Implementation and Impact of Health Care Gardens: A Systematic Scoping Review

Abstract

Background:

In community and school settings, gardens and garden interventions have been shown to confer several psychosocial, physiological, and nutritional benefits. However, little is known about the implementation and impact of health care gardens on patients, visitors, and staff health and well-being. The primary aim of this review is to identify and describe the types of gardens and common design elements implemented in health care settings and the impact these gardens have on the health and well-being of patients, visitors, and staff. A secondary aim is to assess the quality of available evidence.

Methods:

PubMed, CINAHL, EMBASE, and PsycINFO were systematically searched on October 28, 2022. Primary qualitative and quantitative studies (excluding case reports and studies) were eligible for inclusion if they described the types of gardens and common design elements implemented in health care settings (hospitals, aged care, rehabilitation facilities, and medical centers) and/or assessed the impact of garden interventions on the health and well-being of patients, visitors, and staff. Review, selection, and data extraction were conducted by two independent researchers, with findings synthesized and presented in narrative form. Articles were critically appraised using the mixed methods appraisal tool (MMAT).

Results:

Eighteen articles were included. Eight studies provided detailed descriptions of the types of gardens implemented in health care settings (healing [n = 3], therapeutic [n = 2], sensory [n = 2], children's fairy gardens [n = 1], and enriched [n = 1] gardens). Studies examining the psychosocial impacts of gardens were most frequently reported (n = 16), followed by physical (n = 4) and nutritional (n = 2). A wide range of positive outcomes, predominantly relating to patients (n = 12), were reported, including improvements in stress, quality of life (QOL), cognitive function, physical activity, and fruit and vegetable intake. The evidence was heterogeneous and low-medium quality.

Conclusions:

The findings suggest that implementing gardens and garden interventions in health care settings may positively impact the health and well-being of patients, visitors, and staff. Most studies related to the impact of gardens on patients' mental health and QOL, indicating the need for further research to explore physical and nutritional outcomes, as well as health outcomes of staff and visitors. Findings also suggest the need for high-quality study designs (e.g., cluster control trials) and standardized measurement tools.

Introduction

Gardens and garden interventions have been associated with numerous health and well-being benefits for individuals, including psychosocial, physical, and nutritional.^1

–5 For example, community and school gardens have been shown to improve fruit and vegetable (F&V) intake,^6

–10 decrease body mass index (BMI)¹¹ and blood pressure,¹² and reduce stress, anxiety, and burnout.^3,5 These are important concepts of health as high F&V intake is known to reduce the risk of chronic diseases such as heart disease and type 2 diabetes, lower blood pressure, and prevent some types of cancer such as bowel cancer.^1,13,14 Furthermore, mental well-being is understood to be integral to good health as it is associated with positive health behaviors¹⁵ and has been shown to improve recovery from illness.¹⁶

Like schools and communities, health care settings such as hospitals, medical centers, aged care, and rehabilitation facilities can serve as valuable sites for gardens. They have the potential for short-term benefits for patients and visitors, such as reducing stress in family members of hospitalized patients,¹⁷ and ongoing benefits for health care workers, such as reduced burnout in nursing staff.^18,19 This is important as health care workers commonly report poor diets,^20,21 inadequate physical activity,²² and poor mental health as a result of burnout.²³ Some hospitals in the United States now offer on-site gardens or farms and locally sourced produce in patient and staff meals.^20,21 These projects have been shown to produce several beneficial outcomes, including access to healthy food, physical activity, nutrition education, and environmental sustainability.^20,21

Gardens located in hospitals, medical centers, aged care, and rehabilitation facilities are a business innovation²⁰ that may provide complementary therapy to facilitate health improvements for their patients, visitors, and staff. Despite this, collated information on how health care settings implement gardens on-site is difficult to find. Moreover, the effectiveness of implementing gardens in health care settings is relatively unknown, given the heterogeneity inherent in this research. Therefore, the primary aim of this systematic scoping review was to (1) identify and describe the types of gardens and common design elements implemented in health care settings and (2) identify and describe the impact these gardens have on the health and well-being of patients, visitors, and staff. A secondary aim was to (3) assess the quality of available evidence.

Methods

The systematic scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist.²⁴ The protocol was registered with Open Sciences Framework (https://doi.org/10.17605/OSF.IO/T5JZK) on November 16, 2022.

Search strategy

Searches were conducted in Medline (PubMed), CINAHL, PsychINFO (EBSCOHost), and EMBASE databases on October 28, 2022. The search strategy was developed in consultation with the Bond University Health and Medical Sciences Faculty Librarian and included relevant MeSH (Medical Subject Headings) terms, subject headings, and keywords such as “horticulture” OR “garden” AND “healthcare setting” OR “hospital” OR “aged care” OR “rehabilitation” AND “psychosocial” OR “wellbeing” OR “nutrition” OR “health outcome” (Supplementary Material).

To ensure all relevant literature was included, no limit on time or language was set. Before exporting articles into Covidence for screening, retrieved articles were deduplicated using the systematic accelerator deduplication tool.²⁵ Screening by title and abstract was conducted in duplicate by two researchers. Non-English studies were translated with the assistance of bilingual researchers. The remaining full-text articles were assessed in Covidence for relevance against inclusion criteria. At both screening stages, conflicts were resolved through consensus or with a third research team member (an experienced academic researcher).

Study eligibility

Studies met the inclusion criteria if they described the implementation of health care gardens and/or assessed individual health benefits of horticulture or garden-based interventions. The term health care encompasses hospitals, medical centers, aged care, and rehabilitation facilities. There was no restriction on the types, design (e.g., randomized and nonrandomized control trials, cohort, qualitative), population, or sample size of included studies. To be included, studies had to describe primary research (excluding case reports and studies) and be peer reviewed. Thus, protocol articles, systematic reviews, and gray literature were excluded.

The primary outcome was related to the positive impact health care gardens had on patients, visitors, and staff health and well-being. The term “well-being” referred to the following: psychosocial (such as, but not limited to, anxiety, depression, burnout, mood, happiness, quality of life [QOL], connectedness to nature, socialization, and knowledge sharing), nutritional (dietary intake), and physiological components such as heart rate (HR), blood pressure, and cholesterol. Studies that reported on garden interventions outside of predefined health care settings and/or did not sufficiently describe health care gardens were excluded. In addition, to maintain a targeted scope of the implementation of health care gardens, studies assessing the benefits of nature views or pictures of nature were also excluded.

Quality appraisals

Eligible studies were assessed using the Mixed Methods Appraisal Tool (MMAT).²⁶ The MMAT is a validated critical appraisal tool designed to assess multiple study designs, including qualitative research, randomized control trials, nonrandomized control trials, quantitative descriptive studies, and mixed method studies.²⁶ Two researchers completed quality appraisals of all article, and discrepancies were resolved through consensus or consultation with a third researcher. The researchers critically appraised the quality of studies based on the adequacy of collected data and whether the data answered the research question.

