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The goal of this study was to understand successes and weaknesses of a rooftop hospital garden used primarily for physical therapy.
Literature on the healing benefits of nature and designed outdoor spaces in healthcare contexts continues to become more focused on specific patient populations. This study contributes to the knowledge of rooftop hospi...
Context in source publication
Citations
... However, due to their heavier focus on design and planning, these studies introduced environmental factors and mediators that can impact patient outcomes. The mediators introduced by these studies included (1) patient motivation (Arbel et al., 2020;Detweiler & Warf, 2005;Lakhani et al., 2022;Medina-Mirapeix et al., 2013); (2) patient confidence (Orr & Mattson et al., 2004); and (3) social interaction among patients, patient and staff, or patient and family members (Anåker et al., 2018, Blennerhassett et al., 2018Kevdzija & Marquardt, 2022a;Killington et al., 2019;Nordin et al., 2021;Rosbergen et al., 2019;Ribbe Kelso et al., 2024); (4) physical activity (Anåker et al., 2018;Blennerhassett et al., 2018;Janssen et al., 2022;Kevdzija et al., 2022;Orr et al., 2004;Ribbe Kelso et al., 2024;Rosbergen et al., 2019); (5) trust in care plan and perception of quality of care (Arbel et al., 2020;Colley et al., 2018;Davis, 2011;Gawlak & Stankiewicz, 2022;Medina-Mirapeix et al., 2013;Rehn & Schuster, 2017); (6) predischarge plan readiness (Atwa et al., 2013;Skubik-Peplaski et al., 2016); and (7) better rest and comfort (Killington et al. 2019;Nordin et al., 2021;Rehn & Schuster, 2017;West et al., 2017). ...
Aim
This literature review is conducted to identify knowledge gaps and shape a framework for the development of guidelines and future research on programming and design of rehabilitation environments.
Background
Patients suffering from trauma, stroke, neurological or cardiopulmonary conditions, or recovering from surgery or cancer treatment require rehabilitation services. A comprehensive rehabilitation program can support continuum of care for inpatient and outpatient groups. However, within most facilities, rehabilitation environments are found to be outdated and undersized compared to other programs or lack the correct adjacencies within the facility. Unfortunately, this deficiency is echoed by limited guidelines on programming, planning, and design of these environments. General guidelines derived from healthcare environments research is not adaptable to rehabilitation environments, because the paradigm used in most healthcare environment research does not address specific needs of rehabilitation patients in regaining confidence or relearning daily life skills.
Method
We conducted a structured literature review, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a basis for reporting the available body of work on evidence-based research in rehabilitation environments.
Result and Conclusion
Through analysis of the limited literature, specific mediators such as patient confidence and motivation were identified. An environment that creates a balance between privacy and social interaction can promote these mediators. Creating enriched environments through elements that engage the senses and encourage more social and physical interaction is essential for recovery. Finally, accessibility and wayfinding are of great importance in these environments due to potential limited mobility or cognitive impairments of patients.
... A POE study of a rooftop hospital garden by Davis (2011) concluded that providing easy access and visibility to the garden encourages exploration. The study mentioned that the space should be organized to avoid ambiguity and help patients get around instead of creating confusion, and long-term maintenance should be another aspect to consider in the design process. ...
It has been documented that patients with mental or physical disabilities can benefit from being placed within the setting of a natural environment. Consequently, the concept of creating spaces that can enhance health preservation or patient recovery, while also augmenting environmental and aesthetic value, has merged as a contemporary discourse. Green areas around hospitals can offer a great opportunity to incorporate healing gardens to benefit their patients and not only. The aim of this paper is to propose a design for a sensory-therapeutic garden based on key principles derived from selected academic literature, focusing on the application of these principles in a healthcare setting in Cluj-Napoca, Romania. The design was informed also by onsite data collection and analysis, and it aims to create a healing landscape that addresses the needs of patients, healthcare providers, and visitors. This study seeks to augment the discourse in the field by demonstrating the practical application of key therapeutic garden design principles in a specific context and how these principles impacted the design process.
... Gardens specifically located on hospital grounds are increasingly commonplace and are employed for a number of reasons, including physical therapy [16], support for pregnant women and their partners [17], and to treat individuals with metabolic or cardiovascular disease [18]. Feasibility, including acceptability, demand, and willingness to engage in gardening activities in a hospital-based program is supported by a small study examining individuals with cardiovascular risk factors [18]. ...
