NACHRI_2009_Positive Distraction Study

1. Healthcare
Positive Distractions
Engineering the Waiting Experience of
Pediatric Patients

2. Presenters
2009 NACHRI F iliti D i2009 NACHRI Facilities Design
Conference, Austin, TX
Debajyoti Pati, PhD, FIIA, HKS Architects
Jeff Stouffer, FAIA, HKS Architects

3. The Ongoing Debate
In a time of rising health… In a time of rising health
costs, it doesn’t make a ton
of sense for facilities to be
spending lavishly on perks.
Jacob Goldstein, in Behind Hospitals’ Pretty
Facades, Dingy Rooms for Patients, Wall
Street Journal, August 20, 2008

4. Question
What role do hospital waiting areas play?

5. Learning Objectives
Understand the influence of positive
distractions on pediatric patients while
waiting
Understand the role of positive distractions in
the parents’ waiting experience
Distinguish the difference between uni-g
sensory and multi-sensory distractions

6. Agenda
Waiting Experience
Positive DistractionsPositive Distractions
Study Objectives
Study Procedure
Children’s Data Analysisy
Parent’s Data Analysis
ImplicationsImplications

7. Acknowledgments
Children’s Medical Center Dallas
American Art Resources
Mohawk
Catherine Mayer Fine Art
Henry Domke Fine Art

8. Acknowledgments
Co-Investigators
Dr Upali Nanda, American Art Resources
Laurie Waggener, WHR Architectsgg ,

9. Agenda
Waiting Experience
Positive DistractionsPositive Distractions
Study Objectives
Study Procedure
Children’s Data Analysisy
Parent’s Data Analysis
ImplicationsImplications

10. Waiting Experience
The Cornell
University Studyy y
Location: Weill Cornell
Medical College, New York
Six clinical outpatient servicesSix clinical outpatient services
Key findings:
Physical environment
attractiveness correlated with
perceived care quality and
anxietyanxiety
Physical environment
attractiveness correlated with
perceived waiting timeperceived waiting time

11. Agenda
Waiting Experience
Positive DistractionsPositive Distractions
Study Objectives
Study Procedure
Children’s Data Analysisy
Parent’s Data Analysis
ImplicationsImplications

12. Positive Distractions
Outcomes during
procedures:p
Better pain control
Reduced anxiety, fatigue
and distress
Reduced patient-controlled
sedation doses
Reduced pulse rate
Greater relaxation
Most studies on adult
patients

13. Agenda
Waiting Experience
Positive DistractionsPositive Distractions
Study Objectives
Study Procedure
Children’s Data Analysisy
Parent’s Data Analysis
ImplicationsImplications

14. Study Objective # 1
Can positive distractions produce positiveCan positive distractions produce positive
behavioral outcomes in children (with and
without neurological disorders)?without neurological disorders)?

15. Study Objective # 2
Do positive distractions in an environment actDo positive distractions in an environment act
as points of focus that can improve the
overall waiting experience?overall waiting experience?

16. Study Objective # 3
Are multisensory distractions more effective
than purely visual distractions?

17. Agenda
Waiting Experience
Positive DistractionsPositive Distractions
Study Objectives
Study Procedure
Children’s Data Analysisy
Parent’s Data Analysis
ImplicationsImplications

18. Study Site # 1
Children’s Medical Center Dallas - Dental Clinic

19. Study Site # 2
Children’s Medical Center Dallas – Cardiac Clinic

20. Distraction Conditions
5 positive distraction conditions
Still nature photo slide show Naturep
Ambient Art
Ambient Art with Sound
Nature
Slides
Aquarium
Aquarium with sound
Ambient Art
All nature themes
No-Distraction condition
as control
Aquarium

21. Subjects and Data Collection
Subjects:
Pediatric patients visiting the
Process:
10 min randomized distraction
clinic
>= 5 years old
With and without
10 min no-distraction
Trained observers
O b hild
With and without
developmental/neurological
problems
One observer per child
Parent questionnaire
Data Collection
Dental Clinic: 6 days in
Sample size
Children data: 81 (Dental) + 77
December 2008
Cardiac Clinic: 6 days in
January 2009
(Cardiac)
Parents: 51 (Dental) + 24
(Cardiac)

