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Wall color of patient's room: effects on recovery

University of Florida Institutional Repository

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WALL COLOR OF PATIENT’S ROOM: EFFECTS ON RECOVERY By KORTNEY JO EDGE A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF INTERIOR DESIGN UNIVERSITY OF FLORIDA 2003

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Copyright 2003 by Kortney Jo Edge

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iii ACKNOWLEDGMENTS I want to thank my thesis committee for th eir assistance in the completion of this thesis. Dr. M. Jo Hasell and Dr. John P. Marsden were able to successfully guide me through the trials and tribulations of this research project. My sincere thanks go out to the wonderful staff at Shands Hospital for the knowledge they provided me about the workings of a hospital. Brad Pollitt and Tina Mullen provided information from the perspe ctive of the facilities department. Dr. Paulus, Dr. Gravenstein, and Dr. Graham-Pole provided valuab le insight into the area of healing and recovery. A special thank you goes out to Marcia Kent and the entire staff of the cardiac care unit of Shands Hospital. Their cooperation and interest in this study made it an extremely enjoyable experience. Lastly, and most importantly, I would like to thank my family and friends. Without their constant support and enc ouragement this project would have never been completed. They provided me with the strength to follow my dreams.

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iv TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iii LIST OF TABLES.............................................................................................................vi LIST OF FIGURES.........................................................................................................viii ABSTRACT....................................................................................................................... ix CHAPTER 1 INTRODUCTION........................................................................................................1 Purpose........................................................................................................................ .1 Significance..................................................................................................................2 Basic Assumptions........................................................................................................5 Hypotheses of the Study...............................................................................................6 Summary.......................................................................................................................6 2 REVIEW OF LITERATURE.......................................................................................8 Color Explained............................................................................................................8 Historical Overview of Beliefs A bout the Healing Power of Color.............................9 Intuition, Beliefs, and Research-Based Evidence About the Effects of Color...........12 Laboratory Studies on Huma n Responses to Color....................................................13 Chromotherapy Explained...................................................................................16 Cardiac Illness and Patient Respons es to Environmental Factors..............................17 Summary.....................................................................................................................19 3 METHODOLOGY.....................................................................................................20 Hypotheses..................................................................................................................21 Research Setting.........................................................................................................22 Participants.................................................................................................................27 Data Collection...........................................................................................................28 Gaining Consent..................................................................................................29 State-Trait Anxiety Inventory..............................................................................30 Documenting Length of Stay and Medication Requests.....................................31 Discussions with Staff and Patients.....................................................................32

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v 4 FINDINGS..................................................................................................................33 Anxiety Level.............................................................................................................33 Gender and Anxiety.............................................................................................37 Window View and Anxiety.................................................................................39 Surgery and Anxiety............................................................................................41 Length of Stay.............................................................................................................44 Pain Medication Requests...........................................................................................45 Patients’ Opinions About the Colors..........................................................................49 Hospital Employee’s Opinions About the Colors......................................................51 5 DISCUSSION.............................................................................................................53 Limitations and Assumptions.....................................................................................57 Suggestions for Further Research...............................................................................59 Conclusion..................................................................................................................62 Framework for Future Researchers............................................................................63 APPENDIX STATE-TRAIT ANXIETY INVENTORY (STAI)....................................66 LIST OF REFERENCES...................................................................................................67 BIOGRAPHICAL SKETCH.............................................................................................70

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vi LIST OF TABLES Table page 2.1 Human Responses to Color ...................................................................................15 3.1 Number of male and female patient s who occupied each colored room...............28 4.1 Average anxiety levels of patients occupying rooms of each color.......................34 4.2 Chi-squared test for color and anxiety levels.........................................................36 4.3 Fischer’s Exact Test on co lor and anxiety levels...................................................37 4.4 Number of male and female patient s who occupied each colored room...............37 4.5 Anxiety scores of the fe male and male patients.....................................................38 4.6 Number of patients in each colored room based upon location of bed..................40 4.7 Mean anxiety scores for patients in re lation to their proximity to a window........40 4.8 Number of surgery and observation pa tients in each set of colored rooms...........41 4.9 Mean anxiety levels of surgery patients and observation patients.........................42 4.10 Mean anxiety of the surgery patients based upon the color of the room they occupied.................................................................................................................42 4.11 Chi-squared test on color and anxiet y levels within surgery patients....................43 4.12 Mean anxiety of the observation patients based upon the color of the room they occupied.................................................................................................................43 4.13 Chi-squared test on color and anxiet y levels within observation patients.............44 4.14 Average length of stay for surgery and observation patients recovering in each set of colored rooms...............................................................................................45 4.15 Number of patients who requested medi cation during their stay in each colored room.......................................................................................................................46

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vii 4.16 Average number of medicati on requests by surgery patien ts during their stay in the hospital.............................................................................................................47 4.17 Average number of medi cation requests by observation patients who request pain medication during their stay in the hospital...................................................49

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viii LIST OF FIGURES Figure page 3.1 Layout of the fifth floor cardiac care unit at Shands Hospital.................................23 3.2 Enlarged layout of a typical room in the cardiac care unit at Shands Hospital........25 3.3 Purple paint color.....................................................................................................26 3.4 Green paint color......................................................................................................26 3.5 Orange paint color....................................................................................................27 3.6 Beige paint color......................................................................................................27

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ix Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Interior Design WALL COLOR OF PATIENT’S ROOM: EFFECTS ON RECOVERY By Kortney Jo Edge August 2003 Chair: M. Joyce Hasell Cochair: John P. Marsden Major Department: Interior Design This pilot study examined the effects of the environmental factor color on a patient’s recovery in the hosp ital. The literature suggested that there are many widely held beliefs and intuitions about the healing pow ers of color. However, this researcher found no scientific studies on color completed within a natural hospital setting, rather than in a laboratory. Based on previous research on environmen tal factors, the recovery of cardiac patients was examined by assessing their anxi ety levels, lengths of stay, and medication requests, within a control setting and an experimental setting. The study was conducted within ten rooms of a hospita l cardiac care unit. A mid-t one shade of either purple, green, or orange was painted on the wall at th e foot of the bed in six of the patients’ rooms. Beige was the paint color in the other four rooms. An anxi ety test was given to the 39 participants in the study to determine if a particular color promoted a higher level of anxiety. The participants’ lengths of stay and medication requests were also noted to

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x determine if these variables were affected by the particular color painted in each room. Informal interviews were also conducted on the patients and staff regarding their particular preferences for certa in colors. Throughout the stu dy, notes were kept regarding patient and staff commen ts about the colors. There were no significant findi ngs to determine that anxiety levels, lengths of stay, or medication requests were dependent upon th e color of the patient’s room. Having no significant findings is believed to be caused mainly by the small sample size. Additionally, the pilot study revealed numerous variables that may also play a role in patient recovery. Many things about conduc ting a study within a hospital environment were learned through this study and a framework for future research in the area of color in the medical environment was developed. The guidelines for future research provided in this study recommend further testing in a na tural research setting such as a hospital to learn more about the role that color plays on patient well-being.

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1 CHAPTER 1 INTRODUCTION As early as 1888, Florence Nightingale assert ed that environmental factors have an effect on health and recovery. She was quoted as saying (Palmer and Nash, 1997:148); The effect in sickness of beau tiful objects, of variety of objects, and especially of colour is hardly at all appr eciated. I have seen in fe vers (and felt, when I was a fever patient myself) the most acute suffe ring produced from the patient not being able to see out of a window and the knots in the wood being the only view. I shall never forget the rapture of fever patients over a bunch of bright coloured flowers. People say the effect is only in the mind. It is no such thing. The effect is on the body, too. Little as we know about the wa y in which we are affected by form, by colour, and by light, we do know this; they ha ve an actual physical effect. Variety of form and brilliancy of colour in the objects presented to patients are actual means of recovery. Purpose The purpose of this study is to explore how one environmental feature, namely color, may impact patient recovery in the cardiac care unit of Shands Hospital in Gainesville, Florida. Shands Hospital is located at the University of Florida and is a 576bed private, not-for-profit hospital Shands specializes in ter tiary care for critically ill patients and is the primary teaching hospital for the University of Florida College of Medicine. Using the cardiac care unit of the hospital is significant to this study because medical researchers believe that coronary diseases are substan tially influenced by environmental factors related to st ress (MacMahon and Lip, 2002). Designers have a responsibility for creating spaces that will help patients to become healthier in a shorter amount of time. Poor design is believed to be associated with anxiety, delirium, elevated blood pressure, a nd an increased intake of pain medication

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2 (Ulrich, 1991). Although, research on huma n responses to specific colors has been conducted in laboratory settings, this rese archer found no scientific research about whether or not a specific color can effect a patient’s recovery process. A natural research setting, within the interior of a hosp ital unit, provides a uni que challenge to learn about the relationship between people and the phys ical environment. It is believed that color will express the way we feel by either raising or lowering our spirits (LaddFranklin, 1973). Based on the beliefs of colo r researchers, this st udy tested whether or not color had a positive impact recovery and that orange, co nsidered a universal healer, had a greater impact than green or purple. This research aims to provide the interi or design profession as well as the medical profession with a source of knowledge that will provide evidence about the physical environment’s impact on patient well-being. It is hoped that this study will demonstrate that a designer’s personal preference for a part icular color should have little to do with the selection of colors in hospitals. Inst ead, colors should be chosen based upon their ability to aid in the patie nts’ recovery process. Significance Environmental factors have a tremendous im pact on the behaviors that occur within particular building settings. Beginning in the 1960’s, designers began to believe that, “If a man can manipulate his surroundings to improve his physical well-being, they reasoned, he can manipulate it to foster de sired behavior and to eliminate negative responses” (Chaney, 1973:61). This concept play s a large role in the design of hospital facilities. Under normal situations, when pe ople feel uncomfortable with their physical environment, they can solve the problem by simply leaving or adapting the environment (Malkin, 1992). Unfortunately, this is not the case in healthcare facilities. Patients are

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3 held captive in their environments and have no control over leav ing or changing the environment, and this condition places an in credible responsibility on designers (Malkin, 1992). Designers face a great challenge in designing a positive hospital interior environment. Patients enter a hospital se tting already suffering from some ailment; therefore, it is extremely important that the design positively impacts the patients’ psychological states, contributes to their recovery, or at l east does not exa cerbate their illness (Chaney, 1973). Roslyn Lindheim, a criti c of the modern hospi tal facility says (Verderber, 1983:17); The adjectives used to describe hospita ls include dehumanizing, depersonalizing, neutering, frightening, uncaring. I have neither heard anyon e describe a hospital as beautiful, peaceful, healing, warm, joyous …indeed a look at the modern hospital speaks not of human healing but of our tec hnological progress, not of caring but of an increase in the G.N.P. (Gross National Product), not of generating health but of saving jobs and institutions. Despite this the belief in hospita ls is strong today. Modern hospitals face a great ch allenge to not only care for the ill, but also to run a successful business. By caring for patients, in a timely manner, hospitals are able to be profitable, efficient, and to improve the car e of patients (UCLA, 1987). Today’s patients are consumers. If the hospital does not cr eate a welcoming, healing environment, the patients will go elsewhere. The Vidar Klinik is a hospital that was created with healing in mind (Moore, 2000). Wall colors were chos en in this hospital based upon Austrian theoretician, Rudolf Steiner’s philosophies about the hea ling powers of color (Moore, 2000). The patient rooms were painted pink or blue. Pink is believed to be healthful for the spirit and blue is believed to relieve migraines (Moore, 2000). The majority of the patients in this hospital are cancer sufferers or are patients being treated for depression (Moore, 2000). With this in mind, patients in the Vidar Klinik are placed in rooms with

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4 particular wall colors depending on their illne ss. There have been no studies completed to determine the effectiv eness of this strategy. Many designers remain skeptical about the effects of human responses to environmental factors and continue to se lect colors based on their own personal preferences, despite many researchers’ at tempts to document the effects of color on human behavior and physiologi cal systems of the body with in a laboratory setting. However, if one sees the hospital from a quadr iplegic’s point of view, then the effects of the environmental factors can be fully apprec iated. A quadriplegic’s view is limited to that in a fixed, horizontal positi on in bed day in and out. Ther efore, his or her behavioral, physical, and psycho-emotional repertoire of coping mechanisms is much more restrictive than that of an average, healthy individu al (Verderber, 1983). With this example, it is easy to comprehend how the na tural light entering th e room, the color of the walls, the art that hangs on the walls, and anything else th at is within immediate view of the patient can effect not only a quadri plegic patient but ot hers as well. In 1997, The Center for Health Design co mpiled a list of environmental design features that were considered important to creating higher quality interiors in healthcare environments. This list of possible research areas included texture or finish of walls and furnishings, noise, windows, and color of wa lls and furnishings (Rubin et al., 1998). These researchers conducted an extensive review of the existing published articles that explored how particular envir onmental factors effected patient s. They found no scientific published articles that addressed the issue of co lor (Rubin et al., 1998). The physiological effect of visible color in a natural setting has not been documented by

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5 medical science (Birren, 1961), despite many wide ly held beliefs and declarations about the impact of color on people. Although the literature review for this work did not reveal any research on how color effects a patient’s recovery in a hosp ital setting, there are two significant studies that suggest that environmental factors can effect a patient’s rec overy in healthcare facility design. Verderber (1983) and Ulri ch (1984) both conducted research on the effects of a window on a hospital patient’s well-being. Verderber (1983) found that a patient’s proximity to a window and the view context out the window had an effect on the patient’s well-being. Ulrich’s (1984) study showed that the patient’s recovery was effected by whether he or she had a view of a natural scene or a view of a brick wall. These two studies are related to the current research on wall color in a patient’s room because they show that patients’ wellbeing and recovery can be effected by environmental factors. Currently, there are no subs tantive guidelines for the selection of color in healthcare facilities (Malkin, 1992). In fact, Faber Birren believes that, “the medical profession has always been wary of any claims for color theory chiefly because all color experience is highly personal and difficult to test and verify” (Pierman, 1976:5). This study will test the impact of wa ll color at the foot of a patient’s bed on recovery in order to provide the interior design profession with a source of knowledge that may help professionals design the most beneficial healthcare facilities for patients. Basic Assumptions The basic assumptions made in relati on to this study were the following: 1. The participants of the study are suffering from a cardiovascular illness and therefore are temporarily residing in the cardiac care unit of a hospital.

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6 2. Being cardiovascular patients, it is assumed that the typical stay in the hospital will be between three and four days. 3. Orange, green, purple, and beige painted wa lls at the foot of a patient’s bed are assumed to cause differences in the anxi ety levels, lengths of stay, and pain medication requests of the participants. 4. A hospital situation with cardiovascular patients can be used to determine the degree of differences in their anxiety leve ls, lengths of stay, and pain medication requests as influenced by the wall color at the foot of their bed. 5. The State-Trait Anxiety Inventory can be us ed to measure the participants’ levels of anxiety. 6. The participants’ medical r ecords can be used to determine the lengths of stay and the pain medication requests. Hypotheses of the Study Three hypotheses are defined for this study. 1. There is a relationship between the color on the wall at the foot of the patient’s hospital bed and anxiety levels in a hospital setting. 2. There is a relationship between the color on the wall at the foot of the patient’s hospital bed and recovery time in a hospital setting. 3. There is a relationship between the color on the wall at the foot of the patient’s hospital bed and the amount of pain me dication requested in a hospital setting. Summary Investigating the psychologi cal attributes of color can further the understanding of its effect on patient well-being. Research ha s shown that environmental factors have an effect on patient well-being, but evidence on how patients are effect ed by wall color in their hospital room is lacking. Chapter 2 inve stigates some ancient beliefs about color, gives a brief definition of color, and explores studies on human responses to color. The chapter also describes how heart disease is effected by environmental factors and how color therapy is believed to work. Chapter 3 explains the methods used to conduct this

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7 research on how color effects a patient’s rec overy, and chapters four and five report the findings of this research and the rese archer’s conclusions about this study.

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8 CHAPTER 2 REVIEW OF LITERATURE It is believed that color can effect human emotions and can induce physiological responses. Kenneth Edwards (1979) has shown that if people are e ffected by color in their normal lives, then they are even more susceptible to the effects of color on their behavior when they are not f eeling their best. Thus, an a ppropriate color scheme may aid in a patient’s recovery (Carpman, 1993). Th e following review of literature attempts to explain the relationship between co lor and psychological well-being. Color Explained “Color is that part of pe rception that is carried to us from our surroundings by differences in the wavelengths of light, is pe rceived by the eye, and is interpreted by the brain” (Nassau, 1997:3). The human eye does not have the capacity to see color. Light reflects off surfaces and triggers an electrochem ical response in the eye, which translates into color within the brain (Miller, 1997). Different colored surfaces are distinguished by a different pattern of nerve signals that ar e generated by color receptors found within the retina of the eye (Verity, 1980). There are two types of rece ptors found within the retina, called rods and cones. The cones are the ones responsible for the perception of color (Verity, 1980). Cones can detect visible wa velengths between 400 (violet) to 700 (red) nanometers (Miller, 1997). Color can be measured with spectrophot ometers and radiometric colorimeters. Spectrophotometers measure the reflection char acteristics of an object in wavelengths (Nassau, 1997). Spectrophotometers illuminate the object with polychromatic light,

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9 which contains all the wavelengths in the visible spectrum, and analyzes the light reflected off the surface of th e object (Nassau, 1997). Radiometric colorimeters detect color in a similar way as spectrophotometers do, with the exception that they can only measure self-luminous objects, such as lamp s, displays, and computer screens (Nassau, 1997). Paints are comprised of pigments, which ar e chemical components that selectively reflect colored light to the observer (Verit y, 1980). The primary pigment colors are magenta, cyan, and yellow, which can be mi xed together to produce innumerable colors (Verity, 1980). Pigments absorb wavelengt hs, transmit wavelengths, and bend light in different directions (Nassau, 1997). The pigm ent is a finely ground organic or inorganic material that is combined with a liquid vehi cle before it can be a pplied to a surface in a paint form (Verity, 1980). Organic material s are derived from vegetable or animal sources, native earths, and calcium natural earths (Verity, 1980). Today, inorganic, or synthetic pigments are more often used than organic materials (Verity, 1980). In order to perceive color fully, hue, saturation, and brightness need to be described. Hue describes the actual color (Nassau, 2001). The hues that the human eye sees are determined by reflected wavelengt hs (Miller, 1997). Satu ration describes how pure the color is, or how much white is mi xed in (Nassau, 2001). A high-saturation hue is bright and vivid (Miller, 1997). Bri ghtness describes how much light a surface receives. Brightness differentiates objects from their backgrounds and provides shade and shadow (Miller, 1997). Historical Overview of Beliefs About the Healing Power of Color “Color is an ubiquitous, primary, and nonve rbal aspect of human environments, and investigating its psychol ogical significance furthers th e understanding of human

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10 behavior on the most basic level” (Ireland et al. 1992:1). Thr oughout history, color has been assumed to have an effect on health. The Assyrians, Babylonians, and Egyptians all used forms of color and light therapies in healing (Demarco and Clarke, 2001). The Persians are believed to have practiced a form of color therapy based on the emanations of light (Birren, 1961). Pythagoras, a Greek philosopher around 500 BC, is believed to have used music, poetry, and color to cure disease (Birren, 1961). Celsus, who practiced medicine at the beginning of th e Christian era, prescribed me dicine with color in mind. He once wrote, “there is one plaster almost of a red color, which seems to bring wounds very rapidly to cicatrize” (Birren, 1961:21). The early be liefs behind the healing power of color were fairly simple. “Colors were associated with disease because disease produced color” (Birren, 1961:35) The Egyptians were the fi rst civilization to research color healing. They created “color halls” within their great temples, such as Karnack and Thebes, in which they explored the impact of color on an individual’s ability to heal (Anderson, 1975). With the advancement of modern medicine the interest in th e healing power of color was left to the artists and poets. Johann Wolfgang von Goethe (1749-1832) was a famous German poet, who developed his own theory on color, which explained, Experience teaches us that the individual colours induce particular moods. In order to experience fully these important indi vidual effects the eye should be entirely surrounded by one colour; we should be in a room of one colour, or look through a coloured glass. We are then identified with the colour; it induces both eye and mind in unison with it. (Boos-Hamburger, 1963:5) Goethe had very particular beli efs as to what emotions part icular colors would induce. He believed that orange gave people a warm feeling that is reminiscent of the setting of the sun (Boss-Hamburger, 1963). Goethe belie ved that green was very satisfying to the eye. “If both mother colours (yellow and blue ) are absolutely balanced in the mixture so

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11 that neither is more noticeable than the othe r, the eye and the mind rest on the mixture as though on something simple. Therefore, a green wallpaper is so often chosen for a room which is in constant use” (B oss-Hamburger, 1963:7). Further, Goethe believed that a very pale form of purple has a certain am ount of life in it, but no joyousness (BossHamburger, 1963). Through the efforts of S. Pancoast in 1877, color therapy was reunited with medicine. He wrote, “to accelerate the Nervous System, in all cases of relaxation, the red ray must be used, and to relax the Nervous Sy stem, in all cases of excessively accelerated tension, the blue ray must be used” (Birren, 1961:53). Around this same time, Edwin D. Babbitt began to wonder how to incorporate co lor therapy with modern medicine. He wrote, Substances combine in a harmonizing union with those substances whose colors form a chemical affinity w ith their own and thus keep up that law of equilibrium which is the safety of all things. This law having been so abundantly explained, it is obvious beyond guesswork, that if the re d arterial blood vessel should become overactive and inflammatory, blue light or some other blue substance must be the balancing and harmonizing principle. While again if the yellow and to some extent the red and orange principle nerves s hould become unduly excited, the violet and also the blue and indigo woul d be the soothing principles to have applied. This applies to the nerves of the cranium, stomach, bowels, and kidneys, as well as elsewhere, in which the heating and expa nsive action of these thermal principles may beget the condition of delirium, emesis diarrhea, diuresis, etc., that can be assuaged only by the cooling and contrac ting influence of substances possessing the electrical colors. Can this law, which thus stands out clearly and simply like a mathematical demonstration be shown to have a basis in actual practice harmony with the experiences of the medical wo rld for ages back? (Birren, 1961:57-8). Although there is no scientific backing to the historical be liefs about the association between color and health, the historical be liefs found show the long standing fascination with the association. This association can be dated back to 500 BC, and yet there is still a lack of scientific evidence to pr ove the effects color has on health.

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12 Intuition, Beliefs, and Research-Based Evidence About the Effects of Color Today there are numerous widely held beliefs about the effects of color on humans, but very few theories that have a scientif ic backing. Two Univ ersity of Washington researchers, B.K. Wise and J.A. Wise, revi ewed previous research, and came up with a summary of what is empirically known about responses to color (Carpman, 1993). They also looked at the perception of a setting on one’s behavior in that setting. After reviewing over 200 laboratory studies they f ound that, “A positive reaction to color is a mixture of social and emotional context and general fashion, as well as a specific response to the interaction among light sour ce, background color, a nd object order.” They also found that, “Perceived appropriatene ss of colors varies with the function and style of an interior; includi ng its decoration and with educ ation and sociocultural norms (taste). Characteristic appearance preferen ces for each style are unique to that style” (Carpman, 1993:174). When classic color pr eference studies were examined (Park and Guerin, 2002), it was found that various colors have different meanings to different cultures. These differences effect their prefer ences for certain colors that can ultimately effect their cognitive and moto r abilities. Further, Park and Guerin (2002) discovered that there is a relationship between color a nd meaning, and that the most preferred hue temperature, value level, chroma level, and contrast level depends on the culture. Certain colors tend to stimulate the body’s functions in different ways. Marberry (1995) believes that the immune system detect s elements of the environment, such as color, that elude other senses. Dr. Deepak Chopra believes that, “ our immune cells are constantly eavesdropping on our internal conv ersations. Immune cells are thinking cells, ‘conscience little beings’ like brain cells, equi valent to a circulat ing nervous system” (Marberry and Zagon, 1995:86). This idea may contribute to the causation of illness.

