nature’s influence on hospitalized patients’ health outcomes -rakan ayyoub m-arch 2015
TRANSCRIPT
Rakan W. Ayyoub, Assoc. AIA
Nature’s influence on
hospitalized patients’
Health Outcomes Abstract
This literature review aims at reviewing the most relevant body of breaking research
from the 1980s until this day in time in the field of nature’s influence on patient’s
health outcomes. It will try to evaluate, critique, and propose an area of
investigational expansion based on the deficiencies that the literature provides.
Nature’s influence on hospitalized patients’ Health Outcomes
1
Table of Contents 1. Introduction ............................................................................................................................................... 2
2. Current research concepts in academia ................................................................................................ 4
A. Viewing Nature positively impacts recovery time. ...................................................................... 4
B. Nature depicting photography may affect patient and staff satisfaction .................................. 6
C. Effects on patients’ stress, anxiety, and perception ...................................................................... 7
D. Testing for evidence of pain reduction ........................................................................................... 8
E. The Hospital Garden ......................................................................................................................... 9
F. Uses of Media and Virtual Reality .................................................................................................. 9
G. The case of Indoor plants ................................................................................................................ 11
H. Most Recent Studies ........................................................................................................................ 13
3. Relationships between various researches, criticism and future propositions .......................... 14
Bibliography ................................................................................................................................................. 16
Nature’s influence on hospitalized patients’ Health Outcomes
2
1. Introduction
ith the changing face of the healthcare environment, the looming age of built hospitals,
the introduction of the affordable care act, and the aging of baby boomers, millions of
American patients will require access to quality healthcare in the coming years.
“Since the Affordable Care Act was signed into law in March 2010, the health care industry
has gained nearly 1 million jobs—982,300, to be more precise—according to Bureau of Labor
Statistics estimates released on Friday.” (Diamond, 2014)
“This year, the last of the baby boomers turn 50. The oldest are on the cusp of 70. As people
born between 1946 and 1964 are getting older and becoming a predominant health care
demographic, facility designs are responding to their needs and expectations”. (Eagle, 2014)
The trustworthiness of nature as a positive health outcome has been fairly well studied in
many contexts other than hospitals and generalized healthcare settings. Nature exposure is
backed by strong evidence on the way it positively affects stress recovery, attention
W
Nature’s influence on hospitalized patients’ Health Outcomes
1. Introduction 3
restoration, significant reduction in fear, anger, and a major influencer of feelings of
wellbeing.
It is known by many researchers and authors that humans evolved around the natural
landscape, and that our evolutionary adaptations stemmed mainly from natural stressors.
The tactical urbanization and the sequential removal of humans from the natural
environment has impacted humans in many ways, including their healing abilities. This
idea was well understood as early as the 19th century by many U.S. political movements,
which thereafter influenced the creation of many Parks and Gardens around the United
States, where New York’s, Central Park is one of the most famous until this day.
The Long-term goal of this review is to reevaluate where we currently are in the research
process. The Objective here is to show that it is worthwhile to further investigate this poorly
understood body of knowledge.
The central hypothesis lies in the fact that exposure to natural environments - indoors and
outdoors - by patients, positively improves their overall post-operative wellbeing, in the
form of increased pain tolerance, decreased anxiety levels, decreased fatigue, shorter
hospitalization periods, better mental wellbeing, and more satisfaction with their healthcare
provider. The rationale of this review stems from the fact that simple modifications to
healthcare environmental design can save millions, if not billions of dollars for both the
patients and healthcare providers by providing simple, non-intrusive methodologies to
increase general patient wellbeing and healthcare provider safety and accuracy.
This literature review aims at reviewing the most relevant body of breaking research from
the 1980s until this day in time. It will try to evaluate it, critique it and propose an area of
investigational expansion based on the deficiencies that it provides.
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 4
2. Current research
concepts in academia
A. Viewing Nature positively impacts recovery time.
“Roger Ulrich, previously at Texas A&M University, was the first to use the standards of
modern medical research—strict experimental controls and quantified health outcomes—
to demonstrate that gazing at a garden can sometimes speed healing from surgery,
infections and other ailments”. (Franklin, 2012)
In 1984, in his publication titled “View through a window may influence recovery from
surgery” Professor Roger Ulrich carried out a controlled investigation of the impact of green
views on surgical patients who have underwent a gall bladder surgery (Cholecystectomy).
