Publications IPH Magazine Revista IPH Nº18 The therapeutic garden

This article discusses the effects of gardens on health and satisfaction of users in hospital environments. Based on a literature review, a selection of studies was carried out to highlight the most relevant concepts, and that have contributed to deepen the understanding of therapeutic gardens, presenting some examples of projects that incorporate these concepts and the theories that underpin them. This document is part of a more comprehensive research that aims to identify the implications, benefits, and therapeutic possibilities of the use of gardens in health centers in order to establish concepts of projects to be applied in a case study of nursing homes.  

Keywords: therapeutic garden, biophilia, evidence-based design, gardens in health centers.

Gardens have been an integral part of hospitals, nursing homes, rehabilitation centers, nursing homes and nursing homes that care for the elderly. Thanks to important advances in medicine, technological innovations, economic, social, and cultural changes in care for the population, health facilities have varied their infrastructure, also modifying the design of its outdoor spaces. Nowadays, there is a growing     interest of doctors, architects, and researchers in the humanization of health centers, introducing new variables and research focused on rethinking how the design of health center environments influences    patient recovery and the well-being of the team. One of the environments that has aroused much interest in this aspect is the introduction of landscaped spaces, both inside and outside hospitals, nursing homes, rehabilitation centers and residences for the elderly. The concepts of biophilia, evidence-based design and therapeutic gardens stand out among the most used ones in the area of space design intended for health    services.

The need of human beings to connect with the nature and be in contact with other animal or plant organisms is called biophilia, word that comes from Greek, bios, life, and philia, love. It literally means "to love life". 

The term was defined by Erich Fromm, German psychoanalyst, in "... passionate love for life and the whole living, the desire for growth and development in a person, a vegetable, an idea or a social group" (Fromm, 1973, p. 261).

Later, Edward Osborne Wilson (Wilson,1984), an American biologist, deepens the concept of   biophilia and formulates a theory. According to Wilson's theory, people need to have contact with     nature, which is critical to psychological development. It states that throughout the millions of years in which Homo sapiens related to its surroundings it has been developed a deep and congenital emotional need to be in close contact with the rest of living beings, plants, or animals. The satisfaction of this vital desire has the same importance as establishing relationships with others. Just as we feel good about    socializing, we find peace and  refuge when we go to a forest or a beach, look at green walls, or when   we are with our pets.

Howard Frumkin (1) (Frumkin, 2017) and Roger Ulrich2 (Ulrich, 2001), among others, referred to E. O.Wilson in their studies and to the theory of  biophilia as one of  the main ones that support the related benefits between health and nature. Recently, in the field of architecture, the biophilia project is discussed, considered as a sustainable design strategy that seeks to reconnect human beings with  their natural surroundings.

An example of the application of biophilia concept in architecture to improve health of the sick is the Royal Children's Hospital, designed by Billard Leece Partnership and Bates Smart (Bull, 2012), in Melbourne, Australia, located in a green surrounding (Picture 1). Today, it has 

become a reference in the provision of health services aimed at children. The principles used were: evidence-based design, family-centered design, sustainable design, introduction of daylight and nature in the work and sanitary surroundings, gathering of clinical, research and education facilities.

(1) Professor of Environmental and Occupational Health Sciences at the University of Washington School of Public Health.

(2) Professor, Department of Architecture and Center of Sanitary Architecture, Chalmers Technological University. 

 

The patient rooms are separated into three areas (clinic, patient, and family), responding to the emotional needs of children. Each child can customize their space (Picture 2), as well as views of the inner courtyards or the Royal Park, which improves patient's experience and recovery rates, which has been proven in different studies. They also ensure shorter hospital stays for patients hospitalized in rooms overlooking nature, unlike patients in other types of rooms (Bates Smart, 2019).

Another example is Khoo Teck Puat hospital, located in Yishun, Singapore (Picture 3), opened in June 2010. The architectural project was in charge of CPG CONSULTANTS PTE LDT, and the landscaping was conceived by PERIDIAN ASIA PTE LTD, which holds a LEAF certification (Linking environment   and Farming) and has already won several awards. It was created under the concept of hospital in a garden, focusing on sustainability through three key principles: (I) to elaborate gardens in a practical  and self-sufficient way; (II) to create natural gardens with people in mind; and (3) to implement the landscape and ecological characteristics efficiently in the use of resources and  energy (National  Parks  Board  Greenroofs.com, 2020).  In this way, by being able to maximize the creation of therapeutic green spaces and to offer high-quality environments, architecture can link indoors and outdoors, providing the view of the gardens from different angles.

