S8 EP2: Katharina Nieberler-Walker, Biophilic Benefits

Katharina discusses her research into the ‘Healing Gardens’ of the Queensland Children’s Hospital in Brisbane identifing the benefits of access to nature on patient care. As a Director of the Australian Institute of Landscape Architects, Katharina's research provides a unique view to benefit all. 

If you'd like to learn more about the AHDC, please connect with us on our website www.aushdc.org.au or on LinkedIn at linkedin.com/company/aushdc.

Transcript

David Cummins: G'day, and welcome to the Australian Health Design Council podcast series Health Design on the go. Today I'm speaking to Katharina Nieberler-Walker regarding biofueling benefits in design. 

[00:00:28] This is a follow-up interview for discussing Katerina's PhD, which is soon about to finish.

[00:00:34] Welcome Katerina. Thank you for your time to be here.

[00:00:37] Katharina Nieberler-Walker: Hello David. I'm so happy to be here. 

[00:00:39] David Cummins: Very exciting times. I think it's after three and a half years. You're about to embark on finishing your PhD in the next few months, so that's very exciting. 

[00:00:49] Congratulations on reaching this milestone.

[00:00:51] Katharina Nieberler-Walker: Thank you. It's very exciting. We are so close. 

[00:00:54] David Cummins: It's very exciting. I must admit most people I speak to who do a PhD, they say they're doing an over five, seven plus years, you've managed to do it over three plus during covid. What was your biggest driving factor to pushing your PhD in such a short period of time?

[00:01:10] Katharina Nieberler-Walker: I think it's the university's more and more push PhDs to complete in a three-year timeframe, which looking back now is very challenging. 

[00:01:21] And it would be much better to actually have a little bit more time to think it through, because part of the PhD, it's not just producing stuff, it's the biggest, or the most important part is really thinking about what the research is about and how we could improve what we are doing. 

[00:01:40] David Cummins: Yeah, I must admit, even in the word of construction, people try to rush it and if you rush too much mistakes are made, well, not all the time, but can be made. So I totally agree with more planning, more thinking time for anything or for any problem.

[00:01:52] For those of you that might not have finished or listen to your first podcast, do you mind just telling people what your PhD is on and what it's about? 

[00:02:01] Katharina Nieberler-Walker: So my PhD is on the topic of therapeutic hospital gardens and I am establishing a global therapeutic hospital garden framework that serves designers to design better therapeutic hospital gardens 

[00:02:15] Decision makers to make better decisions about therapeutic hospital gardens and serves clinical specialists to introduce therapeutic hospital gardens in their professional practice to deliver better healthcare. 

[00:02:29] So my research and my manuscript really argues that the lived experience of global experts in healthcare design, healthcare governance and healthcare delivery can be channelised to establish the first global therapeutic hospital garden framework that can support designers, decision makers, and clinical specialists.

[00:02:53] David Cummins: That's amazing. And I know we talked about it in your first interview about, of course it makes sense that therapeutic garden and biophilic benefit improves patient care. But there was this huge shift from the seventies, probably onwards, where land equaled money and people just got rid of land to try and make more profit, to try and improve patient care, inverted commas by having more buildings and more space.

[00:03:16] So what has the shift been now, especially in the last few years, where people are starting to understand the benefit of therapeutic gardens, with the benefit of patients, especially long-term patients. And what has your research shown in reference to the change in how developers and operators think about space for this type of benefit?

[00:03:37] Katharina Nieberler-Walker: Well, I mean, the world is becoming more urbanised, more people live in cities now. I can't quite remember the figures but it is significant and this has shown to disconnect us from nature or being in nature, which has been found to be beneficial or to be really important to our health and wellbeing.

[00:04:01] And it wasn't until Ulrich established in 1984, that connection between nature and health and proved that a view of trees can have health outcomes. And it was only until then, until we had that proven evidence that it really took off to look seriously at connecting nature into hospitals.

[00:04:26] Based on evidence-based design, so we can actually have more consistent health outcomes. 

[00:04:31] David Cummins: And when you talk about there was connection between patient outcomes and visibility over nature or trees, what have those outcomes been from a clinical point of view or from a patient outcome point of view? 

