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Today, a growing number of healthcare facilities are focusing on health and well-being rather than solely on sickness and disease, providing access to nature to promote patient healing and relief from stress.

Based on overwhelming evidence and emerging research, some of the ways to formalize the incorporation of access to nature can be found in sustainable healthcare design guidelines, mainly the Green Guide for Health Care (GGHC) and LEED for Healthcare (LEED-HC). Because those rating systems were strategically viewed through the lens of health intent, new focus has emerged on how access to nature influences our health outcomes and supports our well-being as a component of sustainability.

Case in point, in the Sustainable Sites section of GGHC and again in LEED-HC, there are two separate credits for “Connection to the Natural World: Outdoor Places of Respite and Exterior Access for Patients.”

Recently, the Environmental Standards Council (ESC) of The Center for Health Design submitted a successful proposal to the Facility Guidelines Institute to include “access to nature” as one of the key elements of the physical environment in the chapter on Environment of Care for the 2014 Guidelines for Design and Construction of Health Care Facilities.

The ESC authored the chapter for the 2006 guidelines, but its recommendations were largely placed in the appendix of the document, suggesting that access to nature should be integrated into healthcare facilities instead of specifying that they shall be integrated into the design process. This new proposal raises the issue once again, supporting it with a trove of both qualitative and quantitative research. No longer simply a site amenity that can be easily value-engineered out of the budget, access to nature has become one of the most documented areas of research in healthcare’s evidence-based design repertoire and one of the most meaningful to patients, staff, and visitors. 

The attempt to formalize this integration of nature into actual design guidelines, however, raises questions about what this really looks like on the ground. What kind of access to nature gives way to positive health outcomes? Do all types of nature give the same results? Lack of clarity on what access to nature really means for health and well-being can result in “wink-and-nod” solutions, such as simulating nature via artificial turf on roofscapes.

Drawing on new research on green roof aesthetics and health, as well as work in other disciplines, researchers are looking at examples of health outcomes influenced by aesthetics, social values, and nearby nature or views of nature. For this purpose, green roofs will be used as an example, as they’re an increasingly acknowledged design choice for facilities wanting to provide natural views and support sustainable design objectives.


Where nature and design meet
Numerous studies by Rachel and Stephen Kaplan between 1987 and 2005 showed that access to nature, even only visually, improves concentration.

Roger Ulrich’s subsequent studies using physiological measures showed a reduction in stress and increase in positive feelings in subjects shown images of nature versus images of cities. Research on aesthetics by these same researchers has pointed to people’s preference for savannah-like landscapes that tend to be less “messy” over uncultivated forests or grasses with dense underbrush. This type of nature has fit in well with traditional urban parks and their landscaped short grasses and mature trees.

The problem is that while this research weighs evolutionary predispositions, it hasn’t generally taken into account social and cultural values that we have about nature, particularly in the city, which researchers in geography and other disciplines have shown to affect our perceptions of nature. This issue has been coming to a head recently with the attempt to incorporate environmental and ecological goals into the design of urban nature projects.

For example, homeowners’ complaints that “prairie-style” or naturalized lawns were messy and unkempt support research by Jack Nasar and Bonnie Fisher (1993) that showed that nature can be scary and forbidding, as well as work done by Joan Nassauaer (1995) that argues naturalized urban greening projects often need some kind of sign or symbol that the “messiness” is intentional.


A fresh look
Doctoral research conducted by Angela Loder on office workers in central business districts of Toronto and Chicago reveals the influence of social and cultural values on perceptions of green roofs and participants’ health and well-being. For example, though some participants thought the prairie-style green roofs on Chicago’s city hall were beautiful and most visitors found these roofscapes more interesting than sedum green roofs, they didn’t always like the messy look of the green roofs and associated it with neglect.

This supports work in the social sciences on the social and cultural impact on our values and perceptions of nature in the city, with researchers like Noel Castree and Bruce Braun (1998), and Maria Kaika (2005) showing that ideas of modernity, progress, and sanitation mean we associate messy in the city with “bad,” “unhealthy,” and “poor.”

However, participants who had close access to the wilder green roofs over time, and who could watch them change through the seasons, felt calmer; had better concentration, improved creativity for problem-solving, and a heightened sense of hope; and associated it with positive childhood experiences in nature. They also found that the wilder green roofs provided a respite from the fatigue of concrete, steel, and glass of the city.

This supports work in environmental psychology that argues that nature allows for a soft fascination that can restore attentional fatigue and concentration. It also supports work in the social sciences that has found that nature is highly symbolic and can trigger memories or associations with other nature experiences, particularly those just outside the city.

This is important since nature experiences have been associated with reduced stress, improved positive affect and stress control, and emotional well-being, which bodes well for the careful incorporation of nature in healthcare design.

Lastly, though one would expect that participants’ would prefer the neat sedum green roofs—which, from a distance, often look like a mown lawn—the research shows that viewers were less interested in them and associated them with a lack of care and effort, particularly if the green space did not cover the entire roof.


