How medicine also embraces the effects of more green space

Aesthetics are very often at the center of the design and layout of gardens and public green spaces. The same is certainly true of the place of greenery in interior spaces. Yet there is currently a remarkable turnaround, with the emphasis shifting to functional greenery. This revolves around greenery as a determining factor for a healthy living environment and even as a healing factor for body and mind. Two major underlying social issues are driving this green revolution: rapid global warming and ever-increasing healthcare costs. Together with De Bloeimeesters - a group of experienced garden specialists with an impressive amount of plant knowledge - Greenpro brought together experts from healthcare, construction and greenery for a themed special "Green in Healthcare. On the next 10 pages you will find the result. Green is also - or perhaps especially - an investment that pays off in several ways.

Dr. Jolanda Maas, associate professor at the Department of Clinical Psychology at the Vrije Universiteit Amsterdam was closely involved in the research for this. A few years back, together with environmental psychologist Dr. Agnes E. van den Berg and Dr. Karin Dijkstra, lecturer in health promotion in the living environment, she compiled the evidence-based inspiration guide 'Green in and around hospitals' (2021), which incorporated the outcomes of the research program 'Green Healthy Hospitals' conducted in the years 2015-2020. It looked at the effects of green interventions on five hospital wards. 

"Many green interventions have indeed been realized in recent years," says Maas, "but there is still a problem, because they are generally only used to a limited extent. As a result, the effects are still limited, which makes it more difficult to justify the investments. That it doesn't work as it should does not only have to do with the design, but also with the fact that the facility is not really integrated into the care. So there is still a lot of room for improvement.'

Remarkably, these often involve the obvious. Maas: "To ensure that the green space is used, the facility must be easily accessible, people must know where to find the entrance. Furthermore, it is important to map out well in advance how the intended users would like to use the garden and what facilities are needed to do so, and it is good to let the staff experience the importance of the green facility. When designing, you need to know that the surface of a green space next to an oncology department needs to be suitable for people with an IV pole and that for a geriatrics department you need to think about more and also higher benches. So that still happens too little."

Why things go wrong during implementation is hard to say, according to Maas: "Of course it's pretty new, the care workers are super busy, and for most landscapers and gardeners it's also about new target groups. It is a bit similar to the process surrounding the construction of green schoolyards. It often has to be done quickly and on a limited budget."

Fortunately, there are more and more designers who do get it right, Maas observes. "But they have to get into the picture with a care institution. Healthcare institutions now often have ongoing contracts with landscapers, who are then also deployed in such a green intervention, while the necessary expertise is not always present. The bottom line is that both hospitals and landscapers and gardeners will need to be trained on this issue. Both parties need to become aware that with some extra steps they can really realize something of value, rather than what it often is now: a nice decorative element." 

Fine example of greenery in a hospital is the VieCuri Medical Center in Venlo. There, the Oncology Center has the BuitensteBinnenTuin with a beautiful greenhouse. Maas: "That is a beautifully designed garden of experience for patients and visitors. Unfortunately, there too, they see that use lags behind. Why that is, we are now investigating." 

Something similar also played out at the Isala Hospital in Meppel and the Leeuwarden Medical Center, both of which had gardens that were not actually being used.

"So we redesigned those gardens, together with a team of professionals - including people working in the hospitals themselves - using our design-implementation model," says Maas. "And set up a process around it to ensure that healthcare professionals also integrate the garden into their work processes. Only then does a garden like this really start to add value."

Demonstrating health claims is not so easy, because only limited research has been done. Maas: "General literature suggests that such a garden reduces stress, provides a nice distraction for care workers and also increases job satisfaction. I think it is very important what kind of story you tell around it. I see these green spaces myself as a kind of refuge for the brain: to get away from that stressful environment.'

So it is not only a matter of really implementing such a green project properly, but also of getting a better picture of the health effects or perception effects? Maas: "Definitely! And then not only the effects on the patients, but also on the employees and visitors. I think that's just as important with the growing shortages of healthcare workers and the high dropout rates due to stress and burnout."

What is true on a small scale for healthcare environments is true to some extent for the entire living environment. But what actually constitutes a healthy living environment in our increasingly fossilized country? To find out more, we spoke with Judith van der Poel, landscape architect and director of Niek Roozen Landscape.

Since 2019, Van der Poel has succeeded the firm's namesake, Niek Roozen. She studied Garden and Landscape Design at Van Hall Larenstein University of Applied Sciences in Velp (2001) and then attended the Landscape Architect course at the Academy of Architecture in Amsterdam.

Niek Roozen, known for such things as the Floriade, has been pushing urban greening with the goal of a healthier world since the last century. Van der Poel: "We released, with input from researchers, governments and institutions, 'The Green City Guidelines' in 2011, but we are noticing more and more now, that this approach is super topical, also from a health care perspective."

"We wrote The Green City Guidelines some 10 years back in cooperation with Wageningen University and Research (WUR), in which you find numerous facts. It is indeed true that people in the hospital recover faster if they have a view of greenery. So it really has a scientific basis that greenery has a positive effect on health and that is of course nice for our field."

The collaboration with WUR provided important new insights, for example the added value of greenery in terms of air purification. And now the results of a study which states that if cities had 30% of foliage, thousands fewer people would die of heat stress. Van der Poel: "So there are very strong arguments to go green and also to preserve existing green spaces. Large trees are still often cut down far too easily, even though we now know that a 20-year-old tree provides just as many ecosystem services as 400 small trees. Twenty years ago, greenery was just a nice topping for a plan, but that has really changed now. I notice that as a landscape architect I am getting more and more of a say. In the past, you weren't called in until the houses were pretty much already there." 

For example, her firm developed the new care center for people with dementia De Hogeweyk, owned by the Vivium Care Group, together with an architect. Van der Poel: "That was originally an apartment building with a piece of greenery. After demolishing the old apartment building, it was replaced by a complex of low-rise buildings of two or three stories with all kinds of indoor gardens linked to the different lifestyles with which the residents still have a strong connection from the past, creating a walking route. That has become a very beautiful and unique project, which has attracted a lot of attention in the healthcare world."

Vivium aims to normalize care for people with severe dementia. This called for a completely new approach, shifting the emphasis from the medical to the social side: from large nursing wards they switched to smaller residential groups of seven people, who were also given the freedom to do what they wanted to do, without help or supervision. This placed special demands on the environment. Van der Poel: "In the design, for example, the different profiles of the residents were taken into account. For example, people who come from the city get a city house on a square and there are houses with specific furnishings and an Indian garden for people with an Indian background. Because of this layout, new residents feel at home very quickly."

While the vision underpinning De Hogeweyk arose in the care practice and there was no scientific basis for it beforehand, residents in this new care center appear to live an average of 2.5 years longer and also require less medication. Van der Poel: "One explanation is that the residents become more active and their senses are more stimulated. They can walk around the greenery, go to the hairdresser and their own supermarket and even do a little gardening. Because there are also visitors walking around, it is as if the residents are still part of normal society. And that apparently catches the eye: not only is there a hefty waiting list, but experts from all over the world come to see them."