Introduction Gardening is a healthy activity that promotes nutrition and satisfaction, with positive impacts on patients with chronic diseases, including patients with obesity, diabetes, and cardiovascular disease. Hospital-based gardening programs may provide opportunities to introduce patients to gardening. However, few studies have included participant experience as a metric of evaluation. The objective of this study was to explore participant experience in a hospital-based gardening intervention designed for individuals with metabolic syndrome. Methods This study was a qualitative evaluation of free text responses from four questions included in post-participation questionnaires from 59 community-dwelling adults who participated in a hospital-based garden program located at the University of Vermont Medical Center in 2020 and 2021. Eligible participants included a convenience sample of novice gardeners with self-reported hypertension, diabetes, pre-diabetes, or overweight/obesity. We used an interpretative phenomenological approach to analyze the questionnaire data. The phenomenological cycle for each of the questions included: 1) reading and re-reading participant responses, 2) exploratory noting, 3) constructing experimental statements, 4) searching for connections across statements, and 5) naming the themes. This process also involved working with individual question-level themes to develop group themes across questions. Results This dataset was one of positivity about gardening, new information gleaned, and the quality of instruction. Several themes and codes emerged: program implementation (new knowledge, new skills, new connections, instructor ability, climate), self-efficacy (confidence, vicarious experience, mastery experience, verbal persuasion), and future change (behavior change, future issues/problem-solving, passing it on). Conclusion This study supports analyzing participant experience as part of hospital-based gardening interventions. We found positivity around program implementation, increased self-efficacy, and intentions to change behavior in ways that support healthy lifestyles.
... The rehabilitation environment is a key factor contributing to the improvement of rehabilitative efficacy. With the shift of the medical model towards biopsychosocial pattern, the value of the natural environment for rehabilitation began to be noted, and an increasing number of rehabilitation institutions began to seek outdoor space for outdoor rehabilitation training [1][2][3][4][5][6]. An exploratory study of US therapists' use of the outdoor environment for rehabilitation showed that physical therapists used the outdoor environment more frequently than occupational therapists and that walking ability and balance were the most supported rehabilitation goals for outdoor physiotherapy [2]. ...
The added value of natural environments in rehabilitation exercise is unclear. This study aimed to investigate whether there are more acute health benefits for older adults after a single rehabilitation exercise session performed in an outdoor natural environment compared with an indoor environment. Twenty-two nursing home residents were randomly assigned to the outdoor (n = 11, 79.5 ± 2.1 years) or indoor group (n = 11, 78.8 ± 5.2 years). Performance test outcomes were measured pre- and post-training session. The indoor group had a significantly higher blood pressure, greater increase in heart rate, higher perceived exercise intensity and physiological fatigue than the outdoor group. The combination of rehabilitation exercise with an outdoor natural environment may reduce exercise fatigue and improve cardiovascular health in older adults, with greater acute health benefits compared with an indoor environment. Rehabilitation exercise in the natural environments may be a highly valued environmental intervention for physiotherapy in older adults.
... A building's rooftop is an ideal location for a green space with open views, providing people with opportunities for relaxation, recreation, and social interaction. Rooftop green spaces are also used therapeutically in hospital and welfare facilities due to their intrinsic capacity for stress reduction and restoration [24,25]. The health effects of green space are related to the type of green space which can be characterized by vegetation features [26]. ...
Connectedness to nature has been recognized as an important factor for well-being, with rooftop green spaces being used for stress reduction in modern cities. This study aimed to examine psychological and physiological responses to three different vegetation models on an urban rooftop. An analysis of psychological parameters indicated that the existence of vegetation in rooftop spaces could have positive effects on mood states, and the size of the effect was greater in a structured vegetation design than in a monotonous one. An analysis of the physiological parameters of heart rate variability and systolic blood pressure indicated that greater restorative effects are elicited from the use of vertical elements, such as shrubs and trees, added to grassy areas than from concrete environments. However, a fully enclosed vegetation with trees was not associated with higher parasympathetic activities than a half-open vegetation model. Based on these findings, an open and structured vegetation design that includes both grass and shrubs may have more potential for stress reduction than a monotonous vegetation model. A larger volume of vegetation was not necessarily linked to higher psychological and physiological benefits.
