Expert's Corner

Published in Issue 3, 2011.

Part one of this two-part series discussed behavioral economics as a sub-discipline of economics concerned with how people make decisions.  Behavioral economics concepts are furthered by brain imaging research conducted by those in the field of neuroeconomics.  Also in part one, “Choice Architecture” was introduced as a system for improving group outcomes through strategies that help people overcome their natural short term thinking, including suggestions to address NIMBYism and to increase the likelihood of positive stakeholder meetings.  

In part two, I review behavioral economics and neuroeconomics concepts that can assist designers and planners with stakeholder selection of optimal alternatives, stakeholder acceptance of mitigation measures, understanding large scale proposals, and improving long term decision making. (References to the behavioral economics and neuroeconomics work from researchers Tsversky, Kahneman, Thaler, Sunstein, Gilbert, Bar, Peters, Buchel and Ariely appear at the end of the article.)

Conundrum in the Cornucopia of Alternatives
In stakeholder meetings it can become difficult to gain consensus to eliminate alternatives from consideration.  People resist narrowing down a list of alternatives because they become attached to many of the ideas.  This is loss aversion at work. People often want all or many of the alternatives kept on the table, even though in the end, only one or a few can be implemented.  People also resist narrowing down the list of alternatives even though the window of opportunity for some of the best alternatives may be lost while multiple alternatives are still being explored.

Another factor is ownership bias, which applies to ideas as well as tangible things.  People are reluctant to part with ideas, especially their own.  This can make it difficult to take alternatives off the table.

“Choice Architecture” solutions for narrowing down alternatives:

• Utilize ranking systems to assist stakeholders in focusing on feasible alternatives, but take care to avoid peer pressure that could result in good alternatives being de-selected. For example, the very common “dot” exercise can result in peer pressure as people see others placing dots and are influenced by the opinions of others.  
• Instead, create evaluation matrices for the various alternatives in order to quantify short and long-term impacts.  This will aid in overcoming exaggerated fear associated with loss aversion, status quo bias and ownership bias.  (As explained in part one, loss aversion is a basic human heuristic: people hate losing something they have, so much so that losing something makes them twice as unhappy as the happiness they experienced when they first obtained that same thing.  Status quo bias is an extension of loss aversion.  People generally try to maintain their current situation, whatever it is, and will put up with significant inconvenience to avoid potential loss presented by change.  Ownership bias results from people’s attachment to the things they have, including objects as well as ideas.)
• Remind participants of the costs of keeping infeasible alternatives open, including the possibility that some of the best alternatives may be lost if decisions are not made timely.  This approach uses loss aversion as a tool in the process of winnowing alternatives.

  Lowest Common Denominator – Why Groups Choose Sub-optimal Alternatives
People tend to make choices based on comparisons of like things, and they tend to avoid trying to compare things that are dissimilar -- the “relativity” heuristic.  People will generally choose the “best” of several similar alternatives, and discard an outlier, which may actually be the best alternative.  Designers and planners need to take great care in structuring proposed alternatives so as to use the relativity heuristic productively.

Choice Architecture solutions to arrive at optimal decisions:

• Craft the presentation. Ensure that in the range of alternatives being examined, you have not created a likely front runner solely because it is the best of several similar alternatives, leaving a better but “unique” or different alternative as an orphan that will be discarded.
• Establish clear criteria to eliminate sub-optimal alternatives early in the process.
• Utilize “mapping” in the stakeholder process – provide overviews of the decision-making process to help participants understand when different levels of decisions will be made.  For example, use a a large flip chart agenda to cue participants as to when 1) ideas will be generated; 2) priorities and preferences will be identified; 3 )preliminary choices will be made;  and 4) final choices will be selected.

In the Eye of the Beholder – “Reasonable” Mitigation Proposals
Stakeholder groups often reject what appear to be reasonable alternatives.  Due to loss aversion, people value the things they have more than they value the things that someone else has.  This is demonstrated by the delta (difference) between what someone is willing to accept in payment for a thing versus what another person is willing to pay for that same thing, also referred to as WTA/WTP.  

Similarly, once a person has a particular object they don’t want to give it up, but if they don’t already have that same object they do not necessarily feel the need to obtain it.  This bias is true to such an extent that losing something makes people approximately twice as unhappy as the happiness they experienced when they first obtained that same thing.

Due to WTA/WTP, if community members or stakeholders perceive that a proposed plan or project will cause a loss to themselves or the community, the mitigation offered must be significantly more valuable than the perceived loss in order to be viewed as equitable.  

Secondly, people care about fairness, so much so that they will decline an offer of free money if they feel the offer is unfair. This has been demonstrated through behavioral economics experiments such as “the ultimatum game” in which one participant (the proposer) will receive a portion of $10 if he or she is able to get acceptance of the offer from the other participant (the responder).  The proposer selects the amount to be offered and the responder must either accept or reject the offer – no other communication is allowed.  If the responder rejects the offer, neither person receives any money.

In theory the responder should accept any offer above zero since the responder will receive nothing if they reject the offer; however, in practice, responders are influenced by “fairness” and will reject offers they deem to be too low, or “not fair.”  Neuroscientists observe through brain imaging that rejection of unfair offers is the result of a strong, negative emotional response rather than a deliberative thought process.  Emotional responses are not likely to be swayed by logic.

Designers and planners should take special care in situations where there seems to be  tradeoffs between people’s welfare that could trigger emotional responses. Two examples: 1) an action that benefits one person at the expense of others; or 2) a situation in which stakeholders believe there are limits to how much someone should be allowed to benefit at a cost to other people.  

