Photo Courtesy of HKS Inc.

Photo Courtesy of HKS Inc.

Relationships between Exterior Views and Nurse Stress: An Exploratory Examination

Read the journal paper here


Debajyoti Pati (PI) and Tom Harvey

Paul Barach, MD, MPH, Professor, Anesthesia and Patient Safety, Center for Patient Safety, Utrecht University Medical Center, Netherlands
Gary Evans, PhD, Professor, College of Human Ecology, Cornell University, USA
Craig Zimring, PhD, Professor, College of Architecture, Georgia Institute of Technology, USA

HKS Inc.

WHAT was the aim

This study extended earlier studies focused on the positive impact of view on patients, to look at possible influences on care givers. The study objective was to examine the relationships between acute stress and alertness of nurse, and duration and content of exterior views from nurse work areas.


Nursing is a stressful job, and the impacts of stress on numerous parameters of performance have been well documented in literature. High stress and fatigue in nursing jobs are typically addressed through operational interventions. The physical environment, however, has been shown to modulate stress in building occupants. 


A survey-based method was used to collect data on acute stress, chronic stress, and alertness of nurses before and after 12-hour shifts. Control measures included physical environment stressors (that is, lighting, noise, thermal, and ergonomic), organizational stressors, workload, and personal characteristics (that is, age, experience, and income). Data were collected from 32 nurses on 19 different units at two hospitals (part of Children's Healthcare of Atlanta) in November 2006.

WHAT did WE Find

Among the variables considered in the study view duration is the second most influential factor affecting alertness and acute stress. The association between view duration and alertness and stress is conditional on the exterior view content (that is, nature view, non-nature view). Of all the nurses whose alertness level remained the same or improved, almost 60% had exposure to exterior and nature view. In contrast, of all nurses whose alertness levels deteriorated, 67% were exposed to no view or to only non-nature view. Similarly, of all nurses whose acute stress condition remained the same or reduced, 64% had exposure to views (71% of that 64% were exposed to a nature view). Of nurses whose acute stress levels increased, 56% had no view or only a non-nature view. Overall, the finding suggested that although long working hours, overtime, and sleep deprivation are problems in healthcare operations, the physical design of units is only now beginning to be considered seriously in evaluating patient outcomes. Access to a nature view and natural light for care-giving staff could bear direct as well as indirect effects on patient outcomes.


Future studies should address one major confounding factor that was not dealt with in this study. This confounding factor pertains to view as opposed to natural light. In other words, it is not clear whether the positive influence of exposure to the exterior on patients and staff is associated with the view, with natural light, or both.