Cover Story: Growing strong

Modern medicine cures many ailments, but nothing nourishes the spirit like the healing nature of a garden. Civilizations throughout the ages have recognized the restorative properties of gardens. From Zen-inspired courtyards to the great gardens of Egypt, the concept of using nature to heal is rooted in ancient traditions. Incorporating the idea of healing gardens into the sophisticated modern health care landscape is not only a burgeoning trend but is also rooted in evidence-based science that the gardens promote health and reduce patient stress.

While using plants and nature to heal is not a new idea, there’s a growing demand for hospitals, nursing homes and health care facilities to design therapeutic landscapes to benefit patients, visitors, family members and hospital staff. In fact, the Joint Commission on Accreditation of Healthcare Organizations now includes access to nature as part of its evaluation, and well-established studies link healing gardens with lower patient stress and increased patient and staff satisfaction.

Research during the past two decades show patients heal faster when they have access to nature. One pivotal study from Texas A&M University’s Center for Health Systems and Design found that patients whose windows overlooked trees and gardens recovered faster than those whose windows faced brick walls. Dr. Roger Ulrich, is the leading scholar on the healing nature of gardens and says exposure to nature has significant health outcomes. In his book “Theory of Supportive Gardens” Ulrich says, “Gardens in health care situations are important stress-mitigating resources for patients and staff to the extent that they foster a sense of control and access to privacy, social support, physical movement and exercise and access to nature and other positive distractions.”

Teresia Hazen, a horticultural therapist with Legacy Health Systems in Portland, Oregon, says Ulrich’s work has influenced the outdoor garden design of all Legacy hospitals including the Emmanuel Children’s Hospital and the award-winning Oregon Burn Center. The 8,000-square-foot healing gardens at the Burn Center is known for its lush, significant shade and serene, private courtyard. The American Horticultural Therapy Association recently awarded the Oregon Burn Center its Therapeutic Garden Design Award. The garden was selected based on activities for patients, accessibility, sense of safety, well-defined perimeters, comfort and sensory stimulation. “The garden offers great shade for the protection of burn survivors’ highly sensitive skin and an intriguing botanical collection of four seasons of sensory stimulation,” says Hazen. The plants were chosen for use with burn survivors’ physical, speech and recreational therapy.

Under Hazen’s guidance, the healing gardens of the Legacy hospital incorporate all the characteristics of what’s known as therapeutic landscaping. (see page 45)
“The healing nature of gardens can include all aspects of rehabilitative and restorative medicine,” Hazen says.

Characteristics of a healing garden
What differentiates a therapeutic garden from a typical hospital landscape? “Healing gardens are designed with the intent to achieve a balance between a plant-dominated landscape and a restorative, interactive, therapeutic benefit between patients, staff and visitors,” says Hazen. All aspects of the healing process may take place in the garden setting.

Speech pathologists use the garden for cognitive and communication treatments. Recreational therapists find many uses for the gardens including music and other social programming, walking, bird watching and learning adaptive gardening strategies. Children’s hospitals utilize play therapy and the “letting off of steam” for critically ill patients. Physical therapists may lead their patients on walks through the garden, while stroke victims may be asked to identify plants and flowers on both sides of their body. The horticultural therapist uses the garden to help patients increase strength and endurance, mobility, focus and memory. The garden can also encourage the development of new leisure interests.

Mark Epstein, a landscape architect with ESA Adolfson in Seattle and co-chair of ASLA Healthcare and Therapeutic Design Professional Practice Network, says the trend toward designing landscapes within a health care setting begins with the intent to improve the overall quality of patient care and restorative benefits of plant/patient interaction. While every setting is unique, the American Horticultural Therapy Association published common characteristics of therapeutic landscapes in 1995. The AHTA identifies seven key characteristics:

  • Features are modified to improve accessibility. Alzheimer’s residents enjoy sitting on benches while they work with staff therapists. Wheelchair-bound patients may prune annuals in containers and are able to work with flowers on raised beds. Children also are able to work effectively from wheelchairs, digging in the soil of the various raised beds. The grade of the garden allows for challenge activities; spinal cord injury patients with greater upper extremity function are able to reach the top of the healing gardens, while frail elders may propel their wheelchairs independently only near the entrance to the garden.
  • Edges of garden spaces and special zones of activities within the garden are intensified to direct the attention and energies of the user into the garden.
  • A profusion of plants and people/plant interactions is essential. Lush, rich botanical collections with great variety are critical to therapeutic applications both in horticultural therapy and to those who use the garden independently.
  • Therapeutic goals focus on mobility, motor skills, social interaction, cognitive ability and emotional status. Restorative goals promote general well-being, with focus on play, relaxation, socialization, education and creativity.
  • Benign and supportive conditions are identifiable. Plants are selected for, among other characteristics, their disease and pest resistance, thereby avoiding potentially hazardous chemicals, pesticides or irritants. Shade is essential.
  • In the hospital garden setting, it is important to design and program for the widest possible range of user abilities. Therapeutic gardens commonly stimulate old memories as well as the full range of senses – hearing, touch, smell and sometimes taste – as necessary supplements to the visual experience.
  • Therapeutic gardens in the hospital setting should be simple, unified and in easily comprehended places.

