Hospital Garden Eases Nurse Burnout

Hospital Garden Eases Nurse Burnout

Garden Visits Encouraged by Medical Director of Employee Health

Ever heard of a hospital medical director whose mandate is to promote employee health? I sure hadn't, until I met Dr. Minot Cleveland at Legacy Health in Portland in 2018.

And it gets better! His speaker bio from the therapeutic garden conference I attended says Dr. Cleveland is “an expert in health promotion and preventive medicine” and he “believes that taking advantage of nearby nature is a key opportunity for employees and medical staff to reduce stress, build resilience and enhance quality of life.”

Having facilitated therapeutic garden programs in healthcare settings for over 20 years, I am elated that a hospital system is investing to such an extent in employee health, and actively encouraging staff to make use of their hospital gardens for health promotion.

But then I shouldn’t be surprised, since Legacy already set a record by establishing 12 therapeutic hospital gardens ("the most of any health system" says Dr. Cleveland) under the direction of Teresia Hazen, horticultural therapist. Teresia’s accomplishments keep me travelling to Portland to learn and seek inspiration.

Looking down from Terrace Garden to Children's Garden at Legacy Health

Healthcare gardens and therapeutic garden programs are still far from mainstream, and Legacy Health’s work provides hope that change is in the wind. (Teresia’s advice? “Get a physician on board!”)

Nurses and Doctors in Need of Stress Reduction Strategies

At the 2018 event, Dr. Cleveland gave a talk entitled ‘Nature and Hospital Gardens: Strategies to Reduce Stress and Cultivate Good Health.’

He painted a picture of clinician burnout, using stark statistics, even before Covid19:

  • 82% of nurses at significant risk for workplace stress; 50% report being bullied; 30 to 70% report burnout.
  • “Physician burnout was at 54.4% in a 2014 national U.S. survey.
  • “Impacts of burnout to the healthcare system include quality of patient care, patient safety and satisfaction, and costly clinician turnover.”

Dr. Cleveland then made an evidence-based argument for contact with nature as a health promotion and preventive medicine strategy. The list of proven benefits is long, including reduced stress, depression and anxiety, and improved sleep, happiness, well-being, life satisfaction and social cohesion (Frumkin 2017).

Therapeutic Terrace Garden at Legacy Health

Minimum Dose of Nature for Stress Reduction

An Australian study Dr. Cleveland cited recommends 30 minutes or more per week of nature contact. This minimum weekly ‘dose’ decreased depression by 7%, and high blood pressure by 9%. (Shanahan 2015)

A single dose of viewing nature for 3 to 5 minutes has been shown to provide stress recovery by reducing blood pressure, muscle tension and heart rate (Ulrich 2002).

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That means if you spend 5 minutes viewing nature, and do that 6 days out of 7, you’ve reached the recommended minimum weekly dose of 30 minutes. Of course, more than half an hour per week can increase the benefits, and future studies may alter these minimum recommendations.

Reducing Workplace Stress with Garden Breaks

Workplace stress has shocking impacts on healthcare costs and number of deaths, not to mention job performance. A 2015 article from Stanford Business School suggests that looking at the environment and atmosphere of the workplace setting is critical.

Legacy Health is on the leading edge of supporting employee health. They’re providing a variety of programs, including garden access 24/7 (think night shift employees), as well as garden activities and events.

When I stepped out the door to the Terrace Garden, the first thing that caught my attention was a hummingbird. Later I noticed purple and red salvia blooms right next to the door: hummingbird magnets! 

Purple salvia attracts hummingbirds

Legacy’s Good Health Team, chaired by Dr. Cleveland, is making therapeutic gardens a "top priority for reducing staff stress and fatigue" and for encouraging staff to take regular breaks in the garden near their unit.

As part of this effort, the Good Health Team recently completed a ‘Recharge at Work’ study, which pointed to the essential role of supervisors in getting their staff to make a habit of taking breaks in the garden:

The idea, said Dr. Cleveland, is to draw employees outside, into the garden, helping them to create new habits. A key insight that he and his colleagues learned from their soon-to-be published Recharge @ Work study is that the support and urging of employees’ direct supervisors is essential in getting employees out and into the garden space. As a result, Legacy has made it a priority to target managers, educating them on the importance of the role they play in changing employee behavior.

Hospital Gardens: Measuring Clinical Outcomes

Roger Ulrich, a professor at the Center for Healthcare Architecture at Chalmers University (Gothenburg, Sweden), says “there have been few controlled trials measuring outcomes in hospital gardens.”

The Legacy team, along with Ulrich, are breaking new ground. Well, actually it’s a second-floor terrace garden where this ambitious research project is taking place. The project is funded in large part by the TKF Foundation through its Nature Sacred National Awards program.

The research aimed to describe the design process for the Terrace Garden (also known as A Nature Place) and to describe how the garden affects three different user groups.

