Therapeutic Hospital Gardens: Literature Review and Working Definition

Abstract

Aim:

This review explores the role of purposefully designed and well-integrated therapeutic hospital gardens (THGs) for the benefits of patients, their families, and staff.

Background:

Significant benefits are realized when people are in contact with nature in the city. Although hospital gardens are prevalent and the beneficial effects of nature on health are widely acknowledged, the establishment of a consistent definition for hospital gardens that promote health is vital to attain reliable and quantifiable health outcomes.

Methods:

Twenty-eight peer-reviewed journals were critiqued for the period of 2016–2021 and updated with 12 articles from 2021 to 2023 to analyze and synthesize the latest thinking and development in this emergent field. Subsequently, current books and exemplar practice literature were synthesized with the results of the literature review to produce a working definition of THGs.

Results:

Three themes and 14 subthemes were established showing the interconnectedness of THG definition, user needs and experiences, and the benefits and values of THGs. Two original findings can be established—a need to have a consensus on terminology and to establish design processes. The working definition was produced as a foundational step to guide stakeholders in implementing THGs.

Conclusion:

THGs can play a role in improving well-being when they are purposefully designed and well-integrated in hospital programs and health policy. Hospital CEOs, designers, and healthcare experts can use the findings and working definition to assist the establishment of such health promoting gardens.

Introduction

Humans are increasingly disconnected from nature with the World Bank predicting seven of 10 people will live in cities by 2050 (World Bank, 2023). In recent years, there has been a stark rise of scientific curiosity regarding the benefits of human contact with nature for health and well-being. Two recent reviews suggest a broad range of significant benefits, although with levels of evidence that vary (Bratman et al., 2021; Frumkin et al., 2017). Research activities about nature and health show the various benefits, acknowledge the complexity of this relationship, and suggest the need for a targeted cross disciplinary approach (Bratman et al., 2021; Frumkin et al., 2017).

Nature has several positive effects on human health, including (1) reduced stress by lowering blood pressure and cortisol levels (Stigsdotter et al., 2010; Ulrich et al., 1991; van den Berg & Van den Berg, 2011; Ward Thompson et al., 2016), (2) improved mental health by reducing depression and enhancing mood and self-worth (Astell-Burt et al., 2014; Gascon et al., 2015; White et al., 2013), (3) better cognitive and creative function by restoring the ability to think deeply and be creative (Magsamen & Ross, in press), and (4) enhanced physical health by reducing obesity and diabetes and increasing cardiovascular health (Astell-Burt et al., 2014; Dadvand et al., 2014; Sanders et al., 2015).

More benefits include improved immune function by increasing the effectiveness of natural killer cells and white blood cells (Li & Kawada, 2011; Li et al., 2008; Li et al., 2006); better cognitive and motor development for children by encouraging curiosity, physical activity, and self-reliance (Kellert, 2002; Louv, 2005); a sense of calmness by reducing anxiety and soothing all the senses (Bratman et al., 2015; Maas & Verheij, 2009; Song et al., 2015); better social connectedness and behavior by providing a relaxed natural environment and places conducive to social interaction (De Vries et al., 2013; Williams Goldhagen, 2017); and more happiness by improving general well-being and life satisfaction (Van Herzele & De Vries, 2012; White et al., 2013).

Gardens are increasingly included in hospital developments because of their nature content, health promoting qualities, capacity to reduce stress, and ability to improve well-being and enrich the hospital environment (Cooper Marcus & Sachs, 2014; Farrow, In Press; Kamp, In Press; Nieberler-Walker et al., 2019; Reeve et al., 2017). Clinical and unfamiliar environments, such as hospitals, can add to stress, anxiety, and irrational thinking because the environment looks, smells and feels “unfamiliar” and is vastly different from any “normal” living environment (Williams Goldhagen, 2017).

Health-promoting hospital gardens are a tool to improve well-being, contributing to emotional, mental, and physical health of patients, their families, and staff (Cooper Marcus, 2016). Patients’ hospital stays, medication intake, and negative feedback are reduced when access to nature is provided (Ulrich, 1984; Ulrich et al., 1991). Staff satisfaction rates increase, user feedback to hospital administration is positive (Copeland, 2021; Cordoza et al., 2018), and staff productivity and teamwork improve when garden access is provided (Verderber et al., 2021). Several recent literature reviews confirm health outcomes for patients, their families, and staff (Blaschke, 2017; Gaminiesfahani et al., 2020; Jiang, 2020; Roberta Guglielmetti & Menicucci, 2021; Valipoor & Bosch, 2021; Verderber et al., 2021; Weerasuriya et al., 2019).

Health-promoting hospital gardens are being established around the world to support health outcomes (Battisto & Wilhelm, 2019; Cooper Marcus & Sachs, 2014). Such gardens can be found in dedicated outdoor spaces, courtyards and are increasingly placed on roof tops because of space constraints, adjacencies to medical departments and easy access. Good examples of therapeutic hospital gardens (THGs) can be found at the Bendigo Hospital Victoria (Keane & Grant, 2022) and the Queensland Children’s Hospital in Australia (Nieberler-Walker et al., 2019; Reeve et al., 2017); the Khoo Teck Puat Hospital in Singapore (Khoo Teck Puat Hospital, 2019); and the Legacy Hospitals in the United States (Cooper Marcus & Sachs, 2014). What is less well understood is how health-promoting hospital gardens must be designed and established to achieve positive health outcomes.

Method

Overview

This article suggests the need for a clear theoretical and practical understanding of what THGs are and which factors elicit the health promoting qualities of nature for the benefits of many. The aim of this review was to explore the question “What is the role of purposefully designed and well-integrated THGs?” The review was guided by a systematic literature review (Page et al., 2021; Pickering & Byrne, 2014). Primary and conceptual research papers were included to make the review more comprehensive and to provide the latest scientific evidence and thinking in this emergent transdisciplinary field of hospital gardens, well-being, and design.

The literature review was undertaken using the period 2016–2021, updated with 12 articles published from 2021 to 2023. This time frame represents the latest research and development in the emergent field that examines how gardens in hospitals can help people get and feel better. Gardens are increasingly included in hospitals because of the therapeutic effects of nature on our health and well-being. The PRISMA flow diagram (Page et al., 2021) illustrates the process of article selection. The Mixed Method Appraisal Tool (MMAT; Hong et al., 2018) was pertained to appraise the methodological quality of the selected primary research articles. This process enables the review to be repeated.

Database Search

Abstract and full article screening were conducted in 2021 Covidence software (Babineau, 2014) which facilitates collaboration and minimizes biases through its prescribed conflict resolution process. NVivo version 1.7 (1533) (Bandara, 2006) was used for qualitative data analysis to support data extraction and analysis. Multidisciplinary, scientific, and medical databases were searched initially to establish the extent of literature in the field. Initial databases searched to find relevant articles are presented in Supplementary Material 1.

A targeted Boolean string was created with key words from the research question, “What is the role of purposefully designed and well-integrated THGs?” Table 1 presents key words and alternative phrases. “Hospital gardens” define the boundaries for the therapeutic gardens. “Health” defines what the hospital gardens are about. “Therapeutic” describes the characteristics of the hospital gardens. Synonyms for “hospital garden” and “health” were included and “therapeutic” was substituted with words alluding to purposefully designed and well-integrated THGs.

Table 1.

Key Words for the Boolean Search String.

Question Key Words	Hospital Garden	Health	Therapeutic
Alternative key words/phrases	“Hospice Garden” OR “Clinic Garden”	“Well-being” OR “Wellbeing”	“Biophilia” OR “Biophilic” OR “Therapy” OR “Co-design” OR “Context” OR “Ecology” OR “Ecological” OR “Evidence-based” OR “Experience-based” OR “Nature-based” OR “Health-promoting” OR “Healing architecture” OR “Horticultural therapy” OR “Landscape design” OR “Landscape architecture” OR “Senses” OR “Sensory” OR “Green infrastructure” OR “Green space” OR “Art therapy” OR “Music therapy” OR “Biodiversity” OR “Biodiverse” OR “Community” OR “Healing Garden” OR “Outdoor area”

The Boolean string was revised over multiple iterations with a discipline specific research methods librarian to ensure a cohesive result that was replicable across databases. Key words and synonyms were tested in Scopus. Synonyms yielding positive results in Scopus were included in the Boolean string for the database searches. The resultant Boolean search string was:

(“hospital garden” OR “hospice garden” OR “clinic garden”) AND (health* OR well-being OR wellbeing) AND (biophili* OR therap* OR co-design OR context* OR ecolog* OR evidence-based OR experience-based OR nature-based OR “health-promoting” OR “healing architecture” OR “horticultural therapy” OR “landscape design” OR “landscape architecture” OR sens* OR “green infrastructure” OR “green space” OR “art therapy” OR “music therapy” OR biodivers* OR community OR “healing garden” OR “outdoor area”).

