Healing or Restorative Gardens
Elaine Sims
Director, Gifts of Art
University of Michigan Health System
The Resurgence of Healing Gardens
Restorative Gardens--also referred to as Healing or Contemplative Gardens--have a long history of association with hospitals dating back to the Middle Ages in Europe. They flourished in the Middle Ages, suffered decline with the advent of the plague and the Renaissance, and made a comeback in the eighteenth and nineteenth centuries with the Enlightenment and growth of Romanticism. In most of the 20th century gardens disappeared as medicine became increasingly scientific and focused on cure, not care. Gardens are enjoying a renaissance in the 21st century as hospitals and healthcare centers are seeking ways to enhance the environment of care for their patients, visitors and staff. There are many factors driving this new popularity including competition for patients, the current reliance on patient satisfaction surveys, the proven correlation between staff satisfaction and patient satisfaction, and the costly issues of staff retention. Overall, there is a new aesthetic defining how healthcare centers and hospitals should look and feel.
There have been many new hospitals built beginning in the late 1970’s that replaced older out-dated facilities from the early 20th century. The older of these facilities have aged to the point where entrances are being redesigned and additions built. There is also a trend to build free-standing comprehensive medical centers such as cardiovascular, cancer, pediatric, geriatric, women’s, integrative and so on. A time of remodeling or new construction is the ideal time to design and create garden spaces. It is typically the most cost-effective time to do so. As a result, we are seeing more healing gardens in the plans for these new facilities. In some cases, they are the focal point for the building.
A Healing Garden is a natural extension of a hospital or healthcare center’s mission of care. The effects of nature and the built environment on health and well-being is a rapidly growing area of study, one that has caught the attention of the Joint Commission on the Accreditation of Hospitals and Health Care Organizations (JCAHO). The Joint Commission updated its accreditation standards, which became effective January 1, 2001, to include elements of a supportive environment that are consistent with a healthcare center’s mission and vision, and with the cultural background, age and cognitive abilities of the patients served. JCAHO recognizes orientation and access to nature and the outdoors as key elements that can be significant in their ability to positively influence patient outcomes and satisfaction. A facility’s environment should also support the development and maintenance of the patient’s interests, skills and opportunities for personal growth. Effective management of the environment of care includes using processes and activities to maintain an environment which is sensitive to patient needs for comfort, social interaction, positive distraction, and self-control, and which minimizes unnecessary environmental stresses for patients, visitors and staff.
The Argument for Healing Gardens
There is an increasing awareness of the beneficial effects of nature and gardens in healthcare settings. A landmark study in the 1980’s by Dr. Roger Ulrich at Texas A&M demonstrated that patients having a view to nature through a window had statistically significantly shorter hospital stays than patients who did not. Indeed, Drs. Rachel and Stephen Kaplan, two pioneers in environmental psychology, also conclude that it is not essential to be in the setting to benefit from the effects of nature. (With People in Mind) Many studies have demonstrated the nearly immediate affects of nature in reducing blood pressure and other indicators of stress. Other studies are in progress to determine the effects of being in nature on clinical outcomes. For example, Dr. Bernadine Cimprich of the University of Michigan is studying the effects of nature on breast cancer patients under a 5-year NIH grant.
Nature is understood to have restorative qualities. Nature allows for what is called undirected attention, which is a balm for the mind, especially for the stresses of modern life and other conditions like illness. Dr. Cimprich has demonstrated that such periods of undirected attention result in students scoring higher on subsequent cognitive tests. The Kaplans believe that “natural settings are particularly effective for R & R. They do not have to be dramatic. It is not essential that one is in the setting. Even a very short exposure can be helpful. Restorative benefits can be achieved even if that was not one’s intention. One does not necessarily realize the gains immediately.” (With People in Mind)
While all of nature can be perceived as having some degree of restorative powers, a healing garden is more than mere landscaping. It has specific requirements. It must reflect and further the mission of the healthcare facility of which it is a part. Landscape architect Clare Cooper Marcus, who has written several books on healing or therapeutic gardens, lists twelve elements of healing gardens which she believes are essential:
- Visibility
- Accessibility
- Security
- Comfort
- Familiarity
- Quiet
- Exercise and Movement
- Social Support
- Reflective/Meditative
- Sheltered
- Natural distractions
- Views to nature
In a book she co-authored with Marni Barnes entitled Gardens in Healthcare Facilities: Uses, Therapeutic Benefits and Design Recommendations, the authors found that 95% of those spending time in hospital gardens reported a therapeutic benefit from doing so. “Employees said they were more productive, patients spoke of feeling better and having more tolerance for their medical procedures, and friends and relatives felt relief from the stress of the hospital visit.”
Dr. John Zeisel, a sociologist, is an expert in environmental design for therapy and healing. His particular interest is Alzheimer and dementia patients, but his findings apply to the general population as well. He says that emotional memory remains in Alzheimer patients. He is involved in the research and design of gardens in Alzheimer facilities. He theorizes that nature enables the brain to function better. For example, Alzheimer patients lose social norms and impulse control. But when put in social situations, they tend to behave normally. He uses gardens and the environment to create a social setting. Patients extract emotional cues from nature that aid in communication. Gardens he has designed incorporate horticultural therapy which aids in the competency for carrying out daily life chores. He also creates safe garden spaces that allow for wandering with visual cues and landmarks for comfort and ease of circumlocution.
