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Service Delivery Innovation Profile

Rooftop Garden Provides Healing Environment, Enhancing Recovery for Rehabilitation Hospital Patients


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Snapshot

Summary

Schwab Rehabilitation Hospital's rooftop healing garden is an escape from the stress of the institutional environment, designed to meet the unique needs of rehabilitation patients. Therapists were active in the design process to ensure that the healing garden offered space for therapeutic activities; included design elements for sensory therapy; and was an inviting place for patients, families, and staff to relax during leisure time. Anecdotal evidence from patients, therapists, and administrators suggests that Schwab's healing garden is beneficial to patients; evidence from other settings demonstrates that viewing or spending time in pleasant outdoor environments can reduce pain, anxiety, emotional distress, and complications.

Evidence Rating (What is this?)

Suggestive: The evidence consists of anecdotal reports from Schwab patients, staff, and administrators, along with research studies on the benefits of outdoor gardens in other health care settings.
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Developing Organizations

Schwab Rehabilitation Hospital
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Date First Implemented

2003

Problem Addressed

Patients in rehabilitation hospitals often have significant physical obstacles to overcome during their recovery, which can be complicated by stress and anxiety. Although spending time outdoors has the potential to reduce stress and facilitate recovery,1 few rehabilitation hospitals offer such an option, particularly those in urban areas.
  • High-stress environment: Health care environments are known to create stress for patients, families, and employees, which has negative effects on the patient's physical, psychological, and behavioral outcomes.2
  • Lack of access to outdoor areas: Access to nature can aid recovery2 (see the Results section for more information). Few rehabilitation hospitals offer patients this opportunity, particularly those in urban areas where spending time outside can create safety concerns. Schwab therapists used to take some patients to a park across the street from the hospital for occasional physical therapy sessions, but safety concerns and physical access barriers led to the discontinuation of this practice.3

What They Did

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Description of the Innovative Activity

The Schwab Rehabilitation Hospital's rooftop healing garden provides a handicapped-accessible alternative location for therapeutic activities and a comforting environment for patients, family members, and staff to relax. Key aspects of the healing garden are described below:
  • Garden design: A secure alternative to the neighborhood park, the 10,000 square-foot, rooftop healing garden includes a 50-foot stream filled with Koi (a type of goldfish), a waterfall, a vegetable garden, shaded seating areas, half-court basketball, garden paths for walking, and a children's playground.
    • Handicapped accessible: Each feature of the healing garden is designed to accommodate patients with disabilities. For example, the garden pathways were designed to minimize fall hazards, and there are raised garden beds of different heights so that they can easily be accessed by both wheelchair-bound and ambulatory patients.
    • Sensory stimulation: Sensory stimulation is particularly important for visually impaired patients and for patients with low cognitive function. Schwab strategically selected design elements that incorporate sensory elements. For example, plants were chosen that are colorful throughout the year, that stimulate the olfactory senses (lavender and Echinacea), and that have tactile qualities (blue fescue). The waterfall and stream also serve as soothing auditory elements.
  • Alternative location for rehabilitative therapy: To remind patients that there is life outside of the hospital and to give them a chance to practice life skills without leaving the security of the hospital, many rehabilitation therapies make use of the healing garden. Regular group activities that occur in the healing garden include:
    • Ambulation and mobility: Instead of going to the gym, patients can practice ambulating and wheelchair mobility skills with a physical therapist in the garden. The healing garden incorporates several different surfaces, architectural barriers, and outdoor environmental factors that prepare patients for life after discharge.
    • Motor coordination: Occupational therapists hold classes that work with patients on pulling weeds, planting, and watering to build dexterity and motor coordination. These practical skills are critical for patients after they return home.
    • Relaxation: Therapists use the sound of the stream and the serene environment as a backdrop for teaching patients relaxation and deep-breathing techniques to reduce stress.
    • Leisure skills training: Patients have the opportunity to learn gardening skills and about wildlife, which helps to bolster their coping skills after discharge. Staff also teach cooking, using vegetables that patients grow in the garden.
    • Horticulture therapy: Patients can work toward therapy goals while also learning about gardening and planting techniques and maintenance.
  • Outdoor retreat and recreation area: The healing garden is also available for recreational activities to reduce stress, including working in the vegetable garden and playing adaptive sports such as tennis, hand cycling, golf, and wheelchair basketball. Patients, staff, and family members regularly use the healing garden as a place to eat meals and relax during their free time.

Context of the Innovation

Schwab Rehabilitation Hospital is a 120-bed, nonprofit physical medicine and rehabilitation hospital located in downtown Chicago, IL. In addition to general rehabilitation, Schwab has specialty programs for pediatrics, traumatic brain injury, stroke, and spinal cord injury. The average inpatient stay at the facility is 2 to 4 weeks. Schwab therapists have always believed in the benefits of providing therapy in an outdoor setting, and, as noted, for many years offered therapy in a local neighborhood park to those patients with adequate mobility. In the late 1990s, however, growing concerns about the safety of the surrounding neighborhood ended this practice. As a result, hospital staff advocated for the development of a rooftop garden as a safe, alternative outdoor setting.

Did It Work?