This search string was used to search Scopus, ProQuest, Web of Science, Ovid, CINAHL Complete (via EBSCOhost), EMBASE, Medline via EBSCOhost, Cochrane, Avery Index to Architectural Periodicals (via Ebscohost), GreenFILE (via EBSCO), and Google Scholar. Database searches for peer-reviewed articles included title, abstract, and key words and were limited to journal articles published with no time limit (Search 1), and for the last 10 (Search 2) and 5 years (Search 3) with all results, other than Google Scholar exported and saved in Endnote for processing.

Search 3 identified approximately a 2.2-fold increase in papers published in Scopus, ProQuest, and Ovid in the 5-year period (2016–2021) compared with the previous 5-year period (Search 2). Therefore, the research for this review focused on these most recent publications within the 5 years of 2016–2021. Employing this time frame is supported because the last 5 years have produced as many papers as has ever been produced previously as identified in Search 1 and Search 2.

The additional Google Scholar searches were scanned and used as a “large fish net” to identify if any relevant articles were missed. The author team decreased the number of databases and scanned the article titles and abstracts in the other databases to ensure important articles were not missed. Table 2 shows the database search results before screening.

Table 2.

Database Results Before Screening.

Databases Searched	Article Count
	Search 1 No Time Limit	Search 2 10 Yearsa 2012–2021	Search 3 5 Yearsa 2016–2021
Scopus	175	138	102b
ProQuest	100	67	42b
Web of Science	4	2	1
Ovid	78	46	27b
CINAHL Complete (via EBSCOhost)	15	10	8
Medline via EBSCOhost	7	6	4
EMBASE	6	4	3
Cochrane	0	0	0
Avery Index to Arch (via EBSCOhost)	0	0	0
GreenFILE (via EBSCO)	0	0	0
Subtotal	385	273	187
Google Scholar (excluded)c	153c	90c	59c

^a Inclusion dates for 10-year database searches: January 1, 2012 to July 20, 2021; and for 5-year database searches: January 1, 2016 to July 20, 2021. All database searches were conducted July 20, 2021.

^b Articles included in title and abstract survey.

^c Not included in database analysis but reviewed for inclusion in Supplementary Literature.

Journal Article Screening

The top three yielding databases for the period 2016–2021 were selected for title and abstract screening, that is, Scopus, ProQuest, and Ovid. No articles were captured in Cochrane, Avery Index Arch (via Ebscohost), or GreenFILE (via EBSCO), showing a lack of research on this topic in medicine, design, and science. To check the lack of design related articles, a simplified search using the key words hospital AND garden and (therap* Or heal*) was conducted in Avery Index Arch to identify design related research articles. No documents were identified. The full-text screening process yielded 28 articles for the literature review analysis as summarized in Figure 1. Inclusion and exclusion criteria were developed within the author team and refined over four sessions as presented in Table 3.

Figure 1.

Flow diagram for article selection.

Table 3.

Inclusion and Exclusion Criteria.

Inclusion Criteria

Exclusion Criteria

Written in English Peer-reviewed scholarly journal article Published between January 1, 2016 and July 2021 About the benefits and values from therapeutic hospital gardens Hospital gardens or gardens in clinical care facilities Definitions, typologies, and characteristics of health promoting therapeutic hospital gardens Benefits for humans and environment Views out to nature/community from a hospital

Non-English articles Nonacademic articles Unpublished working papers or industry reports Dissertations, magazines, or textbooks Published prior to 2016 Hospital gardens in rural or remote locations Hospital interior Virtual or pictures of hospital gardens Building focused Papers involving meta-analysis (literature reviews)

Critical Appraisal of Methodological Quality

The 28 articles (24 primary and four conceptual research studies) were selected from the final screening. The Mixed Methods Appraisal Tool (MMAT) was used to evaluate the 24 primary research articles (Hong et al., 2018; Pace et al., 2012). Four conceptual research articles were excluded because MMAT does not appraise conceptual research papers. MMAT enables researchers to report on methodological quality and, in doing so, the usefulness of the content and methodological process presented in the articles, given the variety of the study designs (Hong et al., 2018; Pace et al., 2012).

The MMAT appraisal was independently conducted by two coauthors to give rigor to the appraisal. Incongruities in the assessment results were discussed and negotiated between coauthors. As recommended in Hong et al. (2018), no primary studies were excluded because of low methodological quality, hence no overall MMAT score was produced. Results were contrasted and linked to study characteristics to strengthen the arguments presented in the following sections. MMAT results are presented in Supplementary Materials 2.1 and 2.2.

Thematic Analysis and Synthesis Design

The Boolean string used for the initial database searches was the first step to evolve the thematic analysis with the key words “hospital garden,” “health,” and “therapeutic” clearly defining the scope for the review. An inductive, abductive approach was used to guide the qualitative thematic synthesis in line with Pluye (2013) and Hong et al. (2018) based on (1) predefining themes to which data were assigned—hospital garden, health, and therapeutic; (2) revising themes to reflect the data; and (3) deriving new themes from the data. NVivo software was used to help code, analyze, and develop the themes for the 28 articles.

Literature Update to April 2023

Fifty-eight articles were identified in a Scopus database search on April 4, 2023, using the original Boolean string and exclusion and inclusion criteria. The search period was from the end date of the original review search to April 4, 2023. Title and abstract screening by the first author eventually produced 12 articles for full-text review. Search results and final article selection processes are presented in Table 4.

Table 4.

Article Selection for Literature Update 2021–2023.

Year	No of Articles Found	Included After Title and Abstract Review	Articles Selected After Full-Text Review
2023a	10	6	3
2022b	40	18	9
2021c	8	2	0
Total	58	26	12

^a January 1 to April 4, 2023.

^b January 1 to December 31, 2022.

^c July 21 to December 31, 2021, excludes article from January 1 to July 20, 2021, these were included in the original search conducted on 20 July.

Results

Having examined the 28 articles that address the role of purposefully designed and well-integrated THGs, it is obvious that hospital gardens are valued by users because of the capacity of the gardens to reduce stress and anxiety and put the mind at ease. Study contexts are diverse, making a meaningful comparison between study results challenging. The distilled three themes and 14 subthemes are discussed below and according to the thematic sequence presented in Figure 2.

Figure 2.

The role of therapeutic hospital gardens—themes and subthemes.

...hospital gardens are valued by users because of the capacity of the gardens to reduce stress and anxiety and put the mind at ease .

The first emergent theme—what makes a THG—became THG Definition with subthemes of Typology, Character/Function, and Design Processes. For academic research to contribute new knowledge, the key terms and processes need to be clearly defined to deliver sensible and comparable research results. The second emergent theme—who are the THG users and what are their needs—became “User Needs and Experiences,” with the subthemes of Definition—User Needs and Experiences; Patients; Hospital staff; Visitors & Volunteers; and Open and Restricted Access. Exploring user needs and experiences is critical to inform design and achieve personalized patient care and staff well-being. The third emergent theme—who benefits from THGs and how do they benefit—became “Benefits and Values,” with the subthemes of: Definition—Benefits and Values; Individual Benefits; Community Benefits; Organizational Benefits; and Environmental Benefits. Identifying THG benefits is critical in demonstrating the value proposition for individuals, communities, and organizations.

Study Characteristics and MMAT

Twenty-four articles were primary and four were conceptual research studies. The largest number of articles were published in the first half of 2021 (n = 6 for the first 6 months), followed by 2020 (n = 7 for 12 months), 2018 (n = 6), 2017 (n = 5), and 2016 and 2019 (n = 2 each). The largest portion of first authors were affiliated to the United States (n = 8), followed by Australia (n = 6), Sweden (n = 2), Iran (n = 2), and the United Kingdom, Germany, Spain, Denmark, Greece, Turkey, Italy, Argentina, Slovakia, and Serbia (n = 1 each). The 28 articles included 11 qualitative, 11 quantitative, and six mixed method studies. A detailed account of the review articles’ study characteristics is presented in Table 5.

Table 5.

Characteristics of Included 28 Review Articles.

