There is a long history of the therapeutic use of plants and gardens in the care of patients with both physical and mental illnesses. In particular, the use of gardens and gardening has been a topic of interest for a range of professionals in the mental health field. Mental institutions in Europe in the 18th and 19th centuries incorporated gardens as part of their grounds on the theory that nature contributed to the healing of the sick (Warner & Baron, 1993).
Dr. Benjamin Rush, a signer of the Declaration of Independence, believed "digging in the soil has a curative effect on the mentally ill" (Tereshkovich, 1973, p. 4). Hospitals in Spain observed that agricultural activities were beneficial to psychiatric patients as early as 1806 (Olszowy, 1978). In the United States in the late 19th and early 20th centuries, outside agricultural work involving patients was a common feature of mental institutions. In such institutions, residents would grow, produce, and raise animals for use in the facility. After World Wars I and II, many veterans' hospitals incorporated gardening therapies as part of their treatment regimens.
This focus on the therapeutic value of gardens in patient care began to change later in the 20th century. Many inpatient psychiatric programs were under political pressure to become self-supporting. In many institutions, patients were forced to contribute unpaid labor in many contexts, one of these being the care of the institutions' gardens (Griffiths & Griffiths, 1976). In later decades, the rise of more technical, biomedical approaches to treating both physical and psychiatric disorders decreased patient interactions with outdoor gardens and plants.
Increasingly, medications became a primary tool in addressing psychiatric disturbance. Institutions moved away from having residents work to provide their own food for consumption. With the deinstitutionalization movement in the 1960s, the place of residential psychiatric care itself was questioned.
However, in the early 1970s, interest in the therapeutic value of gardens in mental health care was growing. Many articles published during this time point to myriad possible benefits, both psychological and emotional, which sprang from such involvement in gardens. In the 1980s and 1990s, the research emphasis on gardens has broadened both to the consideration of the effect of gardens on physical health and the benefits of gardening to a variety of patient populations.
GARDENING EFFECTS RESEARCH
The literature on the therapeutic effects of gardening can be divided into two principle areas of inquiry: the passive influence of plants or garden environments on patients and the benefits to patients of active participation in gardening activities. Benefits to physical, as well as psychosocial, health of both active and passive interactions with plants have been studied with a wide range of patient populations (Sidebar).
Passive gardening activities can include looking at plants, wandering through gardens, and participating in group discussion activities with gardening or plants as a focus. In perhaps the most well-known study of the therapeutic benefits of merely viewing outdoor scenes, Ulrich (1984) found that the length of stay in a hospital for a group of gall bladder surgery patients with a window view of a grove of trees was shorter than for a comparable patient group whose windows looked onto brick walls. In this study, many other factors (e.g., length and complications from the surgery) failed to adequately account for the different outcomes in the two patient groups.
POSSIBLE PHYSICAL, EMOTIONAL, AND PSYCHOLOGICAL BENEFITS OF GARDENS
Exposure to plants within ward environments has also been shown to have positive effects on patient well-being. Talbot, Stern, Ross, and Gillen (1976) found that placing flowering plants on a ward resulted in significant increases in socializing (including increased eye contact) and food consumption on the part of severely withdrawn patients with schizophrenia in a psychiatric hospital. Simple exposure to plants and outdoor gardens has been shown to facilitate the coping strategies of older adults, including caregivers of frail older adults (Wells, 1997).
Exposure to sunlight has been linked with such health benefits as increased bone density - a result of increased vitamin D absorption (Glerup et al., 2000). Hypovitaminosis has been found in general inpatient medical populations (Thomas et al., 1998), inpatient nursing homes (Ley, Horwath, & Stewart, 1999), and in elderly women with Alzheimer's disease (Sato, Asoh, & Oizumi, 1998). Exposure to sunlight has also been linked to circadian rhythms and sleep cycles (O'Connor & Youngstedt, 1997; Refinetti, 1999). By allowing patients increased exposure to sunlight, outdoor gardens may have a positive influence on both uptake of vitamin D and circadian rhythm cycles.
