PROPOSAL FOR A RAISED GARDEN FOR THE SPINAL INJURIES AND REHABILITATION UNITS

An Initiative supported by Diversity Health, POWH

Project Background The outdoor area attached to the Spinal Injuries Rehabilitation Unit was assessed in 2004 for its capacity to house a potted garden. The outcome of this assessment flagged the area as satisfactory for raised (potted) gardening and it was agreed that it is a space in desperate need for improvement to facilitate recreation and relaxation for its users. Currently the area offers some small potted trees and an expanse of concrete. The site is used daily by Spinal and General Rehabilitation patients and their families as a communal meeting place beyond the hospital walls, and offers a fresh air reprieve for those people enduring a prolonged hospital length of stay due to a generally high level of disability. The two units comprise over 40 inpatient rehabilitation beds. Gardening offers an age appropriate activity to all who attend from the respective units. Rationale for the raised garden project An extensive raised garden bed with wheelchair access for wheelchair dependent rehabilitation inpatients would improve the environment and assist with therapy in the two rehabilitation units attached to it. It is proposed that appropriate wheelchair accessible benches would be provided along with adaptive gardening tools. It is envisioned that a range of plants will be grown including annuals, vegetables, herbs and fruit trees. In addition to work benches, a wheelchair accessible greenhouse is necessary to offer protection to some varieties of plants (fruit trees and vegetables) and can double as a secure storage area for tools. Provision of shade by a trellis or similar would also be a useful feature. Gardening offers patients a meaningful and worthy activity to engage with and/or can be structured by an occupational therapist to specifically target functional goals. These functional outcomes can relate specifically to upper limb function, balance, fine motor dexterity and education pertaining to joint protection and energy conservation. In addition produce from the garden could be used in cooking sessions as part of the occupation and nutrition intervention programs. Patients undergoing rehabilitation for spinal cord injury, neurological event eg stroke or from amputation are engaged in an intensive and demanding program, where learning new and difficult skills to negotiate ones future is paramount. This is often done in a context of isolation, as during this phase patients cannot access their homes or the wider community including public gardens, beaches and national parks. Providing an accessible natural garden setting at the ward is a sustainable and invaluable asset to the rehabilitation program.

Proposal for a Raised Garden for the Spinal Injuries and Rehabilitation Units An Initiative supported by Diversity Health, POWH, December 2005

The impetus for developing this project arose from participation by the project coordinator in the Diversity Health Leadership Project at POWH. The Leadership Project supported a group of hospital staff to build their knowledge and skills in Diversity Health and take a leadership role in this area through training and ongoing support from the Diversity Health Coordinators. Part of the project involved developing and implementing a diversity health project. The development of a community garden lent itself well to the aims, objectives and processes that were promoted in the leadership course. This project is supported by Diversity Health, POWH. Project Aims and Objectives The project aims to create a garden for rehabilitation patients, their families and staff on the verandah adjacent to the Rehabilitation Wards at POWH. The project aims to achieve the following objectives: To create a garden that offers patients a space for rest and relaxation, in a natural environment that reflects wellness, uses natural light and offers a pleasant, green, natural and beautiful setting. To extend the patients treatment regimes and influence patients healing including the design of wheelchair accessible space with appropriate workbenches, furniture and seating for: o meetings, o future therapeutic activity programs eg art, woodwork, o gardening, o patient education sessions o peaceful retreat for patients, families and staff o BBQs and social events To provide a venue which can be incorporated into occupational therapy, creative arts and nutrition intervention programs, including growing of a range of plants including vegetables, herbs, fruit trees and flowers and utilising produce from the garden to be used in cooking sessions. To utilise community cultural development processes to support patients, staff and families to work alongside each other, using familiar and new skills in the process of creating and maintaining the garden.

