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March 2008 | Back to Table of Contents

Clinical and Health Affairs

Therapeutic Responses to Natural Environments

Using Gardens to Improve Health Care

By Stephen Mitrione, M.D., M.L.A.

Abstract
Gardens are experiencing a renaissance in health care settings as a growing body of research is showing that exposure to natural environments can improve both the patient experience and health outcomes. This article reviews studies that have shown a connection between exposure to nature and improved healing, less medication use, shorter hospitalizations, and decreased anxiety and stress among family members and staff. It also provides guidelines for garden design in medical settings.


Facility designers and health care providers are recognizing the effect of the physical environment on patient outcomes. Studies have shown that a facility’s design can influence the rate of nosocomial infections, errors in patient care, and the cost associated with treating a given condition.1,2 Architects and interior designers who work with hospitals are becoming increasingly aware of this growing body of evidence and are taking it into account in their work.

Figure 1

Healing Garden at Legacy Good Samaritan Hospital

The 13,000-square-foot garden in Portland, Oregon, is designed to meet the needs of people with a variety of abilities. Wide paths, raised beds, and lots of seating options make it user-friendly for people in wheelchairs or those who are ill. The garden is used informally by patients, family members, and staff, and for patients’ therapy.

Photos courtesy of Legacy Health System

Figure 2

Hospital Staff in the Healing Garden at Legacy Good Samaritan Hospital

The garden contains an assortment of plants designed to provide interest throughout the year and attract birds and butterflies. The pattern of the paths, seating options, and spaces for horticulture, therapy, and socializing encourage visitors to interact with each other and the environment.
But what role can the space outside the hospital, clinic, or long-term care facility play in helping patients recover from illness? The idea of including gardens within a health care setting is an old one, dating back to medieval times. When technologies and therapies were few, hospitals were seen as places of rest and recuperation. Gardens were considered part of a patient’s therapy. Today, therapeutic landscape design is an emerging field within landscape architecture, and evidence is accumulating that demonstrates a role for gardens in improving outcomes both from a clinical and an experiential standpoint. For that reason, landscape architects have begun to explore how gardens can be used to improve outcomes in health care.

Therapeutic Gardens: Definitions and Theories
It is important to distinguish a therapeutic garden from a healing garden. In the case of a healing garden, “healing” refers to an improvement in well-being that incorporates the spiritual as well as the physical, not a cure for a specific illness. Therefore, a healing garden may provide relief from the psychological distress associated with a disease but not alter the disease’s outcome. A therapeutic garden, however, is designed to produce a given effect or outcome. It is less focused on healing in a spiritual context (although it may have that effect), and more focused on ameliorating a disease.

How is it possible that viewing or sitting in a garden can affect one’s health or recovery from illness? One theory, the biophilia hypothesis, suggests that physiological responses to certain natural environments are the result of evolutionary encoding in our genes. According to this hypothesis, environments that supported survival of our ancestors (such as those with lush vegetation and water) were encoded as visually attractive and produced a relaxation response.3 This response has been documented in numerous studies of healthy adults who are exposed to a stressful situation in a laboratory setting. All show that physiological measurements of stress (heart rate, blood pressure, muscle tension, and skin conduction) return to normal faster if the subject is allowed to recuperate in a natural setting as opposed to a man-made environment. In addition to experiencing physiological improvements, those same individuals had more positive feelings, experienced less fear, and showed less aggression in the natural environment.4 EEG measurements show a similar effect in individuals who were not under stress. In one study, subjects looking at a green hedge produced more alpha (relaxation) activity than those viewing a concrete wall. The concrete wall actually produced more beta (arousal) activity, simulating stress.5 The relaxation responses in these studies often occurred within minutes of exposure to the natural environment, suggesting a hard-wired response.

Based on these studies, it is possible to further hypothesize that natural environments interact with the central nervous system to reduce stress responses, which can favorably influence the outcome of diseases that are characterized by an overactivation of the stress response. This effect can be wide-ranging, producing changes in the endocrine, cardiovascular, and immune systems that have a positive effect on disease outcomes. For example, it has been shown that stress can increase viral replication and decrease the effectiveness of antiviral drugs in HIV disease.6 By reducing stress in these patients using natural environments, treatment may be more effective and the progression of disease slowed.

Gardens in Health Care Settings: Evidence of Improved Outcomes
In the early 1990s, gardens experienced a renaissance in health care settings, as patients began demanding not only effective treatment but also care that is delivered in a more humane environment. Sterile wards were replaced by spaces that resemble hotels and shopping malls. In a study of patients with a variety of medical conditions from throughout the United States, respondents indicated almost universally that they preferred facilities that provided access to nature either through a garden, views out windows, balconies, pictures, or indoor plants.7

Current Design Guidelines

Although the design of therapeutic or healing gardens will vary depending on the site conditions, climate, patient population, and culture, research and experience have produced some basic design guidelines that have universal application. Developed by Ulrich, these guidelines have been used to create gardens that have been successfully used in health care settings.1

1. Have a variety of spaces. Research has shown that when individuals are stressed and perceive themselves as having some control over their situation, they are less likely to experience negative consequences of stress. A garden that provides a variety of accessible spaces allows individuals to choose the one that suits their needs at the moment.