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Results

Anecdotal evidence from patients, therapists, and administrators suggests that Schwab's healing garden is beneficial to patients; evidence from other settings demonstrates that viewing or spending time in a serene natural environment can reduce pain, anxiety, emotional distress, and complications.2
  • Positive anecdotal reports: Schwab patients report that the healing garden serves as a source of optimism and motivation. Therapists report that daily access to nature and the outdoors makes the rehabilitation process easier for patients, while administrators believe that the garden helps patients to gain more independence.
  • Evidence of positive impact in other settings: A growing body of evidence from long-term care facilities shows that healing gardens can reduce stress levels and improve health outcomes.1 Research has shown that just viewing a scene with trees and water significantly reduces pain and anxiety during the postoperative period for cardiac surgery patients.4 Another study showed that patients in rooms with a nature view had fewer postsurgical complications, shorter lengths of stay, and less need for pain medication than did patients whose rooms faced a wall.4 In addition, hospitalized patients with access to an outdoor garden report less emotional distress and lower levels of pain when they are in the garden than when inside the hospital.5

Evidence Rating (What is this?)

Suggestive: The evidence consists of anecdotal reports from Schwab patients, staff, and administrators, along with research studies on the benefits of outdoor gardens in other health care settings.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Securing funding: Program advocates secured a 2002 grant to cover construction of the garden.
  • Designing the garden: Schwab staff played a primary role in designing the healing garden for recovering patients, making sure it would enhance therapeutic activities and thrive within the local midwestern climate. Staff also collaborated with a team of master gardeners, horticulturists from the Chicago Botanic Garden, representatives of the mayor's office, and a landscape architecture firm during the development process. To keep utility costs to a minimum, the design called for use of high-insulating materials whenever possible.
  • Building the garden: Construction of the healing garden began in the spring and was completed in the fall of 2003. The entire design and construction process took approximately 5 years.

Resources Used and Skills Needed

  • Staffing: The Schwab recreation therapy department oversees maintenance of the garden, a task that requires approximately 20 to 30 person-hours a week during 9 months of the year. The department formed a relationship with the University of Illinois Extension program for master gardeners, which provided three volunteers to assist with this task, each spending roughly 4 hours per week on tasks such as weeding, watering, pruning, and mulching. The remainder of the maintenance work is done by a paid employee of the hospital. Therapists and other staff who use the garden do so as part of their regular staff duties.
  • Costs: The garden cost roughly $480,000 to design and construct. Annual maintenance costs, not including staff time, are approximately $10,000.
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Funding Sources

Schwab Rehabilitation Hospital
The original design and construction of the garden was funded by a $400,000 grant from the city of Chicago's Heat Island Reduction Initiative and $80,000 in private donations. Ongoing maintenance is funded primarily through private donations.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Designate an appropriate advocate: The individual appointed to oversee the design should have a strong background in construction and the ability to understand how the garden can be used to enhance patient care.
  • Consider the patient population: Because the garden is used by patients with special needs, adjustments may need to be made throughout the design and construction process. For example, use of control joints in concrete walkways can create gaps that pose a potential hazard to elderly patients and those with intravenous lines. As a result, joints should be made as narrow as possible and/or should be beveled to create a smoother surface.
  • Develop a maintenance plan: Before the garden is built, determine who will be responsible for maintenance; options include an outside contractor or a full-time employee with the appropriate skills. Although some facilities initially rely on building engineers, competing priorities make it unlikely that these employees will be able to take care of the garden over the long term. Schwab did not initially have a maintenance plan for the healing garden, and it became overgrown as a result.

Sustaining This Innovation

  • Develop and maintain a relationship with a master gardener program to assist with garden upkeep: Having been educated in horticulture, master gardeners are ideally qualified to oversee maintenance of the garden. They also need to log service hours to maintain their certification, making the relationship mutually beneficial.

More Information

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Contact the Innovator

Dianne Hunter
Director of Public Relations and Communications
Sinai Health System
California Avenue at 15th Street
Chicago, IL 60137
(773) 257-5228
E-mail: Dianne.hunter@sinai.org

Innovator Disclosures

Dr. Hunter has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Wehner M. Urban oasis. Healthcare Design Magazine. 2006. Available at: http://www.healthcaredesignmagazine.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=FDE85F5E666444B9A8811949A1CE6ACA

Footnotes

1 Del Sole M. Therapeutic gardens bloom in senior living communities. Assisted Living Success. 2003 June.
2 Ulrich RS. Effects of health care environmental design on medical outcomes. In: Dilani A, editor. Design and health: Proceedings of the 2nd international conference on health and design. Stockholm, Sweden: Svensj Byggtjanst; 2001:49-59. Available at: http://www.designandhealth.com/uploaded/documents/Publications/Papers/Roger-Ulrich-WCDH2000.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 Joint Commission. Award winning healing garden: nature's power aids recovery at Schwab Rehabilitation Hospital. Environment of Care News. 2008;11(4):4-5. Available at: http://www.ingentaconnect.com/content/jcaho/ecn/2008/00000011/00000004/art00002
4 Ulrich RS. Health benefits of gardens in hospitals. Paper for a conference, Plants for People, International Exhibition Floriade. 2002.
5 Sherman SA, Varni JW, Ulrich RS, et al. Post-occupancy evaluation of healing gardens in a pediatric cancer center. Landscape and Urban Planning. 2005;73:167-83.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 19, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 27, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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