In the context of healthcare environments, there is a compelling body of literature on the use of “restorative” visual images that can reduce stress, anxiety, and pain perception. While various theories are in place, evidence has not extended to the particular case of emergency department (ED) waiting, which is a uniquely high-stress environment with prolonged wait times.

Wait times in emergency departments have been addressed as one of the most important concerns for patients. Research also shows that the perceived wait time is a more compelling indicator of patient satisfaction than actual wait time, and perceived wait time can be effected by emotional or affective states, and vice versa.

Fear, anxiety, stress, and perception of pain are significant factors in the waiting experience of the emergency department.


Study design
Ben Taub General Hospital and Memorial Hermann Hospital are the only two Level 1 trauma centers in all of Harris County, Texas, located no more than 100 yards apart.

Ben Taub is one of the nation’s busiest trauma centers, with more than 100,000 emergency patients annually and a majority of uninsured, Medicare or Medicaid patients. Due to the large volume of patients, the time spent in the emergency department can be 10 to 12 hours, making the experience of waiting a critical concern.

The Memorial Hermann Hospital Emergency Center sees more than 40,000 patient visits/admissions per year, and the wait averages between 3.6 to 4 hours. The challenge in this waiting room was the long linear layout. Due to the presence of multiple televisions in a relatively small area, the staff complained of high noise levels. This site offered a reasonable contrast to Ben Taub given the more high-end clientele and lower waiting times. 

A systematic observation was implemented in each ED waiting room to study the behaviors of patients and visitors, before and after an art intervention. The images used in the art intervention were selected based on previous literature in the field of evidence-based art. The art intervention consisted of canvas art, plasma screens displaying a slide show of nature images, and window films.

Two types of subject behaviors were identified: continuous behaviors, such as reading, dozing, or watching TV, which are over a period of time and cannot be counted; and discrete behaviors, such as, getting out of seat, changing seats, stretching, and pacing, which are specific events that can be counted.

Continuous behaviors were mapped on a scaled layout of the emergency waiting area, including furniture. Observers annotated this plan with symbols marking the people and their behaviors for a period of five minutes, every 20 minutes, to obtain the behavior map. A data collection plan was developed based on a uniform sampling of peak and non-peak times, different times of the day, and different days of the week.

A total of 30 observations (lasting approximately 65 minutes) were completed before and after the art intervention in each site. Noise levels were also recorded during each observation.


Key findings
The most common behaviors in both sites before the intervention included people getting out of their seats, talking, looking at the TV, watching other people, talking on cell phones, and dozing. After the intervention, these behaviors were still the most common, but there was a significant decrease in restless behavior.

In Ben Taub, this was seen in the decrease in out-of- seat behavior, pacing, front desk queries, and stretching. In Memorial Hermann, this was witnessed in the decrease in out-of-seat behavior, pacing, fidgeting, and stretching.

We can argue that the decrease in restlessness came from (a) the presence of a positive distraction, giving patients something additional to look at while they were in the waiting room, and (b) the content of the distraction—serene nature images that were arguably calming in nature. The findings discussed below attest to these two arguments.  

At both sites, a significant decrease in people watching (people staring at other people) was found, which has a strong implication for privacy. Waiting rooms are often set up as open plans, and as seen in the data, looking at other people is the most common activity. Being looked at can be stressful for vulnerable populations, and any reduction in this behavior can be hypothesized to have an impact on patient stress and implications for privacy.

In Ben Taub, a significant increase in talking was also found. This implies an increased socialization. In Memorial Hermann, while there was an increase, it was not significant. The absence of this effect can be attributed to layout, which was more intimate and promoted talking, thus the mean talking/person ratio was higher to start with.

Increase in socialization can be considered to be an indicator of positive mood. There is a significant amount of literature on the importance of social support in healthcare settings, and this finding has implications from that perspective, as well. 

Finally, there was a significant decrease (approximately 6 decibels) in the average noise levels in both sites before and after the intervention. A 6-decibel difference in noise levels is considered a significant reduction in perceived loudness. While the difference in noise levels can be attributed to the difference in the number of TVs with sound in Memorial Hermann, this is not the case in Ben Taub, where there were two screens showing regular TV programming at the same volume for the duration of the study. 

Previous studies argue that noise levels contribute to patient stress. We'll argue here that patient stress contributes to noise levels.

In Memorial Hermann, the change in noise levels can be attributed to the environmental noise levels, since some of the TVs were replaced with silent nature videos. However, in Ben Taub, there was no change in environmental noise sources, and the change can only be attributed to a change in behavior and the decibel levels of average conversation.

Arguably, raised voices are a sign of stress, and a beautiful environment compels people to speak in softer tones. This finding warrants further investigation.


Implications for the visual environment of emergency departments
ED waiting rooms can be stressful places. By including a simple visual art intervention, patient behavior can be impacted. Behavioral observation shows that providing an evidence-based positive distraction can impact patient experience by reducing restlessness, reducing the tendency of people to stare at other people and increasing socialization.

Using passive positive distractions like video and still art, instead of loud TVs, can also help to bring down the noise level, which is a significant need for patient and staff satisfaction.

Furthermore, creating a peaceful environment through visual art, which promotes calm behavior, can potentially reduce noise levels. We automatically speak in softer voices in museums and art galleries. Is it possible that art can be a medium to create quieter health environments? 

Funded by a 2009-10 grant from The Center for Health Design, this project has been accepted for publication in The Journal of Emergency Medicine. A full report of the project is available at

Upali Nanda, PhD, Assoc. AIA, EDAC, is research consultant and chair of the advisory council for the RED center
at American Art. Kathy Hathorn, MA, EDAC, is CEO and creative director at American Art Resources. Additional information can be requested at or