Over a period of 9 years, samples were
taken out from records of patients staying
in the same rooms. The rooms were almost
typical with very similar setting and
dimensions. The same nurses who took care
of the patients in that period were kept in
mind. Most patients sampled were between
the ages of 20 and 69. Ulrich made sure that
most environmental variables were controlled, when he
even made sure that the sampled records were all taken in the period between May and
October of the corresponding years when foliage was present.
Figure 1 Patient Rooms in Study
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 5
The only variable that Ulrich made possible was the view through the windows of the
rooms, and what the hospitalized patients would see on a regular day. Two views were
chosen to be the subject of the study, a view of a brick wall, and another of a field containing
deciduous trees. See Figure 1 Patient Rooms in Study. (Ulrich R. , 1984)
The study used the records to match many patients according to their gender, smoker or
nonsmoker, weight classifications, nature of previous hospitalization, years of surgery,
room color and floor levels that the rooms were at. Ulrich Ultimately pared 46 patients into
groups containing 23 pairs. (Ulrich R. , 1984)
Ulrich went on further to construct data tables
on the number of hospitalization days for each
patient. The strength and frequency of
analgesics used per day such as
acetaminophen, non-steroidal anti-
inflammatory drugs and opiates was also
measured. The frequency and dosage of
antianxiety drugs, tranquilizers and
barbiturates administered was also monitored.
(Ulrich R. , 1984)
Then Ulrich went on to record any minor
complications suffered by the patients during
their hospitalization periods such as
headaches or nausea. And any notes taken by
the nurses about the patients in record and
were split into either positive or negative
notes. (Ulrich R. , 1984)
Data analysis was performed primarily by
defining the length of hospitalization which
was hence defined as the period between the
day of surgery and the day of patient
discharge. Ulrich used a research method
known as the Wilcoxon matched-pairs signed
ranks analysis, a statistical hypothesis test that is often used to compare matched samples,
which was the 23 pairs produced by Ulrich. Data analysis began to show that the average
hospitalization length for patients with the tree views was about 7.96 days compared to an
8.7 days of hospitalization for the patient with the brick wall view. The collected nurse notes
Figure 2 View From window to a brick wall
Figure 3 View to a green area
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 6
for each group of paired patients, showed statistically insignificant results, where 3.96
negative notes on average were collected for patients staying in the brick view windows,
compared to about 1.13 negative notes for patients staying in tree view windows. (Ulrich R.
, 1984)
Ulrich used another test known as the multivariate two-sample Hoteling test, to compare
the analgesic doses administered during the hospitalization period. There was a
significantly less use of the drugs in the rooms with the tree view when compared to the
rooms facing the brick wall. (Ulrich R. , 1984)
In his summary of results Ulrich stated that there was a significant reduction in the period
of hospitalization when comparing patient’s stating the two rooms, with a shorter
hospitalization period for the rooms with a natural view, and longer hospitalization for the
patients with the view containing the urban elements. The rooms with the tree view also
had fewer negative comments from the nurses, fewer doses of analgesics, and a slightly
lower score for any postsurgical complication. (Ulrich R. , 1984)
Ulrich by that time came to the conclusion that the design of the patient room should take
into consideration the views that the windows look out from. Ulrich stated that “These
cautions notwithstanding, the results imply that hospital design and siting
decisions should take into account the quality of patient window views.”
(Ulrich R. , View Through A Window May Influence Recovery From Surgery ,
1984)
B. Nature depicting photography may affect patient and staff
satisfaction
In 1986 Stephen Verderber, a professor at
Tulane University, investigated the views of
windows. Verderber went on to investigate
6 hospitals by creating a photo-questionnaire
and interviews for about 250 people. The
study aimed to psychologically study effects
of various windows, by examining the view,
the amount of daylight received, the sill
height and the aperture size. Verderber
went on to present pictures of another
hospital settings of physical medicine and rehabilitation environments (PMR) in different
Figure 4 Lone Cypress Monterey, CA
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 7
hospitals. The pictures were followed by various questioners on personal preference, rating
and satisfaction with the windows in their corresponding units. (Verderber, 1986)
Verderber came up with three dimensions for results of the analysis. These were the degree
of preference, degree of satisfaction and the associated behaviors with viewing the pictures.
He realized that window views that gave more information about what was going on
outside were much preferred, more satisfactory and were associated with more positive
behaviors than windows that did not give that information, or were windows that lacked
enough sill height, were far away from the viewer, or when the views where partially or
completely obstructed. (Verderber, 1986).