22. Subject Attributes
Dental Clinic
Age = 10.95 (mean); 5 – 17 years
Cardiac Clinic
Age = 11.57 (mean); 5 – 17 yearsg ( ) y
Ethnicity
White = 25.3%
Bl k 13 9%
g ( ) y
Ethnicity
White = 40.8%
Bl k 22 4%Black = 13.9%
Hispanic = 58.2%
Asian = 2.5%
Black = 22.4%
Hispanic = 35.5%
Asian = 1.3%
Gender
Male = 59.3%
Female = 40 7%
Gender
Male = 53.9%
Female = 46 1%Female = 40.7%
Developmental/ Neurological
deficiencies
P t 47 8%
Female = 46.1%
Developmental/ Neurological
deficiencies
P t 12 5%Present = 47.8% Present = 12.5%

23. Outcome Measures
Attention
Positive distraction
Other art work
Toy
B kBook
Wall
Ceilingg
Floor
Door
Window
Furniture
PeoplePeople
Themselves

24. Outcome Measures
Physical Behavior
Calm
Fidgety
Fine movement
Gross movement
Intense

25. Outcome Measures
Activity
Playing with toysy g y
Playing with non-toys
Non-play activity or other play

26. Outcome Measures
Location
In seat
Out of seat
On Lap

27. Outcome Measures
Social Behavior
Positive interaction
Negative interaction
Solitary behavior

28. Analytical Procedures
Paired sample t-tests for identifying significant
differences between distraction and no-distraction
diticonditions
Covariance models to compare the five distraction
conditionsconditions
Factorial Design to identify main effects
C l ti A l i t l l ti hi b tCorrelation Analysis to explore relationships between
children’s behavior and parent’s perception
Mediation analysis to explore the true pattern ofMediation analysis to explore the true pattern of
relationship between waiting experience and perceived
care quality

29. Agenda
Waiting Experience
Positive DistractionsPositive Distractions
Study Objectives
Study Procedure
Children’s Data Analysisy
Parent’s Data Analysis
ImplicationsImplications

30. Distraction vs No-Distraction
What differences in attention, behavior andat d e e ces atte t o , be a o a d
activities were observed during the presence
of positive distraction conditions?

31. Attention :: Dental Clinic
Attention
Type
Distraction No-
Distraction
Difference Significance
TV Monitor 27 73 2 16 25 57 0 000TV Monitor 27.73 2.16 25.57 0.000
Other Artwork 0.36 0.42 -0.06 0.886
Toy 4.24 8.22 -3.98 0.007
Book 1.97 2.17 -0.2 0.829
Wall 7.1 7.57 -0.47 0.818
Ceiling 2.91 2.52 0.39 0.723
Floor 2.66 3.83 -1.17 0.373
Door 3.65 3.5 0.15 0.910
Window 3 52 5 7 2 18 0 179Window 3.52 5.7 -2.18 0.179
Furniture 3.19 5.16 -1.97 0.245
People 36.12 51.64 -15.52 0.000
Themselves 6.53 7.10 -0.57 0.792

32. Attention :: Cardiac Clinic
Attention
Type
Distraction No-
Distraction
Difference Significance
TV Monitor 20 58 0 41 20 17 0 000TV Monitor 20.58 0.41 20.17 0.000
Other Artwork 1.52 1.24 0.28 0.825
Toy 19.13 13.16 5.97 0.081
Book 8.09 15.47 -7.83 0.017
Wall 1.95 3.0 -1.05 0.333
Ceiling 0.52 0.37 0.15 0.737
Floor 3.42 3.04 0.38 0.726
Door 0.75 1.02 -0.27 0.737
Window 4 03 5 11 1 08 0 369Window 4.03 5.11 -1.08 0.369
Furniture 0.97 1.21 -0.24 0.730
People 32.27 44.36 -12.09 0.008
Themselves 6.75 11.6 -4.85 0.028

33. Attention :: Key Inferences
Substantial diversion of attention to the TV monitor
during distraction conditions
Presence of distraction conditions diverted attention
from two or more of the following to the TV monitor:
people, book, toy, themselves
Positive Distraction do help focus attention
“People” drew most attention even in the presence of
distraction conditionsdistraction conditions

34. Physical Behavior: Dental Clinic
Behavior
Type
Distraction No-
Distraction
Difference Significance
Type Distraction
Calm 64.92 58.3 6.62 0.080
Fidgety 20.99 19.41 1.58 0.570
Fine 10 79 15 36 4 57 0 051Fine
Movement
10.79 15.36 -4.57 0.051
Gross
Movement
2.63 5.18 -2.55 0.079
Intense
Movement
0.67 1.75 -1.08 0.153

