What Can Therapeutic Gardens Offer to Intensive Care Unit Family Visitors

2016 - 1 February - Technological Game Changers
Larry Beresford
Larry Beresford discusses the benefits of therapeutic gardens to ICU visitors based on early research and ICU program testimonials.


Research has shown that access to gardens and nature—even just looking out a hospital window—can offer health benefits such as stress reduction. Could such benefits be mobilized through interludes in a blooming hospital garden by intensive care unit (ICU) family visitors, who are known to suffer negative outcomes and even symptoms of posttraumatic stress disorder(1,2) months after their loved ones’ hospitalizations? And can those benefits be quantified using medical research methods?

Legacy Emanuel Hospital in Portland, Oregon, USA, is attempting to answer these questions by studying outcomes from access to a therapeutic garden built as a place of respite and relaxation, for strolling among the plants and stopping to smell the flowers on a second-floor terrace. Located between the hospital’s birthing center, cardiovascular ICU and trauma center, the Terrace Garden was opened in 2014 with the support of a $560,000 research grant from the TKF Foundation(3) and is now the setting for medical research on outcomes of access to nature for stressed family visitors of ICU patients and birthing mothers and hospital staff.

Principal investigator Roger Ulrich, PhD, guest professor at the Center for Healthcare Architecture at Chalmers University of Technology in Gothenburg, Sweden, is the author of a landmark 1984 study(4) comparing matched gallbladder surgery patients whose hospital rooms faced either a brick wall or a small stand of deciduous trees. The latter healed faster, needed less pain medication and experienced fewer postsurgical complications.

There is more and more data showing that gardens and plants can promote healing, reduce pain and discomfort and even buffer a person’s immune system from stress, Ulrich noted in a keynote address at the recent American Horticultural Therapy Association (AHTA) annual conference in Portland in October. But there are significant gaps in research. No study specifically looks at the effects of garden access for acutely stressed families of ICU patients.

But measuring the impact of garden access on ICU visitors poses methodological challenges, he said. A randomized controlled trial that denied garden access to the non-garden control group would be ethically problematic, so Legacy researchers are using observational methods instead. Data collection is not yet complete for a study comparing family members who visit the garden versus an ICU waiting room, hospital cafeteria or atrium cafe, using a brief symptom inventory with visual analog scales. “Our hypothesis is that garden exposure will reduce family members’ stress,” Ulrich reported at AHTA. “Early findings suggest that family members who use the garden are less stressed.”

The Garden as a Feature of Hospital Design

A number of other hospitals around the United States have developed therapeutic gardens in proximity to their ICUs or waiting rooms. The Mary Catherine Bunting Center of Mercy Medical Center in downtown Baltimore, Maryland, USA has a 9th-floor garden directly accessible from a 24-bed mixed ICU and visible from half of its patient rooms. 

“The garden adds an opportunity for patients and families to get outside without having to go down 10 flights of stairs,” says Joseph Costa, MD, medical director of Mercy’s ICU. “It’s a great place for people to go out and relax when spending long hours in the ICU. We have a policy of open 24-hour visiting here, and a room where family visitors can take showers or clean up. They like to use the garden when the weather is nice,” Dr. Costa reports.

“When we have patients who are well enough, we’ll take them off their monitors or send them out into the garden with their monitors. It makes a world of difference in their attitudes. We have two special wheelchairs that make it easier for patients to get out the door and into the garden,” he says. “The effect is hard to quantify, but anybody who works on our unit thinks it is real. It just makes sense for us, being in such a vertical urban space.”

The hospital’s multilevel rooftop gardens were an integral design feature of the replacement towers of Mercy’s high-rise urban facility, which opened in 2010. The goal was to provide outdoor places of respite for connecting patients, staff and visitors to the health benefits of a natural environment. There are also benches, a curved stone walkway, running water and mature trees.

Making a Better Garden

Typically, hospital gardens are supported by foundations or fundraising departments and may have to compete with other demands for precious space. More evidence to quantify their benefits might help justify the investment. Basic concepts of designing therapeutic hospital gardens emphasize safety, security, privacy and 24-hour accessibility. That means unlocked doors, gently sloping paved paths wide enough to accommodate wheelchairs, and alcoves offering privacy, shade and protection from inclement weather.