Outdoor gardens have been suggested as a means of improving morale, self-confidence, cooperation, social interaction, and physical functioning for residents of a geriatric facility (Hill & ReIf, 1982). Ideally, such gardens incorporate a variety of plants to stimulate the senses (Vellas & Sedeuilh, 1991).
The importance of regular physical activity in maintaining good health later in life has been recognized (Galloway & Jokl, 2000). Regular participation in common physical tasks, such as gardening, can help prevent age-related declines in musculoskeletal function (Galloway & Jokl, 2000), increase bone mineral density (Coupland et al., 1999), and reduce risk of primary cardiac arrest (Lemaitre et al., 1999). Again, access to a garden or to small gardening activities on inpatient wards could have positive health benefits - particularly for older adults.
Active participation in gardening activities in inpatient settings usually includes actually planting or propagating plants. Various patient groups have been successfully involved in active horticultural therapy programs, including psychiatric patients (Goodban & Goodban, 1990), aphasie patients (Sarno & Chambers, 1997), and developmentally disabled individuals (Rothert & Daubert, 1981a). Gardening activities can improve patients5 psychomotor skills (Griffiths & Griffiths, 1976) and can help orient psychiatric patients to reality-based experiences (Haas & McCartney, 1996).
Participation in plant-based activities has been shown to increase autonomy in older residents in long-term care (Catlin, Milliorn, & Milliorn, 1 992) and to provide patients with a mode of self-expression (Burgess, 1990). In terms of older psychiatric patients, gardening activities can provide both physical and mental stimulation. Gardening offers a pleasant and engaging activity that can be incorporated into therapeutic programs addressing depression (Riordan & Williams, 1988), and it helps offer stimulation to those in long-term care settings (Stein, 1997).
An enclosed, safe garden area for patients with Alzheimer's disease to wander in has been cited in several studies and texts on the care of dementia patients (Regnier & Pynoos, 1992). Gardens attached to dementia care wards can provide safe places for mental, visual, and auditory stimulation, along with a pleasant place for exercise (Burgess, 1990). Gardens can provide a means of interaction between patients, requiring minimum verbal skills (Bryan, 1991).
Confused dementia patients were able to derive benefits from gardening therapies in terms of increasing social connections (Bryan, 1991). Dementia patients on a day-care ward were able to participate in a range of gardening activities, including growing vegetables and visiting a nursery (Pachana, 1995). In this study, the caregivers of dementia patients reported positive benefits from the study, such as more restful sleep for those patients involved. Moderateintensity exercise, such as gardening, has been shown to improve self-rated quality of sleep in older adults (King, Oman, Brassington, Bliwise, & Haskell, 1997). When older, frail patients are involved in such gardening activities, garden features (e.g., wheelchair height planters, tools designed for arthritic individuals) should be designed for the specific needs of older individuals. This helps increase patient participation and enjoyment (Rothert & Daubert, 1981b).
Caregivers themselves can also benefit from gardening.
Participation in plant-related activities has been shown to encourage dementia caregivers to engage in positive and rewarding activities outside the caregiving situation (Smith & McCallion, 1997). Finally, positive benefits have also been reported for staff (e.g., student nurses) (Smith, 1998) on wards where some form of horticulture therapy has been initiated.
Construction of a Passive Garden Environment on an Inpatient Geriatric Ward
In New Zealand, the effect of horticultural activities on geriatric inpatient populations has not been examined. The authors set out to create a passive garden conservatory on an existing geriatric inpatient unit of a mid-sized regional hospital in New Zealand, and evaluate the garden's effect on patients, visitors, and staff. The overall aims of the study were to:
* Ascertain whether the addition of a garden space on the ward influenced patient use of the garden conservatory space or the attached outdoor gardening space.
* Measure any change in the pleasantness ratings of the ward after the addition of the garden conservatory to inpatients, their visitors, and ward staff.
During the time period of the study, the patient population averaged 22 patients, with a mean age of 77.9 (SD 8.36) (all patients were older than 65). Approximately 70% of the patients were women. The patients fell into three care groups: patients diagnosed with dementia (25%), patients with primarily a psychiatric diagnosis (25%), and patients with a primary medical diagnosis with or without co-morbid psychiatric diagnoses (50%). The dementia and psychiatric patients stayed an average of 30 to 40 days; the average stay of patients with a primary medical diagnosis was considerably longer (60 to 75 days). All patient participants either were competent to consent to participation in the study, or had their legal guardian consent to their participation in the study, consistent with ethical guidelines and the regional human ethics committee approval of the project.