No.	First Author/Year/Country	Methodology/Study Design	Setting/Sample Description
Qualitative
1	Blaschke et al. (2017), Australiaa	Grounded theory approach/Qualitative	Australian tertiary cancer care hospital inpatient wards and outpatient clinics, at least 18 years old and sufficient English to answer the questions; 20 cancer patients, nine females, mean age = 53 years; 11 undergoing treatments, five were inpatients, 15 were outpatients, eight face to face interviews and 12 phone interviews
2	Blaschke et al. (2018) Australiaa	Content analysis/Qualitative	Eligible adults with any cancer diagnosis; 12 patients (nine female) participated
3	Blaschke et al. (2020), Australiab	Concept analysis/Qualitative	Five cancer studies—first study—240 cancer patients across 11 studies; second study, 20 patients; third study, 20 patients; fourth study, 73 patients, 13 staff, 52 carers, five others; fifth study, 38 healthcare and design experts
4	Butterfield and Martin (2016) United Kingdoma	Exploratory Study/Qualitative	Two separate projects undertaken with staff, visitors and volunteers at 10 Maggie Centers in England, Scotland, Wales, and China; Martin’s project—(19 females, three males); 12 focus groups with 66 Center users in total (45 female and 21 males); one of the focus groups was with seven volunteers; Butterfield’s research—125 interviews (38 male and 87 female)
5	Dushkova and Ignatieva (2020), Germanyb	Unspecified/Qualitative	Review of primarily based peer-reviewed literature.
6	Igeño-Cano (2020), Spaina	Not specified/Qualitative	Intensive Care Unit (ICU)—lived experience from “healing walk” using “healing walk protocol”; experience from over 400 patients
7	Lygum Lygum et al. (2019), Denmarka	Post-Occupancy evaluation (POE)/Qualitative	Evidence-based crisis shelter garden. The interviewees included the crisis shelter leader, four childcare workers, three social workers, two psychologists, three residents or former residents, the janitor, and a weekend guard.
8	Reeve et al. (2017), Australiaa	POE/Qualitative	New premier state children’s hospital located in state capital city in Australia. Hospital has 11 purposefully designed healing gardens for patients, their families, and staff
9	Silva et al. (2018), United Statesb	Not specified/Qualitative	Conceptual research
10	Totaforti (2018), Swedenb	Not specified/Qualitative	Conceptual research
11	van der Riet et al. (2017), Australiaa	Narrative inquiry/Qualitative	Child-centered environment called a “Fairy Garden” in a Thailand hospital. Participants—Eight family members (seven parents and one grandparent)
Quantitative randomized controlled (trials)
12	Copeland (2021), United Statesa	Quasi-experimental pilot study/Quantitative	Suburban trauma center, level 1. 225 beds; participants—nurses randomly selected into five groups
13	Cordoza et al. (2018), United Statesa	Study intervention/Quantitative	Hospital—442 bed Level 1 trauma center with approximately 1,500 registered nurses; participants—21 nurses completed the Maslach Burnout Inventory survey
Quantitative nonrandomized controlled
14	Mihandoust et al. (2021), United Statesa	Cross-sectional study/Quantitative	Large tertiary care hospital. Nurses (n = 51) working in six units with varying level of nature exposure during breaks
15	Ulrich et al. (2020), Swedena	Study/Quantitative	442-bed hospital in Portland, Level 1 trauma center with multiple critical care units. Participants—family members or closed loved ones of ICU patients, excluded younger than 18-year-old and non-English speaking person; 65% of approached consented to participate
Quantitative descriptive
16	Allahyar and Kazemi (2021), Irana	Unspecified/Quantitative	Children’s Super Specialty Hospital. Questionnaire: children (n = 60), 60% female and 40% male, between 6 and 15 years old; staff (n = 60), 70% female and 18% male, 45% were between 20 and 30 years old, and 36.7% were nurses
17	Duzenli et al. (2017), Turkeya	Case study/Quantitative	Three Cardiovascular Surgery and Chest Diseases Training and Research Hospitals; total of 375 users in the three hospitals
18	Guido et al. (2018), Argentinaa	Case Study/Quantitative	Pediatric hospital on 9 ha plot with approximately 3 ha green spaces maintained to keep them looking well maintained
19	Karanikola et al. (2020), Greecea	Not specified/Quantitative	General University Hospital: Building area is 93,544 m2; hospital grounds are 200,000 m2; 673 beds; 370 medical staff, 563 nurses, 80 administrative staff; and 187 other technical and medical staff
20	Martin et al. (2021), United Statesa	Not specified/Quantitative	Major hospital, visitor satisfaction rates re-rooftop atrium; sample visitor size (n = 96); 67.6% female, non-Hispanic white (n = 77.1), half of the sample consisted of individuals 50 years and older
21	Paraskevopoulou et al. (2020), Italya	Unspecified/Quantitative	Clinic in Greece with 278 beds; outdoor surface area 5,500 m2; long stay and short stay medical cases; participants—patients and medical staff
22	Trau et al. (2016), United Statesa	Study/Quantitative	Large medical facility, medical staff with more than 800 physicians and 600 hospital beds. Participants—42 clinical and nonclinical staff, 18 or older
Mixed methods
23	Belčáková et al. (2018), Slovakiaa	Conceptual landscape design research, study area analysis + questionnaire to revitalize the hospital using the principle of therapeutic design/Mixed methods	Psychiatric hospital, six clinics, 480 beds, 340 employees. Questionnaire: Total participants (n = 77), hospital employees (n = 41), patients (n = 19), and visitors (n = 17)
24	Cacciatore et al. (2020), United Statesa	Not specified/Mixed methods	Carefarm with 30 animals, sustainable and vegan; includes horses, donkeys, pigs, sheep, goats, dogs, and cats. Formally designed “restorative spaces”—The Quiet Place; participants had suffered the death of child or sibling
25	McLaughlan et al. (2019), Australiaa	Phenomenology/Mixed methods	Royal Children’s Hospital, Melbourne. Participants: 246 children and young people—observation, 178 surveys, 25 photo-elicitation interviews, and 43 drawing exercises
26	Milliron et al. (2017), United Statesa	Cross-sectional study/Mixed methods	Outpatient clinic community garden in area of high poverty rates. Participants include adult male and female patients were randomly selected, 71 community volunteers, and clinical staff
27	Vujcic Trkulja et al. (2021), Serbiaa	Study/Mixed methods	Nature-based rehabilitation program at botanical gardens; participants were psychiatric patients and users of the Day Hospital of the Institute of Mental Health. Age 25–65 years old, 70% female
28	Zabihi et al. (2021), Irana	Unspecified/Mixed methods	Three hospitals in Iran

^a Empirical study (n = 24).

^b Conceptual study (n = 4).

The 24 primary research articles included in the MMAT appraisal included seven qualitative, two quantitative randomized controlled, two quantitative nonrandomized, seven quantitative descriptive, and six mixed methods research studies. Fifteen of the 24 studies achieved full marks. Six of the seven qualitative research studies scored full marks, five of the 11 quantitative research studies scored full marks, and four of the six mixed method research studies scored full marks. Based on Hong et al. (2018), the MMAT appraisal of the 24 primary research articles is presented in Supplementary Materials 2.1 and 2.2.

The outcome of the MMAT appraisal, while providing insight into the methodological quality for each article, does not offer a baseline for what can be considered a “pass” or “fail” for a study (Hong et al., 2018). Rigorous research is critical to evidence-based design, and it is hoped that over time methodological research quality can be improved and, in that way, aid in comparing mixed methods research results. The results of the 28 articles evidenced in Table 6 and Figure 2 illustrate the themes and subthemes and the interconnectedness of definition, user needs and experiences, and the benefits and values of THGs.

Table 6.

Evidence Summary.