Results

Study characteristics

From 5821 citations, a total of 18 full-text studies (n = 613)^{17
–19,27

–42} were eligible for inclusion (Fig. 1). Of the 18 articles included, 9 were quantitative (n = 407),^{17
–19,27,28,32
–34,42} 6 were qualitative (n = 145),^{31,35,36,38
–40} and 3 were mixed methods studies (n = 61).^29,30,41 Sixteen studies evaluated the impact of gardens on patients (n = 471),^{27

–36,41,42} two studies on health care staff (n = 86),^18,19 and two studies (n = 56) on visitors.^17,39 Hence, overall findings are primarily related to patients.

FIG. 1.

PRISMA flowchart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

Most studies (n = 16) assessed the impact of gardens on psychosocial outcomes, including cognitive function, mental health, social, burnout, and QOL.^{17
–19,27

–32,34
–36,38
–40,42} Four studies reported specific physiological outcomes,^41,42 for example, HR and physical function, and two studies reported nutritional outcomes,^33,41 for example, dietary behavior and intake. The studies were conducted across 3 settings: 12 in a hospital setting,^{17
–19,27,32
–34,36

–40,42} 3 in an aged care facility,^28
–30 2 in a rehabilitation setting^31,35 and 1 in a medical center.⁴¹ A detailed description of the implementation of gardens was provided in 8^{17,18,27,28,30
–32,38} of the 18 studies. Sixteen studies were published in English,^{17
–19,27

–33,35,36,38

–42} one in French,¹⁹ and one in Korean.³⁴ Country of origin included the United States,^{17,18,33,35,36,41,42} Thailand,^38
–40 France,^19,28,32 Australia,^29,30 Switzerland,^27,31 and South Korea.³⁴ Characteristics of the included studies are summarized in Table 1.

Table 1.

