Interior effects on comfort in healthcare waiting areas

Abstract

BACKGROUND: This study compared the effects of pre-experience and expectations on participant comfort upon waking, arrival to, and after an appointment, as well as the assessment of properly placed Feng Shui elements in three healthcare waiting rooms.

METHODS: Participants assessed comfort levels using self-report surveys. The researcher conducted ‘intention interviews’ with each doctor to assess the goals of each waiting area design, and conducted a Feng Shui assessment of each waiting area for properly placed Feng Shui elements.

RESULTS: The waiting area designed by the Feng Shui expert rated ‘most comfortable’, followed by the waiting area design by a doctor, and the lowest comfort rating for the conventional waiting room design. Results show a sufficiently strong effect to warrant further research.

CONCLUSIONS: Awareness of the external environment, paired with pre-experience and expectation, influences comfort for people over time. Fostering and encouraging a holistic approach to comfort utilizing eastern and western concepts and ergonomic principles creates a sense of “placeness” and balance in the design for comfort in built environments. This is new research information on the influences of the comfort experience over time, to include pre-experience, expectations and the placement of elements in the external environment.

Keywords

Environmental design patient comfort expectations Feng Shui pre-experiences

1 Introduction

Optimal human comfort and well-being requires that internal and external environmental conditions, including good quality air, water, and climate, adequate space, smooth flow of work, general safety and safe working conditions, promote occupants’ physical comfort and health [1, 2]. Other factors to consider beyond the physical environment, which may also promote comfort and well-being, are the psychological (intellectual and emotional) aspects of occupants. Including all these factors promotes well-being e.g. emotional growth, cognitive flexibility and creativity [3 –6].

Comfort is a term associated with a subjective physical state that may be influenced by an environmental factor, such as temperature, noise, light level, space, furniture design, etc. [1]. Helander and Zhang [7] note that discomfort due to sitting in a chair is related to static postures, compression at pressure points beneath the ischial tuberosities and the stiffness of associated joints. Participants in the study linked comfort more to terms such as luxury, relaxation and feeling refreshed [7]. Richards [8] stresses that comfort involves the sense of subjective well-being, and is the reaction a person has to an environment or situation. According to de Looze et al. [9] some issues generally accepted in comfort literature are: (1) comfort is a construct of a subjectively defined personal nature; (2) comfort is affected by factors of a various nature (physical, physiological, psychological), and (3) comfort is a reaction to the environment. Slater [10] defines comfort as a pleasant state of physiological, psychological and physical harmony between a human being and his/her environment. There is ample research available on many scientific databases regarding physiological comfort. The psychological (intellectual and emotional) and socio-cultural aspects of comfort are less studied and data are difficult to quantify due to subjectivity [11].

This concept of discomfort or comfort discusses the need for opposites to comprehend and appreciate the difference. For example, Vink [12] explains it as the ‘sweetness of discomfort’. Comfort is experienced best when a greater degree of discomfort has previously occurred. For example, if a person sits in a comfortable chair immediately after sitting on a very hard uncomfortable one, the difference is obvious.

Most comfort research focuses on the effect of a physical intervention and previous experiences and expectation are not taken into account [13]. However, more information is surfacing about the influence pre-experience has on the comfort experience in the recorded moment [12]. For example, Konieczny [14] found that 40% of the comfort in an airplane was determined by preflight experiences. The comfort experience also changes over time, which is evident during a flight [13]. Part of a holistic approach to comfort in an interior built environment is taking into account the previous experiences and expectations of occupants and time as a factor to consider in a comfort study. This study compares patient (participant) pre-experience and perceived comfort levels upon waking, before, during and after a healthcare appointment.

There is an increasing interest in applying a Feng Shui approach to Western design. According to the Feng Shui principles a “holistic” approach to build environments, e.g. workspace and workplace design, includes design elements that are purported to improve the comfort, health and well-being of occupants [15].

1.1 Feng Shui

Feng Shui is an ancient Chinese system of geomancy that has and continues to influence design in many Asian countries, but is seldom considered in building design in the Western World [16]. It is challenging to link Feng Shui with Western scientific literature and culture and it is difficult describe in scientific terms because Feng Shui is not generally accepted as science in Western academia. Some researchers have attempted to study Feng Shui scientifically. Mak [17] developed a structured framework and a prototype model using a ‘knowledge based expert systems (KBES) approach’ to Feng Shui. It is linear and a challenge from the standpoint that Feng Shui is considered a more ‘holistic’ process and the KBES model may be comparable to the human factors engineering top-level analysis tool (functional requirements and allocation) used in the preliminary design process [18].