Literature Review The following literature review provides evidence for the value and benefits that can be derived from community, restorative and healing gardens in the health care setting. It is organised into four clusters: Healing environments and health care design The relationship between well-being and nature The roles and benefits of community and healing gardens Community cultural development

Proposal for a Raised Garden for the Spinal Injuries and Rehabilitation Units An Initiative supported by Diversity Health, POWH, December 2005

Overview of the literature The field of health care design has increasingly recognised the impact of physical environments on the well-being of patients, staff and family in terms of health outcomes such as healing rates, reduced stress and overall quality of health care delivery. There has also been a renewed acknowledgment of the relationship between connecting with nature and our state of health and well-being (theory of biophylia). Based on this theory there is now more acceptance of the positive responses induced through human contact with living things. The restorative and therapeutic qualities of gardens have also been highlighted in the literature, especially the research work by Ulrich, which focuses on the effects of built and natural environments on people's psychological well-being and health. Ulrich has investigated extensively the links between nature, specifically access to gardens and resulting improved health outcomes of hospital patients. The benefits for health care workers and families in reducing stress have also been noted. The concept of a community garden where people interact and work alongside each other to create a beautiful space has been used as a health promotion strategy in various settings, especially in public housing estates. The positive outcomes in terms of fostering community building, developing social supports and inclusion in community are well recognised and as a result community gardens have been adopted in many other settings. The act of creating the garden as a communal, participative activity and the use of the garden setting for creative art pursuits is a newly emerging area. Creative arts have a well-recognised potential to promote health and wellbeing and the art for health movement is being adopted by many services and programs. The above concepts are explored in more detail below. Healing environments in health care design The physical environment affects well-being and there is growing international acceptance that the design of health care facilities should be human centred and functionally efficient to benefit patients, their families and staff.1 In a review of 600 studies in peer reviewed journals establishing how hospital design can affect clinical outcomes, the physical environment was found to be linked to patient and staff outcomes in four areas, namely, reduced staff stress and fatigue and increased effectiveness in delivering care, improved patient safety, reduced stress and improved outcomes, and improved overall health care quality.2 Ulrich has written several theoretical articles focusing on the effects of design on healing and wellness and how we need to move away from health care and design that is psychologically hard to design that is more physically and psychologically supportive.3 Ulrich proposes a stress model stating that there are two major sources of stress for hospital patients: illnesses that reduce control and physical capability and
1

Martin C. Putting patients first: integrating hospital design and care. The 2nd International Conference on Health and Design, Stockholm Sweden, June 18-21, 2000. The Lancet. 2000; 356:518. 2 The role of the physical environment in the hospital of the 21st century: a once in a lifetime opportunity. AIA Architect 02/05 www.aia.org/aiaarchitect/thisweek05. 3 Ulrich RS. Cited in Mroczek J, Mikitarian G, Vieira EK, Rotarius T. Hospital Design and Staff Perceptions: An Exploratory Analysis. The Health Care Manager. 2005; 24(3):233-244.

Proposal for a Raised Garden for the Spinal Injuries and Rehabilitation Units An Initiative supported by Diversity Health, POWH, December 2005

often bring about an uncomfortable level of uncertainty and physical-social environments that can be noisy, lack privacy, and provide little social support. These stressors can have a variety of negative physiological and psychological consequences that can hinder healing and well-being. Principles of supportive design should therefore include elements such as nature, easy access to social support and an environment that fosters a sense of personal control. Research work by Ulrich has substantiated the physical benefits hospital patients realise from just being able to view garden areas. These benefits are measurable in reduced blood pressure, reduced requirements for pain relief, fewer complaints to nursing staff and decreased time for recuperation.4 Investigators have reported consistently that stress reducing or restorative benefits of simply viewing nature are manifested as a constellation of positive emotional and physiological changes. Mounting research is providing convincing evidence that visual exposure to nature improves outcomes in dealing with stress and pain.5 The movement in the health care design field to focus on patient centred care and healing environments is often reflected in the health care facilities incorporation of features meant to mitigate the stressful nature of serious illness. These features may range from a resource centre to allow patients and families to educate themselves about their illness, to providing space in rooms so that family members can remain with patients, to more ambient features such as soft lighting, water feature or healing gardens. Research has shown that such features can in fact have positive effects for patients and may reduce stress and speed physical healing.6 The Relationship between well-being and nature The concept of Biophylia Edward Wilson, a Harvard entomologist coined the term biophylia which translates as the love of living things. He hypothesised about the connection between nature and human health and human responses to nature. His idea was that humans evolved as creatures deeply enmeshed with the intricacies of nature, an affinity which we still have ingrained in our genotype. Those humans who developed sensitivity to their environment survived. The rewards and dangers associated with the natural environment favoured those who readily learned and remembered adaptive responses.7 Research by bioscientists suggests that humans gain enormous psychological, physiological and health responses by engaging with living things.8 Internationally, there are recent examples of landscapes being integrated into hospital and health settings to reduce stress and to distract and comfort people. The key elements required for a garden to be effective in reducing stress are promoting a sense of
4