Quantitative, Mixed Methods, and Qualitative Study Characteristics

Author (year), country; setting	Aim(s)	Sample	Garden description	Intervention description and evaluation
Quantitative
Attwell et al. (2019), Switzerland	To determine the effectiveness of a neurosensory stimulation approach enhanced by outdoor therapy in the early phases of recovery in patients presenting with CMD.	N = 15 (11 male/4 female) with early-phase CMD, mean age 52.5 years (SD, 17.2)	Hospital outdoor TG located in the enclosure of the hospital. The TG was designed for use by patients with mobility difficulties and is centered around increasing multisensory stimulation by providing a variety of structures and spaces, including an array of different plants and trees, aromatic herbs, a fountain, and several therapeutic training spots for example, walking paths, parallel bars, stairs, soft and hard ground.	Nonrandomized cross-over control trial. The participants completed two sessions with a 5-h break between the sessions on the same day. The session was 1 × 25 min in the garden and 1 × 25 min in the intermediate care unit of the physiotherapeutic area. The sessions were video recorded with observations rated offline.
Bernez et al. (2018), France	To study the effect of the presence of a garden in a hospital care sector on caregiver burnout and to compare three different services with a TG versus with a regular garden versus with no garden.	N = 88 nurses and caregivers from 9 sectors across 3 types of service (cognitive behavioral unit, palliative care, postacute and rehabilitation care) 90.9% Female Mean age 41.3 (SD, 11.8)	Description of hospital gardens was not given. A distinction between therapeutic and regular garden was made. Regular garden was an outdoor space without facilities such as benches, tables, or art, and dedicated solely for walks. The TG was “adapted for therapeutic activities”—nil other description given.	Recruitment from three different hospitals allowed comparison between a TG, regular garden, and no garden. Participants were surveyed (at unknown time-point) from the cognitive behavioral unit, palliative care, and postacute and rehabilitation unit from each of the three hospitals (nine sectors in total). This ensured similar working conditions for all participants.
Bourdon and Belmin (2021), France	To evaluate the benefits of an enriched environment on residents with Alzheimer's disease.	N = 120 residents with dementia Intervention group 1 (I¹) = 41 (13 Male/28 Female) Intervention group 2 (I²) = 40 (11 Male/29 Female) C = 39 (13 Male/26 Female) Mean age 81.1 years	Four aged care facilities had both a CSG and an EG. All gardens were designed by a specialized landscape architect. In all four aged care facilities, the CSG and EG were separated with no possibility to direct travel between the gardens. Gardens were accessible to the residents only during the day. To enhance sensory stimulation the CSG at each of the facilities offered an array of plants, shrubs, trees, garden furniture, and ergonomic planters for gardening. The EG at each facility differed from the sensory garden in that it had integrated 12 different modules (specially designed pieces of equipment) that targeted cognitive stimulation, supported autonomy, and fall prevention.	Cluster pilot control trial of four aged care facilities. Residents were allocated to groups according to the accessibility of their rooms to the garden. Staff members were instructed to invite residents to visit either an CSG or EG for a minimum of 4 × 15-min weekly visits for 6 months. The control group did not receive an incentive to visit the gardens. Evaluation undertaken at baseline and after 6 months.
Cordoza et al. (2018), United States	To compare the effect on nurse burnout of taking daily work breaks in a hospital integrated garden versus indoor only break.	N = 29 (2 Male/27 Female) nurses Mean age 42.8 years	The hospital garden was designed for patients, visitors, and staff using natural design features. Design attributes included easy accessibility, comfortable seating, and privacy. A more detailed description of the garden is provided by Ulrich et al.¹⁷	Prospective cross-over trial. Nurses were randomly assigned to either 6 weeks of daily (minimum 15 min) work breaks in an outdoor garden or in indoor unit break room. After a 1-week washout, the groups were switched for subsequent 6 weeks. Burnout assessed before and after each 6-week interval and immediate changes in symptom level were assessed before and after each break.
Gueib et al. (2020), France	To evaluate the impact of hospitalization and a specific healing garden on self-consciousness in patients with Alzheimer's disease and related disorders.	N = 34 in residents with Alzheimer's and related disorders Intervention (I) = 16 (5 Male/11 Female) C = 18 (8 Male/10 Female) Mean age 82	General design recommendations for a healing garden for individuals with Alzheimer's and related disorders were employed. The garden's design features include shade to avoid glare and transition of lighting between indoors and outdoors, hygiene standards (no standing water), clearly visible signage, looped pathways, views from indoor windows, seating, and places to eat, presence of running water, and conscious choice of different sensory plants and textures. The garden is designed to provide autonomy to aged care residents. Access is restricted to patients and visitors of the facility, which is easily accessible through a main share room and is unlocked during the day.	Participants in the intervention group were required to visit the therapeutic healing garden for a total of 12 h for 2 weeks. The control group consisted of participants who did not visit the garden, due to the weather. Levels of self-consciousness were tested within the first 48 of admission before visiting the healing garden and after a minimum cumulative 12 h in the garden.
Kim et al. (2022), Korea	To identify the effects of a HT program on interpersonal relations, self-efficacy, and stress awareness for patients with mental illness.	N = 43 patients diagnosed with clinical depression I = 23 (14 Male/9 Female) C = 20 (10 Male/10 Female)	Two hospitals with a rooftop garden were part of the intervention group. Hospital (1)—the mental health ward connected to an outdoor (uncovered) rooftop garden with a vegetable garden 5 × 3 m long. Hospital (2)—garden was an indoor vegetable container garden (with drip trays). Both hospitals had an area to store gardening materials, compost, and tools.	Nonequivalent control group, prestudy and poststudy design. The hospitals were selected at a ratio of 1:2. The intervention group participated in a 1 × 90-min weekly HT session for 8 weeks. No HT for the control group for 8 weeks. Evaluation time points not defined.
Wichrowski et al. (2005), United States	To assess the effects of HT on mood state and HR in patients participating in an inpatient rehabilitation program.	N = 107 cardiac rehabilitation patients I = 59 (34 Male/25 Female) C = 48 (31 Male/17 Female)	HT sessions were held in a rehabilitation greenhouse and sensory gardens designed for patients. Detailed description of garden was not provided.	Cardiac rehabilitation patients were assigned to participate in either a 1 × 60-min HT session or a PEC. Each group evaluated before and after the class.
Kim and Thompson (2020), United States	To increase fruit and vegetable consumption, improve behaviors toward nutrition and healthy eating, and increase home gardening practice and child involvement in food preparation.	N = 17 children 9–15 years of age from ambulatory clinics Equal gender distribution and diverse ethnic backgrounds	Description of hospital garden was not provided.	Cohort study where participants undertook a 3 × 2-h gardening and cooking program. Data collected at baseline and follow-up 1 year after program.
Ulrich et al. (2020), United States	To measure the immediate change in 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 an indoor hospital environment intended for respite and relaxation.	N = 42 ICU patient families	The hospital garden was designed using best practice design guidelines. In line with the guidelines, the garden is easily accessible (open 24 h/7 days/week) to targeted populations (patients, visitors, and staff), safe, has easy accessibility paths for people in wheelchairs, walkers, and crutches, provides private shaded areas, comfortable portable seating, and a play area for children. In addition, the garden is planted with an abundance of vegetation and colorful flowers. There is a visual connection to the garden from the building's interior windows.	A convenience sample of ICU patient families completed a survey before and after breaks to an outdoor garden and an indoor area (atrium/café and/or ICU waiting room), designed especially for respite and relaxation.
Mixed methods
Cox et al. (2004), Australia	(1) To examine the effectiveness of two types of multisensory environments, a Snoezelen room and a landscaped garden, in improving the well-being of older individuals with dementia and	N = 24 (1 Male/23 Female) residents with dementia	The aged care facilities garden was designed for use by patients, visitors, and staff. Design attributes of the garden were not provided.	Cross over study design. Each resident experienced visiting three different environments: a Snoezelen room, landscaped garden, and a normal living room. Evaluation of each environment occurred through observation and interviews with caregivers/visitors who were present at the time residents experienced the garden.
	(2) To assess the response of caregivers and visitors to the multisensory environment.	N = 12 (6 caregivers and 6 visitors)
Edwards et al. (2013), Australia	To evaluate whether a TG can improve the QOL of aged care residents with dementia and their carers.	N = 10 (1 Male/9 Female) residents with Alzheimer's disease/dementia+their carers and family membersAge ranged between 79 and 90 years	The aged care facilities garden was designed specifically to increase the QOL for residents living in the dementia-specific unit. The garden is described as an interactive, sensory wander garden. It incorporates evidenced-based therapeutic design features to elicit pleasure and memories, including a memory box, tinker car, bird aviary, woodpile, quiet area with water feature, and raised beds when residents can garden and pick produce. The garden has an adjoining atrium/sunroom and is partially open to the air, smells, and sunlight from the garden.	Quasi-experimental study design. Participants visited a garden 3 months before and after construction of a TG. Evaluation occurred through observation and interviews with carers, visitors, staff, and residents at baseline and 3 months.
Veldheer et al. (2020), United States	To assess feasibility in terms of acceptability, demand, and participants' willingness to engage in gardening activities during an intervention delivered at a hospital-based community garden for patients at risk of CVD.	N = 15 (5 Male/10 Female) adults with CVD risk factor >1Mean age 46 years (SD, 18)Mean BMI 26.7 (SD, 5.1)	Four garden plots (∼450 sq. ft.) located at a medical center were utilized for the project. The participants had shared access to a gardening shed with tools and watering equipment.	In this prestudy and poststudy design, participants attended 5 × garden-based education and nutrition session over 12 weeks. Evaluation was completed at baseline and week 12 of the program.
Qualitative
Eriksson et al. (2011), Sweden	To explore and describe how women with stress-related ill health, who are on sick leave, experience the rehabilitation process in a TG and how these experiences connect to their everyday lives.	N = 5 Female patients with mental health disordersAge range 36–52 years	The garden was situated at a vocational rehabilitation clinic in Sweden. The TG was divided into several areas with various characteristics to encourage different modes and activities. One area was designed with stones, a brook, and hammocks to promote relaxation. Another area was separated by walls from the rest of the garden and equipped with blankets and cushions to facilitate awareness of how the body reacts to stress, for example, how breathing changes in character according to experiences of stress. Other areas were designed with chairs and tables and materials to work with to encourage conversation and activation.	Exploratory longitudinal study. The participants completed 10 × 3-h group garden-based sessions over 10 weeks and two follow-ups at 3 and 4 months after the rehabilitation period. All sessions consisted of training and discussion, relaxation, and participation in activities, including cleaning pots, arranging a bouquet of flowers, or creating bowls in cement.
Lehmann et al. (2018), United States	To assess the experiences of a veteran-initiated horticultural therapy garden during their 28-day inpatient SARRTP.	N = 56 veteran rehabilitation patients for mental illness and substance abuse	Vegetable box gardens were situated in the courtyard of the rehabilitation clinic.	Retrospective study. Participants self-initiated with therapeutic box gardening during a 28-day rehabilitation program. Included passive activities (sitting and looking at plants) and active tasks (watering plants, monitoring the growth of vegetables, pulling weeds, and harvesting vegetables). Group interviews with the veterans from the last three rehab groups to gain insight into veteran's emotional reactions to utilizing the garden.
Pieters et al. (2019), United States	To explore and describe the experiences of gardening among adults in an acute psychiatric inpatient setting in the participants' own words.	N = 25 psychiatric inpatients diagnosed with major depressive disorder, anxiety, and PTSD (11 Male/14 Female)Mean age 28 years	Raised planter boxes located on the outdoor deck of the psychiatric unit filled with an array of nontoxic herbs, succulents, and flowers.	Novel exploratory study. Participants spent 20–25 min to engage in different garden tasks and activities: turn the soil, water plants, remove dead leaves and flowers, take clippings of the plants (with help from staff), and smell/touch the plants. Evaluation occurred once, immediately postexperience.
van der Riet et al. (2014), Northern Thailand	To report on the experiences of nurses in a Thai hospital that recently constructed a healing haven environment called a “Fairy Garden” to support the formal and informal activities of sick children.	N = 8 nurses on children's ward	The FG was 6 m wide and 30 m long. Within the FG was a gazebo with bench seats and wishing well with hanging mobiles of animals, birds, and fairies. Bridges on either side allowed access to garden pathways. The garden also contained a cubby house, and two whale structures for children to touch and climb over. The garden also had a swinging bridge, swings, wooden fort, slippery slide, and three rocking/spring toys to encourage different activities. Bench seats were provided along the perimeter and flower beds throughout the garden.	Narrative inquiry. Three separate focus group interviews over 7 months (November 2011 to June 2012). Interviews were 45 min to 1.5 h and contained open-ended questions to generate reflection and discussion among participants.
van der Riet et al. (2017), Northern Thailand	To explore the experiences of family members of sick children who have participated in a Fairy Garden Healing Haven in a hospital in Thailand.	N = 8 family members of hospitalized childrenAges ranged 29–35 years for parents, and 60 years for grandparent	As described in the 2014 study [see van der Riet et al. (2014) study above]; photographic evidence is available in article.	Narrative inquiry. Participants were organized into four different focus groups and interviewed in pairs over 5 weeks. Semistructured interviews were conducted lasting between 40 min and 1.5 h with several key questions to guide and encourage discussion.
van der Riet et al. (2017), Northern Thailand	To report on the stories and beliefs of student nurses who participated in formal and informal activities in a healing haven environment called an FG within a hospital in northern Thailand.	N = 43 Australian+Thai nursing students; (48 Female/14 Male)	As described in the 2014 study [see van der Riet et al. (2014) study above].	Narrative inquiry. Participants interviewed in focus groups, and the length of interview was between 40 min and 1.5 h. Interviews were unstructured and centered upon overall nature of usage of the FG and the student nurses' beliefs as to the value of the FG.