[00:04:44] Katharina Nieberler-Walker: Look, there is actually quite a lot of evidence in particular, in the health-nature context. Franklin has done lots of research and compiled it into papers, so that's accessible. What I found so in my research is that there is a real lack of evidence. 

[00:05:03] How to actually go from the evidence saying, for example, that nature is good for our mental health.

[00:05:08] We need to have access to nature, to feel to improve our mental health. But how do we do it? How do we go from that knowledge to actually designing that into hospitals? 

[00:05:21] And this is why my research really focuses on the processes and the evidence. A common understanding of what therapeutic hospital gardens are and what sort of evidence we need and what sort of processes we can apply to actually achieve health outcomes consistently.

[00:05:42] And I think this is what my research is about, to make it more credible and make the design more consistent so we can actually predict health outcomes 

[00:05:53] In saying all this, therapeutic Hospital Garden is still in its infancy and we have to recognise this, that we are slowly increasing therapeutic hospital garden knowledge.

[00:06:06] And while I'm saying this is because in my research, what I've found is that therapeutic hospital gardens were not defined. 

[00:06:15] Therapeutic hospital, gardens meant many things to different people. So what I did after I did my literature review, I defined therapeutic hospital gardens as a foundational step for credible research and design. 

[00:06:30] And this also led me to my research really investigating what's happening in practice.

[00:06:37] Because what I also found is that practice is at a higher level than what evidence currently shows in the literature. So we need to bring the literature up to the level of what we are already doing in practice to inform both evidence and practice. 

[00:06:55] David Cummins: Yeah. 

[00:06:55] As a physiotherapist, we were always taught what does a research show, and I do find that this world of health design, especially in this space is limited. 

[00:07:03] But again, it's a great opportunity to pretty much pave the way. It was one of my questions to ask, what is the definition of a therapeutic garden and does it have a spatial parameter as a definition? 

[00:07:17] Katharina Nieberler-Walker: Well, look, the premise of therapeutic hospital gardens is that they have to be purposefully designed.

[00:07:23] That means they have to be designed for the needs of the users. And these needs can be many, they can be emotional needs, physical needs and mental needs. And then they have to be well integrated into the hospital planning and into the hospital program. Meaning, has to be outdoor spaces have to be adjacent to indoor spaces.

[00:07:43] For examples, they have to be obvious to users, so everybody can find them easily, they have to be safe and so forth. 

[00:07:51] So this is the basic premise of what therapeutic hospital gardens are, but the definition also alludes to the three dimensions of therapeutic hospital gardens and these dimensions.

[00:08:03] There's the health dimensions to therapeutic hospital gardens. There is a spatial dimension. We need to have actually space in the hospital and in the clinical program to include therapeutic hospital gardens, and that is the cultural dimension and that is really important. 

[00:08:19] So there is no prescriptive description for therapeutic hospital gardens because they're different in different parts of the world in a different geographical context and climatic context.

[00:08:32] I also have to say that my research is sort of focused on westernised, healthcare systems and hospitals. So I'm not talking about hospital systems in urban areas, that is also a qualification of what I'm doing. 

[00:08:47] David Cummins: So on that definition, would I be correct in saying not all therapeutic gardens have to be outside and there is opportunity for therapeutic gardens internally as well?

[00:08:59] Katharina Nieberler-Walker: Absolutely. 

[00:09:00] And I think that would be another extension of the research I'm doing because I'm currently looking at external area. But absolutely there is great potential to actually include that, to extend that into inside the hospital itself. 

[00:09:14] And there have been many studies on even very small gardens in a glass being useful for people to actually make them feel better.

[00:09:24] But I'm sort of at the moment concentrating on the bigger picture and how we can include that into hospital program and hospital planning. 

[00:09:32] David Cummins: So what a lot of people might think of when they hear this, absolutely love it. Sounds phenomenal. Sign me up. And then we'll ask the architects for a design.

[00:09:39] And generally speaking, the architects will be super excited about the potential to design a therapy garden, internal or external for these benefits. 

[00:09:48] Then one of two things will happen. The the FM team will be come involved and they'll say, well, who's gonna maintain it? Or the finance people will become involved and they'll say, who's paying for it? Because we want more space and unless it can prove to me, it would reduces patient stays or reduce anxiety, we're not paying for it. 

