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The Healthcare Garden Evaluation Toolkit: A Standardized Method for Evaluation, Research, and Design of Gardens in Healthcare Facilities. Doctoral dissertation.
Abstract and Figures
As healthcare organizations and designers accept, and even embrace, healing gardens and other natural spaces as modalities for promoting the health and well-being of patients, visitors, and staff, the spaces provided must be designed and programmed to best optimize user health outcomes. Valid, reliable research instruments can aid in the evaluation of existing spaces. They can also be used as guides and tools for future design and research. The Healthcare Garden Evaluation Toolkit (H-GET) is a set of four standardized instruments developed for use, individually or in combination, by researchers, designers, and healthcare providers to evaluate, design, and research gardens in general acute care hospitals. Evaluation is an important component of research on the designed environment, and is a critical part of evidence-based design. The more valid and reliable the instrument, the greater the likelihood that results will be credible and generalizable. To date, despite a clear need, there are no rigorously tested, validated instruments available for the evaluation of outdoor spaces in general acute care hospitals. The H-GET fills this need. This mixed methods study involved development and testing of the four H-GET instruments: (a) the Garden Assessment Tool for Evaluators; (b) Staff and Patient/Visitor Surveys; (c) Behavior Mapping protocol ; and (d) Stakeholder Interviews. All four instruments were tested at eight Pilot Test sites across the United States. Emphasis with data collection and analysis was on establishing instrument reliability and validity. Data from each instrument were analyzed, and data from the four instruments were triangulated to examine support for validity and to explore specific hypotheses about physical and programmatic factors that promote garden use and user satisfaction. Through H-GET pilot testing, a Healthcare Garden Evaluation Method (HGEM) emerged—a methodological process that the individual instruments facilitate in a rigorous, standardized, research-based format for future studies’ design, protocol, data collection, data analysis, and dissemination of findings.
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... For my doctoral research, I developed a toolkit for evaluating gardens in healthcare facilities (the H-GET; Sachs, 2017). One of the four tools was a pair of surveys, one for patients and visitors and one for caregivers. ...
... At the Kaiser Permanente medical office building in Oakland, CA, the garden is sited in between the building and the staff parking lot; we observed caregivers admiring the plants, taking pictures, and stopping to sit on a bench, especially on their way from the building to the parking lot (presumably at the end of a shift). At St. Joseph Hospital in Bryan, TX, and Legacy Health in Portland, OR, the healing garden is sited between two hospital buildings, and caregivers often walk back and forth through the garden many times a day-sometimes even if it is not as direct a route (Sachs, 2017). ...
... Walking allows caregivers time to be alone or to have a more private meeting with a colleague. During our behavior observations, we often saw caregivers walking around the building, even if it was through parking lots (Sachs, 2017). ...
... For instance, while studying the use of green outdoor environments at acute care hospitals in Denmark, Shukor (2012) noted that although for a shorter period, the hospital staff was a more frequent user group of these areas than patients. In the USA, a study found that the three highest-ranked reasons healthcare staff gave for visiting hospital gardens are to get fresh air (69.85%), relax (61.01%), and look at nature (45.72%), and their self-reported stress dropped by 60% after just spending 15 minutes in the gardens (Sachs, 2017). Also, in an experimental study of the effect of work breaks on burnout, Cordoza et al. (2018) discovered that nurses who use hospital gardens for daily work breaks achieved a significantly higher reduction in emotional exhaustion than those that took indoor-only breaks. ...
... Healthcare policymakers and relevant government agencies should also prioritize the long-term goal of implementing evidence-based design considerations for hospitals (Arjmandi et al., 2022;Iqbal, 2021a). This design approach is based on evaluating all hospital users' design, environmental, and psychological needs (Sachs, 2017). However, lack of awareness and studies focusing on this area are challenges to effective provision and use of hospital outdoor spaces. ...
... A well-designed hospital garden should utilize the best practices suggested below and the existing resources to provide amenities and arrangements that optimize users' health outcomes and best suit their relevant contexts (Sachs, 2017). First, the healthcare providers' perspectives should influence the design of an outdoor facility to ensure an effective therapeutic environment (Mourshed & Zhao, 2012). ...