Feng Shui developed over 3,000 years ago in China and is a complex body of knowledge that balances the energies of the environment to assure good health and good fortune for the inhabitants and has made a significant contribution to design in the eastern world for many centuries [16]. It is an ancient Chinese system of geomancy with a growing influence on Western architecture and design and literally means “wind” and “water” [19].

Feng Shui emphasizes harmony with nature, surroundings, and cycles of time, with the goal of creating and maintaining positive ‘qi’, or energy. Chi or ‘qi’ is pronounced “Chee” and is literally translated as “life-force energy”. Wind and Water symbolizes the flowing Chi or ‘qi’, which can be translated as “vital energy flow” or, “breath of nature”, because ‘qi’ can be gathered by water and flowing energy [20]. Feng Shui recommends situating the human built environment in locations in space and time where ‘qi’ is balanced. This balancing of the energies of the environment is believed to assure the health and good fortune of those inhabiting the given space [21]. Feng Shui has an extensive influence on Chinese architecture and has made a significant contribution to build environment design in the Eastern world for many centuries. In Western society, the primary concern when constructing a building has included methods involved in scientific analysis using measurable data. Both of these approaches are included in bioclimatic design, ecological design, and environmental psychology [19, 22]. In the West, a more scientific approach is the norm for many designers and architects. Lee [22] describes architects are trained in practical design to include comfortable living and built environments. Architects often unconsciously applied some rational Feng Shui principles [23].

There are two main schools of thought and practice in Feng Shui: the Compass school and Form school. The Form School analyses the shape of the land and flow of the wind and water to find a place with ideal ‘qi’. It also considers the time of important events such as the birth of the resident and the building of the structure [16]. There are five elements associated with Form School: Earth, Wood, Metal, Fire and Water. Figure 1 represents the shapes found outside and in the landscape as well as inside or interiors of the built environment [24].

The correct use of these elements is the key to implementing proper Feng Shui. Table 1 explains the interaction of the five elements in three types of cycles: the “Productive Cycle”, the “Controlling Cycle” and the “Reductive (weakening) Cycle”. It is necessary to know the cycles of the five elements and to understand how to balance and enhance ‘qi’ in the environment. Each of the five elements is related to one another and affects each another in various ways depending on the cycle [21, 19].

The productive cycle: Wood produces fire. The decay of wood provides fuel for fire. Fire produces earth. The burning of wood by fire produces ash that feeds the earth. Earth produces metal. Earth compacts and pulls inward forming metal. Metal produces water. When metal contracts it condenses and liquefies. Water produces wood. Water stimulates growth in wood.

The controlling cycle: wood burdens earth; fire melts metal; earth blocks water; metal pierces wood; and water diminishes fire.

The weakening cycle: wood absorbs water; water corrodes metal; metal moves earth; earth reduces fire; and fire burns wood [25]. The ideal environment strives to have the five elements in the productive cycle. In Feng Shui, numerous cycles change the combinations of the elements. However, if a controlling cycle is approaching through a cycle of time, for example a yearly cycle, the weakening cycle may be applied to offset negative ‘qi’ from the controlling cycle.

Classical Feng Shui is not as simple as the aforementioned relationships and cycles of the five elements are not black and white. There are exceptions to the rules. The element number combinations change through cycles of time. There is no one simple chart or table to explain all the nuances associated with Feng Shui and the principles. Therefore, this paper attempts to introduce a very basic overview to help clarify the tools used to perform the Feng Shui assessments for properly placed Feng Shui elements for the three waiting areas by the researcher.

The Feng Shui Bagua is a tool used by Form School practitioners. The Bagua model represents the five elements, cardinal directions, areas of life and other aspects specific to each section of the grid. The bagua is a blueprint placed over a specific area or in this study an interior layout [25]. Figure 2 illustrates a Feng Shui Bagua [26]. The bagua consists of the eight trigrams of Yijing and represented by the blue ring in Fig. 2. The five elements of Feng Shui (Water-Wood-Fire-Earth-Metal) and associated aspects are identified in each square of the bagua (grid), e.g., color, compass direction, and body part.

