Recommendations for Implementing Therapeutic Gardens to Enhance Human Well-Being

Abstract

Using nature to address socio-environmental challenges has emerged as a promising alternative to improve human well-being. Therapeutic gardens are landscaped outdoor spaces in health institutions, squares, and schools developed to improve the well-being of their users. However, there are information gaps on how to implement them. This study aims to systematize information about therapeutic gardens and use it to develop recommendations for implementing these spaces. We conducted a systematic review, which included 27 studies that contained the words therapeutic gardens, design, and/or implementation. The results indicated that the topic does not have a constant number of publications. Most articles are case studies in Europe (n = 8) and published in journals about environmental and health issues (n = 25). Furthermore, most studies (n = 23) relate the implementation of therapeutic gardens to health institutions. A framework with seven stages of recommendations was developed to guide the implementation and monitoring of these gardens in different spaces. This study is expected to contribute to the development of therapeutic gardens with an interdisciplinary team, promote SDG 3 (good health and well-being), and, mainly, improve the well-being of users.

1. Introduction

Human activities are degrading ecosystems worldwide, posing existential threats to biodiversity and humanity. Data from the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) indicate that 3.2 million people have their well-being negatively affected by land degradation [1]. Furthermore, there is growing concern about how the current unsustainable use of natural resources will compromise human well-being [2]. This scenario highlights how restoration, conservation, and management strategies for ecosystems for different objectives are essential for maintaining human life on this planet since nature positively impacts human health and well-being [3,4].

Nature-based rehabilitation is an approach that indicates the influence of nature on the rehabilitation of people with various health problems, whether physical or mental [5,6]. Interest in the health benefits of nature dates back to the Roman and pre-Columbia times when plants, springs, and mineral baths were used clinically to promote healing and well-being [7,8,9,10]. During the 20th century, the development, implementation, and management of ecosystems, creating gardens of nature-based healing and therapy, have gained greater prominence [11].

There is a rapidly growing body of research examining the relationship between green space and physical and mental well-being [5,12,13,14]. Green space is defined as an area of grass, trees, or other vegetation set apart for recreational or aesthetic purposes in an urban environment [15]. Green space has been associated with health-promoting benefits for adults and children, including improved mood and self-esteem, a buffer for daily stress, greater self-discipline, lower levels of depression, anxiety, and stress, improved mental and social health, increased physical activity, and reductions in violence [14]. The literature suggests that developing access to nature can be an important investment in the health and well-being of communities [16,17,18,19].

According to the Oxford English Dictionary, “gardens” are land where plants, flowers, vegetables, fruits, or herbs are grown [20]. The word “therapeutic” is defined by the Merriam-Webster Dictionary as a process that has beneficial effects on the body or mind [21]. In the Aurélio Dictionary, it is a part of medicine that studies and puts into practice the appropriate processes to alleviate or cure patients [22]. Thus, therapeutic gardens can be understood as spaces in which the process/procedures of alleviating and treating physical and mental illnesses can occur through contact with vegetation that grows and is cultivated. The presence of vegetation and gardens can directly influence human well-being, generating several benefits and cobenefits for society and consequently for ecosystems [19]. In Japan, studies have been conducted to investigate the effects of Shinrin-yoku/forest bathing on human health [23]. Several benefits have been reported, such as a reduction in blood pressure and heart rate, showing a preventive effect on hypertension and heart disease; reduction of stress hormones such as adrenaline and cortisol; and increases in the number of NK cells and intracellular levels of anticancer proteins, suggesting a preventive effect on cancers [24]. The difference between Shinrin-yoku and therapeutic gardens is that the second is designed for a specific group of actors, with an intentional design, while the first is not. However, both can be used in rehabilitation medicine [14,25,26].

The terms healing garden and therapeutic garden have been used interchangeably in studies, but they are different. Generally, the healing garden describes a space designed in healthcare institutions to cure a patient with some comorbidity/disease [12]. In contrast, therapeutic gardens are landscaped outdoor spaces in healthcare institutions, squares, and schools, among others, that meet the needs of patients and/or users of these spaces for their psychological well-being [27,28].