The COVID-19 pandemic has created considerable implications for healthcare staff around the globe. During the pandemic, the frontline healthcare workers experience intense anxiety, stress, burnout, and psychological breakdown, with severe implications on their mental and physical wellbeing. In addition to these implications, anxiety and stress can hinder their productivity and ability to perform their duties efficiently. The literature indicates that hospital gardens and contact with nature can help alleviate psychological distress among hospital staff. However, few studies investigated the role of outdoor spaces as areas for respite and work breaks in healthcare facilities during the pandemic. The present opinion paper highlights the challenges of job stress and psychological distress health workers face during the pandemic. The paper also underscores the role of hospital outdoor spaces and garden facilities in coping with the challenges. While other measures to reduce stress among hospital staff and ensure their health and safety are important, hospital administrators and relevant government agencies should also underscore the provision of gardens and open spaces in healthcare facilities. These spaces can act as potential areas for respite for hospital staff and help them cope with the stress and anxiety accumulated through working under crises.
... During the site visits, the research team interviewed the staff member or administrator who oversees the grounds. Indicative site evaluations using the Garden Assessment Tool for Evaluators (GATE) audit tool were conducted on the main therapeutic garden spaces to evaluate whether the design elements and qualities fulfilled the requirements of an ideal therapeutic garden space in a general hospital environment (Sachs, 2017). Onsite observations and behaviour mappings were conducted at selective garden spaces. ...
... The GATE audit tool is a scored checklist of elements and qualities that should be incorporated into an ideal restorative garden space in a general hospital environment (Sachs, 2017). The latest version of GATE is a six-page, 96-item rating system evaluating the level of restorativeness of garden spaces in a general acute care hospital environment. ...
... Scores can be interpreted by individual domain or sub-domain when aiming to understand specific aspects of a garden's level of restrictiveness. Scores can also be converted to a 10-point scale for easier interpretation (Sachs, 2017). ...
... During the site visits, the research team interviewed the staff member or administrator who oversees the grounds. Indicative site evaluations using the Garden Assessment Tool for Evaluators (GATE) audit tool were conducted on the main therapeutic garden spaces to evaluate whether the design elements and qualities fulfilled the requirements of an ideal therapeutic garden space in a general hospital environment (Sachs, 2017). Onsite observations and behaviour mappings were conducted at selective garden spaces. ...
... The GATE audit tool is a scored checklist of elements and qualities that should be incorporated into an ideal restorative garden space in a general hospital environment (Sachs, 2017). The latest version of GATE is a six-page, 96-item rating system evaluating the level of restorativeness of garden spaces in a general acute care hospital environment. ...
... Scores can be interpreted by individual domain or sub-domain when aiming to understand specific aspects of a garden's level of restrictiveness. Scores can also be converted to a 10-point scale for easier interpretation (Sachs, 2017). ...
... In a study of over 1,100 residents at a senior care facility, "to get fresh air" was the most frequent write-in response from survey participants who were asked what was most important about the outdoor environment (Rodiek, 2009). I took this research into account during my doctoral studies when designing the Healthcare Garden Visitor Survey (for patients and visitors) and Healthcare Garden Staff Survey (Sachs, 2017). In both surveys, I included "Get fresh air" as one of the 24 multiple-choice options in the question "Why do you visit the garden, and what do you do when you go there?" ...
... (e.g.,Jacob, Kasali, Steinberg, Zimring, & Denham, 2013; Joseph, Bayramzadeh, Zamani, & From the Healthcare Garden Staff Survey and Healthcare Garden Visitor Survey(Sachs, 2017), comparison in percentages of staff and patient/visitor responses to the question, "Why do you visit the[healing] garden and what do you do when you're there?" ...
... Research indicates that a hospital garden should be located close to targeted groups (Nejati, Shepley, Rodiek, Lee, & Varni, 2016) and unlocked (Pasha, 2013) for it to be frequently used and effective in reducing stress. Proximity and being unlocked also are recommended in best practice design guidelines for healthcare gardens authored by qualified professionals (Marcus & Sachs, 2013;Sachs, 2017). A second-floor terrace location was chosen because it enabled short walking times (<1 min 20 s maximum) from the CVICU, NTICU, and a maternity unit and is unlocked, accessible, and safe 24/7. ...
