lazarus, Averill, & Opton, 1970) where emotions are defined as “valencedreactions to events, agents, or objects, with their particular nature beingdetermined by the way in which the eliciting situation is construed” (Ortony,Clore, & Collins, 1988, p. 13). In this way, an important distinction is drawnbetween the resulting mood or emotion and the appraisal or evaluation of thesituation. With respect to person-environment relationships, Russell andSnodgrass (1987) made a similar distinction between an individual’s internalemotional state and the affective appraisal of the environment that gives riseto it.

Following Russell and Snodgrass (1987), affective appraisal is operation-ally defined as an individual’s rating of a setting on a series of adjectives




highly saturated in affective meaning—for example,boringversusstimulat-ing, dull versusbright, andtenseversusrelaxed—but with little or no refer-ence to objective, perceptible properties of the place described. This is todifferentiate affective appraisal from environmental evaluation, which refersto judgments of specific and identifiable features within the environment, forexample, the furniture or furnishings present. For the purpose of this re-search, the patients’emotional state that resulted from appraisal of the differ-ent waiting areas was operationally defined as their self-reported stress andarousal. However, an additional measure of physiological arousal was usedto strengthen the validity of any findings (Ulrich et al., 1991).

Accordingly, the two waiting areas were compared in terms of patients’(a) affective appraisal of the environment, (b) emotional reactions contingentupon that appraisal, (c) pulse rate as a base, physiological indicator, and (d)more detailed evaluation of specific environmental features. It was hypothe-sized that the nouveau design would be associated with (a) more positiveaffective appraisals of the waiting area, (b) more positive emotional reactionsexperienced by the waiting area occupants, and (c) more positive evaluationsof particular design features compared to the traditional design.

METHOD

RESEARCH DESIGN

The study utilized a two-sample comparative design with data being gath-ered from patients prerelocated and postrelocated to a neurology outpatientclinic. The equivalence of the two samples was determined by comparing theage and gender composition and the health profiles. The differently designedwaiting areas constituted the independent variable in this field experiment,the dependent variables being patients’ appraisals and evaluations of thoseenvironments together with their mood and physiological arousal.

SETTING

The impetus for this study was the rehousing of the neurology clinic froma shared, medical outpatient department to a nearby building within the samehospital complex, which was to serve exclusively as a neurology clinic. Relo-cation to the new site afforded a senior consultant the opportunity to designthe interior waiting area in a manner believed to be less “clinical and intimi-dating” and more “supportive” for patients (personal communication).




However, no structural changes were made to the building to accommodatethe neurology clinic. The major design attributes of the two waiting areaenvironments—traditional and nouveau—are outlined in Table 1. Ease ofaccess to the two waiting areas was similar in terms of distance from parkinglots and pedestrian entrances and situation within their respective buildings.

SAMPLE

The sample comprised 145 neurology outpatients interviewed in twogroups: 81 patients were interviewed in a traditional waiting area and 64 in a


TABLE 1Design Attributes of the Traditional and Nouveau Waiting Areas

Waiting Area

Design Feature Traditional Nouveau

General layout Square plan; enclosed recep-tion area; files and paper-work visible from waitingarea

L-shaped plan; open-planreception area; no files orpaperwork visible

Color scheme Magnolia & dark brown; nocolor coordination

Grey and pink tones; colorcoordination

Floor covering Red, patterned, flat carpet Lilac, pile carpetCurtains Flimsy, window-length Heavy, full-lengthFurniture Plastic-covered, blue-grey

benches and armlesschairs

Fabric-upholstered, deepblue, armless, woodenchairs

Lighting Fluorescent strip lighting Wall-mounted fixturesWalls & pictures Cork notice-boards Wall-mounted nature photog-

raphy; wooden panelingPlants & flowers Small, wall-mounted, dried

flower arrangementsFree-standing, ceramic-

potted indoor plantsReading material Large piles of easy-reading

magazines (e.g., Woman’sOwn)

Selection of glossy maga-zines (e.g., Homes &Gardens)