Health and Safety Issues
Health and safety issues must be considered in the selection of plant materials and in the physical design of the garden space. It should be understood that at this time there are essentially no regulations regarding gardens in health care centers. Even institutions with gardens do not always have guidelines or policies for their use. This is an emerging field and for now the best course is to check with local experts. A physician in infectious disease will have guidelines or informed opinions about the uses of gardens for patients with immunosuppressed systems or other special needs. Things to consider would be exposure to bee stings and whether to use or where to place flowering plants. Bird droppings are another health concern. When a building is surrounded by gardens, the ventilation system should be checked for air from the garden containing aspergillus, a fungus found commonly in soil. It can be quite dangerous to patients with immunosuppressed conditions. Water features must be carefully evaluated in the light of Legionnaires disease. A horticulturist should review the plant materials for toxicity and eliminate any poisonous plants from the garden. Thorns and prickers should not be in areas patients can reach into. Aging eyes and illness can change the perception of colors. Scents can also be pleasant or noxious. Sun sensitivity should also be a consideration. Areas of shade, dappled sunlight and full sun would be ideal. Common allergies should be considered. A horticulturist can advise on such issues as well.
Physical safety issues can be reviewed by experts in physical medicine, gerontology and landscape architecture. There are ADA guidelines and regulations for accessibility and smooth and non-slip surface design as well as seat and raised garden bed heights. Ease of entrance into and exit from the garden as well as seating configurations should be carefully considered. Sight lines and placements are critical for creating a sense of comfort and security as well as interest and engagement. Seating should allow for ease of sitting down and getting up. Seating material should also be carefully considered for maintenance, durability, comfort, and cleanability. If the garden is intended for hortocultural therapy, a hortocultural therapist will provide the input and sources you need to create a safe and sucessful environment for patients.
Funding
Garden projects attract support. In addition to champions, there are various sources of funding available. Some gardens are donor financed, others are combinations of grants, gifts and facility capital expenditures. There are grants available to promote the use of native plants and environmental sustainability, all of which are appropriate in a low-maintenance restorative garden. There are foundations that support humanities in medicine. Oftentimes the hospital foundation or Friends organizations champion such special projects that provide direct patient benefits. The development office of your institution may help you identify donors—and if you are fortunate, woo them for you. Some facilities build the costs into their budget. This is especially true at times of new construction or when remodeling.
One critical factor to build into the project from the beginning is maintenance funding. Many donors will fund gardens, but without funding for on-going maintenance and upkeep, the project is doomed. If the proposed site is currently landscaped, it probably has a maintenance budget. That may suffice. Low maintenance native plantings help keep the existing budget sufficient. There are gardens with donor-established trust funds specifically assigned for maintenance.
Getting Started
There are many new books available about healing or restorative gardens. A web search will also reveal good information. There are landscape architects who specialize in the field, and others who are interested in the challenge. Seminars and workshops are offered at several botanical gardens across the country. A few universities offer courses in the field, such as the University of Virginia in Charlottesville. There is a new certificate program at the School of the Chicago Botanic Gardens. The Society for Arts in Healthcare offers a consultant service for many topics including Healing Gardens.
The first step should be to create a mission statement for the proposed garden. The following recommendations are general and have been successful in creating a healing garden, but every institution is different. Any department can serve as the project lead, even fledgling arts programs, but typically a garden project will be carried out through facilities departments and construction services. The Kaplans recommend “start early and involve many.” The broader the base of support, the better.
Gardens tend to be magnets for generosity of spirit and support. A healthcare center or hospital usually has all the right people for generating internal as well as external support. Everyone knows someone useful to the cause, be it a landscape architect, master gardener, environmental psychologist—or whomever. Form a consortium of all the people who will be needed to make the garden a reality. Get them on-board early. Clarify your mission and goals and write a proposal. Use your proposal to generate institutional support. To raise funds you will need a concept plan or drawing and a tentative budget. The more work you and your committee do up-front, the less you will do later on.
Once you have the green light from your institution and have secured funding, the actual design can take place. Don’t forget to include the end-users in your planning. The Kaplans and others are strong proponents of user input in the design of outdoor and natural spaces. They believe in starting early and continuing through to post-construction feed-back. Their theories are based on their understanding of preference. For them “preference is intimately tied to basic concerns. We see preference as an expression of underlying human needs. Preference can be expected to be greater for settings in which an organism is likely to thrive and diminished for those in which it may be harmed or rendered ineffectively.” (The Experience of Nature) The patient population at a health care center can be a challenging one from which to elicit preference information. But coupled with that of the experts, family members and staff, useful information can be obtained. A survey of users, including patients, visitors and staff, is often very informative. It is important to bear in mind that questions should not be asked about things that cannot be changed, only those things for which feedback can make a difference. Even when a proposed garden is restricted by size, location and funding, preference input could focus on areas such as plant materials, seating and design.
Don’t be shy about calling on experts locally or across the country for guidance or advice. Be prepared to raise more money or alter the design. Projects very easily go overbudget, not least because the concept drawing and tentative budget are generated before there is an actual design. Try to negotiate for additional support in your funding requests. There are many ways to meet this challenge, so be prepared and don’t let it derail the project. Check your design as you develop it to make sure it still meets your goals and addresses all the various issues of accessibility, comfort, safety, security, maintenance, etc.
Once your garden is completed, don’t forget to celebrate and dedicate it. Consider appropriate signage and printed materials so that patients, visitors and staff know about the garden, can find it and enjoy it’s peace and tranquility, whether as a view through a window or a moment or longer within it’s sheltering spaces.