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Inspiring people. Nurturing landscapes.

Healthy Landscapes: Ensuring Therapeutic Gardens Deliver Health Outcomes

by Susan Mitchell

Introduction Today, healthcare providers are being pressured to reduce costs while improving the patient experience and health outcomes. Though it may seem frivolous at first, adding a healing, activity, or other type of therapeutic garden is scientifically proven to have a positive impact on health outcomes. This paper provides healthcare facility management, quality practitioners, nursing officers and others with an overview of research, guidelines, and best practices for effective therapeutic gardens. Readers will gain a better understanding of the importance of therapeutic gardens for improving patient health outcomes and how to ensure positive health outcomes for existing or future gardens in healthcare settings.

What Research Tells Us Whether it is simply a view of nature through a window or a stroll in a garden, most of us have experienced the calming and positive effects of nature and green spaces. And in fact, over 30 years of research studies provide solid evidence of these effects. In a 2012 Scientific American article, Nature that Nurtures, Deborah Franklin notes a 1984 study by Roger Ulrich, an Environmental Psychologist, revealing “patients with bedside windows looking out on leafy trees healed, on average, a day faster, needed significantly less pain medication and had fewer postsurgical complications than patients who instead saw a brick wall.” The data also suggests, “Just three to five minutes spent looking at views dominated by trees, flowers or water can begin to reduce anger, anxiety and pain and to induce relaxation, according to various studies of healthy people that measured physiological changes in blood pressure, muscle tension, or heart and brain electrical activity.” Clare Cooper Marcus, co-author of the recently published Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces, says, “Let’s be clear, spending time interacting with nature in a well-designed garden won’t cure your cancer or heal a badly burned leg. But there is good evidence it can reduce your levels of pain and stress—and, by doing that, boost your immune system in ways that allow your own body and other treatments to help you heal.” In a 2012 presentation, “Healing Garden”, Professor Susan Rodiek at the Center for Health Systems & Design at Texas A&M University, summarized the research findings of Takano, Nakamura & Watanabe, 2002; Fujita, Fujiwara, Chaves, Motohashi & Shinkai, 2006; Connell, Sanford & Lewis, 2007; Jacobs, Cohen, Hammerman-Rozenberg, Azoulay, Maaravi & Stessman, 2008; and Rodiek, 2002 as follows:

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Inspiring people. Nurturing landscapes.

Effects of Landscape Surroundings on Well-being Psychological

Reduces stress (lowers Cortisol levels)

Increases sense of freedom and autonomy

Encourages social interaction

Improves positive mood (outdoor light reduces Melatonin and increases Serotonin)

Deepens spiritual connection

Physical

Higher physical activity increases Calcium absorption

Sunlight promotes Vitamin D absorption (strengthens bones, improves sleep patterns)

Reduced pain

Lower blood pressure

Less urinary incontinence

Design guidelines and standards As access to nature became well-documented as an element for evidence-based healthcare design, guidelines and standards are now incorporating best practices for architecture, landscape design, construction, and sustainability practitioners. The Guidelines for Design and Construction of Health Care Facilities, published by The Facility Guidelines Institute (www.fgiguidelines.org), is revised every four years and is the basis for healthcare facility design and construction code in 42 states. With the publication of the 2014 Guidelines, there are now two publications, Guidelines for Hospitals and Outpatient Facilities and Guidelines for Design and Construction of Residential Health, Care, and Support Facilities. Both Guidelines include “views of and access to nature” in the Environment of Care Requirements section. The Green Guide for Health Care and LEED for Healthcare are two sustainable design guidelines that give separate credits for “Connection to the Natural World: Outdoor Places of Respite and Exterior Access for Patients.” 2

Best Practice for Better Outcomes As a result of this growing evidence of improved patient outcomes, Cooper Marcus, Rodiek and others began to question what makes a therapeutic garden most effective. Via observation, interviews, focus groups, and surveys in different types of healthcare facilities with garden spaces, they learned which elements have the most impact such as the ease of moving through the space, time spent outdoors, types of activity (passive and active), connection to the surrounding community, relaxation benefits, etc. These studies showed that all gardens benefit from certain elements. However, the data also showed different user populations (children, elderly, Alzheimers, dementia patients, and staff) benefit from different design elements.

