When people refer to their “healthcare experience,” they typically (and correctly) note their experiences in the examination, treatment, and recovery rooms as well as interactions with the caregivers and support staff.

However, it is common knowledge that a sizable proportion of a patient’s and the accompanying family members’ time are spent waiting.

Today’s planners are paying considerable attention to waiting time as well as waiting spaces. After all-from a lean process perspective-any waiting time is a waste that should be purged from the system.

While a wait-free healthcare model does not exist, the time people spend waiting is increasingly being acknowledged as a crucial aspect of the overall healthcare experience, with a general appreciation that the waiting period is not the best part of the healthcare experience for patients and families.

Positive distractions in pediatric waiting rooms promote a positive healthcare experience
Positive distractions in pediatric waiting rooms promote a positive healthcare experience


Prior studies on waiting

Studies are providing more information on the waiting experience. A 1996 article, published in the Annals of Emergency Medicine, reported that it is not the actual wait time, but the perception of wait time that is the determining factor in patient satisfaction.

The International Journal of Research in Marketing subsequently reported that the attractiveness of the waiting environment has a greater role in contributing positively to the waiting experience, as compared to reducing the objective waiting time.

A 2008 report from Cornell University further articulated the potential association between the quality of the waiting environment, the perceived waiting experience, and the overall healthcare experience. Sets of independently collected data on environmental attractiveness and a host of perception measures from actual patients in six clinic waiting areas demonstrated significant correlations between the attractiveness of the physical environment and perceived waiting time, perceived care quality, level of anxiety, and quality of interaction with staff.

These findings raise important questions. What attributes of the waiting area contribute to environmental attractiveness? Are those architectural elements, interior elements, the artifacts in the environment or all of the above? The key underlying phenomena that is producing these results appears to be the diversion of one’s attention from the immediate ailment to environmental stimuli that is pleasant to the senses.

Debajyoti Pati, PhD, FIIA, LEED AP
Debajyoti Pati, PhD, FIIA, LEED AP


If the attention-diversion hypothesis is true, then introducing positive distractions in the waiting area could contribute positively to the attractiveness of the waiting area environment. Or will it? Is the impact of positive distractions only evident in the ultra high-stress and painful processes of examination and procedures, and less relevant to passive situations such as waiting?

The HKS study

To investigate in detail, the HKS Clinical Solutions & Research (CS&R) team, in collaboration with American Art Resources, designed a study to examine the influence of positive distractions in the dental and cardiac clinic waiting areas at Children’s Medical Center of Dallas.

A positive distraction has been defined as “an environmental feature that elicits positive feelings and holds attention without taxing or stressing the individual, thereby blocking worrisome thoughts.” The term distraction itself refers to “the direction of attention to a nontoxic event or stimulus in the immediate environment.”

A number of studies have shown beneficial impacts of positive distractions on both adults and children undergoing procedures and treatments. These studies have associated positive distractions with reduction of pain, anxiety, stress, fatigue, distress, and other physiological and psychological outcomes. However, the concept of using the attention-diversion potential of positive distractions in the waiting areas had not been examined.

Pediatric waiting areas were chosen, since they constitute one of the most challenging situations. Holding children’s attention is considerably more challenging than those of adults. In addition, children with Attention-Deficit Hyperactivity Disorder (ADHD or AD/HD), a neurobehavioral developmental disorder, could display characteristics of attention problems and hyperactivity with each behavior occurring infrequently alone.

In the case of autistic children, the issue is further compounded by their variable sensitivity to sensory stimuli. A considerable proportion of the children visiting the dental clinic have various forms of neurological challenges (close to 48% in the sample), which was not the case at the cardiac clinic. This provided the opportunity to include population with attention and behavioral challenges in the study sample.

Five distraction conditions were created in the two clinic waiting areas:

  1. Nature slide show without audio
  2. Aquarium with audio
  3. Aquarium without audio
  4. Ambient art with audio
  5. Ambient art without audio

Ambient art is a relatively newer genre of art typology that uses modern technology to create a number of visual and audio teasers within a common art theme, where the teaser segments are displayed in a predetermined manner to maintain attention of the audience until the end. The conditions were manipulated using a 32-inch flat screen television. An electronic medium was used since electronic-based audio and/or visual displays will increasingly dominate the healthcare environment in the future.

Distraction conditions were randomly displayed on the monitor for a 10-minute duration, followed by a 10-minute no-distraction condition (as a control condition). Data on behavior and activities of the children were recorded using a systematic observation protocol by trained observers. Data was collected during December 2008 and January 2009.

