Therapeutic Garden - garden in hospitals and other health care setting
Authors: Thaneshwari, Pooam Kumari, Narendra Singh Bhandari


1. Therapeutic Garden

A therapeutic garden is designed for use as a component of a treatment program such as occupational therapy, physical therapy or horticultural therapy programs and can be considered as a subcategory of a healing garden. A garden can be described as being therapeutic in nature when it has been designed to meet the needs of a specific user or population. It is designed to accommodate client treatment goals and may provide for both horticultural and non-horticultural activities. It should be designed as part of a multi-disciplinary collaborative process by a team of professionals. A therapeutic garden may exist on its own as an extension of an indoor therapeutic program area or it may be part of a larger healing garden (Anonymous, 2012). These gardens are less focused on healing in a spiritual context (although it may have that effect) and more focused on ameliorating a disease.

2. Benefits of gardens in hospitals and other health care setting

It has been shown that stress can increase viral replication and decrease the effectiveness of antiviral drugs in HIV disease (Cole et al., 2001). Several studies of non patient groups as well as patients have consistently shown that simply looking at environments dominated by greenery, flowers or water as compared to built scenes lacking nature (rooms, buildings, towns) is significantly more effective in promoting recovery or restoration from stress (Ulrich, 1999). In the case of hospitals and other healthcare facilities, there is mounting evidence that gardens function are especially effective and beneficial settings with respect to fostering restoration for stressed patients, family members and staff (Ulrich, 1999). A study of a garden in a children’s hospital identified mood improvement and restoration from stress as primary benefits for users (Whitehouse et al., 2001). Horticultural therapy or therapeutic gardens are also effective in decreasing the levels of anxiety, depression and stress among persons with psychiatric illness (Michael and Andrew, 2010).

It has been known for decades that healthcare occupations such as nursing are stressful because they often involve overload from work demands, lack of control or authority over decisions and stress from rotating shifts. Workloads and pressures have mounted further, however, as healthcare providers everywhere have been forced to control or cut costs. These conditions have in many locations lowered lower job satisfaction, increased absenteeism and turnover, contributed to shortages of qualified personnel, increased providers’ operating costs and eroded the quality of care that patients receive. These serious staff related problems imply major importance for the aforementioned finding that healthcare staff heavily uses gardens for positive escape from workplace pressures and to recuperate from stress. Additionally, it should be emphasized that evidence has begun to appear showing that hospital gardens increase staff satisfaction with the workplace and may help hospital administrators in hiring and retaining qualified personnel (Whitehouse et al., 2001).

Findings from a few studies focusing on hospitals and other healthcare facilities suggest that views of nature can have important benefits in terms of improving patient clinical outcomes. A medical outcomes study compared the recovery records of gall bladder surgery patients who had a bedside window view of either trees or a brick building wall with no nature (Ulrich, 1984). The outcomes data showed that those with the nature view, compared to those who looked out at the wall, had shorter hospital stays and suffered fewer minor post-surgical complications (such as persistent headache or nausea). Further, patients with the view of trees more frequently received positive written comments from staff about their conditions in their medical records (“patient is in good spirits”). Those in the wall view group, however, had far more negative evaluative comments (“patient is upset,” “needs much encouragement”). Another major difference was that persons with the view of trees, compared to the wall view patients, needed far fewer doses of strong narcotic pain drugs. The above findings not only indicated that views of nature in hospitals could enhance clinical or medical outcomes; as well, the results suggested that nature could improve economic outcomes by reducing the costs of care. The findings clearly implied that by providing nature it would be possible to achieve cost savings, for instance, because length of hospital stays might be shortened and some patients would have reduced need for costly injections of strong pain drugs.

3. Design principles in therapeutic landscapes/ therapeutic gardens

“Therapeutic Landscape Design” is more specific and relates to a particular aspect of a disease or healing process. The Therapeutic Landscape is designed to produce a given effect and measurable outcome upon a disease process within a given patient and/or group of patients. It can be thought of as similar to a medication taken for a specific disease or illness. The Therapeutic Landscape is thus less focused on healing in the spiritual context and more akin to the disease model of illness as practiced in most allopathic medical systems. Numerous healthcare institutions within and outside the United States have begun to incorporate therapeutic landscape design. As Cooper-Marcus and Barnes have noted in their book “Healing Gardens: Therapeutic Benefits and Design Recommendations” (1999), these gardens focus on providing stress relief, alleviation of physical symptoms and improvement in the overall sense of wellness for both patients and healthcare staff. Successful gardens include the following design principles:

3.1.Variety of spaces: There should be space for both group and solitary occupancy. By providing a variety of spaces, the patient is given choices, thus providing an increased sense of control leading to lower stress levels. An area for solitary occupancy allows one to “get away” from the sterilized environments of the hospital. Areas for small groups (e.g., family members or support staff) to congregate provide social support to the patient.

3.2. A prevalence of green material: The goal would be to minimize hardscaping to only one-third of the space being occupied.

