One of my greatest pleasures (and a potent stress reliever) is to walk in the Japanese gardens near my home in Portland, Oregon. When I heard about the work being done at a local hospital with the use of a healing garden for mothers and their families, I was so impressed I had to share it. Today's column is guest authored by Dr Roger S. Ulrich and Dr R. Serene Perkins, in the hope that their important work will continue and that the healing powers of nature will come to be a routine part of healthcare for patients, families, and clinicians. - Lisa A. Miller, CNM, JD

Come forth into the light of things, let Nature be your teacher. - William Wordsworth

In 2013, the Legacy Emanuel Medical Center in Portland, Oregon, partnered with the Tom and Kitty Stoner Foundation (TKF, http://www.naturesacred.org) in Annapolis, Maryland, to embark upon an ambitious goal to design a hospital green space that would promote the well-being of patients, families, and caregivers. After receiving 1 of 5 TKF National Nature Sacred Awards granted nationally, we knew that we were on the path to accomplishing this goal. Incorporating ideas and findings from environmental psychology, landscape architecture, interior design, medicine, and public health research, the aim was demonstrate how specific design changes in health care environments can reduce stress and alleviate the physical outcomes associated with it. This multiyear grant also funded 3 clinical research projects on the impact of the garden on laboring patients, families, and nurses who are exposed to the high-stress clinical environment of tertiary referral center.

It is well known that illness and hospitalization induce stress and can be detrimental for patient outcomes, including for women in maternity units.1 While modalities to combat patient stress have abounded in recent years,2-4 the use of nature, specifically gardens, has not been well studied in the hospital setting. Read this story of a pregnant mother who used the Legacy Emanuel Medical Center healing garden during her 40-day period of inpatient bed rest:

What would I do without the gardens during my 40-day stay at the hospital? After three days in a row of not spending time in the gardens, I can tell you that my mood deteriorated, I didn't feel like doing my room exercises, and cried every day. I continued my garden visits after these three days and noticed an immediate improvement of my well-being.

It's hard to describe in words the happiness created in me by the gardens. As I sit here now, birds are singing songs to me, bees are collecting pollen from the beautiful flowers, and a white butterfly flutters around me as if to say hello. Sometimes the birds come to me because they have learned I have bird seed. By sharing the seed with others, I have witnessed happiness and joy of others who also receive gratification from the birds.

My eyes and senses are also brought to life by the gardens. The lilies are amazingly beautiful with a sweet aroma. The lavender and rosemary beg me to rub my hands on them so I may smell like their fragrance. Even the big bowl of mixed greens invited me to eat a small sample so that I may taste fresh life.

For this mother, the hospital garden not only provided pleasant nature views but also alleviated stress5 and promoted restoration by providing an opportunity for positive escape from interior clinical spaces.6

Approximately 1800 births occur yearly at Legacy Emanuel Medical Center, many of which are high-risk pregnancies requiring lengthy hospital stays. Would newly constructed garden provide a welcome respite from stress and confinement? Initial response to answer this question was to design a clinical trial measuring neonatal outcomes related to pain, anxiety, and stress-such as fetal heart rates and cord blood pH levels after delivery. However, we encountered 2 unexpected obstacles: (1) many mothers did not want to risk being randomized to the control group (without garden access) and, therefore, opted not to participate; and (2) mothers who did enroll tended to arrive at the hospital in active labor and did not have time to utilize the garden prior to delivery. Planned or emergent cesarean delivery (21%), fetal monitoring (14%), delivering too quickly (13%), lack of knowledge about the garden (6%), and delivering at night (4%) were the most common reasons.

These obstacles helped to recognize that we needed to open a dialogue with mothers on needs surrounding labor and delivery-why was the draw to the garden so powerful? In a follow-up survey of 141 postpartum mothers (only 12% had the opportunity to use it), we discovered an intriguing fact: 75% (15 of 20 surveyed) of partners also utilized the garden. In addition, 86% of mothers and 100% of partners had a positive impression about access to a garden during labor. Of the 32 mothers and partners who used the garden, 84% and 100%, respectively, found it beneficial. Mothers spent an average of 35 (between 5 and 120) minutes in the garden, often in a single visit. Features that were especially pleasing included a rocking chair, a fountain, and a journal in which patients and families shared stories about the hospital experience. Some (12.5%) reported a sense of personal calm while in the garden; 87% with children or family members present during labor thought that access to an outdoor space was a good idea.

Legacy Health's Therapeutic Gardens program has grown to include 9 therapeutic gardens in 4 acute care hospitals that are often noted for their specific patient-centered design elements. While patients, families, and staff have the most priority for a garden, they are for everyone and are designed to support the widest range of users. The gardens must create and keep going to support the psychosocial, physical, and spiritual needs of individuals and incorporate tailored design elements. While Legacy has made significant strides in the development and support of sacred green spaces, there is still much work to be done. We believe that everyone should have access to the healing power of nature and will continue to work toward this goal both within own organization and through education and advocacy efforts with colleagues around the world.

-Roger S. Ulrich, PhD

Professor

Department of Architecture and Centre for Healthcare Architecture

Chalmers University of Technology

Gothenberg, Sweden

-R. Serene Perkins, MD, FACS

Director of Surgical and Clinical Research

Director, Legacy Institute for Surgical Education and Innovation

Legacy Research Institute

Legacy Health

Portland, Oregon

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