35. Physical Behavior :: Cardiac Clinic
Behavior
Type
Distraction No-
Distraction
Difference Significance
Type Distraction
Calm 68.88 59.92 8.96 0.029
Fidgety 11.50 13.08 -1.58 0.473
Fine Movement 18 33 23 32 4 99 0 183Fine Movement 18.33 23.32 -4.99 0.183
Gross
Movement
1.28 3.49 -2.21 0.049
Intense 0 00 0 19 -0 19 0 176Intense
Movement
0.00 0.19 0.19 0.176

36. Distraction vs No-Distraction Inferrences
Dental Clinic Cardiac Clinic
Most children were observed to
be ‘calm’, ‘solitary behavior’, ‘in
seat’, ‘not playing’, and ‘watching
Most children were observed to
be ‘calm’, ‘solitary behavior’, ‘in
seat’, ‘not playing’, and ‘watching
other people’.
Distraction condition results in:
other people’.
Distraction condition results in:Distraction condition results in:
More attention on TV Monitor
More calm; less fine and
t
Distraction condition results in:
More attention on TV Monitor
More calm; less gross
tgross movement movement

37. Distraction Conditions Comparison
How is attention distributed between the
distraction conditions?

38. Distribution of Attention
Dental Clinic %
Attention
Cardiac Clinic %
Attention
Ambient Art with Sound 42.35 Ambient Art 37.18
Aquarium 28.87 Ambient Art with Sound 23.67
Still Art 28.00 Aquarium with Sound 23.00
A i ith S d 23 49 A i 14 53Aquarium with Sound 23.49 Aquarium 14.53
Ambient Art 4.66 Still Art 9.11
Both Clinics %Distribution by Clinic Both Clinics %
Attention
Ambient Art with Sound 66.02
Distribution by Clinic
Aquarium with Sound 46.48
Aquarium 43.40
Ambient Art 41.84
Still Art 37.11Combined Mean Distribution

39. Distribution of Attention :: Key Inferences
Overall, multi-sensory (visual + auditory) stimuli attract
greater attention
Still nature slide show demonstrate least preference
HOWEVERHOWEVER
Substantial differences between the two clinics
A pattern observable for cardiac population
Ambient art conditions, Aquarium conditions, Still, q ,
Nature
No meaningful pattern identifiable for dental population

40. Interaction Effects?
Did bj t tt ib t ( th i itDid subject attribute (ethnicity,
developmental disability, illness type)
interact with attention and behavior?interact with attention and behavior?

41. Physical Behavior :: CALM
CALM
(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium Ambient Art
Ambient Art with Sound Aquarium with Sound
Still Art Ambient Art with Sound
Aquarium with Sound Still ArtAquarium with Sound Still Art
Ambient Art Aquarium
Pole ReversalPole Reversal

42. Physical Behavior :: FIDGETY
FIDGETY
(Least to Most)
Dental Clinic Cardiac Clinic
Ambient Art with Sound Aquarium
Still Art Aquarium with Sound
Aquarium Ambient Art
Aquarium with Sound Ambient Art with SoundAquarium with Sound Ambient Art with Sound
Ambient Art Still Art
Block ShiftBlock Shift

43. Physical Behavior :: FINE MOVEMENT
FINE MOVEMENT
(Least to Most)
Dental Clinic Cardiac Clinic
Ambient Art with Sound Ambient Art
Aquarium Still Art
Aquarium with Sound Ambient Art with Sound
Still Art Aquarium with SoundStill Art Aquarium with Sound
Ambient Art Aquarium
Pole ReversalPole Reversal

44. Physical Behavior :: GROSS MOVEMENT
GROSS MOVEMENT
(Least to Most)
Dental Clinic Cardiac Clinic
Aquarium Ambient Art
Aquarium with Sound Still Art
Ambient Art with Sound Ambient Art with Sound
Still Art Aquarium with SoundStill Art Aquarium with Sound
Ambient Art Aquarium
Total ReversalTotal Reversal

45. Activity :: PLAY TOY
PLAY TOY
(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium Aquarium with Sound
Ambient Art with Sound Aquarium
Still Art Still Art
Aquarium with Sound Ambient Art with SoundAquarium with Sound Ambient Art with Sound
Ambient Art Ambient Art
Partial ReversalPartial Reversal

46. Activity :: PLAY NON-TOY
PLAY NON-TOY
(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium with Sound Still Art
Ambient Art Ambient Art with Sound
Still Art Aquarium
Ambient Art with Sound Aquarium with SoundAmbient Art with Sound Aquarium with Sound
Aquarium Ambient Art
Block ShiftBlock Shift

