June 1996
Flower Power
Publication: Health Facilities Management, Vol 9/6
Title: Flower Power
Author: Susan Edge-Gumbel
Edge-Gumbel, Susan, “Flower Power”, Health Facilities Management, June 1996, Vol. 9/6.
FLOWER POWER
The proper garden can cultivate a wealth of hospital benefits
BY SUSAN EDGE-GUMBEL
In this hectic, stressful working world, it’s no wonder that we gravitate toward nature when we plan our weekends or vacations. We like to hike in woods, climb mountains, head for beaches, or simply sit on a park bench. These experiences calm us, renew us, and give us hope and respite from our daily stresses. Simply being near nature can be very therapeutic.
The effect may seem intuitive, but researchers have tried to verify it. For example, a nine-year study by environmental psychologist Roger S. Ulrich concluded that patients recovered faster after gallbladder surgery and needed fewer painkillers if their hospital rooms had a natural view rather than one facing a brick wall. Preliminary results from similar studies with cardiac patients in intensive care are consistent with these findings.
Hospital employees also need the same restorative and healing environment to prevent burnout. A natural setting, like a garden, not only benefits patients and staff, but it can have a positive effect on the community, not to mention the hospitals’ public relations and marketing efforts. All of which means an improved environment of care and greater productivity important considerations in this competitive industry.
Relearning old lessons
The notion of nurturing the human spirit in concert with treating physical ailments is not new. Restorative courtyard gardens were used by European hospitals and monasteries in the Middle Ages to comfort and nurture patients, but the value placed on this natural healing environment began to fade by the 15th century. Although early 20th-century hospital practices included wheeling beds onto porches and roofs for fresh air, these practices later declined. With new technologies and rapid advances in science, the low-rise, pavilion-type hospital gave way to multistory complexes with elevators, air conditioning and viewless windows.
The design emphasis gradually shifted away from the patient’s connection to the environment and toward efficiency and time-saving measures that benefited clinicians. Indeed, the landscaping that remained, if any, was merely cosmetic and usually located near the facility’s entrance. The only outdoor experience afforded most patients and staff was the walk from the paved parking lot.
James Burnett, a Houston landscape architect, remembers the way health facilities developed in the 1960s and ‘70s: “There was no regard for open space,” he says. “We lost our connection to nature because we thought we could solve everything with technology. If a health facility is really community-minded, then the total environment should be about healing. A patient’s stay then becomes a holistic experience.
“Hospitals are very sacred spaces. You usually begin your life in a hospital and, for many, their lives end there.”
Burnett knows this only too well. His mother died of lung cancer four years ago in a hospital outside of Dallas. Her tiny room had an equally tiny window overlooking a graveled rooftop. During the months she underwent invasive procedures, she desperately missed her home with its view of a lake. As an architect, Burnett had always concentrated on landscaping for corporate office parks. But after his mother’s death he turned to designing landscapes and gardens for hospitals. “Gardens have a symbiotic relationship with healing and hospitals,” he says. “It’s important that I do something that talks to the nature of healing.”
Fruits of the garden
Even as they strive to remain competitive, hospitals face rising costs and increasing pressure to reduce lengths of stay. How can they justify the expense of creating or expanding gardens, and what are the benefits to patients and staff?
First, gardens don’t have to cost a lot of money. They can be interior or exterior, large or small, simple or complex, inexpensive or costly, low- or high-maintenance. And even the priciest ones can be justified by the many benefits – the first and most important being the benefit to patients. In a 1995 study, scholars at the University of California, Berkeley, found overwhelming evidence of the therapeutic effects of hospital gardens. Clare Cooper Marcus, a professor of architecture and landscape architecture at the university’s College of Environmental Design, and Marni Barnes, a landscape designer and social worker, set out to investigate the use and possible benefits of hospital gardens and to discover what qualities were most related to a change of mood. They looked at 24 hospitals, most of them in Northern California.
Ninety-five percent of the people they interviewed in hospital gardens reported a therapeutic benefit. Employees and patients’ families used a hospital’s outdoor spaces to reduce stress; after even a short break outdoors, they reported feeling calmer, more relaxed and more productive. Patients indicated feelings of rejuvenation and strength after spending time in a garden; they also felt they could better tolerate their medical procedures.
Barnes emphasizes that hospital CEOs and facility managers must realize the importance of exterior spaces: “They need to consider outdoor space in terms of healing.” Mona Gold, director of rehabilitative therapies at a Friends Hospital in Philadelphia, concurs. “CEOs and facilities need to make a commitment to the environment in which a patient lives, and that includes both indoors and outdoors. You don’t need a lot of dollars – you need a commitment to changing people’s lives.”
In addition to the healing, there are other, less obvious benefits to creating gardens at your health facility. Gardens are the ultimate public relations tool. At most hospitals, there is nothing extraordinarily unusual to see. But a garden is an exception. Fund-raising events can be held in gardens. Interviews with potential employees can be conducted in an atrium or greenhouse. Health fairs can use the outdoors to educate the public about the facility’s wellness and prevention programs. Television ads can be filmed with the gardens as a backdrop.