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All therapeutic gardens should consider safety and security, privacy, and accessibility. Ideally, they should appeal to all of the senses with a high ratio of greenery to hardscape and a variety of vegetation that changes with the seasons. There should be ample choices for where to walk

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Inspiring people. Nurturing landscapes.

and sit, alone or in groups and with options for sitting in the sun or shade.1 Loder and Smith recommend designs that encourage exploration, mystery and views, and features that provide habitat for butterflies, birds, and other wildlife. They also note the importance of properly maintaining the natural space because patients will immediately associate poorly tended or dying plants with lack of attentiveness to their own medical care. It is also important in our Western culture, especially in city settings, to provide “cues to care” in naturalized lawns or roof garden designs to indicate that the “messy” look is on purpose. Using signage or educational material, adding colorful annuals, or incorporating straight mowed areas can signal the intentionality of the area.2 Medical and support staff should have separate respite garden areas from patients or residents.

Keep the User in Mind It is important to keep in mind that will be using the garden to ensure the best outcomes. A patient taking psychotropic drugs may be sensitive to glare and UV exposure, while cancer patients undergoing chemotherapy can be bothered by strong smells. Elderly populations tend to have diminishing eyesight and stamina, while sick children and their parents benefit from activities that provide a distraction from ongoing medical care. A study of gardens at a children’s cancer center by clinical psychologist Sandra A. Sherman revealed that elements enabling children and their parents to interact together were twice as popular as one that allowed only the child to play.3 At the other end of the age spectrum, Rodiek observed that specific landscape features significantly increased the amount of time elderly residents in long-term care settings spent outdoors as shown in the chart below.

Chart credit: http://www.asla.org/2010awards/images/largescale/564_08.jpg

In order to ensure health outcomes, it is important to understand the requirements of different users. The following table provides some examples of recommendations from Rodiek, Cooper Marcus, Sachs, Barnes, Loder, and Smith for both general and specific populations, though this is by no means a comprehensive list.

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Inspiring people. Nurturing landscapes.

General

Green/Hardscape lush greenery and flowers at various heights should be 70% and walkways and plazas 30%

Sculpture should be realistic, not abstract

Water Features avoid any that sound like dripping faucets, buzzing helicopters or urinals, keep free from unpleasant odors

Entry should be easily accessed(or viewed) for intended users

Visibility ensure visibility of the garden by both users and staff from indoors

Separate Spaces create different spaces with seating for individual solitude or social interaction and activity

Elderly - assisted living, skilled nursing, retirement communities

Pathways should be smooth with good traction, avoid concrete expansion joints greater than 1/8th of an inch

Seating located every 20 feet or so along a walkway, visible from the outdoor entry, moveable seating, must have back and arms, easy to get in and out of

Finishes avoid untinted concrete and white or aluminum furniture (reduce glare)

Entry Area covered or filtered shade, offers seating, entry doors and threshold easy for walkers and wheel chairs to navigate

Activity Areas create rehabilitative and activity areas such as raised flower or vegetable gardens with access to appropriate gardening tools

Fencing fencing that encloses the space should be open to allow views outside

Dementia Patients

Pathways use courtyards with simple looped or figure-eight path that leads back to the entry, avoid forks or junctions

Plants only non-toxic and non-hazardous, choose native plants familiar to residents

Special Features incorporate bird feeders, cultural artifacts to stir memories, and raised bed gardening areas

Mental and Behavioral Health Patients

Safety & Security must address possibility of attempted escape and harm to self and others

Paths and Seating homelike, non-institutional, create sense of freedom and control via path choices and moveable seating

Special Features shaded areas, space for one-on-one and group interaction, open areas for group exercise

Children

Plants only non-toxic and non-hazardous (no thorns, sharp edges)

Activity Areas create elements that enable children and parents to interact with the garden together

Water Features enable touching or interacting with the water if possible

Special Features seek to incorporate some whimsy or discovery, separate areas of distraction from treatment and quiet solitude

Cancer Patients

Plants use low pollen plants, avoid flowers or plants that are very fragrant, use multisensory plants

Seating provide flexible individual seating and area for group seating, at the height of and room for a wheelchair

Special Features water features with pleasing sound, shady areas, garden views from inside treatment areas, areas for group therapy such as nutrition, relaxation and yoga

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Inspiring people. Nurturing landscapes.

