Healing by Design: Healing Gardens and ... - InformeDesign

ImplicationsVOL. 02 ISSUE 10www.informedesign.umn.eduA Newsletter by InformeDesign. A Web site for design and human behavior research.IN THIS ISSUEHealing by Design:Healing Gardens andTherapeuticLandscapesHealthcare Costs andEnvironmental DesignRelated ResearchSummariesHealing by Design: HealingGardens and TherapeuticLandscapesSteve Mitrione, MD, MLAJean Larson“Quality of life,” “well-being,” and “healing”are phrases that embody conceptsbeing recognized with increasing importancein the 21st century. Healthcarecosts are climbing. Also, in today’s culturewe as individuals are having moredemanded of each of us to meet expectations—ours,our family’s, and ouremployer’s/employee’s. Stress or associatedillness can be an outcome. As aresult, non-traditional alternatives arebeing considered as possible healthfuloptions. This issue of Implications illustratessome not-so-new concepts thatare gaining renewed acceptance as viableoptions for consideration.Plant Usage in Healthcare:Past, Present, and FutureWithin the last 20 years there has beenrenewed interest in the role of designednatural environments and health.However, the importance of natural environmentsto health is ancient. The use ofthe garden as a place for healing can betraced back to early Asian, Greek, andRoman cultures.For example, the Chinese wrote the “PenTs’ao”—the oldest list of medicinal herbsknown - on silk in 3000 B.C. The Greekscreated healing temples for their gods.The temple for the god Aesclepius (god ofhealing) was built in pastoral settingswith mineral springs, bathing pools,gymnasiums, and healing gardens. Herepeople would come to worship, lodge,recreate, and heal. In the 1st-centuryA.D., Dioscorides, a surgeon in theRoman Army, recorded the “De MateriaMedica,” including 950 curative substancesof which 650 are herbal. Themanuscripts included drawings, descriptions,and medicinal qualities of plants,methods of preparations, and contraindicationsand warnings (Gerlach-Spriggs, et al., 1998).Presently, hospitals and healthcare institutionsoften keep up extensive gardensand landscapes as an important part ofhealing. However, over the last 50 yearswith the rapid growth of medical technologyand economic pressure, this ancientconcept has been neglected. In theUnited States, healthcare reform hasprompted our public officials and healthcareadministrators to measure successby the length of time spent in the hospital(shorter being better) and the efficiencyof service delivery (Beal, 2004).

ImplicationsDespite a long history in healthcare, the effects ofnatural environments on health have only beenrecently systematically studied. Since the mid-1980s, an integrated approach to medicine hashelped reawaken the belief that gardens can play asignificant role in the healing process. Perhaps thebest-documented study to date is that of surgicalpatients and their access to views to the outsideworld conducted by Roger Ulrich in 1984. This studydemonstrated a relationship between the duration ofhospitalization, pain medication usage, and the abilityto view nature through a hospital window. Basedon the findings of Ulrich’s study, patients with accessto a view recovered faster and needed less pain medicationto do so—a winning outcome for both thepatient and the facility.Healthcare institutions are increasingly recognizingthe need for exposure to natural environments withinthe context of healthcare. The Joint Commissionfor the Accreditation of Hospitals Organization(JCAHO) has stated, “Patients and visitors shouldhave opportunities to connect with nature throughoutside spaces, plants, indoor atriums, and viewsfrom windows” (1999).Unfortunately, most of our information regardingnatural environments and healthcare is anecdotal. Itremains difficult at present to make firm recommendationsfor the precise design of landscapes to promotehealth and healing. Also, the needs of specificpatient populations are unknown. Does one designcure all, or are different designs needed for differentconditions? Moreover, what features of the designmight be positively influencing patient outcomes?These questions have gone unanswered.Design Principles in Therapeutic LandscapesAn emerging area of research and design focus withinlandscape architecture has sought to address therelationship of designed natural environments towww.informedesign.umn.edu2health and healing. As landscape architectureincreasingly addresses the interface betweendesigned natural environments and health, confusionhas developed regarding various terms appliedto this concept.“Healing gardens” is a term frequently applied to gardensdesigned to promote recovery from illness.“Healing,” within the context of healthcare, is a broadterm, not necessarily referring to the cure from agiven illness. Rather, healing is seen as an improvementin overall well-being that incorporates the spiritualas well as the physical.Therapeutic landscape designed for people with vision loss,outside London, England.“Therapeutic Landscape Design” is more specific andrelates to a particular aspect of a disease or healingprocess. The Therapeutic Landscape is designed toproduce a given effect and measurable outcome upona disease process within a given patient and/orgroup of patients. It can be thought of as similar to amedication taken for a specific disease or illness. TheTherapeutic Landscape is thus less focused on healingin the spiritual context and more akin to the diseasemodel of illness as practiced in most allopathicmedical systems.Where Research Informs Design ®