... The garden has other design features that researchers have linked to stress reduction and user satisfaction: visual connections from the building interior (windows) to attract users to the garden ( Figure 4); access to privacy ( Figure 2); options of comfortable movable seating to promote socializing; shade access (Figures 2 and 3); accessible paths for users with crutches, walkers, or wheelchairs ( Figure 3); and a play area for children (Marcus & Sachs, 2014;Rodiek, Nejati, Bardenhagen, Lee, & Senes, 2016;Sachs, 2017;Sherman et al., 2005;Ulrich, 1999). Finally, the design reflects attention to environmental sustainability. ...
Objectives
Measure the immediate change in intensive care unit (ICU) family members’ state stress levels from the beginning to the end of a person’s visit to a hospital garden and compare the changes produced by the garden with those associated with spending time in indoor hospital environments intended for respite and relaxation.
Background
No previous research has compared the efficacy of different physical environments as interventions to foster stress reduction in family members of ICU patients, a group of hospital visitors known to experience high levels of distress.
Method
A convenience sample of 42 ICU patient family (from 42 different families) completed the Present Functioning Visual Analogue Scales (PFVAS) before and after each visit (128 total visits) to a garden, an atrium/café, or ICU waiting room.
Results
Stress scores significantly declined (i.e., improved) from the start to the end of a break on all PFVAS subscales ( p < .0001) in both the garden and indoors locations. However, it is noteworthy that garden breaks resulted in significantly greater improvement in the “sadness” scale than breaks in indoor locations ( p = .03), and changes in all five other PFVAS scores showed somewhat more reduction of stress for breaks spent in the garden than indoors, although these differences were not statistically significant.
Conclusion
Creating an unlocked garden with abundant nature located close to an ICU can be an effective intervention for significantly mitigating state stress in family members of ICU patients and can be somewhat more effective than indoor areas expressly designed for family respite and relaxation.
... Sachs (2019) asserted the main reason people visited gardens or outdoor spaces in healthcare facilities is to get a breath of fresh air. In a Healthcare Garden Visitor Survey (for patients and visitors) and Healthcare Garden Staff Survey, Sachs (2017) reported that getting fresh air rank as the number one reason for visiting the garden. In a recent study, in healthcare facilities focusing on caregivers, the physical environment and access to nature are substantial in overcoming the level of stress, burnout, fatigue, and moral distress faced by the caregivers (Sachs, 2023). ...
This paper seeks to address the existing research gap by introducing a novel database in the context of mapping the carbon sequestration of mature trees, utilizing Geographic Information System (GIS) for enhanced landscape planning and management strategies. While previous studies have explored the use of GIS in landscape planning, limited attention has been directed towards its application in mapping the carbon sequestration of mature trees, particularly in health facilities. One objective of this study is to provide a carbon sequestration database that consists of spatial and attributes data that can be used by the management of landscape planning for monitoring works and become more aware of existing trees that can give more benefit to the environment and climatic change globally. The methodology consists of presenting the sequential method of developing the database with spatial and attribute data using Entity-Relationship Diagram (ERD), and performing spatial analysis and carbon sequestration of mature trees map at Hospital Gerik, Perak using GIS software. The analysis shows the total amount of carbon sequestration area for 14 species of trees and 49 trees with a range of Diameter Breast at Height (DBH) between 0.5 cm to 450cm and a range height between 0.6m to 20m height. This paper provides valuable insights for health facility management, highlighting the environmental value of the mature trees currently located within the vicinity of their buildings. Depending on spatial maps of carbon sequestration, the recommendations and implications for improving the landscape planning and management at Hospital Gerik are discussed in comprehensively.
