The pandemic has caused all of us to rediscover the need for nature, so much so that many people have decided to move away from the cities, which have responded to an adjustment in urban planning because of the benefits of contact with greenery.
Nature, however, has played a central role in human life since its origins. Throughout history, the relationship with it has been fluctuating. Reviewing historical junctures, during prehistoric times, groups of people lived in harmony with the natural environment and there was a kind of deep respect for it, so much so that it was revered as a divine force. With the arrival of the industrial revolution, the situation changed dramatically. There is an exploitation of natural resources and nature becomes an entity to be dominated and exploited. The birth of modern science leads to the conception of nature as a benevolent and nurturing mother, yet industrial development depletes fertile lands and leads to the extinction of thousands of living organisms. It was not until the 20th century that the first environmental movements and ecological psychology emerged. There is an understanding of how the role of nature relates to the well-being of the individual and the community, and a balance must be struck between progress and sustainability. This focus also grows with the advent of technologies and urbanization in which people, now defined only by their profession, live almost overwhelmed with pressures and in a state of imbalance.
Roszak, in his volume The Voice of the Earth (1992) coined the term Technocracy, which he defines as the excessive power given to progress in contemporary society; In addition, he highlights how modernity has reduced the human being to a passive consumer and calls for a new synthesis of knowledge, in which science, art and ecological sensitivity are integrated to form a more holistic and sustainable worldview. As the social system has changed, human needs and discomforts have also evolved, it is necessary to complement traditional medicine with a deeper reflection on psychological and social dynamics: in this framework, nature has a therapeutic role especially against stress and depression, toward which traditional treatments are sometimes ineffective.
This is the context for the reflection of this article, in which a possible solution regarding the improvement of public green areas, including hospital green areas, will be described; a green area that adapts to the patient’s needs, supporting conventional medical care, with the aim of improving the patient’s quality of life, again with a view to protecting the environment and increasing biodiversity. It must be remembered that these interventions do not eliminate problems but can help to deal with them better by finding some degree of relief.
In care environments and recent scientific research this is studied as biophilic design. Included in this term are applications such as therapeutic gardens. According to the American Horticultural Therapy Association (AHTA), therapeutic gardens are “plant-dominated environments, including natural elements such as water and vegetation, associated with health care facilities and accessible to all.” Their purpose is to provide a refuge and refreshment space for patients, visitors and healthcare staff. Clare Cooper Marcus emphasizes the importance of a multisensory experience in therapeutic gardens. The more the garden engages the visitor’s senses, the less the perception of pain will be. To achieve this effect, a garden should include a variety of colours, different shades and textures of green, scents, wildlife, and natural sounds and movements, such as those produced by water or wind. Natural spaces that have not been modified by humans are not considered in this context, although there is evidence on their effectiveness, because they cannot, however, be defined as gardens in the traditional sense of the term.
Naomi Sachs coined the phrase landscape for health, defining them as any landscape, wild or designed, that promotes human well-being. This broad and inclusive concept represents an umbrella category under which the different types of therapeutic gardens fall. They fall into two main categories: enabling gardens (enabling gardens) and restorative gardens (restorative gardens). Enabling gardens are designed to improve accessibility and support people with physical or cognitive difficulties, for example, therapeutic gardens, used in rehabilitation, or memory gardens, designed to stimulate the senses in patients with dementia. Restorative gardens, on the other hand, are spaces dedicated to stress reduction and emotional regeneration, such as meditation gardens, which encourage contemplation, or sensory gardens, enriched with aromatic plants and tactile surfaces to stimulate multiple senses. In addition, there are gardens specifically designed for emotional support in sensitive settings, such as hospice gardens, designed to offer comfort to terminally ill patients and their families. In addition, depending on the specific needs of patients, it is possible to have gardens in which psychological sessions, infusion therapies or educational activities such as horticulture are done.