The reference heuristic also plays a role in the evaluation of fairness because the current status quo (whatever it is in any given situation) becomes a reference point for the then-current participants to be “entitled” to an existing favorable arrangement.   So for example, changing access or cost of access for current beneficiaries of a public good or service (such as a public park) may be viewed as less “fair” than restricting access or increasing cost of access for those not presently in the equation.

Choice Architecture solutions for presentation and acceptance of mitigation proposals:

•    Establishing value for mitigation:  To overcome the WTP/WTA differential, any proposed mitigation has to be at least twice as good as the status quo to be seen as “equal” to status quo by stakeholders.  For example, if a new building project requires removal of a historic structure, mitigation to relocate that historic structure AND to improve the exterior facade of another historic building might be seen as equitable.  

•    Designers and planners need to take care when crafting mitigation measures to ensure the mitigation addresses anyone who will lose their current rights of access, or who will experience increased costs. Consider grandfathering in those who already have access or a favorable cost structure.  For example, funding building improvements at a community center through increased fees for future residents, while maintaining current fees for those who already participate, may be viewed as more fair than increasing fees for everyone.

•    Take care in structuring proposed mitigation; draft or “frame” mitigation to illustrate fairness.

Too Big to Grasp:  Why Stakeholders Reject Large Scale Proposals
When it comes to public-policy decisions, people exhibit predictable, but seemingly illogical, biases. They value a smaller scale service, such as upgrading emergency medical service equipment more than a larger public good, such as improving disaster preparedness.  Due to the relativity heuristic, human reaction to large dollar amounts or less tangible outcomes is generally less supportive because people generally have little experience to allow them place the large scale alternative in context. Scope insensitivity is a significant factor that must be taken into account in preparing information for public design and planning processes.

Choice Architecture Solutions to Scope Insensitivity:

• Present large scale proposals as itemized breakouts that include smaller scale specific projects that stakeholders can relate to.
• Frame each specific project or component as an essential part of the larger scope proposal.
• Utilize loss aversion to call attention to what will be lost if the comprehensive proposal is not adopted.

Decisions for Today vs. Ten Years from Now
Due to hyperbolic discounting, a.k. a. reward delay discounting, on average people naturally choose immediate rewards over longer term gains.  Bar, a neuroeconomist, observes that immediate and delayed rewards stimulate different parts of the brain, with immediate rewards triggering the brain’s emotional centers, while delayed rewards trigger areas of the brain dealing with reason.  

Emotions related to short term rewards win out disproportionately to reason-centered long term solutions.  For example, if you ask people who are not already committed to a regular exercise regimen whether they want to be healthy they will say “yes.”  If you ask them to pick an activity for today and one for next week, they will elect to PLAN to exercise next week and will select the immediate gratification of watching television or shopping for today. Alternatives that won’t yield results for years or decades are even more challenging due to reward delay discounting.  
Choice Architecture Solutions for Long-Term Decision Making
Expanding on neuroeconomics research by others, Bar postulates on how to counteract reward delay discounting by cueing people to imagine specific desired future events tied to their personal goals.  

According to neuroeconomists Peters and Buchel, when test participants were asked to visualize future events related to their receipt of future rewards, they were much less likely to choose short term rewards over long term goals and rewards.  In preparation for this experiment, individual participants were asked about their personal plans and goals.  Participants provided examples such as  vacations, weddings, education, or social and family events.  When the researchers cued the participants to  imagine one of these  personally relevant future goals or events, the areas of their brains associated with long term memory were activated in addition to the areas of the brain associated with decision making and predictions.  

The key concept for those designing public decision systems is that “appreciating the value of future rewards and the benefit of acting to obtain them relies on our ability to imagine the relevant future.”   

Here is a series of recommendations for designers and planners to help stakeholders focus on long term choices in the design of projects:

• Survey stakeholders about their future goals that might be supported through your design project (e.g. physical fiss, social interaction, family interaction, etc.)

• Help stakeholders imagine personally relevant future events and conditions as part of your design or planning process.
• Help stakeholders visualize the relevant future your plan or project proposes through drawings, photographs, video, computer simulation, etc.
• Most importantly, make it relevant to the stakeholders’ lives through association with the goals they stated at the outset.

Behavioral economics and neuroeconomics research provide much needed insight into seemingly irrational stakeholder responses and decisions.  Designers and planners can utilize “choice architecture” concepts and methods to obtain improved outcomes that result in more positive and productive stakeholder meetings as well as better long-term decisions. Improved decision making by the stakeholders in the design process results in better designed projects for the long-term.

Kathleen M. Fox is a registered landscape architect,  Fellow of the American Society of Landscape Architects, and executive director of the Ohio Cultural Facilities Commission.  A 2002 Loeb Fellow at the Harvard Graduate School of Design, she also holds a graduate certificate in Alternative Dispute Resolution from Capital University Law School and is author of the research paper Utilizing Behavioral Economics to Improve Public and Private Decision Systems in Community Planning and Development.  She can be reached at:  kfox@post.harvard.edu.          

References:

Dan Ariely. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York:
Harper Collins Publishers, 2008.

Moshe Bar. ”Wait for the Second Marshmallow? Future‐Oriented Thinking and Delayed Reward
Discounting in the Brain.” Neuron 66, 66, April 15, 2010.

Daniel Gilbert. Stumbling on Happiness.  New York:  Vintage Books, 2007.

Kurt Lewin. Field Theory in Social Science: Selected Theoretical Papers. New York: Harper &
Row, 1951.

Moshe Bar. ”Wait for the Second Marshmallow? Future‐Oriented Thinking and Delayed Reward
Discounting in the Brain.” Neuron 66, 66, April 15, 2010.

Daniel Gilbert. Stumbling on Happiness.  New York:  Vintage Books, 2007.