This research will address the concept of therapeutic gardens as it relates to a larger group of actors and spaces and incorporate a process of improving physical and mental well-being. Using these gardens then emerges as a treatment option, as a complementary therapy for people and patient in different situations [6,29,30]. These spaces must be integrated into hospital programs and health policies, as the benefit of nature on human health and well-being is known [31].

The implementation of therapeutic gardens is in line with the 2030 Agenda and specifically with SDG 3 “ensuring healthy lives and promoting well-being at all ages is essential for sustainable development”. Gardens can perform multiple functions that become solutions to everyday problems [25,27,32]. Understanding these gardens’ functions is important to expand their use and solve problems. However, despite the many benefits of therapeutic gardens highlighted in the literature on the subject, there is little systematic guidance on the project design phase, implementation of these gardens, and monitoring [27,29,30,33,34,35]. To fill to these gaps in knowledge, this work aims to systematize information about therapeutic gardens and use it as a basis for developing guidelines for implementing these spaces in health institutions, schools, and squares.

2. Materials and Methods

The research was divided into three stages:

Stage 1—A systematic review of the literature was carried out using the Web of Science, Scopus, and Scielo databases, seeking to access articles with no defined date. The following word combinations were used in the advanced search engine: ALL = (therapeutic gardens AND design AND implementation). A total of ten articles were found in Web of Science, six in Scopus, and eight in Scielo; duplicates were removed. All articles were analyzed by their titles, keywords, and abstracts to check their suitability for the topic. In addition, we have read references from these articles (snowball method) aiming to access a higher number of studies [36]. Eligible studies must contain the words therapeutic gardens, design, and/or implementation.

In the end, the total data comprised 27 studies. The bibliographical survey contributed to the construction of the conceptual and theoretical basis of the work.

Stage 2—The second stage of the research consisted of analyzing and systematizing the data collected in the literature review. This data were organized, highlighting the year of publication, journal, keywords, type of study, objective of the study, location of the study, definition/characterization of therapeutic gardens, benefits, implementation/design, and mention of the SDGs. This information is available in Supplementary Material S1.

Step 3—Based on data collected from the articles, information on the implementation and design of therapeutic gardens was analyzed. The step-by-step implementation was systematized into a structure to guide the process from garden design to monitoring. This framework was developed through discussions by the authors, who considered the main concepts associated with therapeutic gardens and developed guidelines on how to implement them.

3. Results and Discussion

3.1. Characterization of Published Studies on Therapeutic Gardens and Design/Implementation

The 27 studies evaluated were published from 2007 to 2023 (Figure 1). The topic does not have a constant number of publications, requiring greater engagement from researchers involved in it. Most articles (n = 25) are published in journals related to environmental and health issues. Considering the entire database, the main themes related to the articles are gardens, dementia, evidence-based design, and healing gardens (Figure 2).

Fourteen articles were case studies, while the other thirteen were reviews. Most studies are in Europe (n = 10) with the Nordic countries having the largest number (n = 7). Meanwhile, no studies on the continents of Africa and Oceania have been presented (Figure 3).

Only six studies used therapeutic gardens as their main concept. In other studies, therapeutic gardens were mentioned and associated with other concepts, such as healing gardens, health gardens, rehabilitation gardens, sensory gardens, sensory stimulation therapeutic gardens, nature-based rehabilitation, horticultural therapy, and therapeutic horticulture. Most studies (n = 22) are related to health institutions, understood here as hospitals, rehabilitation clinics, and nursing homes [37]. Considering the publications from 2015, the year of the 2030 Agenda’s publication, no article has referenced the SDGs to date, representing a large gap in the topic (Supplementary Material S1).