ImplicationsNumerous healthcare institutions within and outsidethe United States have begun to incorporate therapeuticlandscape design. As Clare Cooper-Marcusand Marni Barnes have noted in their book HealingGardens: Therapeutic Benefits and DesignRecommendations (1999) these gardens focus on providingstress relief, alleviation of physical symptoms,and improvement in the overall sense of wellness forboth patients and healthcare staff. Successful gardensinclude the following design principles:1. Variety of Spaces: Spaces for both group andsolitary occupancy. By providing a variety ofspaces, the patient is given choices, thus providingan increased sense of control leading to lowerstress levels. An area for solitary occupancyallows one to “get away” from the sterilized environmentsof the hospital. Areas for small groups(e.g., family members or support staff) to congregateprovide social support to the patient.2. A Prevalence of Green Material: Hardscaping isminimized and plant materials dominate the garden.The goal would be to minimize hardscapingto only one-third of the space being occupied. Itis through the softening of the landscape patientscan feel an improvement in their overall sense ofwellness.3. Encourage Exercise: Gardens that encouragewalking as a form of exercise have been correlatedwith lower levels of depression.4. Provide Positive Distractions: Natural distractionssuch as plants, flowers, and water featuresdecrease stress levels. Other activities such asworking with plants and gardening can also providepositive distractions in the garden setting.www.informedesign.umn.edu35. Minimize Intrusions: Negative factors such asurban noise, smoke, and artificial lighting areminimized in the garden. Natural lighting andsounds are additive to the positive effects of thegarden.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-indicatedeffects. Numerous studies show that abstractionin design is not well tolerated by persons who areill or stressed. Clearly identifiable features andgarden elements should be incorporated into thedesign. Abstract art in the facility and garden isoften inappropriate.Healing garden entrance with arbor at Cortesia’s HealingSanctuary in Oregon.Design Elements in the Healing GardenWhereas the Therapeutic Landscape Design is morespecific and relates to a particular aspect of a diseaseor healing process within a given individual and/orgroup, the healing garden is a term frequentlyapplied to gardens designed to promote improvementin overall well-being that incorporates the spiritualwithin the healing process.Where Research Informs Design ®