Medical informationdisplays

Leaflet carousels & informa-tion boards

None

Windows Metal-framed, clear glass;view onto adjacent hospi-tal buildings

Metal-framed, clear glass;view onto adjacent hospi-tal buildings

Noise No music or television; noisefrom waiting patients, staff,and telephones

No paging system or televi-sion; noise from waitingpatients, staff, andtelephones



newly refurbished (nouveau) waiting area. Seventy subjects (48%) weremale and 73 (50%) were female (2 respondents did not indicate gender). Chi-square analysis revealed no significant difference between the two patientgroups in terms of gender,χ2(1, 145) = .38,ns. The age of subjects rangedfrom 15 to 78 years with a mean age of 48 years and a standard deviation of15.8 years. An independent samplest test revealed no significant differencein age between the two groups,t(143) = .57,ns.

Of the patients sampled in the traditional waiting area, 39% were makingtheir first visit to the neurology outpatient clinic. In the nouveau waiting area,this figure was 30%. Chi-square analysis revealed no significant differencebetween the two patient groups in terms of their status as new or returningpatients,χ2(1, 145) = .80,ns. However, for the returning patients in the tradi-tional waiting area, the group median for the number of previous visits was 4(57% having attended for at least 4 previous visits). For returning patients inthe nouveau waiting area, by contrast, the group median for the number ofprevious visits was 1 (84% returning for only their first time). Not surpris-ingly, the chi-square test revealed a significant difference in the number ofprevious visits made to the different waiting areas,χ2(1, 145) = 33.2,p< .001.

Diagnoses for patients were similar in both groups with multiple sclerosis,Parkinson’s disease, and epilepsy together accounting for approximately twothirds of patients. When possible, every patient attending during data collec-tion was included in the study. However, on the advice of a senior medicalconsultant, a few patients were excluded because of the disabling nature oftheir medical condition, such as advanced motor neuron disease. To deter-mine the equivalence of the two samples, both self-reported and medicallyjudged ratings of the pain, anxiety, and disability currently experienced weregathered. Each of these six measures was a single item based on a 7-pointLikert-type scale, ranging from 1 (none at all) to 7 (a great deal). For eachpatient, doctors also provided details of medical condition and treatment.Multivariate analysis of variance showed the two patient samples to be simi-lar in terms of self-reported and medically judged ratings of pain, anxiety,and disability, multivariateF(7, 123) = 1.67,ns. Table 2 provides the descrip-tive and univariate statistics for each of these six ratings where lower scoresindicate greater severity. These figures clearly demonstrate the equivalenceof the two patient groups with respect to both their demographic characteris-tics and their health status.

INSTRUMENTS

Information was gathered from patients using a structured interviewmethodology appropriate for the medical condition of many of the subjects.




The schedule for the interview consisted of five sections. Sections 1 and 2were completed at Time 1. Sections 3, 4, and 5, were completed approxi-mately 7 minutes later at Time 2.

Section 1 included biographical information (i.e., age, gender, and num-ber of visits made to the clinic) together with 7-point rating scales measuringself-reported pain, anxiety, and disability.

Section 2 consisted of an abbreviated version of Cox and Mackay’s (1985)Stress Arousal Checklist (SACL). The SACL comprises a set of unipolarmood-adjectives rated on 4-point scales (do not feeltodefinitely feel) derivedfrom a series of factor analytic studies to measure two fundamental aspects ofmood: self-reported stress and self-reported arousal. As reported by theauthors of the scale (Cox & Mackay, 1985), the SACL demonstrates goodreliability and validity with respect to the measurement of transient emo-tional states.Stressrelates to feelings of tension and hedonic tone, whereasarousalrelates to the person’s energy level and has to do with the physiologi-cal and behavioral states of attentiveness and wakefulness (Gotts & Cox,1988). Only the 20 highest loading items of the original instrument were usedto facilitate more rapid assessment of mood given the restricted time avail-able for interviews. Twelve items pertained to the stress factor (e.g.,nervous,distressed, peaceful, relaxed) and 8 to arousal (e.g.,lively, alert, tired,drowsy). Scoring followed the procedure set out in the user’s manual (Gotts& Cox, 1988), so that each item was scored 0 or 1 according to the presenceor absence of feelings associated with stress or arousal (with reverse scoring