The primary means of data collection was through behavioral observation of the patients. This approach was taken to overcome several obstacles to gathering quantifiable data, including a relatively high rate of turnover among patients on the ward, and because many of the dementia patients were severely impaired (i.e., MiniMental State Examination [Folstein, Folstein, & McHugh, 1975] scores below 15) and, thus, were unable complete evaluation forms. The behavioral observations (i.e., charting patient movements on the ward) provided data on patient use of ward space before and after implementation of the conservatory. Only six of the participating patients were observed before and after the installation of the garden because of patient turnover. For this reason, more formal statistical analysis of the data was not attempted.
For a 5 day period 1 month before the installation of the conservatory garden, and a 5 day period 1 month after the garden installation, patients' location was charted on a simple schematic of the ward floor plan. For each day of observation, patient location was charted in the morning, afternoon, and early evening. Because of high turnover among ward patients, specific individuals were not charted. Instead, the age, gender, and diagnoses of the patients were recorded in terms of their location on the ward at the varying times of day (i.e., morning, afternoon, and evening).
Photo 1 . View of the garden conservatory
CONSTRUCTION OF THE CONSERVATORY GARDEN
The conservatory was constructed within a room located at the opposite end of the ward from the entrance (Photos 1 and 2). This room, coincidentally, led into the ward's outdoor garden. Patient use of the garden prior to the implementation of the study was low, in part because of physical obstacles (e.g., a steeply sloped ramp connecting the second floor ward to the garden below) and low patient awareness of the outside garden.
Several modifications to the existing room were made to convert it into a conservatory. The room had approximately 132 square feet of floor space. Individual chairs were removed from the room and replaced with benches with orthopedic padding. Rattan blinds were installed in the windows to decrease glare. A variety of plants - none of which were poisonous, and some of which were actually edible - were placed at various positions and heights within the room. Several baskets of hanging plants were installed. Most plants were installed in wheelchair-height planters.
The conservatory took approximately 3 hours to install. By prior agreement, it was determined that one member of the nursing staff would be designated as the primary caretaker for the plants, with additional staff willing to provide care as needed. It was also determined that patients wishing to water or otherwise care for the plants would be allowed to do so. However, the patients were not considered the primary caretakers of the plants.
Photo 2. Flowering edible ginger plants in the garden conservatory.
Measurements of patient movements were made at Time 1(1 month before installation of the garden conservatory), Time 2(1 month after the installation of the garden conservatory), and Time 3 (6 months after the installation of the garden conservatory). For each time period, three observations were made each day during the 5day period. Thus, each time period has 15 observations. All observations were made as close as possible to 10 a.m., 2 p.m., and 5 p.m.
Observations are presented for the garden conservatory, the dining room (which directly borders the conservatory), and the outdoor ward garden. At Time 1, no patients were present in the conservatory at 10 of the 15 observation times. In contrast, between one and five patients were present in the conservatory during the majority of observations after plants were added to the conservatory (Times 2 and 3).
Similarly, use of the nearby dining room increased among patients after plants were added to the conservatory. During Time 1, no more than three patients were ever observed in the dining area, regardless of time of day. However, after the implementation of the conservatory garden on the ward, three or more patients were recorded as being present in the adjacent dining room area more than 90% of the time.
Finally, the effects of the plants in the conservatory appeared to increase use of the outside garden area. At Time 1, patients were observed in the outside garden during only 2 of the 15 observation times were any patients (a single patient on each occasion). However, this increased to between one and three patients observed in the garden during at least half of the observation periods at both Times 2 and 3. This is of particular note, because Time 3 took place in the southern hemisphere winter, when temperatures were considerably cooler than at Times 1 and 2.