Jan Peters and Christian Buchel. “Episodic Future Thinking Reduces Reward Delay Discounting
through an Enhancement of Prefrontal‐Mediotemporal Interactions.” Neuron 66, 138–148,
April 15, 2010

Richard Thaler and Cass Sunstein. Nudge: Improving Decisions About Health, Wealth, and
Happiness. New Haven, CT: Yale University Press, 2008.

Amos Tversky and Daniel Kahneman. “Judgement Under Uncertainty: Heuristics and Biases.” Science 185 (1974): 1124‐31

Published in Issue 2, 2011

Designers and planners increasingly work on complicated, multi-stakeholder projects. NIMBYism (Not In My Backyard) is rampant, while public and private clients seek results that satisfy all constituencies. Understanding stakeholder expectations and needs is critical to project success. Behavioral economics, a sub-discipline of economics that focuses on how people actually behave (as opposed to the prevailing “rational actor” economic theories that propose how people should behave), provides insights and approaches to help designers and planners better understand stakeholders’ perspectives and achieve successful outcomes. Behavioral economics research has been further supported by neuroeconomics research, which utilizes brain imaging to uncover brain activity that underlies human responses.  By explaining basic behavioral economics and neuoreconomics  concepts as they apply to design projects, I hope to give designers more tools to aid in understanding how people react to design and planning problems in their communities.

Basic research in behavioral economics, led by Tsversky and Kahneman, shows that humans adopt sensible “rules of thumb” or heuristics to aid in decision making.  People are faced with too many decisions on a daily basis; deliberating every one of them would result in mental gridlock, so people make many decisions on “auto pilot” through the use of heuristics that simplify their lives. Although essential, use of heuristics increases the likelihood of short term rather than long term outcomes.  Designers and planners can use insights about human heuristics to aid in crafting stakeholder input processes that achieve better long term outcomes. (References to the behavioral economics and neuroeconomics work from researchers Tsversky, Kahneman, Thaler, Sunstein, Gilbert, Bar, Peters, Buchel and Ariely appear at the end of the article.)

Behavioral economists Thaler and Sunstein propose packaging behavioral concepts into a framework of “Choice Architecture,” or asymmetric paternalism, to aid in improved decision making.  Choice Architecture is not architecture as planners and designers think of it in the built environment, but rather, it involves designing how choices are presented to people in order to obtain the best long-term outcomes. 

Some people argue that purposeful presentation of information should not be used to influence decisions; however, virtually every choice that people make is already organized in a way that will predispose them to a particular choice, whether the organization of the choices is accidental, or instead is thoughtful and intentional. Proponents of Choice Architecture argue that people will be influenced by how things are presented, so the presentation should be structured toward arriving at the best long term-outcomes.

According to Thaler and Sunstein, the Choice Architect is responsible for organizing the context in which people make decisions.  Every aspect of how choices are presented to people affects the decisions they make.   To achieve positive results, all default choices must set people in the best direction, while still allowing individuals to make a change if they request to do so.

Designers who learn to employ behavioral economics concepts and become “choice architects” can add significant value to their projects through improved stakeholder interaction and decision-making.

Are NIMBY’s Normal? 
Why do stakeholder groups dislike or distrust new projects and other changes in their environment?  People are naturally fearful of potential negative impacts on property values, property rights, traffic, safety, schools, and the livability of their homes and neighborhoods.  According to behavioral economists, this fear arises out of a basic human heuristic, Loss Aversion. People hate losing something they have, so much so that losing something makes people twice as unhappy as the happiness they experienced when they first obtained that same thing.

Loss Aversion contributes to another human heuristic called status quo bias. People have a tendency to want to maintain their current situation, whatever it is. For example, most teachers would observe that students tend to sit in the same seats in class, even when seats are not assigned. This is a simple example of a bias that humans employ for much more important matters, and people will put up with a significant amount of inconvenience or other costs in order to avoid the potential loss presented by a change. 

The Ownership Bias or Endowment Effect also plays into NIMBYism.  According to Ariely, people become attached to the things they have and the more work they put into something, the more ownership they begin to feel. This has been dubbed, tongue in cheek, “the IKEA effect” because pride of ownership rises proportionally with the difficulty in assembling the furniture.  It’s easy to see how a strong sense of ownership develops when people invest significant time and effort in making a place their home. 

NIMBYism is also affected by Virtual Ownership Bias. People can begin to feel ownership of something before they actually own it. You see this at work at an auction, where the bidders begin to imagine themselves as the owner of an item they are bidding on. The longer they are engaged in the auction, the more they imagine themselves owning the item, and the more intensely they feel about bidding to win it. This concept also translates to people’s feelings about their neighborhood park, and from there, resistance to any proposed changes to the park.  Likewise, virtual ownership takes hold over vacant land in a community, even if that open land is actually owned by someone else who has plans for future development; the virtual ownership phenomenon explains the otherwise irrational resistance to development by the neighborhood or community.

Impact Bias also plays a role in NIMBYism by escalating people’s fears about new proposals.  According to Gilbert, impact bias is the heuristic that causes stakeholders to substantially overestimate the negative effect that a given change will have on them and their level of satisfaction or happiness.

“Choice Architecture” Solutions to NIMBYism
 A number of behavioral economics concepts can be employed to help alleviate NIMBYism. Here are three:

•    Structure stakeholder processes:  Identify in advance the issues that are most likely to trigger “loss aversion” and “ownership bias.” Prepare information that will assist participants in understanding what will be GAINED by potential changes. 

•    Utilize framing:  Framing is the proven psychological concept that the choices people make partially depend upon the way in which the choices are stated, or “framed.” Two proposals of identical quantitative value will yield very different responses, on average, due solely to how the choices are worded and presented. In general, people will respond to the choice that appears to offer the most gain or the least loss.  Frame a call to action for adoption of something new by framing the status quo as a “loss,” thus showing the need for change.

