A Brief History of Hospital Gardens

Hey, it’s Kat again. In today’s guest post, I’ll be talking about the history of hospital gardens as we know them today.

Tracing the history of hospital gardens shows us that there is a common thread of belief in the importance of fresh air, sunshine, access to nature and working the land as positive contributions to the healing process.

Healing gardens have long since served as places for recovery; for the restoration of the mind, soul and body. Monastery settings in the Middle Ages were the first instances where a garden was specifically incorporated as a part of the healing environment.

These spaces served as places for contemplation as well as for growing vegetables, fruits and herbs.

The Cloisters in New York City showcase a traditional monastic courtyard garden. Image: Kat Shiffler

A document believed to have been written by a monk in the early part of the ninth century describes a plan of an ideal garden for the Benedictine Monastery of Saint Gall in Switzerland, laying out many of the same formal features that show up in healing gardens today: intersecting paths for contemplative walking, a well or fountain, an herb garden, a green “court” or lawn.

In addition, outside the monastery’s walls there were also several acres of crops to supply necessary food for clergy, workers, visitors and the poor.

The Monastery of St. Gall was an early healing landscape. Image: Alarmy.com

The Church itself was instrumental in the establishment of hospitals during the Middle Ages that have influenced the delivery of healthcare through the centuries.

Later, the religious connection between spiritual healing and the garden began to fade and give way to a much more human-centered built environment. As hospitals developed, the formal cloistered garden features were often replaced by an open area for patients to walk and take in the sunshine and fresh air.

Some progressive hospitals that primarily cared for people with mental illness placed a greater emphasis on the active work of tending to gardens and fields. A prominent example is that of the Hospital at Zaragossa in fifteenth-century Spain. At this hospital, a routine of normal daily activities, including gardening, was encouraged for patients who were able—rather than confining them as was the custom at the time.

German horticultural theorist Christian Cay Lorenz wrote some of the first recommendations for hospital garden design at the end of the eighteenth century:

“The garden should be directly connected to the hospital… A view from the window into blooming and happy scenes will invigorate the patient… [and] encourages patients to take a walk… The plantings should wind along dry paths, which offer benches… The spaces between could have beautiful lawns and colorful flower beds… Noisy brooks could run through flowery fields… A hospital garden should have everything to enjoy nature and to promote a healthy life.”

Classic open-air hospital design at Hospital del Salvador in Santiago, Chile. Image: Wikipedia

Florence Nightingale, the founder of the modern nursing profession, stressed the importance of fresh air and natural sunlight on the well-being and healing of patients in her landmark, Notes on Nursing published in 1859. She described the value of plants and outdoor spaces in the healing process,

“People say the effect is only on the mind. It is no such thing. The effect is on the body too.”

Florence Nightingale, Notes on Nursing

Throughout Victorian and Edwardian periods, green spaces in hospitals were seen as places for healing. But in the decades the followed, priorities in hospital construction changed; the industrial revolution and two World Wars took place. Park areas were replaced by parking lots.

But in 1984 a study by American psychologist Roger Ulrich provoked a renaissance in the hospital garden movement. Ulrich showed that patients with views of the outdoors from their hospital bed recovered faster after surgery, and spent less time in the hospital than those who did not have an outdoor view. Ulrich has gone on to publish widely on the health benefits of nature:

“Just looking at an image of nature could be healing”.

Roger Ulrich, ‘Forest Bathing’: How Microdosing on Nature Can Help With Stress

Today there are many beautiful contemporary examples of outdoor hospital environments that promote healing through a connection to plants. These spaces are once again being seen as critical for health and well-being. Working farms at hospitals, however, continue to be somewhat rare—a growing part of the overall movement to create spaces that heal.

A contemporary courtyard garden at Great Ormond Street Hospital, London designed by Chris Beardshaw. Image: The Telegraph

Hospital gardens provide a natural and calming view, stimulate the senses of therapy patients, provide restoration and relaxation for visitors and staff—and have the potential to grow healthy food for surrounding communities.

Gardens as Antidote to Nurse Burnout

Healthcare practitioners take a break outside. / Photo: Legacy Health

Hey, it’s Kat again. In today’s guest post, I’ll be talking about the timely topic of nurse burnout and research into hospital-based gardens.

Burnout among nurses was on the rise even before COVID-19. In a 2017 survey, 63% of registered nurses employed in hospitals self-reported workplace burnout.

Characterized by symptoms of emotional exhaustion, depersonalization, and loss of personal efficacy, burnout has far-reaching negative consequences for individual wellbeing, quality of patient care and costs to the healthcare system. One study estimated that nurse burnout adds up to $14 billion annual

In 2019, the World Health Organization included burnout in the 11th Revision of the International Classification of Diseases as “an occupational phenomenon” rather than a medical condition, saying burnout “is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”

Research indicates that hospital gardens are one way we can lessen the fatigue and stress that lead to burnout.

For a study in 2018, a team of researchers that included legendary healthcare designer Roger Ulrich, looked at indoor and outdoor break environments and their effect on nurse burnout.

Time outdoors can help reduce symptoms of burnout. Photo: Legacy Health

Nurses at Legacy Emanuel Medical Center in Portland, Oregon were randomly assigned to 6 weeks of a daily work break in the garden and 6 weeks of indoor-only breaks. Researchers had the nurse-participants complete the Maslach Burnout Inventory-Human Services Survey (MBI), a tool used to measure burnout in healthcare workers, at the start and end of each 6-week period.

The nurses also recorded the immediate psychological impact of a break in both environments using another tool that asked them to rate feelings of anxiety, sadness, anger, worry, fatigue and pain on a defined scale.

What they found was that for the nurses who took their 20-minute break outside, the garden provided greater reduction in burnout.

They concluded that taking daily work breaks in a garden may be beneficial in mitigating burnout among nurses working in high-stress hospital environments.

The research setting was featured the Portland news recently, highlighting the positive response to the garden in light of COVID-19. One nurse said of the Legacy Health garden,

“It takes you to such a different place that it’s so refreshing to your spirit and your soul and your psyche.”

Gardens provide respite for practitioners, patients and their families. Photo: Legacy Health

Another nurse said of the garden,

“It is transformational for me. It really is. Just to even get five minutes in the garden, you shift your paradigm. You’re no longer thinking about the hospital. You’re looking at the plants, you’re smelling the herbs that are growing here, you’re seeing the sunshine.”

Providing spaces for respite is more important than ever—in hospital environments and public spaces alike. What’s good for the mental health and wellbeing of nurses is good for us all.

In the next blog post, I’ll be exploring best practices for designing restorative spaces, according to prominent thinkers in environmental psychology.

Guest post by Kat Shiffler, collaborator with The Farm at St. Joe’s and graduate student in Landscape Architecture at the University of Michigan.