Friends Hospital has set up exhibits at the Philadelphia Flower Show to tell people about the hospital and grounds. It also opens its 99-acre grounds to the public in the spring so they can enjoy a spectacular 14-acre display of azaleas in bloom. The Friends Hospital Garden Club meets monthly to allow staff members, former patients and community members a chance to discuss topics related to horticulture.
Concerts, community meetings about social issues, recreational activities, barbecues and school health fairs also can be set up in the garden, allowing the public to see what the hospital has to offer. And gardens are a great way to recruit staff and volunteers. Tours of the hospital should always include the gardens.
Gardens help facilities tap into additional sources of grants and donors. The donor who gives money for hospital gardens is usually not the same one who donates funds for a new MRI. In fact, the funding for gardens and the funding for capital expenses generally come from vastly different sources. For instance, a family whose loved one dies in the hospital might give money to establish a memorial garden. An elderly gardener in the community with no living relatives may decide to bequeath money to the facility for new landscaping. Civic groups can be encouraged to donate a tree or shrub, a bench, flower pots, or a water fountain to offset expenses.
Gardens can bridge the gap between the community and the health facility. Because a garden is nonpolitical and nonthreatening, it can be a neutral meeting ground between community and facility leaders. A garden also can serve as neutral ground for staff and doctors. The setting helps keep attention focused on the problems or issues, not the hierarchy, and thereby increases employee morale.
Gardens can enhance the mission of the health care facility. At St. Michael Health Care Center in Texarkana, Texas, the gardens and landscaping “enhance the healing process form a holistic point of view,” says Sister Damian Murphy, director of mission effectiveness and pastoral care. “When you drive into the 60-acre hospital grounds, it’s like driving into a resort. It has ‘wellness’ written all over it. As soon as a patient sees the grounds, he knows he will be cared for.”
At St. Michael and elsewhere, gardens improve the physical and aesthetic hospital environment. Health facilities are alien places to people, whereas gardens are familiar and comforting. When patients are confined to their rooms, the gardens allow families and visitors a place to which they can relate, where they can lose their fears and compose themselves. They are equally important to the health and well-being of employees. They, too, must have opportunities to get away from the stresses of caretaking for a few minutes and rejuvenate.
How should your garden grow?
Whether outdoor garden spaces are created during new hospital construction or existing grounds are modified to accommodate gardens, here are some ways to make your garden a success:
Consider the use of outdoor spaces from the beginning of the planning process rather than as an afterthought. Make a conscious site selection for usable outdoor space. Many existing buildings have ample outdoor spaces that aren’t being utilized. And, be sure to consider the building’s orientation to the sun and prevailing winds.
Obtain input from the people who will use the gardens. Talk to patients, families and employees from each of the hospital’s units, including physical, occupational and horticultural therapists.
Define the psychological and physical needs of each user group. Alzheimer’s patients, for example, need a garden design that lets them explore without getting lost – its path must be circular. It is also helpful if the garden can be observed from the nursing station. Terminally ill patients have a strong need for meditative gardens. Stroke patients can regain strength and motor abilities by working in rehabilitative gardens as part of their physical therapy. Some medications taken by AIDS sufferers require that they stay out of the sun.
In short, give users lots of choices. Providing as many specialized spaces as possible to meet the needs ot patients and staff will mean high levels of internal and external customer satisfaction.
Choose a team of experts to plan and install the garden. Include an experienced landscape architect and a landscape contractor with references. They usually work closely with horticulturalists, nurserymen and arborists to ensure proper planting times for minimal stress to the plants. The landscape architect draws the landscape plan, specifying the total number of plants. He is responsible for knowing the cultural requirements of plants so that they are sited properly. All plant material should conform to the current issue of the American Standard for Nursery Stock published by the American Association of Nurserymen.
The landscape contractor usually provides all materials, labor and equipment to complete the work shown on the plans and specifications. He works with utility companies to locate utilities before digging, is responsible for relocating existing plant material before planting, and knows all underground features, including existing irrigation, septic systems, drainage systems, landscape lighting, and natural gas and security systems.
Before planting, a soil test should be done by a state laboratory or recognized commercial laboratory to determine if soil amendments are required. Once the installation is complete, the work should be inspected by the architect or the facility’s representative and given an initial acceptance. The standard warranty period for plant materials (excluding bulbs and annuals) is one year, beginning on the date of the initial acceptance. The contractor inspects the site periodically during this time to determine if maintenance is being performed correctly.
A garden should not be designed or installed without considerable thought about how it will be maintained. That includes sufficient funds, staff, training, equipment and plant replacement. Some facilities contract out all the maintenance; others place this groundskeeping responsibility under the supervision of the facility manager.