•    Start public engagement early:  Start working with stakeholders before negative opinions and coalitions solidify.  Some clients want to avoid the unpleasantness of stakeholder input, so they wait until their plan is ready or the design completed.  They are then disappointed with a less than positive reception from stakeholder groups or the public to the already completed plan.  Instead, create stakeholder ownership in the project by involving people early in the process.  This uses ownership bias in service to the project and can help minimize impact bias by allowing stakeholders time to understand the nature of the changes.

When Stakeholder Meetings Go Bad, They Get Worse
What causes difficult stakeholder meetings to devolve into even more challenging circumstances?  People are influenced by the actions of others, and they are influenced by their own inferences about others people’s likely views or actions, a concept called Herd Mentality.  For example, peer pressure causes people to give different answers to the same questions, depending upon the method for collecting responses. When responses are solicited publicly, such as by raising hands or asking for vocalized “yes’s” or “no’s,” there is much more conformity in the results when compared with use of written surveys or other anonymous methods.  So, if there are vocal participants who are unhappy, they can sway the attitudes and opinions of others in the group.

Another contributor to devolving stakeholder meetings is the Availability Heuristic.  People assess the likelihood of risks based upon how many examples come easily to their minds. Recent events, particularly dramatic events, heavily influence people’s assessment of any given risk.  Personal experiences of negative events or close affiliation with a person who experienced a negative event also increase a person’s assessment of the importance and likelihood of that risk.  Biased perceptions about risks can inappropriately influence how communities respond to challenges,  allocate resources or plan future development.  So for example, if a community has experienced a number of recent fatal traffic accidents, then any proposal that is perceived as increasing traffic may be opposed by the community just due to the community's knowledge of those fatal accidents.

Expectations Alter Opinions.  A person’s prior knowledge of an experience they are about to have modifies their brain activity, causing their experience to be altered from what it would have been if they had not had the information in advance.  The result is that if a person expects something to be good, the odds are that they will experience it positively; likewise, if they expect it to be bad, they will experience it as bad.

 “Choice Architecture” Solutions for Positive Stakeholder Meetings
Here are a set of behavioral economics ideas for better meetings:

•    Intention is a motivator.  Obtain a better meeting turnout through advance contact with stakeholders you believe are essential to a good process; request a statement of intent to participate from potential participants. By asking people to state their intention to participate, you will increase the likelihood that they will attend.  Likewise, by asking participants to write down their reasons for participating, designers can gain important insights while stakeholders reinforce to themselves what is important to them.

•    Help potential participants overcome small roadblocks to attendance through use of Channel  Factors.  For example, the person who said they will attend a public meeting is even more likely to attend if you ask them to look at a map and locate the meeting site in relation to where they live or work, then trace the route they would take to get to the meeting.  This activity is simplified through technology such as on line maps.

•    Set a positive expectation at the beginning. “Frame” the introductory information in a positive light with regard to your goals.  Ask one or two representatives of the stakeholder group, who you know will be positive, to speak about the importance of the meeting and their own enthusiasm about it.

•    Provide information about who supports the initiative (e.g., names of community leaders, groups, or statistics about the percentage of supporters).  This will help stakeholders approach the subject more positively.

•    Avoid negative peer pressure—obtain input anonymously. Use paper surveys or feed-back methods rather than a show of hands or voice vote when you want to measure uninfluenced opinions.

•    Priming results from simple, sometimes seemingly irrelevant cues such as furniture and objects.  For example, on average, people behave more competitively, less cooperatively and less generously when they are in a room set up like a business environment with, for example, boardroom tables and briefcases.  When designing a process to achieve cooperation from the stakeholders, select non-competitive meeting locations, settings, furniture and other visual cues (such as briefcases).  Avoid hierarchical room set ups, such as business settings with boardroom tables, raised daises, etc. that might cue participants to behave competitively.

•    Avoid creating factions.  Take care if you use “break out” sessions. Peer pressure within small groups can cause the members of each small group to align in support of a particular viewpoint.  These differing small-group viewpoints are consistently defended when the small groups are brought together into a larger group.  Some facilitators favor processes such as World Café, where the members of small discussion tables are rotated after each question or discussion item so that factions are less likely to form or become entrenched.

In the next issue of Research Design Connections, we will examine how the choice architect can help groups select optimal alternatives, arrive at acceptance of mitigation measures, and better understand large scale proposals and long-term outcomes.

Kathleen M. Fox is a registered landscape architect,  Fellow of the American Society of Landscape Architects, and executive director of the Ohio Cultural Facilities Commission.  A 2002 Loeb Fellow at the Harvard Graduate School of Design, she also holds a graduate certificate in Alternative Dispute Resolution from Capital University Law School and is author of the research paper Utilizing Behavioral Economics to Improve Public and Private Decision Systems in Community Planning and Development.  She can be reached at:  kfox@post.harvard.edu.    

References:

Dan Ariely. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York:
Harper Collins Publishers, 2008.

Moshe Bar. ”Wait for the Second Marshmallow? Future‐Oriented Thinking and Delayed Reward
Discounting in the Brain.” Neuron 66, 66, April 15, 2010.

Daniel Gilbert. Stumbling on Happiness.  New York:  Vintage Books, 2007.

Kurt Lewin. Field Theory in Social Science: Selected Theoretical Papers. New York: Harper &
Row, 1951.

Jan Peters and Christian Buchel. “Episodic Future Thinking Reduces Reward Delay Discounting
through an Enhancement of Prefrontal‐Mediotemporal Interactions.” Neuron 66, 138–148,
April 15, 2010

Richard Thaler and Cass Sunstein. Nudge: Improving Decisions About Health, Wealth, and
Happiness. New Haven, CT: Yale University Press, 2008.