BMI, body mass index; CMD, cognitive motor dissociation; CSG, conventional sensory garden; CVD, cardiovascular disease; EG, enriched garden; FG, Fairy Garden; HT, horticultural therapy program; HR, heart rate; ICU, intensive care unit; PEC, patient education class; PTSD, post-traumatic stress disorder; QOL, quality of life; SARRTP, Substance Abuse Residential Rehabilitation Treatment Program; SD, standard deviation; TG, therapeutic garden.

Description of gardens

Eight studies^{17,18,27,28,30
–32,38} provided detailed descriptions of the implementation of gardens, as seen in Table 1. The studies described a range of garden types, including two therapeutic gardens,^27,31 a children's fairy garden,³⁸ two sensory gardens,^28,30 an enriched garden,²⁸ and three healing gardens.^17,18,38 Of these eight studies, four were in a hospital setting,^17,18,27,38 three in an aged care facility,^28,30,32 and one in a rehabilitation facility.³¹ All hospital healing gardens^17,18,38 were designed for patients, visitors, and staff, whereas the aged care^28,30,32 and rehabilitation^27,31 gardens were designed for use by patients and visitors.

Five of the eight studies^{17,18,28,30,32} described incorporating evidence-based practice recommendations into the design process. Common design themes emerged from the studies, including easy accessibility, both in terms of direct access to the garden (24/7) and pathway for people with wheelchairs, crutches, and walkers; providing shade, acceptable hygiene, and safety standards (e.g., no stagnate water), views from indoor windows, portable seating, and running water, that is, fountains. In addition, there was the provision of an array of different textured flora and hard landscapes to illicit the senses.^{17,18,27,28,30
–32,38}

Of the 18 included studies, 12 studies^{17
–19,27

–32,38
–40} examined the benefits of therapeutic garden-based interventions for various populations, which included physical therapy, cognitive behavioral therapy, socializing, sitting, walking, and viewing from within the garden. Four studies^34
–36,42 examined horticultural therapy interventions that included a range of activities for participants. Some of these activities focused on passive involvement, such as sitting, walking, and viewing from within the garden. Other interventions involved active participation, including gardening, education sessions, crafts, and meditation. Finally, two studies^33,41 focused on culinary nutrition interventions that involved a combination of activities related to nutrition education/promotion, vegetable and herb gardening, and cooking. These interventions aimed to improve participant's knowledge and skills in nutrition, promote healthy eating habits, and encourage the consumption of fresh, homegrown produce.^33,41

Health outcomes

Psychosocial outcomes

Twenty-one psychosocial outcomes were reported in 16 studies.^{17
–19,27

–32,34
–36,38
–40,42} Twelve studies reported on the emotional well-being benefits of gardens for patients, visitors, and staff.^{17,18,29

–32,35,36,38
–40,42} Six quantitative studies (including two mixed methods^29,30) assessed anxiety, depression, stress, and mood, using six different assessment tools,^{17,18,29,30,32,42} detailed in Tables 2 and 3. Of the six studies, five reported significant improvement in emotional well-being.^{17,29,30,32,42} These quantitative findings were supported by eight qualitative studies (including two mixed methods^29,30) that further emphasized the emotional well-being benefits of gardens.^{29
–31,35,36,38
–40} Commonly reported themes from semistructured open-ended interviews with patients, visitors, and staff emerged, including a perceived reduction in stress, improvements in relaxation and happiness, and the healing properties of being surrounded by nature (e.g., escapism from illness).^{29
–31,35,36,38
–40}

Table 2.