	First Author	Study Aim	Typology	Method of Data Gathering and Analysis	Key Findings	Author Conclusions and MMAT Appraisal
Qualitative
1	Blaschkea	To explore cancer patients’ subjective experiences with nature to examine the relevance of nature-based care opportunities in cancer care contexts	Nature	Semi-structured interviews (open ended); inductive, comparative method with grounded theory	Nature contact for patients is important because it helps cancer patients to deal with reality and to accept a shifting normality by offering a place of comfort and safety	Nature and nature-based therapy are broad concepts, clarification of the research field could strengthen the study findings and practical application. Perfect Mixed Method Appraisal Tool (MMAT) score = high-quality paper.
2	Blaschkea	To explore cancer patients’ recommendations for nature engagement based on their subjective nature experiences and observations in the cancer setting.	Nature	Semi-structured interview (open ended) and audio recorded; transcribed textual data; deductive analysis using three determined categories—features, function, and cautions	Nature offers sensory stimulation and engagement, personal space and freedom, distraction and comfort, and physical activity and movement which is important to cancer patients’ well-being	Nature and nature-based therapy are broad concepts, clarification of the research field could strengthen the study findings and practical application. Perfect MMAT score = high-quality paper.
3	Blaschkeb	To consolidate existing research related to nature- based supportive care opportunities and generate a conceptual framework for discerning relevant applications in the supportive care setting	Nature and nature experiences	Conceptualizing research findings from the five studies, in a two-step analytical process, into a conceptual framework constructed from previous research investigations for guiding nature-based supportive care design and future research	Nature is valued by cancer patients because it allows connecting with what is genuinely valued, distancing from the cancer experience, sense-making and reframing the cancer experience, finding comfort and safety, and vital nurturance	Nature and nature-based therapy are broad concepts, clarification of the research field could strengthen the study findings and practical application. Excluded from MMAT appraisal because of conceptual research
4	Butterfielda	To explore the designed environment to enhance the experience of well-being through the provision of communal areas within which visitors can find private places for emotional retreat, encouraging the experience of affective sanctuary.	Gardens	Includes 22 semi-structured interviews and 12 focus groups. Observation and photo-elicitation interviews where staff and visitors took their own photographs. Photographs were used for short oral interviews; all data analyzed using Framework, a qualitative data management tool for social research	The designed environment enhances the experience of well-being for cancer patients by offering visitors private places for emotional retreat and thereby encouraging the experience of affective sanctuary	Research aim could be made clearer by focused research question. The reflective style of this paper is more relaxed in the coverage of methods and results but is evident and structured
5	Dushkovab	To explore the main types of healing gardens and therapeutic landscapes and to suggest a framework of design principles for healing and therapeutic landscapes	Nature and gardens	Review and discuss existing scientific evidence on the human–environmental relationships and health benefits from the contact with nature; individual and community scale; feature practice examples. Explorative survey. Detailed onsite analysis including surveys and a series of interviews. Analyze to what extent the principles, and concepts that were revealed can be recognized and applied in urban planning and governance in cities. Analysis based on the methodical approaches for the assessment of therapeutic values of landscape, healing gardens and cobenefits from nature-based solutions	Healing gardens and therapeutic landscapes provide multiple benefits and can be regarded as nature-based solutions. These essential aspects of multifunctionality, multiculturality, and social inclusion are well-intertwined with the approach of biophilia.	Very conceptual, hard to relate to practice outcomes. Excluded from MMAT appraisal because of conceptual research
6	Igeño-Canoa	To explore the lived experience of staff taking patients for 15-min walks in their beds to outside gardens to stimulate the patient’s senses and thereby improve health outcomes	Nature and gardens	A 15 min “healing walk” and observed improvement. Analysis observation—recording of patient improvements	Suitable patients secure positive health outcomes from a 15 min “healing walk”—the bed being wheeled through outdoor hospital gardens. The benefits evidenced in healthy individuals and in noncritical patients could be extrapolatable to patients admitted to the ICU	Does not define what restorative and therapeutic gardens are; setting and sample unclear, method of data collection and data analysis would benefit from more detail and strengthen the findings. Research question and methods not clear = no score in MMAT appraisal
7	Lyguma	To explore the benefits of an evidence-based crisis shelter garden as a setting for everyday activities and nature-based therapy	Garden and nature	Landscape analysis, observation of physical traces, interviews (semi-structured and open ended), and subsequent participatory design. Landscape analysis and observation-generated hypotheses which were explored through interviews; thematic content analysis to analyze interviews	Participatory design makes gardens safer, positively distractive, and more versatile in terms of activities. Maintenance, accessibility, safety, therapeutic setting and free space, many ways to play, and social and private spheres are important aspects of crisis shelter gardens	Perfect MMAT score = high-quality paper
8	Reevea	To explore visitor feedback about healing gardens at a children’s hospital to gain insight into end-user experiences	Healing gardens	Visitor books/bench diaries were left in four healing gardens to collect unsolicited visitor feedback. Thematical analysis of collected data and coding the comments according to themes	The healing gardens provide emotional respite to visitors, through appreciation of the views, being able to have time out, being in nature, restorative experiences, and access to outdoor air. The garden design is critical to enhancing visitor benefits	Perfect MMAT score = high-quality paper
9	Silvab	To explore and advocate for advancing environmental health research through environmental epidemiology that more fully and directly accounts for the salutogenic effects of the natural environment on individual well-being	Natural environments and nature	Literature review and conceptualization.	Defining “natural environments” broadly, considering exposure/uses comprehensively, doing individual-level assessments/experiences and collecting representative data is important in advancing the inclusion of nature in the built environment for human health and well-being	Very conceptual, clarification of natural environment/research fields, and what a dose of nature is would strengthen the findings. Excluded from MMAT appraisal because of conceptual research
10	Totafortib	To explore a new architectural language—biophilic design—for hospitals and to shed light on the key features of health-inducing buildings	Nature and natural environments	Review and conceptualization Analysis	The humanization of healthcare spaces and contact with nature can empower the patient and have a positive impact by reducing stress and pain and improving emotional well-being. Further studies to deepen our understanding of the human–nature relationship and its impact on health are needed	Excluded from MMAT appraisal because of conceptual research
11	van der Rieta	To explore experiences of family members of sick children who have participated in formal and informal activities in a child-centered environment called a “Fairy Garden”	Gardens, nature and healing gardens	The eight family members were organized into four focus groups and interviewed in pairs over a 5-week period. Interview time varied from 40 min to 1.5 hrs. Using Clandinin—a narrative view of the experience and not just approaching this research as an analytical device	The Fairy Garden improves the quality of life for sick children and their families and includes storylines of happiness and relaxation, cooperation from the children, and social interaction and learning	Larger sample would have strengthened the findings. Perfect MMAT score = high-quality paper
Quantitative randomized controlled (trials)
12	Copelanda	To explore the feasibility, acceptability, and effectiveness of brief, 5-min interventions, that is, break outdoors on nurses’ burnout, compassion fatigue, and perceptions of teamwork	Gardens and nature	Meditation app on mobile phone/questionnaire; Postintervention survey, participants record keeping logs. ProQOL and teamwork variable scores to determine the magnitude of the effect of the interventions; Pearson r correlation to examine ProQOL and teamwork variables	Intentional 5-min interventions such as a break outdoors can improve nurses’ well-being. The outcome of this study can inform the feasibility, acceptability, and effectiveness of these brief workplace interventions to inform a larger study	The aim was general effectiveness of the intervention and not to make inferences which validates the small sample
13	Cordozaa	To explore the impact of nurses taking daily work breaks in a hospital garden compared to indoor-only breaks on nurse burnout in a hospital	Gardens	Maslach Burnout Inventory (MBI)—Human Services Survey over a 6 week period; participants rate items on a point scale from ‘never' to ‘daily'; responses are quantified into 3 subscales; Statistical analysis: Analyses were performed using R, Version 3.2.2 (R Project for Statistical Computing)	Compared with indoor breaks, total symptom scores improved significantly when nurses took a break in the garden. Significant improvement was apparent in scores for emotional exhaustion and depersonalization but not for personal accomplishment for nurses spending daily work breaks in a garden	MMAT: Crossover design for nurses to use as their own controls, MBI completed by 21 of the 29 nurses, not explicitly mentioned, but usual control trial protocol followed, with statistical analysis of results. It is inferred that the nurses were de-identified as part of standard methods
Quantitative nonrandomized controlled
14	Mihandousta	To investigate the relationship between perceived visual access to nature views in nurse work and break environments	Nature and gardens	Questionnaire using standard instruments—MBI, nurse work index (NWI), and a self-report on nurses’ demographics and their works environment perception. Outcome variable was nurse burnout, measured by MBI. MBI instrument included 22 statements	Nature views are an independent or integrated intervention to meditation and relaxation techniques to alleviate nurse burnout. Unit and break room design with access to nature views could work as a consistent preventive intervention for burnout	Perfect MMAT score = high-quality paper
15	Ulricha	To explore and compare the stress levels of ICU family members visiting a hospital garden compared with ICU family members visiting indoor recreation spaces.	Garden and nature	Peds QL TM module of Present Functioning Visual Analogue Scales (PFVAS)—self report instrument that measures stress and six symptoms. Mathematical analysis—calculating the difference between the scores at the start and end of the study	Stress scores significantly declined from the start to the end of a break in both the garden and indoors locations. However, garden breaks resulted in significantly greater improvement in the “sadness” scale than breaks in indoor locations.	Not all MMAT questions could be appraised
Quantitative descriptive
16	Allahyara	To examine the preferences of children and therapists on landscape design factors in a children’s hospital to improve well-being	Green spaces and gardens	Simulated images-photo demonstration/photo montages and questionnaire-based interviews, printed photos presented as flashcards. SPSS software package Version 22 was used in two formats—descriptive and inferential	No significant differences were reported between children’s and therapists’ preferences on the preferred landscape of a children’s hospital which included weeping-form trees, warm colors, topiary animal shapes, cartoon characters, combinations of flowers and turf and water features, and flower beds.	Images presented are biased, limited and not representative of landscape design options. Subfactors (colors, tree forms, the presence of topiary or shaped plant elements, design styles, fountain and water element, and furniture) trivialize the process of landscape design. The majority of MMAT questions could not be appraised
17	Duzenlia	To explore if and how three hospital gardens meet user preferences, user needs, and user expectations.	Gardens and nature	Landscape evaluation using questionnaire; Stage 1—Landscape evaluation of hospital ground using a questionnaire with 30 criteria and scoring 0–2; Stage 2—Primary standards is the cultural setting—“demand and expectations”; evaluation through pairs of adjectives using a 5-point Likert-type attitude scale to evaluate user perceptions of the gardens	The hospital gardens do not have the quality to be able to meet the needs of the users, they do not have enough landscape value to contribute to the physical–spiritual development of the users and they do not have adequate landscape criteria	Tools could be more detailed to support the findings and replication in the future. Perfect MMAT score = high-quality paper
18	Guidoa	To explore the extent of knowledge on how natural green spaces affect the health of hospitalized patients	Green spaces and gardens	Taxonomic survey of existing plants—69 different plant species. Analysis—Relating plant species survey outcome to therapeutic green space	Gaining a detailed knowledge of existing species in the hospital’s natural green spaces together with a strategic plan based on people’s interaction with nature (in different modalities) may help to improve the well-being and health of patients, care givers and healthcare staff	Methods are arguably questionable—Simplistic view of what makes a therapeutic garden which is trivializing the complexity of landscape design. Perfect MMAT score = high-quality paper
19	Karanikolaa	To explore the hospital indoor and outdoor spaces in relation to environmental parameters and their psychological effects on their users	Outdoor spaces and green spaces	Survey and face-to-face interview using a questionnaire; 300 questionnaires were distributed randomly—22.33% of employees participated. Statistical package SPSS was used for data processing. Use of a two-step cluster analysis and the hierarchical cluster analysis to derive important design findings for healthcare environments	A lack of appropriate hospital green spaces—even though their beneficial role was acknowledged—and marginal satisfaction with available spaces is apparent	The baseline for user satisfaction are the current hospital grounds, arguably, the satisfaction rate is questionable because it is up to the participant to imagine a better hospital garden. Perfect MMAT score = high-quality paper
20	Martina	To measure hospital visitors’ satisfaction with a rooftop atrium and its resultant impact on the visitors’ behavioral intentions toward the healing garden, the hospital, and overall satisfaction with the hospital	Gardens and healing gardens	Questionnaire with two healing garden experiences questions administered by trained grad student. Power analysis was conducted employing G*Power Version 3.1	Visitors’ experience with the healing garden can lead to overall satisfaction with the hospital and behavioral intentions toward the hospital. Visitors’ satisfaction with the healing garden significantly predicted their satisfaction with the hospital, their intent to revisit the hospital, and their intent to recommend it	Scant detail on what the rooftop atrium is, better description of the research field could strengthen the findings. Perfect MMAT score = high-quality paper
21	Paraskevopouloua	To explore how the needs of patients, staff, and visitors can inform the design of hospital healing gardens	Gardens, healing gardens and green spaces	Site analysis and questionnaire survey. Statistical analysis using SPSS Statistical Software Version 16.0	Most of the patients visit the hospital grounds during morning and noon hours, while the staff visits during noon and early evening hours. Staff requested staff only seating areas. Most medical staff allowed patients to participate in mild outdoor activities such as, walking, gardening, and light exercise. Most patients wanted to do gardening and preferred color, a pergola or kiosk, and perfumed plants in the hospital grounds whereas staff preferred plant shade	Method of data gathering questionable because of the complexity of design which, arguably, cannot be adequately addressed with survey questions. Research question and methods not clear = no score in MMAT appraisal
22	Traua	To explore the effect on staff well-being pertaining to the amount of outdoor, indoor, and indirect nature contact exposures hospital employees have in a workweek	Nature, gardens, and green spaces	Nature Contact Questionnaire (NCQ) collecting data from postsurgical floor staff. A nonparametric Mann–Whitney U test was used to analyze the data and perform the statistical review	Employees on the fourth-floor postsurgical floor have limited ability to reduce stress through nature contact exposures which could impact their perceived levels of work stress and stress-related behaviors and health outcomes	The study finding would have benefited from defining what nature exposure is and how long the nature exposure lasted. MMAT only partly completed—The incentive to participate (nature print) would bias participation by those who like nature
Mixed methods
23	Belčákováa	To explore outdoor environmental factors that will bring positive changes for patients while serving as a relaxation space for employees	Gardens and nature	Hospital ground description and analysis, literature analysis, and questionnaire. Content (thematic) analysis via site assessment and questionnaire—statistical	Landscape therapeutic design incurs some considerable financial costs, but according to surveys, the creation of healing gardens in medical facilities reduces healthcare expenses	Researchers influence on findings not considered. Trivializes the process of design and the principles of therapeutic design. MMAT appraisal could not determine study aim and method
24	Cacciatorea	To explore the efficacy of care- farming as an intervention for individuals affected by traumatic grief	Nature and care- farming	Traumatic Grief Inventory Self-Report (TGI_SR)—QUAN Semi structured interviews—QUAL; seven related items were added asking about coping with difficult grief-related experiences rather than the severity of the experiences themselves. These items were matched to TGI-SR questions to create an overall coping score—QUANT Transcripts were analyzed in NVIVO following a “thematic analysis” approach	This care farm intervention was beneficial, yielding significant reductions in subjective distress to grief intensity. The study’s findings add to the growing body of evidence on care-farming and support green care as a therapeutic potential for individuals affected by traumatic grief	Perfect MMAT score = high-quality paper
25	McLaughlana	To explore whether, in the context of a pediatric hospital, a distraction needs to “hold attention” to secure positive benefits for patient well-being	Gardens and nature	Surveys, drawings, photo-elicitation interviews with patients and spatial observation. Analysis	Positive distraction and its contribution to well-being within the pediatric hospital environment is more complex than existing models accept. Environmental features can positively transform expectations of visiting the hospital. This is relevant in the context of absenteeism from outpatient appointments and in reducing patient resistance to future, or ongoing, treatments	The great majority of the research concerns the building. Perfect MMAT score = high-quality paper
26	Millirona	To conduct a process evaluation of patient, volunteer, and staff participation in the clinic community garden	Gardens	Patients—Three question community garden participation screener during appointment check-in procedures; volunteers—online survey. In-depth patient survey with a minimum of 150 participants. All statistical analyses were performed using Statistical Analysis Software, Version 9.2	Volunteers reported learning about gardening, feeling more involved in the neighborhood, environmental concerns, and medical staff endorsed the garden for patient education/treatment	Clarification of the research field could strengthen the study findings and practical application. Perfect MMAT score = high-quality paper
27	Vujcica	To explore the clinical benefits of a nature-based rehabilitation program (NBRP) for people with stress-related mental disorders	Gardens and nature	Clinical Global Impression (CGI) and site observations, descriptive and inferential statistics; Statistical Package for the Social Sciences, Version 18	Psychological recovery of the participants seems to be related to NBRP. The restorative potential of the garden was recognized through the observed interaction between participants and the natural entities employed through the various themed activities	Perfect MMAT score = high-quality paper
28	Zabihia	To explore the effects of planting design in hospital landscapes on the users’ wayfinding using space syntax techniques	Green spaces and gardens	Space syntax technique using five main syntactical measures; depth map software. Mathematical analysis—comparison techniques	Planting configurations in the hospital landscape can affect individuals’ wayfinding. Integrated and regular planting design can pave the way for intelligible space and easier wayfinding	Method of data gathering questionable—quantitative analysis of planting design is arguably questionable. MMAT appraisal could only partly be completed

