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August 22, 2013

A Special Section of


Contractors can help with health care transition
Skanska USA

Pregnancy center offers one-stop care for new moms

Not all healing gardens deliver as advertised
By MARK EPSTEIN Hafs Epstein Landscape Architecture

Outpatient clinics multiply as big projects dry up

Workplace health clinics are making a comeback
McGranahan Architects

Integrated delivery pays off for Kirkland hospital

How buildings help with patient care

Children's addition built to be safe after an earthquake
Coughlin Porter Lundeen

August 22, 2013

Not all healing gardens deliver as advertised

  • A poorly designed garden may actually harm patients. Here's how to get it right.
  • mug
    Hafs Epstein Landscape & Architecture

    Stress is a known cause of both mental health disorders and cardiovascular diseases. Not only is stress an adverse outcome in itself, but it negatively influences a variety of other health outcomes.

    Gardens with particular characteristics have been shown to have positive effects in health outcomes, primarily through the facilitation of stress reduction.

    The benefits of properly designed gardens for reducing stress has tremendous health implications, and reducing stress has been shown in numerous studies to improve a number of health outcomes. There are at least 60 scientific studies that suggest contact with nature has numerous beneficial effects.

    Attention diversion, produced from contact with nature, has been clinically shown to improve pain alleviation. Nature has a direct effect, quickly reducing cortisol levels (a hormone produced by stress) in subjects, but it also provides a distraction that reduces the obsession of pain when undergoing medical procedures that produce pain or discomfort. Simply viewing nature has been shown to reduce agitation and aggression in mental health and emergency room departments.

    Three principles

    Gardens in health care have improved significantly and proliferated, and many health care grounds have evolved into functional spaces that provide intentionally restorative or therapeutic benefits. But not all gardens deliver as advertised.

    Some health care gardens featured in leading design magazines appear attractive in photographs, yet are missing elements and characteristics that optimize the health, safety, and welfare of the people that use them. Some gardens may actually be doing some harm, which is unacceptable in a medical setting.

    The following three general principles are essential for health care gardens to provide positive results:

    Photo courtesy of Hafs Epstein Landscape Architecture [enlarge]
    Harrison Medical Center in Bremerton has a 3,000-square-foot rooftop garden that serves its oncology department.

    Know the garden type. The term healing garden is an umbrella term commonly used in health care settings.

    Gardens cannot cure a disease or mend a broken bone, but gardens can facilitate stress reduction and foster healing, promote satisfaction with the health care system, and provide an environment of caring. Healing gardens are generally restorative places where physical, psychological and social benefits are derived from simply being in the garden.

    A therapeutic garden or enabling garden -- outdoor space designed to achieve specific medical outcomes -- requires greater design expertise, with specialized knowledge in environmental psychology, physical therapies and specific medical goals.

    Understand who will use the garden. Health care gardens, particularly therapeutic gardens, require a deeper understanding of the client groups that will use the space.

    Gardens in medical settings should be tailored to meet the particular needs of their specific patient and staff populations. This is best done in conjunction with an interdisciplinary design team that includes staff and administrators, and in some cases patients and their relatives.

    Gardens for dementia care, hospice, psychiatric treatment or senior care facilities will each look and feel different from one another, and should be based more on the needs and abilities of the users than abstract design principles.

    Integrate the garden with the building. Research reveals that 60 percent of hospital garden users are staff.

    Staff use health care gardens to find a moment of respite and escape from the stress of their jobs. Most garden users reported their primary activity in the garden was to simply relax (followed by eating and talking).

    Doctors and spiritual care frequently use a garden for difficult consults with family. Patients or family members use the garden to express difficult emotions that may feel uncomfortable in the hospital room or lounges. These uses require peaceful settings with opportunity for private conversation.

    Gardens that are not close enough to patient rooms or nurse stations inhibit garden use. Health care gardens have also been settings for weddings and special occasions, and for fundraising or community events. The garden is a normalizing element in an unfamiliar environment.

    Photo courtesy of Hafs Epstein Landscape Architecture [enlarge]
    Gardens are more likely to be used if they are located near patient rooms and nurse stations. Sixty percent of garden users are hospital staff.

    A mental escape

    Post-occupancy evaluations of hospital gardens have indicated the high value placed on access to the outdoors by staff, visitors and patients alike.

    Among the garden elements most valued are features that represent life and health, such as trees, plants and flowers, and elements that arouse the senses, such as fragrances, the sounds of birds and water, and the feel of sunlight or a gentle breeze.

    These elements represent a marked contrast to the beeping machines and smell of sanitizer found in most hospital interiors, providing a sense of distance or 'mental escape' and allowing for reflection and restoration. Gardens that have a ratio of greenery to hardscape of around 7-to-3 (70 percent nature to 30 percent paved area) seem to be preferred by most people.

    Other factors can limit the benefits of gardens. These include: lack of information on a garden's location and accessibility, insensitivity to specific patient mobility needs, intrusive sensory stimuli (noise, allergic pollens, and so on); lack of accommodation for competing user needs (such as smoking areas and the desire for fresh air), and design elements that evoke mixed or ambiguous interpretations (such as benches in a garden used by cancer patients that resemble tombstones, or sculptures in a children's garden that look like monsters).

    This last aspect is particularly significant in a medical setting, where the fragile emotional state of many users predisposes them to place negative meanings on many things except the most unambiguously positive stimuli.

    Research indicates that U.S. hospital workers are less healthy, consume more medical services, and accrue higher health care costs than the U.S. workforce at large. Much of the cause may be that hospitals are full of sick people, but how much healthier would staff be, and how many fewer medical errors would occur, if they had easy access to fresh air and a stress-relieving outdoor environment?

    We don't know yet, but since hospital staff are the biggest users of hospital gardens, and staff who use the gardens consistently report positive feelings about being there, it is well worth the effort to provide an appropriate garden, at least for staff.

    While almost any garden provides a connection with natural elements, a garden design created on evidence-based principles -- based on design, led by an informed designer and properly implemented -- can facilitate stress reduction and improve health outcomes.

    Mark Epstein is a principal of Hafs Epstein Landscape Architecture in Seattle. He is a board member and instructor of the Healthcare Garden Design Course at the Chicago Botanic Garden, and serves on the advisory board for the Therapeutic Landscapes Network.


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