These results demonstrate a positive reaction to the garden by the geriatric inpatients in this ward. Patients appeared to increase their use of a nearby room, as well as their use of the outside ward garden, after the garden conservatory was installed. In examining the observations, the observers were unable to identify any change in the characteristics of the patient groups between the observation times. Nor were staff purposely encouraging patients to use the garden areas, or physically placing them there. Times 1 and 2 took place during the southern hemisphere summer season - average outdoor day temperature of 66°F. The observations at Time 3 occurred in winter - average outdoor day temperature of 440F.
Positive effects for the ward were generated by this study, beyond the patient changes already described. Interest in the study and its results have been used by nursing staff to successfully argue for retaining a safe and secure outdoor gardening space for geriatric patients when the current ward facilities are renovated. Patients and visitors continue to use the conservatory as a place for conversation and contemplation. The possibility of introducing other gardening activities (e.g., cultivating house plants) has been discussed by the occupational and diversional therapists.
Of several possible research projects contemplated for this inpatient ward, setting up a garden study was most enthusiastically received by nursing staff. The staff felt patients were not making efficient use of the attached garden space, and promoting its use was an on-going nursing objective. The nursing staff were impressed with the resulting increased patient movement toward the conservatory and the adjoining areas. Use of the areas was enhanced, and positive results from informal staff surveys about the pleasantness of the ward increased after the plants were installed. The plants have become a permanent, living part of the ward, and spontaneous feedback from nursing staff suggests this project has had positive results on morale.
In changing health care environments, it is difficult to argue for the incorporation of gardens and places for plants within institutions. The nursing staff of the ward in which this garden conservatory was added have pointed to the positive results of this small study, and have been successful in convincing the hospital administration of the value of attaching a larger and more patient- friendly garden to the geriatric wards when refurbishing the hospital.
Therapeutic Garden Space Considerations
In setting up such a therapeutic garden space, several issues must be addressed. Gaining the interest and cooperation of all ward staff is vital to ensure the success of the project. This can be facilitated by consulting staff at several points. Ethical concerns, such as possible toxic reactions to the plants, should be considered. It is prudent to seek expert horticultural advice on the types of plants that work best in the chosen setting, and which do not pose a risk of accidental poisoning. Ideally, the plants should be easy to care for and tolerant of occasional neglect.
The patient population may pose concerns about introducing plants. Aggressive patients easily can use potted plants as objects to throw. Patients in advanced stages of demenda often place objects in their mouth - hence the need for nontoxic plants on such a ward. Plants should not have thorns, to prevent accidental bruising or cutting, and plants producing excess pollen are best avoided, because they may provoke allergic responses.
The question of who will care for the plants should be given careful consideration. Some gardening projects in which patients with dementia have cared for plants have had positive results (Pachana, 1995). However, an unstructured therapeutic endeavor can become a burden on patients.
Practical considerations for setting up an indoor garden environment include lighting, temperature ranges, humidity, and available space. Outdoor gardens should have a sturdy, secure fence or other enclosure, to prevent unwanted entry or exit from the area. However, bare, high chain-link fencing can increase the feeling of entrapment and should be disguised with planting, if possible. Walkways should be wheelchair friendly, and benches and places to shade patients should be planned. More specific guidelines for both indoor and outdoor patientfocused gardens have been extensively reviewed elsewhere (ReIf, 1992), and much has been written particularly with older adults in mind (Rothert & Dauben, 1981b).
Gardens and gardening can have a positive effect on physical and psychological health, including cognitive and emotional wellbeing. Horticultural therapy as a formal intervention has a short formal history and a long and rich informal place in the care of institutionalized patients. The effects of both passive and active gardening activities have been studied with a wide range of patients, both young and old. Many descriptions exist in the literature of well-received small and large scale garden intervention projects. Although it is sometimes difficult to measure quantitatively the exact benefits of such activities on patients, positive outcomes are indicated in many studies.
More research about possible physical and psychological benefits of gardens is needed. Research based on geriatric patients could focus on both inpatient and assisted living environments. In general, more emphasis on therapeutic environments as aids in rehabilitation and recovery could also prove useful. Perhaps with the increased interest in such research and the growth of horticultural therapy as a profession, knowledge of the therapeutic effects of gardens and gardening will be enhanced.
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POSSIBLE PHYSICAL, EMOTIONAL, AND PSYCHOLOGICAL BENEFITS OF GARDENS