3.2. Experiences on the Implementation of Therapeutic Gardens in Healthcare Institutions

Healthcare institutions are organizations whose primary purpose is patient care or treatment or public health promotion, including hospitals and nursing homes [37]. According to the objective of the studies accessed, the majority (n = 23) relate the implementation of therapeutic gardens to health institutions. Reports in the literature indicate that green spaces in healthcare institutions are widely encouraged, not only as an alternative to allopathic care, but as a vital addition to modern medicine [38]. Although Pouya et al., 2017 state that health is the primary goal of allopathic medicine [39] we should highlight that this medicine focuses on the immediate relief of symptoms related to the disease and not on the root of the problem. In addition, the medications can cause negative effects on other parts of the body. Therefore, we believe that therapeutic gardens used as a complement to allopathic medicine can help the actors who use them to improve their well-being and physical and mental health.

Incorporating gardens into hospital settings has become a growing trend with the goal of positively impacting the individuals who visit them [40]. Gardens can facilitate a connection with nature and create a sense of restoration among visitors, alleviating the negative emotions often related to the hospital environment [41].

Well-designed hospital gardens not only provide calming and pleasant views of nature but can also reduce stress and improve clinical outcomes through other mechanisms, such as promoting access to social support and privacy and providing opportunities to escape stressful clinical environments [40]. In addition to relieving stress and improving mood, gardens and nature in hospitals can significantly increase healthcare worker satisfaction and overall quality of care [39]. Previous studies have shown that in hospitals with different categories of patients (adults, children, and elderly patients; outpatient settings or intensive care wards), the presence of nature—indoor and outdoor gardens, plants, views of nature from windows—increases patient and family satisfaction [39,40,41].

According to Berg et al. (2021), after the “greening” of hospitals, the gardened wards gain several positive adjectives from patients to characterize their feelings, such as “happier area”, “more natural”, “more relaxing”, “more special”, “more colorful environment”, “cozy”. The place became more positive, with less stress. Some negative comments also occur, such as: “the place will now have to maintain the plants”, “it needs maintenance, generating more work in the hospital”, and “the place will have visitors from other areas to stay in the garden, which will be more crowded, busier and relatively dark because of the plants” [25]; some do not have good accessibility, as the design does not include accessible routes and experiences for all types of users, such as wheelchair users, people with canes, blind people, and people with disabilities [42].

Healthcare staff can make intensive use of gardens to positively escape the pressures of the workplace and to recover from stress. In addition, evidence has begun to appear showing that gardens increase staff satisfaction with the workplace and may assist hospital administrators in hiring and retaining qualified staff [41]. For hospital staff, therapeutic gardens can serve as a place of relaxation and an escape from the stress of their work [40,41]. Garden users pointed to regaining control and reducing stress as the main reasons for garden use [43].

Studies among the elderly have shown that access to a garden can improve cognitive functioning and alleviate agitation, wandering, aggressive behavior, and stress levels in patients with Alzheimer’s disease and other forms of dementia [25]. It is realized that “greening” hospital areas in geriatric healthcare facilities is a low-cost solution to improve the physical environment and reduce the functional decline of patients and their staff, making this place more enjoyable for everyone, given the global trends of an aging population and the growing demand of the elderly for healthcare services [25].

According to the World Health Organization (WHO) “Healthy Aging is the process of developing and maintaining functional capacity that enables well-being in old age”. Healthy aging, therefore, represents the continuous interaction between people and their environment. The beneficial effects of outdoor activities on people with dementia have also been documented in studies. Hiking in nature has been found to have benefits for people diagnosed with mental disorders [12].

Children can also benefit from therapeutic gardens. Hospital facilities that can support the well-being of sick children and their families by providing an environment outside the pediatric ward can be beneficial for health outcomes [44,45]. There is a positive association between access to green spaces and children’s mental well-being, general health, and cognitive development. Access to gardens promotes restoration of attention, memory, competence, supportive social groups, and self-discipline, moderates stress, and improves behaviors and symptoms of attention deficit hyperactivity disorder (ADHD) [14]. Children’s experiences in green spaces have been decreasing, a situation described as a nature deficit. Children have been living more and more indoors, using television, computers, and cell phone screens, which can increase problems related to emotional, physical, and social health [46].

