Research on Nature in Healthcare: What Do We Still Need?

Do We Even Need More Research?

In response to my question, “What research still needs to be done on access to nature in healthcare?” one person wrote, “99% of it?” Clearly, they think we still have a lot of work to do. In contrast, another person wrote “Nothing…all is done…just…need to implement it.” Three others had similar sentiments, that perhaps we are at the point where rather than more primary research, we need better translation of research into practice: “I’m not sure if it’s a need for more primary research or better dissemination of the existing data.” “How to transfer knowledge to action so city planners, school administrators, property developers understand that what they do impacts health outcomes.”

My sense is that more than more research per se, or perhaps hand-in-hand with ongoing research…what is need[ed] are a proliferation of demonstration projects that allow the public direct experience of healing gardens, healing groves, nature trails etc. All intentionally and expressly tied to human experience of healing spaces.

Dosage: What Kind of Nature?

Several people suggested research on different types of nature settings and climates such as desert or tropical landscapes, urban landscapes, and green roofs: “We very much privilege views of “green” in [most] studies. What effects does landscape such as xeriscaping or desert views have?” And similarly, “Do people react the same way [to] different types of garden experiences? For example a pine grove vs a sugar maple vs bushes. And the surface under foot—concrete vs stone vs gravel?” “Are benefits the same in different climates? Desert vs. tropical vs. Temperate…it may also depend on what climate is ‘home’ or ‘comfort’ for you.” “How can you connect people to nature in a healthcare location that is very urban and does not have the luxury of an open space? Does having an indoor nature space work?” “I came across a top ten in relaxing music. Is there a top ten in relaxing therapeutic areas which could be easily replicated in a hospital environment?” One respondent suggested using the Shinrin yoku (forest bathing) research as a “jumping-off point to replicate the methodology in different forest types and with different populations.” Another echoed that sentiment: “Be fascinating to develop a multi-country scheme to evaluate outdoor space and health interventions.” Another respondent wanted to know about the effects of active interaction with nature through gardening.

Dosage: How Much Nature?

On Twitter, one respondent suggested, “Ask what is the most effective #naturedose and for how long a course, to treat and prevent mental ill health. Common estimates say 45 mins/week, but for how many weeks?” In other words, how much time does one need to spend in nature for it to be effective? Another respondent wanted to know about the size of the dosage: “‘How much ‘nature’ does it take to improve mental health outcomes? A whole park, small garden, or a row of street trees, or…?” This respondent also bemoaned the lack of recent research on the benefits of street tree planting: “Some of the street tree studies from 20–30 years ago haven’t been replicated, and we can’t keep using the same few set of studies only from the 80 s.”

Mechanisms

One person simply wrote, “What is the mechanism of action?” Another, “How design of therapeutic environment matters.” On that feed, I suggested Kuo’s (2015) article, “How might contact with nature promote human health? Promising mechanisms and a possible central pathway.” Another respondent was more specific:

Does access to nature effect changes in neurological changes, molecular changes and DNA methylation; does access to nature affect the stress response and increase resilience? How does nature get under the skin? Need to understand the relationship between epigenetics and genetics and human health.

Nature Access for Specific Populations

Five respondents wanted to see more research about specific populations: “Access for LGBTQ kids.” “Adapted greenhouses for people in wheelchairs…even those with dementia.” “I have been looking for information regarding the impact of design and nature for trauma affected communities—especially urban. We are working on several playgrounds in highly traumatized urban neighborhoods.” In a similar vein, a respondent suggested, “Possibly most importantly, looking at outdoor spaces and factors affecting [their] use in vulnerable populations, areas of high relative poverty etc. There is where huge health gains and quality of life improvements are likely to be made.” Another respondent wrote,

I watched an inspiring BBC2TV programme last night on the importance of good palliative healthcare (We Need to Talk About Death). Several dying individuals touched on the desire, need even, to have the opportunity to be outdoors occasionally, to feel the breeze, the warmth of the sun.

Technology and Representations of Nature

I was surprised that the role of technology did not come up more because it comes up every time I give a presentation. “Does using virtual tech to bring people to say a redwood forest or the beach virtually bring benefits?” Similarly, “Not sure this qualifies as access, but I’m interested how immersive high resolution video of nature scenes might be worked into waiting rooms & the like. News on televisions seems completely antithetical in that stressful environment!” One respondent had several questions: “1-How do paintings & photographs of nature compare in effectiveness? 2-Effect of EBD art on senior living center staff turnover. 3-Whether/how well TV views of nature work.” In response to the thread, one person wrote,

Yes! Along with all the other “real” important details: open windows and fresh air, “a view through a window,” live plants, aromatherapy, a view of birds and sound of birdsong, a welcome hello from a therapy dog, etc. Rather than virtual nature, to what degree can we promote real nature therapy? Thx!

One respondent suggested using technology as a means for gathering large amounts of data:

It would be good if, at government and local government level, data were collected and distributed to researchers about population level effects. So linking health data and census records, for example. I feel that it might be interesting to use drones in some way, to map outdoor space use, to see if the way people use space is how we think they use it, and how they report that they use it. There has been a little work on outside space characterization, and that could be expanded.

The Business Case and the Need for More Quantitative Research

Another topic I am often asked about is “the business case.” If a healthcare organization is going to invest thousands, even millions, of dollars into creating and maintaining a garden and other biophilic elements in their facility, they need to know what their return on investment will be. As one respondent said, “The business case for nature in healthcare settings is very weak. Nature is often value engineered from facility plans to cut costs. Validating the economic return on investment would help tremendously.”

As far as I know no one has researched the financial benefits of nature in health establishments…we need quantitative research…. From all the discussions I have had with health executives, we need numbers showing the financial benefits of having nature in health establishments. Money talks….

What’s the tipping point at which we prioritize nature over medicine, as a first line for maintenance therapy.

Although there has not been nearly enough work on this subject, a few articles are worth looking at. Cooper Marcus and Sachs’s (2014) “The Business Case and Funding for Therapeutic Gardens” addresses the question head-on and specifically for healthcare. Rodiek, Boggess, Lee, Booth, and Morris (2013) found that word of mouth referrals were higher in assisted living facilities when the outdoor spaces were better. Berry et al. (2004) wrote an excellent article on the business case overall for evidence-based healthcare design, and their arguments and methodology can easily carry over to access to nature. “The Economics of Biophilia” by Terrapin Bright Green (2012) makes the business case for bringing nature into buildings and cities of all kinds, including healthcare.

Along the same lines, a respondent said that we need the kind of research that scientists still pay the most attention to: quantitative. “We need quantitative control group research. Until we do that, it’s just observation.” I personally disagree that qualitative research is “just observation.” I think that qualitative research, when conducted rigorously, can be just as or even more powerful than quantitative. I also believe strongly in mixed methods research. That is an editorial for another time.

What Role Does Programming Have?

One person suggested that in addition to questions about design, we should also be asking about programming: “Does programming to encourage engagement with the garden provide more benefit than a garden by itself? And what kind of programming? A guided sensory stroll, hands-on gardening, signage, creative arts, etc.”

Are We Asking the Right Questions?

One respondent who has been studying energy medicine and reading the early “forest bathing” research out of Japan said, “I can’t help but think there is a whole realm of research for which we have not yet formulated the right questions to be asking.” I like this idea that we have much more to discover. Let’s hope we have many more students and other curious minds who will ask the questions and dive in to the research yet to come.