C. Effects on patients’ stress, anxiety, and perception
By the 1990s some research has been
conducted on patient anxiety in dental
clinics, questionnaires where given to
patients inside the clinics’ waiting rooms
on days when a large wall drawing was
depicting natural scenes, and on others
that did not. The studies showed a
significant reduction of stress during those
days. (Heerwagen, 1990).
Another research in the same year investigated the effect of pictures of different arousal
levels, for example natural scenes, or sailing, etc… The pictures were mounted on ceilings
above patients held in pre-surgical rooms. The study aimed to examine the relationship of
viewing these pictures and their effect on patients’ heart rate and the blood pressure. The
result were quite pleasing with a drop in both for some pictures, but it also showed that
some pictures were not appropriate for highly stressed individuals. (Coss, 1990)
A two year study conducted in 1990 studied the effects of visual stimulation on intensive
care unit ICU patients, and its effect on their postoperative general wellbeing. The studied
patients had undergone a heart pump open heart surgery. This kind of surgery was known
to cause some kind of brain disability and some perceptive impairments for about 60% of
the patients. The visual stimulation came in the form of natural views or abstract pictures
showing either curvilinear abstractions, rectilinear abstraction, white panels or no picture
whatsoever. (Ulrich & O. Lunden , 1990)
Figure 5 Patient being positively distracted
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 8
The study examined about one hundred and sixty patients in a Swedish hospital. The
pictures were randomly given to patients, and many reading for verbal, psychological and
behavioral patterns were recorded before and after the surgery.
Results of the study showed that patients who were shown pictures concerning nature and
water, showed less postoperative anxiety than most patients that were shown other
pictures. The highest anxiety levels was recorded with patients that were exposed to white
pictures or no pictures. (Ulrich & O. Lunden , 1990)
As the mental impairment of the operation was an issue, the patients usually after a few
days, sit for a visual and perceptual functioning test. The study showed that patients who
were exposed to the pictures with natural views, completed the test faster than all the other
groups. The slowest to complete the test were patients who were exposed to white pictures
or no pictures at all. (Ulrich & O. Lunden , 1990)
D. Testing for evidence of pain reduction
By 1992 more research was evolving in the field of pain reduction and nature viewing. In
one of the researches, it was scientifically accepted that analgesics seemed to not reduce
pain effectively for about 75% of patients who have been burnt. Scientist were studying how
distraction therapy, in particular positive distraction that came from natural scenes, can
affect pain reduction. Videos depicting natural scenes with background music, along with
varied analgesic doses, or no videos as a control, were shown to 17 patients randomly.
(Miller, Hickman, & Lemasters, 1992)
Patients who were to undergo a process of a burn dressing change, were given
questionnaires before and after the process, to rate the intensity of pain and anxiety. Using
the McGill questionnaire for a pain index, and a Spiel Berger questionnaire for anxiety
indexing data was generated and analyzed. (Miller, Hickman, & Lemasters, 1992)
The findings of the research showed that natural scenes significantly reduced pain and
anxiety, and it was suggested that doctors should always show these scenes during burn
dressing changes. (Miller, Hickman, & Lemasters, 1992).
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 9
E. The Hospital Garden
By 1995 as evidence on nature and positive health outcomes
was mounting, researchers moved to study the effect of
designing gardens in hospitals. Observing patient behavior
and doing interviews with patients was becoming a very
popular research methodology. By performing a post
occupancy evaluation of four hospital gardens in California
(Cooper-Marcus & Barnes, 1995) reached a conclusion that
patients that use these gardens as well as their families and
hospital staff, were significantly able to recover from stresses
and achieve a better mood. The gardens investigated had
many visually pleasing natural elements like trees and water
were strongly emphasized. (Cooper-Marcus & Barnes, 1995).
Natural hospital gardens seemed to also influence other health outcomes in patients, their
families and hospital staff by increasing social interaction giving them a sense of support,
and by reducing the stressful effects of the clinical environment. Research from collected
questionnaires show that hospital gardens, good window views throughout the hospital
were shown to dramatically increase the patient and family satisfaction with their
healthcare provider quality and service. (Whitehouse, et al., 2001). Whitehouse has studied
children’s hospitals and tried to understand weather concrete hardscapes played a positive
effect on children’s’ health outcomes, apparently children with avoided largely concrete
areas, and from the questionnaires many people stated that gardens with less hardscapes
were more favored.