[00:10:07] And unfortunately it does get VN'd out a lot. So knowing that they're pretty much the two main barriers, did your research go into that?

[00:10:14] Like, I want an argument to tell the world and say... Hey, use these lines and we'll be okay.

[00:10:19] Look. What I did in my research, because of the lack of evidence in the literature, I've actually asked thirty-six global experts around the world, how they managed to establish therapeutic hospital gardens.

[00:10:31] Katharina Nieberler-Walker: And these experts are from three key sectors that make therapeutic hospital gardens happen. 

[00:10:38] So therefore, for designers, they're decision makers and there I've got clinical specialists. So designers include architects, landscape architects, health planners, a decision-maker includes hospital CEOs, government officials and consultants to government.

[00:10:56] And then the third group, clinical specialists includes healthcare delivery specialists, hospital environment specialists, and of course medical specialists, clinicians. 

[00:11:08] And I've asked these experts who are already establishing therapeutic hospital gardens how they managed to design them in a way so they actually are successful and impactful.

[00:11:21] And this is why my research will actually be the outputs of my research are in three areas addressing these three important sectors that make therapeutic hospital gardens happen.

[00:11:34] So I'm currently working on three papers. One paper is aimed at designers to design therapeutic hospital garden well, based on the insights of 12 global expert designers.

[00:11:50] So I'm actually using the expertise of designers, healthcare designers, they're already doing therapeutic hospital gardens to inform other designers who would like to design therapeutic hospital gardens well. 

[00:12:03] This is the first group, the second group decision makers, mainly hospital CEOs and government officials to give them the findings from my research.

[00:12:14] What other hospital CEOs and healthcare professional set, how they managed to include therapeutic hospital gardens in their hospitals to make them healthier. 

[00:12:26] And the same for the third group, using the expertise of these professional clinical specialists to inform you know people that design hospital environments, healthcare delivery specialists and medical specialists who want to increase therapeutic hospital gardens in their practice, how they can do that.

[00:12:47] And the findings, I'm currently writing up the results and the findings for all three groups and it is actually insightful what came out of it because only some of the results from the interviews are backed up in the literature other parts are completely silent. 

[00:13:08] For example the first finding was therapeutic hospital gardens included early in the hospital project are likely to be successful, is a finding that has implications for designers and decision makers, because it is early in the project, you need to include therapeutic hospital gardens in the feasibility studies and in the planning and in particular in the master planning to actually enable these hospital gardens to happen because if they're not included earlier, you can appreciate if it's not in the clinical program, it's very tricky to retrofit that.

[00:13:46] So and that is also important for hospital CEOs, for example, to say, look, if we want to include them, we need to think about them early and include them in, for example, in the area schedule or in feasibility studies. 

[00:14:01] But what's really interesting about this is the lens I'm looking at hospital developments because I'm looking at the lens of the field of health promotion.

[00:14:12] So I'm using salutogenesis as a theory. Which is the origin of health, it's a theory about the origin of health, and how we can use that to actually improve health and wellbeing in hospitals. 

[00:14:28] David Cummins: Yeah, it's very, very interesting and like everything, if it's planned properly, it should get up. 

[00:14:32] And just like with sustainability, if people don't prioritise it and those decision-makers aren't part of that business case, then unfortunately it does fall off the wayside, which is unfortunate. So what countries are dominating in this space? 

[00:14:46] Who are world leaders in this world?

[00:14:47] Katharina Nieberler-Walker: Scandinavia is still leading in lots of ways, in particular in the healing garden theories and Lycan for example, has established a model for evidence-based design, which I find really very interesting, which I think we can use to establish a process for therapeutic hospital gardens because my framework is really a six-step plan, how therapeutic hospital gardens can be established. 

[00:15:15] So this is my ultimate output of my research, is actually to have a plan in six simple steps, how therapeutic hospital gardens can be done. 

[00:15:26] David Cummins: Yeah. Fantastic. 

[00:15:27] And I know we're finishing up soon, but for decision makers who are planning now and for designers that are talking about new projects now, what are some of the things that we can do to try and increase the opportunity for having therapeutic gardens in our hospitals or in our healthcare system?

[00:15:45] And my follow up question was, what are the opportunities for this to be legislation through the Australian Health Facility guidelines or through BCA or how can we actually make it a stronger need to make sure that we do achieve these goals. 