^a Empirical study (n = 24).

^b Conceptual study (n = 4).

Definitions of THGs (Theme 1)

A THG can mean different things to different people, therefore making it necessary to say what makes THGs, how they are used and by whom, and importantly how such gardens can be established successfully.

A THG can mean different things to different people, therefore making it necessary to say what makes THGs, how they are used and by whom, and importantly how such gardens can be established successfully .

Typologies (Theme 1.1)

Various terms were used in the 28 articles to name the clinical setting and this diversity of terminology, as presented in Figure 3, ranged from conceptual descriptions such as nature or nature experience to specific descriptions such as gardens or healing gardens. When one considers the different terms used, for example, “healing garden” in the Reeve et al. (2017) study and “nature experience” in the Blaschke et al. (2017) study, the need for common terminology is obvious. It is critical to have a universal understanding of the clinical setting in which the nature and health relationship is explored to compare results between studies.

Figure 3.

Terminology used to describe hospital gardens in the 28 articles.

Character and Function (Theme 1.2)

For gardens to become therapeutic places, they must be tranquil, peaceful, natural, comfortable, appealing and stimulating all at the same time (Duzenli et al., 2017). Above all, the character of the garden must suit the needs of the user. The purpose of a health-promoting hospital garden can vary from open access to restricted access characterized by medically led rehabilitation or therapy programs. While 22 of the 28 articles named the functional and, or the aesthetic characteristic of the researched typology, the great majority failed to be explicit in describing what those entail, thereby weakening the outcome of the results and making comparisons between studies difficult.

