Wilson (1984) asserts that humans are characterized by their tendency to pay attention to, affiliate with, or otherwise respond positively to nature. Their wide range of human activity and behavior suggests people intuitively believe the natural environment has beneficial effects on man. People attempt to bring nature into urban environments by building parks, creating public gardens, and lining streets with trees. Communities build suburbs that offer living environments with more outdoor space and opportunities to be closer to nature.
Others bring nature indoors by introducing plants, flowers, water, or even windows with views of nature into interior designs. And when individuals escape from every day life, it is often to natural settings, such as the mountains, the seashore, or the country. It does not seem to matter whether experiences with nature are active, such as gardening or hiking, or passive, such as sitting in a park or simply viewing a garden from a window. Humans' interactions with the naturai environment appear to have beneficial effects on their well being (Ulrich et al., 1991b).
The belief that the natural environment has the capacity to enrich life's experiences, that nature is somehow good, or beneficial, to human existence, is not new. The ancient cultures of Egypt, Mesopotamia, and China routinely included gardens in the design of their cities and homes, suggesting the importance these early civilizations placed on maintaining contact with nature in their urban settings (Davis, 1998). A culture's use of natural environments to promote health varied through the centuries and reflected each culture's beliefs and values.
During the Middle Ages, monasteries used nature for restorative purposes. Patients were placed in courtyards to receive the benefits of the sun and fresh air. In the 1800s, societies began to appreciate the influence of the natural environment on physical, social, and mental well being. Parks were built to bring nature into urban environments, and expanses of wilderness began to be preserved for public use.
The significance and use of the natural environment as an intervention to promote healing emerged in health care settings in the early 190Os. Psychiatric institutions exposed patients to parklike settings and used agricultural and horticultural activities as therapeutic interventions. Rehabilitative centers and older adult care settings began to use elements of nature as therapy in physical, occupational, recreational, and speech programs.
More recently, long-term care facilities for older individuals joined this movement to incorporate elements of the natural environment into the everyday living experiences of their residents. Programs such as the Eden Alternative™ (Brück, 1997; Reid, Macdonald, & DiMauro, 1997; Thomas, 1996) promote "human habitats" for older adults that transform institutionalized environments into environments that are less homogenous and more home-like. In these human habitats, plants and animals become part of the resident's daily experience and environment.
Wilson (1984) provided us with an evolutionary biophilia framework to study man's interaction with the natural environment. The biophilia framework asserts that humans have inborn responses to animals and to natural settings in which they evolved. These responses are referred to as the "biophilia tendency" and are thought to be adaptive (Kellert, 1993). Wilson's biophilia hypothesis suggests that as humans, our survival and our ability to thrive and gain fulfillment has been and continues to be dependent on our relationship with nature.
Despite the usefulness of this theory and the growing popularity and prevalence of using the natural environment to promote or maintain health, nurses and other health care providers do not use this theory in their studies. They have a limited understanding of the beneficial effects of the natural environment on man. Thus, the aim of this study was to examine and identify the current therapeutic uses of the natural environment and its beneficial effects as presented in the literature. With this awareness, there is the hope that staff and administrators in institutional settings will consider the effect of the environment in their designs and methods.
The natural environment is a multifaceted concept that is defined in different ways in the literature. Wohlwill (1983) characterized the natural environment as "organic and inorganic matter that is not a product of human activity or intervention" (p. 7). According to him, plant material, animal life, water, and soil all are considered elements of the natural environment. When several elements or features of the natural environment are combined, the definition expands to encompass natural settings such as savannahs, mountains, desserts, shorelines, or woodlands.
Kaplan (1992) proposes that nature can be experienced indoors as well as out of doors, and broadens the picture of the natural environment to include a flower in a vase, an aquarium, or a window with a view of nature. Finally, the natural environment can also be defined by what it does not include - elements that are man-made, such as buildings and roads, or settings that include a predominant human influence. While these definitions lack discrete boundaries, they do provide a guide for differentiating what may or may not be included in the concept of natural environment.
This integrative review of the literature examined written work describing the use of the natural environment as a therapeutic intervention. Journals, dissertations, and texts from 1980 through December 1998 (found through computer searches of Mediine, Cumulative Index to Nursing Health and Allied Health Literature, and PsycINFO) were used to guide this review. Additional sources were located by review of the bibliographies of already obtained studies. Excluded from the review were any unpublished manuscripts, abstracts from presentations, or manuscripts published in languages other than English.