Enlisting the right professionals If your facility is planning a new outdoor space, be sure to enlist the help of an experienced and knowledgeable Landscape Architect who can design a space for your specific intended users. Even existing garden spaces may need updating due to poor initial designs, cost constraints that may have affected implementation, adjacent buildings being repurposed, etc. Not all Landscape Architects are familiar with current research and recommended practices for therapeutic gardens. Experience in designing parks and corporate plazas is not the same as designing an outdoor space for users with specific needs and the required elements to deliver health outcomes.4 Look for landscape architects who are Certified in Healthcare Garden Design by the Chicago Botanic Garden (http://www.chicagobotanic.org/education/certificate_programs/healthcare), have attended specialty courses and conferences on the topic, and/or are active in the American Society of Landscape Architects’ professional practice network devoted to Healthcare and Therapeutic Design (http://www.asla.org/healthcare). The same holds true for maintaining these special purpose outdoor spaces. Therapeutic gardens typically have water features, a large variety of plantings, are densely planted, and have specialty irrigation or soils (roof gardens especially). Maintaining a therapeutic garden requires a higher level of horticultural knowledge and more frequent care than other outdoor landscaped areas. Facility managers should plan for ongoing maintenance and future redesigns in their expense and capital budgets.

Certification on the horizon Just because a healthcare facility has a therapeutic garden which looks beautiful does not mean it is providing the desired health outcomes. “New hospitals are now competing on the basis of whether they have a ‘healing garden’ or not,” says Cooper Marcus. “But when you go to look, some are not much more than a rooftop with a chaise lounge and a few potted plants.”3 Now that the Guidelines and other standards require “access to nature”, the next logical step, especially for healthcare facilities where accreditation certification is common, will be development of industry recognized audit tools and certification for existing and new therapeutic gardens. Cooper Marcus and Sachs are currently developing an audit tool for acute hospitals with the expectation of developing future audit tools for more specific populations and spaces. These audit tools can become the basis for certification to ensure therapeutic gardens meet minimum standards.4 Until certification is in place, seek out the right professionals, educate yourself (see Resources for Learning), and incorporate healthy landscapes whenever possible in your healthcare facility.

Resources for Learning Healing Gardens: Therapeutic Benefits and Design Recommendations Hardcover – June 15, 1999 by Clare Cooper Marcus (Editor), Marni Barnes (Editor) Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces Hardcover – October 21, 2013 by Clare Cooper Marcus (Author), Naomi A Sachs (Author)

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Inspiring people. Nurturing landscapes.

Access to Nature for Older Adults, a set of three educational videos, is available at http://www.accesstonature.org based on research from Texas A&M University Center for Health Systems & Design. Landscape Architecture for Healthcare Communities, Awards Edition, December, 2013 - http://mydigimag.rrd.com/publication/frame.php?i=189736&p=&pn=&ver=flex Therapeutic Landscapes Network listing of gardens in Healthcare and related facilities, http://www.healinglandscapes.org/healthcare-gardens/index.html American Horticultural Therapy Association, www.ahta.org advances the practice of horticultural therapy (HT). HT techniques are employed to assist participants to learn new skills or regain those that are lost. HT helps improve memory, cognitive abilities, task initiation, language skills, and socialization. In physical rehabilitation, HT can help strengthen muscles and improve coordination, balance, and endurance. In vocational HT settings, people learn to work independently, problem solve, and follow directions. Most successful therapeutic gardens employ planned HT activities to further health outcomes.

References 1. The Perfect Setting by Clare Cooper Marcus and Naomi A. Sachs, December, 2013, Landscape Architecture for Healthcare Communities, pp. 2-7, http://mydigimag.rrd.com/publication/frame.php?i=189736&p=&pn=&ver=flex 2. Designing Access to Nature by Angela Loder and Jerry Smith, December, 2013, Landscape Architecture for Healthcare Communities, pp. 12-17, http://mydigimag.rrd.com/publication/frame.php?i=189736&p=&pn=&ver=flex 3. Nature that Nurtures by Deborah Franklin, Scientific American, March, 2012. 4. Gardens in healthcare facilities: steps towards evaluation and certification by Clare Cooper Marcus and Naomi Sachs, World Health Design, http://www.worldhealthdesign.com/Gardens-in-healthcare-facilities-steps-towards-evaluation-and-certification.aspx

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