3.3. Encourage exercise: Gardens that encourage walking as a form of exercise has been correlated with lower levels of depression. When setting up the design principles, it is essential to base them on the premise that the hospital outdoor spaces need to accommodate various types of activities and experiences which are in a close relation to the users' particular needs. In brief, they should be planned according to following requirements: (1) to create opportunities for movement and exercise. (2) to offer a choice between social interaction and solitude. (3) to provide both direct and indirect contacts with nature and other positive distractions

3.4. Provide positive distractions: Natural distractions such as plants, flowers and water features decrease stress levels. Other activities such as working with plants and gardening can also provide positive distractions in the garden setting.

3.5. Minimize intrusions: Negative factors such as urban noise, smoke and artificial lighting should be minimized in the garden. Natural lighting and sounds are additive to the positive effects of the garden.

3.6. Minimize ambiguity: Abstract environments (i.e., those with a high sense of mystery or complexity) can be interesting and challenging to the healthy, but to the ill they may have counter-indicated effects. Numerous studies show that abstraction in design is not well tolerated by persons who are ill or stressed. Clearly identifiable features and garden elements should be incorporated into the design.

4. Design elements in the therapeutic garden

In the book “The Sanctuary Garden” by C. Forrest McDowell and Tricia Clark-McDowell (1998), they say, “the key to a healing garden is to honor and celebrate our broader human relationship with nature and spirit, not just plants.” The design elements for therapeutic and healing gardens are:

  • A special entrance that invites and embraces the visitor into the garden
  • The element of water for its psychological, spiritual and physical effects
  • A creative use of color and lighting (be they plant or human-designed light sources) to elicit emotion, comfort and/or awe in the visitor
  • The emphasis of natural features as grounding points, such as the use of rocks, wood, natural fences, screens, trellises, wind and sound etc.
  • The integration of art to enhance the overall mood/spirit of the garden
  • Garden features that attract wildlife and provide habitat to a diversity of wildlife
5. List of useful plants for therapeutic garden

Plant help in enhancing the sense of smell to relax and reminisce: Lavendula officinalis, Rosa damascene, Mathiola incana, Centaurea cyanus (scented flowers). Lonicera japonica, Hiptage benghalensis, Solanum jasminoides, Trachelospermum jasminoides, Quisqualis indica, Tecoma jasminoides (scented Climbers). Abelia x grandiflora, Gardenia jasminoides, Cestrum diurnum, Murraya exotica, Jasminum sambac, Cestrum nocturnum (scented shrubs). Solanum lycopersicum, Fragaria x ananassa (sweet scented fruit). Thymus vulgaris, Lavendula officinalis (sweet scented herbs).

Plant help in enhancing the sense of sound to calm the nerves: Bamboos, Magnolia grandiflora, Peltophorum ferruginium, Platanus orientalis, Musa paradisiaca ,Sweet corn (rustle in the wind), Lavendula officinalis (attract buzzing bees).

Plant help in enhancing the sense of taste increasing our enjoyment of food and drink: Fruit and vegetables, Ornamental plums, Ornamental Peaches , Ornamental Cherry, Tropaeolum majus, Ocimum sanctum, Passiflora sp., Solanum lycopersicum, Fragaria x ananassa.

Plant help in enhancing the sense of sight to bring visual pleasure: Using different textures and colours of plants such as those with large leaves, curled stems and favourite colours.

Anti-stress herbs : Lavandula officinalis, Ocimum sanctum, Valeriana officinalis , Passiflora sp., Rosemarinus officinalis , Melissa officinalis, Matricaria recutita, Piper methysticum.

Plant with a higher phytoncide emission : Pinus roxberghii, Quercus spp.

References:

Anonymous, 2012. American Horticultural Therapy Association Definitions and Positions. AHTA. ahta. Org/ sites/ default/ files/ Defination and Position. Pdf

Cole, S. W., Naliboff, B. D., Kemeny, M. E., Griswold, M. P., Fahey, J. L. and Zack, J. A. 2001. Impaired response to HAART in HIV-infected individuals with high autonomic nervous system activity. Proc Natl Acad Sci USA.98: 12695-700

Cooper-Marcus, C. and Barnes, M. 1999. Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: John Wiley & Sons.

Michael, C. Y. Kam, and Andrew, M. H. Siu. 2010. Evaluation of a horticultural activity programme for persons with psychiatric illness. Hong Kong Journal of Occupational Therapy. 20(2): 80-86

Ulrich, R. S. 1984. View through a window may influence recovery from surgery. Science.;224: 420-421

Ulrich, R. S. 1999. Effects of gardens on health outcomes: Theory and research. In : Cooper-Marcus C & Barnes M. Eds. Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: John Wiley. pp. 27-86

Whitehouse, S., Varni, J. W., Seid, M., Cooper-Marcus, C., Ensberg, M. J., Jacobs, J. J. and Mehlenbeck, R. S. 2001. Evaluating a children's hospital garden environment: Utilization and consumer satisfaction. Journal of Environmental Psychology 21: 301- 314



About Author / Additional Info:
I am currently pursuing Ph.D. in Floriculture and Landscape Architecture from IARI, New Delhi