Interviews carried out at a hospital in San Diego revealed that most people did not even know the garden existed, which leads us to believe that these spaces may be poorly promoted [41]. Integration of the use of gardens into patient therapy programs is necessary. Furthermore, few post-occupancy garden evaluations do not allow for essential reflection on design practices that generate gardens with maximum benefits for their patients, families, and healthcare facility staff [47]. Decision-makers need empirical evidence of the benefits of therapeutic gardens to justify expenses, as well as to help designers understand which features are most valuable to users of these spaces [47]. A dialogue with the target audience must also be encouraged to design a space that meets the needs of all users.

3.3. Development of Recommendations for the Implementation and Design of Therapeutic Gardens

Gathering the recommendations for implementation of therapeutic gardens in the literature and considering the experience of the authors in functional landscaping and garden implementation, the guiding framework (Figure 4) was developed to guide each necessary step from implementation to monitoring of the gardens. Among the stakeholders that can make use of this framework are architects, landscape designers, and health institution managers.

3.3.1. Stage 1: Identification and Analysis of the Target Audience

The first step to be considered is for stakeholders to identify the target audience of the garden and their demands, characteristics, limitations, and needs. Therapeutic gardens are built according to the characteristics of each public to provide a therapeutic aid directed to their needs. At this stage, the goals and activities of the garden should also be established, so that it is designed with form, design, furniture, etc. suitable for its purpose [48,49,50]. At this stage, the following questions are expected to be answered: (I) Who will be the main visitors? (II) What are the demands and needs of the target audience? (III) What are the busiest times? (IV) What are the objectives intended with the creation of the garden? (V) What activities are expected? (VI) What level of activity is expected? (VII) What areas are available for intervention?

The target audience and the goals of the garden will directly influence the level of involvement of these users with the designed space. A study found that there are five types of involvement that a user can have with the garden. The first level is “introspective involvement”, characterized by a shallower contact, where there is very limited mental capacity. At this level, the user is characterized by a need to be with themself, seeking quieter spaces without much interaction. The second level was called “contemplative participation”, because the user remains in a contemplative state, without being able to participate or become emotionally involved. He/she only contemplates, with enchantment or admiration. The third level was classified as “cognitive and emotional intelligence involvement”, where intuition is developed through a more sensorial communication with the world, increasing the individuals’ capacity for personal and social development. The fourth level corresponds to “active participation”, where mental capacity is more developed. At this level, the user has the capacity for social interaction, being able to integrate with other users of the space. The fifth level is classified as “extrovert involvement”, characterized by the user’s high mental capacity, where there is leadership and proactivity in the activities performed in the garden. At this level the user can organize activities in this space [51].

The age group is a central factor in directing the design and activities that will be adopted in the garden (Figure 5). If children are the public, the garden has to promote playfulness, be dynamic, be interactive, and stimulate curiosity. However, if the target audience is made up of adults, the garden has to be aesthetically attractive, awaken the senses, be cozy, and promote tranquility. In addition, if the target audience is elderly, the garden has to be comfortable, promote socialization, allow occupational therapy, and stimulate the senses. If the target audience is multiple groups, common aspects for the three age groups (green box) must be considered, such as security, accessibility, and sensory stimulus and (if possible) in addition to spaces for all age groups, there should be little spaces for each group’s demands.

3.3.2. Stage 2: Analysis of Space and Context

The second step consists in the analysis of the space and context (Figure 4). In this step the available space for the garden construction and its characteristics such as: prevailing temperature/climate, wind circulation, natural lighting, endemic species, soil type, and details of the available environment should be analyzed [49,50,52]. At this stage, some guiding questions must be answered: (I) What are the predominant climate and microclimate at the site? (II) What is the rainfall like at the site? (III) What is the soil type? (IV) In which biome is this area found and what are its characteristics? (V) Which species are endemic to this location? (VI) Which exotic species adapt well to this location? (VII) What are the limitations and potentialities of this site for the implementation of a therapeutic garden?

