We all know it’s sound advice: being around nature is good for people. We get our breath of fresh air and clear our head in the outdoors. If we look at historical examples, the health sector used to believe so too. Convents and sanatoriums were all located in natural surroundings. In the past 60 years however, the healthcare industry has taken another turn: one of efficiency and optimal hygiene. And these have no place for green. Thankfully, people are starting to see differently. Because it’s no longer just common sense. More and more evidence is gathered that greenery and natural surroundings are beneficial to people; it helps them feel good, get better and stay healthy.

What does the evidence say?

For some years now organisations in the healing environments movement, such as Planetree, have been proposing to use greenery for making patients (feel) better. Concepts like ‘Helende Hellingen’ (Healing Hills) and ‘Care Landscapes’ and research on the use of plants in hospitals (WUR: Agnes van den Berg) as well as recent research from TEEB by KPMG have demonstrated that green does have a positive effect on getting well. Yet still too few hospitals can boast a green interior. If there is any green, it’s used for their outdoors environment, for example around the new building of the Meander Medical Centre in Amersfoort. On of the few examples of a green hospital interior is the newly finished building for Isala Hospitals in Zwolle. Here the planting has been moved to indoor areas with glass roofing. Unfortunately, the ambitions for interior landscaping in care institutions are often the first to be pruned back in the building process. Hygiene being the most-heard argument.

Isala klinieken Zwolle
Isala Klinieken, Zwolle. Photograph: Norbert Waalboer.

In 2005, the Dutch National Working Group on the Prevention of Infections wrote an article describing guidelines for the use of potted plants in hospitals (which were a translation of the protocols of the American Center for Disease Control). In the article it was concluded that in wards with patients with intact immune systems potted plants could be used. However wards with patients with weakened immune systems should not use them, because every possible contact with potting soil, that can contain fungi, needs to be avoided.

We could benefit from a multidisciplinary approach

How can more opportunities for greenery in hospitals be created, and which obstacles need to be cleared in order to come to a realization in hospitals?

Together with the Princess Maxima Centre for Children’s Oncology the Dutch ‘Knooppunt Bouwen met Groen‘ started a debate on ‘green and hygiene in hospitals’. The Maxima Centre, a new centre for children with cancer, faced an ambitious green challenge. In the design of the centre (by LIAG Architects) patients and their families were put first and a strong focus was on the physical and psychological development of the child. An important part of the building are the care units. Green could be used as an important connecting element between these units and various other parts of the building such as the patient rooms and the family facilities, as well as highlighting the identity of these various parts.

Promo prinses maxima

One of the biggest problems that needed to be solved was the ‘not invented here’ syndrome. Many studies and advice relating to greenery and hygiene are approached from a specific area of medical interest and are considered less relevant for other specialties. In order to find an answer that is acceptable to all medical specialists, a wide range of experts were invited to discuss the topic: a building manager, a medical doctor, a micro-biologist, several experts on interior and exterior planting and, of course, an architect. It was believed that in using a multidisciplinary approach, new and sound connections could be forged.

What problems are we talking about?

During the meeting first of all, the problems and risks when using greenery in a hospital were charted. For this every spot for outside and inside planting – possibly even in the patients’ rooms – were considered. Some of the views and conclusions were:

  • Man poses a greater risk than greenery or outside dirt. People can be seen as the greatest source of micro-organisms (each person releases about 37 million micro organisms in any room per hour) and viruses in hospitals.
  • Mechanical ventilation in hospitals can cause many problems. In a hospital micro-organisms are often coming from people and they are mostly sick. This leads to an accumulation of micro-organisms, including pathogens, coming from patients and health workers. Mechanical ventilation can cause a very unhealthy microbiotic ecosystem in a hospital because pathogens and spores act like fine particles and are spread around by the system. This partly explains unintentional and unwanted hospital infections.
  • People can be allergic to certain plants, mainly because of the pollen of flowering plants. However, any professional interior landscaper or horticulturalist will know these and can easily avoid them.
  • Dirty water and potting soil can become a breeding ground for fungi. As is the case when a vase of flowers starts giving off a bad smell.
  • The Fungus Aspergillus is dangerous for children with a weak or inactive immune system. The fungus resides in potting soil, among other places. If a patient doesn’t touch the soil and the plants are tended properly, this would not have to be a major issue.

Greenery is experienced in two ways: it is beneficial to people’s health, but it can also be unhygienic. A conscious effort needs to be made to tackle the fears that accompany the latter characteristic.

How can greenery offer solutions?