Design Processes (Theme 1.3)

Rigorous design processes are critical to support reliable and replicable design outcomes when various stakeholders and multiple disciplines are involved. Three of 28 articles explored design processes for hospital gardens, including interdisciplinary design collaboration and project evaluation. The Lygum et al. (2019) Post-Occupancy Evaluation (POE) study of a crisis shelter garden outlines the importance of POE in improving design processes to optimize user benefits. A cyclical process of evidence-based and participatory design is used to optimize design outcomes. The project outcome shows the value of collaboration among different disciplines and in that way enables designers to solve diverse problems that they cannot solve alone.

Theoretical frameworks can inform design processes and support practical design outcomes, such as improved health and well-being. The theoretical context prevalent in the writing includes stress recovery, stress reduction, and supportive design (Ulrich, 1984; Ulrich et al., 2020; Ulrich et al., 1991); salutogenic or health promoting environments (Antonovsky, 1979); biophilia, the love of nature, and biophilic design (Wilson, 1984); and nature-based therapy (Naor & Mayseless, 2021). Figure 4 presents a summary of the theoretical contexts.

Figure 4.

Theoretical context for the 28 articles.

The criticality of design processes to achieve the outcome is mentioned in 22 of the 28 articles, but scant detail is offered how such gardens are designed, who is involved, and what is a quality design process.

User Needs and Experiences (Theme 2)

Exploring user needs and experiences is critical to inform THG design, achieve personalized patient care and staff well-being. The theme, user needs and experiences, is addressed in 26 of the 28 articles, demonstrating the research interest in exploring the human–nature experience and resulting benefits to health and well-being while in care.

Defining User Needs and Experiences (Theme 2.1)

While user needs and experiences are mentioned in 26 of the 28 articles, they are not defined enough to inform a purposeful design or support the integration of user needs and experiences for hospital programming. The lack of detail may be because of insufficient stakeholder engagement or feedback from patient/user cohorts. User needs and experiences are well covered by Blaschke et al. (2017), Butterfield and Martin (2016), and Lygum et al. (2019). Most articles focus on a collective group of users, rather than differentiating users in terms of patients, their families, communities, or hospital staff. This bundling of users in the 28 articles weakens the results. Only when the patient’s personal circumstances and medical conditions are sufficiently detailed, research results are comparable and suitable to inform improvements.

Patient Needs and Experiences (Theme 2.2)

A patient’s needs while in hospital depend on personal circumstances, on their life situation, and mental and physical capacity after serious illness (Blaschke et al., 2017). People living with cancer value being in nature because it enables a connection with what is truly valued, offers time out from the cancer experience, supports sense making, and reframes the cancer experience by feeling vital support, strength, and hope for the future (Blaschke et al., 2018; Blaschke et al., 2020; Blaschke et al., 2017). User experience validates that sensory stimulation, distraction, relaxation, personal safety, physical activity, and individual freedom are experienced by patients when in nature, all of which are important to patient well-being. Incongruity was identified between the needs of patients and the recommendations from experts. Experts focus on practical needs and exercise opportunities for patients, whereas patients focus on the experiential qualities of their nature engagements (Blaschke et al., 2020).

Butterfield and Martin (2016) concur that garden users, experiencing a crisis that challenges perception, purpose, and meaning, are comforted by being in nature, and they draw personal symbolism from the garden experience to make sense of it all. According to Igeño-Cano (2020), carers reported improved patient conditions because of increased brain function after taking patients for 15-min garden walks in their beds. Carers conjecture that the benefits noticeable in healthy individuals and in noncritical patients may be extrapolated to patients admitted to intensive care units (Igeño-Cano, 2020). The lack of opportunities to access suitable gardens prevents user needs from being satisfied (Igeño-Cano, 2020). Despite the evidence of dissatisfied hospital garden users (Karanikola et al., 2020), the literature largely focuses on visitor experience without questioning the quality of garden spaces.

Staff Needs and Experiences (Theme 2.3)

Ten of the 28 articles explored staff needs or experiences of nature, illustrating the importance placed on staff well-being. Research findings acknowledge the vulnerability of nurses from experiencing burnout because of their demanding work, which affects patient care and hospital efficiencies. Workplace interventions addressing burnout, compassion fatigue, and teamwork found that short outdoor breaks can improve nurses’ well-being and performance (Copeland, 2021). Cordoza et al. (2018) assert that easy access to nature during work breaks was shown to improve the working conditions for nurses as evidenced in reduced stress levels, boosted staff morale, and improved nurses’ well-being and teamwork. Offering easy access to a staff garden in the work environment is a cost-effective way of supporting patient care and staff well-being (Copeland, 2021; Cordoza et al., 2018).

Visitor and Volunteer Needs and Experiences (Theme 2.4)

According to Reeve et al. (2017), researchers used “bench diaries” to establish that healing gardens at a children’s hospital offer an emotional breather and distraction to visitors, a connection with normality and a restorative experience. Compatible with similar studies and their findings, this visitor feedback reveals the criticality of the garden design, eliciting positive visitor experiences to satisfy visitor needs, and resulting in improved well-being (Reeve et al., 2017). Gardens provide emotional respite to visitors, through enjoying a view as a connection to the outside world, being able to have time out in a natural environment, and being part of something bigger (Blaschke et al., 2017; Reeve et al., 2017).

Milliron et al. (2017) claimed volunteers working in a hospital garden feel more involved in the neighborhood, have a greater appreciation of their self-worth, and provide a vital connection between the hospital and the local community. Volunteers are critical in supporting patient care and hospital operations because of their valued psychological and physical support for patients, their families, and the hospital organization (Milliron et al., 2017).

Open Visitor Access (Theme 2.5)

Open access gardens, meaning unrestricted use of hospital gardens, are important for patients and staff. It gives patients the opportunity to be in control themselves in a monitored and clinical hospital environment (Ulrich et al., 2020). This brings a sense of normality to patients’ lives, which encourages feelings of well-being (Butterfield & Martin, 2016; Ulrich et al., 2020). Gardens are used by patients in different ways depending on their need for care and power of mind (Lygum et al., 2019). Unrestricted access to hospital gardens can improve a patient’s mood, outlook on life in times of heightened medical needs, pose respite from the emotional demands of medical treatment or from caring for loved ones, and offer places of sanctuary and sociability (Blaschke et al., 2017; Reeve et al., 2017).

Restricted Visitor Access (Theme 2.6)

Restricted visitor access applies to gardens purposed for medical interventions such as therapy and rehabilitation. There, patients actively join in organized health promoting activities, including horticultural and nature-based therapy, important to individual care needs (Dushkova & Ignatieva, 2020). Therapy gardens are designed for safety, including feeling safe and protecting from self-harm and physical and mental comfort. They are also designed for social interaction, based on the mental power of the patient, and nature contact by offering access to various nature experiences (Lygum et al., 2019).

Benefits and Values (Theme 3)

Hospital gardens can be beneficial for individuals, communities, the hospital organization, and the hospital environment. The health promoting qualities of nature experienced in the gardens can add value to patient care, well-being of visitors and volunteers, and the hospital environment and so increase societal, economic, and environmental health. These benefits are significant because it shows the wide-ranging impact such gardens have on healthy hospital communities.

Defining Benefits and Values (Theme 3.1)

Reported benefits in this context means using measurable outcomes to show how gardens can be helpful for patients, families, staff, and the hospital organization. Measuring the positive effects of hospital gardens is critical for recreating these benefits. The measured benefits will substantiate the health and economic values of the gardens.

Individual Benefits (Theme 3.2)

Twenty-two of the 28 review articles explored health and wellness benefits experienced by patients, family members, and staff. Gardens in hospitals can help people feel better and recover more quickly (Ulrich et al., 2020). Gardens provide sensory stimulation that can lead to physical and mental benefits, such as reduced stress, improved immune function, and increased social connectedness (Dushkova & Ignatieva, 2020).

Patients, families, and staff appreciate being in a familiar and calming environment that evokes memories of the outside world and a desire, consciously or unconsciously, to get better sooner (Reeve et al., 2017). Gardens in hospitals are valued when gardens are easy and safe to access and offer a sense of normalcy (Reeve et al., 2017). According to Blaschke et al. (2017), such spaces are experienced by cancer patients as a sanctuary, a place of sensemaking, and a place to have a moment to just be, think, and let the world go by.