47. Location :: OUT OF SEAT
OUT OF SEAT
(Least to Most)
Dental Clinic Cardiac Clinic
Aquarium Still Art
Still Art Ambient Art with Sound
Aquarium with Sound Aquarium
Ambient Art Aquarium with SoundAmbient Art Aquarium with Sound
Ambient Art with Sound Ambient Art
Partial ReversalPartial Reversal

48. Location :: IN SEAT
IN SEAT
(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium Still Art
Still Art Ambient Art with Sound
Ambient Art with Sound Aquarium with Sound
Ambient Art Ambient ArtAmbient Art Ambient Art
Aquarium with Sound Aquarium
Pole ReversalPole Reversal

49. Social Behavior :: POSITIVE INTERACTION
POSITIVE
INTERACTION
(Most to Least)
Dental Clinic Cardiac Clinic
Aquarium with Sound Still Art
( ost to east)
Ambient Art with Sound Ambient Art
Aquarium Aquarium with Sound
Ambient Art Ambient Art with SoundAmbient Art Ambient Art with Sound
Still Art Aquarium
Pole ReversalPole Reversal

50. Social Behavior :: SOLITARY BEHAVIOR
SOLITARY BEHAVIOR
(Least to Most)
Dental Clinic Cardiac Clinic
Aquarium with Sound Still Art
Ambient Art with Sound Ambient Art
Aquarium Aquarium with Sound
Ambient Art Ambient Art with SoundAmbient Art Ambient Art with Sound
Still Art Aquarium
Block ShiftBlock Shift

51. Key Behavioral Inferences
Population attribute (ethnicity, developmental
disability, illness type) may constitute ay, yp ) y
factor determining physical and social behavior
Most frequent top and bottom conditions:
Dental Clinic Cardiac Clinic
Most frequently at the
top
Aquarium Ambient Art + Still Art
Most frequently at the
bottom
Ambient Art Aquarium

52. Question
Is patient attribute (as defined by clinic) a
major predictor of behavior?
Method: 2 x 5 Factorial Designg
Still Art Ambient
Art
Ambient
Art +
Aquarium Aquarium
+ Sound
Sound
Dental
Cardiac

53. Factorial Analysis: Attention
Attention WITHOUT Covariate
Clinic Distraction Interaction
WITH Covariate
Clinic Distraction Interaction
TV Monitor Yes
Other Art
Toy Yes
Yes
Yes
Book Yes
Wall Yes Yes
Ceiling Yes
Yes Yes
Ceiling Yes
Floor
Door Yes Yes
Window
Furniture Yes
People
Yes
Themselves

54. Factorial Analysis: Behavior and Activity
Attention WITHOUT Covariate
Clinic Distraction Interaction
Calm
WITH Covariate
Clinic Distraction Interaction
Calm
Fidgety Yes
Fine Movement Yes
Gross Movement Yes
Yes
Yes
Gross Movement Yes
Intense
Play Toy Yes
Play Non-ToyPlay Non Toy
None/Other Play Yes Yes
Out of Seat
In Seat
On Lap Yes
Positive Int Yes
Negative Int
Yes
Yes
YesNegative Int
Solitary Yes
Yes
Yes

55. Key Inferences
A number of behavior outcomes associated with patient attribute:
Culture and/or Neurological State and/or Illness Type
Difference reduces when controlled for no-distraction condition data
Multi-sensory distractions more effective in Dental Clinic
Behavior Dental Clinic Cardiac Clinic
Calm Ambient Art (S); Aquarium Ambient Art
Fidgety Ambient Art (S) Aquariumg y ( ) q
Fine Movement Ambient Art (S) Ambient Art
Gross Movement Aquarium Ambient Art
Intense Movement Aquarium (S) Aquariumq ( ) q
Positive Interaction Aquarium (S) Still Art
Negative Interaction Aquarium Still Art
Solitary Behavior Aquarium (S) Still ArtSolitary Behavior Aquarium (S) Still Art

56. Agenda
Waiting Experience
Positive DistractionsPositive Distractions
Study Objectives
Study Procedure
Children’s Data Analysisy
Parent’s Data Analysis
ImplicationsImplications

57. Inferences
Presence of distraction conditions associated with change in
children’s attention, activities and behavior
P ’ i i i i d i h hild ’ iParents’ waiting experience associated with children’s attention,
activities and behavior
Elements of parents’ waiting experience associated with their
perceived waiting time
Parent’s waiting experience (including perceived waiting time)
associated with their:associated with their:
Exam room experience
Perception regarding staff
Overall visit
Overall experience