F. Uses of Media and Virtual Reality
Research containing moving nature videos that were shown to studied individuals
continued within the early years of the current century, when some soundless video tapes
were played depicting natural scenes as opposed to motionless nature images. The 46
studied individuals were healthy people that have undergone a pain inducing procedure.
Pain tolerance in the studied individuals was significantly higher for the group that
watched the motion videos. It was later suggested that nurses should use natural visual
stimulus to increase pain tolerance in various patients. (Tse, Ng, Chung, & Wong, 2002)
Wall mounted Television sets that played natural videos on various days in blood donation
rooms, apparently showed a significantly lower blood pressure and pulse rates for donors
Figure 6 Walking Though a
Hospital Garden
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 10
when the natural videos where playing as opposed to when they were not. (Ulrich, Simons,
& Miles, 2003)
Distraction therapy by using natural
sights and sounds was also
researched on patients during flexible
bronchoscopy (FB). Murals showing
natural scenes were placed near the
patient beds during the imaging
process, and natural videos that had
sound were played before and after
the procedure. Control group
patients didn’t receive any of these
distractions. A multivariate ordinal
logistic regression model that gave a pain index of 1 to 5 for patients where one is high pain
and 5 significantly less pain. (Diette , Lechtzin, Haponik, Devrotes, & Rubin, 2003)
It was clear from the study that the patients suffered less pain when shown the scenes. It
was advised that doctors use this “non-intrusive strategy” along with analgesic
administration to increase pain tolerance in FB procedures. (Diette , Lechtzin, Haponik,
Devrotes, & Rubin, 2003)
Building upon the previous works, more investigation of the use of virtual reality (VR)
techniques in hospitals were on their way, when 123 patients undergoing chemotherapy for
breast, colon and lung cancer were virtually walked through a forest while in the comfort
of their beds. The visual reality scenes engaged hearing this time when sounds of birds were
played along the journey. Adapted Symptoms Distress Scale-2, Revised Piper Fatigue Scale,
and State Anxiety Inventory tests were used to measure the patients’ distress symptoms.
(Schneider & Hood, 2007)
It was evident from the study that virtual reality influenced a shorter time perception for
the chemotherapy treatment as opposed to patients that did not use the VR technique.
However the findings stated that although chemotherapy was shown to feel shorter in
duration, the study did not have significant improvement on chemotherapy post treatment
symptoms. (Schneider & Hood, 2007).
Figure 7 Patient using virtual Reality distraction techniques
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 11
G. The case of Indoor plants
It was shown in previous research that
indoor plants had an influence on
reducing indoor pollutants,
improving indoor air quality,
increasing relative humidity to human
comfort levels inside buildings,
reduction in mold spores, and
airborne microorganisms.
Research on nature and its effects on
patients extended to the study of flora
and fauna inside patient rooms. In one
study, random clinical trials with 90 patients recovering from appendectomy were carried
out. Some patient rooms had indoor plants and some others did not. The researchers went
on to collect data about vital signs, pain index, distress, fatigue, and anxiety after the
operation. The researchers also collected questionnaires from patients. The research
showed a significant reduction the amount of postoperative analgesics, lower blood
pressure, lower hear rate, higher pain tolerance, less anxiety and fatigue, with an increased
feeling of satisfaction about their rooms. (Park & Mattson, 2008)
Another research that was carried out later in 2009 researched another set of 80 female
patients that were recovering from thyroidectomy. The research also involved studying
effects of viewing 12 different indoor plants including floral plants on various data sets after
the surgery. The researchers went on to collect data about vital signs, pain index, distress,
fatigue, and anxiety after the operation. The researchers also collected questionnaires from
patients. The setting was an 809 bed university affiliated hospital in the suburbs of South
Korea. (Park & Mattson, 2009)
The study needed many approvals from various regulating bodies due to the fact that
patients’ medical history would be studied. As the approvals were obtained different
patients were assigned to different rooms containing plants. The patients studied were all
healthy individuals between the ages of 19 and 59. The rooms studied were situated on the
Figure 8 Positive Impact of Indoor Plants
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 12
same floor, and on the same side of the building. The windows of these rooms mainly
showed the sky with no significant view of anything outside. (Park & Mattson, 2009)
The typical study that was performed included collection of data on the length of