3.3.3. Stages 3, 4, and 5: Elaboration of the Preliminary Design, Basic Project, and Executive Project

Steps 3, 4, and 5 are project development steps. This elaboration begins with the preliminary project, which is adjusted to become the basic project. The basic project undergoes final adjustments according to the demands of the client(s) and from these adjustments the executive project is elaborated.

Table 1. Steps to elaborate the Therapeutic Gardens project.

Steps of the Project	Description
1st Step: Pre-project	It consists in the presentation of the initial solution of the landscape project containing the necessary drawings for the perfect understanding of the solutions adopted. A study will be carried out by means of schematic drawings in plans, aiming at the best use of the land.
2nd Step: Basic Project	It consists of the presentation of the changes that will be introduced in the preliminary project. In the Basic Design stage up to three studies will be developed to achieve the client’s objectives.
3rd Step: Execution Project	It consists of the presentation of the formulated project proposal on the plants, including any modifications that may be necessary in the Basic Project, with a level of detailing that allows for the perfect execution of the project. Delivery of a botanical plan, containing specification, size, quantity of the plants and materials chosen.

below summarizes the characteristics of each of these project stages [48,50].

In all these stages of project development, the design of the gardens must be considered. Thinking about the design of therapeutic gardens is fundamental, as it is the design that will determine the form and functionality of these environments.

The potential activities in a therapeutic garden range from passive (walking, sitting, resting, reading, etc.) to active (occupational therapy, physical therapy, herb and fruit picking, pruning plants, play, etc.) [52]. In addition, the activities have different levels of interaction, which vary according to the time spent in these spaces and also the amount of senses stimulated. To begin to build a set of design guidelines for the outdoor space of a hospital, one can take as a reference the Supportive Garden Design Theory [53]. The author proposes four design guidelines for the realization of therapeutic gardens: exercise, sense of control, social support, access to nature, and other positive distractions. The author suggests the need to consider that for the garden to be used and reach its full potential, it must possess the following qualities: visibility, accessibility, familiarity, tranquility, comfort, and unambiguous artistry.

In the literature on the subject, there are different recommendations on the design of therapeutic gardens, which should be considered in these three stages of project development. Some design features such as choice of species that stimulate the senses, wooded areas, natural light, water and sounds, street layout, appropriate building forms with accessibility, signage and orientation that generate safety, among others, are points appreciated by users [12]. On the other hand, it is also important to highlight criticisms that arise regarding these projects, such as the use of exotic species or intensive gardening techniques, justified by the possibility of harm to local ecosystems. Recently, a study examined evidence-based design of healing gardens [12]. The study showed that the design of healing gardens should be tailored to the needs of each type of patient. The literature review also reported a limited number of evidence-based design strategies and post-occupancy evaluations for healing gardens in hospitals.

Table 2. Recommended features and forms to guide the design of Therapeutic Gardens.

Functionalities	Mechanisms/Forms
Awakening the senses	Mix native plants, ornamental, aromatic, and medicinal herbs; the sound of running water; birdsong, flowers with pleasant scents that attract birdlife and butterflies; colors that awaken the eye; textures that can be felt with the hands; flavors to be appreciated.
Cozy/comfort	Create spaces and sub-spaces with green walls within the garden itself, with different privacy dynamics; create niches that offer opportunities to stay for just one or two people, creating an intimate and cozy atmosphere; rest and meditation areas; parts with protection from the sun ans wind.
Interactivity	Create recreation areas; areas for group activities; areas for parties.
Accessibility	Implement use of color coding to improve orientation; various degrees of light and shade, access facilitation for users with and without disabilities; well-defined paths with possibilities for different walking levels; wide streets and non-slip floors accessible to wheelchair users and other people with motor limitations; signage.
Beauty	Provide color mixing; think about different views into the garden (coming from inside or outside the buildings); plant diversity.
Safety	Create well-defined and identified boundaries with plants and fences; handrails along the paths; textured materials as paving in therapeutic gardens, consisting of gravel, mulch, bark, pebbles, or even rubber, textured concrete with a brush, and synthetic grass; safe walking trails; stable surface for walking; night lighting; slip-resistant flooring.
Tranquility	Provide quieter, more intimate spaces.

summarizes the general functionalities that therapeutic gardens need to have and the mechanisms and ways that can activate them [12,28,39].