The Compass School is based on the eight cardinal directions, each of which is said to have unique ‘qi’. The main tool is the Loupan, a disc marked with formulas in concentric rings around a magnetic compass [21, 27]. The Flying Star is a system that calculates the ‘qi’ pattern of a building according to the building orientation and date of construction [25, 28].

A Feng Shui assessment considers cycles of time important as life is not static and change is constant and inevitable. Feng Shui studies the connection and change of the human, heaven and earth through cycles of time. Energy changes with time. Therefore, the time dimension is important when assessing or studying the energy of a space based on direction, shape and landscape, such as in Feng Shui practice. The Chinese measure time with both lunar and solar calendars.

The method of Feng Shui known as San Yuan (Flying Stars) uses the solar calendar (Hsia calendar) for the study of time dimension [27]. The Flying Stars map consists of the numbers 1–9 that fill a grid, establishing nine time periods.

Each period lasts for 20 years and a complete cycle lasts 180 years. The Earth’s magnetic forces are in constant movement according to planetary bodies’ movement therefore, Feng Shui influences do not stay constant. For example, every 20 years, Saturn and Jupiter come into a new alignment. When this alignment occurs, the repercussions are taken into account through a cycle and over time [27].

2 Hypotheses

This study compared the effects of pre-experience and expectations on participant comfort upon waking, arrival for and after an appointment. It also assessed and compared properly placed Feng Shui elements for three healthcare waiting rooms. The three waiting rooms were designed differently. A professional Feng Shui practitioner designed the first waiting area. A doctor with some familiarity with Feng Shui principles designed the second waiting area. The third waiting area was a conventional Western design that did not incorporate traditional Feng Shui principles.

Hypothesis 1 predicted that properly placed Feng Shui elements found in the interior environment (healthcare waiting areas); the more comfort is experienced by occupants.

Hypothesis 2 predicted that comfort levels before experiencing the arrival for an appointment influence comfort levels upon arrival to the office waiting area.

3 Methods

3.1 Research sites

The three different healthcare office locations were based on contacts of the researcher, but care was taken that all three selections had varied amounts of Feng Shui elements at the entrance and in the patient waiting area. The waiting area sites are named by Area and the properly placed Feng Shui (FS) elements in the specific waiting area. The designations for the three waiting areas are as follows: Area 1 (ideal FS), Area 2 (many FS), and Area 3 (less FS).

Figure 3, Area 1 (ideal FS): The entrance door was red entrance door and opened into a spring green and cream color space, tile floor, and wide space not broken up by walls. A decorative screen placed in the middle of the room guided occupants directly forward to a table with information literature or to the right for ‘holistic’ merchandise and a sitting area with comfortable chairs or to the left to a sitting area and refreshments (tea and water) and receptionist desk. Behind the screen were exercise machines for patients to use while waiting for an appointment. The air was clean, the light was soft but well lit, although the temperature was a bit cool.

Figure 4, Area 2 (many FS): The entrance door was a French glass door that opened into a long and narrow space. There were blue accented rugs on a wooden floor and sitting areas on either side of the door with comfortable blue chairs and tables with informative literature and magazines. The receptionist desk was to the left of the direct path from the door and had glass panels, which reflected the natural light from the windows. The air was clean and the light was subdued. The temperature was a bit on the cool side.

Figure 5, Area 3 (less FS): The entrance door that was solid wood and a bit worn and opened directly into a room with yellow walls, green carpet and a large receptionist desk. The desk was very high and the receptionist was hidden from view. The furniture was large for the space and the room felt tight and constricted. There were chairs lining the walls on either side of the door. The traffic flow or way finding was erratic and the air was stuffy. The light was fluorescent and a bit harsh, although there were windows. It was also cool in temperature.

All locations were in the southern USA and research was conducted at the same time of the year. The healthcare service, provided at each location, was similar. Doctors at each location granted permission for the researcher to conduct a self-assessment comfort survey of participants (patients), assess the waiting areas using Feng Shui principles, and report the results of the study.