Sterile installation and constant communication
Landscape contractors face unique challenges when installing the gardens. Most hospitals require retro-fitting to accommodate new garden design and existing space may be in the middle of a busy health care setting. You may have to work through issues such as infection and disease control, patient confidentiality while minimizing patient disruption.

Brian Bainnson, president of Portland, Oregon-based Quatrefoil, says the construction management part of a health care landscape project has unique challenges. “Because you are working around the constraints of sick patients, communication between the contractor and the client is crucial,” he says.

Bainnson installed the hardscape for a therapeutic garden in an existing courtyard at the Legacy Children’s Hospital in Portland. The pre-construction consultation included meeting with an infection control specialist, nurses, doctors and the medical official assigned to coordinate the project. Clear communication between the staff person and Bainnson’s team turned the potential for a negative patient/staff experience into a positive one for everyone concerned.

All tools had to be brought to the work site clean and wrapped in plastic. At the end of the day, equipment and tools were cleaned and shrink-wrapped to reduce the potential for infection and disease. Windows and doors were sealed to reduce dust and soil contamination potential.

Communication between the professional health care staff and workers included daily detailed explanations about the job. There were no surprises regarding noise or vibrations. Workers who had contact with patients were instructed not to interact with them unless the patient initiated contact. If the patients were interested, the workers then provided information and explanations about the work in progress.

Instead of a distressing, disruptive experience, Bainnson says that the opposite can occur with clear, upfront communication. “Many patients are energized by the construction process. They looked forward to seeing the progress of the job and become animated by the excitement.” During one health care job, he says he looked up and patients and their visitors were gathered in front of every window surrounding the courtyard – watching the site.

As the population ages, the niche for health care landscaping will continue to grow. But Bainnson says that while the business is steady and well-compensated, the emotional rewards more than compensate for the often complicated jobs. “There’s a lot of opportunity for work in health care. The key to success is open, clear communication between you and the client. It’s crucial to run a tightly organized operation with a neat clean construction site. Once you get your foot in the door, health care clients tend to be loyal to their contractors. Long-term opportunities for maintenance and future construction projects can lead to steady work.”

A growing market?
Epstein says post-occupancy evaluations of hospital gardens reflect the high value placed on access to the outdoors by not only patients but also staff and visitors. In contrast to the often sterile, intimidating interiors, a hospital garden represents hope and a sense of distance and escape from what can be an alarming, impersonal medical experience.

These rave reviews are not lost on marketing-savvy health care administrators. Lee Domanico, CEO of Legacy Health Systems says they’ve enjoyed rave reviews of the gardens by patients, visitors and staff. “In our philosophy of healing and optimal health, we strive to support the balance of physical, mental emotional and spiritual components for our patients, staff and visitors, family and community. Our healing gardens and horticultural therapy programs are invaluable tools for achieving these goals.”

According to Epstein the health care industry is avidly studying the hospitality industry and modeling marketing strategies on successful aspects of hotels and resorts including their landscape design. “As the population ages, even small retirement units are looking to incorporate healing gardens into their overall design.”

While the industry continues to study the benefits of therapeutic gardens, not all gardens are created equal. Some well-meaning designs may even harm patients. Dr. Ulrich used a post-occupancy evaluation to study an award winning courtyard garden in a well known hospital setting. His study found that the modern sculpture and artwork in the garden actually set back patients recovery. They were disturbed by what they perceived as sculptures symbolizing death. In general, therapeutic gardens are not good spaces for abstract art or experimental design. The overall goal is to promote serenity and to reduce stress and the design needs to be naturalistic and inspire hope and optimism. Because this is a fairly new field, rigorous scientific studies about the benefits of different aspects of therapeutic garden design is important to continue adding to the renewed interest in promoting well being and health through nature. The mainstream medical community’s interest continues to grow as evidence-based design leads the way in this specialized field.

Horticultural therapists such as Hazen are becoming strong partners in advocating for the creation of non-clinical healing spaces. The Chicago Botanic Garden offers a certificate program in health care garden design and members of ASLA are working to ensure inclusion of a therapeutic garden in the planned National Healthcare Museum in Washington, D.C.

While modern medicine continues its quest to cure and heal diseases of the body with advanced technologies and sophisticated pharmaceuticals, the interest in alternative therapies, holistic healing, exercise, mediation continues an upward swing in popularity. Ultimately, patient satisfaction and staff retention benefits will drive the demand for the stress-reducing, aesthetic nature of healing gardens in healthcare settings.

Elements of healing
Color: Warm colors like reds, oranges and yellows inspire optimism and energy while blues and greens create a sense of peace and harmony. Concrete hardscapes should be muted with earth-toned tints to reduce harsh glare.

Water: A babbling brook or fountain sooths the senses and calms anxiety.

Herbs: Many therapeutic gardens grow herbs and specimen plants known for their healing properties.

Shade: Shade and glare reduction enhances the enjoyment and restorative properties of a healing garden

Transition points: Well-lit, easily traversed pathways or shrubbery labyrinths create the “place-apart” ambiance.

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