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13 According to Carol Vernolia (1988:63), “Red stimulates and invi gorates the physical body. It increases circulation, muscular ac tivity, blood pressure, respiration, nervous tension, heart rate, and hormonal and sexual ac tivity. It stimulates the nervous system, liver, adrenals, and senses in general.” Yellow raises blood pressure, pulse and respiration. It can relieve de pression, tension, and fear, a nd soothe mental and nervous exhaustion (Vernolia, 1988). Orange is an appe tite stimulate, and is seen as a universal healer that can counteract de pression and humorlessness (Ver nolia, 1988). Green effects the whole nervous system and is especially beneficial to th e central nervous system. It has a sedative effect, relieving irritation and exhaustion. It soothes emotional disorders and nervous headaches (Vernolia, 1988). “Green harmonizes us. If we wish to refresh ourselves we go to the countryside, where the green of nature restores us after the city has taken its toll of our nerves” (Anderson, 1975: 8). Purple induces relaxation and sleep, lowers body temperature, and decreases sensitivit y to pain. It also increases the activity of the veins (Vernolia, 1988). Laboratory Studies on Human Responses to Color Laboratory research studies have shown th at color can have a direct effect on a person physically, as well as, mentally. Ku rt Goldstein is a re cognized authority on psycho neurology. He wrote, “It is probably not a false statemen t if we say that a specific color stimulation is accompanied by a specifi c response pattern in the entire organism” (Birren, 1961:144). His studies have docum ented the effects of specific colors on individuals having certain diseas es. In one such case, a woma n with a cerebellar disease had a tendency to fall unexpectedly and to walk with an unsteady gait. When she wore a red dress, her symptoms were more pronounce d. Green and blue cl othing restored her equilibrium to almost normal (Birren, 1961). Another study showed that when patients

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14 suffering from tremors and twitching wore gr een glasses, their sy mptoms were relieved (Birren, 1961). The Environmental Docility Hypothesis, developed by M. Powell Lawton, states that, “the less competent the individual, the greater the impact of environmental factors on the individual” (Malkin, 1992:47). A patient ’s emotions can be related to their environment, which can effect wellness. Cohen (1986) found that environmental stress, or a situation in which the demands on an individual tax or exceed his adaptive capabilities, could effect a person’s p hysiological and psychological well-being. Research on the psychological effects of color has been difficult because human emotions are not stable and an individual’s psychic ma ke-up varies from person to person (Birren, 1961). In 1976, a special workshop, “Color in the He alth Care Environment,” was held at the National Bureau of Standards in Gaith ersburg, Maryland. This workshop brought together the architects, engineers, financ ial institutions, build ers and users of the healthcare facilities. Marcella Graham (Pierman, 1976), an environmental design consultant, was a speaker at the workshop. Graham believes that the human response to color falls within six categories, which are shown in Table 2.1.

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15 Table 2.1. Human Responses to Color (Pierman, 1976). Physiological: Changes in blood pressure, pulse rate, automatic nervous system, hormonal activity, rate of tissue oxidation and growth. Within the eye: Change in size of pupil, shape of lens, position of eyeball, chemical response of retinal nerve endings. Cognitive: Memory and recall illusi on and perceptive confusion, values judgment, associative response Mood: Stimulating, irritating, ch eerful, relaxing, boring, exciting, melancholy, gay Impressionistic: Space seems larger, sma ller, warmer, cooler, clean or dirty, bright or drab; people appear healthy or unhealthy, food is appetizing or not, olde r, younger, old, new Associative: With nature, with techno logy, religious and cultural traditions, with art and science, typical or atypical Some of the responses that Graham pred icts color can produce may be detrimental to a patient’s recovery within the hospital setting. Alterations in blood pressure due to an organismic or physiological response or cha nges in mood can lead to patient stress. Graham did not specify whether she believes that particular colors promote these specific responses, or if color in general promotes these responses. The Physiological Model of Stress states that the sympathetic-adrenal medullar system reacts to various emergency situations with increased adrenalin. The in creased adrenalin, repeated over time, can result in a sequence of respons es that can ultimately accumulate in illness, which might include increased blood pressure, increased heart rate, increased cardiac demand for oxygen, and provocation of ventricular arrhythmias (Cohen et al. 1986). During the past 30 years, no studies have been focused on how color effects patients in a hospital setting. However, 84 studies have examined how other environmental factors have been shown to impact well-being (Rubin, 1998). The Center for Health Care Design stated that color is an important environmental feature in the design of hospitals that needs to be further explored. Alt hough the human response to the application of color on walls within the in terior hospital environment has not been

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16 thoroughly explored, the application of colore d lights has been expl ored. Studies have been able to show that co lored lights can have impacts on concentration, alertness, aggression, stress, and even dys lexia (Demarco and Clarke, 2001). The use of applying colored lights to relieve illne ss in known as chromotherapy. Chromotherapy Explained Chromotherapy, or color healing, is the appl ication of beams of colored light to the body to restore imbalance (Anderson, 1975). Colo r light rays activate the nerves, glands, and blood (Stevens, 1938). This healing tec hnique examines the electro-magnetic field, which surrounds every human body. It is beli eved that the aura around the effected human body part will appear discolored, which tells the color healer where the chemical imbalance, which produces illness, is loca ted (Anderson, 1975). Today, a process called Kirlian photography is able to photograph the subject and show the emanations of energy, or aura. A color health practitioner interpre ts the photograph to reve al the individual’s physical, emotional, and psychological char acteristics (Demarco and Clarke, 2001). Color raying energy reaches both the ment al and physical conditions, where most diseases originate, which then directly treats the cause and not just the symptoms (Stevens, 1938). Proponents of chromotherapy believe that it is much safer than drugs because it leaves no harmful residuals that the body has to overwork to eliminate. Drugs can also be unreliable because people re act differently to each drug (Anderson, 1975). It is believed that chromotherapy was utilized as early as 1876, when Augustus Pleasanton used blue light to tr eat a variety of diseases that were associated with pain (Demarco and Clarke, 2001). During the 1920’s, Dinshah Ghadiali, a Hindu scientist developed the Spectro-Chrome system of h ealing (Demarco and Clarke, 2001). This system explains how and why the different co lored rays have various therapeutic effects

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17 on organisms. Ghadiali believed that each organism and system of the body has a color that can stimulate it, and anot her color that inhibits it (Ande rson, 1975). He said that the Spectro-Chrome system could be implemente d by applying the correct color that will balance the action of the abnormally functioni ng organ or system (Anderson, 1975). It is believed that palpitation, or abnormal beating or throbbing of the heart, can be treated with projected blue light (Stevens, 1938). Through this system of treatment the nor malizing color ray should be projected on the nude body, or the part of the body with the ailment in twenty-minute intervals (Stevens, 1938). The normalizing color ray va ries depending on the part of the body that is out of balance and thus creating illness. Also, different color rays are believed to promote different functions in the body. It is believed that the violet ray causes bone growth, the green ray increas es vitality and energy, and the orange ray acts as a nourishing tonic (Stevens, 1938). Cardiac Illness and Patient Responses to Environmental Factors It is estimated that 5 perc ent of all hospital admissions can be attributed to heart failure (MacMahon and Lip, 2002). The Nationa l Center for Health Care Statistics reported that in 2000 heart disease was the num ber two leading cause of death for people between the ages of 45 and 64, which total 100,1 24 deaths in the United States. For the population over 65 years of age, heart dise ase was the leading cause of death with 605,673 deaths. This current study was conducted using the cardiac care unit of a hospital because there is clear evidence of cardiac illnesses being effected by environmental factors. Sirois and Burg (2003) believe that specific negative emotional states, namely depression, anger, and anxiety, can have a negative influe nce on medical variables and

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18 quality of life for patients with coronary heart disease. The effect that negative emotional state can have on patients with coronary heart disease need s to be examined. Evidence shows that the physical environment can effect emotional states. Introducing the colors of red and blue to an environment has been attributed to feelings of anxiousness or depression (Birren, 1961). The impact that psychological factors can have on cardiac functioning has been extensively tested (MacMahon and Lip, 2002). When a patient begins to feel anxious their body is in a state of stress, which can negatively effect the cardiac output of a patient with cardiac heart failure (MacMa hon and Lip, 2002). Psyc hological stress can cause a patient’s heart rate to increase, which places an even greater physical stress on the body (MacMahon and Lip, 2002). A study c onducted by Frasure-Smith in 1995 found that patients with higher anxi ety levels were 4.9 times more likely to suffer from inhospital cardiac complications or death afte r a myocardial infract ion than those with normal stress levels (Sirois and Burg, 2003). Depression can have an equally devastating effect on pati ents with coronary heart disease. Major depression is found in 16 pe rcent to 23 percent of all coronary heart disease patients (Sirois and Burg, 2003). Th e general population has a depression rate of 5 percent (Sirois and Burg, 2003). Major depr ession can be attributed to patients not complying with their medical treatment afte r coronary heart failure (MacMahon and Lip, 2002). Noncompliance is believed to contri bute to a high rate of readmission rates for these patients (MacMahon and Lip, 2002). Pa tients with depression who suffer from a myocardial infraction are found to have a 40 percent morta lity rate within 12 months (Sirois and Burg, 2003). Based on these st udies, it is extremely important to

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19 acknowledge the effects that anxiety and depr ession can have on a patient with coronary heart disease. By addressing hospital envir onmental factors that may contribute to a coronary heart disease patient’s anxiety and depression, we can aim to decrease the likelihood of mortality due to heart failure while recovering in the hospital setting. Summary As this review of literature shows, there are many widely held beliefs about the effect of color on the recovery process. The beliefs date back prior to the Christian era, and yet today there still are many people who remain skeptical about the healing effects of color. Color can be implemented into th e healing process in various forms, including chromotherapy and applying it to the physical environment. The important concept to understand is the effect that color can have on a patient’s psychologi cal state while in a hospital environment. It has been shown that a patient’s psychological state plays a large role in the recovery process, particularly wi th coronary heart patients. By examining the impact of color in relation to recovery, researchers can provide evidence to support designers as they strive to create healing environments, which foster the recovery process.

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20 CHAPTER 3 METHODOLOGY Using an experimental research design within the natural setting of a hospital, this study explored the impact of wall color at the foot of the hospital bed on patient recovery in the cardiac care unit of a hospital. Data was collected from multiple sources to examine the effect of wall color on a patient’s anxiety level, amount of pain medication requests, and length of stay. Anxiety level wa s used to measure a patient’s recovery in this study because research shows that a nxiety can have a negative influence on a patient’s recovery (MacMahon and Lip, 2002). A pre-interv iew process with several doctors, who were currently practicing in the hospital, suggested that there is a belief among physicians that anxiety can e ffect a patient’s recovery. Amount of pain medication and length of stay were also used to measure a patient’s recovery based on work by Verderber (1983) and Ulrich (1984). Verderber’s (1983) study was a good base for the current research study because an environmental factor within a hospital setti ng was linked with patient recover y. Verderber’s study used patient and staff interviews to determine the effect that a window can have on a patient. His findings suggested that the interview pr ocess was a good beginning for a study involving a hospital setting. Ulrich’s (1984) study built upon Verderber’s findings. His study examined patients’ records looking for pain medication requests and lengths of stay and compared patients with a view of a brick wall with those with a natural scene. He found that the frequency of pain medication reque sts and lengths of stay were accurate measures in determining patient recovery. Verderber’s (1983) and Ulrich’s (1984)

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21 studies helped this researcher identify measur es to use for testing patients’ recovery rates in a hospital setting. Pain medication requests and length of stay were the same measures used in Ulrich’s (1984) study. Ulrich (1984) wa s able to show that when a patient had a view from a window there were fewer pain medication requests and the length of stay was shorter than when the patient had a view of a brick wall. The following is a definition of the hypotheses and a description of the study participants, the setting, and the tools used to collect the data. Hypotheses Based on previous research on physical en vironmental variables and beliefs about color, it is believed that a patient’s recovery will be positively e ffected by the wall color within their particular hospital room. It is anticipate d that this study will determine generally, whether wall color im pacts recovery and specifica lly, which colors have the greatest impact on recovery. It is expected that the results will s how that orange will have the most positive effect on the patient. Previous research sugge sts that orange is considered the universal healer and is ofte n used in the hospital environment (Venolia, 1988). Three hypotheses are defined for this study. They are: There is a relationship between the color on the wall at the foot of the patient’s hospital bed and the patient’s recovery time in a hospital setting. There is a relationship between the color on the wall at the foot of the patient’s hospital bed and the amount of pain me dication requested by the patient in a hospital setting. There is a relationship between the color on the wall at the foot of the patient’s hospital bed and the patient’s anxiety level in a hospital setting.

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22 Research Setting The hospital selected for this research was Shands at the University of Florida. Shands Health Care began in 1958 as the Univ ersity of Florida Teaching Hospital. In 1979, Shands Teaching Hospital changed from a state institution to a private, not-forprofit corporation and was renamed Shands Ho spital. Through the years, Shands has added a network of facilities. Shands Health Care now includes eight hospitals. Shands Hospital, located on the University of Florid a campus, specializes in tertiary care for critically ill patients. Shands is also the primary teaching hospital for the University of Florida College of Medicine. In 2001, Sh ands treated 46,653 patients throughout their network of facilities. The facility at the Un iversity of Florida cont ains 576 patient beds and has over 500 physicians who represent 110 different specialities.

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23 N Figure 3.1. Layout of the fifth floor car diac care unit at Shands Hospital. The area of the hospital used for this st udy was the cardiac care unit located on the fifth floor of the hospital. This unit was chosen based upon the opinions of the Shands Hospital administration. The ad ministration determined that the cardiac care unit was the only area of the hospital where there were te n rooms located in close proximity to each other that were used for patients with similar illnesses. It was also determined that the patients would have similar lengths of stay a nd medication requests in this unit. The unit

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24 consists of a total of twenty-two rooms. Th e eleven rooms located on the west side of the unit are double occupancy rooms that are used for patients recovering from surgery and patients that are under cardiac obs ervations. The eleven rooms located on the east side of the unit are single occupancy rooms that are us ed for patients waiting for heart transplants and patients recovery from transplant surger y. Staff and service rooms occupied the core of the unit. Figure 3.1 shows the arrangement of the rooms. The rooms numbered 5438, 5440, 5442, 5444, 5446, 5448, 5450, 5452, 5454, and 5456 were used in this study. Shands donated ten rooms for the use of this study and so the first ten rooms in the hall were selected for use. They were all double occupancy rooms with an area of 244 squa re feet. They all contain th e same size window that looks out over the west side of the building. The artwork on the wa lls that were painted for the study was removed from each room so that as many of the environmental factors that could influence the patient were eliminated. The walls that weren’t painted were left in their current beige color. The curtains sepa rating the two patients were a combination of orange, yellow, green, blue, and purple. Th e laminate countertops were green and the floors were orange and green. All the furniture in the rooms was neutral shades of white, gray, or beech wood. Figure 3.2 shows an enla rged version of the layout and dimensions of the typical room used for this study.

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25 N Figure 3.2. Enlarged layout of a typical room in the cardiac care unit at Shands Hospital. Prior to the start of the study, the wall at the foot of the patients’ beds were painted in rooms 5438, 5440, 5442, 5444, 5446, and 5448. The paint colors were chosen to coordinate with the colors al ready found within the room so that the patients would not suspect anything about being involved in a st udy. An attempt was also made to choose colors that were perceived to not be harmful, in any way, to the patients. The walls at the foot of the patients’ beds were painted purple; Sherwin Williams color SW6556 (Figure 3.3), in rooms numbered 5438 and 5444. Purple was chosen for use in this study because it is believed to induce relaxation and sl eep, lower body temperature, and decrease sensitivity to pain. The walls at the foot of the patients’ beds were painted green; Sherwin Williams color SW6451 (Figure 3.4), in rooms 5440 and 5446. Green was chosen because it is perceived to have a sedative effect and re lieve irritation and exhaustion. Orange, Sherwin Williams co lor SW6346 (Figure 3.5), was painted on the walls in rooms 5442 and 5448. Orange is believe d to be a universal healer that can be used to counteract depression and humo rlessness. The rooms numbered 5450, 5452, 5454, and 5456 were left unpainted in their na tural beige color, similar to Sherwin

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26 Williams color SW6658 (Figure 3.6). There was an attempt made to have one room of each color located close to the nurses’ stati on and it just worked out that all the beige rooms were located next to each other. Figure 3.3. Purple paint color. Figure 3.4. Green paint color.

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27 Figure 3.5. Orange paint color. Figure 3.6. Beige paint color. Participants The participants were thirty-nine patients who occupied a bed in the cardiac care unit on the fifth floor of Shands Hospital in Gainesville, Florida between February 3, 2003 and March 2, 2003. Ten of the participan ts were recovering from cardiac surgery, while twenty-nine patients were undergoing card iac observations. The patients ranged in

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28 age from 26 to 89. There were a fairly e qual number of male and female participants with 19 females and 20 males (Table 3.1). Although there was no specific demographic information collected, except for age and gende r, it was the researcher’s perception that the patients were from vari ous religious, ethnic, and so cioeconomic backgrounds. The patients were randomly placed in the hospita l rooms by the hospital administration upon their admission to the hospital. Table 3.1. Number of male and female patients who occupied each colored room. Beige Purple Green Orange Total Female 7 3 3 6 19 (17.9%) (7.7%) (7.7%) (15.4%) Male 6 7 6 1 20 (15.4%) (17.9%) (15.4%) (2.6%) Total 13 10 9 7 39 Data Collection A quantitative approach, consisting of thr ee parts was used for this study. The three parts included administer ing an anxiety test, documen ting the length of stay and medication requests, and informally interviewing patients and staff. This researcher determined that a sample size of 100 pa rticipants would likely provide enough information to determine if the patients’ rec overy process was being effected by the color painted on the wall at the foot of the bed. There was no research found to help determine the required sample size. The hospital admi nistration estimated that conducting the study for four weeks would provide th e appropriate sample size. Due to variables out of the researcher’s control, the four-week study only produced 39 participants. During the length of the study there was an unusually low number of admissions. Also, eleven patients had to be eliminated fr om the study for various reasons.

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29 All three instruments were conducted on the day that the patient was being released from the hospital. The final day of the patient’s stay in the hospital was chosen for multiple reasons. First, the researcher want ed to be sure that each patient had spent enough time in the room to have an opportunity to be effected by the color. Second, the nursing staff determined that the doctors notifie d the nurses of who was to be released at a certain time everyday. It then took the nurses time to prepare the patients to be released. This was suggested to be the best time to conduct the rese arch because all the patients were awake, prepari ng to go home, and all the medi cal information was available to the researcher. Lastly, conducting research on the final day proved to be of the least inconvenience to the nursing staff. The researcher was able to check the notes board to determine who was being sent home, and ther efore who should be interviewed, without bothering any of the hospital staff. Gaining Consent The Medical Internal Review Board determin ed that the researcher could not be the first person to approach the patient to partic ipate in the study. Therefore, the patients were first approached by the nurse manager fo r the unit and asked to participate in this study. If they agreed to participate the prin cipal investigator then approached them to explain the study and obtain a si gned informed consent form. Eleven patients who were approached could not be used in the study. Th ree patients explained that they would just prefer not to participate. Tw o of the patients were considered legally colorblind. It was the researcher’s opinion that they would not be effected by the color on the walls and therefore should not be used in the study. One patient was extremely confused and could not understand the information being explaine d to him. He was eliminated from participating in the study. One patient felt uncomfortable with having the principal

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30 investigator examine his medical records and was therefore eliminat ed. One patient was considered extremely depressed by the nur se manager and was not approached to participate in the study and tw o patients could not speak Engl ish and were therefore left out of the study. Lastly, one patient was ex tremely nervous and worried that the anxiety test would reveal that she s hould have to stay in the hospital for an extended amount of time. It was the researcher’s opinion that sh e altered her answers on the test to make it appear as though she had no anxiety in her life. This left thirty-nin e patients who could participate in the study. Once each patient signed the informed consent form, the researcher explained the anxiety test and how it was going to be used. The patient wa s told that the test would take approximately ten to fifteen minutes and that it would en tail answering forty multiple-choice questions about how they feel at the moment and about how they “generally” feel. Once the re searcher felt the patient unders tood what was being asked of them, the patient was told that they would be left alone to take the test while the researcher examined their medical records to document the length of stay in that particular room and the pain medication they had requested. State-Trait Anxiety Inventory The anxiety test used in this study was the State-Trait Anxiety Inventory (Appendix), which was developed by Charles D. Spielberger. The test consists of two separate 20-item self-report scales, which were self-administered to measure state anxiety and trait anxiety. State anxiety consists of subjective feelings of tension, apprehension, worry, and activation of the autonomic nervous system (Speilberger et al. 1999). Trait anxiety is the differences in proneness to anxiety (Speilberger et al. 1999). The StateTrait Anxiety Inventory was chos en as the tool to measure a nxiety because of its ability

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31 to access both state and trait a nxiety with reliable, relativel y brief, self-report scales (Speilberger, 1985). Today, the State-Trait Anxiety Invent ory has become widely used in many different disciplines including: counseling and guidance, criminal justice, education, nursing, speech and hearing, sports psychol ogy, sociology and anthropology, fine arts, political science and government, and teach er education (Speilberger, 1985). The particular area of interest for this study is its use in assessing wh ether color produces or alleviates anxiety, which can imp act recovery (Speilberger, 1985). During the study, the participants were gene rally left to complete the anxiety test on their own. The researcher ad ministered the test orally to four of the participants. One patient could not read. The three other patien ts had left their read ing glasses at home and therefore could not see the test. Documenting Length of Stay and Medication Requests While the patient was taking the anxiety test, with the nurses’ permission, the researcher examined the daily nurses’ notes to determine medication requests and length of stay. Located in the ha llway outside the patients’ r ooms were carts that held a notebook, which contained the daily nurses’ notes for each patient. The notebooks were divided according to the bed num ber. To find the length of st ay that each patient was in the particular room of interest, the researcher looked at the first page of nurses’ notes where the patient’s name and the date they were admitted could be located. The researcher noted the date the patient was admitted and the date that they were being released to conclude how many days the patient had spent in that room. To document the pain medication requested by the patient, the researcher turned to the section in the nurses’ notes that listed pain medication admi nistered by date and time.

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32 The researcher noted how many dosages were administered to the patient each day that they were in the particular hospital room of interest. The lengths of stay and medication requests were then recorded on the researcher’s data chart and the re searcher returned to the patient’s room to pick-up the anxiety test and to thank the patient for participating. Discussions with Staff and Patients Throughout the four-week study the patients a nd staff were very willing to offer their opinions and beliefs about the colors located in the rooms. The researcher documented the informal staff and patient conve rsations at the end of each day. These notes were then compiled at the end of th e study to compare the findings in the study with the patients and staff’s pref erences for particular colors.