58. Question
Any explanations for the apparent importance
of waiting experience?

59. Items in Overall Visit and Experience
Felt cared
Child treated in timely mannerChild treated in timely manner
Felt welcome
Less anxiety feeling
Recommend this clinic to others
Quality of care child received
Quality of service parent’s receivedQuality of service parent s received
Quality of interaction with staff
Quality of interaction with doctor

60. Mediation Analysis
Perception
Wait
Area
regarding
Staff
Overall
Perception
regarding
Exam
Room
Experience
Overall
g g
Staff

61. The Ongoing Debate
… In a time of rising health
costs it doesn’t make a toncosts, it doesn t make a ton
of sense for facilities to be
spending lavishly on perks.p g y p
Jacob Goldstein, in Behind Hospitals’ Pretty
F d Di R f P ti t W llFacades, Dingy Rooms for Patients, Wall
Street Journal, August 20, 2008

62. Agenda
Waiting Experience
Positive DistractionsPositive Distractions
Study Objectives
Study Procedure
Children’s Data Analysisy
Parent’s Data Analysis
ImplicationsImplications

63. Implications
Waiting experience
associated with keyCarefully engineer
waiting experience
associated with key
organizational
objectivesobjectives

64. Implications
All positive distractions
are not the same
Culture and/or
neurological state and/or
li i t i t d ithclinic type associated with
behavioral outcomes
Positive distractions are
attention grabbers
Locate distraction
conditions carefully
Positive distractions
associated with calm
behavior
Take advantage of
behavioral influence of
positive distractionbehavior positive distraction

65. Implications
Attention on People:
Do not ignore
physical placement,
dj i iWhether distraction
conditions were switched
on or not, most attention
was fixated on other
adjacencies, view
corridors, and
activities aroundwas fixated on other
people
activities around
hospital waiting areas

66. Q U E S T I O N S

68. Definitions of Terms: Attention
Attention Eye-fixation on any object/person will be recorded as
attention. Objects can include art work, toys, furniture,
etc.
Positive distraction The flat screen TV in the waiting room on which
artwork/music will be displayed
Other artwork Any other artwork in the waiting area: painting,
sculpture, … at any location in the waiting lounge
Toy Any piece of toy/game in the waiting area or brought
in by the subjectin by the subject
Book Book or books in the waiting lounge or brought in by
the subject
Wall Blank portions of any of the wall in the waiting room
Ceiling Ceiling of the waiting room
Floor Floor of the waiting room
Door Any of the doors of the waiting room
Window Any window – external or internal – in the waiting
room, including the reception desk/windowg p
Furniture Any unoccupied furniture in the waiting lounge –
without any person or thing on the furniture
P l A i h i iPeople Any person in the waiting room
Themselves Any portion of the patient’s own body

69. Definition of Terms: Physical Behavior
Calm No visible major motor movement
Fidgety This will be coded whenever repetitive,
restless motor movements is observed which
appeared to be primarily purposeless (e.g.,
taping a pencil, kicking one's foot)p g pe c , c g o e s oo )
Fine Movement Defined as fine motor movement involving
very low intensity purposeful movements of
body parts.
Gross Movement Defined as gross motor movement involving
taking one or more steps or, if sitting, moving
the buttocks from one spot to another
Intense Defined as engaging in inappropriate or
excessively vigorous physical activities (e.g.,
throwing toys, running about, yelling or
singing loudly)

70. Definition of Terms: Activity and Location
Playing with toys Defined as playing with toys in the room (ifPlaying with toys Defined as playing with toys in the room (if
available)
Playing with non toys Defined as playing with non toy objects in the
room (e.g., doorknob, table)
Non-play activity/ Other Play Defined as neither playing with a toy or non-
toy item (e.g., standing and gazing at the door;
reading; eating; drinking)
OR
Other play activities (not involving toys or
non-toys)
Out of seat This will be coded if a child left the seat
entirely at the time of observation
In-seat This will be coded if a child is in his/her seat at
the time of observation
Parent’s lap This will be coded if a child is sitting on the
lap of another accompanying adult.

71. Definition of Terms: Social Behavior
Positive interaction All vocalizations directed to
sibling/parent/objects excluding screams,
shouts, cries, and whines; all cooperative
responses involved with sharing an object; andespo ses vo ved w s g objec ; d
hugs and holding hands
Negative interaction Screams, shouts, or other utterances that
indicate rejecting and oppositional behavior;
hit, pinch, kick, and “nonplaying” push or pull;
grabbing objects from sibling/parent; and
destroying possessions of sibling/parent
Solitary behavior All solitary activity (excluding parallel play
conducted between two children within two
feet of one another)