Key findings

Data on 158 pediatric patients show that even in passive activities such as waiting, positive distractions attract considerable and meaningful attention. The surprise finding, however, was that the significant diversion of attention between the distraction and no-distraction conditions held true for both the cardiac population as well as the dental population.

When the flat screen monitors were turned on-providing positive distractions-attention was increased 26% in the dental clinic and 20% in the cardiac clinic. An increased attention on the positive distraction also effected a significant reduction in attention on toys, other people, books, and themselves.

Per the HKS study, views to nature-located on a flat-screen television at Children's Medical Center of Dallas-provided pleasant distractions for patients and visitors
Per the HKS study, views to nature-located on a flat-screen television at Children’s Medical Center of Dallas-provided pleasant distractions for patients and visitors


The presence of positive distractions was also associated with changes in physical behavior. Calm behavior increased by seven percent in the dental clinic and by nine percent in the cardiac clinic.

“Our goal is to create an excellent patient and family experience from the time the families arrive to the time they leave,” says Joy Parker, RDH, MS, practice administrator/dental and orthodontic service for Children’s Medical Center of Dallas. “That includes our wait time. We want to put the patient at ease-even before entering our dental clinic. For most, going to the dentist is an anxious event.

“The results from the study help us to better equip our wait areas and potentially change the way in which we create our environment for patients who are in the dentist’s chair,” says Parker.

The Dental Clinic waiting area at Children's Medical Center of Dallas
The Dental Clinic waiting area at Children’s Medical Center of Dallas


The study found that kids waiting in the dental clinic were more attracted to view and listen to the video while kids in the cardiac clinic preferred distraction conditions without sound.

Dental Clinic: Behavioral Differences between Distraction and No-Distraction Conditions

Attention type Mean (%) during distraction conditions Mean (%) during no-distraction condition (%) Difference
Note: Only statistically significant differences included
TV monitor 27.73 2.16 25.57
Toy 4.24 8.22 -3.98
People 36.12 51.64 -15.52
Physical behavior type
Calm 64.92 58.3 6.62
Fine movement 10.79 15.36 -4.57
Gross movement 2.63 5.18 -2.55
Social behavior type
Positive interaction 20.33 32.16 -11.83
Solitary behavior 76.07 65.45 10.62

Cardiac Clinic: Behavioral Differences between Distraction and No-Distraction Conditions

Attention type Mean (%) during distraction conditions Mean (%) during no-distraction condition (%) Difference
Note: Only statistically significant differences included
TV monitor 20.58 0.41 20.17
Toy 19.13 13.16 5.97
Book 8.09 15.47 -7.83
People 32.27 44.36 -12.09
Themselves 6.75 11.6 -4.85
Physical behavior type
Calm 68.88 59.92 8.96
Gross movement 1.28 3.49 -2.21
Activity type
Play with Non-Toys 9.24 14.95 -5.71
Joy Parker, RDH, MS
Joy Parker, RDH, MS

“Because our population is really dedicated to children who have complex medically special needs, they are highly likely to have some type of visual disturbances or are more acutely aware of other stimuli that involve all of their senses,” says Parker. “A child with a cardiac condition might not necessarily have any type of cognitive or developmental delay such as we see in the population treated in our dental service. We see a high number of autistic, cognitive/developmental delayed children. The noise gets their attention.”

Design implications

Calm behavior is associated with reduction of chaos-a major contributor to stress in staff and families in waiting areas. The reduction of chaos, in turn could impact the waiting experience of the accompanying adult.

The fact that positive distractions are such attention-grabbers implies that artifacts in the waiting environment need to be selected more carefully. This is especially true for the electronic media that are increasingly being used in hospitals. The five distractions used in this study had one commonality-all had nature themes. Nature-themed distractions have been shown in a number of studies to have a positive impact on patients.

Further studies are required to examine the comparative advantages or disadvantages of the wide variety of distractions used indiscriminately in hospital environments. Pending such information, positive distractions should be considered more systematically and holistically during design as well as value engineering processes. HD


Dr. Upali Nanda, Director of Research at American Art Resources, contributed to this study as co-investigator. This study was partially funded by financial grants from American Art Resources, Catherine Mayer Fine Art, Mohawk, Henry Domke Fine Art, and Gail Nash.

Debajyoti Pati, PhD, FIIA, LEED AP, is Director of Research at HKS Architects, Inc.

For more information, visit http://www.hksinc.com.

Healthcare Design 2010 March;10(3):28-34