Ulrich R. Effects of Gardens on Health Outcomes: Theory and Research, 1999 cited In. Bartolomei L. et al. A Bountiful Harvest: Community Gardens and Neighbourhood Renewal in Waterloo 2003 5 The role of the physical environment in the hospital of the 21st century: a once in a lifetime opportunity. AIA Architect 02/05 www.aia.org/aiaarchitect/thisweek05 6 Mroczek J, Mikitarian G, Vieira EK, Rotarius T. Hospital Design and Staff Perceptions: An Exploratory Analysis. The Health Care Manager. 2005; 24(3):233-244. 7 Forbes I. Hospital healing havens. Hospital & Healthcare. July 2005 8 Forbes I. Hospital healing havens. Hospital & Healthcare. July 2005.

Proposal for a Raised Garden for the Spinal Injuries and Rehabilitation Units An Initiative supported by Diversity Health, POWH, December 2005

control, landscapes that encourage social support, offering opportunities for physical movement and providing access to natural distractions.9 The roles and benefits of community and healing gardens Gardens are increasingly recognised and valued for their therapeutic or restorative qualities.10 Hospital gardens provide restorative and calming nature views but can also reduce stress and improve outcomes through other mechanisms such as fostering access to social support and providing opportunities for positive escape from stressful clinical settings. They also provide health care workers with a pleasant escape and recuperation from stress. Post occupancy studies indicate that patients and family who use hospital gardens report positive mood change and reduced stress. The benefits of a healing garden are related to the alleviation of stress and the abilities of the space to soothe, calm, rejuvenate or to restore ones mental and emotional health. A main role of the space is to provide sanctuary, to allow for meditation or to evoke other qualities desired by the garden user.11 Community gardens have been credited with various outcomes which encompass: reclamation of public spaces, environmental education, community enterprise, community building, social and cultural expression, restorative/environmental and social/environmental sustainability.12 Working alongside community members from different backgrounds, sharing responsibility for a communal area, learning about different gardening methods and cuisines all contribute to fostering a sense of community.13 Gardens may provide a common ground for the interaction of people from diverse ethnic backgrounds and experiences. Other important benefits identified from community gardens are community cohesion and increased capacity for community organisation. Therapeutic horticulture is a professional field that has evolved since the 1930s within the sphere of occupational therapy. Patients in hospital or other health care facilities benefit from actively participating in gardening activities, even with relatively little physical exertion.14 Horticulture therapy uses plants and gardening-related programs to improve the mental and physical health or vocational skills of participants.15 A community/healing garden can provide an environment for creative activities such as art and crafts and an emerging Arts for Health Movement has developed. Art is
9

Ulrich R. Gardens Have The Potential To Improve Health, Research Shows http://rev.tamu.edu/stories/03/111403-9.html 10 Gerlach-Spriggs N. Restorative Gardens. 1998 cited in. Bartolomei L, Corkery L, Judd B, Thompson S. A Bountiful Harvest: Community Gardens and Neighbourhood Renewal in Waterloo. 2003 11 Healing Gardens: Creating Places for Restoration, Meditation, and Sanctuary: What are the defining characteristics that make a healing garden? A thesis Prepared by Annalisa Gartman Vapaa, 2002. Virginia Polytechnic Institute and State University College of Architecture and Urban Studies Masters of Landscape Architecture. 12 Bartolomei L, Corkery L, Judd B, Thompson S. A Bountiful Harvest: Community Gardens and Neighbourhood Renewal in Waterloo. 2003 13 Ross B. Traxside community garden project. In McEwen C (ed). Health Education and Cultural Action. The Bulletin of Good Practice in Popular Education. 2000; 5:29-31. 14 Bartolomei L, Corkery L, Judd B, Thompson S. A Bountiful Harvest: Community Gardens and Neighbourhood Renewal in Waterloo. 2003 15 Champagne W. Flower Power. Health and Science, Sydney Morning Herald. 18 Aug 2005 p.4-5.

