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The Effects of Presence and Influence in Nature Images in a Simulated Hospital Patient Room

Originally Published:
Key Point Summary
Key Point Summary Author(s):
Schechtman, Suzanne
Key Concepts/Context

While some research has looked at the impact of variables such as nature murals, nature sounds, nature videos, and nature views on such outcomes as pain intensity and tolerance, pain quality, need for medication, and anxiety, this topic has not been widely studied in the research literature. As hospitals purchase art for display, to create a restorative environment, and encourage wellness, more direction is needed to inform decisions between different types of art and nature images that may or may not truly benefit patients. One area of interest the researchers pursue in this study is the way in which different types of nature images might promote a sense of perceived presence – “a feeling of 'being there'” – and perceived influence – “a sense that the image is affecting thoughts” – each of which may have important implications for distraction from pain. These types of images are based on Appleton's Prospect-Refuge Theory, which posits that people seek balanced landscapes with prospects (access to views), refuges (places for hiding/shelter), and hazards (threat).


The purpose of this study is to understand the impact of nature images, perceived presence, and perceived influence in a simulated clinical environment, and also to test the research methodology in a simulated setting before conducting a similar study in a true hospital environment.


109 healthy undergraduate and graduate students were recruited to participate in the study, which took place in a simulated hospital patient room within the School of Nursing Clinical Learning and Resource Center at Clemson University. Participants were randomly assigned to view one of four nature images during the experiment, or were assigned to the control group, viewing a blank, black screen for the same duration that the other participants viewed a nature image. The four images were selected through a focus group process that asked focus group participants to sort and rank the most representative images within four categories from Appleton's prospect-refuge theory:  prospect, refuge, hazard, or mixed prospect and refuge. Prospect indicates access to a view in a landscape. Refuge presents opportunities for hiding or shelter. Hazard images present incidents that pose a threat to life, real or symbolic. The mixed images combined characteristics of prospect and refuge. The experiment was split into five periods:  pre-reporting (10 minutes), rest (15 minutes), introduction of pain stressor (two minutes), recovery (15 minutes), and post-reporting (18 minutes). The pain stressor period was a cold pressor challenge, which involved participants placing their non-dominant hand into a cooler of ice water for as long as they could. Physiological data readings as well as readings of perceived presence and influence were taken multiple times during the rest, stressor, and recovery periods. During this same timeframe, participants were exposed to their specific nature image (or no image for the control group) on a flat-panel display situated in front of the hospital bed. Finally, after the recovery period participants completed the Profile of Mood States survey to report their current mood condition. Data were analyzed using t-tests, repeated measures of analysis of variance, and correlation analysis.

Design Implications
At this point, the insignificant finding relating to presence cannot tell us much about potential design directions. However, the significance of the hazard image to seemingly increase perceived influence, or a person's belief that an image is influencing one's thoughts, and to limit the rise of blood pressure during a pain task, presents a case for better understanding the role of distraction through imagery during a painful episode. While the researchers do not recommend the use of a hazard image to effectively distract from pain over time, since the image also significantly lowered participants' mood and did not distract from pain during the recovery stage, there may be something relevant to learn about the distracting nature of hazard images.

There was no significant difference between participant reports of presence resulting from their perception of their particular type of image. On the other hand, particularly for participants viewing the hazard image, perceived influence levels spiked significantly higher during the introduction of the pain stressor than for any other image, and then dropped lower during the recovery phase. It is possible that the hazard image acted to distract participants during the pain stressor, although the presence of fire in the image, juxtaposed against an ice water task, may have been a confounding variable. Results from the POMS survey portray a marked difference for the hazard image as well, with higher mood disturbance and lower vigor (a positive emotion) than any other image or the control group. As a result, participants experienced a more unpleasant mood as a result of the hazard image. Finally, diastolic blood pressure was found to be significantly different for those in the hazard image group than any other group, particularly during the pain stressor challenge. While blood pressure rose for every other group, it did not rise in the hazard group, suggesting some degree of distraction at play.


Limitations include the unexpected confounding variable inherent in the hazard image of fire. Additionally, from an outside perspective, it seems that an additional control group comparison aside from using a black screen, but perhaps another type of image that is not nature-based might be worth studying. This could help determine how other types of images/distraction in general produce similar or different effects as compared with the natural images.

Key Point Summary Author(s):
Schechtman, Suzanne
Primary Author
Vincent, E.