Amos Tversky and Daniel Kahneman. “Judgement Under Uncertainty: Heuristics and Biases.” Science 185 (1974): 1124‐31

Credit: Healing HealthCare Systems

Published in Issue 1, 2010

Two sets of smoky glass doors slide open automatically, widening onto a blank corridor of sterile linoleum.  The walls are nondescript, with overhead fluorescent lights and painted arrows on the floor.  The sounds are a combination of crying, laughing, talking, machinery, beepers, Muzak^®, loudspeakers, all mixed together with an ominous silence.  Upon entering the aloneness of the hospital room, the sounds continue to intrude beyond the four visible walls.  The noises are exaggerated, distorted, unending.  The din coming from everywhere soon blends into the still characterless walls, never yielding to the fear it creates, enrolling all present in its relentless chorus.  (Mazer, 1994)

While the description above may not detail every modern hospital, it does portray an uncomfortable reality that patients and families fear the most.  Further, it is the antithesis of a healing environment that is supportive of patient recovery bringing warmth, assurance, and comfort, along with the best medical science and clinical care.    In Part I of this two-part series (in RDC 2009, Issue 4), we looked at the history of the healing environment through the writings of Florence Nightingale and then focused on the auditory environment.  

 “… [The] physical environment of hospitals can convey different messages.… landscape pictures, plants and comfortable chairs can convey positive messages, while sparsely decorated and run-down environments can convey negative values.”  (Edvardsson, Sandman, & Rasmussen, 2006)  In this article, we will look at the impact of the “characterless walls,” as they define the patient space and how nature elements mitigate some of the generic, impersonal features common to institutional care.

Nature at the Bedside

I have seen, in fevers (and felt, when I was a fever patient myself), the most acute suffering produced from the patient (in a hut) not being able to see out of window, and the knots in the wood being the only view. I shall never forget the rapture of fever patients over a bunch of bright-coloured flowers. I remember (in my own case) a nosegay of wild flowers being sent me, and from that moment recovery becoming more rapid.   (Nightingale, 1860)

 Florence Nightingale could not have better validated studies that were to define the benefits of nature and natural elements done over a century after she wrote her Notes on Nursing.   She further characterized the environment of care, the “sick room” as requiring fresh air and natural sunlight, something to stimulate the mind and body, beauty as well as functionality.   She was most sensitive to the need for patients to have hope symbolized in all that they saw, heard, and experienced.  (Nightingale, 1860)   Nightingale did not isolate nature or quiet, fresh air or warmth, cleanliness or good diet from patient care.  Rather, in the middle of the 19^th century, prior to penicillin and other modern drugs, the environment of care was primary care. Well integrated into daily life, “nature” was linked to Godliness and considered requisite for recovery from illness.  Therefore, to not mandate and arrange for its presence was foreign to culture and practice.

Without question, the role of nature, its prominence in our daily lives and in our health, is not only undisputed, but is also well documented.  Walks in the park, gardening, fresh sunlight and the smell and sound the surf, as well as birds singing…all of these are considered the best of our life experiences.     To the hospitalized patient confined to a narrow bed, who is tethered to IV poles and constrained by illness and debilitation, these experiences exist only in memory, in the abstract, or as provided in some symbolic way. 

Sunlight streams through the hospital window for the patient who has access to one.  Of course, if the direct sunlight hits the bed, glare and uncomfortable heat could also plague that same patient. Views to nature, so clinically significant following the breakthrough study by Ulrich (1984) are availed by patients whose rooms are not on the upper floors.   For those patients whose windows are far above the surrounding grounds, sky or the tops of other buildings may be the only accessible view.  Furthermore, any connection to nature for a patient who cannot ambulate may be limited to potted plants removed from their natural habitat, flowers that are cut and bloom for only a few days, and photographs or videos of natural settings.   The question here is, how effective is nature when it is provided in unnatural settings, in technologically dominated spaces, where actual nature is not accessible?

The broader background

            In a study that looked at the ways in which people feel a “connectedness to nature,” Mayer and Franz created a scale that could be used to quantify the relationship between humans and nature. (F. Stephan Mayer & Frantz, 2004) The study supported connection to nature as “an important predictor of … subjective wellbeing.”  It also saw an overlap into altruistic behavior and self-reflection.  Perrin and Benassi subsequently defined what the scale measured and, as opposed to emotional connectedness, claimed that it indicated one’s cognitive beliefs.  (Perrin & Benassi, 2009).   In reviewing both studies, what seems more relevant is that the perception of nature as part of one’s self, life, values, or beliefs, has an impact on behavior and health.  

            While individuals may feel connected to nature, there is a clear distinction between what is considered “natural” and “unnatural.”   Studies have revealed that natural environments were thought of as those without human interference, environments devoid of human artifacts and, as well, devoid of people. (Vining, Merrick, & Price, 2008) Within the study, Vining, et al. also asked,  “What words come to mind when you think of a natural environment?” and,  “What words come to mind when you think of an unnatural environment?” The responses included, respectively, beauty, serenity, calm, peaceful, pristine, tranquil, pleasing, soul satisfying, beautiful, and quiet and, on the other hand, jarring, discordant, tainted, busy, noisy, populated, and out-of-synch.    While this study looked at the dichotomy between natural and unnatural on a global framework, having nothing to do with healthcare, the responses offer some insight into the attitudes and expectations that are held regarding natural settings or the symbols of nature, and the built urban industrial environment. 