hospitalization, the amounts and types of used analgesics, data about vital signs, pain
intensity index, pain distress data, anxiety and fatigue readings (PPAF). The study also
collected a State-Trait Anxiety Inventory Form Y-1 (STAI-Y1), and Environmental
Assessment Scale (EAS) and a patient room satisfaction questionnaire (PRQS). (Park &
Mattson, 2009)
Significant shortening in the hospitalization period was evident from the results that
showed a 6.08 day hospitalization period for the patients that had plants in their rooms as
opposed to a 6.39 days for patients that didn’t. A significant difference in analgesic intake
was shown in the 4th day to the 5th day after the surgery, where plant exposure resulted in a
lowered analgesic dose compared to the control group. Vital signs were not different in both
groups, however using the PPAD and SATI-Y1 tests the recorded values for fatigue, pain
and anxiety were considerably decreased with the presence of plants. (Park & Mattson,
2009)
The Environmental Assessment Scale for both groups were also different, were patients
with plants in their rooms reported fragrances, and more pleasant visual engagement with
an increase in the feelings of comfort and calmness. 95% of patients PRQS questionnaire
indicated that plants were the most positive aspect of their room other than television, large
windows, sunshine, appropriate temperature. (Park & Mattson, 2009)
“Hospital patients with plants in their room display less fatigue and pain,
shorter hospitalization, less anxiety, and higher hospital and room
satisfaction.” (Park & Mattson, 2009)
Nature’s influence on hospitalized patients’ Health Outcomes
2. Current research concepts in academia 13
H. Most Recent Studies
One of the latest research in the field was done in a residential rehabilitation care center
in Røros, Norway. A longitudinal quasi-experiment was carried out for 278 patients
suffering from cardiac and pulmonary diseases. The study extended on Ulrich’s 1984
research and was set to measure the effects of a window view on various data readings.
The Scientists measured a Self-reported physical and mental health study (SF-12),
wellbeing of patients, their emotional state, and the level of using their private bedroom
and the contribution of leisure activities, such as watching Television, walking and
engaging in social contact. The study looked at 3 different window views from different
patient rooms, showing different
“openness” to the natural
environment. A view that had a
“panoramic view “ with most green
open space on the outside, another
“partially blocked view” which had
some building in the way and a
“blocked view condition” as the
name indicates. (Raanaas, Patil, &
Hartig, 2012)
The patient which were mostly recovering from postoperative physical damage due to
either a cardiac operation “heart patients” and pulmonary operations “ lung patients”,
usually undergo a four week rehabilitation program within groups of 20 people.
(Raanaas, Patil, & Hartig, 2012)
By using the previously described tests, results showed that women with the blocked
view showed a negative effect on the overall physical health outcomes, were as for men
it seemed to mostly affect their mental wellbeing. “Lung patients” Patients that had a
“panoramic view “slightly improved their metal wellbeing than “heart patients”. There
seemed to be a tendency for those patient with a “panoramic view “to spend more private
time in their rooms than any other studied groups. (Raanaas, Patil, & Hartig, 2012)
“An unobstructed bedroom view to natural surroundings appears to
have better supported improvement in self-reported physical and mental
health during a residential rehabilitation program, although the degree
of change varied with gender and diagnostic group.” (Raanaas, Patil, &
Hartig, 2012)
Figure 9 Panoramic Patient Room Views
Nature’s influence on hospitalized patients’ Health Outcomes
3. Relationships between various researches, criticism and future propositions 14
3. Relationships between
various researches,
criticism and future
propositions
By examining the previous body of research on the topic, it can be clearly seen that there
is a true effect of nature on the health outcomes of patients. Research has progressed
pretty well over the past two decades, however some questions may be drawn from the
research. For instance the researches that dealt with windows did not take the view angle
into account, nor did they mention any climatic weather influences during the long years
that many of the studies were executed. There also seemed to be a lack of a more major
surroundings description and changes to the overall built environment that can be
perceived from the views. With the current technologies, we may be able to store more
information on weather, take hourly pictures of the views and reduce down the variables
to a considerable level.
Some of the researches also lacked a controlled environment when dealing with
photographs, there should have been a more precise starting point for how patients felt
before and after viewing the photographs. Viewing conditions such as lighting intensity
and color blindness or vision problems were not taken into account in the recorded data.
