Green revolution in care and living environments

In the effort to keep healthcare costs manageable, the coming years will see a heavy focus on shifting care to lifestyle-based health, prevention and early diagnosis. For a long time, official medicine kept away from anything to do with green and nature, especially in the hospital setting. But in recent years there has clearly been a turnaround. Dr. Jolanda Maas, associate professor at the VU and landscape architect Judith van der Poel share their insights.

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

After the factor of greenery almost completely disappeared from the hospital environment during the last century, a counter-movement arose at the beginning of this century. This was partly under the influence of Planetree in America, which had been advocating the transformation of hospitals into "healing environments" since the 1970s. There was also a reaction in our country to the emergence of technocratically based mega-hospitals, which completely lacked the human touch. Thus a new view of hospital design emerged, with a clear increase in the number of green elements in and around the building. Very noteworthy in this regard was the news, last summer, that the Rijnstate hospital in Arnhem had created an outdoor space on a balcony for two intensive care beds. 

Dr. Jolanda Maas, associate professor at the Department of Clinical Psychology at the Vrije Universiteit Amsterdam was closely involved in the research for this. Some years back, together with environmental psychologist Dr. Agnes E. van den Berg and Dr. Karin Dijkstra, lecturer in health promotion in the living environment, she compiled the evidence-based inspiration guide 'Green in and around hospitals' (2021). It incorporates the results of the research program 'Green Healthy Hospitals' that was carried out in the years 2015-2020. It looked at the effects of green interventions on five hospital wards. "Many green interventions have indeed been implemented in recent years," Maas says, "but there is still a problem, because they are generally only used to a limited extent. As a result, the effects are still limited, which makes it harder to justify the investments. The fact that it doesn't work as it should does not only have to do with the design, but also with the fact that the facility is not really integrated into care. So there is still a lot of room for improvement."

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

Why things go wrong during implementation is hard to say, according to Maas: "Of course it's pretty new, the care workers are super busy, and for most landscapers and gardeners it's also about new target groups. It is a bit similar to the process surrounding the construction of green schoolyards. It often has to be done quickly and on a limited budget." Fortunately, however, there are more and more designers who do get it right, she notes. "But they then have to get into the picture with a healthcare institution. Care institutions now often have ongoing contracts with green suppliers, who are then also deployed in such a green intervention, while the expertise required for this is not always present. The bottom line is that both hospitals and landscapers and gardeners will need to be trained on this issue. Both parties need to become aware that with some extra steps they can really realize something of value, rather than what it often is now: a nice decorative element."   

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

Something similar played out at Isala Hospital in Meppel and Leeuwarden Medical Center, both of which had gardens that weren't actually being used. "So we redesigned those gardens together with a team of professionals - including people working in the hospitals themselves - using our design-implementation model," says Maas. "And around that, we set up a process to ensure that the healthcare professionals also integrate the garden into their work processes. Only then does a garden like this really start to add value."

Demonstrating health claims is not so easy, because only limited research has been done. Maas: "General literature suggests that such a garden reduces stress, provides a nice distraction for care workers and also increases job satisfaction. I think it is very important what kind of story you tell around it. I see those green spaces myself as a kind of refuge for the brain: a break from the stressful environment." So it's not only a matter of really implementing such a green project well, but also of getting a better picture of the health effects or perception effects. Maas: "Definitely! And then not only the effects on patients, but also those on staff and visitors. I think that's just as important with the growing shortages of healthcare workers and the high dropout rates due to stress and burnout."

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

Since 2019, Van der Poel has succeeded the firm's namesake, Niek Roozen. She studied Garden and Landscape Design at Van Hall Larenstein University of Applied Sciences in Velp (2001) and then studied Landscape Architecture at the Academy of Architecture in Amsterdam. Niek Roozen, known for the Floriade, among other things, has been committed to urban greening with the goal of a healthier world since the last century. Van der Poel: "We released, with input from researchers, governments and institutions, 'The Green City Guidelines' in 2011, but we are now increasingly noticing that this approach is super topical, also from a healthcare perspective."

"We wrote The Green City Guidelines some 10 years back in cooperation with Wageningen University and Research (WUR), in which you find numerous facts. It is indeed true that people in the hospital recover faster if they have a view of greenery. So it really has a scientific basis that greenery has a positive effect on health and that is of course nice for our field." The cooperation with WUR yielded important new insights, for example about the added value of greenery in terms of air purification. And now again the results of a study that states that if cities had 30% foliage, thousands fewer people would die of heat stress. Van der Poel: "So there are very strong arguments to go green and also to preserve existing green spaces. Large trees are still often cut down far too easily, even though we now know that a 20-year-old tree provides just as many ecosystem services as 400 small trees. Twenty years ago, greenery was still a nice sauce to put over a plan, but that is really different now. I notice that as a landscape architect I'm getting more and more of a say. It used to be that you weren't brought in until the houses were pretty much already there." 

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

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

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