To promote these and other different functionalities, the furniture that will compose the gardens is fundamental.

Table 3. Types of furniture, decorative structures, and their functions in the therapeutic gardens.

Furniture and Decorative Structures	How Can It Be Used?
Easy-to-move benches, chairs, or loungers	It serves as a decoration and resting place and can be used in different arrangements (if they are furniture).
Bird feeders and nests	Attract birdlife.
Fences	Delimitation of spaces.
Source of water	Decoration and sensorial stimulation.
Sporadic raised beds with flowers to be touched	Sensory stimulation for wheelchair users (flowers would be at an ideal height so they could be touched).
Pergolas	For shading and resting, when used with the planting of flowering and fragrant climbers.
Gazebo	For resting and an intimate place for reading or being with oneself in moments of reflection.
Sculptures	They evoke past or recent memories. They sharpen cultural memories and promote surprise elements in the garden.
Walls	Protection, limitation of spaces. Ideal with living fences with plants that form hedges to cover the entire wall.
Mosaics	To awaken curiosity, attention, and positive distraction through stimulating formatting, colors, and designs.

shows some elements considered essential in therapeutic gardens [39,54].

Besides functionality and furniture, other elements should be considered for the design and implementation of therapeutic gardens [55], some of them are: comfortable seating protected from rain and sun, lawns, inspiring views, color, presence of water in the form of a stream or waterfall (can be appreciated by the senses of sight and hearing), safe places for walking, accessibility and mobility for wheelchair users and people with other needs, diversity of colors, diversity of textures, green walls, places for reading and relaxation, places for physical activities with safe and playful equipment. Figure 6 and Figure 7 illustrate some of these elements and design recommendations for therapeutic gardens. Therapeutic gardens can be more onerous than regular gardens. This fact may be a counterargument for implementing these spaces and is related to the possibility of higher implementation and maintenance costs with these elements, as well as limited space in urban areas, making the space unit more expensive.

It can be seen that several points must be taken into consideration when encouraging the use of these gardens, such as accessibility for users, aesthetic value, maintenance, planting, quality of the sensory equipment, safety, and location of the garden. The presence of a therapeutic sensory garden in hospitals, special schools, nursing homes, or in public spaces promotes sensory stimulation, physical mobility, social interaction, and behavioral changes. Positive developments are significant in sensory therapies [45].

3.3.4. Stage 6: Implementation of Therapeutic Gardens

The implementation of therapeutic gardens will be based on the executive project. This step requires care related to the choice of plant species that will compose the gardens. After all, vegetation is the basic structure of parks and gardens, and following the care and recommendations can avoid problems in their use and maintenance.

The choice of plants has functions that go beyond the aesthetics and functionality of the gardens, such as stimulating the senses of the people who frequent them. We can mention the stimulus of smell, with aromatic plants with their pleasant aromas that refer to lived experiences, and other plants that stand out for the stimulus of touch with different textures, the sense of sight that is stimulated by the aesthetic beauty of the design of the gardens, hearing that is stimulated by the ecosystem that was created there attracting local fauna such as birds, and finally taste with the flavor of the products grown in the space. There are some general recommendations for choosing plants, such as being non-poisonous/toxic and hypoallergenic, resistant to pests, multidimensional use (culinary, decoration, etc.), flowering at alternate times of the year, different colors and shapes, different textures, easy propagation and growth, tree species with large canopies to generate shade, and low maintenance costs [28]. Therapeutic gardens focus on these aspects and are concerned with promoting well-being and stimulating different senses. They differentiate themselves from common urban gardens, where the objective is to practice growing plants and fruits [55].

Before planting, it is necessary to check and test the waterproofing system to validate its perfect functioning, the drainage, and complementary installations to avoid future problems and movement of the garden after it is finished. The drainage and irrigation systems must follow the recommended techniques for each garden project to guarantee hydration and survival of the species chosen for planting.

