Nature’s influence on hospitalized patients’ Health Outcomes -RAKAN AYYOUB M-ARCH 2015

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


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


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.


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



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



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



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



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).



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



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



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



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)



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


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.


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.


Bibliography 16

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Coss, R. (1990). Picture perception and Patient Stress: A Study of Anxiety Reduction and

Postoperative Stability.

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ago-healthcare-has-gained-almost-1-million-jobs/

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nature sights and sounds reduces pain during flexible bronchoscopy: a complementary

approach to routine analgesia.

Eagle, A. (2014). Retrieved from hfmmagazine.com: http://www.hfmmagazine.com/display/HFM-

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article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HFM/Magazine/201

4/Nov/cover-building-hospitals-for-boomers

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Howell, G. (2005). Lean Construction Institute Notes.

Miller, A. C., Hickman, L. C., & Lemasters, G. K. (1992). A distraction technique for control of

burn pain.

Park, S.-H. P., & Mattson, R. H. (2009). Therapeutic Influences of Plants in Hospital Rooms on

Surgical Recovery.

Park, S.-H., & Mattson, R. F. (2008). Effects of Flowering and Foliage Plants.

Raanaas, K. R., Patil, G. G., & Hartig, T. (2012). Health benefits of a view of nature through the

window : a quasiexperimental study of patients in a residential rehabilitation center.

Schneider, S. M., & Hood, L. E. (2007). Virtual Reality: A Distraction Intervention for

Chemotherapy.

Seed, W. R. (2011). Healthcare Design .


17

Tse, M. M., Ng, J. K., Chung, J. W., & Wong, T. K. (2002). The effect of visual stimuli on pain

threshold and tolerance.

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Environmental Psychology.


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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-

2A5yq9-fxYLZ-48sv2H-pez5m5-pw2DtU-97nDN7-5wDwwQ-7L8oyd-peyuAw-8TLeLs-b5jPRT-cwouHL-ZWwcr-4twciM-rqQ7t8-qNnaZc-rsAeSW-c2eDx7-ayUnUp-

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-

aUB1f8-aL94yZ-7PqnyG-cxkp37-88xEU2-8UzcKr-oCY1oC-bBr9UW-rvqP7u-JxVru-rXzypy-7b7UbE-q7C6Rp-9Mpeqh-pg62Ba-7uskT9-8DiZWx-7Z56er-b14CNP-

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


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-

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ms3KPD-aFEBmM

Documents

Nature’s influence on hospitalized patients’ Health Outcomes -RAKAN AYYOUB M-ARCH 2015