3.2 Feng Shui assessment and intention interviews

The researcher used a standard compass and the Feng Shui (Business Model) [29] Bagua, and Flying Star system to assess the proper placement of Feng Shui elements in the three healthcare waiting areas. The foundation of the Feng Shui assessment was a ‘to scale’ room layout, overlaid with a modified Feng Shui Bagua (see Fig. 6), and the compass reading.

The researcher conducted “intention interviews” with each doctor/owner of each office. An “intention interview” discussed the ‘power of intention’ when setting up the environment after a remodel, new construction or after a space clearing [21, 27]. The interview consisted of questions (see Fig. 7) about the office space and environment, as well as what the interviewee/doctor desired or intended for the waiting area environment or space.

3.3 Participants

Table 2 shows the overall participant characteristics from eighty-one participants from the three different healthcare office locations. Most of the participants were retired workers, working professionals or homemakers.

3.4 Research instruments and procedure

The healthcare office staff distributed a comfort self-report survey (Figs. 8 and 9) to each participant over a two-week period, with no repetition of participants. Each participant who completed the self-assessment comfort survey also signed a permission form, allowing the researcher to report the findings of the study. Participants were asked to self-assess and rate their comfort level (physical, intellectual, and emotional) where each was rated from 1 to 5 for three different times the day of their appointment, and answer several questions relating to comfort.

The survey asked participants to recall their waking comfort level (physical, intellectual, and emotional) and respond using a 1–5 rating (1 rated as excellent and 5 rated as very bad). In addition, participants were asked to circle a word and a color that best described their comfort level upon waking. Participants were asked whether they were looking forward to the appointment (“yes” or “no”).

Participants were also asked to rate their comfort level (physical, intellectual, and emotional where each was rated 1–5), a word and a color to best describe comfort levels in the waiting room upon arrival at the medical office. Additionally, participants circled the word that best described the most significant thing they saw and most significant thing they heard on their way to their appointment.

The last part of the survey was completed after the appointment in the waiting room. Participants were asked to rate their comfort level (physical, intellectual, and emotional where each was rated 1–5) with a word and a color that best described their comfort level immediately after treatment. In addition, they circled a word that best described what made them most comfortable and a word that made them the most uncomfortable in the waiting area.

3.5 Data analysis

The one-day self-reported comfort survey data were coded and analyzed using a multivariate statistics package (SPSS, version 17). Paired comparisons between each test group were made for each time-period using the Mann Whitney statistical test for difference of medians (ranked data). A significance level (alpha) of p < 0.05 was applied to the research results.

4 Results

The results for the Feng Shui (FS) assessment for each waiting room were based on a compass reading, Feng Shui bagua (business model), and waiting room layout. Figure 10 and 11 show three completed Flying Star layouts for each waiting areas [25, 27]. All three waiting areas were similar in size and square footage. Each waiting room area had the main door facing East and the back of the space or sitting direction to the West. The dates of construction for waiting areas, 1(ideal F S) and 3(less FS), were in period six and waiting area 2 (many FS) was in period eight. The periods correspond to the year the buildings were constructed.

A Feng Shui practitioner designed the waiting area in location 1. After taking a reading of the interior space and using the Feng Shui principles to establish the placement of Feng Shui elements, area 1 (ideal FS) had the most ideally placed Feng Shui elements, e.g., water elements in the northeast (fountain) and wood to offset the fire and water in the south sector (plants and green wall color). Metal was properly located in the west (reception area metal desk and southeast where the exercise machines were located. The northeast seating area had a balance of all properly placed elements, following the productive cycle.

Waiting area 2 incorporated many Feng Shui elements in the interior design of the office. The doctor had some familiarity with the concept of Feng Shui and attempted to incorporate some of the principles. A reading of the interior space determined that area 2 (many FS) had many properly placed Feng Shui elements, Many of these elements included wood in form of plants and a sculpture in the south-east corner of the office. However, the brown earth elements blocked the blue water elements in the northeast or southeast sectors to reduce the controlling cycle. Metal was properly placed in the northwest sector. The fire elements were not placed properly in the northwest or northeast sectors.

The Feng Shui assessment of the third waiting area location 3 (less FS) revealed the fewest properly placed Feng Shui elements. The placement of the wood element was ideal in the southwest and south sectors. The wood elements (green carpet) overburdened the earth element (yellow walls) and brown (chairs).