Proposal for a Raised Garden for the Spinal Injuries and Rehabilitation Units An Initiative supported by Diversity Health, POWH, December 2005

now considered as contributing to the healing process and has a well-recognised potential to promote health and wellbeing. 16 People faced with life threatening illnesses or adjusting to a traumatic disability have found solace, strength and affirmation by using the creative process to take an active role in their own healing. The visual, literal and performing arts and crafts are now considered as contributors to enriching the healing process by bringing restoration and relief to patients, visitors and staff of hospitals, hospices and other health centres. Examples include healing gardens, paintings in patient rooms, and live music. The reason why some of these things work are due to beautiful surrounding have the capacity to change our experience, celebrating together helps to forge stronger communities of support for each other and music can touch the spirit (move us or bring us joy). 17 One of the arts most powerful contributions to health is that they reflect and create an inclusive sense of community. There is now considerable evidence that the stronger people feel this sense of belonging, the healthier they are.18 Through participation in community arts activities, people can develop skills and capacity to express and celebrate their culture, get involved in group activities, access supportive relationships, build self-esteem and self-confidence and increase a sense of selfdetermination and control. VicHealth has identified the following benefits of promoting health through Community Arts Participation: Participants learn transferable skills such as communication, problem-solving, negotiation, cooperation. The arts can provide a powerful tool for advocacy by creating and enlarging understanding of unfamiliar people and issues. Arts projects transcend language and cultural barriers. A community is created among those working on the project, bolstering individual connections to the community. Events allow the general public to gain an appreciation of the talents of people that they may otherwise never encounter and may hold fears and prejudices about. Groups are linked to relevant support services. Inter-agency links are created, increasing communication and improving services. Organisations outside the arts sector develop an understanding of health promotion through partnership. Community Cultural Development The community garden project will also embrace concepts from the Community Cultural Development (CCD) approach. CCD involves artistic and other creative processes as a way of exploring and expressing our cultures and the values underpinning these cultures and our society. Australian and overseas research shows that direct involvement by communities in arts activity can contribute significantly to
16

Palmer J. An introduction to the Arts-for-Health Movement or How the Arts sneaked in on the medical model. Community Arts Network. www.communityarts.net 17 Palmer J. An introduction to the Arts-for-Health Movement or How the Arts sneaked in on the medical model. Community Arts Network. www.communityarts.net 18 VicHealth Website (http://www.vichealth.vic.gov.au/)

Proposal for a Raised Garden for the Spinal Injuries and Rehabilitation Units An Initiative supported by Diversity Health, POWH, December 2005

individual and community well being.19 CCD covers an enormous range of activities that give communities the opportunity to tell their stories, build their creative skills, and be active participants in the development of their culture. CCD describes collaborations between communities and artists which can take place in any art form. They result in a wide range of artistic and developmental outcomes.20 CCD differs from community arts. While both practices involve communities and artists collaborating on cultural activities, CCD tends to focus on community empowerment through their direction and control of the project. The artists role is to facilitate and empower rather than to direct the work. Many CCD projects also focus on developing social or economic aspects of the community through cultural activities. 21 Key Points for Good Design of Raised Garden for POWH Rehabilitation Units Some key points for good design of the POWH garden are apparent from the Literature Review and an initial Needs Assessment and are outlined below. 1. A safe, accessible outdoor space should be created. 2. The environment should provide the opportunity for learning and purposeful activity. 3. The garden must be maintainable and sustainable to ensure physical safety and therapeutic benefits of the space. 4. The garden must be environmentally sound. 5. The garden must be cost effective. 6. The garden must be visually pleasing and stimulate the users' senses. 7. The garden should provide a safe retreat from the internal ward environment. 8. The garden should provide learning and creative opportunities that promote reflection and self-awareness. 9. The garden must adhere to organic gardening principles. 10. The garden must be accessible and appropriate for all users (eg people with dementia, wheelchair users, gait training, various ages, neurological impairment, sensory deficits, various physical abilities, diversity of cultural backgrounds) 11. The garden must be managed in a way that fosters inclusion and shared responsibility. Project Co-Ordinator Anna Martin, Permanent Part Time Occupational Therapist Spinal Injuries Unit, POWH Ph 9382 5024 Anna.Martin@sesiahs.health.nsw.gov.au For information about the project co-ordinators personal interest in the project, please refer to Appendix 1. Appendix 1 Project Co-ordinators Personal Profile and Interest in the project
19