TABLE 2Descriptive and Univariate Statistics (Health Status Ratings)

for the Two Patient Samples

Traditional NouveauWaiting Area Waiting Area

(n = 81) Area (n = 64)

Variable M SD M SD F(1, 129) p

Patient’s ratingDisability 4.58 1.97 4.17 1.83 1.43 .234Pain 4.42 2.45 5.04 2.13 2.22 .138Anxiety 3.79 2.03 3.79 2.11 .00 .992

Doctor’s ratingDisability 5.05 1.36 5.27 1.36 .81 .369Pain 5.75 1.6 6.12 1.25 1.96 .164Anxiety 4.70 1.60 5.02 1.37 1.57 .213



where appropriate) and the item scores summed. The maximum possiblescore for stress was 12 and for arousal was 8. The shortened version of theSACL demonstrated adequate alpha reliability coefficients at both data col-lection points, Time 1 (α = .91 for stress,α = .72 for arousal) and Time 2 (α =.91 for stress,α = .79 for arousal).

Section 3 comprised Fisher’s (1974) Perceived Environmental QualityIndex (PEQI) as a measure of affective appraisal. The PEQI consists of four-teen 7-point scales anchored by bipolar adjectives connoting at one end posi-tive and at the other end negative perceptions of the environment (refer toTable 3). A negative response was scored 1; a positive response was scored 7.

Section 4 included ten 7-point rating scales each requesting evaluation ofwhether a specific design feature (e.g., general layout, furnishings, and light-ing) added to or detracted from the overall pleasantness of the room (refer toTable 4 for complete details). An additional 7-point scale, ranging from 1(not at all satisfied) to 7 (completely satisfied), measured overall satisfactionwith the environment as a hospital waiting area. This single-item measurewas included to ascertain the extent to which subjects felt the environmentfulfilled the function for which it was built. On all these items, a high scoreindicated a positive evaluation.

Section 5 included an alternative version of the adapted SACL includingthe same items as in Section 2 but in a different order to minimize any mem-ory effects from completing the SACL previously at Time 1.

The physiological arousal (pulse rate) of subjects was recorded using adigital exercise pulse monitor (Elexis Pulse Coach 3). Pulse rate was mea-sured via a clip that fitted comfortably onto the earlobe. To ensure consis-tency, the pulse rate reading was always recorded after the clip had beenattached to the earlobe for 15 seconds. Pulse rate readings were recorded asbeats per minute.

PROCEDURE

Data collection was undertaken in the traditional waiting area some weeksbefore the clinic relocated. In the nouveau waiting area, it commenced 4weeks after relocation to allow time for staff to get used to their new workingenvironment.

Having registered with the receptionist on arrival and after finding a seat,patients were approached by the researcher and informed of the nature andpurpose of the study. Voluntary participation was then sought and absoluteanonymity assured. Patients’hospital reference numbers (as indicated on theclinic attendance list) were used to link questionnaires to information sup-plied by the medical staff.




Initial measures were taken at Time 1, which coincided with the subjectshaving been in the environment for approximately 3 minutes. The first mea-sure obtained was pulse rate, then Sections 1 and 2 of the questionnaire werecompleted. Subjects were then informed that the researcher would return inapproximately 7 minutes during which time the patient was left to take in theenvironment. When the researcher returned at Time 2, the pulse rate wasagain taken, and Sections 3, 4, and 5 of the interview schedule were thencompleted.

The entire procedure for each subject took approximately 12 minutes.Following the medical consultation, the doctors provided the requestedinformation on each patient’s health status by means of a single-page ques-tionnaire. In addition to the pain, anxiety, and disability rating scales, thisquestionnaire requested a diagnosis for the patient’s condition.

DATA ANALYSIS

All data were analyzed using the Statistical Package for the Social Sci-ences, Version X (SPSSX)(Nie, Hull & Bent, 1986). Prior to the use of para-metric statistical techniques, all data were checked for normality. Variableswith excessive skew or kurtosis were transformed using a square root trans-formation. To assist in interpretation, however, descriptive statistics arereported here in their raw form.