Quantitative Study Outcomes

Author (year), sample	Outcomes (measure)	Findings
Attwell et al. (2019), N = 19 patients with early CMD	Voluntary and purposeful behavior (Behavioral grid comprising 44 items with 6 subcategories)	The outdoor group scored significantly higher intentional behaviors for 7/44 features of the grid. Auditory (reaction to a simple command, p ≤ 0.001; eyes orient toward an auditory stimulus, p < 0.005; and reaction when addressed by own name, p < 0.001), Visual (exploration/fixation of an individual on command, p < 0.001), Motor (spontaneous movement related to an object, p < 0.001; and movement on command, p < 0.001), and Oro-motor (spontaneous swallowing, p < 0.001).
Bourdon and Belmin (2021), N = 120 residents with Alzheimer's	Cognitive function (MMSE)	Six-month changes in cognitive function showed significant improvement in the group visiting the EG compared to CSG and C groups, respectively (p < 0.0001).
	Independence (KATZ ADL)	Six-month changes in independence showed significant improvement in EG group compared to CSG and C groups, respectively (p < 0.0001).
	Risk of falls (Unipodal stance and TUG)	Significant improvements were shown in Unipodal (p < 0.0007) and TUG (p < 0.0001) in the EG group compared to the CSG and C groups.
Bernez et al. (2018), N = 88 nurses and caregivers	Burnout (SMBQ)Vigour (SMVM)	There was a significant difference in the SMBQ score (p ≤ 0.05) observed between the TG and no garden groups, as well as between regular garden and no garden groups, whereby burnout occurred more frequently among participants without a garden than among participants with a garden, regardless of the type of the ward.There was a significant difference in the SMVM score (p ≤ 0.05; both physical and psychological) between the TG and no garden groups, whereby “the feeling of vigor” was observed to be higher among the TG group compared to no garden group. There was no significant difference observed between the regular garden and no garden groups.
Cordoza et al. (2018), N = 29 nurses	Burnout (MBI)	Compared with indoor breaks, there were significant improvements in depersonalization (<0.001) and emotional exhaustion (p = 0.02), but not personal accomplishment (p = 0.055) for breaks in the garden.
	Immediate psychological symptoms (Pediatric Quality of Life Present Functioning VAS)	Compared to outdoor breaks VAS total symptoms score and individual symptoms, anger and fatigue, improved significantly when nurses took breaks in the garden (p = 0.048, p = 0.03, and p = 0.03, respectively). No significant improvement for anxiety, sadness, worry, and pain.
Gueib et al. (2020), N = 34 residents with Alzheimer's and related disorders	Self-consciousness (SCQ)	There was a significant difference in the SCQ total score (p = 0.03) driven by an increase in anosognosia (p = 0.03) observed between both time intervals for the control group. Comparison of the garden group for both intervals showed a significant improvement in total SCQ score (p = 0.02) due to significant improvement in body representation (p = 0.03). No significant improvement in comparison of anosognosia, moral judgment, prospective memory, introspection, affective state, and identity between the two groups. Comparison of the total SCQ score in the control versus intervention groups found a significant difference (p = 0.0079).
Kim et al. (2022), N = 43 patients diagnosed with clinical depression	Interpersonal relationship (Interpersonal relationship scale)	No difference in comparison of interpersonal relationships between HT and C groups.
	General self-efficacy (General self-efficacy scale)	Significant improvements found in self-efficacy for HT group compared to C group (p = 0.02).
	Perceived stress (Perceived stress scale)	Significant improvements in stress awareness for HT group compared to C group (p = 0.004).
Wichrowski et al. (2005), N = 107 cardiac rehabilitation patients	HR (Pulse oximeter)	Postintervention, pulse oximeter showed HR fell in HT group by 5 bpm, but remained relatively unchanged in C group. Reported significant improvement for HR in HT group compared to C group (p < 0.001).
	TMD (POMS)	Postintervention, total and individual POMS scores showed significant improvement for TMD in HT group compared to C group (p < 0.001).
Kim and Thompson (2020), N = 17 children	Food preparation and gardening behaviors and attitudes (Survey)	The summary results table in the study only reported baseline, not outcome assessment data from the intervention. Nine participants were lost to follow-up at 1 year. Of the nine who completed the survey, it was reported that 78% of children were gardening at home and 100% cooking at home. Baseline data reported 61% of children were gardening at home, with 65% of children reportedly helped prepare meals at home.
Ulrich et al. (2020), N = 42 ICU patient families	Stress level (immediate changes; Pediatric Quality of Life Present Functioning VAS)	In both the indoor and outdoor locations, from the start to the end of the break, stress scores significantly declined (improved; p < 0.0001). For garden breaks, there was a significantly greater improvement in sadness scale (p = 0.032) compared to the indoor group.

C, control; CMD, cognitive motor dissociation; CSG, conventional sensory garden; EG, enriched garden; HR, heart rate; ICU, intensive care unit; KATZ ADL, Katz Index of Independence in Activities of Daily Living; MBI, Maslach Burnout Inventory Human Services survey; MMSE, Mini mental status examination; POMS, profile of mood states; SCQ, Self-Consciousness Questionnaire; SMBQ, Shirom-Melamed Burnout Questionnaire; SMVM, Shirom-Melamed Vigor Measure; TG, therapeutic garden; TMD, total mood disturbance; TUG, timed up and go; VAS, Visual Analog Scale.

Table 3.

Mixed Method Study Outcomes

Author (year), sample	Outcomes (measure)	Findings
Cox et al. (2004), N = 24 residents with dementia	Quantitative: QOL (ARS)	For the affected QOL states, significantly greater sadness was seen in the residents who visited the living room compared to the Snoezelen room and outdoor garden. However, most recorded affect states in the three environments were for contentment, interest, and pleasure. A comparison of the affect ratings obtained before and during each session found statistical significance for all three environments for pleasure (p < 0.001) and contentment (living room and garden, p < 0.001; Snoezelen room, p < 0.01).
N = 12 Caregivers and visitors	Qualitative: Semistructured open-ended interviews were recorded and transcribed verbatim
	QOL	Both the Snoezelen room and garden were described as “making a difference to the day.” Everyone commented on the “fresh air, the wind, and the sun in the garden.” All caregivers spoke about “how residents sat and sipped their tea, looked at colored flowers, touching them, and smelling the perfume,” and spoke of many instances of residents spontaneously taking the hose and watering the garden. “I'm sad that [the research project] is finished. I think it is sad for those residents because it really proved to me that they all need that special time with someone else. With all day-to-day things that go on, there isn't time … we don't make time for them.”
	Stress	Caregivers spoke of feeling “calmer” and “feeling less stressed.”
Edwards et al. (2013), N = 10 residents with Alzheimer's	Quantitative: QOL (DEMQOL)	Significant improvements in all measures of QOL (p < 0.0001).
	Agitation (CMAI Short Form)	Mean agitation scores significantly decreased (p < 0.00001).
	Depression (CSDD)	Mean depression scores significantly decreased (p = 0.02).
	Qualitative: Semistructured open-ended interviews
N = (N/A) visitors, staff	QOL	Family member: “I can't say how much of a difference the garden has made for XX. Today I have taken her up on the viewing platform and we wrote a letter, she talked about the birds, she loves animals. It's relaxing for us both to be out here. It has improved XX's quality of life, and I enjoy coming more too”General Practitioner: “This garden has improved the quality of life of the residents here to the point that I don't have to come as often. I know this is a big statement with such a small sample, but I really believe that the new environmental changes have had an impact on the residents' physical and emotional well-being. It would be great if all facilities could provide environments like this.”
Veldheer et al. (2020), N = 15 outpatients with >1 CVD risk factor	Quantitative: F&V (servings), fiber (g), and energy intake (%; National Cancer Institute's Food Frequency Questionnaire)	Attrition rate 93.3% (14/15). Significant changes from baseline to follow-up were reported for F&V servings (1.2 servings, p = 0.0005) and fiber (3.8 g, p = 0.01) but not for percentage energy intake from fat (p = 0.75)
	Blood pressure (diastolic and systolic) and HR (beats/min; portable, electronic sphygmomanometer)	No significant changes in systolic (p = 0.10), diastolic (p = 0.62) or HR (p = 0.15) from baseline to follow-up.
	BMI (Measured height and weight)	No significant change in BMI (p = 0.10) from baseline to follow-up.
	Physical activity (Godin PA questionnaire)	Significant improvements in physical activity scores (p = 0.02) from baseline to follow-up.
	Anxiety (Promise anxiety score)	No change in anxiety score.
	Qualitative: Semistructured interviews
	Psychosocial	“Something where the group can get to know each other. Cause I met people (at the session) and got their names the first time, but I didn't necessarily know them. … something where people can talk back and forth with ideas.”