Evolutionary Theory:  Biophilia  

            When Edward O. Wilson came out with his evolutionary theory that posited human beings to be inherently attracted to life and all living things, it added substantially to the overall discussion regarding human beings and nature.   While remaining a hypothesis, when applied to research considering how human beings respond to nature, biophilia replaced a psychological or emotional rationale with one of inherency.  Nonetheless, although a welcome explanation to what could not before be explained, the direct proof that Biophilia is factual has not been found.  Rather, the theory is used to justify or explain patterns of behavior, beliefs, and responses.  (Schroeder, 2005; Kellert S, Wilson E O , 1993) 

When we consider the hospitalized patient as profiled by their confinement, nature is most often provided as potted flowers, artificial plants, photographs, paintings, prints, or any other representation.   Therefore, the very environment it is intending to affect, in this case, delineates nature.   Ulrich et al (Roger S. Ulrich, et al., 2008) further points to the restorative impact of nature images on patient outcomes, implying some parity between real nature and mediated nature.   In this case, only visual stimuli was considered, although natural experiences stimulate all the senses.  And, even with this limitation, nature, whether as a symbol or icon, is therapeutic.  

            In its most “real” state, natural environments are multi-sensory experiences, with each sense being aroused to some degree.   Flowers and plants, grass and trees have identifiable scents; the wind, birds, insects, and other creatures make sounds; the wind brushes on ones cheeks and the sunlight is warm.  For the acute care patient, while the object represented, a flower, tree, or landscape, will be identifiable, the accompanying sounds or scents are more difficult to provide.   For this reason, nature, whether real or simulated, actual or mediated, is actually a representation of a larger experience, providing a positive distraction and a time for reflection (F. Stephan  Mayer, McPherson Frantz, Bruehlman-Senecal, & Dolliver, 2009; Roger S. Ulrich, et al., 2008)  

Dijkstra points out that the exclusive or singular value of specific environmental stimuli is far more difficult to verify than the value of multiple factors working in tandem. (Dijkstra K., 2006) According to Craik’s person-environment theory that claims there is no separation between an individual and his or her environment, the senses serve to integrate the two, as to be inseparable.  The role of nature can then be assumed to be even more pronounced to the patient whose sensitivities are heightened. (Salthouse & Craik, 1991)  

 Attention Restoration Theory:  Critical for both staff and patients, families and visitors

 Attention Restoration Theory (ART) addresses the mental fatigue that can occur when direct attention held over long period of time causes diminished capacity. “…Attentional fatigue is a manifestation of overuse of the neural inhibitory mechanism underlying the capacity to inhibit competing stimuli.” (Kaplan & Kaplan, 1982 as cited in (Tennessen & Cimprich, 1995). “The result is a lowered ability to concentrate and suppress distraction, heightened irritability, and a greater likelihood of accidents or errors in functioning.” (Herzog, Chen, & Primeau, 2002), In this state, noise, discomfort, lights, or any other distraction becomes strongly intrusive, rather than mild annoyances.  ART claims that a restorative environment can assist an individual in recapturing their attention ability. Given the nature of the healthcare environment and requirements for critical levels of attention, the diverse risks of attention-fatigue are relevant to this discussion.

The qualities of the restorative environment must meet four criteria:   (1) It must feel like a person is being taken to another place, sufficiently different from where they normally are; (2) It must coherent, understandable; (3) It must be complex enough to be engaging, have a quality of “fascination”; and (4) It must be compatible with the individual and serve the expectations or purpose of the environment. (de Korta, Meijndersa, Sponseleeb, & IJsselsteijna, 2006; Herzog, et al., 2002; F. Stephan  Mayer, et al., 2009; Tennessen & Cimprich, 1995; Roger S. Ulrich, et al., 2008)   Relevant to our discussion about nature is that these four qualities can definitively serve as standards for effectively introducing nature in the healthcare environment.

Another point of view on this topic that is worth considering is described by Schroeder ( 2007) as the “good gestalt,”  when a place or view is experienced as in the right order, having a balanced aesthetic and devoid of any detractor.   This is also in keeping with the concept of the natural environment being one without human intervention or disturbance, artifacts, or incongruence.  

 

Credit: Healing HealthCare Systems

In the picture of the Colorado River and red rock (above), the fence could be seen as a barrier, an interruption . . . which would be disturbing to the sense of place the picture represents.  This perception could interrupt the restorative qualities of this pictorial view of nature. 

 

Credit: Healing HealthCare Systems

In contrast, the picture of the garden in Sri Lanka (above) is completely devoid of human interaction and is, itself, ‘nature made’ as opposed to a well-groomed human-made garden.  In addition, there is a depth of field that offers both complexity and accessibility, a sense of place and possibility beyond itself.  The picture, as a whole, if considered a “view of nature” is wholly undisturbed, even by the photographer, who is the surrogate viewer.

However, before we move into operational issues, other studies are equally important in considering mediated, artificial, or representative nature.   Hartig, et al. (Hartig, Book, Garvill, Olsson, & Garling, 1996) looked at the pictorial responses to different environments: urban/technological and natural environments.   Through self-report, it was found that natural environments generated a positive emotional response.  However, this was not significantly transferred to job performance or productivity, which, it was concluded, is more complex to measure.

Bringslimark et al. (Bringslimark, Hartig, & Patil 2009) point to Ulrich’s psychophysiological theory, which involves stress reduction and positive emotional response, rather than attention restoration.  In a review of studies looking at indoor plants, especially flowering plants, outcomes showed positive differences in reports of pain intensity and distress.  However, corresponding changes in psychophysiological measures were not found.