In Aurora, Ill., Copley Memorial Hospital contracts out all of its landscape maintenance. “The biggest benefit is that the crew can come in and more efficiently take care of maintenance than we can,” says Scott Fixmer, coordinator for security and grounds. “They do in half a day what it would take us a week to do.” The noise pollution levels and disturbance to patients are kept to a minimum, and the hospital doesn’t have to invest in expensive, heavy equipment and additional groundskeeping staff.
Other hospitals rely on local garden clubs and volunteers to maintain them. Because this involves the community, it can be a good service project. At San Francisco General Hospital, for example, the gardening staff contacted a local developmentally disabled group of teens and young adults to help maintain the grounds.
Regardless of the method used, landscape maintenance should be an ongoing responsibility. All services should be performed by trained personnel using current, acceptable, horticultural practices and in a manner that preserves the integrity of the original design.
Marcus and Barnes found that the very presence of gardeners on the hospital grounds was therapeutic to patients. “Gardeners themselves play an important but often unrecognized social role in the healing process,” Marcus says. “They said that patients not only inquire about the plants, but also vent some of their frustrations to the gardeners.”
Another important aspect of maintenance is disease and pest control. Good landscape architects incorporate into their designs disease- and pest-resistant plants that are well suited to the site. This reduces the necessity of synthetic chemical pesticides or synthetic fertilizers. Maintenance also includes lawn mowing, raking, aerating, fertilizing, watering and edging; weed control; tree and shrub pruning; spring and fall cleanup; mulching; seasonal color installation; and snow removal and salt applications.
Be aware of safety and security issues. All plantings should be done with security in mind. Avoid thick barriers near doorways or windows. Plantings should never impede walkway or parking lot lighting. Plantings on parking lot islands should be small so that driver visibility is unobstructed.
Another issue to keep in mind is the plant material itself. Choose plants that are not detrimental to humans, especially children. Avoid placing thorny plants in public areas. Trees such as hawthorns and prickly barberry shrubs are better placed in outlying areas.
A few plants are actually poisonous to humans. Choose specimens that are nontoxic, especially if an outdoor area has been designed specifically for families with children or for Alzheimer’s patients.
Make sure that the hospital’s gardens are located on visitor maps. This information should also be made available to patients when they register and employees when they are hired.
Encourage staff to share difficult news with patients in the garden. Nature can soften difficult news; it enables patients and families to focus on something other than their pain or anxiety. Plants aren’t the answer to personal problems or tensions, but seeing healthy, living plants can give people a sense of hope and energy to cope with challenges.
The ideal garden
Once you have made all these efforts, what qualities should your garden have?
Accessibility. A therapeutic garden should be accessible from many different entrances. It should have surfaces and contours that enable safe, free movement without barriers. It should also comply with the Americans with Disabilities Act.
Comfort and user-friendliness. A garden should include ample seating – both movable chairs and permanent benches with backs. This gives people some control by allowing them to move into or out of the sun, shade or breezes, to join others or to sit in solitude. It must have clear paths with clear destinations so that people can’t get lost, yet it should be balanced with a sense of mystery. Interpretive signs should provide plant identification and interesting facts.
Visibility. Not only should a garden be seen from a horizontal plane, but it should be visible from a higher elevation. Many hospitals are multistory buildings, and patients from various levels and sections of the facility should have visible well as physical access to the gardens.
Diversity of sensory input. A garden should provide as much sensory stimulation as possible and interest people on as many levels as possible. Gardens and outdoor spaces can appeal to all the senses at once. The more diverse the plantings, the more diverse the wildlife that will be attracted to the garden, offering even more sensory stimulation. Plants should vary in height, blooming time, texture, color and fragrance, and should provide three- or four-season interest.
Sounds are also important, especially to AIDS sufferers, who lose a lot of visual activity. David Kamp, who designed the Joel Schnaper Memorial Garden for a 156-bed AIDS care unit at New York City’s Terence Cardinal Cooke Health Care Center, says that water fountains play an important role in gardens because of their soothing sounds.
Design variety. A therapeutic garden, regardless of size, needs a clear definition of where it begins and ends, and each space should offer functional and aesthetic variety. A facility’s garden can be made up of many such spaces: a somewhat private space that allows for contemplation and reflection, a space that suggests walking, a space that gives shelter from the sun and wind, or a wide-open space that encourages social activity. Designers should take advantage of vertical as well as horizontal space. Using trees, climbing plants and vines adds layers of dimension and maximizes the space available.
Difference from interior. A variety of plant material, differences in temperature, sounds associated with nature, patterns of sunlight, and spatial relationships all blend to create an environment that contrasts sharply with the sterile environment of the hospital. Patients lose their sense of direction and time the longer they are hospitalized. Having contact with nature helps put everything back in order.
Susan Edge-Gumbel is a part-time gardener at home and a full-time graphic designer for American Hospital Publishing, Inc.
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