ARS, Affect Rating Scale; BMI, body mass index; CMAI, Cohen-Mansfield Agitation Inventory; CSDD, Cornell Scale for Depression in Dementia; CVD, cardiovascular disease; DEMQOL, Dementia Quality-of-Life Instrument; F&V, fruit and vegetable; PA, physical activity; QOL, quality of life.

Four studies cited positive social benefits of gardens.^31,36,39,40 Two nonrandomized controlled trials assessed the impact of taking daily work breaks in a garden on burnout in nurses.^18,19 Both studies reported significant improvements in symptoms of burnout. One measured by the Pediatric Quality-of-Life Present Functioning Visual Analog Scale and the Maslach Burnout Inventory Human Services Survey,¹⁸ while the other study assessed burnout using a questionnaire adapted from the following validated assessment tools: The Demand-Control Support Questionnaire, Effort-Reward Imbalance Questionnaire, Shirom-Melamed Burnout Questionnaire, and Shirom-Melamed Vigor Measure.¹⁹

Six qualitative studies (including two mixed methods^29,30), presented in Tables 3 and 4, evaluated the impact therapeutic gardens have on QOL by way of interviews that were recorded and transcribed, and interpretation given to arising patterns.^{29,30,35,38
–40} The data obtained from focus groups and semistructured interviews highlighted the experiences of patients, visitors, and staff with the gardens.^{29,30,35,38
–40} Overall, the nature-based environment was found to promote joy, calmness, engagement, movement, and socialization among the participants.^{29,30,35,38
–40} Participants reported valuing the esthetics of the natural environment, particularly in contrast to the clinical setting,^{29,30,35,38
–40} as well as appreciating different gardening activities and sensory experiences.^{29,30,35,38
–40} The quantitative components of the two mixed methods studies^29,30 further supported these findings, citing significant improvements in aspects of QOL, measured by the Quality-of-life Assessment in Dementia³⁰ and the Affect Rating Scale.²⁹

Table 4.

Qualitative Study Outcomes

Author (year), sample	Theme	Description of theme	Exemplar quote	Application
Eriksson et al. (2011), N = 5 rehabilitation patients with stress, anxiety, and/or depression	Feelings of acceptance	The natural and calm garden environment allowed thoughts to be thought again.	“In the garden, I can take off my mask, I can just be myself, you are allowed to think and feel whatever you want.”	Participants described how they immediately felt more relaxed when entering the garden. The calm, natural environment with water and plants created feelings of security and consent to leave troublesome thoughts related to their present everyday life outside the garden. Some also experienced troublesome thoughts and awareness of all the good things that they had missed in their lives, which was provoked by the contrast of the calm environment.
	Being present	Discovering enjoyment in garden activities; doing garden activities with natural materials created a sense of competence.	“The activities with the flowers and the plants were good. There was no need for any great effort; the result was nice anyway.”	Participants became reflective and acknowledged that time spent in the garden environment and engaging in garden activities evoked feelings of enjoyment and competence.
	Bridging rehabilitation to everyday life	Bridging the rehabilitation process in a TG and everyday life through desired activities.	“We planted bulbs that will come up in the spring and that generates a small memory. When I think of this, I feel happiness and remember the environment; it makes me calm.”	Participants revealed how the experiences and activities in the garden promoted changes in their everyday lives. The common feature was that the women took a break from their ordinary everyday lives and became absorbed in the present moment, experiencing similar feelings as in the garden. Participants felt they were gaining more happiness postintervention.
Lehmann et al. (2018), N = 56 veteran rehabilitation patients	QOL	Natural environment and its ability to reduce stress and promote calmness and joy.	“Calm”; “serene”; “refreshed.”	Participants expressed appreciation of the quiet, safe, and stress-reducing feelings associated with viewing and sitting in the garden. The veterans especially enjoyed harvesting their vegetables from the box gardens and eating them with their meals or snacks.
Pieters et al. (2019), N = 25 psychiatric inpatients	Psychosocial	Noticing key aspects about the garden group and gardening experience.	“Gardening makes you feel productive in a way that's like, one with nature and just, it's just got a different vibe to it. It didn't feel like work. It felt like something that you do to kind of cultivate your soul a little bit. … It's a break from a lot of stress. It makes me more self-aware to be in nature. It makes me less in my own head.”	Social aspects, nature and sensory experience were all featured as central parts of the gardening experience for participants. Many participants highlighted that being in a natural environment was salient for them, while in hospital. The contrast of the fresh air and sunshine to the controlled temperature of the psychiatric unit was commonly described.
	Mood	Ways in which the garden group was perceived and integrated in relation to the self.	“It was educational as well as therapeutic.”	Favorable and therapeutic terms were overwhelmingly received when asked for overall impression of the gardening experience. More specifically, the positive outcomes associated with participation were centered on cognition, positive emotions, distraction, and productivity.
van der Riet et al. (2014), N = 8 nurses on children's hospital wards	QOL	The degree to which the children are comfortable and able to participate in or enjoy their time, while in hospital.	“It has helped sick children relax when the children are sick and agitated and nurses and parents take them out to the FG they relax they forget about being ill there is a lot more interaction amongst the children amongst each other also parent to parent there is more interaction.” “For the FG they see the environment not really as a hospital. It is nonclinical FG improves their quality of life because it does not look like hospital the kids relax more and don't want to go home.”	It is demonstrated from the storylines that the FG reduces the fear of hospitals among the children. There is also a storyline of improving the children's development socially. The FG is often described as a place of rest for families of sick children; a space of happiness and relaxation; and a distractor from pain. The nurses often emphasized the importance of the FG as a space with positive benefits for sick children. Children were described as becoming calmer, less agitated and actively engaged in the facility. In addition to becoming a space for relaxation and play, the FG was described as an encouragement for children who have undergone surgery to move more readily rather than lie in their hospital bed.
	Spirituality and emotional well-being	Ability to handle life's stresses and adapt to changes in a difficult situation.	“I have three experiences from children who have visited the FG and passed away, the first is a little girl, 12 years of age who came from another Province, her name was Min, this little girl had leukemia and when the ward was noisy she went into the FG and said a Buddhist prayer and meditation she prayed over the wishing well and did some meditation in the FG over the wishing well after this she was very calm and she went back to her community hospital the nurse rang to say that she died a beautiful and peaceful death. she had accepted her dying.”	Participants often focused upon the influence of the FG on terminally ill children learning to cope with their prognosis. Spirituality through strategies of meditation and visualization for the FG as children with a life-limiting illness manage their illness. The FG provides a space to express their spirituality as they learn to deal with their imminent death.
van der Riet et al. (2017), N = 8 family members of children in hospital	QOL	The degree to which the children are comfortable and able to participate in or enjoy their time, while in hospital.	“Lek likes it. He laughs. FG makes him happy. The distress is gone. Children are happy and less bored. FG makes the children forget they are sick, their fever and pain.”	Majority of family members interviewed describe how the FG makes the children happy and is a space which encourages socialization with the other children. Family members often described their children forgetting about the distress of their illness. There is a storyline of play and enjoyment in the experience of the FG.
	Psychosocial	Combination of the influence of psychological factors and the surrounding environment has on the physical and mental wellness of the children.	“In the FG Ball learns about the plants and flowers. He wants to know their names. Here the children can develop their skills playing with other children. There is more interaction with other children, especially when they are waiting to have their blood transfusions … The FG is a beautiful place. It is a lovely place to see, to relax. For the children they are less stressed in the hospital and are not bored. In the garden they can play around walking, running they feel relaxed themselves. It is a nice place visually. They feel relaxed.”	Recurring storylines emerge of the FG creating a space to support children and reduce boredom and stress. Here they can play and relax. The sociality of the garden becomes an important dimension of interaction among the children. The FG becomes a space for the parents to interact, relax, and enjoy the aesthetics of the FG. There was also recognition of the value of the garden as an educational experience for children, supporting knowledge and skill development.
	Physical well-being	FG encourages children to engage in care during time in hospital, which supports emotional and physical well-being.	“There, in the garden there is more interaction. For the other children they can exercise and make them healthy. Sometimes when the children go to hospital they don't want to eat or take their medicine but when they go to the FG they sit down they eat and then take their medicine.”	The storyline of the FG reducing the children's distress is a central plotline, along with a therapeutic recurring thread of cooperation that the space is an incentive for the children to eat. The sociality dimension of increased interaction of family members is also evident since the FG provides a resting, peaceful, and stimulating experience. There is an energy storyline that the FG has the potential to improve health through activity and exercise.
van der Riet et al. (2017), N = 62 Australian and Thai nursing students	QOL	The degree to which the children are comfortable and able to participate in or enjoy their time, while in hospital.	“The FG is a brilliant use of space within the hospital environment. It has a real positive energy that is reflected in the happiness on the faces of the kids/family of those using it. The FG is suitable for all age groups and has both a calming serenity and a happy feeling which is desperately needed at this hospital. It meets the physical, emotional and spiritual needs of those who use it which is strongly linked to Thai culture. A real healing environment.”	The FG was often described as a healing environment with positive energy. Descriptions of seeing the happiness on the children's faces when in the FG and being able to see the calming aspect of the garden. There is a common theme of seeing the FG as holistic in meeting the physical, emotional, and spiritual needs of the children. The experience of hospital is transformed from sad and stressful to an environment of enjoyment in the garden.
	Psychosocial	FG encourages children to engage in care during time in hospital, which supports emotional and physical well-being.	“I had this child who refused to eat so I took him to the FG to spend some time there. Then when he went back to bed he ate and he took his medicine.”	There was a theme of the FG encouraging children to engage in care at the hospital. The children were more cooperative with their medications and eating. The FG enabled student nurses to successfully care for the children and better manage the essentials of care such as medication and food.

