Professional Documents
Culture Documents
2
Art and Design Discourse
Abstract
Creating gardens as places for restoration of good health and wellness has been observed throughout history, from ancient
times up through the present. Current research from a variety of academic disciplines reveals that contact with nature provides
stress reduction, which in turn leads to improved health outcomes. This research leads to additional questionswhat kind of
contact with nature? How much? Are there certain types of plants which are more therapeutic than others? A look at the existing
knowledge base reveals a complexity of variables which prohibits a formulaic approach to garden design for best health
outcomes. However, careful study of the field reveals factors of garden design which should be considered in order to achieve
maximum restoration for garden users.
Gardens which are designed for stress relief have four primary considerations embedded in the design: social support for
garden users; provision of privacy and control; opportunity for physical activity and movement; and provision of nature elements.
Universal design, which provides accessibility to the greatest possible range of garden users, should also be a consideration of
any restorative garden space.
Furthermore, landscape architects and other garden designers must design for the users and the anticipated uses of the garden.
Gardens in healthcare settings have three primary user groups patients, staff, and visitors. The needs of each must be
considered in the garden design. Garden designers must be aware of specialized needs of garden users. A garden which is
designed for cancer patients undergoing chemotherapy treatments will have very different design requirements from a garden
designed for patients recovering from joint replacement surgery. A garden designed for a hospice setting will have a totally
different set of design requirements altogether. In addition, it is critically important that the garden designer consult the
therapists who will use the garden space for patient activities. Bringing together the expertise of therapist and garden designer
yields tremendous value to the garden design.
A landmark study which looks at where people choose to go when stressed is examined, and new versions of the same survey
are reviewed. Results of the new surveys are puzzling, and yield new questions. Suggestions for new areas of research are also
given.
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Introduction
Throughout history, contact with nature has been viewed as
beneficial for health and well-being in widely different
cultures. From ancient healing springs to medieval monastic
cloisters and continuing on to tuberculosis sanatoria in the
early twentieth century, contact with nature was believed to
be beneficial for individuals who were troubled in body, mind,
or spirit. However, during the twentieth century the
connection between healing and nature was gradually
severed, as technology took on a greater role in the medical
community indeed, in Western culture as a whole.
Healthcare
designers
and
administrators
became
preoccupied with creating environments that were functional
and efficient. The need to accommodate modern
technologies in healthcare facilities overshadowed
previously-held beliefs about the importance of providing
therapeutic elements such as gardens. As a result, this new
functional emphasis produced environments that were
efficient but starkly institutional. These types of environments
are now considered stressful and unsuited to the emotional
and psychological needs of patients, visitors, and staff
(Horsburgh, 1995; Malkin, 1992; Ulrich, 1992).
By the late twentieth century, however, a growing awareness
appeared in regards to the benefits of patient-centered
healthcare facilities. In addition, a body of research began to
be published relative to environmental characteristics that
help patients cope with psychological and physical effects of
sickness. Some of these environmental characteristics
related to design of the healthcare facility itself, but other
characteristics related to contact with nature, such as in a
healing garden or nature views through a window (Ulrich,
1995). Researchers investigated a broader concept of health
and wellness, addressing other incidents of contact with
nature and its benefits to a larger audience. Much of this
research focused on the ways contact with nature provided
stress mitigation for everyday situations, and did not focus
solely on healthcare environments (Hartig et al., 1991;
Kaplan, 1995; Ulrich et al., 1991b; Wilson, 1984).
Current knowledge relative to restorative garden design has
progressed. This paper will begin with a cursory overview of
a broad concept of health and wellness and proceed to look
at Kellert and Wilsons work on biophilia and biophilic design,
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Dimensions of wellness
A state of wellness is achieved when the many dimensions of
a persons life are in balance when a person is whole.
Many models exist which portray dimensions of wellness -- a
detailed discussion of models of wellness is beyond the
scope of this paper. This particular model portrays a balance
between six dimensions of life and health physical, social,
environmental, emotional, spiritual, and intellectual. The
wheel portrays each area in balance with the others, calling
attention to the importance of nurturing all dimensions of life
in order to achieve wellness. When one (or more) area
becomes out of balance, wellness is compromised. One
common result of being out of balance is experiencing stress.
Modern society and life styles are full of stressful events at
home and at work; these events result in new states of ill
health (Annerstedt & Wahrborg, 2011). Stress interferes with
wellness in a myriad of ways. Stress, and ways to mitigate its
effects, has been well-studied over the last several decades.
SOCIAL
SUPPORT
SENSE OF
CONTROL
Patients
Family
Staff
Privacy
Choices
Escape
PHYSICAL
MOVEMENT/
EXERCISE
Exertion
Rehabilitation
NATURE &
DISTRACTIONS
Plants, Flowers,
Water, Wildlife,
Nature Sounds
92
Social Support
Social support is the first major component in the theory of
restorative garden design model. Generally, social support
refers to perceived emotional support or caring, and material
or physical aid, that a person receives from others (Brannon
& Feist, 1997). A large body of research has shown that
people who receive higher levels of social support are
usually less stressed and have better health status than
persons who are more socially isolated (Cohen & Syme,
1985; Shumaker & Czajkowski, 1994) In fact, low social
support maybe as great a risk factor in mortality as is
cigarette smoking (Berkman & Syme, 1979).