Designing for access
As positive distractions and a sense of well-being are important factors for healing in stressful environments, there’s promise for combining environmental goals with human health goals in healing environments. Based on the research outlined above, some supportive suggestions for incorporating the health benefits of nature into healthcare settings might include the following.

Cues to care. Acknowledge the social and cultural associations many Westerners have with “messy” nature in the city and how this might hinder combining sustainable and/or ecological goals with access to nature in healthcare.
One solution would be to provide “cues to care” that combine straight mowed areas, lines, or other indicators to let patients know that the messiness is not a result of neglect.

Signage or educational material on the ecosystem, habitat, or plant selection can communicate the purposeful design of the feature. Adding colorful annuals, as the city of Chicago did on the prairie-style green roof of its city hall, is another way to signal that the nature feature is intentional. 

Provide interest and positive distractions. The Kaplans found that landscape designs that encourage exploration, mystery, fascination, and views have been found to increase the soft fascination found to be most beneficial for health outcomes. The wild and natural landscapes, versus manicured lawns and formal annual plantings, provide a respite and change from the sterile and clinical order found in most healthcare facilities.

Reference something larger than the site itself. Nature features that also provide habitat for butterflies, birds, or even bees signal the cycle of life and provide additional interest to distract patients from their illnesses. Landscapes that reference the immediate hinterland, nearby nature, or ecosystems outside of the built environment reflect the rhythm and cycles of nature, which in turn reflect human life cycles (see Jodi Rosenblatt Naderi and Jerry Smith’s essay in Robin Guenther and Gail Vittori’s Sustainable Healthcare Architecture, 2009).

In this case, nature acts as a mediator in times of stress and can provide a sense of familiarity and connection with life’s challenges, which is particularly important in the healthcare setting where one is confronted with life-changing or life-challenging events. 

Be attentive to patients’ perceptions of effort and care. Participants were very aware of when the minimal effort had been made on a nature feature, or when it looked half-completed. Minimally designed landscapes, poor use of design, or poorly tended or dying plants will be sensed immediately by patients and will be associated with a lack of attention to their own medical care.

Engage the senses. Where possible, engage the patients’ senses with color, smell, touch, and sound in the nature feature. Work in horticultural therapy has long shown the positive impact that close contact and care for plants has on health and healing outcomes. Adding fragrant plants, variations in color or texture, and opportunities to get close to a nature feature will enhance patients’ sense of calm, positive distraction, and memories of experiences in nature.

Note that a thorough knowledge of user group impairments or environmental sensitivities of patient treatment will be necessary, as not all sensory stimulation is considered positive when undergoing certain medical treatments. 

Implement standards for infection control. When nature is incorporated into interior design, there must be programs in place to ensure proper maintenance and infection control. Live plants and natural systems require water and other organic nutrients for growth, and those systems need to be well maintained to prevent airborne pollutants. Likewise, water features should be under strict cleaning and maintenance programs to prevent the development of mold and fungi.

Potting soils, fertilizers, and pest management systems must be well programmed and maintained regularly. Fresh air, when provided, should be allowed only in settings that are free from environmental pollution and mechanical exhaust systems, and where air quality testing is strictly monitored. 

Provide shade in sunny areas. Areas with natural sunlight, while encouraged, need to provide opportunities for shade so that patients and visitors can benefit from natural daylight and still be free from direct sunlight. Many patients have light sensitivity due to various visual or physical conditions, including conditions due to age. Options for sun or shade should be incorporated into the design along with operable controls that are accessible by staff.


The human connection
Thoughtfully integrating access to nature in healthcare facility design offers the possibility of improved patient health and patient satisfaction, while also offering the opportunity to combine sustainability and human health goals. Evidence-based design in exterior spaces that supports health and well-being will further improve our understanding of the relationship between the natural and the built environments, as well as nature’s influence on human health.

The human connection with other living systems innately binds us through our familiarity with similar life cycles and natural rhythms, and mediates our sense of understanding in times of stress. Positive distractions and elements of surprise and wonder, which nature so vividly provides, offer a respite from the anxieties that are oftentimes apparent in healthcare facilities. When healthcare facilities and healing environments are designed for sustainability, with people as part of the environmental equation, access to nature is a natural no-brainer.  

Angela Loder, PhD, is a researcher and strategic planner whose work focuses on the relationship between occupant health, buildings, and urban nature. She is an adjunct professor at the University of Denver, teaching graduate courses for University College’s masters program in global affairs and an active core member of the National Institutes of Health’s Healthy Buildings Roundtable. Jerry Smith, FASLA, EDAC, LEED AP, is a principal at Smith|GreenHealth Consulting in Columbus, Ohio, and is a member of the Environmental Standards Council of The Center for Health Design. He serves on the Core Committee of the Sustainable Sites Initiative (SITES), is co-chair of the SITES Human Health and Well-being Subcommittee, and was on the steering committee of the Green Guide for Health Care.


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