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33 CHAPTER 4 FINDINGS The purpose of this study was to explore the effect that wall color has on a patient’s recovery while occupying a hospital room. A review of literature showed that there are many widely held beliefs about how color eff ects healing, but ther e are no scientific studies that have been conducted in a hospital se tting. In an attempt to test some of the suppositions about color, the study hypothesized that wall color at the foot of the patient’s bed can effect a patient’s anxiety le vel, length of stay in the hospital, and the amount of medication requested by the patient while in th e hospital. All data was collected by using the nurses’ notes, regarding pain medica tion requests and lengths of stay, and administering an anxiet y test on the last day of the patients’ stay in one of the hospital rooms used for this study. Anxiety Level Anxiety levels were recorded using the State-Trait Anxiety I nventory developed by Charles D. Speilberger. There are two parts to this anxiety test. The first part analyzes a person’s anxiety levels base d on his or her feelings of tension, apprehension, nervousness, and worry (Speilberger, 1983). The second part of the anxiety test examines clinical anxiety and is largely us ed for screening for anxiety problems and evaluating the immediate and long-term outcome of psychotherapy, counseling, behavior modification, and drug-treatment programs (Spe ilberger, 1983). It was determined that the first part of the test, the State Anxiety Le vel, would be more beneficial in determining the effects of wall color on patient anxiety becau se it examines a person’s feelings at the

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34 moment of the test. This study was interested in how the patients’ anxiety levels were effected while in the hospital, which was a relatively short amount of time. The second part of the State-Trait Anxi ety Inventory examined long-te rm anxiety, which would not have been beneficial in understanding how the colors effected the patients. The state anxiety was scored based on tw enty questions. Each question was given a score of 1 to 4, with 4 indicating the highest level of anxiety. The scores for each of the twenty questions were then added together to give each participant an anxiety score between 20 and 80. The publishe r of the test provided normative data about the state scores for general medicine and surgery patien ts. The data provided was collected in six veterans hospitals throughout the southeastern United States The mean state anxiety score for the 161 patients tested was 42.4. The normative data provided suggested that there was no significant differen ce in anxiety scores based upon age. Within this current study, the mean anxiety scores were much lower. The average anxiety level for all participants of this study was 32.5. When the patients were separated based upon the color of the wall at the foot of their bed, th e average anxiety level of the patients with a beige wall at the foot of their bed was 29.7. The patients with a purple wall at the foot of their bed had an average anxi ety level of 33.2, the patients with a green wall had an average anxiety level of 35.3, and the averag e anxiety level of a pa tient occupying a room with an orange wall was 33.0 (Table 4.1). Table 4.1. Average anxiety levels of patients occupying rooms of each color. Mean N Std Deviation Beige 29.69 13 10.363 Purple 33.20 10 10.717 Green 35.33 9 10.173 Orange 33.00 7 5.066 Total 32.49 39 9.578

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35 A chi-squared test was used to test the independence of color and anxiety levels. To perform this test, anxiety scores were pl aced into two categories, low anxiety and high anxiety. No information was found by this researcher that indicated what a normal anxiety range is for a populati on similar to the one in this study. Therefore, this researcher created two categorie s, low anxiety and hi gh anxiety, in an effort to compare the effects of the various colors on anxiet y levels. The mean anxiety level of all participants in this study was determined to be 32.49. The low anxiety represented all the anxiety levels that were belo w the average anxiety level for this study. The high anxiety represented all the anxiety levels that were above the average a nxiety level for this study. The low anxiety was determined to be between 20 and 32 (or less than the mean anxiety score) and the high anxiety was determined to be between 33 and 80 (or more than the mean anxiety score). The results of the chi-sq uared test are reported in Table 4.2. This test was not significant (p>.05) possibly due to the low number of cases in each cell. Therefore, there is no evidence that the anxiet y levels of the patients are dependent on the color of the wall at the foot of the bed.

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36 Table 4.2. Chi-squared test for color and anxiety levels. Low Anxiety High Anxiety Total Beige Count Expected Count % within color Adjusted Residual 10 7.7 76.9% 1.6 3 5.3 23.1% -1.6 13 13.0 100.0% Purple Count Expected Count % within color Adjusted Residual 5 5.9 50.0% -.7 5 4.1 50.0% .7 10 10.0 100.0% Green Count Expected Count % within color Adjusted Residual 5 5.3 55.6% -.2 4 3.7 44.4% .2 9 9.0 100% Orange Count Expected Count % within color Adjusted Residual 3 4.1 42.9% -1.0 4 2.9 57.1% 1.0 7 7.0 100.0% Total Count Expected Count % within color 23 23.0 59.0% 16 16.0 41.0% 39 39.0 100.0% Because of the small sample size, a Fisc her’s exact test was run which requires a 2x2 table. The anxiety levels of the patients were explored based on color (purple, green, and orange) and no color (beige). The averag e anxiety score for pati ents with no color on the wall at the foot of the bed was 29.7. Th e average anxiety score for the patients with color on the wall at the foot of the bed was 33.9. The resu lts of Fischer’s Exact Test, similar to chi-squared, are repor ted in Table 4.3. This test used measures of low anxiety (20 to 32) and high anxiety (33 to 80). This test was not signifi cant (p>.05) and suggests that anxiety levels are not de pendent on the color of the wa ll at the foot of the bed.

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37 Table 4.3. Fischer’s Exact Te st on color and anxiety levels. Low Anxiety High Anxiety Total No Color Count Expected Count % within color Adjusted Residual 10 7.7 76.9% 1.6 3 5.3 23.1% -1.6 13 13.0 100.0% Color Count Expected Count % within color Adjusted Residual 13 15.3 50.0% -1.6 13 10.7 50.0% 1.6 26 26.0 100.0% Total Count Expected Count % within color 23 23.0 59.0% 16 16.0 41.0% 39 39.0 100.0% Gender and Anxiety Other factors that were believed to have a possible effect on anxiety levels were also tested. One factor is the impact of gender on anxiety levels Nineteen of the participants of this study were female and twenty were male. Of the female patients, seven occupied a room with a beige wall at th e foot of the bed; th ree occupied a room with a purple wall; three occupied a room w ith a green wall; and six occupied a room with an orange wall during their stay in the hospital (Table 4.4). Out of the twenty male patients, six occupied a room with a beige wall at the foot of the pati ent’s bed. Seven of the male patients occupied a room with a purple wall; six of the patients had a room with a green wall; and one patient occupied a room with an orange wall during their stay in the hospital (Table 4.4). Table 4.4. Number of male and female patients who occupied each colored room. Beige Purple Green Orange Total Female 7 3 3 6 19 (17.9%) (7.7%) (7.7%) (15.4%) Male 6 7 6 1 20 (15.4%) (17.9%) (15.4%) (2.6%) Total 13 10 9 7 39

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38 A t-test comparing the anxi ety levels of the female and male patients showed no significant difference (p>.05) in their anxiety scores. As seen in Table 4.5, the female patients had a mean score of 33.0 and the male patients had a mean anxiety score of 32.0. It is unknown why the standard deviations are high. The standard deviations were also found to be high in similar studies conducted on general medicine and surgery patients (Speilberger, 1983). These scor es indicate that there is li ttle difference between the anxiety scores of the female and male pati ents. Thus, gender cannot be credited with effecting the patient s’ anxiety levels. Table 4.5. Anxiety scores of the female and male patients. Mean N Std. Deviation Female 33.00 19 10.661 Male 32.00 20 8.675 Total 32.49 39 9.578 Female patients. A t-test run on the female participants in this study showed no significant difference (p>.05) on anxiety scores based upon whether or not they occupied a room with a color (purple, green, or ora nge) on the wall. With in this study twelve patients occupied a room with a color painted on the wall at the foot of their bed (Table 4.4). The mean anxiety score of the female patients who occupied a room with color on the wall was 35.9 and the mean anxiety score for patients in a beige room was 28.0. A chi-squared test was not signi ficant (p>.05) in determining whether anxiety scores were dependent upon the color of the wall for female patients. Male patients. A t-test run on the twenty male participants in this study showed no significant difference on a nxiety scores based upon whethe r or not they occupied a room with color (purple, green, and orange ) painted on the wall. Within this study fourteen male patients occupi ed a room with a color painted on the wall at the foot of

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39 their bed (Table 4.4). The mean anxiety scor e for the male patients who occupied a room with color on the wall was 32.1. The mean a nxiety score of the patients in a beige room was 31.7. A chi-squared test was not signi ficant (p>.05) in dete rmining that anxiety scores were dependent upon the color of the wall for male patients. Window View and Anxiety Based on previous studies (Ulrich, 1984, and Verderber, 1983), distance from a window and view from a window are believed to have an effect on patient recovery. For this study, the views out of the windows are the same from all rooms. Because these rooms were double occupancy, some patients we re closer to the windows than others. This factor was examined to test the effect it had on patient anxiety levels. The patients were divided into two groups based upon the lo cation of their beds. Group A included the patients who occupied beds closest to the window. Group B included patients who occupied beds furthest from the window. Fi fteen patients were included in Group A and twenty-four patients were included in Group B. The participants were randomly assigned to a bed by the hospital administration. Havi ng more participants in Group B may have effected the outcome of the results. Within Group A, five patients occupied room s with a beige wall at the foot of the bed, three patients occupied rooms with a pur ple wall, six patients occupied rooms with a green wall, and one patient occu pied a room with an orange wall (Table 4.6). Within Group B, eight patients occupied a room with a beige wall at the foot of the bed, seven patients occupied a room with a purple wall, three patients o ccupied a room with a green wall, and six patients occupied a room with an orange wall duri ng their stay in the hospital (Table 4.6).

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40 Table 4.6. Number of patie nts in each colored room based upon location of bed. Beige Purple Green Orange Total Group A 5 3 6 1 15 (12.8%) (7.7%) (15.4%) (2.6%) Group B 8 7 3 6 24 (20.5%) (17.9%) (7.7%) (15.4%) Total 13 10 9 7 39 A t-test comparing anxiety levels of pa tients in Group A (closest to the window) and Group B (furthest from the window) f ound no significant diffe rence (p>.05) in anxiety levels between the two groups based on proximity to a window. The mean anxiety score of the fifteen patients in Group A was 32.6 a nd the mean anxiety score of the twenty-four patients in Group B was 32.4 (Table 4.7). Table 4.7. Mean anxiety scores for patients in relation to their proximity to a window. Mean N Std. Deviation Group A 32.60 15 10.322 Group B 32.42 24 9.311 Total 32.49 39 9.578 Group A. A t-test on the fifteen patients that occupied a bed closest to the window found no significant (p>.05) diffe rence between the anxiety sc ores based upon whether or not they occupied a room with a color (pur ple, green, or orange) painted on the wall. Within this study there were ten patients who occupied a room with color (Table 4.6). The mean anxiety score of the patients in a room with color was 34.8 and the mean anxiety score of the patients in a beige r oom was 28.2. A chi-squared test was not significant (p>.05) in determining that the anxiety scores were dependent upon the color painted at the foot of the patient’s bed. Group B. A t-test on the twenty-four patients who occupied a bed away from the window found no significant (p>.05) differen ce between the anxiety scores based upon whether or not the patients occupied a room with color (purple, green, or orange) on the

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41 wall. The mean anxiety score of the patient s occupying a room with color on the wall at the foot of the bed was 33.3. The mean anxi ety score of the patient s in the beige rooms was 30.6. A chi-squared test was significant (p<.05) in determining that anxiety scores were dependent on the color painted at the foot of the bed. Because of the small sample size, it is suggested that furt her tests should be run before any conclusions can be made. Surgery and Anxiety Ten of the patients included in the st udy were recovering from surgery, while twenty-nine of the patients were simply being observed in the hospital. The effects of a patient having surgery was examined in relation to a patient’s anxiety levels. Of the ten surgery patients, three occupied rooms with a beige wall at the foot of the bed, four patients occupied a room with a purple wall, three patients o ccupied a room with a green wall, and there were no patients who occupied a room with an orange wall (Table 4.8). Out of the twenty-nine patients under observa tion, ten occupied rooms with a beige wall at the foot of the bed, six patients occupied rooms with a purple wall at the foot of the bed, six patients occupied a room with a green wall, and there we re seven patients who occupied a room with an orange wall at the foot of the bed (Table 4.8). Table 4.8. Number of surgery and observat ion patients in each set of colored rooms. Beige Purple Green Orange Total Surgery 3 4 3 0 10 (7.7%) (10.3%) (7.7%) (0.0%) Observation 10 6 6 7 29 (25.6%) (15.4%) (15.4%) (17.9%) Totals 13 10 9 7 39 A t-test comparing the anxiet y levels of the surgery pati ents and the patients under observation found a significant (p <.05) difference in their an xiety levels. The mean

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42 anxiety level of the ten surg ery patients was 38.2 and the mean anxiety level of the observation patients wa s 30.5 (Table 4.9). Table 4.9. Mean anxiety levels of surgery patients and observation patients. Mean N Std. Deviation Surgery 38.20 10 11.650 Observation 30.52 29 8.074 Total 32.49 39 9.578 Based on the significant difference in anxi ety levels between the surgery patients and the observation patients, the two groups we re separated to exam ine the effects of color on anxiety levels within the two groups. Surgery patients and anxiety. Within the ten surgery patients, the mean anxiety score was 38.2. Three occupied a room that had a beige wall at the foot of the bed. These three patients had a mean anxiety scor e of 38.0. Four of the surgery patients occupied a room with a purple wall at the foot of the bed and had a mean anxiety score of 41.0. Three surgery patients occupied a room with a green wall at th e foot of the bed and had a mean anxiety score of 34.7 (Table 4.10). Table 4.10. Mean anxiety of the surgery pa tients based upon the color of the room they occupied. Mean N Std. Deviation Beige 38.00 3 16.093 Purple 41.00 4 11.633 Green 34.67 3 10.693 Total 38.20 10 11.650 A chi-squared test measured whether the anxiety scores were dependent on the color of the wall at the foot of the patient bed (Table 4.11). The color on the wall at the foot of the bed made no signifi cant (p>.05) difference in the a nxiety levels of recovering surgery patients.

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43 Table 4.11. Chi-squared test on color and anxiety levels within surgery patients. Low Anxiety High Anxiety Total Beige Count Expected Count % within color 1 .9 33.3% 2 2.1 28.6% 3 3.0 30.0% Purple Count Expected Count % within color 0 1.2 .0% 4 2.8 57.1% 4 4.0 40.0% Green Count Expected Count % within color 2 .9 66.7% 1 2.1 14.3% 3 3.0 30.0% Total Count Expected Count % within color 3 3.0 100.0% 7 7.0 100.0% 10 10.0 100.0% Observation patients and anxiety. Within the twenty-nine observation patients, 10 occupied a room with a beige wall at the f oot of the bed, 6 with a purple wall, 6 with a green wall, and 7 had a room w ith an orange wall at the foot of the bed. The mean anxiety score of the observati on patients was 30.5. The patients who occupied a room with a beige wall at the foot of the bed had a mean anxiety level of 27.2. The patients with a purple wall had a mean anxiety of 28.0. The patients who occupied a room with a green wall had a mean anxiety level of 35.7 and the patients with an orange wall had a mean anxiety level of 33.0 (Table 4.12). Table 4.12. Mean anxiety of the observati on patients based upon the color of the room they occupied. Mean N Std. Deviation Beige 27.20 10 7.465 Purple 28.00 6 6.663 Green 35.67 6 10.930 Orange 33.00 7 5.066 Total 30.52 29 8.074

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44 A chi-squared test compared the anxiety levels across observation patients in the different colored rooms (Table 4.13). No significant (p>.05) difference was found on patients’ anxiety levels and therefore color c ould not be proven to effect anxiety levels. Table 4.13. Chi-squared test on color and anxiety levels within observation patients. Low Anxiety High Anxiety Total Beige Count Expected Count % within color 9 6.9 45.0% 1 3.1 11.1% 10 10.0 34.5% Purple Count Expected Count % within color 5 4.1 25.0% 1 1.9 11.1% 6 6.0 20.7% Green Count Expected Count % within color 3 4.1 15.0% 3 1.9 33.3% 6 6.0 20.7 Orange Count Expected Count % within color 3 4.8 15.0% 4 2.2 44.4% 7 7.0 24.1% Total Count Expected Count % within color 20 20.0 100.0% 9 9.0 100.0% 29 29.0 100.0% Length of Stay The study sample of 39 patients was broken into two groups in order to compare patients who were in the hospital for similar reasons and to provide a more accurate account of how the length of stay was effected by the color of the wall located at the foot of the patient’s bed. The first group consis ted of 10 patients recovering from surgery. Their length of stay ranged from 2 to 6 days. Three patients recove red in a room with a beige wall at the foot of the bed; four pa tients recovered in a room with a purple wall; three patients recovered in a room with a green wall; and there were no surgery patients who recovered in a room with an orange wa ll (Table 4.8). The second group comprised 29 patients under observation. The patients who were occupying the observed hospital rooms while under physician observation had leng ths of stay ranging from 2 to 6 days.

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45 Ten of these patients occupied rooms with a beige wall at the foot of the bed; six occupied rooms with a purple wall; six occupied rooms with a green wall; and seven occupied rooms with an orange wall (Table 4.8). As shown in Table 4.14, the average length of stay for a patient recovering from surgery in a room with a beig e wall at the foot of the bed was 5.3 days. The average length of stay for patients with a purple wall was 4.3 days and for patients with a green wall the average length of stay was 4.0 days (T able 4.14). Chi-squared tests revealed that there was no significant (p>.05) difference betw een the patients’ length of stay based on the color of the wall at the foot of the bed. Table 4.14. Average length of stay for surgery and observation patients recovering in each set of colored rooms. Beige Purple Green Orange Total Surgery 5.3 4.3 4.0 4.5 Observation 3.8 3.0 2.7 3.0 3.2 Totals 4.2 3.5 3.1 3.0 3.5 Patients under observation who occupied a room with a beige wall at the foot of the bed had an average length of stay of 3.8 days The average stay for a patient occupying a room with a purple wall was 3. 0 days. A patient occupying a room with a green wall had an average length of stay of 2.7 days, and a pa tient in a room with an orange wall had an average length of stay of 3.0 days (Tab le 4.14). There was no significant (p>.05) difference between the average lengths of stay based on the wall color at the foot of the patient’s bed. A small sample size may have yielded results that are not statistically significant throughout the study. Pain Medication Requests Nurses’ notes were reviewed to determin e the number of pain medication requests for each day of the patient’s hospital stay. Fo r example, if a patient requested three doses

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46 of pain medication on the first day of their hos pital stay, a three would be recorded under day one for that particular patient. The sa mple was again divided into two groups for the purpose of analysis. The firs t group contained the ten surg ery patients and the second group contained the twenty-nine patients under physician observation. Out of the twentynine total patients under observa tion, thirteen of them ha d no medication requests during their stay. Therefore, only the sixteen observation patients who requested pain medication during their stay were included in the examin ation of pain medication requests on observation patients. Seven of th e sixteen observation patients who requested pain medication occupied a room with the wa ll at the foot of the bed painted beige. Three of the patients occupied a room with a purple wall, three of the patients occupied a room with a green wall, and th ree of the patients occupied a room with an orange wall (Table 4.15). Out of the ten surgery patients, three of the surgery patients recovered in a room with a beige wall at the foot of the hospital bed, four recovered in a room with a purple wall, three recovered in room with a green wall, and there were no surgery patients who recovered in a room with an orange wall (Table 4.15). Table 4.15. Number of patients who reque sted medication during their stay in each colored room. Beige Purple Green Orange Total Surgery 3 4 3 0 10 (7.7%) (10.3%) (7.7%) (0.0%) Observation 7 3 3 3 16 (43.8%) (18.8%) (18.8%) (18.8%) Total 10 7 6 3 26 Pain medication requests were examined sepa rately for the first and last days of a patient’s stay in a hospital. It was anticipat ed that a patient would experience the highest level of pain on the first da y and the least amount of pain on the last day making it difficult to compare medication requests for all other days in between. The “middle

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47 days,” after the first day and before the la st day, were all compared together. The patients’ length of stay vari ed and these could be any wher e from the second day in the hospital to the fifth day. Surgery patients’ medication requests. The surgery patients’ medication requests varied from 2 to 6 doses on the first day of their stay in the hospital. Surgery patients recovering in a room with a beige wall at the foot of the bed had an average of 5.3 doses of medication requested on their firs t day of their hospital stay. The patients recovering in a room with a purple wall at the foot of the bed had an average of 4.3 doses requested and the patients occupying a room with a green wall had an average of 4.0 doses of medication requested on the first day of their stay in the hospital (Table 4.16). There were no surgery patients that recovered in an orange room. The average number of pain medication requests on the first day of the patients’ hospital stay was not statistically significant (p>.05). Table 4.16. Average number of medication re quests by surgery patien ts during their stay in the hospital. Beige Purple Green Orange Total First Day 5.3 4.3 4.0 4.2 Middle Days 3.5 3.2 3.5 3.4 Last Day 0.0 0.8 0.3 0.4 Totals 3.1 3.2 2.3 2.9 During the “middle days” of the surgery patients stay, the patients’ medication requests ranged from 0 to 10 doses per day. The three surgery patients who occupied a beige room during their stay requested an av erage of 3.5 doses of pain medication during the middle days of their stay. The four su rgery patients who occupied a room with a purple wall average 3.2 doses of medication requested and th e patients who occupied a room with a green wall requested 3.5 doses of pain medication (Table 4.16). There were

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48 no surgery patients that occupied an orange r oom during their stay in the hospital. The average number of the pain medication request s during the “middle days” of the patients’ stay was not statistically significant (p>.05). The doses of pain medication requested on the final day of the hospital stay ranged from zero to two doses. The three patients w ho occupied the rooms w ith a beige wall at the foot of the bed had 0.0 requests for pain medication on the final day of their stay in the hospital. The four patients who occupied a room with a purple wa ll had an average of 0.8 pain medication requests and the three pa tients who occupied a room with a green wall had an average of 0.3 pain medication re quests on the last day of their stay in the hospital (Table 4.16). There were no surger y patients that occupied an orange room during their stay in the hospital. The aver age number of the pain medication requests during the final day of the pa tients’ stay was not statisti cally significant (p>.05). Observation patients’ medication requests. The observation patients who requested pain medication during their stay had a range of zer o to four doses requested on the first day of their stay in the hospital. The patients who occupied a room with a beige wall at the foot of their be d had a mean of 0.7 doses of medication requested and the patients with a purple wall had an average of 1.0 medication requests. The observation patients who occupied a room with a green wall had an average of 2.0 pain medication requests and the patients who occupied a room with an orange wall had an average of 0.3 medication requests on the first day of thei r stay in the hospital (Table 4.17).

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49 Table 4.17. Average number of medication requests by observation patients who request pain medication during thei r stay in the hospital. Beige Purple Green Orange Total First Day 0.7 1.0 2.0 0.3 0.9 Middle Days 1.3 1.4 0.5 0.7 1.4 Last Day 0.4 0.0 0.3 0.3 0.3 Totals 1.1 1.0 1.0 0.5 1.0 During the “middle days” the observation pa tients requested between zero and five doses of pain medication per day. The seven patients who occupied a room with a beige wall at the foot of the bed had an average of 1.3 pain medication requests per day. The three patients who occupied a room with a purple wall had an average of 1.4 pain medication requests per day. The three patien ts who occupied a room with a green wall had an average of 0.5 medication requests pe r day and the patients who occupied a room with an orange wall had an average of 0.7 medication requests per day (Table 4.17). Lastly, the pain medication requests were examined for the observation patients on the final day of their hospital stay. The si xteen observation patients who requested pain medication during their stay requested betw een zero and one dose of medication on the last day. The patients occupying a room with a beige wall at the foot of the bed had an average of 0.4 medication requests on their fi nal day. The patients who occupied a room with a purple wall had no medication requests. The patients who occupied a room with a green wall had an average of 0.3 medicati on requests and the patients who occupied a room with an orange wall had an average of 0.3 medication requests on their final day (Table 4.17). Patients’ Opinions About the Colors Patients willingly gave their opinions about the various colors located in their rooms during their stay. All but 5 of the pati ents who occupied rooms with a wall painted

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50 purple, green, or orange claimed that they had noticed the color upon entering the room. The patients in the rooms with all walls painted beige were di sappointed that they did not get placed in a room with a color on the wall. One patient, located furthest from the window in a beige room, claimed that there wa s no way that color could have any effect on her. In her following statement she said that she had enjoyed her stay in the hospital more on her previous time in the hospital b ecause she had occupied a bed close to the window and she felt this uplifted her mood. Several of the patients also talked about their preferences for a particular color in their room. Patients had mixed feelings a bout the all beige rooms. Some patients, particularly the males, tended to like the be ige rooms and claimed th at if they had had their own way their own homes would all be pa inted beige. Some of the female patients claimed that the beige walls made the space f eel very institutional and that color would make them feel more comfortable. Opinions about the rooms with a purple wall at the foot of the bed varied. Many of the male patients did not care for the color. They claimed that it made the room feel too dark. Some women really enj oyed the purple color. They sa id that it was very soft and made them feel comfortable. Overall, the opinions regarding the pur ple color varied with approximately an equal number of patie nts liking and disliking the color. The green color also produced various opinions. Some of the male patients claimed that they liked the color. They clai med that it probably w ouldn’t be a color that they would put in their homes, but that they didn’t mind it in the hospital rooms. The majority of the women did not care for the green color. They stated that it reminded them

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51 of a “hospital green.” Upon investigation a bout what they believe d a “hospital green” was, it was discovered that it referred to the color associated with a typical pair of scrubs. The patients’ opinions were very similar in regards to the orange color. The patients all claimed that they had noticed the color upon entering th e room. Many said it was a nice surprise to see color on the wall. The patients felt that this color of orange brightened up the room and gave a welcome relief to the beige thr oughout the majority of the hospital. Overall, more female patients than male patients enjoyed the purple color. The one main complaint was that it made the room f eel dark. Regarding the green color, more male patients seemed to like, or at least not mind the color, than female patients. The female patients said the green color made the room feel too much like a hospital. Lastly, both the male and female patients enjoyed the or ange color. Overall, the patients in the beige rooms appeared disappointed that thei r rooms did not contain colors on the wall. Hospital Employee’s Opinions About the Colors The hospital employees, including the nurses, patient care assistants, and general staff, had many opinions about th e colors. Overall, the employees said that they were ready for color in this particular area of the hospital, even asking if the colors could be kept after the study ended. A ll the walls in the cardiac car e unit of the ho spital, except for the ones painted for this study remained be ige. The nurses’ station had recently been remodeled and the nurses claimed they were di sappointed that the only color incorporated was a neutral gray. One of the nurses claimed that the colored rooms helped them to identify the rooms and different patients. The nurses were typically responsible for multiple adjoining

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52 rooms. The rooms next to each other were pa inted different colors for this study, which made the nurses responsible for thre e rooms of three different colors. At the beginning of the study, many of th e hospital employees really enjoyed the purple color. One employee, in fact, pain ted her bedroom in her home a similar color after seeing it at the hospital. Toward the e nd of the study, after the employees had spent some time in the rooms with a wall at the f oot of the bed painted purple, many felt that the rooms felt too dark compared to the other rooms. Most of the interviewed hospital employees st ated that the green color seemed to be the most appropriate color for a hospital. When asked why green was associated with hospitals, no one knew. The nurses believed th at the green seemed to match the laminate and the curtains in the rooms the best. As an interesting side note, none of the patients mentioned whether the colors coordinated wi th the rest of the objects in the room. Every female hospital employee that was in terviewed claimed that they enjoyed the orange color. Four or five of the nurses stat ed that the orange matc hed the orange tiles on the floor well. They felt the color was overall bright and uplifting. A couple of the male employees claimed that the shade of orange was not attractive. The interesting note regarding the opini ons of the patients and the hospital employees is that they are very similar. This is surprising because the nurses’ opinions were based on having the ability to experience all three colors, as well as, the beige control rooms. They also spent more time in all of the rooms than the patients did. The patients had a more limited experience with the colors because they only occupied a single color for between 2 and 6 days.