There seemed to also be a lack of description of the types of natural environments that
were depicted, what kind of vegetation was observed, what the green level of the
vegetation is. It would very helpful if future research dealt with these questions to
determine what separating and mixing plant types, for instance decides trees,
evergreens, shrubs, annuals, would basically do to the patients. And weather certain
plant species has a certain supremacy in promoting positive health outcomes than others.
Keep in mind that these questions can also be addressed for research dealing with indoor
plant, including flower types.
Nature’s influence on hospitalized patients’ Health Outcomes
3. Relationships between various researches, criticism and future propositions 15
I certainly believe that studies should also extend to different climatic settings, such as
deserts and other less green areas, due to the fact that many of the performed studies
were carried out in relatively green areas. It would also be beneficial to start studying
patients from a variety of different cultures, backgrounds and races were various racial
adaptations may respond better to certain climatic variations than others.
There is a strong evident relationship between what can be seen by the eyes and what
the body will act as a response. Starting with the earliest research that involved looking
through different window scenes, photography, views of nearby plants, media and
virtual reality, the most focus of research is based on visual stimuli and to some extent
on auditory stimulus. Most of the reviewed research does not provide a prescription for
smell, touch, and sometimes taste. It is argued by Ulrich that nature engagement should
be an immersive sensory experience that engages all the senses.
It is a question of creating future research that tests each sense individually or a mixture
of all the senses that remains open to questioning, can mixtures of different sensual
stimuli be more beneficial that other ones.
One of the major question that comes to mind when reading the results of most of the
research out there is that why do such effects happen on a psychological and
physiological level in the brain and in the body. I would believe that the next
breakthrough in dealing with this topic is to develop research that investigates the
physiological method of action when dealing with nature, rather than just research than
describes outcomes in general.
Nature’s influence on hospitalized patients’ Health Outcomes
Bibliography 16
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17
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Nature’s influence on hospitalized patients’ Health Outcomes
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Media Bibliography
Front Cover Page 1:
http://www.ucsfmissionbayhospitals.org/images/article/firstclass_side_1.jpg
Lone Cypress Page 2: Photographed by Scott Hampton
https://www.flickr.com/photos/scotthamptonphotography/15428318106/in/photolist-pvmasA-mrJrMa-7Jwf56-qeW34u-j4ozdw-oxKHKM-rD2XJU-hAGyNt-hAGuY4-
hAHhFL-hAHm6G-hAHpBE-9EZC2J-pgZMmu-6JLDfH-gmjJxn-79sS5U-gmjdqF-scban-hAMq8c-iLivht-gmjfLx-c9c8md-5yzkMm-ghfLL-9WKc5Z-pxSxyE-48svwc-
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bLKgEa-nkMW42-cVCeV9