2. Provide for social support. Having the support of family and friends is associated with improved outcomes among ill patients. By offering a quiet space for families to provide support, patients’ conditions can improve. Gardens should provide spaces that can accommodate groups of various sizes and are conducive to conversation.

3. Allow for physical movement and exercise. Exercise alleviates stress and elevates mood. Because they are pleasant places, gardens can encourage patients to move. Gardens should offer easy wayfinding and provide destinations that encourage mild exercise.

4. Provide access to nature and positive distractions. There is a dose-related response to nature and natural scenes; the more greenery in a garden, the greater the effect on health. Thus, it is important to make sure that the hardscape (walls, sidewalks, patios, etc.) in a garden does not dominate the greenscape (plants, trees, and shrubs). A rough guideline is that one-third of the space should be devoted to hardscape and two-thirds to greenscape.

5. Minimize ambiguity. Individuals who are stressed respond negatively to ambiguous art and objects. Abstract images and art, which may be challenging and interesting to people who are well, have been shown to have negative effects on those who are ill. Any design used in a garden should be easy to interpret and overwhelmingly positive.

6. Minimize intrusive stimuli. Noise, odors, and bright light can cancel out the benefits of a garden. Thus, it is important to place the garden away from these negative stimuli or to mitigate their presence in order for the garden to be effective.

Reference
1. Ulrich R. Effects of Gardens on Health Outcomes: Theory and Research. In: Healing Gardens: Therapeutic Benefits and Design Guidelines. Eds. Clare Cooper-Marcus and Marni Barnes. New York, NY: John Wiley; 1999: 27-86.
In addition to improving the patient experience, there is also evidence that incorporating nature into health care settings improves outcomes. The most often-cited research was done by Roger Ulrich, Ph.D., a Texas A&M University professor of architecture who studied patients in an acute care setting. Patients who had abdominal surgery were randomized to either a room with a view of trees or one that overlooked a brick wall. Using an outcomes-based approach, Ulrich noted that patients who could see nature outside their window recovered faster, used less pain medication, and had a shorter length of stay than those whose windows faced the wall.8

Simulated natural environments have been shown to have a similar effect. In a study of patients recovering from heart surgery, panels were mounted at the foot of their beds with 1 of 3 scenes: a nature scene with a view of open water or an enclosed forest, an abstract design with curvilinear or rectilinear forms, or a blank, white panel. Patients viewing the nature scenes used less pain medication. Anxiety levels were significantly lower among those who saw the image of open water as opposed to the enclosed forest, indicating that different scenes had different effects. Conversely, the abstract scenes actually produced higher reported levels of anxiety in patients than the plain, white panel, which was used as a control.9 Burn patients undergoing dressing changes also reported experiencing less pain and anxiety when they watched a videotape of nature scenes accompanied by music as compared with those who did not.10

Sunlight has also been shown to have a dramatic effect on patient outcomes. In a retrospective study of patients admitted to a cardiac intensive care unit, the patients assigned to sunny rooms had a shorter length of stay (2.3 days) than those admitted to a room that had less sunlight (3.3 days). The patients in the sunny rooms also had a lower mortality rate (7%) than those who were exposed to less sunlight (11.6%).11 Exposure to sunlight also decreased the use of pain medication. Patients undergoing spinal surgery who were admitted to the sunnier side of a unit were exposed to 46% more sunlight. Those same patients had less stress and perceived pain, and their use of analgesics was 22% less than that of patients who were not in the sunny side of the facility.12 Although this study took place inside a hospital, it is plausible that exposure to sunlight in a garden would be equally beneficial, if not more so, because the patient would potentially be exposed to more light in such a setting.

Natural environments have also been shown to be effective in long-term care facilities, particularly among patients with dementia. Violent behavior by residents with dementia decreased when they had access to secure outdoor environments. In facilities where this feature was removed, violent behavior increased.13 Patients with Alzheimer’s disease were found to become agitated less often when doors to a secure outdoor garden were unlocked and they could freely access it.14 Given the disruptive effect that violent behavior has among nursing home residents and the difficulty managing it poses for staff, this effect is significant.

In addition to patients, family members and hospital staff benefit from being around nature. Health care environments can be stressful places for family to visit and staff to work. Burnout among health care providers, particularly nurses, is high. In a study of 3 healing gardens at the Children’s Hospital of San Diego Pediatric Cancer Center, Sherman et al. noted that the majority of users were not children but rather visiting adults and staff.15 Another study of a garden at a pediatric hospital found similar usage by adults, despite the fact that the garden had clear design features that would attract children.16 Ninety percent reported a positive change in mood after visiting the garden. Although not directly related to patient outcomes, it is reasonable to conclude that by relieving stress among adult caregivers and staff, the care of pediatric patients would also improve. It is also reasonable to extrapolate this finding to the adult inpatient setting, where stressed family members and staff could find relief in a garden.