... Como abordado anteriormente, pesquisadores como Kaplan e Kaplan (1989), Kaplan (1995), Marcus e Barnes (1995), Marcus e Barnes (1999), Ulrich (1999) voltaram-se para a verificação dos impactos que o contato com elementos da natureza possuem sobre as pessoas, formulando recomendações para projetos de jardins terapêuticos, focando, desse modo, nos espaços exteriores das edificações. A partir de então, a medida que os jardins foram sendo implementados, estudos de casos, avaliações pós ocupacionais e novos estudos continuaram a aprimorar as diretrizes projetuais WINTERBOTTOM, WAGENFED, 2015;MARCUS, 2016;SACHS, 2017). Tal resultado corrobora a natureza do projeto como disciplina, pois, em sua elaboração a atualização é uma busca constante. ...
Esta pesquisa realiza o estudo bibliográfico sobre jardins terapêuticos buscando a identificação de diretrizes projetuais que possam orientar a proposição desses espaços em ambientes hospitalares, contribuindo para a sua qualificação ambiental e, consequentemente, para a humanização do atendimento da saúde. Desenvolve-se a partir do seguinte questionamento: Quais são as diretrizes projetuais para um jardim terapêutico hospitalar? Para isso, objetiva definir o que é um jardim terapêutico; analisar as características de jardins terapêuticos hospitalares através de estudos de casos e demais publicações sobre o tema e identificar um conjunto de diretrizes projetuais para jardins terapêuticos hospitalares. Caracteriza-se como pesquisa qualitativa, de caráter exploratório e realiza a busca de dados em artigos revisados por pares, avaliações pós ocupacionais (APOs) e estudos de casos de jardins terapêuticos hospitalares. Ainda, relaciona os autores com suas contribuições por meio de tabelas, que foram divididas em diretrizes de jardins terapêuticos para trabalhadores da saúde, para pacientes adultos e seus acompanhantes/visitantes e para pacientes pediátricos e seus acompanhantes/visitantes. As diretrizes identificadas nessa pesquisa não têm o intuito de substituir ou sobrepor demais diretrizes projetuais, normas técnicas e leis, mas sim somarem-se a elas.
... Evidence is also very clear that patients highly value shade so they can use the garden on hot sunny days, but this too was reduced because of disrupting the views. In a post-occupancy evaluation [27], the design elements that went against evidence were all identified as problems by patients at this hospital. ...
More than 80% of the people in the USA and Canada live in cities. Urban development replaces natural environments with built environments resulting in limited access to outdoor environments which are critical to human health and well-being. In addition, many urban open spaces are unused because of poor design. This paper describes case studies where traditional landscape architectural design approaches would have compromised design success, while evidence-based landscape architecture (EBLA) resulted in a successful product. Examples range from school-yard design that provides safe levels of solar radiation for children, to neighborhood parks and sidewalks that encourage people to walk and enjoy nearby nature. Common characteristics for integrating EBLA into private, public, and academic landscape architecture practice are outlined along with a discussion of some of the opportunities and barriers to implementation.
SOFIT (System for Observing Fitness Instruction Time) Description and Procedures Manual. Generic version. Contains references, sample recording forms, information for observer video training.
Attention Restoration Theory (ART) suggests the ability to concentrate may be restored by exposure to natural environments. Although widely cited, it is unclear as to the quantity of empirical evidence that supports this. A systematic review regarding the impact of exposure to natural environments on attention was conducted. Seven electronic databases were searched. Studies were included if (1) they were natural experiments, randomized investigations, or recorded ?before and after? measurements; (2) compared natural and nonnatural/other settings; and (3) used objective measures of attention. Screening of articles for inclusion, data extraction, and quality appraisal were performed by one reviewer and checked by another. Where possible, random effects meta-analysis was used to pool effect sizes. Thirty-one studies were included. Meta-analyses provided some support for ART, with significant positive effects of exposure to natural environments for three measures (Digit Span Forward, Digit Span Backward, and Trail Making Test B). The remaining 10 meta-analyses did not show marked beneficial effects. Meta-analysis was limited by small numbers of investigations, small samples, heterogeneity in reporting of study quality indicators, and heterogeneity of outcomes. This review highlights the diversity of evidence around ART in terms of populations, study design, and outcomes. There is uncertainty regarding which aspects of attention may be affected by exposure to natural environments.