Again, these categories are not entirely new. Since ancient times, gardens have been used for healing purposes. Ancient civilizations, such as those of Egypt, Greece and Rome, conceived of these spaces as places for rest, meditation and healing. During the Middle Ages, the concept of the hortus conclusus, a protected garden in which monks grew medicinal plants, such as lavender, sage and chamomile, to prepare remedies for the sick, was born in European monasteries. However, between the 14th and 15th centuries, famines and epidemics led to the decline of the role of monasteries and the loss of the concept of the garden as a therapeutic space. With the advent of Romanticism, the importance of green spaces in the hospital setting was rediscovered, and they were considered an integral part of the healing process.
In the 19th century, gardens began to be used in psychiatric hospitals as therapeutic tools for patients suffering from mental disorders. However, with the progressive urbanization and modernization of the 20th century, the role of gardens in health care facilities underwent a major downsizing. The construction of large, multi-story hospitals, geared toward maximizing beds and medical technology, relegated green spaces to secondary and nonessential elements with respect to new pharmacological and diagnostic approaches. Since the 1980s, the therapeutic function of gardens has been gradually reevaluated, thanks to the pioneering studies of Roger Ulrich. In his famous study View Through a Window May Influence Recovery from Surgery (1984), published in Science, Ulrich showed that postoperative patients with a view of green spaces had faster recovery times and required less analgesics than those whose environment was devoid of natural elements. In the 1990s, Rachel and Stephen Kaplan further explored the link between nature and mental health through Attention Restoration Theory (ART). This theory suggests that exposure to nature helps restore the capacity for concentration and attention, reducing mental fatigue caused by intensive cognitive activities. At the same time, there has been a shift in the approach to hospital care from an exclusively biomedical view, focused on the disease and the compromised organ, to a bio-psychosocial approach, which considers the patient, including the environmental and relational context.
The hospital is traditionally seen as the place of healing, but often, in reality, it can become the antithesis of this concept. In fact, the hospital environment can be chaotic, intimidating, and stressful, not only for patients and their families, but also for health care workers and staff. Negative sensory overload, such as bright lights, disturbing noises, and lack of privacy, can increase stress levels, with physical and psychological consequences. Several studies have documented the negative effects of stress on the body, such as increased heart rate, blood pressure and respiration, but also on mood and behaviour, leading to feelings of fear, anger, depression and isolation and behavioural disorders such as insomnia, irritability and passivity (Ulrich, 1999).If the hospital is meant to be a place of care and healing, would it not be time to rethink the approach and look for alternative solutions that can mitigate these negative effects and foster a healthier environment for all?
In this context of rethinking health care environments, attention has been brought back to green spaces in hospitals, no longer seen as mere accessories, but as fundamental tools for mental and physical well-being. The therapeutic garden is seen as a dynamic process that helps patients connect with the rhythms of nature, finding comfort and stability there. Numerous scientific studies have confirmed the benefits of green spaces in health care, with positive cognitive, psychological, social and physical effects. In countries such as the United States, Canada and Northern Europe, landscape architects, environmental psychologists and physicians have shown that integrating nature into treatment facilities improves patients’ quality of life and promotes recovery. Healthcare professionals also benefit attending even just walks can reduce work stress and consequently reduce burnout and turnover discomfort over time, ensuring more availability and thus better care pathways. In addition, if the nature practitioner is more available, lucidity will be better, and the creation of innovative solutions will be faster. In this way, clinical errors will also be reduced, and more thoughtful decisions will be made.
Case in point is Singapore’s Khoo Teck Puat Hospital: a hospital in a garden and a garden in a hospital. It represents an innovative model of integrating hospital architecture, city and nature, placing the concept of a healing garden at the centre of the project. The facility covers an area of 3.5 hectares and adopts biophilic design solutions to enhance the well-being of patients, healthcare staff and the local community. Each green space has a specific function: rooftop gardens for rehabilitation and relaxation; paths in the greenery for physical activity and therapeutic gardens for patients with mental and cognitive disorders; waiting rooms are transformed into picnic areas; and waterfalls with koi carp are incorporated into the lobby. Vegetation is not just a decorative element, but an active component of the treatment process, contributing to stress reduction and promoting recovery, as shown in studies by Roger Ulrich. In addition to health promotion, the hospital has a strong ecological commitment, reducing energy consumption through natural ventilation, the use of solar panels, and the design of large windows to maximize natural light. In addition, KTPH is distinguished by its urban farming approach, with productive roof gardens that provide fresh ingredients for the hospital cafeteria and engage residents in urban farming activities. This hospital model is not just a place of care, but becomes a social hub, where the community comes together to promote a healthy and sustainable lifestyle. The KTPH demonstrates how hospitals can transform from clinical spaces to environments of healing and inclusion, where nature plays an essential role in collective health and well-being.