The notion of evidence-based design (EDB) is essential for the development of spaces intended for health. It is proposed that to create spaces for people with special needs, which require a design for specific results, the project should be based on solid research and updated. According to the Center for Health Research, EDB defines itself as "...the process of basing decisions concerning the built environment on credible research to achieve the best possible outcomes" (3) (The Center for Health Design, 2018).

 During the last 30 years,  a  number  of  researchers  have  elaborated    several  works linked to the area  of sanitary  project,  open  spaces in the surroundings of  health  and  restorative  landscapes. Roger  Ulrich is one of  the  most  cited  international researchers in  this  area. He began his career in 1979 as an assistant professor, researching environmental aesthetics, where he discovered that most landscapes  of  nature produced positive emotional states and helped relieve stress. His studies are still being implemented  by  design professionals and managers of medical  care  centers.

In 1984, Ulrich (Center for  Health  Systems  and  Design, Texas A&M University) presented a significant study on the positive influence that landscapes have on health  outcomes. Patients  recovering  from gallbladder surgery were analyzed.  Some stayed in  rooms overlooking the trees and  had  fewer complications,  used smaller doses of painkillers, and returned to their homes more quickly, compared to patients who had  the view of  a  wall.

Ulrich and his colleagues carried out some researches and proved the "Theory of stress reduction", which demonstrates that five to seven minutes in contact with nature or looking at a natural landscape can:

From 1991 to 1999, Ulrich presents "A theory of  supportive gardens"  (Ulrich 1991, 1999), which began in a previous conceptual work  aimed primarily at architectural and interior design aspects of  health  facilities,  but  which  has  been  modified  and updated to focus directly  on gardens. It  shows that  the  ability  of  gardens to have healing influences comes largely from their effectiveness in facilitating   health recovery and  facing stress.

(3) It is  the  process  of  basing  decisions on the environment  built  on  a  reliable  search  to  achieve  the  best  results. The use of  quantitative  and  qualitative   research to design surroundings  that  facilitate  health   and improve  results. 

Ulrich proposes that gardens are important stress-attenuating resources for patients and professionals, in addition to bringing improvements in clinical outcomes, patient satisfaction and the cost of care, as long as they fulfill the following guidelines:

The theory also argues there is a necessary condition for the four features above mentioned to be    effective: the garden  should  convey  a  sense  of  security. If the design or characteristics of  a  garden  produce feelings of insecurity or even risk, it is likely the environment will have a stressful influence,    rather than a restorative one. And  many  patients, visitors and  staff  will  prevent  people  undergoing  medical  treatment  from feeling  psychologically  vulnerable.

At the same time, in 1995, a research concerning gardens in hospitals was published: "Gardens in healthcare facilities: uses, therapeutic benefits and design recommendations" (Cooper & Barnes, 1995), from University of California, Berkeley (4), which studied four  gardens in  hospitals located in  the   San Francisco Bay Area, California.

Interviews, behavioral mapping, and visual analysis were elaborated. It was discovered that stress reduction, including  mood recovery, was  the most important category of benefits enjoyed by almost all  garden  users: patients, family members, and employees. According to these studies, the traditional elements of gardens, such as lawns, trees, flowers, and water elements are appreciated: 90% of garden  users experienced  a  positive  change  of mood  after  spending some time outdoors.

(4) It is the  first  systematic  evaluation  after the occupation  of  the  outer  space of  hospitals. 

In 2008, the " Theory of the Restoration of Concentration" was proposed, which proves that exposure to nature restores concentration capacity after concentrated efforts that create mental fatigue. This theory was developed by Rachel and Stephen Kaplan (Pati and Barach, 2008)    colleagues and alumni of University of Michigan. A study was conducted with 32  patients in two Atlanta hospitals after  a 12-hour shift. Sixty per cent of  those  with  access  to  nature improved  their vigilance or remained the  same, and those without access to nature or without a view of natural landscape decreased 67% in surveillance. This research  concludes   that  improving  restorative quality of recess  areas can  lead  to reduced stress  and better  patient  care.

In 2015, a   scientific   study was  initiated in  Japan  to   investigate the  decrease  in  depressive symptoms and increased  memory  performance in  elderly  adults,  it was called "Effects  of  exercise  and intervention  on brain and mental health in older adults with mild memory problems and  depressive   symptoms" (Makizako  et al., 2015).

Initially, the  trial  was  conducted for 20 weeks,  with  90  adults over 65  years old living with  memory  problems  and  depressive  symptoms. Participants were randomly  assigned to perform three  experiments:  exercise,  horticultural activity, and educational control group. They  conducted   a combined program  of  exercises  and  horticultural activities during 20  weekly  sessions of  90 minutes each. Participants in the exercise  group  practiced  aerobic exercises,  muscle strength   training,   postural  balance training and double task training. The  horticultural activity program  included  activities related  to culture, such as cultivation in the field and  harvesting.