... Some have suggested that installing an ecoroof may improve worker productivity or provide a view that can be conducive to test taking (Lee et al., 2015). One pioneering study (Davis, 2011) conducted a post-occupancy evaluation (POE) of one rooftop garden in Georgia designed for physical therapy. This study (Davis, 2011) offers groundbreaking information about the ways in which visitors benefitted from this space, but it also suggests room for improvement in the design process as well as maintenance strategy. ...
... One pioneering study (Davis, 2011) conducted a post-occupancy evaluation (POE) of one rooftop garden in Georgia designed for physical therapy. This study (Davis, 2011) offers groundbreaking information about the ways in which visitors benefitted from this space, but it also suggests room for improvement in the design process as well as maintenance strategy. ...
... Despite the huge potential of ecoroofs to convey horticultural therapy, there are many reasons to suspect that this opportunity may not be fully utilized. As noted by Davis, 2011, not all ecoroofs can be installed in locations that are accessible, or easily viewed. Some pose safety challenges or require expensive railings to be installed. ...
The potential for urban open spaces to convey therapeutic benefits is increasingly substantiated. More work is needed to specifically consider how low impact designs to manage stormwater such as ecoroofs perform in this context. Here, we report on a pilot study addressing: (1) factors determining whether a hospital has an ecoroof, and (2) how ecoroofs might convey therapeutic benefits. We utilized a mixed methods approach which encompassed phone interviews of hospital ecoroof managers as well as analysis of national hospital databases. We also conducted a local case study which compared cortisol samples and stress indicators from patients, staff, and caregivers visiting an ecoroof to those waiting indoors at the Oregon Health and Sciences University in Portland OR. Behavioral observations took place at this same location. In 2017, we identified 105 hospitals with ecoroofs in the contiguous United States. Our analysis of a national hospital database found two factors that significantly increased the likelihood of a hospital having an ecoroof: Medicaid discharges per year; and non-profit status. Interviews with practitioners nationally revealed a wide range of motivations but that therapy was a consideration for a majority, but notably not all, of the hospitals surveyed. They similarly noted variation in roof design, maintenance, and programming around horticultural therapy; we highlight some best practices here. Our physiological case study was limited in sample size. Preliminary findings showed that salivary cortisol levels varied by ecoroof visitor type, ranging on average from 0.09 μg/ml for caregivers to 0.30 μg/ml for patients. We did not observe any significant changes in visitor cortisol. This could be explained by low replication or the short treatment duration. Alternatively, these pilot data may indicate a gap in horticultural therapy theory vs. practice. Behavioral observations demonstrated a wide array of different uses of the ecoroof space such as cell phone use and passing by. Though preliminary, our findings suggest that therapeutic effects may vary by user type and activity and depend on roof design and goals. This study offers both information on the therapeutic potential of hospital ecoroofs as well as lessons learned regarding different approaches to researching this somewhat new topic.
... Furthermore, they can be used to lodge such installations as photovoltaic systems [4] or sports areas [5]. In hospitals in particular, they can also provide garden areas intended for therapeutic purposes [6]. Roofs are classified as sloping (slope ≥5 %) or flat (slope <5 %) [7,8]. ...
Environmental impact reduction, structural security, and material resource optimization are basic aspects in selecting a construction system. In this study the environmental impact of the 10 predominant flat roof systems in the Spanish infrastructure was evaluated. For this purpose, the systems were subjected to life-cycle assessment, and a single-score damage category analysis was carried out for the midpoint and endpoint stages using the ReCiPe 2016 method, the Ecoinvent 3.5 environmental database, the LCA software SimaPro 9.0 and the “cradle-to-grave” perspective. The cost and installation time per functional unit were also taken into account. Results show that trafficable flat roof systems with fixed deck obtained the highest scores in all dimensions analyzed, with impacts in the range 19.15 pt/m²–22.59 pt/m². Moreover, it was determined that the non-trafficable flat green roof systems have lower cost and labour time values, as well as higher environmental impact values. It was concluded that the non-trafficable roof system with gravel finish and PVC membrane is the optimal solution. This roof typology presents the most favorable results in 20 of 22 impact categories and in the three areas of damage, obtaining the global environmental impact values (7.68 pt/m²), as well as acceptable values in the dimensions of cost (US$66.4/m²) and installation time (1.69 h/m²). Generated knowledge will provide engineering managers with a more detailed perspective of the environmental impact of healthcare infrastructures, increasing the socioeconomic and environmental benefits.