RESULTS

ENVIRONMENTAL APPRAISAL

Differences in appraisals of the two waiting area environments were ana-lyzed by the comparison of scores on the 14 PEQI items. A between-subjectsmultivariate analysis of variance, using scores on the PEQI items as depen-dent variables, revealed a significant multivariate effect for waiting area,F(14, 116) = 10.644,p= .000. Table 3 reports the univariate statistics for eachof the 14 ratings and shows that the two waiting areas were perceived inmarkedly different ways. Specifically, the nouveau environment was rated asbeing significantly morecolorful, positive, stimulating, attractive, relaxed,comfortable, cheerful, good, lively, bright, motivating, pleasant, andopen.Figure 3 represents these differences in profile form where the sample meansfor each waiting area are plotted along the horizontal dimension.




SELF-REPORTED MOOD AND PHYSIOLOGICAL DATA

The impact of the two waiting area environments on self-reported moodand pulse rate was examined by means of separate mixed analyses of vari-ance. Waiting area was the between-subjects factor in these analyses,whereas self-reported stress, arousal, and the pulse readings at Times 1 and 2constituted the within-subjects factors.

Although no significant effects were found on self-reported arousal, a sig-nificant Waiting Area× Time interaction was found on self-reported stress,F(1, 132) = 5.88,p = .017. Figure 1 depicts this interaction and shows that,although self-reported stress increased over time in the traditional waitingarea, it decreased across time in the nouveau waiting area. A separate inde-pendent samplest test was conducted to examine whether levels of self-reported stress differed between clinics at Time 1. The result was not signifi-cant,t(143) = .538,ns.

A similar Waiting Area× Time interaction was found with respect topulse,F(1, 136) = 5.83,p = .017. As Figure 2 shows, the tendency here is forpulse rate to increase over time in the nouveau waiting area while decreasingin the traditional waiting area. It should be noted, however, that separate,


TABLE 3Descriptive and Univariate Statistics

for Perceived Environmental Quality Index (PEQI)(Traditional vs. Nouveau Waiting Area)

Traditional (n = 81) Nouveau (n = 64)

PEQI Item M SD M SD F(1, 129)

Open - closed 5.30 1.76 6.03 1.57 6.26*Colorful - drab 3.60 1.90 5.97 1.53 60.61***Positive - negative 4.04 1.86 5.66 2.02 22.57***Stimulating - boring 2.89 1.70 4.64 2.11 27.68***Large - small 4.56 1.59 4.31 2.14 0.56 (ns)Attractive - unattractive 3.54 1.74 6.30 1.35 100.14***Relaxed - tense 4.40 2.03 6.05 1.73 24.67***Comfortable - uncomfortable 4.71 1.93 6.18 1.68 21.25***Cheerful - depressing 4.01 1.85 5.71 1.75 28.77***Good - bad 4.44 1.58 6.44 1.18 66.12***Lively - unlively 3.27 1.95 4.44 1.99 11.56**Bright - dull 4.26 2.01 5.58 1.69 23.83***Motivating - unmotivating 3.36 1.87 4.92 1.99 21.40***Pleasant - unpleasant 4.90 1.69 6.61 1.01 47.68***

*p < .05. **p < .01. ***p < .001.



independent samplest tests revealed pulse levels in the nouveau waiting areato be significantly higher than those in the traditional waiting area at bothTime 1—t(143) = 2.311,p < .05—and Time 2—t(143) = 4.332,p = .001.


Time 1 Time 2Time

Traditional waiting area

Nouveau waiting area

4.68

4.34

4.96

3.68

5.0

4.5

4.0

3.5

Sel

f-re

port

ed s

tres

s sc

ore

Figure 1: Interaction of Waiting Area × Time on Self-Reported Stress Score

Time 1 Time 2Time

77.82

73.30

80.34

71.42

Traditional

waiting areaNouveau

waiting area

81

80

79

78

76

75

74

73

72

71

77

Pul

se r

ate

Figure 2: Interaction of Waiting Area × Time on Pulse Rate



Thus, self-reported stress and pulse readings yielded discordant results—apoint that will be returned to in the discussion.