Preliminary results observed  antidepressant  effects  among old people with  mild  depressive symptoms  and  clinically significant  symptoms of   depression,  suggesting  the  prescription of structured exercises  with mixed elements of  resistance  and  strength  training  adapted  to  individual  capacity. The results of  horticultural activity  showed reductions in agitation levels, it was considered to be necessary  to  carry out well-designed intervention studies  to examine the  effects  of  horticultural activity on brain and   mental health (e.g., depressive  symptoms,  cognitive function and brain volume)  in  non-demented  adults at increased risk of  dementia. 

 

It is  a   delimited   garden space intended for a  given  population  with  a specific purpose. The  design of the physical  aspects and  the  activities  to  be developed in  the  garden  are  based on medical research. It is recommended to  be  designed  by  a specialized multidisciplinary  team,  as  it  is   a meeting point between medicine and  design. The purpose of  the  therapeutic  garden  is to offer its users (patients, visitors, residents, employees) a  place  that contributes  to  improve their  physical, psychological, social and spiritual needs, as well as helping them keep  in  touch  with  reality  and  providing well-being. 

For Naomi Sachs (5),  the  definition  of  "healing garden", "restorative landscape"  or "landscape for  health" is that of  any  wild or projected space, large or small, that favors health human well-being  (Sachs  N. ,  2016). Sachs proposes that  private  residential  gardens can also  be  healing  gardens,  although  there is   a distinction to be made  between  curative  gardens for all and  curative  gardens for  people  who  have  compromised  health.  

The former are designed to help healthy people  stay  healthy. It works  like some  kind of preventive medicine. However, in health facilities, the design process  should be carried out  with  the  greatest  attention, taking into  account  users, and giving  preference to evidence-based projects (Sachs N.,  2018).

(5)Naomi A. Sachs, PhD, MLA, EDAC, Assistant Professor, Department of  Plant Science and Landscape Architecture  at the  University of Maryland and  Founding  Director of  the Therapeutic  Landscapes  Network (www.healinglandscapes.org)

 

In order  to provide  therapeutic  benefits, the  garden needs to meet a number  of features such  as: (I) a wide  variety of plants that are  distinguished  by the changes of  season; (II) views of the sky; (III) small lakes of water and trees that can attract wildlife; (IV) scheduled activities, such as horticultural or  rehabilitation therapies, ensuring universal accessibility; (V) well-defined perimeters, so users can focus their attention on the components of  the garden, that means the functional  organization  should be clear and simple with an orderly  structure of the circulation to  facilitate orientation  and  mobility  user.  

There are many benefits  of  being in contact  with  nature,  including  physical, psychological, social  and  personal  aspects. Spending only 90 minutes a day in a wooded area reduces depression, and  spending  one  day in  nature in a  recurring  way  improves the immune system.

Experts have recorded great benefits in the use of  gardens, parks and green  spaces, both inside and outside health environments, such as: stress  reduction,  sleep  improvement,  anxiety  and depression reduction,  associated with  increased happiness,  reduced aggressiveness, reduced  behavioral disorder  symptoms,   decreased  blood  pressure, improved recovery of surgeries,  improvement of  overall  health, increased life expectancy in older adults, if  they  have  access to parks and   nature, improvement of  quality  of life in chronic or terminally ill patients, besides helping patients to evoke  their  own  healing capabilities (Frumkin, 2017).

Ulrich proposes four design guidelines for conducting a therapeutic garden:  exercise,  sense  of control, social support,  access  to  nature  and  other  positive distractions  in  "A  Theory  of Supportive  Garden  Design"  (Ulrich, 2001). In addition to these basic guidelines, the author's observation on hospital gardens in  the United States, Australia, Canada and the United Kingdom highlights the need to consider that, in order to be used and reach its full potential, it  must possess the  following  qualities: visibility,    accessibility,  familiarity, tranquility, comfort, and art  without ambiguities.

Clare Cooper Marcus, in her article "Healing  Gardens  in  Hospitals"  (Cooper, 2007),  describes some essential design elements and environmental qualities that  a  therapeutic  garden  should  have, and describes the precedents  used by  designers of  contemporary   healing  gardens,  including those  for    medical diagnosis, where  a number  of pathology design recommendations have  been proposed. On  the  other hand,  the  American Society of Landscape Architects (ASLA) and  the American Horticultural Therapy Association contributed to the  development  and  understanding of the  elements for the design of therapeutic  landscapes,  approving the document "Therapeutic Garden  Characteristics" (Hanzen,  n.d.), which serves as  a  reference  for medical professionals and landscape scholars in relation  to well-being. The  combination of  these  fundamental elements  represents  current  practices  for therapeutic gardens.