The investigator examined more than 120 studies. Of these, 24 met the inclusion criteria presented above. The participants in these studies were from the entire life span. Many participants were students, especially in the controlled studies. Articles were published in a variety of health-related journals: psychology, sociology, and nursing, as well as physical, occupational, recreational, and speech therapy. Journals related to disciplines such as agriculture, landscape architecture, horticulture, forestry, and natural resource management, also contributed to the literature. Key words included: nature, natural environment, restorative environment, and transformed environment.
Articles were grouped according to style. All anecdotal or clinically focused articles (n = 15) were grouped and analyzed as reports. All articles of a research nature (n = 9) were grouped and analyzed as research. Articles were organized chronologically by year of publication. When necessary, articles were further organized alphabetically by author. Both groups were structured to provide details about the sample, the methodology (i.e., type of program or the independent variables and study design used), the outcome measures (i.e., dependent variables and method of measurement), and results of the program or study. The rigor of the studies is discussed at the end of this article. The following section provides a summary of the use of the natural environment as a therapeutic intervention as reported in these two bodies of literature.
The reports addressed both at-risk and ill populations. The at-risk populations included low-income urban youths and senior citizens (Kerrigan & Stevenson, 1997; Ragush, 1991), low income community residents (Schwartz, 1997), and family caregivers of older adults who were frail (Smith & McCallion, 1997). Populations included:
* Residents with altered mental health status (Abbott, Cochran, & Glair, 1997; McGinnis, 1989; OffnerLewis, 1985; Spelfogel & Modrazakowski, 1980; Weatherly Oc Weatherly, 1990; Williams, 1989).
* Older adults with altered levels of physical, emotional, or social functioning (Bässen & Baltazar, 1997; Hazen, 1997; McGuire, 1997; Weatherly & Weatherly, 1990).
* Residents with severe learning and physical disabilities (Gillyon & Lambert, 1997).
* Patients with acquired aphasia (Sarno & Chambers, 1997).
Interventions for these populations consisted primarily of therapeutic programs that involved some type of activity associated with plants or plant material, such as supervised horticultural or gardening programs. Activities within these programs varied greatly in type, level, length of activity, and number of participants per program. Programs used a combination of group and individual activities such as planting, plant maintenance, plant propagation, flower arranging, containerized and backyard gardening, crafts related to gardening, garden club meetings, and participation in gardening-related events.
Ages of the participants involved in programs that used the natural environment as an intervention ranged from 9 to 100. Several reports described intergenerational programs combining older adults with children or older adults with middle-aged adults. One report described a community project that included participants of all ages. Regardless of the ages used in the studies, the outcomes can be translated to work with older people within institutions.
Programs that transform the environment and include the natural environment as part of the everyday experience of the participants are quite different from using nature as a therapeutic intervention that is activity-focused and intermittent m delivery. Unlike activity-focused programs, transformed environments do not require active involvement of the participants. Instead, they provide participants with opportunities to interact with the natural environment by integrating nature into the resident's daily experience (e.g., providing sensory gardens within the environment or allowing animals to live within the care environment).
Information presented in the reports for both types of programs, activity-focused and transformed environments, was interesting and informative. Many of the findings were descriptive observations, which increased the risk of bias. Outcomes for all programs were reported as positive, regardless of variation in population, setting, or type of intervention. Benefits to the individual were reported in multiple dimensions including psychosocial, emotional, and physical. Psychosocial and emotional benefits were reported most frequently and included stress reduction, increased socialization, and improvement of self-concept or self-worth.
Physical benefits included improvement in level of responsiveness, a decrease in mortality and infection rates, and a decrease in the use of medications required to manage disruptive behavior of older residents. Additional benefits for participants in programs involving planting and maintaining vegetable gardens included an improvement in the participants* nutritional status.
Improvements to communities and to organizations were also reported. Benefits to the community included providing food for economically disadvantaged households and increasing a family's level of independence and "value of self as a member of the community. Organizational benefits in nursing home settings, which used natural environments as elements in the transformation of the care environment, included increased staff satisfaction and decreased staff turnover and absenteeism.