While in the East the relationship with nature has certainly remained more constant and deeper in customs and traditions, in the West, as described earlier, this connection is being recovered.
These experiences are also being applied in Europe; in fact, a collaboration with Chelsea and Westminster Hospital was born, which produced Greenheaven and Sky Garden. These gardens, located between the floors of the various wards, offer a green retreat in an urban setting, creating a relaxing and rejuvenating environment.
Greenheaven is designed for the rest of health care staff. In addition to nature, there are pods called EnergyPods, in which healthcare workers who work very long shifts can rest inside. The system is designed to recreate a sound and visual environment that promotes relaxation.
Sky Garden is a green space where psychological therapies are conducted. Designed, as an alternative place to be able to get out of the clinical environment. Access is also dedicated for health professionals to be able to escape and take refuge in nature for a moment of respite. Again, this can be accessed with hospital beds thanks to accessible pathways and ad hoc corridors.
In Italy there is the therapeutic garden at Policlinico Gemelli in Rome where this is applied to chemotherapy. The aim is to benefit from contact with nature in reducing anxiety, fatigue and psychological stress related to treatment. The green areas of the Polyclinic include sensory paths with aromatic and medicinal plants, spaces for meditation and socialization areas for patients and their families. The goal remains to increase quality of life side effects of therapy and by fostering a greater sense of well-being.
The development of these practices denotes a growing interest in healing as a holistic approach to the person, in which health is no longer just the absence of disease, but a balance between body, mind and environment. The integration of healing gardens in hospitals demonstrates how modern medicine can benefit from nature, transforming the perception of healing spaces: from places of suffering to oases of well-being, where healing is not just a clinical goal, but an experience involving all the senses.
At a time when stress and burnout affect patients, caregivers, and health care workers, these green spaces represent not only an integrated therapy, but a real paradigm shift in hospital design. Perhaps, in the future, we will no longer ask whether to integrate nature into hospitals, but how best to do so, making every place of care a place of life.
References:
-Buccini F. (2024). Nuove architetture terapeutiche: gli healing gardens per coltivare competenze professionali. Journal of Health Care Education in Practice, VI, 2.
-Cooper Marcus, C., & Sachs, N. A. (2013). Therapeutic landscapes: An evidence-based approach. Wiley.
-Chelsea and Westminster Hospital. (2024). New indoor garden opens at Chelsea and Westminster Hospital. CWPlus. https://www.cwplus.org.uk/latest/new-indoor-garden-opens-at-chelsea-and-westminster-hospital/.
-Diehl E. (2012). Do all gardens heal the same? A study of therapeutic landscapes.
-Fleming L., Figueiredo M. (n.d). Healing Gardens for Cancer Populations. A quarterly publication of the American horticultural therapy association, XXXXI, 2.
-Hasegawa H. (2017). The treatment of Japanese gardens based on therapeutic concepts. International Journal of Architecture and Urban Development, VII, 2, Springer.
-Mulligan M., (2000). Inspiration: A healing garden fort cancer patients created in the Japanese Design Tradition (Master’s thesis). Ball State University.
-Khoo Teck Puat Hospital. (n.d.). About us. https://www.ktph.com.sg/.
-Shahrad, A. (2012). Healing gardens: Design and impact on well-being in healthcare settings (Master’s thesis). Swedish University of Agricultural Sciences.
Carolina Zarrilli – PhD in Medical Humanities and scientific curator