Flower Background Page 4: Photographed by Paul N, https://www.flickr.com/photos/98212880@N05/13747645465/in/photolist-mWQh36-fscYL7-cSMdc7-eCJN4T-9rDkis-ocmUbW-9PJ2id-i9pmPv-82hb72-dENgNM-
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7JnhV3-5x5Mtv-iMGSbm-gigNqs-28Mktg-dMAkCP-fPSJLX-dvNLwy-9c53Ag-egNVX3-5WXpHZ-b7HAgc-omVj45-cbHFNs-gbS6bC-bX6Y1i-nJjvDe-6HRVpY-
5nUoKk-dP7gYS-mHyHB1
Figure 2
http://www.google.com/imgres?imgurl=http://4.bp.blogspot.com/-
TLpBuNk5D50/UzfpS7rQIuI/AAAAAAAABtc/SIJpVmQbNm4/s1600/brick%252Bwall%252Bview.JPG&imgrefurl=http://sherpasheppard.blogspot.com/2014_03_01_ar
chive.html&h=1200&w=1600&tbnid=bO4rPcSmOFa6IM:&zoom=1&docid=71w8W5eFPYV4BM&ei=guFJVePeDcmdsAWy-
IB4&tbm=isch&ved=0CB0QMygAMAA&biw=944&bih=656
Figure 3
http://www.summerinitaly.com/images/photos/houses/1745_L12147_59653.jpg
Figure 4
https://www.flickr.com/photos/scotthamptonphotography/15428318106/in/photolist-pvmasA-mrJrMa-7Jwf56-qeW34u-j4ozdw-oxKHKM-rD2XJU-hAGyNt-hAGuY4-
hAHhFL-hAHm6G-hAHpBE-9EZC2J-pgZMmu-6JLDfH-gmjJxn-79sS5U-gmjdqF-scban-hAMq8c-iLivht-gmjfLx-c9c8md-5yzkMm-ghfLL-9WKc5Z-pxSxyE-48svwc-
2A5yq9-fxYLZ-48sv2H-pez5m5-pw2DtU-97nDN7-5wDwwQ-7L8oyd-peyuAw-8TLeLs-b5jPRT-cwouHL-ZWwcr-4twciM-rqQ7t8-qNnaZc-rsAeSW-c2eDx7-ayUnUp-
bLKgEa-nkMW42-cVCeV9
Figure 5: Photographed by Kiril Pipo
https://www.flickr.com/photos/129903485@N07/16231303258/in/photolist-qJiEYb-6oEegV-7CBrEG-7Ca5rS-6pcTsR-6pbjxM-jC1Hbd-amo8VJ-9TYnRu-dWV2eq-
95JaQm-6pftSy-ngkdSt-9H8mdd-5hRFou-648ghe-dvTkSt-aCwJVi-8h6GwY-nLGavg-85C4Tu-ejg9BQ-q679V6-6ZiKVz-3bzR4Q-bUM9mG-7wmHKY-9DaFH1-6Yx98H-
pcGauu-rYyWLP-r2yGu1-qNu4QV-3yEcoQ-r2yGDE-QUUzB-a2gxJp-8oP9TF-95F8gZ-6Gzzjj-asBjT7-8AQSHz-qFjzdN-5n7KMd-76LznF-75Knkc-75Knjn-75Knir-
9EMfZH-ffzkAm
Figure 6
http://www.google.com/imgres?imgurl=http://www.stchristophers.org.uk/sites/default/files/photos/patients_inpatient_garden.jpg&imgrefurl=http://www.stchristoph
ers.org.uk/patients/inpatientservices&h=350&w=300&tbnid=Xdj4_s2FGiNzgM:&zoom=1&docid=W1YVNoFy2FQWRM&ei=m7xKVbjKF4LFsAXx14HoCQ&tbm=isch
&ved=0CCQQMygHMAc&biw=1920&bih=935
Figure 7
Nature’s influence on hospitalized patients’ Health Outcomes
Media Bibliography 19
http://www.google.com/imgres?imgurl=http://www.gazette.uottawa.ca/wp-content/uploads/2015/01/patient-virtual-
reality_RESIZED.jpg&imgrefurl=http://www.gazette.uottawa.ca/en/2015/01/using-virtual-reality-to-relieve-symptoms-of-parkinsons-
disease/&h=586&w=1024&tbnid=RSXvB6XOntSQOM:&zoom=1&docid=BL9oIDtXHihI4M&ei=UL1KVdHJMMfSsAWEmoH4BQ&tbm=isch&ved=0CEkQMygiMCI&bi
w=1920&bih=935
Figure 8
http://www.google.com/imgres?imgurl=http://s.hswstatic.com/gif/cut-flowers-hospital-1.jpg&imgrefurl=http://health.howstuffworks.com/mental-health/human-
nature/health-myths/flowers-in-
hospital.htm&h=240&w=360&tbnid=G3DguhbbmH10bM:&zoom=1&docid=eHPvSwMmH0yKUM&ei=Ar5KVbzCD8HutQXP64GIBA&tbm=isch&ved=0CC0QMygQ
MBA&biw=1920&bih=935
Figure 9
http://madeintheshadebf.com/wp-content/uploads/2012/12/Treating-Windows-Without-Blocking-the-View.jpg
Flower Background Page 14: Photographed by Barry
https://www.flickr.com/photos/ennor/1550894688/in/photolist-3n3JXA-f9FgE1-8cV7tM-7rViA-fxugM1-9aoG21-czMzfy-7GcRpt-8bdbbE-okJBrJ-onLtdn-dbyWcb-
9E3bH7-p1PjE2-awK3uH-jKmo6W-qzDWVm-oFWh5K-dU544K-eFQVQb-9xwKFY-78nRnz-fV9ExE-k9MBLc-chYtqu-nrAVuX-qGWRny-chywjy-onLsYV-9RCK9j-
oxAd9Y-gaVgCC-6RoU37-pNsw5R-6hpmZV-DFzFL-qbquvg-gaVmxu-cMKJzh-99HVzW-oncmbo-5DvuRM-4APU1-nW6nEd-93KEcB-nxX1Md-d7eT1E-8mwom4-
ms3KPD-aFEBmM