 

The following table, taken from our bibliographic review, summarizes  the   design strategies  for creating a  therapeutic garden.

Some  special recommendations  for  the  design of outdoor spaces in  nursing  homes,  rehabilitation gardens  for people who have suffered cardiovascular accidents and gardens for patients  with  Alzheimer's disease.

BATES Smart. (2019). The Royal Children's Hospital - Architecture.  Available at: https://www.batessmart.com/bates-smart/projects/sectors/health/the-new-royal-childrens- hospital-architecture/

COOPER, M. C., Barnes, M. (1995). Gardens in healthcare facilities: uses, therapeutic benefits, and design recommendations.  The center for health design.  Universidade da California, Berkeley.  Available at: https://www.healthdesign.org/sites/default/files/Gardens%20in%20HC%20Facility%20Visits. pdf

COOPER, M.C. (2007, janeiro). Healing Gardens in Hospitals.  Design and Health, IDRP Interdisciplinary Design and Research e-Journal.

Volume I, p.4-6.

FROMM, E. (1973). Anatomy of Human Destructiveness,  p  261. Retrieved in 2018,  Dispose  of it in:  http://www.ignaciodarnaude.com/textos_diversos/Fromm,Anatomia%20de%20la%20destruc  tividad%20humana.pdf 

FRUMKIN, H., (2017) Seattle Parks and Recreation: Parks, Greenspace and Human Health. (Video) Available at: http://www.seattlechannel.org/misc-video?videoid=x71138

GOLLINGS, Jhon. (2012).  Royal  Children's  Hospital  landscape. Retrieved in May 18, 2017, from https://architectureau.com/articles/new-royal-childrens-hospital/#

HANZEN, T., (s.f).  Therapeutic Garden Characteristics. A quarterly publication of the American horticultural association.  Volume 41, Number 2, p3. Retrieved in 2017 from https://www.ahta.org/assets/docs/therapeuticgardencharacteristics_ahtareprintpermission.pdf

MAKIZAKO, H., Tsutsumimoto, K., Doi, T., Hotta, R., Nakakubo, S., Liu-Ambrose, T. & Shimada, H., (2015).  Effects of exercise and horticultural intervention on the brain and mental health in older adults with depressive symptoms and memory problems: study protocol  for a randomized controlled trial.  Doi: 10.1186/s13063-015-1032-3

National Parks Board Greenroofs.com. (2020). Khoo Teck Puat Hospital (KTPH)

Available at: https://www.greenroofs.com/projects/khoo-teck-puat-hospital-ktph/

PATI, D, Harvey TE Jr, Barach P., (2008).  Relationships between exterior views and nurse stress: an exploratory examination.  HERD. 2008 Winter; 1(2) p27-38.

SACHS, N. ,  (2016). What  is  a  healing  garden?. Retrieved in  May 2017, from: https://healinglandscapes.org/what-is-a-healing-garden/

SACHS, N., (2018). Healing  Landscapes. Retrieved in January 2018 from: https://aiacalifornia.org/healing-landscapes/

The Center for Health Design organization. (2018). The center of health design.  Available at:  https://www.healthdesign.org/

ULRICH, R. (2001). Effects of Healthcare Environmental Design on Medical Outcomes.  Design and Health: Proceedings of the Second. Recuperado de: 

https://www.researchgate.net/publication/273354344_Effects_of_Healthcare_Environmental_Design_on_Medical_Outcomes

ULRICH, R.S., Zimring, C., Zhu, X., DuBose, J., Seo, H., Choi, Y., Quan, X. & Joseph, A., (2008) A Review of the research literature on Evidence-Based Healthcare Design. HERD, Health Environments Research & Design Journal, 1 (3), 61-127. Retrieved in July 2017, from www.herdjournal.com issn: 1937-5867: www.herdjournal.com issn: 1937-5867

WILSON, E.O. (1984). Biophilia, the human bond with other species. Harvard University Press, Cambrige (Massachusetts).

Valentina Moya, Architect, Landscape Architecture Specialist. Tabora+Tabora Office/landscape  architects. 

Email:  arq.valentinam@gmail.com.

Sonia Cedres  de Bello,  Professor-Researcher at the Institute of   Experimental Development of  Construction. Faculty  of Architecture and Urbanism of the  Central  University  of  Venezuela. 

Email:  bello.sonia@gmail.com