ENVIRONMENTAL EVALUATION

Satisfaction ratings for the two waiting areas, whether for the two envi-ronments as a whole or for specific features therein, were compared using abetween-subjects multivariate analysis of variance. A significant multivari-ate effect for waiting area was revealed,F(11, 114) = 13.663,p = .000. Table4 reports the descriptive and univariate statistics for each of the 11 ratingsgiven and shows that the nouveau waiting area was rated more favorably in


Closed

Negative

Boring

Small

Unattractive

Uncomfortable

Depressing

Bad

Unlively

Dull

Unmotivating

Unpleasant

Open

Colorful

Positive

Stimulating

Attractive

Comfortable

Cheerful

Good

Lively

Bright

Motivating

Pleasant

Large

Relaxed

Drab

Tense

1 7

Mean PEQI item score

Traditional clinic waiting area

Nouveau clinic waiting area

Figure 3: Traditional and Nouveau Waiting Area Profiles on the Bipolar Adjec -tives Used to Measure Environmental Affect (Perceived EnvironmentalQuality Index)



terms of its layout, color scheme, floor covering, curtains, furniture, lighting,pictures, and plants. It also received a greater overall satisfaction rating. Nosignificant differences were perceived in temperature or provision of infor-mation. Figure 4 represents these results in profile form where the samplemeans for each waiting area are plotted along the horizontal dimension.

CONTROLLING FOR INTERVENING VARIABLES

Controlling for the number of visits made to each waiting area throughanalyses of covariance made no difference to the pattern of results reportedhere. This fact together with the equivalence of the two samples on self-reported and doctors’health-profile ratings strengthen the probability that allof these reported differences between the two waiting area environments inappraisal, mood, satisfaction, and physiology reflect real differences ratherthan spurious ones.

LINKING APPRAISAL TO MOOD,PHYSIOLOGICAL STATE, AND SATISFACTION

To identify exactly how environmental appraisal might be related to self-reported mood, physiological state, and satisfaction, PEQI items were factoranalyzed for the entire sample to reveal the existence of any underlyingdimensions. These factor scores were then correlated with self-reported


TABLE 4Descriptive and Univariate Statistics for Satisfaction Ratings

(Traditional vs. Nouveau Waiting Area)

Traditional (n = 81) Nouveau (n = 64)

Item M SD M SD F(1, 129)

General layout 4.53 1.74 6.07 1.58 26.87***Color scheme 3.53 1.91 6.19 1.40 79.17***Floor coverings 4.92 1.73 6.61 0.89 47.05***Curtains 5.16 1.60 6.47 1.33 25.07***Furniture 3.97 1.98 6.37 1.42 61.17***Lighting 4.31 1.84 6.48 1.23 60.32***Temperature 5.03 1.50 5.44 2.02 1.63 (ns)Pictures 3.58 1.82 5.81 1.70 50.59***Plants 5.13 1.81 6.40 1.09 22.79***Information 5.33 1.83 5.40 1.78 0.05 (ns)Overall satisfaction 5.16 1.54 6.21 0.93 21.59***

*p < .05. **p < .01. ***p < .001.



mood, pulse, and satisfaction to assess both the degree of associationbetween them and their suitability for use in a series of multiple, linearregression analyses. Table 5 reports the results of the principal componentsanalysis for the PEQI. Oblimin rotation was used, as it was not assumed thatany factors would be orthogonal. Factor 1 is essentially concerned with asense ofgoodnessand is therefore termed Agreeableness. Factor 2, on theother hand, is essentially to do with the arousing nature of the environmentand is accordingly labeled Arousing Potential. Factor 3 contained the singleitem, large.

As would be expected from the comparison of individual items (see Table3), the one-way, between-subjects multivariate analysis of variance withmultiple dependent measures (i.e., the three factor scores) revealed a signifi-cant multivariate effect for waiting area,F(3, 126) = 33.00,p < .001.