The Feng Shui reading indicated the need for the fire element in four of the nine sectors of area 3 (less FS) waiting room. There were however, no fire elements found in the waiting area. The water element was incorrectly placed in the west sector. Metal was present but placed in the northwest sector and pierced the wood element. The water element placed in the northwest sector would have nourished the wood.

In summary, The three waiting areas varied from low to high on properly placed Feng Shui elements and are shown in Fig. 12 in the following sequence: 1 (ideal FS interior elements), 2 (many FS interior elements), 3 (less FS interior elements).

In addition to the Feng Shui analysis of each location, this research also produced data concerning individuals’ feelings about their physical, intellectual, and emotional state, at each location, and at different times (waking up, before the appointment, and after the appointment).

Location 1 (Table 3) exhibits the highest (in percentage) improvement from wakeup to after the appointment, especially in physical and emotional feelings. Intellectual change is also very positive but the pattern does not have as much strength in terms of percentages. These descriptive results provide strength to the general idea that more Feng Shui elements in an office space creates a more positive influence on individual physical, intellectual, and emotional feels about care in a health office.

Table 4 provides the results from Location 2, which had many Feng Shui elements, but was not optimal. It appears that the health office environment is aligned with good improvement in physical, intellectual, and emotional well-being. Location 2’s fewer Feng Shui elements may have influenced the smaller (percentage-wise) increases when compared to Location 1.

Location 3 (Table 5) shows results that one would expect from an office with a minimal number of Feng Shui elements.

While the after appointment physical feeling is strong compared to the before appointment (and stronger than Location 2), the other results (intellectual and emotional) are much less positive that the other locations. This pattern falls in line with the comfort expectations for a healthcare office location with the least number of correct Feng Shui elements.

Table 6 presents the results of the paired statistical comparisons. This table illustrates important patterns within and between the three locations. Location 1, the location with the strongest Feng Shui elements, showed significant differences between “before” and “after” the healthcare treatment with the three comfort levels. This same pattern applies to Location 2, which exhibited fewer Feng Shui elements. Location 3, which holds the fewest Feng Shui elements, departed from this trend with intellectual and emotional support. All three locations exhibit significant differences between the “before” and “after” healthcare treatment regarding physical comfort.

For intellectual and emotional comfort, the differences were also significant with the exception of office location 3 (less FS). For the physical comfort ratings, there were no significant effects for any comparison. Results show that physical comfort levels were comparable between groups of participants for each phase of data collection. However, the differences between pre-and post-healthcare treatment in physical comfort were significant.

A similar analysis for the intellectual comfort levels showed no significant differences between the three groups of participants or the three time-periods. There were significant differences for emotional comfort (see Table 6).

The correlation coefficient between the comfort score at the beginning of the day and the score at the time of the appointment and after the appointment are shown in Fig. 13.

The correlations were higher between the start of the day, or upon waking and before the appointment, than upon waking and after the appointment. This is especially true for the physical comfort. Although there was no significant difference with a t-test, for comparing the comfort levels of the three waiting areas upon arrival to an appointment, it is important to show that the ‘ideal’ waiting area had the highest comfort levels overall and especially for emotional comfort (Fig. 14).

5 Discussion

5.1 Addressing the first hypothesis that predicted the more properly placed Feng Shui elements found in the interior environment; the more comfort is experienced by occupants

Results from this study show a relationship between properly placed Feng Shui elements present in a therapeutic environment and greater emotional comfort levels reported by participants.

As mentioned before, Feng Shui embraces the concept of “flow” or ‘qi’ movement of energy throughout a space over time. According to Heim [30], flow is a smooth, unimpeded movement through space-time. It is an aesthetic quality of spatial movement and occurs throughout the physical world.

The most comfortable area, of the three healthcare areas was area 1 (ideal FS). Although this study reports only a relationship, the layout, intention interviews, Feng Shui assessment and comfort surveys reported good ‘flow’, comfort and a positive calming energy for patients, visitors and staff. The concept of ‘flow’, comfort and a positive energy for patients, visitors and staff was also reported for waiting room 2 (many FS). From the intention interview and Feng Shui analysis area 3 (less FS) concentrated less on the waiting room layout and physical environmental comfort of patients and relied instead on the quality of the treatments to provide patient comfort. The physical “temperature” was the most uncomfortable factor for area 1 (ideal FS) and 2 (many FS) locations and the second most uncomfortable factor for area 3 (less FS). Other studies confirm that discomfort due to temperature is often the number one complaint in the workplace. The majority of scientific papers on comfort also focus on temperature [1 , 32].

