A room with a view

It only seems appropriate to begin examining the effects of green space on health by reviewing the early work of Roger Ulrich. Ulrich is a behavioral scientist who has done extensive research on the effects of healthcare facility design and medical outcomes, including the effect of nature on health outcomes.
While many, both scientists and the lay public, often believe nature is beneficial to one’s health, which Ulrich refers to as the “Health benefit assumption”, there was little to no scientific evidence confirming this assumption before 1979. Despite the lack of evidence, numerous urban green spaces were created to improve the wellbeing of city dwellers.
This scientific gap motivated Ulrich to carry-out studies to evaluate how visual exposure to outdoor environments influenced well-being (Ulrich, 1979 and 1981). These studies found that nature landscapes in the form of photographs resulted in decreased stress when individuals viewed photos of vegetation or water as compared to urban landscapes, with greater improvements observed among individuals who were stressed at the start of the experiment.
These studies, as well as, Ulrich’s personal experience during a childhood illness in which he believed the view of a pine tree outside his bedroom window helped his emotional state, led him to design a study investigating the association between window view (trees vs. brick wall) and recovery from surgery. Published in Science (Ulrich, 1984), this paper raised people’s conscientiousness about the potential positive effects of green space on health, and is considered a seminal paper in the field.
Using hospital records from 1972 to 1981, Ulrich identified and abstracted recovery data on 46 patients who received cholecystectomies, a common type of gall bladder surgery, at a hospital in Pennsylvania. He matched patients on sex, age, smoking status, being obese or normal weight, general nature of previous hospitalization, year of surgery, and floor level of the hospital (2nd or 3rd floor). Patients on 2nd floor were also matched on the color of the room. One member of the matched pair (23 pairs) had a room with a window view of trees, while the other member had a window view of a brick wall. Rooms were similar in all other aspects, and room assignment was based upon availability.
Ulrich found that:
© 2012 Leila Jackson
© 2012 Leila Jackson
  1. Patients with a window view of the trees spent significantly less time recovering in the hospital compared to those with views of the brick wall (7.96 days vs. 8.70 days per patient, respectively).
  2. Individuals having the tree view had significantly fewer negative notes in their medical record (e.g. “upset and crying” or “needs much encouragement”) as compared to those with the brick wall view (1.13 notes vs. 3.96 notes per patient, respectively).
  3. The mean number of pain doses 2-5 days after recovery differed significantly between the two groups. Those with a tree view had fewer moderate and strong pain doses and more weak pain doses than those with a brick wall view (strong doses: 0.96 vs. 2.48 doses, moderate doses: 1.74 vs. 3.65 doses, weak doses: 5.39 vs. 2.57 doses, respectively).
  4. Though not statistically significant, the tree-view group had fewer post operative complications than the brick wall group.
This study had some potential limitations that should be considered when interpreting the results:
  1. The researchers excluded patients with serious complications. If patients with serious complications were more or less likely to be in rooms with tree-views than rooms with brick wall-views, this could have biased the results.
  2. Rooms with the brick wall view were slightly closer to the nurse’s station. Therefore, if two rooms were available at the same time, a patient with more complications may be put in a room closer to the nurse’s station which would more likely be a room with a brick wall view. This could explain the poorer outcomes among this group if this occurred frequently.
  3. The researchers were unable to match patients on the surgeon given the large number of doctors performing surgeries over the study period. This could have introduced some bias if doctors were assigned based upon the difficulty of the surgery, and/or if surgical outcomes varied by doctor.
  4. The researchers measured the length of recovery in days, and not hours or minutes which could have resulted in bias if the timing of surgery and discharge varied greatly between the two groups.
  5. Finally, nurse’s notes in medical records can be subjective and non-standardized, and the nurse’s mood equally could have been influenced by the window view when making notes or interacting with the patient.
It is unclear to what extent these limitations affected the study results, if at all. Regardless, this study provided provoking evidence that window views may influence recovery from surgery, and that green space, in general, may influence well-being. No longer was the “Health benefit assumption” just an assumption, but there was now some evidence to help support what people had believed for many, many years. This prompted additional studies to examine the effects of nature and green space on healing and general well-being, which we will explore in future posts.