ImplicationsIn the book The Sanctuary Garden by C. ForrestMcDowell and Tricia Clark-McDowell (1998), theysay, “…the key to a (healing garden) is to honor andcelebrate our broader human relationship withnature and spirit, notjust plants.” TheMcDowells proposedSitting bench at Cortesia’sHealing Sanctuary in Oregon.seven design elementsas a guideline for designand as a means to identifythe intention of thespace, that is, a marriagebetween the gardenkeeper and thespirit of nature. Theseven design elementsare:—A special entrance that invites and embraces thevisitor into the garden—The element of water for its psychological, spiritual,and physical effects—A creative use of color and lighting (be they plantor human-designed light sources) to elicit emotion,comfort, and/or awe in the visitor—The emphasis of natural features as groundingpoints, such as the use of rocks, wood, naturalfences, screens, trellises, wind, sound, etc.—The integration of art to enhance the overallmood/spirit of the garden—Garden features that attract wildlife and providehabitat to a diversity of wildlifeOverall, the healing garden design should comfortthe soul and renew the spirit—no matter if it consistsof a bench next to a tree or an intricately designedlandscape. Of greatest importance is the intention ofhonoring the design element and its relationship tothe spirit of nature.www.informedesign.umn.edu4DefinitionsAllopathic Medicine: theory of treatment that isbased on germs causing disease. Allopathic treatmentis a system that seeks to cure a disease by producinga condition different from or incompatiblewith the effects of the diseasePsychoneuroimmunology: focuses on the correlationbetween stress and healthReferences—Beal, H., (2004). “Natural Healing.” ArchitectureMinnesota, 30, p. 48-53.—Bilchik, G. (2002, August 12). “A Better Place toHeal.” Health Forum Journal.—Coile, R., Jr. (2002, July-August). “Competing byDesign: Healing Environments Attract Patients,Reduce Costs and Help Recruit Staff.” ThePhysician Executive, p.12-16.—Cooper-Marcus, C., & Barnes, M. (1999). HealingGardens: Therapeutic Benefits and DesignRecommendations. New York: John Wiley & Sons.—Gerlach-Spriggs, N., Kaufman, R., & Warner, Jr.,S. (1998). Restorative Gardens: The HealingLandscape. New Haven, CT and London: YaleUniversity Press.—McDowell, C. F., & McDowell, T. C. (1998). TheSanctuary Garden. New York: Fireside Books.—Joint Commission for the Accreditation ofHospitals Organization. (1999). “Management ofthe Environment of Care,” ComprehensiveAccreditation Manual for Hospitals. www.jcaho.org.—Tieman, J. (2001). “Healing through Nature,”Modern Healthcare, 31(2), p 34-36.—Ulrich, R. (1984). “View Through a Window MayInfluence Recovery from Surgery.” Science, 224, p.420-421.Where Research Informs Design ®

ImplicationsHealthcare Costs andEnvironmental DesignJean LarsonMary Jo Kreitzer, Ph. D.Despite an increase in scientific research to supportbenefits of healing environmental design, few healthcarefacilities seem to be inclined to include therapeuticgardens or any other access to nature in theirremodeling or new construction design. In 2002, only20% of hospitals include healing environmental factorsin their construction plans (Bilchik, 2002).However, evidence-based design supports therapeuticenvironments decreasing health care costs. Forexample, Derek Parker (1991) estimated the cost savingsfrom better-built healing environments (i.e.,with shorter stays, drug savings, and labor costs) at$10 million per year for a 300-bed hospital. Parker’s$10 million estimate of the annual impact of a betterbuilthealing environment could be upwards of $15-$20 million in today’s dollars (Coile, 2002).Also, in 1998, researchers at the Johns HopkinsUniversity prepared a comprehensive review of 84studies about the impact of the health care environmenton patient outcomes. Results indicated thatpatients who were happier with their healthcare environmentused fewer strong medications, were easierto care for, returned to their homes sooner, and recommendedthe hospital to others (Coile, 2002).In the competitive market of healthcare the messageis clear: it is to the advantage of the healthcareadministrator to provide an environment that is welcomingto patients as it improves quality of life andsupports families and employees, or else, suffer theeconomic consequences (Tieman, 2001).www.informedesign.umn.edu5“Healing by Design” Lecture SeriesThe Center for Spirituality and Healing (CSH; est.1995), is charged with integrating complementary,cross-cultural and spiritual aspects of care into theeducation, research and clinical care programs of theUniversity of Minnesota’s Academic Health Center.This is accomplished by teaching healthcare professionals,students, and the greater community aboutthe interconnectedness of body-mind-spirit and thevital role that world culture and spirituality play inachieving optimal health and well-being.In February, 2005, the University of Minnesota willbegin hosting a lecture series entitled Healing byDesign: Therapeutic Health Benefits throughLandscape, Garden, and Interior Design. Leadingprofessionals will share their knowledge and insightgenerated from the fields of environmental psychology,neurosciences, medicine, therapeutic horticulture,clinical psychology, evolutionary biology, andpsychoneuroimmunology. Presenters are ClareCooper Marcus (2/17/05), Forrest McDowell andTricia Clark-McDowell (5/11/05), and Jain Malkin(9/21/05). For more information on this lectureseries go to:http://www.informedesign.umn.edu/Calendar.aspxReferences—Coile, R. (2002 Competing by design. PhysicianExecutive, July-August: 12-16.—Kaplan, R., Kaplan, S., & Ryan, R. (1998). WithPeople in Mind: Design and Management ofEveryday Nature. Washington, DC: Island Press.—Lewis, C. (1996). Green Nature/Human Nature: TheMeaning of Plants in Our Lives. Urbana: Universityof Illinois Press.Where Research Informs Design ®

