Based on an evidence-based design and research session, “Natural Images-The Effects on Patients Undergoing Surgery,” presented at the HEALTHCARE DESIGN.10 Conference, November 13-16, 2010, in Las Vegas.

It was during Professor Dan Nadenicek's landscape architecture readings class that I was first exposed to the prospect refuge theory of landscape preference. The assigned article claimed that we (humans) possess an archetypal preference for those environments or habitats that helped us survive while we were hunters and gatherers. Apparently we humans spent more time in the hunter and gatherer stage than any other developmental stage in history and are biologically hardwired to prefer the environments that helped us survive (back then). I did my best to dutifully read this article at home but had to seriously skim to make it through. When the class began discussing the piece the following week I was surprised to even hear it mentioned and tried to mentally drift away to a better place, but being one of those people who believes they will burst if they don't speak their mind, I exclaimed instead, “You have got to be kidding! You seriously believe this?” I didn't know it at the time but I was one of those people who belonged in the “we like what we do because of our cultural and environmental conditioning” whereas prospect refuge theory belonged to the “evolutionary” or hereditary camp.

After I selected my thesis topic, “The Therapeutic Benefits of Nature Images on Health”, I went to speak with Professor Nadenicek about selecting a landscape preference theory for my research. Theories are a series of interconnected ideas or explanations for relationships that have held true over time. Good research builds upon existing theory in order to have greater credibility. Interdisciplinary research receives a lot of bad press due to the absence of theories, unclear categories for comparisons, and lack of replication, so I was determined to tend to all of those issues. When I asked him what theories I should look at he was silent for a moment then replied, “Appleton's prospect refuge theory.” I replied, “Oh no! Are you serious?”

Appleton first published The Experience of Landscape in 1975. He was a geography professor at University of Hull, England, who meticulously studied landscape paintings for real and symbolic content. His work resulted in three distinct categories: prospect, refuge, and hazard. Prospect is portrayed by real or symbolic access to a view. Hallmarks of the prospect view contain falling ground, so the viewer can see bright light, reflective surfaces and all that is around them from a high spot. Refuge emerges in the view if real or symbolic shelter can be seen. This includes shelter from animate or inanimate threats. Animate threats could be harmful people or animals while inanimate threats might be storms. The third category defined by Appleton is hazard. Anything that can cause real or symbolic harm to life or well-being is considered a hazard. Storms, bramble fields that restrict movement, and turbulent waters or steep cliffs might all be hazards. Not to mention large predacious animals or a band of robbers. Landscapes could be dominated by one category or could be a mix of prospect, refuge, or hazard experiences.

So while I examined Appleton's work I also kept up a dual search for a better theory-one that focused on cultural or environmental reasons for landscape preference. I didn't find any cultural explanations that stood the test of time. My resistance to the evolutionary theory of landscape preference softened when I discovered that respected researchers and authors, E. O. Wilson, Stephen Kellert, Roger Ulrich, Stephen and Rachel Kaplan, Gordon Orians, and Judith Heerwagen all considered an evolutionary explanation for peoples' preferences for certain types of environments as valid. Then I melted and became a convert of evolutionary theory when I read Appleton's second edition, published in 1996. The only thing different from the 1975 edition was the addition of Chapter 11, designed to address the critics who condemned him for not including the cultural aspects of landscape preference in his original work. Appleton agreed with his critics that culture is an important preference factor, only he was leaving that for someone else to develop and study. Bell, Greene, Fisher, and Baum capture my current sentiments regarding evolutionary theory for landscape preference in general and prospect refuge theory specifically in their text Environmental Psychology (Bell et. al., 2001), “Even the most biologically oriented researchers do not suppose that we all have identical landscape preferences” (p. 45) and, “We wait for a theory of landscape aesthetics that successfully accounts for both culture and biology” (ibid, p. 47).

So, I continue to use Appleton's theory of prospect refuge in my research which aims to uncover the most therapeutic landscape images for people in pain in a hospital. The research contains two phases: the first is image selection and the second is a clinical experiment investigating people in pain. For phase one, image selection, Appleton's prospect refuge theory provides clear category titles and well defined category content. Participants who sort and rank photographic images mirror the population being investigated in the clinical experimental group. In the hospital for instance, image selection participants are recruited from people who are registering for upcoming surgery. We match these populations because people in pain or under stress or fear, may have different preferences than when they are healthy, happy, and feeling secure. After conducting frequency analysis on the images selected, the most preferred images are chosen for use by surgery patients in the clinical experimental phase of the research. We collect physiological data by examining participants' heart rate and blood pressure and psychological data is collected through surveys that indicate mood and pain levels. Then we compare the data of image viewers' with conventional surgery patients' that do not have a mixed prospect refuge image in their field of view.

So next time when you are in a state of stress, take a moment to notice what images or views help you to shift to a calmer state of mind, distracting you from the pain of the moment. Is there a view (prospect) that draws you? Is there a place for shelter (refuge) there? Or is there both prospect and refuge within the same scene? And remember to ask yourself, how am I feeling, right now? HCD

Ellen Vincent, PhD, is an environmental landscape specialist at Clemson University's Department of Environmental Horticulture. She can be reached at Healthcare Design 2011 January;11(1):52-53