Adds toDetracts from

General layout

Color scheme

Floor covering

Furniture

Temperature

Pictures

Plants

Overall satisfaction

Traditional clinic waiting area

Nouveau clinic waiting area

Curtains

Lighting

Information

1 7

Mean satisfaction rating

Figure 4: Traditional and Nouveau Waiting Area Profiles on the SatisfactionRatings



Examination of the univariate statistics showed this effect to be common toboth the Agreeableness factor,F(1, 128) = 78.68,p < .001, and the ArousingPotential factor,F(1, 128) = 57.68,p < .001, but not to the single-item largefactor,F(1, 128) = .56,ns. Because of the possible unreliability of a single-item, self-report predictor measure and, in an effort to maximize the ratio ofpredictor variables to number of subjects, this last factor was dropped for thesubsequent correlation and regression analyses.

Table 6 details the intercorrelations between the two remaining factorscores (Agreeableness and Arousing Potential), self-reported mood, pulse,and satisfaction. From Table 6, it can be seen that greater Agreeableness isassociated with lower self-reported stress, higher self-reported arousal, andhigher pulse readings. Arousing Potential is similarly associated with self-reported stress and self-reported arousal but shows no significant associationwith pulse. The existence of these various correlational relationships justifiesthe use of multiple linear regression analyses to determine the predictivepower of the affective appraisal variables. In each regression analysis,


TABLE 5Item-Factor Loadings and Summary Statistics for Principal Components

Analysis of Fisher’s (1974) Perceived Environmental Quality Index

Factor Loadings

Items Factor 1 Factor 2 Factor 3

Agreeableness Arousing Potential

Good .896Comfortable .779Relaxed .768Pleasant .755Attractive .737Positive .664Lively .902Motivating .827Stimulating .561Cheerful .464Large .949Eigen value 5.317 1.063 1.033% variance accounted for 48.3 9.7 9.4

NOTE: Kaiser-Meyer-Olkin measure of sampling adequacy = .881; Bartlett’s test of sphericity =682.685, N = 132, p < .001; subject:variable ratio = 12:1; rotation: Oblimin; extraction rule: Kaiser 1;criterion for item-factor loading: to exceed .4; items discarded due to low communality (< .03), lowanti-image correlation (< .05), or crossloading: colorful, bright and open.



Factors 1 (Agreeableness) and 2 (Arousing Potential) were entered simulta-neously in a single block.

The regression of self-reported arousal onto the two environmentalappraisal factors revealed that only the Arousing Potential of the environ-ment made a significant, independent prediction as shown in Table 7. Self-reported arousal scores increased as the perceived Arousing Potential of theenvironment increased (β = .275,t = 2.505,p = .05).

For self-reported stress, it was the Agreeableness factor that made a sig-nificant independent prediction as shown in Table 7. Self-reported stressscores decreased as the agreeableness of the environment became more posi-tive (β = –.411,t = –3.86,p = .001).

Neither appraisal factor made a significant, independent prediction ofpulse rate as can be seen in Table 7. Cumulatively, however, they did show aweak association (R2 = .039,F = 2.584,p< .1) with the Agreeableness factormanifesting the stronger relationship (β = .185).

Finally, the overall satisfaction rating given for the waiting area wasregressed onto the two appraisal factors. As shown in Table 7, both factorswere found to make a significant, independent prediction (Agreeablenessβ=.457, Arousing Potentialβ = .219) with 38% of the variance in satisfactionratings being accounted for by their cumulative impact.


TABLE 6Intercorrelation of Study Variables Considered

for Use in Regression Analyses

Variable 1 Variable 2 Variable 3 Variable 4 Variable 5

Variable 1Agreeableness 1.000

Variable 2Arousing Potential .669** 1.000

Variable 3Self-reported stress

at Time 2 –.358** –.179* 1.000Variable 4

Self-reported arousalat Time 2 .178* .229** –.186* 1.000

Variable 5Pulse at Time 2 .196* .122 .031 .032 1.000

Variable 6Overall satisfaction .593** .534** –.265** .086 .032

*p < .05. **p < .01.