Implicationswww.informedesign.umn.edu6—Parker, D. (1991). A better buildings and bennefits.Modern Healthcare, 21(47), 30.—Tyson, M. (1998). The Healing Landscape:Therapeutic Outdoor Environment. New York:McGraw-Hill.Additional Resources—www.healinglandscapes.org—www.ahta.org—www.alexstark.com—www.arboretum.umn.edu—www.csh.umn.eduAbout the Authors:Steve Mitrione , MD, MLA,is a Family Physician withtwenty years of clinical experience.Dr. Mitrione recentlyreceived his Master ofLandscape Architecture fromthe University of Minnesotaand is one of only two individualsin the United Statesto hold both degrees. Hisfocus is on the ways in which landscape and thedesigned environment can improve health and aid inthe recovery from illness.At the Minnesota LandscapeArboretum, Jean Larson,MA, HTR, CTRS, serves asthe coordinator ofTherapeutic HorticultureServices. She oversees trainingof professional staffin the principles of therapeutichorticulture, the implementationof therapeutichorticulture programs, andcommunity outreach. Ms. Larson is a faculty memberat the CSH and serves as the center’s healinggarden consultant. She earned her MA inTherapeutic Recreation and Outdoor Education atthe University of Minnesota in 1990 and is a certifiedtherapeutic recreation specialist and registered inhorticultural therapy.As founder and director ofthe Center for Spiritualityand Healing (CSH) at theUniversity of Minnesota,Mary Jo Kreitzer, Ph.D.,RN, brings more than 15years of leadership andexpertise to the field of complementarytherapies andhealingpractices.Currently, she is the principalinvestigator (PI) of a $1.6 million NationalInstitutes of Health (NCCAM) education grant; theco-PI of a five year $2.1 million NIH (NINR) clinicaltrial of mindfulness meditation with solid organtransplant patients; and the PI on a Fetzer Institutefunded evaluation of the Inner Life of HealersProgram. Dr. Kreitzer is also a tenured associate professorin the School of Nursing.Related Research SummariesInformeDesign has many Research Summaries abouthealing, well-being, and related, pertinent topics.This knowledge will be valuable to you as you consideryour next design solution and worth sharing withyour clients and collaborators.“Benefits of Restorative Environments”—Journal of Environmental Psychology“Influences of Favorite Places”—Environment and BehaviorWhere Research Informs Design ®

Implicationswww.informedesign.umn.edu7“Health Benefits of Including Nature WithinHospitals” —Journal of Environmental Psychology“Benefits of Urban Parks”—Landscape and Urban Planning“Influence of Meaningful Landscapes”—Landscape Journal“Creating Beneficial Urban and Natural Settings”—Journal of Environmental Psychology“Physical Features Facilitate Place Attachment”—Environment and Behavior“Mood and the Desire to Be in Nature”—Journal of Environmental Psychology“Alleviating Mental Fatigue in Urban and NaturalSettings” —Journal of Environmental Psychology“Naturalistic and Formal Urban Parks”—Landscape and Urban Planning“Healing Environments for Addiction Treatment”—The Journal of Alternative and ComplementaryMedicine“Pediatric Healing Gardens”—Landscape and Urban Planning“Natural Environmental and TranscendentExperiences” —Journal of Environmental Psychology“Optimal Healing Environments for CancerPatients” —The Journal of Alternative andComplementary Medicine“Children's Favorite Places for Restoration”—Journal of Environmental PsychologyPhotos Courtesy of:Jean Larson, Minnesota Landscape Arboretum(p. 1 & 2)Mary Jo Kreitzer, University of Minnesota (p. 3 & 4)“Health Benefits of Park Use Among Older Adults”—Journal of Leisure Research“The History and Future of Healthcare Spaces”—The Journal of ArchitectureRevision Date: March 2007The MissionThe Mission of InformeDesign is to facilitate interiordesigners’ use of current, research-based information asa decision-making tool in the design process, therebyintegrating research and practice.Created by:Sponsored by: