Sustainable Health and Well-Being: Guidelines for Integrating Therapeutic Gardens for Holistic Hospital Care

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Sustainable Health and Wellbeing: Guidelines for integrating therapeutic gardens for holistic hospital care - REVIEW

 

ABSTRACT

In the first lines of the abstract the authors correctly give a synthetic view of the decision-makers role in establishing TGH. Before that, it should be mentioned why there is the need of integrating therapeutic gardens.

The analysis description is well expressed, on the other hand it is not clearly mentioned the aim of the study: which is the reason why this study has been conducted?  The objective should be explicitly stated in the abstract. 

The methodology adopted should be clarified: which are the steps of the research? How the decision makers have been selected? How the interviews have been structured and conducted? A synthetic/bullet point list is missing.

The important results are well stated, while the conclusion section should be more specific: what is the study adding to the current body of knowledge? At line 38 you mention “three sectors”, you refer to healthcare design, clinical health and? It looks it hasn’t been mentioned.

 

INTRODUCTION

In the second paragraph of the introduction, which concerns the knowledge of decision makers, the authors mention that “healthcare decision-makers understand the criticality of holistic care”(line 62-63). Being more specific, which ones are being taken into consideration? Also, at lines 67-68 “clinical and organizational benefits” are mentioned, for example?

Referring to the last two paragraphs, the position of the author on the topic of THG implementation is not clear. Are therapeutic gardens something rare or not? “Not commonly available” at line 82 goes against “already successfully implementing” at line 92.

For additional reference and clarification of terminology You can refer to recent scientific studies on the topic such as “Therapeutic Architecture. Assessment Tools and Design Strategies for Healing Gardens Implementation”, 2023 or “Green space in hospital built environment. A literature review about therapeutic gardens in acute care healthcare settings before Covid-19”, 2023

 

MATHERIALS AND METHODS

It would be useful for the reader to have a synthetic diagram (i.e. flowchart) representing only the methodological steps of the research, without results incorporated, starting from the selection of participants until the establishment of the systematic steps of the THG Healthcare Decision-maker Guidelines. Moreover, a quantitative analysis would increase scientificity to the research, as for now, results correspond only to the interview data. 

 

 

 

RESULTS

While it is very clear that results correspond to the insights from the 12 Global Healthcare decision-makers, the 5 points seem to be a bit generic and redundant. For example, it is not easily comprehensible the difference between 3.1 “Hospital gardens are more therapeutic when designed for hospital user cohorts” and 3.2“Purposefully designed and well-integrated therapeutic gardens benefit hospital users the most”.

 

DISCUSSION 

In the discussion section the authors take up again the five findings from the interviews and, once again, a certain redundancy is perceived. The concepts which emerge from the paper seem to be the following: 

-       THG are designed to make people feel better and it is acknowledged that they have a positive impact on users

-       Inclusive stakeholder engagement is fundamental for the design phase

What else the authors whish to demonstrate? 

In conclusion, an aspect which has not be stressed is the comparison between the different professionals: are there any relevant analogies or differences between the opinion of managers, clinicians, designers.. More quantitative elements would enrich the study. 

 

CONCLUSION

Please clarify if the study was able to explicitly answer the research question. Do the steps identified turn to be significant guidelines for healthcare decision-makers?

 

 

 

Author Response

We thank Reviewer 1 for providing valuable feedback to improve our manuscript. We have revised the article to address the reviewer's comments. Our response and revised text in the revised manuscript are in dark red.

Comment 1: In the first lines of the abstract the authors correctly give a synthetic view of the decision-makers role in establishing THG. Before that, it should be mentioned why there is the need of integrating therapeutic gardens.

Response 1: The need for THG to be purposefully designed for hospital users and well-integrated into the clinical hospital treatment plan to be effective has been added at the beginning of the abstract. L 23-24.

Comment 2: The analysis description is well expressed, on the other hand it is not clearly mentioned the aim of the study: which is the reason why this study has been conducted?  The objective should be explicitly stated in the abstract. 

Response 2: The study aims to establish how THG can be successfully created by investigating the professional experience of healthcare decision-makers in creating a healthy and sustainable hospital environment. L 27-31.

