There are growing calls for garden power to become a routine care option in every UK intensive care unit, for even the most critically ill patients. Critical care professionals looking after unprecedented numbers of patients for prolonged periods during the COVID pandemic are seeing clear therapeutic benefits.
The issue of incorporating greenery and garden visits into the most high-tech parts of hospitals has been put into the spotlight after 84-year-old explorer Robin Hanbury-Tenison survived COVID-19 after spending time in the ICU at Derriford Hospital in Plymouth.
Mr Hanbury-Tenison cited the moment he felt the air on his face and saw the flowers when wheeled into the ICU's 'Secret Garden' as "the big breakthrough" in his recovery, and is in the process of setting up a charity to ensure that every intensive care unit is equipped with a garden with power, heating and cover, where even ventilated patients can be taken safely as part of their treatment regime.
He told the BBC it was "extraordinary" having his bed wheeled out into the garden
Interest in bringing the garden into the ICU is increasing. The Royal Derby Hospital has set up a similar garden near its ICU, while a new critical care centre at King's College Hospital in south London is planning to include a roof garden for its patients.
Vice Dean of the Faculty of Intensive Care Medicine (FICM) Dr Daniele Bryden, who works as a consultant in intensive care at Sheffield Teaching Hospitals, considers that gardens are underused by the NHS to instigate recovery. She and her team promote the use of the outdoor hospital space as a valuable and inexpensive therapeutic boost.
She told Medscape UK: "For us the benefit of the garden is for the long-term patients as it gives them a sense of normality, to feel the natural environment and have a sense of having escaped from the four walls of a unit. It is such a help in weaning them away from ICU. Patients have come back and said how helpful it has been. The fresh air and the daylight has reminded them of all the things they are missing and acts as a spur to their recovery.
"Patients who survive ICU face a long battle back to health and many weeks in hospital, which can be overwhelming for some." she added. "The treatment for ICU patients is burdensome and it is difficult to see the end goal. There are very few normalising things that we can offer patients and taking them outside into a garden is just a way of saying, 'The outside world is still there for you' and it reminds them of all the activities they really value. It's a treat for them."
The FICM's guidelines for setting up ICUs recommend building in the potential for long-stay patients to spend periods outside, to support their recovery and rehabilitation needs, alongside consideration of natural lighting and potential noise levels.
Before the COVID crisis, average lengths of stays for patients in units like her own were around 5 days, but now many are there for weeks, often on a ventilator because of the complexity of the virus' action. The garden is most useful in Dr Bryden's view in supporting weaning, where patients are not fit enough to return to a normal hospital ward, but have come off sedation.
Kate Tantam, specialist sister in intensive care rehabilitation at Derriford Hospital in Plymouth, was in charge of Mr Hanbury-Tenison's care and also instigated the building of the 20-square-metre flower garden in a courtyard 60 metres from the ICU in 2018, which was completed with the help of colleagues.
She has seen many semi-conscious patients take a turn for the better after visits into the hospital car park - particularly those (like Mr Hanbury Tenison) suffering from delirium. The ICU rehab team she leads, has been recognised by the NHS Parliamentary Awards for their dedication to improving rehabilitation and recovery for survivors of critical illness.
Delirium - in which patients experience their 'worst nightmares' as reality - is a serious problem in ICUs. Inspired by a patient's story, Sister Tantam undertook an 18-month audit, which showed that 33% of ICU patients developed symptoms of PTSD (post-traumatic stress disorder) after being a patient in ICU.
She explained that the delirium was linked to the aggressive noise and light levels in ICU which disrupt patients’ circadian rhythms. Taking them outside helps to link them back into the daily cycle and makes them tired so that they begin to sleep better.
Her observations, and the anecdotal comments of patients, reinforce her belief that gardens are a powerful way of 'humanising' the hostile high-tech intensive care environment and reducing the impact of PTSD, by giving patients the will to live. She is clear that drugs cannot do that - they can only maintain life.
The difficulty lies in providing evidence. Qualitative evidence is abundant, but international researchers have struggled to acquire quantitative evidence to appease doubters.
A study published in 1984 in the journal Science by environmental psychologist Roger Ulrich used strict experimental controls to show that people recovering from gallbladder surgery at a suburban Pennsylvania hospital spent one day less in hospital, needed significantly less pain medication, and had fewer post-surgical negative experiences, if their windows looked out onto leafy trees rather than a brick wall.
Since then a body of research has sought to prove its benefits in a number of health-related areas, including dementia, stress reduction, and as a form of exercise to combat obesity.
The National Garden Scheme sponsors a number of hospital gardens, including the garden of a Marie Curie hospice, a Horatio's Garden for a spinal injuries unit, and a Maggie's Cancer Centre.
NGS chief executive George Plumptre comments: "The National Garden Scheme has been championing the health benefits of gardens for everyone since 2016 when we commissioned a report from the King's Fund, Gardens and Health. In the current crisis it is clear that the benefits offered by gardens have become even more important for people."
The King's Fund report gathers together the growing body of evidence linking gardens with health. A study in the Netherlands indicated that every 10% increase in exposure to green space led to health improvements the equivalent of being 5 years younger, with similar benefits reported by studies in Canada and Japan.
As an advocate of the greening of the ICU, Dr Bryden insists that the clinical risks of taking a patient outside are no greater than moving their treatment to another part of the hospital, with the requisite life support, and only with patient agreement.
Kate Tantam, however, thinks that it has value in easing people out of a coma, by connecting them with the aspects of life which give them an incentive to live, whether it is a beer in the garden or an Easter egg hunt with family. She told Medscape News UK: "Survival is only the start of the journey and you have to give them something to live for.
"Recovery is a symphony with the patient as the composer, and a conductor who can see all the parts of the melody. If you don't have someone who can see all the parts of the person which matter, then you don't get a good recovery."
She is running a fund-raising campaign herself to make her unit's garden suitable for all weathers.