The symbolism of flowers is long held as embedded in social and cultural practices. Bringslimark makes a strong argument in defining a clear distinction between “nature” as a multi-sensory, interactive experience and indoor plants as a passive relationship, often involving only one or two stimuli.   Further, she points out that indoor plants are separated from their natural habitat, surrounded and housed by built and technological structures.  Another distinction pointed out is that outdoor nature experiences involve active participation, taking a walk or hike, planting a garden, being immersed in an interactive natural setting.  Indoor nature experiences, whether with a potted plant or other mediated object, are quieter experiences, involving people “ … sitting quietly while taking a brief respite from work, or who may notice plants in passing as they proceed with their work, or who are receiving treatment for a health problem.” (p. 430)  

 

Credit: Healing HealthCare Systems

The pictures of the single bud (above) and single fall leaf (below) offer a point of undisturbed focus within a perceived context of their environment, a bud on its stem and the leaf on the tree.   The potential for engagement and the mind perhaps adding the environment in which these single elements exist satisfies the qualities needed to be restorative.

 

Credit: Healing HealthCare Systems

Herzog (Herzog, et al., 2002) goes further in investigating preference and choice between what has been shown to be restorative, having what one might consider a more subtle, or softer effect, from other kinds of activities, such as entertainment or exercise.   The study was complex, not only considering the variety of responses, but also considering social context.   He looks at the phenomena of making choices based on “should” or “would,” an interesting factor that other studies do not consider.   Herzog found that preference for nature over entertainment was influenced by the social and physical context.  For example, an individual might chose nature over entertainment if he/she perceived that this choice would gain approval.  This would not be unlike picking vegetables over sugar cookies if one were eating with a dentist.  However, the question also remains open as to when nature is authentically preferred because of its restorative effect and entertainment set aside because of it generating strong arousal.   Although Herzog does challenge the dialectic between nature and entertainment, he concludes that much more must be considered to fully understand the many factors that comprise one’s relationship to the natural world.

Relevant to the hospital environment, however, is the circumstance of “patient-hood,” being hospitalized and in an environment so controlled by factors out of the patient’s control.   While Ulrich’s theory of Supportive Environments (R. S. Ulrich, 1997) refers specifically to the importance of patient control, when it comes to nature elements, other than visitors sending flowers, it is the hospital that must be proactive by making decisions that will optimize the process of recovery.   Going back to the “view from the window,” one must be able to get to the window to see out of the window, a challenge for the most acute patients.

Mediated Nature

“Mediated environments can…shape our “reality” and, contrary to much belief, may even constitute our  “realities” of various phenomena.”  (Adams, 2005)   This statement brings to the fore powerful options for nature at the bedside.  Adams distinguishes between authentic nature, simulated nature, and televised nature.   I would add to this, representative or symbolic nature.    “Authentic nature” is the real thing:  the places we go, the flowers that bloom in the forest, the rivers and lakes we sail-swim in.   “Simulated nature,” according to Adams, is nature in unnatural settings:  zoos, shopping mall landscapes, botanical gardens, and the like.  “Televised nature” and, for this discussion, “Representative nature,” includes the Discovery Channel, National Geographic productions, documentaries about the earth, plus nature photography, art, and artificial and virtual representations of plants, flowers, rocks, whole vistas.   These are mediated nature:  natural images or figures translated into another medium.

Ulrich (1984) points to views of nature having a therapeutic effect; windows bring the outdoors indoors to some degree.  John Portman, the architect who launched the “natural atrium” model in the first Hyatt Regency in Atlanta in 1967, was so successful that for guests, the “outdoors” is the lobby, the hallways and the sidewalks.  Portman launched a new revolution in the experience of indoor space which, to some critics, excluded those actually on the streets.   And, while the Portman innovation became well known for the glass elevators, the use of outdoor elements contributed to how the space functioned.  Basically, the atrium model became self-contained and included much natural ambience as an outdoor environment. (High Museum of Art, 2009)

The “indoors” to the acute care patient, however, is limited most often to their hospital room, if not the bed in which they are hoping to recover.  Regarding televised nature, not all available nature programming is therapeutic or appropriate for a highly medicated or otherwise impaired patient for whom the television takes on a profound role. Since television offers both visual and auditory information, its impact is greater than, for example, a potted plant.    Aggressive animals, reality TV depictions of hurricanes (or Tsunamis), flooding, restless oceans and fast moving rivers can be fearful, over-stimulating, and increase anxiety.

The most common use of nature in hospitals today is simulated nature, such as healing gardens, landscaping, aquariums, fountains, and mediated nature--indoor plants, artificial plants, nature pictures (photography and artwork).   With the multidisciplinary research that has been forthcoming, together with the onset of evidence-based design, nature has become ever more prominent in the design of hospitals, both in architecture and interior design.  

What is not discussed, however, and is an issue that I believe deserves more study -- sensory habituation.  This occurs when a stimulus is repeated or is unchanging, diminishing arousal over time and exposure. Change is what stimulates; sameness desensitizes us to our surroundings.  For that reason, hospital smells are most noticeable to visitors; continuous noise becomes unnoticeable to the staff; views are most attractive the first time we see them.

  This phenomenon, well researched in humans from birth through death, offers several challenges when we consider what is most effective for the patient.

First, nature sounds -- to the human ear these are repetitive.  They are also heard out of context to the patient who has no corresponding visual cue.   They have been effective for patients who hear them with still photographs for a short period of time. (Diette, Lechtzin, Haponik, Devrotes, & Rubin, 2003)  However, over a long period of time, they may become ineffective.

The use of nature sounds, first introduced in audio recordings since the New Age genre started in the late 70’s, became popular in meditation recordings, and is a style of music intentionally selected to be stress reducing.  However, for the immobile patient, the sounds of birds or rushing water may not be restful when they are out of context, broadcast through two-inch bedside speakers. Furthermore, in the natural setting, these sounds are hardly continuous.  They vary in intensity, in quality, in location…and our attention also varies.  Considering the patient who is listening through bedrail speakers or a single pillow speaker, over time, or separated from the visual context, these sounds take on a different character and, as such, may be more disconcerting than helpful.