[00:15:58] Katharina Nieberler-Walker: Well, this is a very interesting question and what I would like to say is quite often it is difficult if a hospital, CEO would like to include therapeutic hospital gardens.

[00:16:11] They don't have the evidence on their fingertips to say oh, we know if we do this, then this will happen and we can use therapeutic hospital gardens to improve health and wellbeing, and this is the evidence that supports that. 

[00:16:25] So this is what one of my papers will do to actually provide five strategies for decision that will help them appreciate the benefits of their beauty hospital gardens for patient outcomes and generally improving the well-being in hospitals.

[00:16:43] So it is really important to, and while evidence-based design is used a lot in practice, it is really important to make sure it's quality evidence the design is based on, and also the process of evidence-based design is not commonly understood. 

[00:17:02] And while I'm saying this, I'm referring mainly to stakeholder engagement for example, the issue of co-design and how is co-design actually conducted, what does it mean, and how do you include stakeholder engagement in your design?

[00:17:20] How is the framework to make sure that you can include the knowledge these experts or stakeholders give you? 

[00:17:30] But you also manage expectations at the same time to make sure everybody knows their role and responsibilities of many within that stakeholder engagement and the design process for therapeutic hospital gardens.

[00:17:44] So this is important and while you ask me about legislation, I think we are still very early in the process and we need to first develop more evidence and processes and have a common understanding within the healthcare design industry, how these things are done. 

[00:18:03] So then we can look towards, changing the structural framework. I'm not saying it shouldn't be prescriptive because it's like design, you can't be prescriptive about design. 

[00:18:15] It is really, you need the skill and the expertise of design professionals to translate the analysis of the data you get from stakeholders for examples or from evidence, and synthesise that into a successful and impactful design. 

[00:18:33] This is isn't a tick-the-box thing, this is really about using all the elements we have available to us, which includes designer expertise of designers that the skill and expertise of designers, but also the evidence we know from research and putting all this together.

[00:18:52] Including stakeholder consultation with good communication skills to actually make these things happen. 

[00:18:59] David Cummins: Yeah. It's a big road ahead, but I think things like this and more education and more people who understand the research the easier will become. 

[00:19:08] I know we are out of time, but I just had one important question.

[00:19:12] Infection control, did that come up in your research at all because a lot of people say you can't have indoor plants, can't have indoor trees because of infection control. because aspergillus and immunosuppress patients will get sick. 

[00:19:25] And I understand that argument, I definitely do, but how do we find that balance of the benefit for multiple patients and the disadvantage for some patients?

[00:19:34] How do we resolve that topic? 

[00:19:36] Katharina Nieberler-Walker: I think this is where the stakeholder consultation is really critical because it is absolutely important to listen to the experts in this field and I'm not an expert in that field. 

[00:19:48] You know what they have to say, but we also need to back it up with real evidence in the literature.

[00:19:54] And when I actually looked at it, it's very thin on the ground, the real evidence. There's a lot of opinion and we have to really distinguish about an opinion on something compared to evidence. 

[00:20:09] And that needs to be established as well. It needs to be right when we talk about that.

[00:20:14] But absolutely, the safety of patients is always the number one and needs to be considered and assessed every time such a garden is designed and established. 

[00:20:25] David Cummins: Yeah, well done. Thank you so much for your time and congratulations on near completion of your paper, we all look forward to reading it.

[00:20:32] I find you absolutely fascinating. 

[00:20:34] Every time we catch up, I could just talk to you for hours and I just think this is such a literally world first. I was certainly Australia first with this research to really have the opportunity to really push this research into better clinical outcomes through access to nature.

[00:20:48] I just think it's fantastic. So congratulations on your research. Congratulations on almost finishing your PhD. 

[00:20:53] You're a big supporter of the AHDC as us to you, so good luck for the future and I look forward to catching up with you soon. 

[00:21:00] Katharina Nieberler-Walker: Thanks, David. It's been absolute pleasure. 

[00:21:03] David Cummins: You have been listening to the Australian Health Design Council podcast series, Health Design on the Go.

[00:21:09] To learn more about the AHDC, please connect with us on our LinkedIn or website. 

[00:21:13] Thank you for listening.