Taking into account the responses from the comfort survey (circling a word or circling a color to describe comfort), the aforementioned waiting area descriptions and impressions are related to the Feng Shui assessment as described in the survey results. The words participants used to described their comfort when they arrived for the appointment are as follows: 27 circled “calm”, 18 “tired”, 15 “anxious”, 14 “relaxed”, 3 “excited”, and 3 “upset”. Green, blue and yellow, in that order, were the colors circled for equating a color to the comfort level upon arrival for the appointment. This is of interest as the wall or accent colors in each of the waiting areas correspond to the color selection. Area one, had a green theme, area two, blue, and area three was yellow. It is worth noting that the color green was chosen most often in the surveys from all three waiting areas. The word and color, “relaxed” and “green”, were circled most often after the appointment.

Comfortable interiors have a sense of ‘Placeness’. ‘Placeness’ is another concept that embraces intention. The spatial features of a built environment support the formation of places and facilitate significant occupant experience/qualities [33]. An alternative for improving the physical environment, maybe to design for comfort and flow first, on order to achieve flow with intention. Feng Shui establishes intention and identifies the “flow/energy” or ‘qi’ of an environment.

Another source of flow is social interaction, resulting from optimal interaction, with a person or people [34]. People and their energy are constantly changing the visible and invisible flow of the physical environment [30]. The number one aspect that participants indicated made them most comfortable in all three waiting areas was “people”. However, “people” was selected as the most uncomfortable factor for area 3 (less FS).

The “people” factor may relate to the receptionist, staff or doctor or that patients go to a healthcare appointment because they do not feel well and anticipate feeling better after the appointment. The receptionists, staff and doctors in offices make or break the comfortable atmosphere in the room. If patients are listened to and taken care of, the response is usually a comfortable situation. If, on the other hand, patients are ignored, or given curt replies to inquiries, the response is usually an uncomfortable situation. Additionally other patients can cause discomfort by being loud, rude or overbearing towards the staff or other patients. Comfort in these cases goes beyond physiological and touches the emotional aspects of comfort. These aspects, although important, are difficult to quantify [11].

The findings from this study suggest that applying some of these aforementioned principles to the design of therapeutic environments may provide a further dimension for improving the design of the built interior environment. Feng Shui is an environmental design process about which architects from the West are gaining knowledge and applying to the built environment [19 , 35]. Some Feng Shui practitioners use the concept of biophilic design in their work. Biophilic design brings fourteen patterns from nature into workplaces and workspaces and purports to promote health and well-being [36 –39].

5.2 Addressing the second hypothesis of comfort levels, before experiencing the arrival for an appointment, influence comfort levels upon arrival to the office waiting area

In this study, after the appointment, all three-comfort levels improved, with the physical level being the most significant. The physical improvement results are consistent with other medical studies that show comfort level improvement after healthcare therapy [40 –42]. For therapy treatment offices, patients generally do not feel well before treatment, that is why they are seeking treatment. The physical comfort level is generally worse before treatment and most patients feel better and more comfortable after treatments [40].

Medical studies often measure pain throughout the day and throughout the treatment series [43]. Other studies conclude that after treatment therapy a release of physical pain causes an emotional surge [41, 42]. Participant physical comfort levels improved the most throughout the day, followed by emotional comfort.

It appears that pre-experiences and expectations may relate to comfort levels since there was a significant difference between waking and arriving at the appointment but not right before and after the appointment. Other studies [14 , 44–46], found correlations between the comfort before arriving at the office and being in the office. If previous experiences, such as found in studies conducted by Vink et al. [13] and Konieczny [14] explained 40% of the present comfort, it is essential that the pre-experience be taken into account for comfort studies.

What participants saw and heard on the way to the appointment may relate to their increased emotional comfort level between waking and waiting for an appointment. The majority of participants were looking forward to their appointment, probably because they hoped to feel better after the treatment. However, the majority also heard singing and talking on the way to the appointment and saw roadway, people and nature.