As much as possible, the garden design should be ecologically sustainable by using recycled materials, taking advantage of green infrastructure for stormwater management, and choosing plants that require low maintenance. If the therapeutic gardens are on a rooftop, it is recommended that elements of universal design such as elevators be included to ensure accessibility for all users. This phase of implementing therapeutic gardens can be considered as a therapy for the professionals and actors involved in the process, as the choice of plants and furniture also works on the senses and creativity.

3.3.5. Stage 7: Monitoring of Therapeutic Gardens

Monitoring and management are fundamental steps, because without them, the entire therapeutic garden, no matter how excellent it may be, can be compromised and generate problems for patients. Therefore, it is necessary to think about monitoring from the initial stages of the project and the responsible institution should prepare financially to carry out the maintenance with the frequency recommended by those responsible for the project [34]. In addition, the institution can also prepare an engagement strategy so that users involved with the gardens can become collaborators, helping with monitoring. This practice can be considered part of the therapeutic project, as it stimulates the senses and cognitive development.

Besides the structural aspects of the gardens, when thinking about implementation, there are important issues to be monitored [55]:

How are therapeutic gardens perceived and evaluated by end users?

What other activities could be performed in these spaces?

Did the target audience have their needs and demands met in the garden?

Is there a need to rethink any structure, design element, furniture, or activity in the garden?

Other questions also addressed to patients and/or users should also be answered, questions of a more intimate nature to better understand people’s relationship with the gardens, such as: Tell me, why are you here? How are you feeling? What do you like? Tell me, what are you thinking? [55].

Berg et al., 2021 [25] also suggest some research themes, regarding the garden area, that should be evaluated by garden users:

Valuation of plants: respondents could be asked if they appreciated the plants, if they knew any kind of benefit from the plants or if they felt something different, trying to make a description of what they felt about the garden;

Employee evaluation of the green space: positive and negative changes after visiting the new green space;

Job satisfaction: more engagement and motivation at work or mental exhaustion remains the same;

Patient well-being: ranking the patient’s well-being before and after the greening of the area;

Background characteristics: respondents’ background, such as age, gender, occupation, hours of work and length of employment, and job satisfaction.

4. Conclusions

As a result of the literature review and the development of the framework with recommendations, the present study highlights that therapeutic gardens can improve the health conditions of end users. To this end, it is recommended that garden projects use these recommendations as a basis, including interdisciplinary teams made up of designers, health professionals, biologists, and architects, among others, in order to contemplate different aspects, such as the selection of plants that are not poisonous/toxic, trees that provide shade, species that can be used in cooking, among others. This dialogue between professionals from different areas can also contribute to better communication/dissemination of the benefits of therapeutic gardens to the general public since this knowledge poses a limitation to the topic of therapeutic gardens today.

The research underscores the diverse benefits that therapeutic gardens can offer their users, particularly in settings like hospital stress relief spaces, where they provide sensory stimulation for memory and creativity. These benefits are manifold and can contribute to the achievement of SDG 3 “good health and well-being”. Furthermore, the research also highlights a knowledge gap regarding therapeutic gardens in schools and squares, which is a limitation of the topic. We encourage researchers to develop studies focusing on these spaces so that the implementation of projects can be expanded.

In this context, the choice of elements that will make up the garden, its design, and the purpose of use for the desired effect are the main factors that determine the success of this connection between the user and the gardens. Through the design of the garden and the choice of its elements, such as the plants that will make up the vegetation, the users’ senses will be stimulated by different smells, textures, sizes, colors, sounds, flavors, etc.

For the successful implementation of therapeutic gardens, it is crucial to adhere to recommendations such as those presented in this study, which are based on the literature and lessons learned. Equally important is the need for ongoing monitoring to assess the positive and negative impacts of the implementation. This allows for the creation of actions to continually enhance these environments, with a primary focus on the well-being of the users. Further studies are warranted to refine the framework developed for guiding the implementation of therapeutic gardens.