FG, Fairy Garden; QOL, quality of life; TG, therapeutic garden.

Three nonrandomized control trials assessed the impact of therapeutic gardens on cognitive function among participants with cognitive motor dissociation and dementia.^27,28,32 Each study used a different assessment tool—A Behavioral Grid,²⁷ Mini Mental Status Examination,²⁸ or Self-Consciousness Questionnaire—to measure varying aspects of cognitive function. All studies reported significant improvements in aspects of cognitive function after exposure to a garden.^27,28,32

Physical outcomes

Four studies examined the physical health outcomes of patients.^27,28,41,42 Of these four studies, two assessed the impacts of horticultural therapy or gardening on HR in patients with cardiovascular disease (CVD)^41,42: One a nonrandomized control trial⁴² and one study with pre- and post-measurements with no comparison group.⁴¹ While one study reported a significant difference in HR,⁴² the other did not.⁴¹ One study assessed participants' blood pressure, BMI, and physical activity.⁴¹ The study reported significant improvements in physical activity levels, but no significant difference in blood pressure or BMI.⁴¹ Physical function was assessed in two studies among participants with dementia²⁸ and cognitive motor dissociation.²⁷ In both studies, participant's access to outdoor gardens appeared to result in significantly better physical functioning,^27,28 measured by unipodal stance,²⁸ timed up and go,²⁸ Katz Index of independence in Activities of Daily Living,²⁸ and Indicators of Purposeful Behavior.²⁷

Nutrition outcomes

Two studies reporting on the impact of vegetable gardens on patients' diets and health were identified.^33,41 Both used a prestudy-poststudy design and sought to measure the consumption of F&V.^33,41 One study also looked at the intake of total fiber and energy from fat,⁴¹ while the other study looked at behaviors toward nutrition and healthy eating, home gardening practice, and food preparation.³³ Following the 12-week hospital-based garden intervention, participants reported an increase of 1.2 serves F&V and significantly more fiber intake, although no reduction in the percent of energy from fat.⁴¹ In the hospital-based cooking and gardening program for children, there was a reported increase in gardening and cooking at home among participants who completed the program, although only 50% of the original participants completed the program.³³

Study quality

Assessment of studies using the MMAT²⁶ indicated that the overall quality of included studies was medium-low (Fig. 2). All included studies had a clear research question. Most studies' data addressed the research question, except for one study, which only reported baseline data.³³ The main reasons for the medium-low quality of studies related to the outcome measures, most of which were heterogeneous, low in reliability and validity, lacked controls, and had variable follow-up lengths. Seven studies were assessed under the quantitative nonrandomized controlled trial category in MMAT.^{17,18,27,28,32,33,42}

FIG. 2.

Quality assessment of included studies using the MMAT—version 2018. MMAT, Mixed Methods Appraisal Tool.

The majority did not meet quality questions, except for represented target population and utilizing appropriate measures. Six studies^{31,35,36,38
–40} were assessed under the qualitative category where the majority met all quality questions, except for one study³⁵ that did not meet any. Finally, three studies were assessed using the mixed methods questions.^29,30,41 One study³⁰ performed poorly on all qualitative questions, and the other two studies^29,41 were of medium quality.