For example, if a person heard a beautiful song and/or saw a wonderful sunrise on the way for an appointment, the emotional comfort may be assumed much different from if a person saw a car accident and/or heard a depressing news story on the radio. What participants saw or heard is possibly related to the higher emotional comfort rating between waking and before the appointment. Additionally, it may be related to what the participants did while waiting in the room before the appointment, e.g., who they spoke with, was music in the room, did they smell or touch something that sparked emotional comfort?

Bakker [47] concluded that people experience the environment with four physical senses, four affective senses and four cognitive senses. An overall ‘feeling’ or ‘vibration’ of the interior emerges within a person and feelings of comfort or discomfort emerge.

Blok et al. [48] found that if passengers lose luggage, the best interiors do not compensate or override the distress over the lost luggage problem. This is important as comfort may be experienced more intensively after an uncomfortable experience [12]. It is not clear if the waiting room environment or the healthcare treatment intervention had more impact on comfort.

6 Limitations

Some limitations of this study could have influenced the outcome: One waiting room was evaluated for each Feng Shui condition. Comfort data were self-reported and the patient sample size was sufficient but not large. Results show a sufficiently strong effect to warrant further research. Another limitation is that self-reported data are used.

On the other hand, comfort is a subjective phenomenon which makes self-reporting the most appropriate way of studying comfort [12]. The limitation of this study is also that the same subject reports the various comfort experiences in time influencing the correlations between the various recordings. However, other studies also report on pre-comfort influences [14 , 44–46]. It is not new that participants’ feelings are influenced by previous experiences. Park et al. [49] confirmed that after walking in the forest participants felt more relaxed than after walking in an urban environment. The forest environment promoted lower concentrations of cortisol, lower pulse rate, lower blood pressure, greater parasympathetic nerve activity and lower sympathetic nerve activity.

Some other drawbacks of this study are possible learning effects as the same scale was used several times in secession. Limited measures were made to ensure that participants had the same understanding of the terms emotional, physical or intellectual comfort. There was no measure of the duration that each Participant spent in the waiting room and no measure of the number of times that patient had been in that particular waiting room. The amount of time a patient spent in an office waiting room or the number of appointments they had in the past was not information the researcher collected. However, these are important points to take into account for future research. The human-to-human relationship influences and actions may disturb comfort study outcomes. There is often one or several researchers conducting the comfort research and it is possible based on the data that the researcher ‘people’ influence the outcome.

Another limitation is that the comfort differences between areas arose because of other characteristics in the interior or because of different sample characteristics. On the other hand, the interviews with the owners of the area showed that Feng Shui was used as an inspirational source for at least two of the waiting areas.

Despite these limitations, this study is a first indication that having more properly placed Feng Shui elements in the interior of healthcare waiting areas increases the comfort experience and pre-experiences and expectations preceding the comfort recording and do influence comfort upon arrival for an appointment. Further studies are recommended to assess whether other healthcare waiting area interiors in other countries are experienced similarly.

7 Conclusion

The effect on comfort was studied in three healthcare area waiting areas, each with different amounts of Feng Shui elements.

Comfort ratings were recorded for physical, emotional and intellectual comfort upon waking, before going to a healthcare appointment and after the appointment. The influences of pre-experiences before and during the appointment were also recorded. The results indicated that emotional comfort differed between waking and arrival for an appointment. The three waiting areas layouts were different. Emotional comfort was higher when ideal Feng Shui elements were present and properly placed in the waiting area environment. Comfort levels at the beginning of the day correlated more strongly with comfort levels after arriving at the waiting area and before the treatment than after the medical treatment. Comparing area settings with high and low levels of Feng Shui design elements may help to elucidate the possible influence on comfort and health, and provide an additional dimension to “holistic” environmental interior design and comfort research for healthcare facilities.

Although eastern and western disciplines do not use the same elements for design, the ultimate purpose of both is to live in harmony with nature and benefit human health. The results of this study are not to challenge conventional design principles but rather to suggest a consideration of an alternative system of analysis and design [17]. Ideally, the aspects should be tested again in a controlled case study or within a subject design study where subjects determine whether they influence the comfort experience. Further research studies, in possibly controlled environments, are warranted to assess if similar effects are found in other Feng Shui influenced healthcare waiting areas and office interiors worldwide.

Conflict of interest

The authors have no conflict of interest to report.

Footnotes

Acknowledgments

The author would like to thank the doctors and participants involved in this study for their time and permission to report the findings in this article.

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