There were considerably fewer numbers of published research reports than there were clinical or anecdotal reports examining the use of the natural environment as an intervention. The research studies that focused on interventions used small, but appropriate, numbers of subjects. These studies primarily focused on healthy populations.
Ill populations were used in only four studies: chronically ill older adults in a long-term care facility (Robb, Boyd, & Pristash, 1980), physically and mentally handicapped children in a longterm care facility (Ackley & Cole, 1987), women newly diagnosed with breast cancer (Cimprich, 1993), and patients recovering from gallbladder surgery (Ulrich, 1981). Most studies used convenience samples (e.g., college students, participants in health care settings). The participants ranged from children to older adults. Use of the natural environment appeared to have a positive effect on social behavior, attentiveness, wakeful relaxation, recovery experience, cognitive skills, stress recovery, positive affect, and mental restoration.
Unlike the activity-focused and transformed environment interventions presented in the clinical and anecdotal report articles, interventions cited in the research studies were more experiential in nature. Examples of these interventions included viewing nature scenes from a window, sitting in a garden, or walking through a park. Interventions were most often ascribed and compared as the presence or absence of nature and the degree of nature experienced (e.g., exposure to a window with either a full view of a natural scene, a window with a part natural, part man-made scene, a window with no natural view). The research studies consistently analyzed intermittent interventions without permanent transformations of the environment.
Findings from the research studies were consistent in suggesting interactions with the natural environment result in beneficial effects. The majority of studies examined the effect of the natural environment on either mood or mental restoration. Findings suggested that exposure to, or interaction with, the natural environment positively effects mood and provides mental restoration (Cimprich, 1993; Hartig, Mang, & Evans, 1991; Tennessen & Cimprich, 1995; Ulrich, 1981, 1984; Ulrich et al., 1991a, 199Ib). Each of these studies evaluated the effectiveness of differing degrees or a range interaction with the natural environment (e.g., viewing natural landscapes tended to promote faster and more complete restoration than did viewing urban or man-built views). In general, the greater the dosage of natural environment, the greater the beneficial effect.
Findings from two studies suggested the beneficial effects of nature can be lasting (Cimprich, 1993; Hartig et al., 1991). Cimprich tested women at 18, 60, and 90 days following a restorative intervention involving nature. There was improvement in attention for all three postintervention time points. Hartig et al. (1991) discovered individuals exposed to wilderness vacations scored higher on positive affect at 21 days postvacation than did individuals who had no exposure to the natural environment.
The purpose of this review was:
* To explore the current literature on the use of the natural environment as a therapeutic intervention.
* To evaluate the publications containing such literature.
* To provide a synthesis of the state of knowledge concerning the beneficial effects of the natural environment to man.
The literature appears to support the underlying premise of the biophilia hypothesis - there is a beneficial relationship between humans and the natural environment. It also appears that interaction with the natural environment has positive effects for some individuals while presenting no negative effects.
Despite the human connection to the natural environment as suggested by Wilson (1984), an abundance of anecdotal evidence, and several controlled studies, little is known about the effect of the natural environment on everyday life, overall health, and well being. The literature reflects multipie uses of the natura! environment by a wide variety of professions to achieve multiple goals for diverse populations. Many interventions appeared to have become popular without a sound theoretical base or empirical studies to support such activity.
IMPLICATIONS FOR NURSING
Robb et al. (1980) conducted the first study directed toward using the natural environment with older populations. Few nurses have built on these findings in the past 20 years. Yet, gerontological nurses particularly manage and contribute to the environment in many settings where older adults live out their days. Many nursing homes still maintain a sterile institutional atmosphere that supports the medical model and contributes to depersonalization in the nursing home. With the Eden Alternative movement in nursing homes, the natural environment may begin to replace the sterile environment.
Some of the value of assisted living is that the environment is more homelike. Perhaps embracing the theories of Wilson and replicating the existing studies will provide gerontological nurses with new areas of inquiry to enhance the environments of older people. Further work is necessary to develop theories addressing the use of the natural environment and its effect on older populations.
Presently, there is little consensus on the definition of the natural environment. Future researchers must agree on a definition of the concept and provide information about the relative effectiveness of specific types and dosages of interventions for older adults. Nurses must interpret the studies and target specific interventions for selected individuals in caregiving environments that require enhancement.
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