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53 CHAPTER 5 DISCUSSION Psychological and physiological responses to color have interested scholars and medical caretakers for centurie s. As early as 500 BC, the Greeks, Persians, Assyrians, Babylonians, and Egyptians believed color cu red diseases. With the development of modern medicine, the focus on the healing power of color was set aside, or left for the artists and poets such as J ohann Wolfgang von Goethe (1749-1832) to ponder. Goethe’s philosophy was that colors produced m oods, which then formed the mind-body connection and effected healing. When color healing was reunited with m odern medicine, it was in a new form known as chromotherapy. Chromotherapy is th e application of colore d beams of light to particular body parts to activ ate nerves and promote hea ling. Modern architects, designers, doctors, and hospital administrators have also started examining the effects that the built environment can have on recovery and healing. Within the built environment, color can have an impact on patients’ emotions, which can ultimately effect wellness. This study was undertaken to examine the sp ecific effects that color can have on a patient’s recovery with in a hospital setting. Recovery was examined through recovery rate (length of stay), perception of pain (pain medication requests), and emotional responses (anxiety levels). Participants of this study included thirty-nine patients suffering from a cardiac illness. The patients ranged in age from 26 to 89. Nineteen of

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54 the patients were female and twenty patients were male. All participants were randomly placed in one of the hospital rooms included in the study. Ten rooms located on the fifth floor of Sha nds hospital in Gainesville, Florida were used in this study. The rooms were part of the Cardiac Care Unit of the hospital and were all double occupancy rooms. The participants were either placed in one of the four control rooms (all beige walls) or one of the six experimental rooms (with one wall in the room painted purple, green, or orange). On th e participants’ final day of their stay in the hospital, their length of stay, pain medication re quests, and anxiety levels were examined. The participants’ anxiety levels were co mpared between the ten surgery patients and the twenty-nine patients under observation by using a ttest to examine the mean scores based upon the color of the wall in the pati ent’s room. A chi-squared test was performed to examine if anxiety levels were dependent upon the color of the wall at the foot of the patients’ beds. Length of stay wa s also examined using a t-test to compare the means and a chi-squared test was used to ex amine whether the patients’ length of stay was dependent upon the color of the wall at the f oot of the bed they occupied. Lastly, the patients’ pain medication requests were exam ined between the two groups of surgery and observation patients. A t-test examined the means of pain medication request on the first day, the middle days, and the final day of the patients’ stay in the hospital. Chi-squared tests were also run to determine whether pain medication requests could be determined to be dependent based upon the color of the wall at the foot of the bed. All findings were inconclusive due to the small sample size. Anxiety levels were analyzed with respect to the color of the wall at the foot of the bed, the participants’ gender, the participants’ proximity to the window within the room,

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55 and whether or not the patient had had surgery. In this study, the a nxiety levels were not dependent upon the color painte d on the wall at the foot of the patients’ beds. Although the evidence was not significan t, it appeared that beige wa s moving in the direction of produced the lowest anxiety levels followe d by orange. Green yielded the highest anxiety levels. The anxiety levels did not appear to vary based upon the partic ipants’ gender or their proximity to a window. A t-test s howed that having surgery was statistically significant (p<.05) in determining the anxiety levels of the patients. Patients having surgery had a higher level of anxiet y than the observation patients. There was not significant evidence (p>.05) that anxiety levels were dependent on the color of the wall at the foot of the bed for patients undergoing surgery. Within this study, the surgery patients who occupied a room with a green wall at the foot of the bed had the lowest average anxiety rates, followed by the patients in the beige rooms. The patients who occupied rooms with a purple wall at the foot of th e bed had the highest average anxiety rates of all the surgery patients. There were no surgery patients who occupied any of the rooms with an or ange wall at the foot of the bed. Similarly, there was not significant eviden ce that anxiety levels were dependent on color for patients under observation. A lthough there was no significant evidence, the observation patients in the beige rooms had the lowest average anxiety rates. This was followed by the average anxiety rate of the patie nts with a purple wall at the foot of the bed and the patients with an or ange wall at the foot of the bed. This highest anxiety levels were associated with the patients with a green wall painted at the foot of the bed.

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56 When all thirty-nine participants’ anxiet y levels were analyzed, it appeared as though the beige control rooms produced the lowe st anxiety levels. The average anxiety levels of the surgery patients suggested that th e rooms with a green wall at the foot of the patients’ bed produced the lowest anxiety le vels. The average anxiety levels of the twenty-nine observation patients suggested th at the beige rooms produced the lowest anxiety levels. Further tests are needed to draw conclusions about colors that produce the lowest levels of anxiety. This study showed that color on the wall at the foot of the patient bed could not be shown to be statistically signi ficant (p>.05) in predicting a patient’s recovery based upon the patient’s length of stay. The surgical pa tients who recovered in a green room had a slightly lower length of stay than the pa tients in the purple and beige rooms. The observation patients in this st udy had the shortest length of stay in the green rooms, followed by the patients in the orange rooms and the patients in the purple rooms. The observation patients who occupi ed the beige rooms had the longest length of stay. Overall, this study suggested that green might be the best color to promote a shorter length of stay. Once again, definitive c onclusions cannot be made based on the small sample size. This study did not find that pain medicati on requests were dependent on the color of the wall at the foot of the bed. Colors that might reduce the patients’ perception of pain or amount of pain medicati on requested were not identified. Some knowledge was gained through the info rmal interviews with the hospital staff and the patients. It was conc luded that based on preference, orange would be the best color to paint the rooms within this unit of the hospital. The purple rooms were the least

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57 liked by both the patients and the staff. Green was viewed as a color typically associated with a hospital setting. Overall, opinions s uggested that color should be incorporated into patient rooms within the hospital setting. Results found in this study fu rther this researcher’s beli ef that colors should be chosen for an environment based on the type of patient who will occupy the space and not based on the designers’ preferences. By investigating the colo r preferences of the people who will ultimately occupy the space and the implications that those colors may have on the individuals, designers can cr eate a space that focuses on healing. Limitations and Assumptions Many factors may have impacted the statis tical results. First the sample size was very small. Because this was a pilot study, it was impossible to determine the number of patients that would qualify to participate in the study. Further, it was not anticipated that the patients would have to be divided into two groups, those who had and did not have surgery. This reduced the sample size of the patients who had had surgery to only ten participants with no particip ants occupying an orange room. The sample size of the observation patients was limited to twenty-nine participants. Second, although an attempt was made to in clude only participants with a similar type of illness, this researcher believes that the various degrees of illness found within the sample had a detrimental effect on the study. The length of stay in the hospital and amount of pain medication requests will va ry by the illness or surgery that each participant experiences. Third, bedside manner may have played a role in the participants’ recovery. It is unclear how much effect doctors ’ and nurses’ reactions and re sponses to the patients can have on the patients’ psychologi cal state and ability to recover. Each participant had

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58 numerous nurses during their stay and this could have effected different patients in various ways. There were also several docto rs who had patients participating in this study. Each doctor may have a different opi nion about how much information to give their patients, which could impact the participan ts’ anxiety level. It is also possible that each doctor varied on his or her beliefs about what criteria should be used to determine when to discharge a patient. Ultimately, it was the doctors’ decision to release the patients and this would effect the patients’ length of stay. Fourth, it is unclear what effect color can have on the amount of pain medication a patient requested. It is po ssible that the amount may be impacted by the individual’s tolerance to pain. The participants’ request s for pain medication may also vary based upon their cultural and religious beliefs. Ther efore, the physical environment may have little, if anything, to do w ith perception of pain. Th ere was a limited amount of demographic information collected on the patients. The demographic information collected about the patients was limited to gender and age. There was no information collected regarding each patient’s religious preference, cultural ba ckground, or social status. Fifth, no attempt was made to determine the participants’ color preferences ahead of time. Color preference may be influenced by psychological types, age, gender, social status, and culture (Park, 2002). It is not known what effect color preference can have on anxiety levels. This researcher believes that if a patient wa s placed in a room with a color on the wall that he or she dis likes, the anxiety levels coul d be altered negatively. Finally, this researcher found it nearly im possible to eliminate many of the colors not being tested from the room. Although, th e tested colors were introduced into the

PAGE 69

59 space through paint on a large wall surface, the drapery, flooring, and countertops contained other colors. It is unclear how much of one color needs to be present in order to have an effect on an individual. Suggestions for Further Research Further studies need to be conducted befo re any conclusions c oncerning the effect of color on patient recovery can be made. Several items should be considered before undertaking another color study including the extensive proc ess of obtaining consent. There are five main areas requiring further exam ination in future studies; the complexity of the participants in terms of illnesses and treatments, the complexity of the colors in terms of hue, value, and intensity, the demographics being studied, the regional characteristics of the area in which the study took place, and the patients’ preferences for particular colors. Gaining consent. Attaining consent to perform research in a hospital requires permission from the Medical Institutional Revi ew Board. Due to the increased likelihood of ill patients being negatively effected by research, the medical review board process requires permission of the docto rs’ of all the patients invol ved. Since many doctors do not have the time to review a study protocol seeking permission from doctors can be time consuming. A non-medical review board process takes approximately two to three weeks; gaining permission for th is study took three months. The hospital staff administration approved a f our week period for the study. At the end of the study, it was apparent that it is mo re appropriate to run a study for as long as needed to get an adequate sample size. The small sample size for this study impacted the conclusions that could be drawn. It is suggested that futu re researchers should consult a statistician early in the study to determine how many participants will be needed to run a

PAGE 70

60 statistical analysis. This study was set-up using a time fram e, upon the conclusion of the study it was determined to be more appropriate to run the study for as long as needed to get the appropriate sample size. Complexity of the participants. Minimizing the differen ces between patients is important. For example, future studies should involve patients with the same illness or same type of surgery who are treated by th e same physician and nursing staff. A better understanding of the participant should be gained through inte rviews with the doctors and nurses. Questions should be asked in regards to the participant’s level of pain tolerance and degree of social support. By gaining a better understanding of the participant, the future researcher will be able to distinguish if the results are related to the complexity of the various patients or by the actual intervention. Complexity of the colors. Future researchers should consider testing different color palettes rather than just one color. In an actual interior environment, people are not surrounded by only one color, but rather by a mu ltitude of colors that are believed to work together to create an environment. By testing palettes, the researcher can provide a designer with an accurate way of producing th e most healing environments, rather than just providing them with one co lor to use. The colors shoul d coordinate with the colors already in the room. They should also be of various values and saturation levels. It would be ideal to test diffe rent types of color schemes, such as monochromatic, analogous, complementary, etc. Patient demographics. Further studies should examine each patient’s demographic characteristics to be able to determine whether or not this information can play a part in determining the outcome of the study. At the conclusion of this study, it is

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61 this researchers belief that the demographic ch aracteristics can play a part in the patients’ recovery rate based upon how comfortable the environment makes them feel. For example, patients within this study who app eared to be from a higher socio-economic class claimed they felt more comfortable in a painted room because it gave them the feeling of being in a hotel, not a hospital. Patients who appeared to be from a lower socio-economic class claimed they felt more co mfortable in the beige rooms because they felt like they were in a hospital and receiving medi cal care. It is antic ipated that a patient who is comfortable in the environment will have a more competent psychological state and be able to better adapt to the healing and recove ry process. This researcher suggests that future researchers explore; age, gender, education, culture, religi on, and social-status. Regional information. Design styles vary in differe nt countries around the world. It is further noted that in the United States design styles vary according to regions and climates within the country. It is unclear what effect the design style of the southeast could have played in the results of this st udy on color. It is suggested that further research should be conducted in various parts of the United States to determine if there are regional differences that could influence the outcome of the study. Patient and staff preferences. Within this study, patient and staff preferences for particular colors were stated informally in c onversations with the res earcher. It is highly recommended that in further studies, a formal qualitative approach should be incorporated to determine what effect the respondent’s pref erence for a particular color has on the outcome of the study. For example, the opinions of both the patients and staff about the particular colors in the envi ronment should be ascertained. Further investigation should also include questions about the color pr eferences incorporated into

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62 the individual’s particular home. It is also suggested that the researcher ask the patients and staff about the colors that they have noticed in other hospitals that they have visited. This information could be beneficial in de termining how an indi vidual’s preference for color can effect his or her recovery process. Conclusion The greatest knowledge gained from th is study was the understanding that the variable of color within the interior of a hospital is more complex than originally anticipated. This study was de signed in a quantitative framew ork that did not take into account the complexity of the effect that color plays on human psychological and physiological states. Some designers select a color palette that focu ses on the meanings and significance of partic ular colors in relation to the users of the space. This works well in a homogenous environment, but hospitals ar e complex environments used by a host of multicultural patients, medical staff, food service and maintenance workers (Park and Guerin, 2002). The optimal way to study color in a medical setting was found to combine qualitative and quantit ative methods. Patient recove ry is a complex variable that may be effected by many variables. When designing a hospital setting, the effects of both qualitative and quantitative variables on patients should be explored. This will allow designers to make an educated d ecision on how to create the most healing environments. The following is a framework de signed to provide future researchers with the knowledge gained from this study. It is intended to provide researchers with a place to start when designing future studies of color in healthcare.

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63 Framework for Future Researchers A framework for future research is discussed below. Research Setting Regional Information Investigate regional design preferences. Study should be conducted in vari ous regions throughout the United States. Area of the Hospital The unit of the hospital used shoul d include patient s with similar illnesses. The unit should have a limited number of doctors and nurses. The unit should include enough similar rooms so a comparison can be conducted. Hospital Rooms Rooms should be single occupancy. Rooms should be the same size. Rooms should have the same size window to provide the same amount of natural light. Rooms should provide the same view out of the window. Design Choose colors that coordinate with existing furnishings. Choose colors that are not believed to be harmful to the patients. Test a variety of color palettes. Test various hues, intensities, and values. Remove as many of the environmental factors that may effect a patient’s recovery as possible. Participants

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64 Illness Patients should all have the same illness or have undergone the same surgical procedure. The illness should not be life threatening. The illness or surgery should require th e patients to stay in the hospital for a similar amount of time. The illness or surgery should require the patients to request a similar amount of pain medication. Data Collection and Analysis Preliminary Research and Literature Review Investigate other enviro nmental factors such as view from a window, ceiling texture, noise level, etc ., that may effect a patient’s recovery. Investigate the illness being studied in terms of typical lengths of stay, medication requests, etc. Investigate hospital dynamics. Study Duration Contact statistician to determine the needed sample size to run appropriate data analysis. Run study until the proper sample size is obtained, not for a specified amount of time. Preliminary Data Collection Collect information about patien t and staff color preferences. Collect demographic information (a ge, gender, education, socialstatus, etc.) on participants. Interview doctors and nurses to gain information about pain tolerance, social support, etc. for each participant. Testing Recovery Variables An anxiety test is a good means of testing the effects of color.

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65 A follow-up test is suggested to determine the patient’s normal level of anxiety. Collect patients’ lengths of stay and compare them amongst each other as well as with predetermined typical lengths of stay. Collect patients’ medication reque sts on a daily basis and compare them among the individual patients as well as with the entire sample.

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66 APPENDIX STATE-TRAIT ANXIETY INVENTORY (STAI) Example: The S-Anxiety scale consists of twenty statements that evaluate how respondents feel “right now, at this moment.” 1 = NOT AT ALL 2 = SOMEWHAT 3 = MODERATELY SO 4 = VERY MUCH SO I feel at ease. 1 2 3 4 I feel upset. 1 2 3 4 The T-Anxiety scale consists of twenty st atements that assess how respondents feel “generally.” 1 = ALMOST NEVER 2 = SOMETIMES 3= OFTEN 4 = ALMOST ALWAYS I feel at ease. 1 2 3 4 I feel upset. 1 2 3 4 The STAI can be ordered from: Mind Garden 1690 Woodside Road, Suite #202 Redwood City, CA 94061 Phone: (650) 261-3500 Fax: (650) 261-3505 e-mail: mindgarden@msn.com website: www.mindgarden.com

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67 LIST OF REFERENCES Anderson, Mary. (1975). Colour Healing: Chromotherapy and How it Works. New York: Samuel Weiser, Inc. Birren, Faber (1961). Color Psychology and Color Therapy. New Hyde Park: University Books, Inc. Boos-Hamburger, H ilde. (1963). The Creative Power of Color. London: Mercury Arts Group. Carpman, Janet R. and Myron A. Grant (1993). Design that Cares. Chicago: American Hospital Publishing, Inc. Chaney, P.S. (1973). Dcor reflec ts environmental psychology. Hospitals 47(11):61-66. Cohen, Sheldon and Evans, Gary W. and Stokol s, Daniel and Krantz David S. (1986). Behavioral Health and Environmental Stess. New York: Plenum Press Demarco, Alison and Clarke, Nichol. (2001) An interview with Alison Demarco and Nichol Clarke: light and co lour therapy explained. Complementary Therapies in Nursing and Midwifery. 7:95-103 Edwards, Kenneth. (1979). The environment inside the hospital. Practitioner 222(1332):746-51 Ireland, SR, Warren, YM, and Herringer. (1992). Anxiety and Color Saturation Preference. Perceptual and Motor Skills. 75(2)545-546 Ladd-Franklin, Christine. (1973). Colour and Colour Theories. New York: Arno Press MacMahon, Kenneth M.A. and Lip, Gregory Y.H. (2002). Psychological Factors in Heart Failure. Archives of Internal Medicine. 162(5)509-516 Malkin, Jain. (1992). Medical and Dental Space Planning. New York: Van Norstrand Reinhold Marberry, Sara O. and Zagon, Laurie. (1995). The Power of Color. New York: John Wiley & Sons, Inc. Miller, Mary C. (1997). Color for Interior Architecture. New York: John Wiley & Sons, Inc.

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68 Moore, J. Duncan (2000). Designed to heal: architecture of Swedish clinic is about more than medicine. Modern Healthcare. 30(47): 32-34 Nassau, Kurt. (1997). Color for Science, Art and Technology. Amsterdam: Elsevier Science Nassau, Kurt. (2001). The Physics and Chemistry of Color (2nd ed.). New York: John Wiley & Sons, Inc. Palmer, J.B. and Nash, F. (1997). Taking Shap e: Environmental Art in Health Care. In C. Kaye and T. Blee (Eds.), The Arts in Health Care: A Palette of Possibilities (pp. 148-154). London: Jessica Kingsley Pub lishers Ltd.Fishman J, 2002, Park, Youngsoon and Guerin, Denise. (2002). Meaning and Preference of Interior Color Palettes Among Four Cultures. Journal of Interior Design. 28(1)27-39 Pierman, Brian C. (ed.) (1976). Color in the Health Care Environment. Proceedings of a Special Workshop Held at the National Bureau of Standards, Gaithersburg, Maryland. November 16, 1976. Wash ington: Department of Commerce. Rubin, Haya R., Owens, Amanda J., Golden, Greta. (1998). Status Report (1998): An Investigation to Determine Whether the Built Environment Affects Patients’ Medical Outcomes. Quality of Care Research. The Johns Hopkins University. Sirois, Brian C. and Burg, Matthew M. ( 2003). Negative Emotion and Coronary Heart Disease. Behavior Modification. 27(1)83-102 Speilberger, C.D., Sydeman, S.J., Owen, A. E., Marsh, B.J. (1999) Measuring Anxiety and Anger with the StateTrait Anxiety Inventory a nd the State-Trati Anger Expression Inventory. In M.E. Marsuish (Ed.), The Use of Psychological Testing for Treatment Planning and Outcomes Assessment. (2nd ed.) Mahwah: Lawrence Erlbaum Associates. Speilberger, Charles D. (1985). Assessment of State and Trait Anxiety: Conceptual and Methodological Issues. The Southern Psychologists. 1985(2):6-16. Speilberger, Charles D. (1983). State-Trait Anxiety Inventory for Adults. Redwood City: Mind Garden Stevens, Ernest J. (1938). True Chromotherapy. San Francisco: The Rainbow Publishers UCLA Office of Instructiona l Development. (1987). How the Hospital Environment Affects Recovery from Illness. Study City: Angus Lake Productions Ulrich, Roger S. (1991). Effect of Interi or Design on Wellness: Theory and Recent Scientific Research. Journal of Health Care Interior Design. 3:97-109

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69 Ulrich, Roger S. (1984). View through a Window May Influence Recovery from Surgery. Science. 224(4647):420-421 Verderber, Stephen F. (1983). Windowne ss and Human Behavior in the Hospital Rehabilitation Environment. Ann Arbor: University Microfilms International. (UMI No. 8314222) Verity, Enid (1980). Color Observed. London: The Macmillan Press Ltd. Vernolia, Carol. (1988). Healing Environments. Berkeley: Celestial Arts

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70 BIOGRAPHICAL SKETCH Kortney Jo Edge was born and raised in Southern California. Upon graduation from high school she began studying interior design at California State University, Fresno, where she was a member of th e 1998 NCAA National Championship softball team. After her third semester, she transferre d to the University of Florida and changed her major to sociology, all while continuing to play softball. Upon receiving a Bachelor of Arts degree in liberal arts and sciences, she took an internship in the interiors department of an architecture firm. While obtaining her master’s at the Univer sity of Florida in interior design, Kortney began her investigation on human respons es to color. In or der to gain a better understanding of the different sp ecialties within the field of interior design, she accepted an internship with a design firm specializi ng in hospitality. Thr ough her experiences in school, and through her internships, she ha s become very excited about all the possibilities that the interior design profession has to offer he r. Kortney is anticipating being able to incorporate her knowledge gained during researching into the profession of interior design. In her spare time, Kortney enjoys spending time with family and friends.


Permanent Link: http://ufdc.ufl.edu/UFE0000857/00001

Material Information

Title: Wall color of patient's room: effects on recovery
Physical Description: x, 70 p.
Creator: Edge, Kortney Jo ( Dissertant )
Hasell, Mary J. ( Thesis advisor )
Marsden, John P. ( Thesis advisor )
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2003
Copyright Date: 2003

Subjects

Subjects / Keywords: Interior Design thesis, M.I.D
Dissertations, Academic -- UF -- Interior Design

Notes

Abstract: This pilot study examined the effects of the environmental factor color on a patient's recovery in the hospital. The literature suggested that there are many widely held beliefs and intuitions about the healing powers of color. However, this researcher found no scientific studies on color completed within a natural hospital setting, rather than in a laboratory. Based on previous research on environmental factors, the recovery of cardiac patients was examined by assessing their anxiety levels, lengths of stay, and medication requests, within a control setting and an experimental setting. The study was conducted within ten rooms of a hospital cardiac care unit. A mid-tone shade of either purple, green, or orange was painted on the wall at the foot of the bed in six of the patients' rooms. Beige was the paint color in the other four rooms. An anxiety test was given to the 39 participants in the study to determine if a particular color promoted a higher level of anxiety. The participants' lengths of stay and medication requests were also noted to determine if these variables were affected by the particular color painted in each room. Informal interviews were also conducted on the patients and staff regarding their particular preferences for certain colors. Throughout the study, notes were kept regarding patient and staff comments about the colors. There were no significant findings to determine that anxiety levels, lengths of stay, or medication requests were dependent upon the color of the patient's room. Having no significant findings is believed to be caused mainly by the small sample size. Additionally, the pilot study revealed numerous variables that may also play a role in patient recovery. Many things about conducting a study within a hospital environment were learned through this study and a framework for future research in the area of color in the medical environment was developed. The guidelines for future research provided in this study recommend further testing in a natural research setting such as a hospital to learn more about the role that color plays on patient well-being.
Subject: color, design, hospital, interior
General Note: Title from title page of source document.
General Note: Includes vita.
Thesis: Thesis (M.I.D.)--University of Florida, 2003.
Bibliography: Includes bibliographical references.
General Note: Text (Electronic thesis) in PDF format.

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0000857:00001

Permanent Link: http://ufdc.ufl.edu/UFE0000857/00001

Material Information

Title: Wall color of patient's room: effects on recovery
Physical Description: x, 70 p.
Creator: Edge, Kortney Jo ( Dissertant )
Hasell, Mary J. ( Thesis advisor )
Marsden, John P. ( Thesis advisor )
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2003
Copyright Date: 2003

Subjects

Subjects / Keywords: Interior Design thesis, M.I.D
Dissertations, Academic -- UF -- Interior Design

Notes

Abstract: This pilot study examined the effects of the environmental factor color on a patient's recovery in the hospital. The literature suggested that there are many widely held beliefs and intuitions about the healing powers of color. However, this researcher found no scientific studies on color completed within a natural hospital setting, rather than in a laboratory. Based on previous research on environmental factors, the recovery of cardiac patients was examined by assessing their anxiety levels, lengths of stay, and medication requests, within a control setting and an experimental setting. The study was conducted within ten rooms of a hospital cardiac care unit. A mid-tone shade of either purple, green, or orange was painted on the wall at the foot of the bed in six of the patients' rooms. Beige was the paint color in the other four rooms. An anxiety test was given to the 39 participants in the study to determine if a particular color promoted a higher level of anxiety. The participants' lengths of stay and medication requests were also noted to determine if these variables were affected by the particular color painted in each room. Informal interviews were also conducted on the patients and staff regarding their particular preferences for certain colors. Throughout the study, notes were kept regarding patient and staff comments about the colors. There were no significant findings to determine that anxiety levels, lengths of stay, or medication requests were dependent upon the color of the patient's room. Having no significant findings is believed to be caused mainly by the small sample size. Additionally, the pilot study revealed numerous variables that may also play a role in patient recovery. Many things about conducting a study within a hospital environment were learned through this study and a framework for future research in the area of color in the medical environment was developed. The guidelines for future research provided in this study recommend further testing in a natural research setting such as a hospital to learn more about the role that color plays on patient well-being.
Subject: color, design, hospital, interior
General Note: Title from title page of source document.
General Note: Includes vita.
Thesis: Thesis (M.I.D.)--University of Florida, 2003.
Bibliography: Includes bibliographical references.
General Note: Text (Electronic thesis) in PDF format.

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0000857:00001


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WALL COLOR OF PATIENT'S ROOM: EFFECTS ON RECOVERY


By

KORTNEY JO EDGE


















A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF INTERIOR DESIGN

UNIVERSITY OF FLORIDA


2003

































Copyright 2003

by

Kortney Jo Edge















ACKNOWLEDGMENTS

I want to thank my thesis committee for their assistance in the completion of this

thesis. Dr. M. Jo Hasell and Dr. John P. Marsden were able to successfully guide me

through the trials and tribulations of this research project.

My sincere thanks go out to the wonderful staff at Shands Hospital for the

knowledge they provided me about the workings of a hospital. Brad Pollitt and Tina

Mullen provided information from the perspective of the facilities department. Dr.

Paulus, Dr. Gravenstein, and Dr. Graham-Pole provided valuable insight into the area of

healing and recovery.

A special thank you goes out to Marcia Kent and the entire staff of the cardiac care

unit of Shands Hospital. Their cooperation and interest in this study made it an extremely

enjoyable experience.

Lastly, and most importantly, I would like to thank my family and friends. Without

their constant support and encouragement this project would have never been completed.

They provided me with the strength to follow my dreams.
















TABLE OF CONTENTS
page

A C K N O W L E D G M E N T S ......... .................................................................................... iii

L IST O F TA B L E S ...................... .. ........ ........................ .. .... ...... ...... ....... vi

LIST OF FIGURES ............ ......... ......................... viii

ABSTRACT ........ .............. ............. ...... ...................... ix

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

P u rp o se ............................................................................. 1
S ig n ific a n c e .......................................................... ................ .. 2
B asic A ssum ptions........... ... .............................................................. ......... .... .5
Hypotheses of the Study ............................................ .... .... ................ .6
Sum m ary ...................................... ................................... .................... 6

2 REVIEW OF LITERATURE ......................................................... .............. 8

C o lo r E x p lain ed ..................................................................................... .. 8
Historical Overview of Beliefs About the Healing Power of Color.............................9
Intuition, Beliefs, and Research-Based Evidence About the Effects of Color ...........12
Laboratory Studies on Human Responses to Color................... ............................ 13
C hrom therapy E explained .............................................................. .................. 16
Cardiac Illness and Patient Responses to Environmental Factors............................17
Summary ............ ........................... .......................................19

3 M E T H O D O L O G Y ............................................................................ ................... 20

H ypotheses ................................................. 21
R e se arch S ettin g ................................................................................................... 2 2
P a rtic ip a n ts ........................................................................................................... 2 7
D ata C o lle ctio n ..................................................................................................... 2 8
Gaining Consent ...... .................... .......... ........29
State-Trait Anxiety Inventory................ ........... ......... 30
Documenting Length of Stay and Medication Requests .............. ................ 31
Discussions with Staff and Patients ........................................32









4 F IN D IN G S .................................................................................. 3 3

A nx iety L ev el ....................................................... 33
G ender and A nxiety ............ .................................................... .. .... ........ 37
W indow V iew and A nxiety ..................................................................... .. .... 39
Surgery and Anxiety .................. ............................ ........ .. ............ 41
L en g th o f S tay ...........................................................................................4 4
Pain M education R equests................................................. .............................. 45
Patients' Opinions About the Colors ........................................ ...................... 49
Hospital Employee's Opinions About the Colors ............................................... 51

5 D ISCU SSION .............. .... .. ..... ............... ............................53

Limitations and Assumptions .................................. .....................................57
Suggestions for Further Research................. ............... ....................59
C conclusion .......................................................................................................... 62
Fram ew ork for Future Researchers ........................................ ........................ 63

APPENDIX STATE-TRAIT ANXIETY INVENTORY (STAI).................................66

L IST O F R EFE R E N C E S ............................................................................. ............. 67

B IO G R A PH IC A L SK E TCH ..................................................................... ..................70






























v
















LIST OF TABLES


Table pge

2.1 Hum an Responses to Color .............................................................................15

3.1 Number of male and female patients who occupied each colored room ..............28

4.1 Average anxiety levels of patients occupying rooms of each color....................34

4.2 Chi-squared test for color and anxiety levels .............. .......................................36

4.3 Fischer's Exact Test on color and anxiety levels............................................37

4.4 Number of male and female patients who occupied each colored room ..............37

4.5 Anxiety scores of the female and male patients ...............................................38

4.6 Number of patients in each colored room based upon location of bed..................40

4.7 Mean anxiety scores for patients in relation to their proximity to a window........40

4.8 Number of surgery and observation patients in each set of colored rooms...........41

4.9 Mean anxiety levels of surgery patients and observation patients......................42

4.10 Mean anxiety of the surgery patients based upon the color of the room they
occupied. ............................................................................42

4.11 Chi-squared test on color and anxiety levels within surgery patients....................43

4.12 Mean anxiety of the observation patients based upon the color of the room they
occupied. ............................................................................43

4.13 Chi-squared test on color and anxiety levels within observation patients ............44

4.14 Average length of stay for surgery and observation patients recovering in each
set of colored room s ............................................................ ...... .......... .... 4 5

4.15 Number of patients who requested medication during their stay in each colored
room ............................................................................... 4 6









4.16 Average number of medication requests by surgery patients during their stay in
the hospital. .........................................................................47

4.17 Average number of medication requests by observation patients who request
pain medication during their stay in the hospital. .............................................49
















LIST OF FIGURES

Figure page

3.1 Layout of the fifth floor cardiac care unit at Shands Hospital. ............................23

3.2 Enlarged layout of a typical room in the cardiac care unit at Shands Hospital........25

3.3 Purple paint color. ................................ ... ........... .. ............26

3.4 Green paint color .................................. .. .. .. .. ...... .. ............26

3.5 Orange paint color ......................... ..... .. ... ............. ......... 27

3.6 B eige paint color. .......................... ...... .................................... .. ..... 27















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Interior Design

WALL COLOR OF PATIENT'S ROOM: EFFECTS ON RECOVERY

By

Kortney Jo Edge

August 2003


Chair: M. Joyce Hasell
Cochair: John P. Marsden
Major Department: Interior Design

This pilot study examined the effects of the environmental factor color on a

patient's recovery in the hospital. The literature suggested that there are many widely

held beliefs and intuitions about the healing powers of color. However, this researcher

found no scientific studies on color completed within a natural hospital setting, rather

than in a laboratory.

Based on previous research on environmental factors, the recovery of cardiac

patients was examined by assessing their anxiety levels, lengths of stay, and medication

requests, within a control setting and an experimental setting. The study was conducted

within ten rooms of a hospital cardiac care unit. A mid-tone shade of either purple,

green, or orange was painted on the wall at the foot of the bed in six of the patients'

rooms. Beige was the paint color in the other four rooms. An anxiety test was given to

the 39 participants in the study to determine if a particular color promoted a higher level

of anxiety. The participants' lengths of stay and medication requests were also noted to









determine if these variables were affected by the particular color painted in each room.

Informal interviews were also conducted on the patients and staff regarding their

particular preferences for certain colors. Throughout the study, notes were kept regarding

patient and staff comments about the colors.

There were no significant findings to determine that anxiety levels, lengths of stay,

or medication requests were dependent upon the color of the patient's room. Having no

significant findings is believed to be caused mainly by the small sample size.

Additionally, the pilot study revealed numerous variables that may also play a role in

patient recovery. Many things about conducting a study within a hospital environment

were learned through this study and a framework for future research in the area of color

in the medical environment was developed. The guidelines for future research provided

in this study recommend further testing in a natural research setting such as a hospital to

learn more about the role that color plays on patient well-being.














CHAPTER 1
INTRODUCTION

As early as 1888, Florence Nightingale asserted that environmental factors have an

effect on health and recovery. She was quoted as saying (Palmer and Nash, 1997:148);

The effect in sickness of beautiful objects, of variety of objects, and especially of
colour is hardly at all appreciated. I have seen in fevers (and felt, when I was a
fever patient myself) the most acute suffering produced from the patient not being
able to see out of a window and the knots in the wood being the only view. I shall
never forget the rapture of fever patients over a bunch of bright coloured flowers.

People say the effect is only in the mind. It is no such thing. The effect is on the
body, too. Little as we know about the way in which we are affected by form, by
colour, and by light, we do know this; they have an actual physical effect. Variety
of form and brilliancy of colour in the objects presented to patients are actual
means of recovery.

Purpose

The purpose of this study is to explore how one environmental feature, namely

color, may impact patient recovery in the cardiac care unit of Shands Hospital in

Gainesville, Florida. Shands Hospital is located at the University of Florida and is a 576-

bed private, not-for-profit hospital. Shands specializes in tertiary care for critically ill

patients and is the primary teaching hospital for the University of Florida College of

Medicine. Using the cardiac care unit of the hospital is significant to this study because

medical researchers believe that coronary diseases are substantially influenced by

environmental factors related to stress (MacMahon and Lip, 2002).

Designers have a responsibility for creating spaces that will help patients to become

healthier in a shorter amount of time. Poor design is believed to be associated with

anxiety, delirium, elevated blood pressure, and an increased intake of pain medication









(Ulrich, 1991). Although, research on human responses to specific colors has been

conducted in laboratory settings, this researcher found no scientific research about

whether or not a specific color can effect a patient's recovery process. A natural

research setting, within the interior of a hospital unit, provides a unique challenge to learn

about the relationship between people and the physical environment. It is believed that

color will express the way we feel by either raising or lowering our spirits (Ladd-

Franklin, 1973). Based on the beliefs of color researchers, this study tested whether or

not color had a positive impact recovery and that orange, considered a universal healer,

had a greater impact than green or purple.

This research aims to provide the interior design profession as well as the medical

profession with a source of knowledge that will provide evidence about the physical

environment's impact on patient well-being. It is hoped that this study will demonstrate

that a designer's personal preference for a particular color should have little to do with

the selection of colors in hospitals. Instead, colors should be chosen based upon their

ability to aid in the patients' recovery process.

Significance

Environmental factors have a tremendous impact on the behaviors that occur within

particular building settings. Beginning in the 1960's, designers began to believe that, "If

a man can manipulate his surroundings to improve his physical well-being, they

reasoned, he can manipulate it to foster desired behavior and to eliminate negative

responses" (Chaney, 1973:61). This concept plays a large role in the design of hospital

facilities. Under normal situations, when people feel uncomfortable with their physical

environment, they can solve the problem by simply leaving or adapting the environment

(Malkin, 1992). Unfortunately, this is not the case in healthcare facilities. Patients are









held captive in their environments and have no control over leaving or changing the

environment, and this condition places an incredible responsibility on designers (Malkin,

1992).

Designers face a great challenge in designing a positive hospital interior

environment. Patients enter a hospital setting already suffering from some ailment;

therefore, it is extremely important that the design positively impacts the patients'

psychological states, contributes to their recovery, or at least does not exacerbate their

illness (Chaney, 1973). Roslyn Lindheim, a critic of the modern hospital facility says

(Verderber, 1983:17);

The adjectives used to describe hospitals include dehumanizing, depersonalizing,
neutering, frightening, uncaring. I have neither heard anyone describe a hospital as
beautiful, peaceful, healing, warm, joyous ...indeed a look at the modern hospital
speaks not of human healing but of our technological progress, not of caring but of
an increase in the G.N.P. (Gross National Product), not of generating health but of
saving jobs and institutions. Despite this, the belief in hospitals is strong today.

Modem hospitals face a great challenge to not only care for the ill, but also to run a

successful business. By caring for patients, in a timely manner, hospitals are able to be

profitable, efficient, and to improve the care of patients (UCLA, 1987). Today's patients

are consumers. If the hospital does not create a welcoming, healing environment, the

patients will go elsewhere. The Vidar Klinik is a hospital that was created with healing

in mind (Moore, 2000). Wall colors were chosen in this hospital based upon Austrian

theoretician, Rudolf Steiner's philosophies about the healing powers of color (Moore,

2000). The patient rooms were painted pink or blue. Pink is believed to be healthful for

the spirit and blue is believed to relieve migraines (Moore, 2000). The majority of the

patients in this hospital are cancer sufferers or are patients being treated for depression

(Moore, 2000). With this in mind, patients in the Vidar Klinik are placed in rooms with









particular wall colors depending on their illness. There have been no studies completed

to determine the effectiveness of this strategy.

Many designers remain skeptical about the effects of human responses to

environmental factors and continue to select colors based on their own personal

preferences, despite many researchers' attempts to document the effects of color on

human behavior and physiological systems of the body within a laboratory setting.

However, if one sees the hospital from a quadriplegic's point of view, then the effects of

the environmental factors can be fully appreciated. A quadriplegic's view is limited to

that in a fixed, horizontal position in bed day in and out. Therefore, his or her behavioral,

physical, and psycho-emotional repertoire of coping mechanisms is much more

restrictive than that of an average, healthy individual (Verderber, 1983). With this

example, it is easy to comprehend how the natural light entering the room, the color of

the walls, the art that hangs on the walls, and anything else that is within immediate view

of the patient can effect not only a quadriplegic patient but others as well.

In 1997, The Center for Health Design compiled a list of environmental design

features that were considered important to creating higher quality interiors in healthcare

environments. This list of possible research areas included texture or finish of walls and

furnishings, noise, windows, and color of walls and furnishings (Rubin et al., 1998).

These researchers conducted an extensive review of the existing published articles that

explored how particular environmental factors effected patients. They found no scientific

published articles that addressed the issue of color (Rubin et al., 1998). The

physiological effect of visible color in a natural setting has not been documented by









medical science (Birren, 1961), despite many widely held beliefs and declarations about

the impact of color on people.

Although the literature review for this work did not reveal any research on how

color effects a patient's recovery in a hospital setting, there are two significant studies

that suggest that environmental factors can effect a patient's recovery in healthcare

facility design. Verderber (1983) and Ulrich (1984) both conducted research on the

effects of a window on a hospital patient's well-being. Verderber (1983) found that a

patient's proximity to a window and the view context out the window had an effect on the

patient's well-being. Ulrich's (1984) study showed that the patient's recovery was

effected by whether he or she had a view of a natural scene or a view of a brick wall.

These two studies are related to the current research on wall color in a patient's room

because they show that patients' well-being and recovery can be effected by

environmental factors.

Currently, there are no substantive guidelines for the selection of color in

healthcare facilities (Malkin, 1992). In fact, Faber Birren believes that, "the medical

profession has always been wary of any claims for color theory chiefly because all color

experience is highly personal and difficult to test and verify" (Pierman, 1976:5). This

study will test the impact of wall color at the foot of a patient's bed on recovery in order

to provide the interior design profession with a source of knowledge that may help

professionals design the most beneficial healthcare facilities for patients.

Basic Assumptions

The basic assumptions made in relation to this study were the following:

1. The participants of the study are suffering from a cardiovascular illness and
therefore are temporarily residing in the cardiac care unit of a hospital.









2. Being cardiovascular patients, it is assumed that the typical stay in the hospital will
be between three and four days.

3. Orange, green, purple, and beige painted walls at the foot of a patient's bed are
assumed to cause differences in the anxiety levels, lengths of stay, and pain
medication requests of the participants.

4. A hospital situation with cardiovascular patients can be used to determine the
degree of differences in their anxiety levels, lengths of stay, and pain medication
requests as influenced by the wall color at the foot of their bed.

5. The State-Trait Anxiety Inventory can be used to measure the participants' levels of
anxiety.

6. The participants' medical records can be used to determine the lengths of stay and
the pain medication requests.

Hypotheses of the Study

Three hypotheses are defined for this study.

1. There is a relationship between the color on the wall at the foot of the patient's
hospital bed and anxiety levels in a hospital setting.

2. There is a relationship between the color on the wall at the foot of the patient's
hospital bed and recovery time in a hospital setting.

3. There is a relationship between the color on the wall at the foot of the patient's
hospital bed and the amount of pain medication requested in a hospital setting.

Summary

Investigating the psychological attributes of color can further the understanding of

its effect on patient well-being. Research has shown that environmental factors have an

effect on patient well-being, but evidence on how patients are effected by wall color in

their hospital room is lacking. Chapter 2 investigates some ancient beliefs about color,

gives a brief definition of color, and explores studies on human responses to color. The

chapter also describes how heart disease is effected by environmental factors and how

color therapy is believed to work. Chapter 3 explains the methods used to conduct this






7


research on how color effects a patient's recovery, and chapters four and five report the

findings of this research and the researcher's conclusions about this study.














CHAPTER 2
REVIEW OF LITERATURE

It is believed that color can effect human emotions and can induce physiological

responses. Kenneth Edwards (1979) has shown that if people are effected by color in

their normal lives, then they are even more susceptible to the effects of color on their

behavior when they are not feeling their best. Thus, an appropriate color scheme may aid

in a patient's recovery (Carpman, 1993). The following review of literature attempts to

explain the relationship between color and psychological well-being.

Color Explained

"Color is that part of perception that is carried to us from our surroundings by

differences in the wavelengths of light, is perceived by the eye, and is interpreted by the

brain" (Nassau, 1997:3). The human eye does not have the capacity to see color. Light

reflects off surfaces and triggers an electrochemical response in the eye, which translates

into color within the brain (Miller, 1997). Different colored surfaces are distinguished by

a different pattern of nerve signals that are generated by color receptors found within the

retina of the eye (Verity, 1980). There are two types of receptors found within the retina,

called rods and cones. The cones are the ones responsible for the perception of color

(Verity, 1980). Cones can detect visible wavelengths between 400 (violet) to 700 (red)

nanometers (Miller, 1997).

Color can be measured with spectrophotometers and radiometric colorimeters.

Spectrophotometers measure the reflection characteristics of an object in wavelengths

(Nassau, 1997). Spectrophotometers illuminate the object with polychromatic light,









which contains all the wavelengths in the visible spectrum, and analyzes the light

reflected off the surface of the object (Nassau, 1997). Radiometric colorimeters detect

color in a similar way as spectrophotometers do, with the exception that they can only

measure self-luminous objects, such as lamps, displays, and computer screens (Nassau,

1997).

Paints are comprised of pigments, which are chemical components that selectively

reflect colored light to the observer (Verity, 1980). The primary pigment colors are

magenta, cyan, and yellow, which can be mixed together to produce innumerable colors

(Verity, 1980). Pigments absorb wavelengths, transmit wavelengths, and bend light in

different directions (Nassau, 1997). The pigment is a finely ground organic or inorganic

material that is combined with a liquid vehicle before it can be applied to a surface in a

paint form (Verity, 1980). Organic materials are derived from vegetable or animal

sources, native earths, and calcium natural earths (Verity, 1980). Today, inorganic, or

synthetic pigments are more often used than organic materials (Verity, 1980).

In order to perceive color fully, hue, saturation, and brightness need to be

described. Hue describes the actual color (Nassau, 2001). The hues that the human eye

sees are determined by reflected wavelengths (Miller, 1997). Saturation describes how

pure the color is, or how much white is mixed in (Nassau, 2001). A high-saturation hue

is bright and vivid (Miller, 1997). Brightness describes how much light a surface

receives. Brightness differentiates objects from their backgrounds and provides shade

and shadow (Miller, 1997).

Historical Overview of Beliefs About the Healing Power of Color

"Color is an ubiquitous, primary, and nonverbal aspect of human environments,

and investigating its psychological significance furthers the understanding of human









behavior on the most basic level" (Ireland et al. 1992:1). Throughout history, color has

been assumed to have an effect on health. The Assyrians, Babylonians, and Egyptians all

used forms of color and light therapies in healing (Demarco and Clarke, 2001). The

Persians are believed to have practiced a form of color therapy based on the emanations

of light (Birren, 1961). Pythagoras, a Greek philosopher around 500 BC, is believed to

have used music, poetry, and color to cure disease (Birren, 1961). Celsus, who practiced

medicine at the beginning of the Christian era, prescribed medicine with color in mind.

He once wrote, "there is one plaster almost of a red color, which seems to bring wounds

very rapidly to cicatrize" (Birren, 1961:21). The early beliefs behind the healing power

of color were fairly simple. "Colors were associated with disease because disease

produced color" (Birren, 1961:35). The Egyptians were the first civilization to research

color healing. They created "color halls" within their great temples, such as Karnack and

Thebes, in which they explored the impact of color on an individual's ability to heal

(Anderson, 1975).

With the advancement of modern medicine, the interest in the healing power of

color was left to the artists and poets. Johann Wolfgang von Goethe (1749-1832) was a

famous German poet, who developed his own theory on color, which explained,

Experience teaches us that the individual colours induce particular moods. In order
to experience fully these important individual effects the eye should be entirely
surrounded by one colour; we should be in a room of one colour, or look through a
coloured glass. We are then identified with the colour; it induces both eye and
mind in unison with it. (Boos-Hamburger, 1963:5)

Goethe had very particular beliefs as to what emotions particular colors would induce.

He believed that orange gave people a warm feeling that is reminiscent of the setting of

the sun (Boss-Hamburger, 1963). Goethe believed that green was very satisfying to the

eye. "If both mother colours (yellow and blue) are absolutely balanced in the mixture so









that neither is more noticeable than the other, the eye and the mind rest on the mixture as

though on something simple. Therefore, a green wallpaper is so often chosen for a room

which is in constant use" (Boss-Hamburger, 1963:7). Further, Goethe believed that a

very pale form of purple has a certain amount of life in it, but no joyousness (Boss-

Hamburger, 1963).

Through the efforts of S. Pancoast in 1877, color therapy was reunited with

medicine. He wrote, "to accelerate the Nervous System, in all cases of relaxation, the red

ray must be used, and to relax the Nervous System, in all cases of excessively accelerated

tension, the blue ray must be used" (Birren, 1961:53). Around this same time, Edwin D.

Babbitt began to wonder how to incorporate color therapy with modem medicine. He

wrote,

Substances combine in a harmonizing union with those substances whose colors
form a chemical affinity with their own and thus keep up that law of equilibrium
which is the safety of all things. This law having been so abundantly explained, it
is obvious beyond guesswork, that if the red arterial blood vessel should become
overactive and inflammatory, blue light or some other blue substance must be the
balancing and harmonizing principle. While again if the yellow and to some extent
the red and orange principle nerves should become unduly excited, the violet and
also the blue and indigo would be the soothing principles to have applied. This
applies to the nerves of the cranium, stomach, bowels, and kidneys, as well as
elsewhere, in which the heating and expansive action of these thermal principles
may beget the condition of delirium, emesis, diarrhea, diuresis, etc., that can be
assuaged only by the cooling and contracting influence of substances possessing
the electrical colors. Can this law, which thus stands out clearly and simply like a
mathematical demonstration be shown to have a basis in actual practice harmony
with the experiences of the medical world for ages back? (Birren, 1961:57-8).

Although there is no scientific backing to the historical beliefs about the association

between color and health, the historical beliefs found show the long standing fascination

with the association. This association can be dated back to 500 BC, and yet there is still a


lack of scientific evidence to prove the effects color has on health.









Intuition, Beliefs, and Research-Based Evidence About the Effects of Color

Today there are numerous widely held beliefs about the effects of color on humans,

but very few theories that have a scientific backing. Two University of Washington

researchers, B.K. Wise and J.A. Wise, reviewed previous research, and came up with a

summary of what is empirically known about responses to color (Carpman, 1993). They

also looked at the perception of a setting on one's behavior in that setting. After

reviewing over 200 laboratory studies they found that, "A positive reaction to color is a

mixture of social and emotional context and general fashion, as well as a specific

response to the interaction among light source, background color, and object order."

They also found that, "Perceived appropriateness of colors varies with the function and

style of an interior; including its decoration and with education and sociocultural norms

(taste). Characteristic appearance preferences for each style are unique to that style"

(Carpman, 1993:174). When classic color preference studies were examined (Park and

Guerin, 2002), it was found that various colors have different meanings to different

cultures. These differences effect their preferences for certain colors that can ultimately

effect their cognitive and motor abilities. Further, Park and Guerin (2002) discovered

that there is a relationship between color and meaning, and that the most preferred hue

temperature, value level, chroma level, and contrast level depends on the culture.

Certain colors tend to stimulate the body's functions in different ways. Marberry

(1995) believes that the immune system detects elements of the environment, such as

color, that elude other senses. Dr. Deepak Chopra believes that, "our immune cells are

constantly eavesdropping on our internal conversations. Immune cells are thinking cells,

'conscience little beings' like brain cells, equivalent to a circulating nervous system"

(Marberry and Zagon, 1995:86). This idea may contribute to the causation of illness.









According to Carol Vernolia (1988:63), "Red stimulates and invigorates the physical

body. It increases circulation, muscular activity, blood pressure, respiration, nervous

tension, heart rate, and hormonal and sexual activity. It stimulates the nervous system,

liver, adrenals, and senses in general." Yellow raises blood pressure, pulse and

respiration. It can relieve depression, tension, and fear, and soothe mental and nervous

exhaustion (Vernolia, 1988). Orange is an appetite stimulate, and is seen as a universal

healer that can counteract depression and humorlessness (Vernolia, 1988). Green effects

the whole nervous system and is especially beneficial to the central nervous system. It

has a sedative effect, relieving irritation and exhaustion. It soothes emotional disorders

and nervous headaches (Vernolia, 1988). "Green harmonizes us. If we wish to refresh

ourselves we go to the countryside, where the green of nature restores us after the city has

taken its toll of our nerves" (Anderson, 1975:8). Purple induces relaxation and sleep,

lowers body temperature, and decreases sensitivity to pain. It also increases the activity

of the veins (Vernolia, 1988).

Laboratory Studies on Human Responses to Color

Laboratory research studies have shown that color can have a direct effect on a

person physically, as well as, mentally. Kurt Goldstein is a recognized authority on

psycho neurology. He wrote, "It is probably not a false statement if we say that a specific

color stimulation is accompanied by a specific response pattern in the entire organism"

(Birren, 1961:144). His studies have documented the effects of specific colors on

individuals having certain diseases. In one such case, a woman with a cerebellar disease

had a tendency to fall unexpectedly and to walk with an unsteady gait. When she wore a

red dress, her symptoms were more pronounced. Green and blue clothing restored her

equilibrium to almost normal (Birren, 1961). Another study showed that when patients









suffering from tremors and twitching wore green glasses, their symptoms were relieved

(Birren, 1961).

The Environmental Docility Hypothesis, developed by M. Powell Lawton, states

that, "the less competent the individual, the greater the impact of environmental factors

on the individual" (Malkin, 1992:47). A patient's emotions can be related to their

environment, which can effect wellness. Cohen (1986) found that environmental stress,

or a situation in which the demands on an individual tax or exceed his adaptive

capabilities, could effect a person's physiological and psychological well-being.

Research on the psychological effects of color has been difficult because human emotions

are not stable and an individual's psychic make-up varies from person to person (Birren,

1961).

In 1976, a special workshop, "Color in the Health Care Environment," was held at

the National Bureau of Standards in Gaithersburg, Maryland. This workshop brought

together the architects, engineers, financial institutions, builders and users of the

healthcare facilities. Marcella Graham (Pierman, 1976), an environmental design

consultant, was a speaker at the workshop. Graham believes that the human response to

color falls within six categories, which are shown in Table 2.1.









Table 2.1. Human Responses to Color (Pierman, 1976).
Physiological: Changes in blood pressure, pulse rate, automatic nervous system,
hormonal activity, rate of tissue oxidation and growth.
Within the eye: Change in size of pupil, shape of lens, position of eyeball,
chemical response of retinal nerve endings.
Cognitive: Memory and recall illusion and perceptive confusion, values
judgment, associative response
Mood: Stimulating, irritating, cheerful, relaxing, boring, exciting,
melancholy, gay
Impressionistic: Space seems larger, smaller, warmer, cooler, clean or dirty,
bright or drab; people appear healthy or unhealthy, food is
appetizing or not, older, younger, old, new
Associative: With nature, with technology, religious and cultural traditions,
with art and science, typical or atypical

Some of the responses that Graham predicts color can produce may be detrimental

to a patient's recovery within the hospital setting. Alterations in blood pressure due to an

organismic or physiological response or changes in mood can lead to patient stress.

Graham did not specify whether she believes that particular colors promote these specific

responses, or if color in general promotes these responses. The Physiological Model of

Stress states that the sympathetic-adrenal medullar system reacts to various emergency

situations with increased adrenalin. The increased adrenalin, repeated over time, can

result in a sequence of responses that can ultimately accumulate in illness, which might

include increased blood pressure, increased heart rate, increased cardiac demand for

oxygen, and provocation of ventricular arrhythmias (Cohen et al. 1986).

During the past 30 years, no studies have been focused on how color effects

patients in a hospital setting. However, 84 studies have examined how other

environmental factors have been shown to impact well-being (Rubin, 1998). The Center

for Health Care Design stated that color is an important environmental feature in the

design of hospitals that needs to be further explored. Although the human response to the

application of color on walls within the interior hospital environment has not been









thoroughly explored, the application of colored lights has been explored. Studies have

been able to show that colored lights can have impacts on concentration, alertness,

aggression, stress, and even dyslexia (Demarco and Clarke, 2001). The use of applying

colored lights to relieve illness in known as chromotherapy.

Chromotherapy Explained

Chromotherapy, or color healing, is the application of beams of colored light to the

body to restore imbalance (Anderson, 1975). Color light rays activate the nerves, glands,

and blood (Stevens, 1938). This healing technique examines the electro-magnetic field,

which surrounds every human body. It is believed that the aura around the effected

human body part will appear discolored, which tells the color healer where the chemical

imbalance, which produces illness, is located (Anderson, 1975). Today, a process called

Kirlian photography is able to photograph the subject and show the emanations of energy,

or aura. A color health practitioner interprets the photograph to reveal the individual's

physical, emotional, and psychological characteristics (Demarco and Clarke, 2001).

Color raying energy reaches both the mental and physical conditions, where most

diseases originate, which then directly treats the cause and not just the symptoms

(Stevens, 1938). Proponents of chromotherapy believe that it is much safer than drugs

because it leaves no harmful residuals that the body has to overwork to eliminate. Drugs

can also be unreliable because people react differently to each drug (Anderson, 1975).

It is believed that chromotherapy was utilized as early as 1876, when Augustus

Pleasanton used blue light to treat a variety of diseases that were associated with pain

(Demarco and Clarke, 2001). During the 1920's, Dinshah Ghadiali, a Hindu scientist

developed the Spectro-Chrome system of healing (Demarco and Clarke, 2001). This

system explains how and why the different colored rays have various therapeutic effects









on organisms. Ghadiali believed that each organism and system of the body has a color

that can stimulate it, and another color that inhibits it (Anderson, 1975). He said that the

Spectro-Chrome system could be implemented by applying the correct color that will

balance the action of the abnormally functioning organ or system (Anderson, 1975). It is

believed that palpitation, or abnormal beating or throbbing of the heart, can be treated

with projected blue light (Stevens, 1938).

Through this system of treatment the normalizing color ray should be projected on

the nude body, or the part of the body with the ailment in twenty-minute intervals

(Stevens, 1938). The normalizing color ray varies depending on the part of the body that

is out of balance and thus creating illness. Also, different color rays are believed to

promote different functions in the body. It is believed that the violet ray causes bone

growth, the green ray increases vitality and energy, and the orange ray acts as a

nourishing tonic (Stevens, 1938).

Cardiac Illness and Patient Responses to Environmental Factors

It is estimated that 5 percent of all hospital admissions can be attributed to heart

failure (MacMahon and Lip, 2002). The National Center for Health Care Statistics

reported that in 2000 heart disease was the number two leading cause of death for people

between the ages of 45 and 64, which total 100,124 deaths in the United States. For the

population over 65 years of age, heart disease was the leading cause of death with

605,673 deaths.

This current study was conducted using the cardiac care unit of a hospital because

there is clear evidence of cardiac illnesses being effected by environmental factors.

Sirois and Burg (2003) believe that specific negative emotional states, namely

depression, anger, and anxiety, can have a negative influence on medical variables and









quality of life for patients with coronary heart disease. The effect that negative emotional

state can have on patients with coronary heart disease needs to be examined. Evidence

shows that the physical environment can effect emotional states. Introducing the colors

of red and blue to an environment has been attributed to feelings of anxiousness or

depression (Birren, 1961).

The impact that psychological factors can have on cardiac functioning has been

extensively tested (MacMahon and Lip, 2002). When a patient begins to feel anxious

their body is in a state of stress, which can negatively effect the cardiac output of a

patient with cardiac heart failure (MacMahon and Lip, 2002). Psychological stress can

cause a patient's heart rate to increase, which places an even greater physical stress on the

body (MacMahon and Lip, 2002). A study conducted by Frasure-Smith in 1995 found

that patients with higher anxiety levels were 4.9 times more likely to suffer from in-

hospital cardiac complications or death after a myocardial infraction than those with

normal stress levels (Sirois and Burg, 2003).

Depression can have an equally devastating effect on patients with coronary heart

disease. Major depression is found in 16 percent to 23 percent of all coronary heart

disease patients (Sirois and Burg, 2003). The general population has a depression rate of

5 percent (Sirois and Burg, 2003). Major depression can be attributed to patients not

complying with their medical treatment after coronary heart failure (MacMahon and Lip,

2002). Noncompliance is believed to contribute to a high rate of readmission rates for

these patients (MacMahon and Lip, 2002). Patients with depression who suffer from a

myocardial infraction are found to have a 40 percent mortality rate within 12 months

(Sirois and Burg, 2003). Based on these studies, it is extremely important to









acknowledge the effects that anxiety and depression can have on a patient with coronary

heart disease. By addressing hospital environmental factors that may contribute to a

coronary heart disease patient's anxiety and depression, we can aim to decrease the

likelihood of mortality due to heart failure while recovering in the hospital setting.

Summary

As this review of literature shows, there are many widely held beliefs about the

effect of color on the recovery process. The beliefs date back prior to the Christian era,

and yet today there still are many people who remain skeptical about the healing effects

of color. Color can be implemented into the healing process in various forms, including

chromotherapy and applying it to the physical environment. The important concept to

understand is the effect that color can have on a patient's psychological state while in a

hospital environment. It has been shown that, a patient's psychological state plays a large

role in the recovery process, particularly with coronary heart patients. By examining the

impact of color in relation to recovery, researchers can provide evidence to support

designers as they strive to create healing environments, which foster the recovery

process.














CHAPTER 3
METHODOLOGY

Using an experimental research design within the natural setting of a hospital, this

study explored the impact of wall color at the foot of the hospital bed on patient recovery

in the cardiac care unit of a hospital. Data was collected from multiple sources to

examine the effect of wall color on a patient's anxiety level, amount of pain medication

requests, and length of stay. Anxiety level was used to measure a patient's recovery in

this study because research shows that anxiety can have a negative influence on a

patient's recovery (MacMahon and Lip, 2002). A pre-interview process with several

doctors, who were currently practicing in the hospital, suggested that there is a belief

among physicians that anxiety can effect a patient's recovery.

Amount of pain medication and length of stay were also used to measure a patient's

recovery based on work by Verderber (1983) and Ulrich (1984). Verderber's (1983)

study was a good base for the current research study because an environmental factor

within a hospital setting was linked with patient recovery. Verderber's study used patient

and staff interviews to determine the effect that a window can have on a patient. His

findings suggested that the interview process was a good beginning for a study involving

a hospital setting. Ulrich's (1984) study built upon Verderber's findings. His study

examined patients' records looking for pain medication requests and lengths of stay and

compared patients with a view of a brick wall with those with a natural scene. He found

that the frequency of pain medication requests and lengths of stay were accurate

measures in determining patient recovery. Verderber's (1983) and Ulrich's (1984)









studies helped this researcher identify measures to use for testing patients' recovery rates

in a hospital setting. Pain medication requests and length of stay were the same measures

used in Ulrich's (1984) study. Ulrich (1984) was able to show that when a patient had a

view from a window there were fewer pain medication requests and the length of stay

was shorter than when the patient had a view of a brick wall. The following is a

definition of the hypotheses and a description of the study participants, the setting, and

the tools used to collect the data.

Hypotheses

Based on previous research on physical environmental variables and beliefs about

color, it is believed that a patient's recovery will be positively effected by the wall color

within their particular hospital room. It is anticipated that this study will determine

generally, whether wall color impacts recovery and specifically, which colors have the

greatest impact on recovery. It is expected that the results will show that orange will

have the most positive effect on the patient. Previous research suggests that orange is

considered the universal healer and is often used in the hospital environment (Venolia,

1988).

Three hypotheses are defined for this study. They are:

* There is a relationship between the color on the wall at the foot of the patient's
hospital bed and the patient's recovery time in a hospital setting.

* There is a relationship between the color on the wall at the foot of the patient's
hospital bed and the amount of pain medication requested by the patient in a
hospital setting.

* There is a relationship between the color on the wall at the foot of the patient's
hospital bed and the patient's anxiety level in a hospital setting.









Research Setting

The hospital selected for this research was Shands at the University of Florida.

Shands Health Care began in 1958 as the University of Florida Teaching Hospital. In

1979, Shands Teaching Hospital changed from a state institution to a private, not-for-

profit corporation and was renamed Shands Hospital. Through the years, Shands has

added a network of facilities. Shands Health Care now includes eight hospitals. Shands

Hospital, located on the University of Florida campus, specializes in tertiary care for

critically ill patients. Shands is also the primary teaching hospital for the University of

Florida College of Medicine. In 2001, Shands treated 46,653 patients throughout their

network of facilities. The facility at the University of Florida contains 576 patient beds

and has over 500 physicians who represent 110 different specialities.








































EtAN



Figure 3.1. Layout of the fifth floor cardiac care unit at Shands Hospital.

The area of the hospital used for this study was the cardiac care unit located on the

fifth floor of the hospital. This unit was chosen based upon the opinions of the Shands

Hospital administration. The administration determined that the cardiac care unit was the

only area of the hospital where there were ten rooms located in close proximity to each

other that were used for patients with similar illnesses. It was also determined that the

patients would have similar lengths of stay and medication requests in this unit. The unit









consists of a total of twenty-two rooms. The eleven rooms located on the west side of the

unit are double occupancy rooms that are used for patients recovering from surgery and

patients that are under cardiac observations. The eleven rooms located on the east side of

the unit are single occupancy rooms that are used for patients waiting for heart transplants

and patients recovery from transplant surgery. Staff and service rooms occupied the core

of the unit. Figure 3.1 shows the arrangement of the rooms.

The rooms numbered 5438, 5440, 5442, 5444, 5446, 5448, 5450, 5452, 5454, and

5456 were used in this study. Shands donated ten rooms for the use of this study and so

the first ten rooms in the hall were selected for use. They were all double occupancy

rooms with an area of 244 square feet. They all contain the same size window that looks

out over the west side of the building. The artwork on the walls that were painted for the

study was removed from each room so that as many of the environmental factors that

could influence the patient were eliminated. The walls that weren't painted were left in

their current beige color. The curtains separating the two patients were a combination of

orange, yellow, green, blue, and purple. The laminate countertops were green and the

floors were orange and green. All the furniture in the rooms was neutral shades of white,

gray, or beech wood. Figure 3.2 shows an enlarged version of the layout and dimensions

of the typical room used for this study.





















ill" -- -in ':--7j A



Figure 3.2. Enlarged layout of a typical room in the cardiac care unit at Shands Hospital.

Prior to the start of the study, the wall at the foot of the patients' beds were painted

in rooms 5438, 5440, 5442, 5444, 5446, and 5448. The paint colors were chosen to

coordinate with the colors already found within the room so that the patients would not

suspect anything about being involved in a study. An attempt was also made to choose

colors that were perceived to not be harmful, in any way, to the patients. The walls at the

foot of the patients' beds were painted purple; Sherwin Williams color SW6556 (Figure

3.3), in rooms numbered 5438 and 5444. Purple was chosen for use in this study because

it is believed to induce relaxation and sleep, lower body temperature, and decrease

sensitivity to pain. The walls at the foot of the patients' beds were painted green;

Sherwin Williams color SW6451 (Figure 3.4), in rooms 5440 and 5446. Green was

chosen because it is perceived to have a sedative effect and relieve irritation and

exhaustion. Orange, Sherwin Williams color SW6346 (Figure 3.5), was painted on the

walls in rooms 5442 and 5448. Orange is believed to be a universal healer that can be

used to counteract depression and humorlessness. The rooms numbered 5450, 5452,

5454, and 5456 were left unpainted in their natural beige color, similar to Sherwin









Williams color SW6658 (Figure 3.6). There was an attempt made to have one room of

each color located close to the nurses' station and it just worked out that all the beige

rooms were located next to each other.


Figure 3.3. Purple paint color.


Figure 3.4. Green paint color.




























Figure 3.5. Orange paint color.



















Figure 3.6. Beige paint color.

Participants

The participants were thirty-nine patients who occupied a bed in the cardiac care

unit on the fifth floor of Shands Hospital in Gainesville, Florida between February 3,

2003 and March 2, 2003. Ten of the participants were recovering from cardiac surgery,

while twenty-nine patients were undergoing cardiac observations. The patients ranged in









age from 26 to 89. There were a fairly equal number of male and female participants

with 19 females and 20 males (Table 3.1). Although there was no specific demographic

information collected, except for age and gender, it was the researcher's perception that

the patients were from various religious, ethnic, and socioeconomic backgrounds. The

patients were randomly placed in the hospital rooms by the hospital administration upon

their admission to the hospital.

Table 3.1. Number of male and female patients who occupied each colored room.
Beige Purple Green Orange Total
Female 7 3 3 6 19
(17.9%) (7.7%) (7.7%) (15.4%)
Male 6 7 6 1 20
(15.4%) (17.9%) (15.4%) (2.6%)
Total 13 10 9 7 39

Data Collection

A quantitative approach, consisting of three parts was used for this study. The

three parts included administering an anxiety test, documenting the length of stay and

medication requests, and informally interviewing patients and staff. This researcher

determined that a sample size of 100 participants would likely provide enough

information to determine if the patients' recovery process was being effected by the color

painted on the wall at the foot of the bed. There was no research found to help determine

the required sample size. The hospital administration estimated that conducting the study

for four weeks would provide the appropriate sample size. Due to variables out of the

researcher's control, the four-week study only produced 39 participants. During the

length of the study there was an unusually low number of admissions. Also, eleven

patients had to be eliminated from the study for various reasons.









All three instruments were conducted on the day that the patient was being released

from the hospital. The final day of the patient's stay in the hospital was chosen for

multiple reasons. First, the researcher wanted to be sure that each patient had spent

enough time in the room to have an opportunity to be effected by the color. Second, the

nursing staff determined that the doctors notified the nurses of who was to be released at

a certain time everyday. It then took the nurses time to prepare the patients to be

released. This was suggested to be the best time to conduct the research because all the

patients were awake, preparing to go home, and all the medical information was available

to the researcher. Lastly, conducting research on the final day proved to be of the least

inconvenience to the nursing staff. The researcher was able to check the notes board to

determine who was being sent home, and therefore who should be interviewed, without

bothering any of the hospital staff.

Gaining Consent

The Medical Internal Review Board determined that the researcher could not be the

first person to approach the patient to participate in the study. Therefore, the patients

were first approached by the nurse manager for the unit and asked to participate in this

study. If they agreed to participate the principal investigator then approached them to

explain the study and obtain a signed informed consent form. Eleven patients who were

approached could not be used in the study. Three patients explained that they would just

prefer not to participate. Two of the patients were considered legally colorblind. It was

the researcher's opinion that they would not be effected by the color on the walls and

therefore should not be used in the study. One patient was extremely confused and could

not understand the information being explained to him. He was eliminated from

participating in the study. One patient felt uncomfortable with having the principal









investigator examine his medical records and was therefore eliminated. One patient was

considered extremely depressed by the nurse manager and was not approached to

participate in the study and two patients could not speak English and were therefore left

out of the study. Lastly, one patient was extremely nervous and worried that the anxiety

test would reveal that she should have to stay in the hospital for an extended amount of

time. It was the researcher's opinion that she altered her answers on the test to make it

appear as though she had no anxiety in her life. This left thirty-nine patients who could

participate in the study.

Once each patient signed the informed consent form, the researcher explained the

anxiety test and how it was going to be used. The patient was told that the test would

take approximately ten to fifteen minutes and that it would entail answering forty

multiple-choice questions about how they feel at the moment and about how they

"generally" feel. Once the researcher felt the patient understood what was being asked of

them, the patient was told that they would be left alone to take the test while the

researcher examined their medical records to document the length of stay in that

particular room and the pain medication they had requested.

State-Trait Anxiety Inventory

The anxiety test used in this study was the State-Trait Anxiety Inventory

(Appendix), which was developed by Charles D. Spielberger. The test consists of two

separate 20-item self-report scales, which were self-administered to measure state anxiety

and trait anxiety. State anxiety consists of subjective feelings of tension, apprehension,

worry, and activation of the autonomic nervous system (Speilberger et al. 1999). Trait

anxiety is the differences in proneness to anxiety (Speilberger et al. 1999). The State-

Trait Anxiety Inventory was chosen as the tool to measure anxiety because of its ability









to access both state and trait anxiety with reliable, relatively brief, self-report scales

(Speilberger, 1985).

Today, the State-Trait Anxiety Inventory has become widely used in many

different disciplines including: counseling and guidance, criminal justice, education,

nursing, speech and hearing, sports psychology, sociology and anthropology, fine arts,

political science and government, and teacher education (Speilberger, 1985). The

particular area of interest for this study is its use in assessing whether color produces or

alleviates anxiety, which can impact recovery (Speilberger, 1985).

During the study, the participants were generally left to complete the anxiety test

on their own. The researcher administered the test orally to four of the participants. One

patient could not read. The three other patients had left their reading glasses at home and

therefore could not see the test.

Documenting Length of Stay and Medication Requests

While the patient was taking the anxiety test, with the nurses' permission, the

researcher examined the daily nurses' notes to determine medication requests and length

of stay. Located in the hallway outside the patients' rooms were carts that held a

notebook, which contained the daily nurses' notes for each patient. The notebooks were

divided according to the bed number. To find the length of stay that each patient was in

the particular room of interest, the researcher looked at the first page of nurses' notes

where the patient's name and the date they were admitted could be located. The

researcher noted the date the patient was admitted and the date that they were being

released to conclude how many days the patient had spent in that room.

To document the pain medication requested by the patient, the researcher turned to

the section in the nurses' notes that listed pain medication administered by date and time.









The researcher noted how many dosages were administered to the patient each day that

they were in the particular hospital room of interest. The lengths of stay and medication

requests were then recorded on the researcher's data chart and the researcher returned to

the patient's room to pick-up the anxiety test and to thank the patient for participating.

Discussions with Staff and Patients

Throughout the four-week study the patients and staff were very willing to offer

their opinions and beliefs about the colors located in the rooms. The researcher

documented the informal staff and patient conversations at the end of each day. These

notes were then compiled at the end of the study to compare the findings in the study

with the patients and staff s preferences for particular colors.














CHAPTER 4
FINDINGS

The purpose of this study was to explore the effect that wall color has on a patient's

recovery while occupying a hospital room. A review of literature showed that there are

many widely held beliefs about how color effects healing, but there are no scientific

studies that have been conducted in a hospital setting. In an attempt to test some of the

suppositions about color, the study hypothesized that wall color at the foot of the

patient's bed can effect a patient's anxiety level, length of stay in the hospital, and the

amount of medication requested by the patient while in the hospital. All data was

collected by using the nurses' notes, regarding pain medication requests and lengths of

stay, and administering an anxiety test on the last day of the patients' stay in one of the

hospital rooms used for this study.

Anxiety Level

Anxiety levels were recorded using the State-Trait Anxiety Inventory developed by

Charles D. Speilberger. There are two parts to this anxiety test. The first part analyzes a

person's anxiety levels based on his or her feelings of tension, apprehension,

nervousness, and worry (Speilberger, 1983). The second part of the anxiety test

examines clinical anxiety and is largely used for screening for anxiety problems and

evaluating the immediate and long-term outcome of psychotherapy, counseling, behavior

modification, and drug-treatment programs (Speilberger, 1983). It was determined that

the first part of the test, the State Anxiety Level, would be more beneficial in determining

the effects of wall color on patient anxiety because it examines a person's feelings at the









moment of the test. This study was interested in how the patients' anxiety levels were

effected while in the hospital, which was a relatively short amount of time. The second

part of the State-Trait Anxiety Inventory examined long-term anxiety, which would not

have been beneficial in understanding how the colors effected the patients.

The state anxiety was scored based on twenty questions. Each question was given

a score of 1 to 4, with 4 indicating the highest level of anxiety. The scores for each of the

twenty questions were then added together to give each participant an anxiety score

between 20 and 80. The publisher of the test provided normative data about the state

scores for general medicine and surgery patients. The data provided was collected in six

veterans hospitals throughout the southeastern United States. The mean state anxiety

score for the 161 patients tested was 42.4. The normative data provided suggested that

there was no significant difference in anxiety scores based upon age. Within this current

study, the mean anxiety scores were much lower. The average anxiety level for all

participants of this study was 32.5. When the patients were separated based upon the

color of the wall at the foot of their bed, the average anxiety level of the patients with a

beige wall at the foot of their bed was 29.7. The patients with a purple wall at the foot of

their bed had an average anxiety level of 33.2, the patients with a green wall had an

average anxiety level of 35.3, and the average anxiety level of a patient occupying a room

with an orange wall was 33.0 (Table 4.1).

Table 4.1. Average anxiety levels of patients occupying rooms of each color.
Mean N Std Deviation
Beige 29.69 13 10.363
Purple 33.20 10 10.717
Green 35.33 9 10.173
Orange 33.00 7 5.066
Total 32.49 39 9.578









A chi-squared test was used to test the independence of color and anxiety levels.

To perform this test, anxiety scores were placed into two categories, low anxiety and high

anxiety. No information was found by this researcher that indicated what a normal

anxiety range is for a population similar to the one in this study. Therefore, this

researcher created two categories, low anxiety and high anxiety, in an effort to compare

the effects of the various colors on anxiety levels. The mean anxiety level of all

participants in this study was determined to be 32.49. The low anxiety represented all the

anxiety levels that were below the average anxiety level for this study. The high anxiety

represented all the anxiety levels that were above the average anxiety level for this study.

The low anxiety was determined to be between 20 and 32 (or less than the mean anxiety

score) and the high anxiety was determined to be between 33 and 80 (or more than the

mean anxiety score). The results of the chi-squared test are reported in Table 4.2. This

test was not significant (p>.05) possibly due to the low number of cases in each cell.

Therefore, there is no evidence that the anxiety levels of the patients are dependent on the

color of the wall at the foot of the bed.









Table 4.2. Chi-squared test for color and anxiety levels.
Low Anxiety High Anxiety Total
Beige Count 10 3 13
Expected Count 7.7 5.3 13.0
% within color 76.9% 23.1% 100.0%
Adjusted Residual 1.6 -1.6
Purple Count 5 5 10
Expected Count 5.9 4.1 10.0
% within color 50.0% 50.0% 100.0%
Adjusted Residual -.7 .7
Green Count 5 4 9
Expected Count 5.3 3.7 9.0
% within color 55.6% 44.4% 100%
Adjusted Residual -.2 .2
Orange Count 3 4 7
Expected Count 4.1 2.9 7.0
% within color 42.9% 57.1% 100.0%
Adjusted Residual -1.0 1.0
Total Count 23 16 39
Expected Count 23.0 16.0 39.0
_% within color 59.0% 41.0% 100.0%

Because of the small sample size, a Fischer's exact test was run which requires a

2x2 table. The anxiety levels of the patients were explored based on color (purple, green,

and orange) and no color (beige). The average anxiety score for patients with no color on

the wall at the foot of the bed was 29.7. The average anxiety score for the patients with

color on the wall at the foot of the bed was 33.9. The results of Fischer's Exact Test,

similar to chi-squared, are reported in Table 4.3. This test used measures of low anxiety

(20 to 32) and high anxiety (33 to 80). This test was not significant (p>.05) and suggests

that anxiety levels are not dependent on the color of the wall at the foot of the bed.









Table 4.3. Fischer's Exact Test on color and anxiety levels.
Low Anxiety High Anxiety Total
No Color Count 10 3 13
Expected Count 7.7 5.3 13.0
% within color 76.9% 23.1% 100.0%
Adjusted Residual 1.6 -1.6
Color Count 13 13 26
Expected Count 15.3 10.7 26.0
% within color 50.0% 50.0% 100.0%
Adjusted Residual -1.6 1.6
Total Count 23 16 39
Expected Count 23.0 16.0 39.0
% within color 59.0% 41.0% 100.0%

Gender and Anxiety

Other factors that were believed to have a possible effect on anxiety levels were

also tested. One factor is the impact of gender on anxiety levels. Nineteen of the

participants of this study were female and twenty were male. Of the female patients,

seven occupied a room with a beige wall at the foot of the bed; three occupied a room

with a purple wall; three occupied a room with a green wall; and six occupied a room

with an orange wall during their stay in the hospital (Table 4.4). Out of the twenty male

patients, six occupied a room with a beige wall at the foot of the patient's bed. Seven of

the male patients occupied a room with a purple wall; six of the patients had a room with

a green wall; and one patient occupied a room with an orange wall during their stay in the

hospital (Table 4.4).

Table 4.4. Number of male and female patients who occupied each colored room.
T Beige Purple Green Orange Total
Female 7 3 3 6 19
(17.9%) (7.7%) (7.7%) (15.4%)
Male 6 7 6 1 20
(15.4%) (17.9%) (15.4%) (2.6%)
Total 13 10 9 7 39









A t-test comparing the anxiety levels of the female and male patients showed no

significant difference (p>.05) in their anxiety scores. As seen in Table 4.5, the female

patients had a mean score of 33.0 and the male patients had a mean anxiety score of 32.0.

It is unknown why the standard deviations are high. The standard deviations were also

found to be high in similar studies conducted on general medicine and surgery patients

(Speilberger, 1983). These scores indicate that there is little difference between the

anxiety scores of the female and male patients. Thus, gender cannot be credited with

effecting the patients' anxiety levels.

Table 4.5. Anxiety scores of the female and male patients.
Mean N Std. Deviation
Female 33.00 19 10.661
Male 32.00 20 8.675
Total 32.49 39 9.578

Female patients. A t-test run on the female participants in this study showed no

significant difference (p>.05) on anxiety scores based upon whether or not they occupied

a room with a color (purple, green, or orange) on the wall. Within this study twelve

patients occupied a room with a color painted on the wall at the foot of their bed (Table

4.4). The mean anxiety score of the female patients who occupied a room with color on

the wall was 35.9 and the mean anxiety score for patients in a beige room was 28.0. A

chi-squared test was not significant (p>.05) in determining whether anxiety scores were

dependent upon the color of the wall for female patients.

Male patients. A t-test run on the twenty male participants in this study showed

no significant difference on anxiety scores based upon whether or not they occupied a

room with color (purple, green, and orange) painted on the wall. Within this study

fourteen male patients occupied a room with a color painted on the wall at the foot of









their bed (Table 4.4). The mean anxiety score for the male patients who occupied a room

with color on the wall was 32.1. The mean anxiety score of the patients in a beige room

was 31.7. A chi-squared test was not significant (p>.05) in determining that anxiety

scores were dependent upon the color of the wall for male patients.

Window View and Anxiety

Based on previous studies (Ulrich, 1984, and Verderber, 1983), distance from a

window and view from a window are believed to have an effect on patient recovery. For

this study, the views out of the windows are the same from all rooms. Because these

rooms were double occupancy, some patients were closer to the windows than others.

This factor was examined to test the effect it had on patient anxiety levels. The patients

were divided into two groups based upon the location of their beds. Group A included

the patients who occupied beds closest to the window. Group B included patients who

occupied beds furthest from the window. Fifteen patients were included in Group A and

twenty-four patients were included in Group B. The participants were randomly assigned

to a bed by the hospital administration. Having more participants in Group B may have

effected the outcome of the results.

Within Group A, five patients occupied rooms with a beige wall at the foot of the

bed, three patients occupied rooms with a purple wall, six patients occupied rooms with a

green wall, and one patient occupied a room with an orange wall (Table 4.6). Within

Group B, eight patients occupied a room with a beige wall at the foot of the bed, seven

patients occupied a room with a purple wall, three patients occupied a room with a green

wall, and six patients occupied a room with an orange wall during their stay in the

hospital (Table 4.6).









Table 4.6. Number of patients in each colored room based upon location of bed.
Beige Purple Green Orange Total
Group A 5 3 6 1 15
(12.8%) (7.7%) (15.4%) (2.6%)
Group B 8 7 3 6 24
(20.5%) (17.9%) (7.7%) (15.4%)
Total 13 10 9 7 39

A t-test comparing anxiety levels of patients in Group A (closest to the window)

and Group B (furthest from the window) found no significant difference (p>.05) in

anxiety levels between the two groups based on proximity to a window. The mean

anxiety score of the fifteen patients in Group A was 32.6 and the mean anxiety score of

the twenty-four patients in Group B was 32.4 (Table 4.7).

Table 4.7. Mean anxiety scores for patients in relation to their proximity to a window.
_Mean N Std. Deviation
Group A 32.60 15 10.322
Group B 32.42 24 9.311
Total 32.49 39 9.578

Group A. A t-test on the fifteen patients that occupied a bed closest to the window

found no significant (p>.05) difference between the anxiety scores based upon whether or

not they occupied a room with a color (purple, green, or orange) painted on the wall.

Within this study there were ten patients who occupied a room with color (Table 4.6).

The mean anxiety score of the patients in a room with color was 34.8 and the mean

anxiety score of the patients in a beige room was 28.2. A chi-squared test was not

significant (p>.05) in determining that the anxiety scores were dependent upon the color

painted at the foot of the patient's bed.

Group B. A t-test on the twenty-four patients who occupied a bed away from the

window found no significant (p>.05) difference between the anxiety scores based upon

whether or not the patients occupied a room with color (purple, green, or orange) on the









wall. The mean anxiety score of the patients occupying a room with color on the wall at

the foot of the bed was 33.3. The mean anxiety score of the patients in the beige rooms

was 30.6. A chi-squared test was significant (p<.05) in determining that anxiety scores

were dependent on the color painted at the foot of the bed. Because of the small sample

size, it is suggested that further tests should be run before any conclusions can be made.

Surgery and Anxiety

Ten of the patients included in the study were recovering from surgery, while

twenty-nine of the patients were simply being observed in the hospital. The effects of a

patient having surgery was examined in relation to a patient's anxiety levels. Of the ten

surgery patients, three occupied rooms with a beige wall at the foot of the bed, four

patients occupied a room with a purple wall, three patients occupied a room with a green

wall, and there were no patients who occupied a room with an orange wall (Table 4.8).

Out of the twenty-nine patients under observation, ten occupied rooms with a beige wall

at the foot of the bed, six patients occupied rooms with a purple wall at the foot of the

bed, six patients occupied a room with a green wall, and there were seven patients who

occupied a room with an orange wall at the foot of the bed (Table 4.8).

Table 4.8. Number of surgery and observation patients in each set of colored rooms.
1 Beige Purple Green Orange Total
Surgery 3 4 3 0 10
(7.7%) (10.3%) (7.7%) (0.0%)
Observation 10 6 6 7 29
(25.6%) (15.4%) 15.4%) (17.9%)
Totals 13 10 9 7 39

A t-test comparing the anxiety levels of the surgery patients and the patients under

observation found a significant (p<.05) difference in their anxiety levels. The mean









anxiety level of the ten surgery patients was 38.2 and the mean anxiety level of the

observation patients was 30.5 (Table 4.9).

Table 4.9. Mean anxiety levels of surgery patients and observation patients.
Mean N Std. Deviation
Surgery 38.20 10 11.650
Observation 30.52 29 8.074
Total 32.49 39 9.578

Based on the significant difference in anxiety levels between the surgery patients

and the observation patients, the two groups were separated to examine the effects of

color on anxiety levels within the two groups.

Surgery patients and anxiety. Within the ten surgery patients, the mean anxiety

score was 38.2. Three occupied a room that had a beige wall at the foot of the bed.

These three patients had a mean anxiety score of 38.0. Four of the surgery patients

occupied a room with a purple wall at the foot of the bed and had a mean anxiety score of

41.0. Three surgery patients occupied a room with a green wall at the foot of the bed and

had a mean anxiety score of 34.7 (Table 4.10).

Table 4.10. Mean anxiety of the surgery patients based upon the color of the room they
occupied.
_Mean N Std. Deviation
Beige 38.00 3 16.093
Purple 41.00 4 11.633
Green 34.67 3 10.693
Total 38.20 10 11.650

A chi-squared test measured whether the anxiety scores were dependent on the

color of the wall at the foot of the patient bed (Table 4.11). The color on the wall at the

foot of the bed made no significant (p>.05) difference in the anxiety levels of recovering

surgery patients.









Table 4.11. Chi-squared test on color and anxiety levels within surgery patients.
Low Anxiety High Anxiety Total
Beige Count 1 2 3
Expected Count .9 2.1 3.0
% within color 33.3% 28.6% 30.0%
Purple Count 0 4 4
Expected Count 1.2 2.8 4.0
% within color .0% 57.1% 40.0%
Green Count 2 1 3
Expected Count .9 2.1 3.0
% within color 66.7% 14.3% 30.0%
Total Count 3 7 10
Expected Count 3.0 7.0 10.0
_% within color 100.0% 100.0% 100.0%

Observation patients and anxiety. Within the twenty-nine observation patients,

10 occupied a room with a beige wall at the foot of the bed, 6 with a purple wall, 6 with a

green wall, and 7 had a room with an orange wall at the foot of the bed. The mean

anxiety score of the observation patients was 30.5. The patients who occupied a room

with a beige wall at the foot of the bed had a mean anxiety level of 27.2. The patients

with a purple wall had a mean anxiety of 28.0. The patients who occupied a room with a

green wall had a mean anxiety level of 35.7 and the patients with an orange wall had a

mean anxiety level of 33.0 (Table 4.12).

Table 4.12. Mean anxiety of the observation patients based upon the color of the room
they occupied.
Mean N Std. Deviation
Beige 27.20 10 7.465
Purple 28.00 6 6.663
Green 35.67 6 10.930
Orange 33.00 7 5.066
Total 30.52 29 8.074









A chi-squared test compared the anxiety levels across observation patients in the

different colored rooms (Table 4.13). No significant (p>.05) difference was found on

patients' anxiety levels and therefore color could not be proven to effect anxiety levels.

Table 4.13. Chi-squared test on color and anxiety levels within observation patients.
Low Anxiety High Anxiety Total
Beige Count 9 1 10
Expected Count 6.9 3.1 10.0
% within color 45.0% 11.1% 34.5%
Purple Count 5 1 6
Expected Count 4.1 1.9 6.0
% within color 25.0% 11.1% 20.7%
Green Count 3 3 6
Expected Count 4.1 1.9 6.0
% within color 15.0% 33.3% 20.7
Orange Count 3 4 7
Expected Count 4.8 2.2 7.0
% within color 15.0% 44.4% 24.1%
Total Count 20 9 29
Expected Count 20.0 9.0 29.0
% within color 100.0% 100.0% 100.0%

Length of Stay

The study sample of 39 patients was broken into two groups in order to compare

patients who were in the hospital for similar reasons and to provide a more accurate

account of how the length of stay was effected by the color of the wall located at the foot

of the patient's bed. The first group consisted of 10 patients recovering from surgery.

Their length of stay ranged from 2 to 6 days. Three patients recovered in a room with a

beige wall at the foot of the bed; four patients recovered in a room with a purple wall;

three patients recovered in a room with a green wall; and there were no surgery patients

who recovered in a room with an orange wall (Table 4.8). The second group comprised

29 patients under observation. The patients who were occupying the observed hospital

rooms while under physician observation had lengths of stay ranging from 2 to 6 days.









Ten of these patients occupied rooms with a beige wall at the foot of the bed; six

occupied rooms with a purple wall; six occupied rooms with a green wall; and seven

occupied rooms with an orange wall (Table 4.8).

As shown in Table 4.14, the average length of stay for a patient recovering from

surgery in a room with a beige wall at the foot of the bed was 5.3 days. The average

length of stay for patients with a purple wall was 4.3 days and for patients with a green

wall the average length of stay was 4.0 days (Table 4.14). Chi-squared tests revealed that

there was no significant (p>.05) difference between the patients' length of stay based on

the color of the wall at the foot of the bed.

Table 4.14. Average length of stay for surgery and observation patients recovering in
each set of colored rooms.
Beige Purple Green Orange Total
Surgery 5.3 4.3 4.0 4.5
Observation 3.8 3.0 2.7 3.0 3.2
Totals 4.2 3.5 3.1 3.0 3.5

Patients under observation who occupied a room with a beige wall at the foot of the

bed had an average length of stay of 3.8 days. The average stay for a patient occupying a

room with a purple wall was 3.0 days. A patient occupying a room with a green wall had

an average length of stay of 2.7 days, and a patient in a room with an orange wall had an

average length of stay of 3.0 days (Table 4.14). There was no significant (p>.05)

difference between the average lengths of stay based on the wall color at the foot of the

patient's bed. A small sample size may have yielded results that are not statistically

significant throughout the study.

Pain Medication Requests

Nurses' notes were reviewed to determine the number of pain medication requests

for each day of the patient's hospital stay. For example, if a patient requested three doses









of pain medication on the first day of their hospital stay, a three would be recorded under

day one for that particular patient. The sample was again divided into two groups for the

purpose of analysis. The first group contained the ten surgery patients and the second

group contained the twenty-nine patients under physician observation. Out of the twenty-

nine total patients under observation, thirteen of them had no medication requests during

their stay. Therefore, only the sixteen observation patients who requested pain

medication during their stay were included in the examination of pain medication

requests on observation patients. Seven of the sixteen observation patients who requested

pain medication occupied a room with the wall at the foot of the bed painted beige.

Three of the patients occupied a room with a purple wall, three of the patients occupied a

room with a green wall, and three of the patients occupied a room with an orange wall

(Table 4.15). Out of the ten surgery patients, three of the surgery patients recovered in a

room with a beige wall at the foot of the hospital bed, four recovered in a room with a

purple wall, three recovered in room with a green wall, and there were no surgery

patients who recovered in a room with an orange wall (Table 4.15).

Table 4.15. Number of patients who requested medication during their stay in each
colored room.
Beige Purple Green Orange Total
Surgery 3 4 3 0 10
(7.7%) (10.3%) (7.7%) (0.0%)
Observation 7 3 3 3 16
(43.8%) (18.8%) (18.8%) (18.8%)
Total 10 7 6 3 26

Pain medication requests were examined separately for the first and last days of a

patient's stay in a hospital. It was anticipated that a patient would experience the highest

level of pain on the first day and the least amount of pain on the last day making it

difficult to compare medication requests for all other days in between. The "middle









days," after the first day and before the last day, were all compared together. The

patients' length of stay varied and these could be any where from the second day in the

hospital to the fifth day.

Surgery patients' medication requests. The surgery patients' medication

requests varied from 2 to 6 doses on the first day of their stay in the hospital. Surgery

patients recovering in a room with a beige wall at the foot of the bed had an average of

5.3 doses of medication requested on their first day of their hospital stay. The patients

recovering in a room with a purple wall at the foot of the bed had an average of 4.3 doses

requested and the patients occupying a room with a green wall had an average of 4.0

doses of medication requested on the first day of their stay in the hospital (Table 4.16).

There were no surgery patients that recovered in an orange room. The average number of

pain medication requests on the first day of the patients' hospital stay was not statistically

significant (p>.05).

Table 4.16. Average number of medication requests by surgery patients during their stay
in the hospital.
1 Beige Purple Green Orange Total
First Day 5.3 4.3 4.0 4.2
Middle Days 3.5 3.2 3.5 3.4
Last Day 0.0 0.8 0.3 0.4
Totals 3.1 3.2 2.3 2.9

During the "middle days" of the surgery patients stay, the patients' medication

requests ranged from 0 to 10 doses per day. The three surgery patients who occupied a

beige room during their stay requested an average of 3.5 doses of pain medication during

the middle days of their stay. The four surgery patients who occupied a room with a

purple wall average 3.2 doses of medication requested and the patients who occupied a

room with a green wall requested 3.5 doses of pain medication (Table 4.16). There were









no surgery patients that occupied an orange room during their stay in the hospital. The

average number of the pain medication requests during the "middle days" of the patients'

stay was not statistically significant (p>.05).

The doses of pain medication requested on the final day of the hospital stay ranged

from zero to two doses. The three patients who occupied the rooms with a beige wall at

the foot of the bed had 0.0 requests for pain medication on the final day of their stay in

the hospital. The four patients who occupied a room with a purple wall had an average of

0.8 pain medication requests and the three patients who occupied a room with a green

wall had an average of 0.3 pain medication requests on the last day of their stay in the

hospital (Table 4.16). There were no surgery patients that occupied an orange room

during their stay in the hospital. The average number of the pain medication requests

during the final day of the patients' stay was not statistically significant (p>.05).

Observation patients' medication requests. The observation patients who

requested pain medication during their stay had a range of zero to four doses requested on

the first day of their stay in the hospital. The patients who occupied a room with a beige

wall at the foot of their bed had a mean of 0.7 doses of medication requested and the

patients with a purple wall had an average of 1.0 medication requests. The observation

patients who occupied a room with a green wall had an average of 2.0 pain medication

requests and the patients who occupied a room with an orange wall had an average of 0.3

medication requests on the first day of their stay in the hospital (Table 4.17).









Table 4.17. Average number of medication requests by observation patients who request
pain medication during their stay in the hospital.
Beige Purple Green Orange Total
First Day 0.7 1.0 2.0 0.3 0.9
Middle Days 1.3 1.4 0.5 0.7 1.4
Last Day 0.4 0.0 0.3 0.3 0.3
Totals 1.1 1.0 1.0 0.5 1.0

During the "middle days" the observation patients requested between zero and five

doses of pain medication per day. The seven patients who occupied a room with a beige

wall at the foot of the bed had an average of 1.3 pain medication requests per day. The

three patients who occupied a room with a purple wall had an average of 1.4 pain

medication requests per day. The three patients who occupied a room with a green wall

had an average of 0.5 medication requests per day and the patients who occupied a room

with an orange wall had an average of 0.7 medication requests per day (Table 4.17).

Lastly, the pain medication requests were examined for the observation patients on

the final day of their hospital stay. The sixteen observation patients who requested pain

medication during their stay requested between zero and one dose of medication on the

last day. The patients occupying a room with a beige wall at the foot of the bed had an

average of 0.4 medication requests on their final day. The patients who occupied a room

with a purple wall had no medication requests. The patients who occupied a room with a

green wall had an average of 0.3 medication requests and the patients who occupied a

room with an orange wall had an average of 0.3 medication requests on their final day

(Table 4.17).

Patients' Opinions About the Colors

Patients willingly gave their opinions about the various colors located in their

rooms during their stay. All but 5 of the patients who occupied rooms with a wall painted









purple, green, or orange claimed that they had noticed the color upon entering the room.

The patients in the rooms with all walls painted beige were disappointed that they did not

get placed in a room with a color on the wall. One patient, located furthest from the

window in a beige room, claimed that there was no way that color could have any effect

on her. In her following statement she said that she had enjoyed her stay in the hospital

more on her previous time in the hospital because she had occupied a bed close to the

window and she felt this uplifted her mood.

Several of the patients also talked about their preferences for a particular color in

their room. Patients had mixed feelings about the all beige rooms. Some patients,

particularly the males, tended to like the beige rooms and claimed that if they had had

their own way their own homes would all be painted beige. Some of the female patients

claimed that the beige walls made the space feel very institutional and that color would

make them feel more comfortable.

Opinions about the rooms with a purple wall at the foot of the bed varied. Many of

the male patients did not care for the color. They claimed that it made the room feel too

dark. Some women really enjoyed the purple color. They said that it was very soft and

made them feel comfortable. Overall, the opinions regarding the purple color varied with

approximately an equal number of patients liking and disliking the color.

The green color also produced various opinions. Some of the male patients

claimed that they liked the color. They claimed that it probably wouldn't be a color that

they would put in their homes, but that they didn't mind it in the hospital rooms. The

majority of the women did not care for the green color. They stated that it reminded them









of a "hospital green." Upon investigation about what they believed a "hospital green"

was, it was discovered that it referred to the color associated with a typical pair of scrubs.

The patients' opinions were very similar in regards to the orange color. The

patients all claimed that they had noticed the color upon entering the room. Many said it

was a nice surprise to see color on the wall. The patients felt that this color of orange

brightened up the room and gave a welcome relief to the beige throughout the majority of

the hospital.

Overall, more female patients than male patients enjoyed the purple color. The one

main complaint was that it made the room feel dark. Regarding the green color, more

male patients seemed to like, or at least not mind the color, than female patients. The

female patients said the green color made the room feel too much like a hospital. Lastly,

both the male and female patients enjoyed the orange color. Overall, the patients in the

beige rooms appeared disappointed that their rooms did not contain colors on the wall.

Hospital Employee's Opinions About the Colors

The hospital employees, including the nurses, patient care assistants, and general

staff, had many opinions about the colors. Overall, the employees said that they were

ready for color in this particular area of the hospital, even asking if the colors could be

kept after the study ended. All the walls in the cardiac care unit of the hospital, except

for the ones painted for this study remained beige. The nurses' station had recently been

remodeled and the nurses claimed they were disappointed that the only color incorporated

was a neutral gray.

One of the nurses claimed that the colored rooms helped them to identify the rooms

and different patients. The nurses were typically responsible for multiple adjoining









rooms. The rooms next to each other were painted different colors for this study, which

made the nurses responsible for three rooms of three different colors.

At the beginning of the study, many of the hospital employees really enjoyed the

purple color. One employee, in fact, painted her bedroom in her home a similar color

after seeing it at the hospital. Toward the end of the study, after the employees had spent

some time in the rooms with a wall at the foot of the bed painted purple, many felt that

the rooms felt too dark compared to the other rooms.

Most of the interviewed hospital employees stated that the green color seemed to be

the most appropriate color for a hospital. When asked why green was associated with

hospitals, no one knew. The nurses believed that the green seemed to match the laminate

and the curtains in the rooms the best. As an interesting side note, none of the patients

mentioned whether the colors coordinated with the rest of the objects in the room.

Every female hospital employee that was interviewed claimed that they enjoyed the

orange color. Four or five of the nurses stated that the orange matched the orange tiles on

the floor well. They felt the color was overall bright and uplifting. A couple of the male

employees claimed that the shade of orange was not attractive.

The interesting note regarding the opinions of the patients and the hospital

employees is that they are very similar. This is surprising because the nurses' opinions

were based on having the ability to experience all three colors, as well as, the beige

control rooms. They also spent more time in all of the rooms than the patients did. The

patients had a more limited experience with the colors because they only occupied a

single color for between 2 and 6 days.














CHAPTER 5
DISCUSSION

Psychological and physiological responses to color have interested scholars and

medical caretakers for centuries. As early as 500 BC, the Greeks, Persians, Assyrians,

Babylonians, and Egyptians believed color cured diseases. With the development of

modern medicine, the focus on the healing power of color was set aside, or left for the

artists and poets such as Johann Wolfgang von Goethe (1749-1832) to ponder. Goethe's

philosophy was that colors produced moods, which then formed the mind-body

connection and effected healing.

When color healing was reunited with modem medicine, it was in a new form

known as chromotherapy. Chromotherapy is the application of colored beams of light to

particular body parts to activate nerves and promote healing. Modem architects,

designers, doctors, and hospital administrators have also started examining the effects

that the built environment can have on recovery and healing. Within the built

environment, color can have an impact on patients' emotions, which can ultimately effect

wellness.

This study was undertaken to examine the specific effects that color can have on a

patient's recovery within a hospital setting. Recovery was examined through recovery

rate (length of stay), perception of pain (pain medication requests), and emotional

responses (anxiety levels). Participants of this study included thirty-nine patients

suffering from a cardiac illness. The patients ranged in age from 26 to 89. Nineteen of









the patients were female and twenty patients were male. All participants were randomly

placed in one of the hospital rooms included in the study.

Ten rooms located on the fifth floor of Shands hospital in Gainesville, Florida were

used in this study. The rooms were part of the Cardiac Care Unit of the hospital and were

all double occupancy rooms. The participants were either placed in one of the four

control rooms (all beige walls) or one of the six experimental rooms (with one wall in the

room painted purple, green, or orange). On the participants' final day of their stay in the

hospital, their length of stay, pain medication requests, and anxiety levels were examined.

The participants' anxiety levels were compared between the ten surgery patients

and the twenty-nine patients under observation by using a t-test to examine the mean

scores based upon the color of the wall in the patient's room. A chi-squared test was

performed to examine if anxiety levels were dependent upon the color of the wall at the

foot of the patients' beds. Length of stay was also examined using a t-test to compare the

means and a chi-squared test was used to examine whether the patients' length of stay

was dependent upon the color of the wall at the foot of the bed they occupied. Lastly, the

patients' pain medication requests were examined between the two groups of surgery and

observation patients. A t-test examined the means of pain medication request on the first

day, the middle days, and the final day of the patients' stay in the hospital. Chi-squared

tests were also run to determine whether pain medication requests could be determined to

be dependent based upon the color of the wall at the foot of the bed. All findings were

inconclusive due to the small sample size.

Anxiety levels were analyzed with respect to the color of the wall at the foot of the

bed, the participants' gender, the participants' proximity to the window within the room,









and whether or not the patient had had surgery. In this study, the anxiety levels were not

dependent upon the color painted on the wall at the foot of the patients' beds. Although

the evidence was not significant, it appeared that beige was moving in the direction of

produced the lowest anxiety levels followed by orange. Green yielded the highest

anxiety levels.

The anxiety levels did not appear to vary based upon the participants' gender or

their proximity to a window. A t-test showed that having surgery was statistically

significant (p<.05) in determining the anxiety levels of the patients. Patients having

surgery had a higher level of anxiety than the observation patients.

There was not significant evidence (p>.05) that anxiety levels were dependent on

the color of the wall at the foot of the bed for patients undergoing surgery. Within this

study, the surgery patients who occupied a room with a green wall at the foot of the bed

had the lowest average anxiety rates, followed by the patients in the beige rooms. The

patients who occupied rooms with a purple wall at the foot of the bed had the highest

average anxiety rates of all the surgery patients. There were no surgery patients who

occupied any of the rooms with an orange wall at the foot of the bed.

Similarly, there was not significant evidence that anxiety levels were dependent on

color for patients under observation. Although there was no significant evidence, the

observation patients in the beige rooms had the lowest average anxiety rates. This was

followed by the average anxiety rate of the patients with a purple wall at the foot of the

bed and the patients with an orange wall at the foot of the bed. This highest anxiety

levels were associated with the patients with a green wall painted at the foot of the bed.









When all thirty-nine participants' anxiety levels were analyzed, it appeared as

though the beige control rooms produced the lowest anxiety levels. The average anxiety

levels of the surgery patients suggested that the rooms with a green wall at the foot of the

patients' bed produced the lowest anxiety levels. The average anxiety levels of the

twenty-nine observation patients suggested that the beige rooms produced the lowest

anxiety levels. Further tests are needed to draw conclusions about colors that produce the

lowest levels of anxiety.

This study showed that color on the wall at the foot of the patient bed could not be

shown to be statistically significant (p>.05) in predicting a patient's recovery based upon

the patient's length of stay. The surgical patients who recovered in a green room had a

slightly lower length of stay than the patients in the purple and beige rooms. The

observation patients in this study had the shortest length of stay in the green rooms,

followed by the patients in the orange rooms and the patients in the purple rooms. The

observation patients who occupied the beige rooms had the longest length of stay.

Overall, this study suggested that green might be the best color to promote a shorter

length of stay. Once again, definitive conclusions cannot be made based on the small

sample size.

This study did not find that pain medication requests were dependent on the color

of the wall at the foot of the bed. Colors that might reduce the patients' perception of

pain or amount of pain medication requested were not identified.

Some knowledge was gained through the informal interviews with the hospital staff

and the patients. It was concluded that based on preference, orange would be the best

color to paint the rooms within this unit of the hospital. The purple rooms were the least









liked by both the patients and the staff. Green was viewed as a color typically associated

with a hospital setting. Overall, opinions suggested that color should be incorporated into

patient rooms within the hospital setting.

Results found in this study further this researcher's belief that colors should be

chosen for an environment based on the type of patient who will occupy the space and

not based on the designers' preferences. By investigating the color preferences of the

people who will ultimately occupy the space and the implications that those colors may

have on the individuals, designers can create a space that focuses on healing.

Limitations and Assumptions

Many factors may have impacted the statistical results. First the sample size was

very small. Because this was a pilot study, it was impossible to determine the number of

patients that would qualify to participate in the study. Further, it was not anticipated that

the patients would have to be divided into two groups, those who had and did not have

surgery. This reduced the sample size of the patients who had had surgery to only ten

participants with no participants occupying an orange room. The sample size of the

observation patients was limited to twenty-nine participants.

Second, although an attempt was made to include only participants with a similar

type of illness, this researcher believes that the various degrees of illness found within the

sample had a detrimental effect on the study. The length of stay in the hospital and

amount of pain medication requests will vary by the illness or surgery that each

participant experiences.

Third, bedside manner may have played a role in the participants' recovery. It is

unclear how much effect doctors' and nurses' reactions and responses to the patients can

have on the patients' psychological state and ability to recover. Each participant had









numerous nurses during their stay and this could have effected different patients in

various ways. There were also several doctors who had patients participating in this

study. Each doctor may have a different opinion about how much information to give

their patients, which could impact the participants' anxiety level. It is also possible that

each doctor varied on his or her beliefs about what criteria should be used to determine

when to discharge a patient. Ultimately, it was the doctors' decision to release the

patients and this would effect the patients' length of stay.

Fourth, it is unclear what effect color can have on the amount of pain medication a

patient requested. It is possible that the amount may be impacted by the individual's

tolerance to pain. The participants' requests for pain medication may also vary based

upon their cultural and religious beliefs. Therefore, the physical environment may have

little, if anything, to do with perception of pain. There was a limited amount of

demographic information collected on the patients. The demographic information

collected about the patients was limited to gender and age. There was no information

collected regarding each patient's religious preference, cultural background, or social

status.

Fifth, no attempt was made to determine the participants' color preferences ahead

of time. Color preference may be influenced by psychological types, age, gender, social

status, and culture (Park, 2002). It is not known what effect color preference can have on

anxiety levels. This researcher believes that if a patient was placed in a room with a color

on the wall that he or she dislikes, the anxiety levels could be altered negatively.

Finally, this researcher found it nearly impossible to eliminate many of the colors

not being tested from the room. Although, the tested colors were introduced into the









space through paint on a large wall surface, the drapery, flooring, and countertops

contained other colors. It is unclear how much of one color needs to be present in order

to have an effect on an individual.

Suggestions for Further Research

Further studies need to be conducted before any conclusions concerning the effect

of color on patient recovery can be made. Several items should be considered before

undertaking another color study including the extensive process of obtaining consent.

There are five main areas requiring further examination in future studies; the complexity

of the participants in terms of illnesses and treatments, the complexity of the colors in

terms of hue, value, and intensity, the demographics being studied, the regional

characteristics of the area in which the study took place, and the patients' preferences for

particular colors.

Gaining consent. Attaining consent to perform research in a hospital requires

permission from the Medical Institutional Review Board. Due to the increased likelihood

of ill patients being negatively effected by research, the medical review board process

requires permission of the doctors' of all the patients involved. Since many doctors do

not have the time to review a study protocol, seeking permission from doctors can be

time consuming. A non-medical review board process takes approximately two to three

weeks; gaining permission for this study took three months.

The hospital staff administration approved a four week period for the study. At the

end of the study, it was apparent that it is more appropriate to run a study for as long as

needed to get an adequate sample size. The small sample size for this study impacted the

conclusions that could be drawn. It is suggested that future researchers should consult a

statistician early in the study to determine how many participants will be needed to run a









statistical analysis. This study was set-up using a time frame, upon the conclusion of the

study it was determined to be more appropriate to run the study for as long as needed to

get the appropriate sample size.

Complexity of the participants. Minimizing the differences between patients is

important. For example, future studies should involve patients with the same illness or

same type of surgery who are treated by the same physician and nursing staff. A better

understanding of the participant should be gained through interviews with the doctors and

nurses. Questions should be asked in regards to the participant's level of pain tolerance

and degree of social support. By gaining a better understanding of the participant, the

future researcher will be able to distinguish if the results are related to the complexity of

the various patients or by the actual intervention.

Complexity of the colors. Future researchers should consider testing different

color palettes rather than just one color. In an actual interior environment, people are not

surrounded by only one color, but rather by a multitude of colors that are believed to

work together to create an environment. By testing palettes, the researcher can provide a

designer with an accurate way of producing the most healing environments, rather than

just providing them with one color to use. The colors should coordinate with the colors

already in the room. They should also be of various values and saturation levels. It

would be ideal to test different types of color schemes, such as monochromatic,

analogous, complementary, etc.

Patient demographics. Further studies should examine each patient's

demographic characteristics to be able to determine whether or not this information can

play a part in determining the outcome of the study. At the conclusion of this study, it is









this researchers belief that the demographic characteristics can play a part in the patients'

recovery rate based upon how comfortable the environment makes them feel. For

example, patients within this study who appeared to be from a higher socio-economic

class claimed they felt more comfortable in a painted room because it gave them the

feeling of being in a hotel, not a hospital. Patients who appeared to be from a lower

socio-economic class claimed they felt more comfortable in the beige rooms because they

felt like they were in a hospital and receiving medical care. It is anticipated that a patient

who is comfortable in the environment will have a more competent psychological state

and be able to better adapt to the healing and recovery process. This researcher suggests

that future researchers explore; age, gender, education, culture, religion, and social-status.

Regional information. Design styles vary in different countries around the world.

It is further noted that in the United States design styles vary according to regions and

climates within the country. It is unclear what effect the design style of the southeast

could have played in the results of this study on color. It is suggested that further

research should be conducted in various parts of the United States to determine if there

are regional differences that could influence the outcome of the study.

Patient and staff preferences. Within this study, patient and staff preferences for

particular colors were stated informally in conversations with the researcher. It is highly

recommended that in further studies, a formal qualitative approach should be

incorporated to determine what effect the respondent's preference for a particular color

has on the outcome of the study. For example, the opinions of both the patients and staff

about the particular colors in the environment should be ascertained. Further

investigation should also include questions about the color preferences incorporated into









the individual's particular home. It is also suggested that the researcher ask the patients

and staff about the colors that they have noticed in other hospitals that they have visited.

This information could be beneficial in determining how an individual's preference for

color can effect his or her recovery process.

Conclusion

The greatest knowledge gained from this study was the understanding that the

variable of color within the interior of a hospital is more complex than originally

anticipated. This study was designed in a quantitative framework that did not take into

account the complexity of the effect that color plays on human psychological and

physiological states. Some designers select a color palette that focuses on the meanings

and significance of particular colors in relation to the users of the space. This works well

in a homogenous environment, but hospitals are complex environments used by a host of

multicultural patients, medical staff, food service and maintenance workers (Park and

Guerin, 2002). The optimal way to study color in a medical setting was found to

combine qualitative and quantitative methods. Patient recovery is a complex variable

that may be effected by many variables. When designing a hospital setting, the effects of

both qualitative and quantitative variables on patients should be explored. This will

allow designers to make an educated decision on how to create the most healing

environments. The following is a framework designed to provide future researchers with

the knowledge gained from this study. It is intended to provide researchers with a place

to start when designing future studies of color in healthcare.









Framework for Future Researchers

A framework for future research is discussed below.

S Research Setting

Regional Information

Investigate regional design preferences.

Study should be conducted in various regions throughout the United
States.

Area of the Hospital

The unit of the hospital used should include patients with similar
illnesses.

The unit should have a limited number of doctors and nurses.

The unit should include enough similar rooms so a comparison can be
conducted.

Hospital Rooms

Rooms should be single occupancy.

Rooms should be the same size.

Rooms should have the same size window to provide the same amount
of natural light.

Rooms should provide the same view out of the window.

Design

Choose colors that coordinate with existing furnishings.

Choose colors that are not believed to be harmful to the patients.

Test a variety of color palettes.

Test various hues, intensities, and values.

Remove as many of the environmental factors that may effect a
patient's recovery as possible.


* Participants









Illness

Patients should all have the same illness or have undergone the same
surgical procedure.

The illness should not be life threatening.

The illness or surgery should require the patients to stay in the hospital
for a similar amount of time.

The illness or surgery should require the patients to request a similar
amount of pain medication.

Data Collection and Analysis

Preliminary Research and Literature Review

Investigate other environmental factors such as, view from a window,
ceiling texture, noise level, etc., that may effect a patient's
recovery.

Investigate the illness being studied in terms of typical lengths of stay,
medication requests, etc.

Investigate hospital dynamics.

Study Duration

Contact statistician to determine the needed sample size to run
appropriate data analysis.

Run study until the proper sample size is obtained, not for a specified
amount of time.

Preliminary Data Collection

Collect information about patient and staff color preferences.

Collect demographic information (age, gender, education, social-
status, etc.) on participants.

Interview doctors and nurses to gain information about pain tolerance,
social support, etc. for each participant.

Testing Recovery Variables

An anxiety test is a good means of testing the effects of color.






65


A follow-up test is suggested to determine the patient's normal
level of anxiety.

Collect patients' lengths of stay and compare them amongst each other
as well as with predetermined typical lengths of stay.

Collect patients' medication requests on a daily basis and compare
them among the individual patients as well as with the entire
sample.















APPENDIX
STATE-TRAIT ANXIETY INVENTORY (STAI)

Example:

The S-Anxiety scale consists of twenty statements that evaluate how respondents
feel "right now, at this moment."

1 = NOT AT ALL 2 = SOMEWHAT 3 = MODERATELY SO 4 = VERY MUCH SO

I feel at ease. 1 2 3 4
I feel upset. 1 2 3 4

The T-Anxiety scale consists of twenty statements that assess how respondents feel
"generally."

1 = ALMOST NEVER 2 = SOMETIMES 3= OFTEN 4 = ALMOST ALWAYS

I feel at ease. 1 2 3 4
I feel upset. 1 2 3 4






The STAI can be ordered from:
Mind Garden
1690 Woodside Road, Suite #202
Redwood City, CA 94061
Phone: (650) 261-3500 Fax: (650) 261-3505
e-mail: mindgarden@msn.com website: www.mindgarden.com
















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69


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BIOGRAPHICAL SKETCH

Kortney Jo Edge was born and raised in Southern California. Upon graduation

from high school she began studying interior design at California State University,

Fresno, where she was a member of the 1998 NCAA National Championship softball

team. After her third semester, she transferred to the University of Florida and changed

her major to sociology, all while continuing to play softball. Upon receiving a Bachelor

of Arts degree in liberal arts and sciences, she took an internship in the interiors

department of an architecture firm.

While obtaining her master's at the University of Florida in interior design,

Kortney began her investigation on human responses to color. In order to gain a better

understanding of the different specialties within the field of interior design, she accepted

an internship with a design firm specializing in hospitality. Through her experiences in

school, and through her internships, she has become very excited about all the

possibilities that the interior design profession has to offer her. Kortney is anticipating

being able to incorporate her knowledge gained during researching into the profession of

interior design.

In her spare time, Kortney enjoys spending time with family and friends.