Reviving Gardens in Health Care
Given the demonstrated benefits of gardens and natural environments on health outcomes, including them in the design of health care facilities is justified. Health care institutions that maintain gardens on their grounds benefit in the following ways: greater patient satisfaction with their care and caregivers, potentially shorter hospital stays, and better outcomes. They also may see less burnout, as staff may retreat to the garden in order to relieve stress. Nursing turnover is expensive and disruptive to patient care. The costs of recruiting a new nurse can be $10,000. Preventing or ameliorating the stress that leads to burnout benefits all.

The use of gardens in health care has also caught the attention of accrediting bodies. In 2001, Legacy Health System in Portland, Oregon, was commended by the Joint Commission on Accreditation of Healthcare Organizations for its extensive use of therapeutic gardens (Figures 1, 2). The Joint Commission’s evaluators felt that these gardens demonstrated the commitment of the health care system to the psychosocial well-being of patients. All of these factors can have a positive impact on the bottom line of an institution that more than compensates for the money spent designing, installing, and maintaining a garden.

We are currently in the midst of a hospital construction boom. Older hospitals are being replaced, and new ones are being built in growing communities. Spending on new hospitals jumped 47% in the last 5 years; in 2005 alone, $23.7 billion was spent on new hospital construction.17 This building boom represents a unique opportunity for facility designers and landscape architects to bring gardens into the hospitals of the 21st century. Whereas adding a garden to an existing hospital often involves squeezing it into an available space, designers working on new construction projects can incorporate them into the plans from the beginning.

Future Trends
The design of health care facilities is improving. Patients and providers alike are beginning to benefit from facility designs that are based on a growing base of research. Although research is important to design, it should not dictate decisions. Health care design, like the practice of medicine, is an art. It requires not only information and skill, but also judgment and experience.

With respect to therapeutic garden design, although studies have shown connections between exposure to natural environments and shorter hospital stays, less use of pain medications, and faster healing, there is a need for more information about how gardens affect specific diseases. There is also no evidence to guide plant selection or the use of hardscape features and other garden elements. In addition, questions about whether certain features of a garden are more effective in improving outcomes and whether specific designs and layouts are more effective than others remain unanswered. Many designers have begun to conduct some of this research on their own. Their work has the potential to greatly improve the design of gardens that make health care institutions more effective and, most important, more humane places
to heal. MM

Stephen Mitrione is a board-certified family physician and a landscape architect. He is currently a research fellow in the University of Minnesota’s College of Design.
References
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3. Kaplan R, Kaplan S. The Experience of Nature. New York, NY: Cambridge University Press; 1989.
4. Ulrich RS, Simmons RF, Losito BD, Fiorito E, Miles MA, Zelson M. Stress recovery during exposure to natural and urban environments. J Environ Psychol. 1991:11:
201-30.
5. Nakamurea R, Fujii E. A comparative study of the characteristics of the electroencephalogram when observing a hedge and a concrete block fence. J Jpn Inst Landscape Arch. 1992:55;139-44.
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7. MacRae S, Michel MJ. Consumer perceptions of the healthcare environment: an investigation to determine what matters. J Healthc Des. 1998;10:7-10.
8. Ulrich RS. View through a window may influence recovery from surgery. Science. 1984;224:420-1.
9. Ulrich RS, Lunden O, Eltinge JL. Effects of exposure to nature and abstract pictures on patients recovering from heart surgery. Psychophysiology. 1993; 30 (Suppl 1):7.
10. Miller AC, Hickman LC, Lemasters GK. A distraction technique for control of burn pain. Burn Care Rehabil. 1992;13:576-80.
11. Beauchemin KM, Hays P. Dying in the dark: sunshine, gender, and outcomes in myocardial infarction. J Royal Soc Med.. 1998;91(7):352-4.
12. Walch JM, Rabin BS, Day R, Williams JN, Choi K, Kang JD. The effect of sunlight on post-operative analgesic medication usage: a prospective study of spinal surgery patients. Psychosom Med. 2005;67(1):156-63.
13. Mooney P, Nicell P. The importance of exterior environments for Alzheimer’s residents: effective care and risk management. Healthcare Manage Forum. 1992; 5:23-9.
14. Namazi KH, Johnson B. Pertinent autonomy for residents with dementias: modification of the physical environment to enhance independence. Am J Alzheimer’s Dis Related Disord Res. 1992;7:16-21.
15. Sherman SA, Varni JW, Ulrich RS, Malcarne VL. Post-occupancy evaluation of healing gardens in pediatric cancer centers. Landscape and Urban Planning. 2005;73(2-3):167-83.
16. Whitehouse S, Varni JW, Seid M, Cooper-Marcus C, Ensberg J, et al. Evaluating a children’s hospital garden environment: utilization and consumer satisfaction. J Env Psychol. 2001;21(3):301-14.
17. Cauchon D, Appleby J. Hospital building booms in ‘burbs. USA Today. January 3, 2006.

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