Based on the problems mentioned above, possible solutions were named during the session, that could improve the chances for greenery in hospitals. The following were mentioned:

Exterior greenery

  • Make a distinction between planting to be looked at and plants that can be actively approached. Greenery that can be admired from a distance is of course appropriate for patients with a weaker immune system. Plants that can be used (by touch or smell for example) can be involved during the rehabilitation process;
  • Every hospital wants to put the development and the well-being of the patient first. Their recovery are at the center of attention major role and greenery could help. Of course safety should be taken into consideration;
  • Decision-makers need to decide on the acceptable risks, as there always will be risks, just like when mechanical ventilation is used;
  • The plants, trees and bushes outside the hospital can have more functions besides decoration, as they are able to improve air quality or reduce noise pollution from a nearby road.

In conclusion: outdoor greenery can be used in making the patient feel better but also in creating conditions for a healthy indoor climate that feels as natural as is possible.

Interior greenery

Interior green can be put to work to improve the air quality (and even clean the air outside), because of the purifying characteristics of plants for particulate matter and germs. Plants can be very helpful for an improved climate in the hospital. If there is a green roof, it can lead to a lesser need for air conditioning. Plants can be put to use as an air filter so mechanical filtering will be less needed. As such greenery can also be connected to other issues, like energy and cost reduction.

video indoor living filter

It’s important to consider the groups of patients who can be around plants safely, and those who can’t? Patients who are critical and have a weak immune system should not be exposed to plants. This target group is usually located in a separate part of the building, where stricter infection prevention measures are already taken. On the entire hospital population they form a fairly small group.

In summary, interior green can be used to help patients become healthier and stronger by contributing to an improved air quality. Furthermore plants have a significant positive psychological effect in making patients feel better. As such they help speed up the recovery process.

Conclusions

The most important conclusion of the debate was that, seen from an hygienic perspective, there are few objections against using greenery in a hospital. On the contrary: for a large number of problems, planting can offer several useful solutions.

Lack of commitment is often the greatest barrier. Hospital policy makers and the Working Group for the Prevention of Infections should be involved in the planning proces an early stage, and not at the very last moment. Their approval is crucial for successfully greening hospitals.

Furthermore, it’s important to calculate the exact costs of green solutions, including maintenance. What are the costs, what are the benefits, how can high quality standards be maintained? Too often, these issues are not taken into account during the design process by a new hospital project team, or even in the building sector in general.

In order to adequately tackle these problems early on in the process, close collaboration is needed of interior landscapers, medical experts, designers and building professionals. Only by applying a holistic approach can we achieve truly green hospitals.


About Dennis Hauer

As an architect and counsellor on sustainability Dennis Hauer is involved in projects with a high level of sustainability in general and healthy living environments in particular. His working method is characterised by a holistic approach. From his specialized knowledge and fascination for planting in the urban landscape, Dennis is involved as an inspirator for ‘Knooppunt Bouwen met Groen’; getting projects started with a holistic approach and an innovating use of greenery to create a vital living and working environment.

It’s important to consider the groups of patients who can be around plants safely, and those who can’t? Patients who are critical and have a weak immune system should not be exposed to plants. This target group is usually located in a separate part of the building, where stricter infection prevention measures are already taken. On the entire hospital population they form a fairly small group.

In summary, interior green can be used to help patients become healthier and stronger by contributing to an improved air quality. Furthermore plants have a significant positive psychological effect in making patients feel better. As such they help speed up the recovery process.

Conclusions

The most important conclusion of the debate was that, seen from an hygienic perspective, there are few objections against using greenery in a hospital. On the contrary: for a large number of problems, planting can offer several useful solutions.

Lack of commitment is often the greatest barrier. Hospital policy makers and the Working Group for the Prevention of Infections should be involved in the planning proces an early stage, and not at the very last moment. Their approval is crucial for successfully greening hospitals.

Furthermore, it’s important to calculate the exact costs of green solutions, including maintenance. What are the costs, what are the benefits, how can high quality standards be maintained? Too often, these issues are not taken into account during the design process by a new hospital project team, or even in the building sector in general.

In order to adequately tackle these problems early on in the process, close collaboration is needed of interior landscapers, medical experts, designers and building professionals. Only by applying a holistic approach can we achieve truly green hospitals.


About Dennis Hauer

As an architect and counsellor on sustainability Dennis Hauer is involved in projects with a high level of sustainability in general and healthy living environments in particular. His working method is characterised by a holistic approach. From his specialized knowledge and fascination for planting in the urban landscape, Dennis is involved as an inspirator for ‘Knooppunt Bouwen met Groen’; getting projects started with a holistic approach and an innovating use of greenery to create a vital living and working environment.

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