Discussion

This systematic scoping review synthesizes the available evidence for the implementation and impact of health care gardens on human health. The findings suggest that exposure to gardens in health care settings may positively impact the health and well-being of patients, visitors, and staff. Most research has measured psychosocial outcomes, but some gardens and garden interventions have been implemented to improve patients' physical health and nutritional outcomes. That said, the overall evidence was of medium-low quality and heterogeneous and may not be sufficient to draw strong conclusions.

Gardens implemented in health care settings appear to support the health and well-being of patients, visitors, and staff. Notably, the studies that provided descriptions of gardens described therapeutic, healing, or sensory-type gardens used for emotional well-being, QOL, and cognitive function in all three settings: hospital, aged care, and rehabilitation. Sensory or enriched gardens were often employed in aged care settings with easy access, an array of trees, plants and flowers, and other stimulating accessories.

This finding aligns with current literature on nature-based interventions in full-time care or rehabilitation settings, which indicates that sensory gardens may produce positive effects for improved well-being in aged care.⁴³ Furthermore, healing gardens were commonly implemented in a hospital setting to address the psychosocial outcomes of patients, visitors, and staff. Although results are limited by sample size and the quality design of studies, the implication is that gardens can provide respite for patients, visitors, and staff from the often stressful stimuli of clinical settings. Most described gardens also utilized evidence-based design recommendations for gardens that provide a sound basis for future implementation of gardens in health care settings.

Regarding psychosocial outcomes, gardens in health care settings appear to positively impact the QOL and emotional well-being of patients, visitors, and staff. Of studies included in this review that assessed psychosocial outcomes, each used a variety of different measures and study designs and the overall reliability and validity of evidence of studies were medium-low quality.

Nevertheless, most studies indicated improved emotional well-being and QOL from both reported outcome measures and the experiences and perceptions of participants taking part in health care-based garden interventions. These findings are consistent with current literature, which highlights community gardens and horticultural therapy as having an overall positive effect on psychosocial well-being.^5,44 Emotional well-being is considered an essential aspect of health because it is related to positive health behaviors.⁴⁵ It is worth highlighting two studies that explored the possible benefits of gardens for reducing burnout in health care staff, as both studies reported significant improvements in reducing burnout symptoms.^18,19 These findings are particularly relevant since health care workers experience high rates of burnout,⁴⁶ which have been exacerbated by the recent COVID-19 pandemic.⁴⁷

Physical health is considered the cornerstone of an individual's overall well-being and is affected by lifestyle choices such as physical activity, diet, smoking, and alcohol consumption.⁴⁸ The results for garden-associated physiological health outcomes were mixed. However, the included studies varied substantially concerning the outcomes assessed, assessment tools, sample size, population characteristics, and study quality and design. Similar to the result from this review, a recent systematic review and meta-analysis (2020)⁴⁹ assessing the impact of community gardens on physical health reported mixed results for HR, blood pressure, and physical activity. However, the meta-analysis for BMI showed a positive association between gardening and weight reduction, which contrasted with the findings from this study.⁴⁹ The authors of the systematic review and meta-analysis also reported significant heterogeneity in included studies and outcomes,⁴⁹ which is a common theme across the breadth of research in this area and may potentially explain the reported inconsistencies.

The impact of garden-based interventions on improving nutrition in health care settings remains inconclusive due to the low-quality studies, such as few randomized trials or evaluations without comparison groups. However, available findings suggest gardening interventions generally showed greater fruit, vegetable, and fiber intake in participants. These findings are consistent with community-based gardening interventions. For example, a horticultural therapy intervention for cancer survivors resulted in significant improvements in overall dietary patterns (increased consumption of F&V and a decrease in consumption of red/processed meat and sugar-sweetened beverages).⁵⁰ A recent systematic review and meta-analysis also reported that gardening was associated with higher consumption of F&V among gardeners compared to nongardeners.⁴⁹ Furthermore, the beneficial effects of garden interventions on behavior and self-efficacy toward nutrition among school children are also demonstrated in another, more recent systematic review.⁵¹

A strength of this review was the systematic approach, which included conducting a comprehensive search in four databases, and multiple researchers screening, assessing, and conducting quality appraisal in duplicate. To strengthen the study's generalizability and ensure all relevant literature was included, the search was developed and executed in consultation with an experienced librarian and included no time or language limit. Publication bias, due to the exclusion of gray literature, is a limitation of this study. However, the main purpose of this review was to assess the available evidence in peer-reviewed journals.

The rationale is that, while many hospitals have implemented on-site gardens,²⁰ evaluations of these interventions are either difficult to find or they lack the study quality, design, and rigor standards required of a scholarly report. Given gardens and garden interventions are multifaceted health interventions, another strength of this study was that all study designs were included (quantitative, qualitative, and mixed methods), which lends to a richer evaluation of health outcomes. A major limitation of the review is that the research in this area is limited, is of low-medium quality, and has significant variability in the study designs, garden types, and outcomes measured, with very few studies reporting using the same measurement tool. However, randomized controlled trials to evaluate the health effects of garden interventions may not be feasible. For example, they may be unethical as it would require withholding access to a therapeutic garden to participants in a control group.

Similarly, a garden intervention to measure objective physical health benefits would require very long intervention and follow-up periods. Finally, despite best efforts, due to the significant heterogeneity in study design, it is possible that not all relevant studies were captured by the search strategy. In saying that, if relevant studies were missed, it is unlikely to change the overall findings, given they are consistent with the larger body of gardening research in other populations and settings.

Conclusion

The overall findings suggest that regardless of the type of garden or health care setting, the implementation of gardens may confer several psychosocial, physical, and nutritional benefits to its users. Health care gardens, be as extensive as rooftop or vegetable gardens or simply include a small collection of plants in an atrium, can offer respite for long-term patients, solace and fresh air for visitors, or a place to take breaks and unwind for staff. Health care providers can feel confident that any investment in on-site gardens may offer a benefit to patients, staff, and/or visitors without any significant risk.

This study also highlighted key gaps in the existing evidence base and quality of primary research, indicating the need for future research to explore the physical, nutritional, and health outcomes of staff and visitors. It is also recommended that researchers in this area use high-quality study designs (e.g., cluster control trials) and standardized measurement tools to determine the effects of health care garden interventions on individual health and well-being-related outcomes.

Footnotes

Acknowledgments

The authors thank the Bond University Nutrition and Dietetics Program (MNDP) team for contributing to the development of this article. This scoping review was partially published as a poster presentation for the Dietitians Australia Conference, July 23–25, 2023.⁵²

Authors' Contributions

C.C. and J.H. developed and executed the search strategy with an experienced librarian. C.C. and J.H. reviewed, selected, and extracted the data from eligible articles and equally contributed to writing the article. Through each stage of the systematic process, J.U. provided guidance and assistance with reviewing and editing the article. S.M. reviewed and edited the final article. All authors read and approved the final article.

Author Disclosure Statement

The authors declare no competing interests.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

Supplementary Material

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