Second, visual habituation occurs when the same view is unchanging.  This can occur if the same picture is on the same wall for an extended period or if the viewer has no option of alternate views.  This factor becomes meaningful not only to the patient, but to the staff whose relationship to the hospital environment is longer term and demands that they be alert and aware of where they are.

These two issues provide some interesting alternatives to consider. 

The need for Variety

“… The nerves of the sick suffer from seeing the same walls, the same ceiling, the same surroundings during a long confinement to one or two rooms. … The effect in sickness of beautiful objects, of variety of objects, and especially of brilliancy of colour is hardly at all appreciated. … Variety of form and brilliancy of colour in the objects presented to patients are actual means of recovery. … You little know…. how the very walls of their sick rooms seem hung with their cares; how the ghosts of their troubles haunt their beds; how impossible it is for them to escape from a pursuing thought without some help from variety. …A patient can just as much move his leg when it is fractured as change his thoughts when no external help from variety is given him.  (Nightingale, 1860, p. 20)

Over a century after Nightingale wrote the above statement, the value of positive distractions was verified as being a solution to a negative distraction, requisite to the health of the mind and body, and included in healthcare design.   Dijkstra points out that in relationship to color, the environmental context informs preference. (Dijkstra, Pieterse, & Pruyn, 2008)  The concept that the patient environment is distinct from other everyday experiences is highlighted not only by Nightingale and Dijkstra, but also by ART and the theory of Supportive Environments that both claim the degree of restorative effectiveness is relative to the acuity of the patient.  Because acuity is changeable, the patient environment, including the use of nature and music, must be dynamic rather than stagnant. 

 For the patient

Authentic nature is in constant flux:  buds become flowers and then die; seasons bring on total changes in the palette of nature; the tides given dynamic changes to oceans and the winds make streams into rivers.   The most obvious change is the way the sun rises and how the light changes continually until the sun sets.  The use of mediated, artificial, or virtual nature must not be stagnant.  Whether changing a picture or photograph or assuring that the video programs are not unduly repetitive, the value of a positive distraction based on quality and variety is well documented. (Malkin, 2003; Roger S. Ulrich, et al., 2008) A restorative environment for one or two hours, or an evening, may be a different environment if the time period for recovery is a series of days, weeks, or months. 

A variety of landscapes, flowers that are changed, and sensitivity to the experience of the patient, broadens how much nature can be therapeutic and what is required over time.

For the Staff

While statistically, the average patient stay is only a few days, the staff stay is far longer.  Nursing, therapists, physicians, those who work in the same unit day after day, become blind to the walls and floors, no longer smell the cleaning fluid or the medicinal agents, no longer hear the HVAC system.    If the staff is to benefit from nature elements, then the elements, whether a picture or a plant, need to be changed periodically to renew or re-sensitize the staff to their environment.  ART is real and, for the nurses whose work is repetitive and critical, the environment needs to both stimulate and de-stress, a complex balance of two opposing responses. 

The Art Cart

The Art Cart, a revolving library of framed artwork including nature photography implemented by many hospitals, is effective for many reasons.  First, this offers the patient a choice in what they would like to see.  Second, each room changes either with a change of patient, or a change of preference.   For the nurses, it is optimal to have the room environment individualized for each patient, if only in the wall art and to have the pictures be restorative. 

About Nature and Music

While the challenge of nature sounds has been discussed, the benefits of nature imagery with accompanying music have yet to be studied significantly.    Nonetheless, there is ample research to point to the effectiveness of music and nature separately and in combination.    Music that offers enough complexity and accessibility can fulfill the requirements to be a positive distraction.  Because of the ways in which visual and auditory senses are integrated, the music can bring a richer multi-sensory experience with which to engage than just passive nature alone.   Also, music offers an increase in pleasure and relaxation while masking other distracting sounds.  

Conclusion

When Nightingale wrote her Notes on Nursing, institutional care had become the work of religious women whose task was to save souls.   This book was written for domestic care givers who, at that time, were women, wives, maids, and daughters.   And, the detail Nightingale offered in ways considered today non-medical, outside of the medical domain, remain those very details that determine the experience of patients and influence their recovery.   

The style of her writing was not to merely provide directions on what to do, but included the consequences of neglecting these details.   The subtitle of her book was What Nursing is and What it is Not, appropriate and understandable regarding her consideration of the risks present when not addressing the very nature of confinement and illness. 

We began, in Part I, a discussion of the environment of care in the context of history, referring not only to Nightingale, but also to the conditions that preceded her and drove her to seek a better way.   Within the context of the sick room, we considered the auditory environment through the research regarding the therapeutic use of music and, as well, the negative effects of ambient noise.  

In Part II, we have looked at the role nature plays in health and well-being specifically for the confined patient.   There is nothing natural about being ill.  Whether one accepts Nightingale’s theory that all illness is reparative or Pasteur’s Germ Theory where symptoms are related to invasive bacteria, the environment of care is not restorative unless mediated by informed design and practice. 

The circumstances surrounding the hospitalized patient are unique and require due consideration regarding the details that make up the patient experience.   Furthermore, while it may seem, next to the most complex and effective medical technologies, that music and nature are of little consequence, for the confined patient, for the family, for the nurse whose task it is to care for the ill, they both offer and symbolize care and healing.

Susan E. Mazer is acknowledged as a pioneer in the use of music as environmental design. She is the President and CEO of Healing HealthCare Systems (www.healinghealth.com) which produces the C.A.R.E. Channel. In her work in health care, she has authored and facilitated educational training for nurses and physicians and is well published in the field of the effects of noise on patients.  She can be reached at smazer@healinghealth.com

Note:  All the photographs except for the Colorado River, are available for desktop downloads at CARE Desktop images

 

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