Other issues to consider include the ratio of greenery to hardscape; a four-season mix of plants, colors and textures; a variety of seating arrangements and distance from the ICU. In 1995, AHTA identified seven characteristics of therapeutic gardens,(5) including well-designed perimeters, recognizable place-making, and a profusion of plants and people-plant interactions. Horticultural therapy in other healthcare settings often involves garden users participating hands-on in gardening activities, but ICU users typically interact more passively with the garden. But they can still benefit from the sights, sounds and smells that a therapeutic garden can offer.

“People are starting to embrace healing gardens and access to nature in healthcare settings, and this is a good thing,” says Naomi Sachs, an architectural doctoral student at Texas A&M University and coauthor of the textbook Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces.(6) To date, only a handful of evaluations have looked at what works and what doesn’t in hospital garden design. But Sachs has developed, and is now testing, a toolkit of measures that could be used for evaluating the effectiveness of a hospital garden and for further research.

Gardens Can Also Benefit Staff

At Concord Hospital in Concord, New Hampshire, USA, a rooftop garden of shrubs and greenery located between two hospital wings is viewable from ICU patient rooms and from an adjoining stone patio. The hospital’s new ICU, opened in 2007, was designed to create access to daylight and pleasing nature views from patient rooms and staff areas, says Jody Case, RN, the ICU’s director. “Families make great use of it. We may also suggest it if we need to get them out of the room for a few minutes for a procedure. Or they just wander down the hallway and see it,” she explains.

“I don’t know about its long-term impact, but I would see it as helping them in that moment of stress. The feedback we receive from families is all positive—they appreciate being offered a chance to get outside and have some space to themselves.” Patients also react positively to getting outside, Case adds. “The other piece of this is that it also benefits staff, who need a place to get away from the unit on their lunch breaks and re-center themselves.”

The 800-bed Our Lady of the Lake Regional Medical Center (OLOL) in Baton Rouge, Louisiana, USA earned a 2015 ICU Design Citation Award from SCCM and the American Association of Critical-Care Nurses for its Heart & Vascular Institute ICU, which opened in 2013. The award recognizes functional design and humanitarian delivery of care. OLOL and architects from VOA Associates were singled out for the facility’s use of natural light and family space and its healing garden.

“The outside garden serves as a tranquil resting place for families, visitors and staff, with seating, waterfalls and landscaping,” says Terrie P. Sterling, OLOL’s executive vice-president and chief operating officer. A lobby with big windows extends along the garden, located just off the food court between the main building and the Heart Institute.

Within the limitations of space, the hospital’s Assisi Courtyard uses plants and paving stones to offer calm, respite and nature access while evoking the feeling of Assisi, Italy, the hometown of St. Francis, patron saint of the Franciscan Missionaries of Our Lady, the religious order that operates the hospital, Sterling says. It offers smaller spaces off the beaten path and plants chosen for their symbolic meaning.

“We convened focus groups of families who talked to us about their most difficult moments when visiting the hospital and how important it was to have a sacred space of respite, whether a chapel or sitting out in a garden,” Sterling says. “We knew we wanted family members to have 24-hour access to a place where they could talk about what’s happening to their loved one—somewhere that’s not a small dark room.”


1. Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005 May;171(9):987-994.
2. Davidson JE, Jones C, Bienvenu OJ. Family response to critical illness: postintensive care syndrome-family. Crit Care Med. 2012 Feb;40(2):618-624.
3. TKF Foundation. A Nature Place. February 17, 2015. http://naturesacred.org/national-awards/a-nature-place/. Accessed February 22, 2016.
4. Ulrich RS. View through a window may influence recovery from surgery. Science.1984 April 27;224(4647):420-421.
5. Hazen T. Therapeutic Garden Characteristics. American Horticultural Therapy Association. 41(2). http://ahta.org/sites/default/files/attached_documents/TherapeuticGardenCharacteristics_ahtaReprintpermission.pdf. Accessed February 22, 2016.
6. Marcus CC, Sachs NA. Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces. Hoboken, NJ: John Wiley & Sons; 2013.