Terrace Garden at Legacy Hospital

It’s no secret that an interdisciplinary garden design process is essential for creating a truly therapeutic garden for its intended user groups. Teresia Hazen emphasizes the Legacy gardens’ clinical focus:

I don’t say ‘healing gardens’—I call them ‘therapeutic gardens,’ because clinicians helped to design them and they’re intended to offer therapeutic benefit to all. Our mantra is ‘rehabilitation, recovery, and restoration.’ If they don’t serve as powerful clinical tools for patients, family, and staff, then our money was not well spent.

Legacy’s research project aims to:

  • “describe an evidence-based design process used to create a hospital garden intended to effectively reduce stress in different user groups,” and
  • describe how the garden affected three specific user groups: “(1) nurses working in high-stress units, (2) stressed family members of ICU patients, and (3) postpartum mothers and their partners.”
Rocking chair in A Nature Place

    A Daily Nature Break: Randomized Controlled Trial

    The nurses’ stress study randomly assigned nurses to take their 15-minute breaks in either the garden or an indoor break room for six weeks, then switched the groups over to the other location for a further six weeks. (Cordoza 2018)

    Results? “Taking a daily break in the garden reduced nurse burnout and immediately reduced feelings of anger and fatigue. The garden clearly out-performed quality interior break rooms,” where burnout "slightly worsened."

    The study concluded that “taking a break in a hospital-integrated garden could be part of a multi-modal approach to reduce burnout for nurses.” Wow!! Now that’s an actionable result!

    Therapeutic Terrace Garden overlooking Children's Garden

    The work that Teresia Hazen and Dr. Cleveland are doing at Legacy Health is inspirational and instructional.

    Their study on nurses’ stress indicates that if more hospitals use an interdisciplinary approach to designing and building therapeutic gardens, and if managers encourage their staff to take breaks in these gardens, the level of stress and burnout experienced by nurses (and perhaps other clinicians?) can be significantly eased.

    Imagine how that would improve patient care and healthcare costs!

    What part might you play in bringing this vision into solid reality? Share this article with healthcare clinicians and managers for starters. Use the share button after the reference section below. Share your thoughts and dreams with your colleagues and managers.

    And if you appreciate what you’ve just read, sign up to hear more from me about the many ways we can thrive with nature in our daily lives. This is my life's work and I'd be honoured to share it with you.

    Get my free nature self-care poster

    Remember to treat yourself to a break in nearby nature today. 😊

    In appreciation for his valuable work promoting employee health, I’ll give the last word to Dr. Minot Cleveland: “This restorative time spent in nature translates not only to better employee health — but to better patient care…. Really deep healing happens in these places.”

    Garden Activity Signs Logo

    To feel the restorative effect of the Terrace Garden yourself, and to hear Legacy Team members describe the project, enjoy this video at full screen: 'The Heart of the Hospital.'

    The Heart of the Hospital from TKF Foundation on Vimeo.


    American Nurses Association Health Risk Appraisal Findings, Executive Summary. (2016).  

    Cleveland, M. (2018, September). Nature and Hospital Gardens: Strategies to Reduce Stress and Cultivate Good Health. In T. Hazen (Organizer), Healing gardens: Promoting health and well being. Conference at Legacy Health, Portland, OR.

    Cordoza, M., Ulrich, R. S., Manulik, B. J., Gardiner, S. K., Fitzpatrick, P. S., Hazen, T. M., ... & Perkins, R. S. (2018). Impact of nurses taking daily work breaks in a hospital garden on burnout. American Journal of Critical Care27(6), 508-512.

    Frumkin, H., Bratman, G. N., Breslow, S. J., Cochran, B., Kahn, P. H., Lawler, J. J., Levin, P. S., Tandon, P. S., Varanasi, U., Wolf, K. L., … Wood, S. A. (2017). Nature Contact and Human Health: A Research Agenda. Environmental health perspectives125(7), 075001. doi:10.1289/EHP1663. 

    Goh, J.; Pfeffer, J. & Zenios, S.A. (Spring 2015). Workplace Stressors & Health Outcomes: Health Policy for the Workplace. Behavioral Science & Policy 1, no. 1: 43–52. 

    Nature Sacred. (2017, May). This Portland hospital system is using nature to help its employees combat stress. 

    Shanafelt TD, Hasan O, Dyrbye LN, et al. (2015). Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 90(12):1600-1613. 

    Shanahan, D.F.; Fuller, R.A.; Bush, R. et al. (2015). The health benefits of urban nature: how much do we need? Bioscience. 65(5): 476–485. 

    Ulrich, R.S. (2002). Health benefits of gardens in hospitals. 

    Ulrich, R.S.; Perkins, R.S. (2017). The impact of a hospital garden on pregnant women and their partners. Journal of Perinatal & Neonatal Nursing. 31(2): 186-187. 

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