Australia Council: Arts Resources: Arts and Wellbeing. www.ozco.gov.au Community Cultural Development NSW http://www.ccdnsw.org 21 Community Cultural Development NSW http://www.ccdnsw.org
20

Proposal for a Raised Garden for the Spinal Injuries and Rehabilitation Units An Initiative supported by Diversity Health, POWH, December 2005 Leafy Imagination Garden: Raised Garden for Spinal Injuries and General Rehabilitation Units, Prince of Wales Hospital Anna Martin One of my most treasured possessions is a publication I picked up in Sri Lanka in 2003. It is entitled The Ocean Stories: Childrens Imagination, Creativity, and Reconciliation in Eastern Sri Lanka. The words in this book, written by the Canadian anthropologist Patricia Lawrence, depict the extraordinary life of The Butterfly Peace Garden (BPG). The BPG is in Batticalloa, a town on the east coast of war-torn Sri Lanka. The children of Batticalloa have this haven, the BPG, as a space they can retreat to that alleviates temporarily the fear of violence they live with in their own backyards. Here their imaginations can run wild. The garden is rehabilitative in that it offers a calm natural environment where people can slow down and work with their brokenness without fear and in friendliness with others.22 Since 1996, I have worked as an occupational therapist (OT) with adults with a variety of disabilities. My OT practise is concerned with promoting independence with clients who have a disability. Experience has taught me the value of treatment directed to a person as a whole, rather than to their diseased or injured parts, and I have come to understand the impact environment has on well-being in the context of healing. Perhaps the small book I procured on my travels in Sri Lanka would not have struck such a chord with me, as I devoured its hefty inspiring ideas, if I hadnt started studying Visual Arts the same year. At art school I was learning selfexpression through creative process and discovering its powerful, soul-fortifying effects. I completed my Diploma of Visual Arts at the Royal Melbourne Institute of Technology in 2004. As an artist, I am motivated by creative process and the nurturing of imagination. With these I believe one is able to get in touch with their individual identity, and that this in itself is healing by fostering a confidence and trust in oneself. It has not been a leap of faith for me to start parallelling my OT practise with my thoughts about the restorative capacity of the arts. Rather, possessing a holistic view of patients as an occupational therapist, enabled me to see clearly the contribution the arts can make in the healing process. In my current role as an OT in the Spinal Unit at the POWH, I approach my work with the view that disability is an asset- that as well as patients having a disability, they have a wide range of abilities, and my focus is squarely on what a person can do. Naturally, my passion for understanding the connections between healthcare and the arts increased, and I began to extensively research the place for a Creative Arts Program within a Rehabilitation model. My own niggling ideas were confirmed at the outset. I learnt that there is already an extensive network of arts workers in healthcare, and that the scope for it is broad indeed. I also tapped into an already simmering idea some staff at the POWH were considering surrounding the prospect of building a garden adjacent to the Rehab Units at the POWH. These exciting discussions reminded me of my reading exploring the healing effects of natural environments and the success of the Butterfly Peace Garden in Sri Lanka. Soon I began to hope that with some determination, grace,
22

Lawerence, P. The Ocean Stories: Children, Imagination, Creativity, and Reconciliation in Eastern Sri Lanka. ICES, Colombo. 2003. p 25

Proposal for a Raised Garden for the Spinal Injuries and Rehabilitation Units An Initiative supported by Diversity Health, POWH, December 2005 commitment and hard work, we as a hospital community could create the POWHs own healing garden. The POWH Rehabilitation Units can be demanding and stressful environments, where inside the hospital building patients participate in an incessant regime of prescribed medical therapy and monitoring. A garden, which adheres to a therapeutic and healing constitution, built adjacent to the rehabilitation units will offer patients, their families, and staff a natural, nurturing sanctuary, while also providing an important educational and community resource for its users.