Sense of Control
Providing a sense of control is the second major component
in the theory of restorative garden design model. Much
research has shown that a sense of control is an important
factor affecting a persons ability to cope with stressful
situations. Control refers to peoples real or perceived ability
to determine what they do, and to determine what others do
to them (Gatchel et al., 1989). Generally, people who feel
they have some control over situations cope better with
stress and have better health status than people who feel
they lack control. Lack of privacy is also considered a
stressor, related to lack of control over regulation of personal
exposure. Stress related to lack of control has been shown to
have many negative effects, including depression, reduced
cognitive performance, elevated blood pressure, higher
levels of circulating stress hormones, and suppression of
immune functioning (Schulz, 1976; Weiss et al., 1990).
Much of the stressfulness of hospitalization has been linked
to loss of control, for example, loss of privacy, inability to
choose clothing, meals, and room temperature, unfamiliarity
with buildings, and complex wayfinding. In response to these
stressful aspects of facility design and operation, many
hospitals and residential healthcare facilities have begun to
offer more patient-centered care, allowing for more choices
and autonomy for patients and visitors. Healthcare staff can
also be positively affected by providing a sense of control in
their workplace. Greater involvement in decision-making
processes has been shown to improve job satisfaction and
reduce turnover in a study of nursing home aides (Waxman
et al., 1984).
Well-designed gardens offer an opportunity for patients, staff,
and other garden users to increase feelings of control. This
phenomenon has been well-studied in parks and other
recreational facilities (Ulrich et al., 1991a). However, only a
small amount of research has focused directly on gardens in
healthcare facilities. Cooper Marcus and Barnes (1995)
found that garden users reported restoration from stress
when they had the opportunity to exercise control over their
situation and escape to the garden.
Nature as Distraction
Natural distraction is the fourth and last major component in
the theory of restorative garden design model. Nature can
engage a patients interest (thereby distracting from pain,
stress, or feelings of sickness), without requiring energy input
(Kaplan, 1995). Others agree, yet caution that a
well-designed garden with optimal restorative design
features will engage all the senses, and not just visual
sensations (Stigsdotter & Grahn, 2002). Garden designers
will do well to heed her caution.
Ulrich (1992) notes that positive distractions, such as those
found in nature, may block or reduce worrisome thoughts,
and foster beneficial changes in physiological systems such
as lowered blood pressure and stress hormones. Even views
of certain nature scenes can significantly reduce stress.
Stressed patient groups in a variety of settings from a dental
office to a pre-surgery ward all experienced more positive
health indicators when exposed to serene nature scenes
(Heerwagen, 1990; Katcher, Segal, & Beck, 1984). Although
studies are rare that examine potentially favorable influences
of gardens on patient stress and other medical outcomes, it
appears that even acutely stressed patients can experience
significant restoration after only a few minutes of viewing
nature settings with greenery, flowers, or water. It is also
important to note that viewing gardenlike scenes apparently
mitigates pain (Ulrich, 1999).
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Chemotherapy
Garden.
Chemotherapy
may
be
administered in an outpatient facility where patients must sit
for several hours receiving their treatment. They may be
allowed to take their treatment in the garden, or more likely
they will view the garden through a window during their
treatment, perhaps relaxing in the garden afterwards.
Chemotherapy treatments often render patients more
sensitive to the sun, and more sensitive to smells. Gardens
that will be used by patients undergoing chemotherapy
treatments should always provide some type of shelter from
the sun. Plants should also be chosen carefully for low-odor
flowers and foliage. It is important in all healthcare gardens
to provide ongoing maintenance; poorly maintained or dead
plants can induce negative thoughts and feelings in patients
who use or view the garden. Chemotherapy patients may be
the population most in need of well-maintained garden plants
and views.
Patients who are undergoing chemotherapy treatment
usually visit the facility numerous times over a period of
several weeks or months, and a family member or caregiver
may accompany them. A pleasant garden space can also
provide a place of respite and stress reduction for caregivers,
who suffer from their own particular troubles when a loved
one is not well.
Figure 16. Iowa 2011 vs. Francis and Cooper Marcus 1992
study
Several factors could account for the difference between the
two studies. There was a twenty-year gap between the two
studies. A new generation of university students has arrived
and perhaps their biophilic tendencies have atrophied, as
99
Conclusion
References
Annerstedt, M., & Wahrborg, P. (2011). Nature-assisted
therapy: Systematic review of controlled and
observational studies. Scandinavian Journal of Public
Health, 39, 371-388.
Berkman, L. F., & Syme, S. L. (1979). Social networks, host
resistance, and mortality: A nine-year follow-up study
of alameda county residents. American Journal of
Epidemiology, 109, 186-204.
Branas, C. C., Cheney, R. A., MacDonald, J. M., Tam, V. W.,
Jackson, T. D., & Ten Have, T. R. (2011). A
difference-in-differences analysis of health, safety, and
greening vacant urban space. American Journal of
Epidemiology.
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