Impact of Visual Art on Waiting Behavior in the Emergency Department

A pre-post study on the impact of appropriate visual art on the waiting behavior in two prominent emergency departments in Houston, TX, was conducted from September 2009 to March 2010.

An extensive literature review on the existing evidence on stress-reducing visual imagery was conducted to determine the content of the art. This incorporated new insights from the field of neuroscience, as relevant to the emotional experience of waiting in the emergency department (ED). Studies on the ED waiting experience were reviewed, and perceived waiting time was found to be a more compelling determinant of patient experience and satisfaction than actual waiting time. Perceived wait time was also identified as a factor of affective/emotional state. Fear, anxiety, and pain were identified from the literature as three key factors that formed the emotional experience and contributed to the stress of the ED.

A review of both theoretical and experiment-based studies revealed that the “restorative” impact of nature images can be attributed to the affective rather than aesthetic response to stimuli. Neuroscientific studies reiterated that the emotional response is often immediate and can occur before a higher-level cognitive response. Moreover, visual properties such as contour, spatial frequency, and context were identified as key factors influencing emotional processing of visual stimuli by the human brain. These factors are identified for the first time in the context of restorative visual images. Other properties such as familiarity, valence, and arousal, which have been studied in the previous literature, were reinforced. Furthermore, the review established that the broad structural properties of an image and the overall content may be more important than the detail in an image when it comes to emotional response.

To test the impact of visual art on waiting behavior, a set of visual images (nature photographs) was selected based on the existing guidelines for evidence‐based art. These images were then evaluated within the context of visual properties identified from the literature review. A visual intervention was designed consisting of wall art and a looped video displayed on plasma screens for two extremely busy ED waiting rooms in Houston (Memorial Hermann Hospital and Ben Taub General Hospital).

Trained observers observed the waiting room for 30 hours (11 nonpeak and 19 peak hours over a period of 3 months) before and after the designed intervention was installed.

Observational data revealed significant reduction in restless behavior and increase in socialization. A decrease in the number of people staring at other people was also found, which has implications for privacy. Trends varied slightly across the two sites (in Ben Taub there was a significant decrease in the front-desk queries, which was not observed in the case of Memorial Hermann). Significant reduction in noise levels was found at both sites as well.

Meaningful conclusions could not be derived from the patient satisfaction, although this data was also collected. Lack of questions that related specifically to the waiting room experience on the patient satisfaction survey, small percentage of the total waiting being spent in the waiting room, and constant changes in the operational variables of the ED process were identified as significant challenges to isolating the impact of the visual intervention on satisfaction scores.