... Continuous observation is occasionally assisted by video recordings which can be watched back and used to generate either qualitative or quantitative data (Bayramzadeh et al., 2018;Colligan et al., 2012;Quan et al., 2016). Two of the studies which used continuous observation methods were designed to collect both qualitative and quantitative data by including "free comment" sections within a structured data collection form, analyzing these comments qualitatively, and using the results to help interpret the quantitative findings (Davis, 2011;D. Harris, 2017). ...
Objective
To provide a taxonomy of spatial observation methods that are commonly used in healthcare environments research and to describe their relative success.
Background
Spatial observation is a valuable but resource intensive research method that is often used in healthcare environments research, but which frequently fails to deliver conclusive results. There is no existing catalog of the different spatial and behavioral observation methods that are used in healthcare design research and their benefits or limitations.
Methods
The review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Ten key databases were searched, and articles were screened by both authors.
Results
Across 67 included studies, 79 observation methods were reported. We categorized those into four, distinct methodological approaches, outlining the benefits, limitations, and suitability of each for obtaining different types of results. Common limitations included difficulty generalizing to other contexts and a lack of detailed description during data collection which led to key environment variables not being recorded. More concrete conclusions were drawn when observation methods were combined with complimentary methods such as interview.
Conclusions
The relative success of spatial observation studies is dependent on the fit of the method selected relative to the research question, approach, and healthcare setting; any complimentary methods delivered alongside it; and the analysis model employed. This article provides researchers with practical advice to guide the appropriate selection of spatial observation methods.
... POE as a research strategy has been established in the field of healthcare research and design, and there has been advocacy that hospital gardens, like what has been conducted to healthcare architecture and interior spaces, should take steps towards evaluation and certification through rigorous POEs (Cooper Marchs & Sachs, 2013a). Prior scholars have studied hospital gardens and their impact on various user groups using the POE strategy, which has helped summarize effective suggestions for the design of future hospital gardens (Davis, 2011;Heath & Gifford, 2001;Sherman, Varni, Ulrich, & Valcarne, 2006). The three most common types of POEs in hospital garden evaluations are indicative (i.e., a short time, walkthrough evaluation sometimes involving the use of an audit), investigative (i.e., prompted by issues identified during an indicative POE to cover those issues in more depth), and diagnostic. ...
... The observations that were conducted are known as on-site observations or participant observations (Bryman, 2008). The observations were used as a tool intended to record the patterns and site activities to better understand how people actually move through and engage with a designed space (Davis, 2011). The observations usually involve behavior mapping, a method suited to studying people's behavior in relation to different components and features in an environment (Adevi, 2012;Pálsdoóttir et al., 2014). ...
... The observational map applied in this research is a table formulated in which items were related to the number of respondents, gender, weather conditions (weather, temperature, sunshine, wind), activities carried out by participants, retention points with an average over time, and plant species recorded on-site, brief comments and additional observations. Along with the table, there was a draft map with marked boundaries and basic landmarks of location, filled in by the on-site researcher (Davis, 2011). ...
... the researchers were able to read and record on-site meteorological data as well as time. Observations were conducted from neutral positions, and the manually mapped data were recorded on table and draft maps by the researcher or the research assistant (Davis, 2011). The observations were made usually following an NBRP daily session at the garden. ...
Aim
This article aims to make clearer, with supporting evidence, the clinical benefits of the nature-based rehabilitation program (NBRP) and the restorative values of visiting botanical garden for people with stress-related mental disorders.
Background
Throughout the years, nature-based therapy has been acknowledged as a valuable rehabilitation practice that integrates specially designed natural environments and nature-related activities for people with mental health conditions.
Subject and Methods
The comparative analyses of parallel conducted the NBRP at botanical garden and occupational therapy realised at the Day Hospital of the Institute of Mental Health in Belgrade included 27 participants divided into two groups. The data collection employed a mixed method combining a Clinical Global Impression (CGI) Scale and on-site observations.
Results
The positive findings on the psychological recovery of the participants seem 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. The observed landscape elements especially solitary plant specimens or tall and single-form trees within the garden can be embraced as design guidelines for the development of an evidence-based practice that can support the recovery process of people with mental health conditions.
Conclusion
Our findings endorse that ongoing social development and progressive urbanization have broadened the interest in scientific research involving nature-based solutions that help preserve the physical and mental health of people in low- and middle-income Western Balkan countries with a high prevalence of mental disorders in the urban environment that relates to social inequalities and natural disasters.