For a child, garden access can improve the psychological and physical markers for the children’s behavior by reducing anxiety and pain, improving muscle strength, and willingness to eat and take their medication (van der Riet et al., 2017). Garden access also stimulates their interest and fascination with the natural world (Karanikola et al., 2020), so providing respite and relief from boredom while awaiting consultation, diagnoses, or treatment (McLaughlan et al., 2019). Long-term exposure to nature strengthens children’s sense of self and self-worth; creates motivation for involvement, curiosity, risk taking, and creativity; and has a positive effect on behavior and cognitive development of school children (Guido et al., 2018).

Gardens in hospitals can also be used for education, promoting a healthy lifestyle through growing and eating fresh produce (Milliron et al., 2017). Importantly, research confirms that learned habits of enjoying and eating fresh produce in hospital are practiced by patients who had left the hospital (Milliron et al., 2017). Copeland (2021) and Cordoza et al. (2018) assert that garden access can be an effective intervention to address burnout and compassion fatigue experienced by nursing staff and in doing so improve staff satisfaction, staff well-being, and teamwork.

Community Benefits (Theme 3.3)

Five of 28 articles discussed the community benefits of hospital gardens. These gardens are important to communities because they provide a place to relax, heal, meet, socialize, and create memories in a comfortable and natural environment (Totaforti, 2018). Milliron et al. (2017) assert that community gardens promote community activities, civic pride, and build social well-being. According to Dushkova and Ignatieva (2020), hospital gardens support many special needs communities and user groups and provide a suitable place for communal activities inspired by nature.

Organizational Benefits (Theme 3.4)

Of the 28 articles, two touch upon the noteworthy financial and organizational advantages for hospitals that arise from the presence of gardens. Although healthcare services are provided in gardens, the gardens are more important to individuals and communities, because they embody the essence of normality for users in a clinical hospital environment. Martin et al. (2021) reveal that gardens in hospitals can enhance organizational efficiencies and social cohesion, while providing environments for health promotion. The 28 articles highlight several organizational benefits linked to gardens, including shorter hospital stays, better staff well-being, improved healthcare outcomes, lower healthcare costs, higher service satisfaction, raised staff productivity and competency, decreased sick leave, greater staff happiness, and improved focus levels (Blaschke et al., 2018; Martin et al., 2021).

Environmental Benefits (Theme 3.5)

None of the reviewed articles were about environmental benefits; however, improved air quality, heat and humidity regulation, stormwater management, noise reduction, impact on biodiversity levels, and improved environmental building performance and importantly a desire to return to the hospital were mentioned (Karanikola et al., 2020; McLaughlan et al., 2019; Silva et al., 2018). Overall, gardens can contribute to a happier, healthier, and more efficient hospital environment.

Literature Review Update

Table 7 presents an update of the literature review to 2023, including key findings and contributions to the three themes and 14 subthemes. The 12 articles show the continuing interest in this research field and fit the parameters set by the themes and subthemes established by the 2016–2021 review. The two original key findings also apply that there is a need to (1) have consensus on terminology and (2) identify the design process to move forward.

Table 7.

Literature Review Update to April 4, 2023—Key Findings and Theme Contributions.

Article No	First Author/Year/Journal	Title	Key Findings	Theme Contributions (Refer Figure 2)
1	Staniewska (2022), Land	“Gardens of Historic Mental Health Hospitals and Their Potential Use for Green Therapy Purposes”	Gardens in former psychiatric institution may be suitable for today’s use in nature therapy. Such repurposing can be beneficial to patients and the owner of the institution.	User needs and experiences—Patients (Theme 2.2); Benefits and values—Individual Benefits (Theme 3.2) and Organizational Benefits (Theme 3.4)
2	Untaru et al. (2022), Journal of Men’s Health	“Green Environment, Mental Health, and Loyalty among Male and Female Patients”	Patients self-reported mental health improvements, and increased satisfaction rates for medical care and loyalty toward the clinical provider when access to biophilic elements was provided.	User needs and experiences—Patients (Theme 2.2); Benefits and values—Individual Benefits (Theme 3.2) and Organizational Benefits (Theme 3.4)
3	Ziabari et al. (2023), Health Environments Research & Design Journal	“Evidence-Based Design in the Hospital Environment: A Staff’s Burnout Study in the COVID-19 Era”	Access to natural light and nature views can reduce burnout in physicians and nurses. Staff in emergency departments had the highest burnout score.	THG Definition—Character/function (Theme 1.2); User Needs and Experiences—Hospital staff (Theme 2.3); Benefits and Values—Individual Benefits (Theme 3.2); and Organizational Benefits (Theme 3.4)
4	Cui et al. (2022), Health Environments Research & Design Journal	“Influence of Hospital Outdoor Space on Physiological Electroencephalography (EEG) Feedback of Staff”	The physiological response from different outdoor spaces affected staff in different ways. Exposure to water and nature reduced stress, whereas paved areas had the opposite effect. More evidence-based design could optimize organizational benefits from outdoor spaces.	THG definition—Typology (Theme 1.1) and Character/Function (Theme 1.2); User Needs and Experiences—Hospital staff (Theme 2.3); Benefits and Values—Individual Benefits (Theme 3.2); and Organizational Benefits (Theme 3.4)
5	Eraslan and Ayşegül (2022), Journal of the Faculty of Architecture	“Outdoor Heals: An Example of a Healing Garden in a Rehabilitation Center”	The design of a themed healing gardens is critical to the physical and mental health needs of users. Concept drawings were developed in consultation with medical experts and 3D sketches prepared to illustrate the design outcome.	THG definition—Typology (Theme 1.1); Character/Function (Theme 1.2); and Design Processes (Theme 1.3)
6	Idris et al. (2022), Planning Malaysia	“The Architects’ and Landscape Architects’ Views on the Design And Planning of the Hospital Courtyard Gardens (HCG) in Malaysia”	Architects and landscape architects have shown to have different priorities designing and planning a hospital courtyard. Architects are concerned with daylight, ventilation, access to nature, and wayfinding. Landscape architects are concerned with forest-like gardens, curvilinear, and organic shapes, providing a place conducive to reducing stress and anxiety and a place to socialize. The paper contributes to an understanding how gardens can be designed to meet the needs of the intended users.	THG definition—Typology (Theme 1.1); Character/Function (Theme 1.2); and Design Processes (Theme 1.3)
7	Iqbal and Abubakar (2022), Health Environments Research & Design Journal	“Hospital Outdoor Spaces as Respite Areas for Healthcare Staff During the COVID-19 Pandemic”	Gardens and open spaces can reduce stress and anxiety for staff in healthcare facilities. This is a call to action addressing Hospital CEOs and government agencies to provide access to nature in healthcare facilities to reduce stress and anxiety in the workforce.	Benefits and Values—Individual Benefits (Theme 3.2) and Organizational Benefits (Theme 3.4)
8	Olszewska-Guizzo et al. (2022), Frontiers in Psychiatry	“Therapeutic Garden with Contemplative Features Induces Desirable Changes in Mood and Brain Activity in Depressed Adults”	Mental health patients benefit from passive contact with therapeutic gardens. The study also established that benefits are experienced by depressed and nondepressed individuals. Mental health patients reliably benefit from being in contact with gardens, whereas mood improvements of nondepressed individual may be affected by social interaction. The study indicates that the quality of landscape design can result in different psychophysiological responses.	THG definition—Typology (Theme 1.1) and Character/Function (Theme 1.2); Benefits and Values—Individual Benefits (Theme 3.2)
9	Pijpker et al. (2022), Frontiers in Psychology	“Developing an Intervention and Evaluation Model of Outdoor Therapy for Employee Burnout: Unraveling the Interplay Between Context, Processes, and Outcomes”	Six outdoor interventions were identified to affect therapy treating burnout: (1) being physically active; (2) regarding body and mind as one; (3) using nature metaphors; (4) establishing relationships; (5) observing what happens; and (6) learning from experience. The study found that applying these interventions may help rehabilitation from burnout. Such interventions are dependent on the therapist, the type of therapy, and the client’s connection to nature.	User needs and experiences—Hospital Staff (Theme 2.3); Benefits and Values (Theme 3.2); and Organizational Benefits (Theme 3.4)
10	Starry et al. (2022), Frontiers in Sustainable Cities	“A Pilot Study Considering Ecoroofs as Therapeutic Landscapes”	Therapeutic effects from ecoroofs may be experienced differently by different users, depending on the activity performed, the goals of the roof, and the roof design. Information regarding the therapeutic potential of ecoroofs and lessons learnt are offered.	THG definition—Typology (Theme 1.1) and Character/Function (Theme 1.2); Benefits and Values—Individual Benefits (Theme 3.2)
11	Tseung et al. (2022), Health Environments Research & Design Journal	“Hospital Outdoor Spaces: User Experience and Implications for Design”	A hospital preoccupancy evaluation which included patients, family, and staff, identified three themes that promotes healing and recovery in hospital outdoor spaces. Identified benefits that promote healing include (1) focus on life beyond the illness, (2) outdoor spaces designed for healing, and (3) hospital programming for use of suitable outdoor spaces.	User needs and experiences—Patients (Theme 2.2) and Hospital Staff (Theme 2.3); Benefits & Values—Individual Benefits (Theme 3.2)
12	Zhu and Shepley (2022), Health Environments Research & Design Journal	“Assessing Preferences and Perceived Restorative Qualities of Break Spaces for Nurses in China”	Nurses want their break room close to the nurses’ station and appreciate windows and balconies in their break areas because of a perceived positive therapeutic effect. Well-designed break areas also increase nurses’ satisfaction rates with their work environment.	User needs and experiences—Hospital Staff (Theme 2.3); Benefits and Values—Individual Benefits (Theme 3.2)

Discussion

Hospital gardens are valued by individuals and communities for providing a place for time out from the clinical hospital environment. Less well understood is what makes health promoting gardens, how such gardens are created, and what is needed to ensure that the therapeutic effects can always be experienced. While the research question was “What is the role of THGs?” the two key findings show that there is a need to (1) collectively agree on terminology and (2) create design processes that facilitate consistent replication. The following is a discussion of these review findings in terms of such effects.