DISCUSSION

Set within the general proposition that a softening of hospital designmight help to buffer the stress known to accompany attendance at hospitalsand other health care facilities (Ingham & Spencer, 1997; Ulrich, 1991),three specific hypotheses were tested in this article. These were that thedesign of the so-called nouveau waiting area would be associated with (a)more positive affective appraisals of the waiting area, (b) more positivemoods, and (c) more positive evaluations of specific and identifiable designfeatures. The data presented in this article offer strong and consistent supportfor all three hypotheses.

With respect to affective appraisal, the difference between the ratingsgiven for each waiting area was statistically significant on all but 1 of the 14dimensions used with the nouveau waiting area being perceived more posi-tively each time. In terms of the results of the principal components analysis,the nouveau waiting area was appraised as being generally more agreeablethan the traditional waiting area and as having a more positive arousingpotential. That this more positive image of the nouveau waiting area is


TABLE 7Environmental Appraisal Factors

as Predictors of the Dependent Variables

Dependent Variable t R R2 Adjusted R2 F

Self-reported arousalAgreeableness .006 .053 (ns)Arousing Potential .275 2.505*

.279 .078 .063 5.220**Self-reported stressAgreeableness –.411 –3.860***Arousing potential .079 .747 (ns)

.367 .135 .121 9.638***Pulse rateAgreeableness .185 1.671 (ns)Arousing Potential .018 .167 (ns)

.197 .039 .024 2.584(ns)Overall satisfactionAgreeableness .457 5.057***Arousing Potential .219 2.419*

.617 .380 .370 37.742***

*p < .05. **p < .01. ***p < .001.



associated with a more positive emotional response is evidenced by thedecrease in self-reported stress over the waiting time in the nouveau waitingarea compared to the increase in self-reported stress in the traditional waitingarea. Importantly, however, the therapeutic impact of the nouveau environ-ment is demonstrated not only by its relationship with decreasing self-reported stress but also by its association with increasing pulse rate. Thisincrease in pulse rate observed in the nouveau waiting area is entirely in ac-cord with the appraisal of that environment as having a greater arousingpotential.

It is important to remember in this context that the restorative aspect ofenvironmental design is not limited to recovery from states characterized byexcessive psychological and physiological arousal (Ulrich et al., 1991).Rather, restoration also applies to recuperation from understimulation orexcessively low arousal (Ulrich, 1981, 1983; Ulrich et al., 1991). As Olsen(1978) and Leventhal et al. (1982) pointed out, in this respect, the commonlycommunicated message of many traditional hospital designs is one of steril-ity and passivity. In marked contrast to this, the image communicated by thenouveau waiting area was evidently one of lively stimulation. Attention tointeresting and enjoyable mental stimuli has been linked to physiologicalmobilization (Lundberg, Melin, Holmberg, & Evans, 1990) with mentalproblem solving and information manipulation, in particular, having beenshown to produce an increase in heart rate (Lacey & Lacey, 1970).

Notwithstanding the anxiety and mental strain known to accompany anymedical consultation (Ingham & Spencer, 1997), the characteristic responseto the nouveau environment can therefore be summarized as one of pleasantsurprise, that is, a positively toned emotional reaction coupled with a verymild startle response. The likelihood is, then, that the nouveau environmentwas more engaging than the traditional waiting area thereby providing moreof a distraction to those waiting there. The beneficial effect of the nouveauenvironment is accordingly evident in the convergence of a positively tonedemotional response and a rising level of physiological activity.

This line of reasoning also accounts for the significant difference in pulserates between the two samples at the time of their first reading. Given that, atthis point in time, the subjects had already been exposed to their respectivewaiting areas for approximately 3 minutes, the novelty aspect of the nouveauwaiting area may already have been operative. Furthermore, this interpreta-tion of the pulse rate data is in accord with empirical research into the speci-ficity of physiological responses to stress (e.g., Mason, 1971, 1974). Thisdemonstrates that the notion of an increased level of arousal being a general-ized and inevitable concomitant of stress (Selye, 1976) is an oversimplifica-tion (Bartlett, 1998) that does not fit much of the available data (Cox, 1978;




Cox & Ferguson, 1991). Rather, the exact nature of any physiologicalresponse to stress is deemed to be the product of both individual differencesand the precise characteristics and meaning of any particular stressor (Bart-lett, 1998). Thus, stress might be associated with either increased ordecreased levels of arousal depending on the precise circumstances.