While the research question was “What is the role of THGs?” the two key findings show that there is a need to (1) collectively agree on terminology and (2) create design processes that facilitate consistent replication .

Why Does It Matter?

Being around nature in the city is good for human health, the environment, and hospital organizations. Hospitals often have gardens for this reason, but there is a need to learn more about how to make these gardens therapeutic. It is critical to define the aspects of THGs and how they relate to health outcomes for them to be taken seriously as a treatment. This includes understanding the different aspects and dimensions of health promoting gardens in hospital. By doing this, consistent garden designs can be created that optimize the health benefits they provide.

Being around nature in the city is good for human health, the environment, and hospital organizations. Hospitals often have gardens for this reason, but there is a need to learn more about how to make these gardens therapeutic .

To claim THGs can help, it is necessary to understand how aspects of health, space, and culture are related to the benefits of these gardens. By learning about the qualitative and quantitative aspects and multiple dimensions of such gardens, the benefits will be clear and enable garden designs to be consistent and well-researched to better garden users the most. Consensus to call them THGs then ensures that all understand the same garden and how it benefits health. This is a foundational step in guiding designers to create purposefully designed THGs and policy makers to make rules based on the benefits of the gardens.

A consensus on what makes a THG will help create consistent and reliable health benefits every time a garden is visited. Only then can these gardens be designed again and again to meet the emotional, physical, and psychological needs of visitors, improve job satisfaction for staff, and increase financial returns for the hospital organization. Defining therapeutic gardens in hospitals is the first step in creating a THG framework that lets designers, health planners, hospital CEOs, and health experts build these gardens in every hospital for everyone’s benefit.

How Can We Do It?

Even though some hospitals are already using health-promoting hospital gardens, there is not a lot of information in the literature about them, so what’s been done in practice was used to help create the working definition based on six important perspectives:

• A view of nature can improve patient care: The seminal article, “View Through a Window May Influence Recovery from Surgery” (Ulrich, 1984), found that patients with a view of trees recovered more quickly were happier and required less pain medication than patients in similar rooms having a view of a brick wall.

• Understanding medical user needs is critical for patient care: Stigsdotter and Grahn (2002) article, “What Makes a Healing Garden?” provided two valuable insights by, firstly, discussing healing influences of gardens based on theories and findings from relevant disciplines, such as landscape architecture, psychology, medicine, and nature-based therapy, and by, secondly, explaining the various needs of garden users depending on their mental capacity.

• Therapeutic effects of nature can be experienced in many ways: The book, Therapeutic Landscapes—An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces (Cooper Marcus & Sachs, 2014) introduces therapeutic landscapes, insights from research and design, the design process, design guidelines, a variety of therapeutic landscapes, and the evaluation of therapeutic landscapes.

• Broad ranges of health benefits exist when people spend time in nature: Frumkin et al. (2017) condensed the many benefits and values of nature in health and well-being in the article, “Nature Contact and Human Health: A research agenda.” Various benefits and seven research domains were identified to display the value of nature for human health and to progress research in this context.

• Emergent design principles are critically important for the efficacy of such gardens: Nieberler-Walker et al. (2019) offered insights into the purposeful design, design process, and emergent design principles in the book chapter, “The Efficacy of Healing Gardens: Integrating Landscape Architecture for Health.”

• Organizational and community culture are at the heart of sustainable health: The book, Seeking Sustainability—The Khoo Teck Puat Hospital Experience (Khoo Teck Puat Hospital, 2019), illustrates this exemplar case study based on the concept of “a hospital in a garden.”

These six important perspectives exhibit the knowledge and skill required to create successful therapeutic gardens in hospitals. And combined with the results of the 28-article review can inform the next step, the best possible working definition of THGs. Figure 5 illustrates the framing of the THGs in the themes and subthemes.

Figure 5.

Framing of the therapeutic hospital garden definition.

Working Definition

The synthesized working definition is:

THGs are purposefully designed and well-integrated gardens within the hospital grounds or hospital building which medically, spatially, and culturally support patient care and visitor and staff well-being.

This working definition of THGs lays the foundation for competently addressing the complexity of THGs in this interdisciplinary and context dependent field and is a good starting point to focus academic research and design practice. This working definition does not imply a lack of validity of past research or specific definitions; rather, it provides a more solid foundation on which to progress these ideas across disciplines.

Implications and Next Steps

It is acknowledged that the working definition introduced here must be reviewed and refined as scientific evidence and practice knowledge becomes available. Successful THGs offer the opportunity to investigate how such gardens were established. Finding out from hospital CEOs, government officers, health experts, hospital architects, and landscape architects, instrumental in creating such hospital gardens, can inform how such gardens were possible and how it was done.

The next part of this research is to strengthen the working definition by talking with these experts to establish what they know and, with their knowledge, learn more about the three critical dimensions of THGs, (1) health—relating to user needs and their health; (2) spatial—relating to functional requirements and adjacencies to hospital departments; and (3) cultural—relating to local and organizational context and practices.

Limitations of the Study

This article provides an insight into the topic in clinical settings/hospitals in Westernized countries and further investigation could be conducted to compare with a similar study in other cultural contexts. Many studies have methodological limitations which must be considered when assessing the credibility of the review results. Applying quantitative measures to assess complex qualitative THG aspects is difficult; however, both experimental and humanistic philosophical inquiries have value in progressing the topic. Conceptual research and integrated research design can strengthen the inquiry by purposefully selecting and combining qualitative and quantitative research methods in the research design.

Conclusion

THGs are defined to provide a universal understanding of what a therapeutic garden in a hospital should look and feel like. They enable discussions on the amount and type of nature required to achieve therapeutic effects for specific individuals as well as how to design such gardens and successfully integrate them into hospital programs and health policies. Establishing evidence-based knowledge on THGs is vital to change health policy. A consensus on what constitutes a THG can revolutionize healthcare. It creates an opportunity to discuss and contribute to THG knowledge and paves the way for investigating the establishment of such gardens in practice. This will involve interviewing experts such as landscape architects, architects, health planners, hospital CEOs, government officials, and healthcare design, medical and hospital environment experts to gather insights on the creation of therapeutic gardens in hospitals and the benefits of doing so.

Implications for Practice

• Access to nature in hospitals has been shown to have positive effects on the emotional, mental, and physical health of patients, their families, and staff.

• THGs can be a powerful tool for improving overall health and well-being, but their success depends on a purposeful design and successful integration into hospital programs and policies.

• A working definition based on books and academic and practice literature was established as a foundational step to move forward in developing THGs as a valuable aspect of hospital design.

• With the working definition in place, a comprehensive framework for THGs can now be developed that will guide the design, inform decision making, and direct the successful implementation of such gardens for the benefit of many.

Key Concepts

Significant health benefits can be gained when people are in contact with nature in the city. While gardens in hospitals are a common occurrence and the health promoting qualities of nature are well known, what makes hospital gardens therapeutic is yet to be well understood.

Twenty-eight peer-reviewed articles were critiqued for the period of 2016–2021 and updated with 12 articles from 2021 to 2023 to establish the latest research and development in this emergent field. Gardens in hospitals can reduce stress and anxiety and are therefore valued by users as a place for time out from the clinical hospital environment.

Many terms were used to describe gardens in hospitals, for example, nature experience, healing gardens and outdoor area. The review established two original findings. There is a need to 1) have consensus on terminology and 2) create design processes to move forward.

Because health-promoting hospital gardens are being built, the results from this review and the essence of exemplar practice literature were combined to produce a working definition of THGs. THGs can be a tool to improve well-being when they are purposefully designed and well-integrated in hospital programs and health policy.