However, the possibility cannot be ruled out that subjects in the nouveauclinic actually had higher baseline pulse rates to begin with. This could onlybe determined by measuring baseline pulse rate prior to entry into the clinic.Unfortunately, this was not pragmatically possible in the current study.

This Waiting Area× Time interaction with respect to both self-reportedstress and pulse rate supports Zimring et al.’s (1987) claim that the stress ofa hospital visit can be at least partially mitigated by a comfortably designedenvironment. It is also in line with Olsen’s (1978) results of a comparisonbetween a traditional surgical floor and a progressive care floor. Occupantsof the progressive care floor rated the environment to be more pleasant andcheerful and also perceived a more positive relationship between their settingand their mood.

More broadly, the Waiting Area× Time interaction demonstrates theimportance in environmental research of considering the possible interac-tions between physical and psychosocial elements—particularly, the possi-bility that one might buffer the impact or effect of the other (Evans et al.,1994; Evans & Lepore, 1992; Leather et al., 1998). Here, there is evidencethat the physical design of the waiting area did indeed buffer the negativeimpact of the stress known to build in the waiting room (Ingham & Spencer,1997).

Consistent with its overwhelmingly more positive environmentalappraisal, the nouveau waiting area received a significantly better evaluationon 8 out of the 10 design elements rated. Similarly, respondents reported sig-nificantly greater overall satisfaction with the nouveau waiting area. Theconsistency in the data between appraisal, emotion, and evaluation providesa degree of validation for a cognitively mediated model of emotion (Lazarus,1991; Ortony et al., 1988). In short, the emotions that are found to character-ize the waiting experience in the two environments are a valenced reaction tothe way in which those environments are construed. Put simply, differencesin these affective appraisals may generate different emotions and result indifferent occupancy evaluations.

In conclusion, the data reported here provide comparative and correla-tional support for the view that the physical design of the hospital environ-ment is an important and integral part of the therapeutic milieu (Reizenstein,1982). The negative imagery of the hospital that derives from a design ethicemphasizing the functional delivery of health care “often produces facilities




that are functionally effective but psychologically ‘hard’ ” (Ulrich, 1991,p. 97).

This conclusion is inevitably strengthened by (a) the demonstrated equiv-alence of the two patient samples in terms of their demographic character-istics, experienced pain, anxiety and disability, and medical diagnoses andjudgments; and (b) the inclusion of both psychological and physiologi-cal measures. There are limitations in the data, for example, the restrictionof range in the number of visits that could have been made to the nouveauwaiting area prevented a firmer test of any adaptation or halo effects. Never-theless, in systematically and rigorously evaluating the impact of the tradi-tional and nouveau waiting areas, the study offers preliminary empiricalevidence in place of the usual anecdote and often-unsubstantiated opinion(Reizenstein, 1982).

The implications of the study are clear. First, it is possible to create a morepositive hospital image. Second, the creation of this image does not necessar-ily entail any structural changes being made to existing buildings. Rather, itcan be achieved relatively quickly and simply by making changes to suchinterior design features as lighting, color scheme, and furnishings. However,it must be acknowledged that the focus of this article on the overall image ofthe waiting area does not allow precise identification of the relative impor-tance of individual design elements. The manipulation of individual ele-ments needed to achieve this was not possible in the current study. Third, thewaiting area is a particularly important site to consider for refurbishment, notleast, because it is here where anxiety and worry about the consultation andpossible treatment regimes are likely to build. It is here, too, where firstimpressions are formed (Ingham & Spencer, 1997). Finally, the results of anysoftening of the traditional hospital image are not confined to subjective out-comes such as mood and satisfaction but are also likely to embrace physio-logical indexes. Other nonclinical factors, such as waiting times and staffattitudes and behavior, will undoubtedly play their part in determining theoverall impact of the hospital on the patient, but the role of the physical envi-ronment should not be underestimated.

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