Comment 3: The methodology adopted should be clarified: which are the steps of the research? How the decision makers have been selected? How the interviews have been structured and conducted? A synthetic/bullet point list is missing.

Response 3: An addition was made to the introduction as to how these decision-makers who already worked with healthcare designers and clinical practitioners to design and establish THG were selected, how the interviews were conducted, and how the data was analysed. L31-33

Comment 4: The important results are well stated, while the conclusion section should be more specific: what is the study adding to the current body of knowledge? At line 38 you mention “three sectors”, you refer to healthcare design, clinical health and? It looks it hasn’t been mentioned.

Response 4: The text has been modified to clearly identify the three sectors critical to the success and efficacy of THG – healthcare design, healthcare governance and clinical health. L 41-46.

Comment 5: In the second paragraph of the introduction, which concerns the knowledge of decision makers, the authors mention that “healthcare decision-makers understand the criticality of holistic care”(line 62-63). Being more specific, which ones are being taken into consideration? Also, at lines 67-68 “clinical and organizational benefits” are mentioned, for example?

Response 5: The text has been modified to explain holistic care as addressing a person’s physical, emotional, social and spiritual needs. L 62-65.

Examples of clinical benefits, i.e. patients’ improved mood and well-being, and organisational benefits, i.e., reduced hospital stay and improved staff satisfaction, have been added. L 68-70.

Comment 6: Referring to the last two paragraphs, the position of the author on the topic of THG implementation is not clear. Are therapeutic gardens something rare or not? “Not commonly available” at line 82 goes against “already successfully implementing” at line 92.

Response 6: I have clarified that THG are increasingly included globally to benefit hospital users and organisations. What is less well understood is how these healthcare professionals managed to create THG successfully. L 76-78.

Comment 7: For additional reference and clarification of terminology You can refer to recent scientific studies on the topic such as “Therapeutic Architecture. Assessment Tools and Design Strategies for Healing Gardens Implementation”, 2023 or “Green space in hospital built environment. A literature review about therapeutic gardens in acute care healthcare settings before Covid-19”, 2023

Response 7: Thank you for the references. They have now been included. L 56-59.

Comment 8: It would be useful for the reader to have a synthetic diagram (i.e. flowchart) representing only the methodological steps of the research, without results incorporated, starting from the selection of participants until the establishment of the systematic steps of the THG Healthcare Decision-maker Guidelines. Moreover, a quantitative analysis would increase scientificity to the research, as for now, results correspond only to the interview data. 

Response 8: A flow chart presenting the methodological steps for this healthcare decision maker study has now been included as Figure 2. L 117-123.

The purpose of this research was to explore how THG  can be established successfully by healthcare professionals by asking 12 healthcare decision-makers how they managed to do so. Future research can be conducted to test and validate the findings proposed in the future research section 4.6 Limitations and future directions. L 632.

This aligns with point 1.11 – add future research to validate the 5 steps in the conclusion.  L 654-656.

Comment 9: While it is very clear that results correspond to the insights from the 12 Global Healthcare decision-makers, the 5 points seem to be a bit generic and redundant. For example, it is not easily comprehensible the difference between 3.1 “Hospital gardens are more therapeutic when designed for hospital user cohorts” and 3.2“Purposefully designed and well-integrated therapeutic gardens benefit hospital users the most”.

Response 9: The word “more” has been removed from the first step wording. The removal of this one word:

- separates steps 1 and 2 clearly.

- highlights the importance of designing for the needs of hospital cohorts to implement THG successfully as the first step.

- emphasises the importance of a purposeful and well-integrated design to optimise the garden's effectiveness as the second step.

Comment 10: In the discussion section the authors take up again the five findings from the interviews and, once again, a certain redundancy is perceived. The concepts which emerge from the paper seem to be the following: 

-       THG are designed to make people feel better and it is acknowledged that they have a positive impact on users

-       Inclusive stakeholder engagement is fundamental for the design phase

What else the authors whish to demonstrate? 

Response 10: Yes, in addition to these two points, the paper highlights the importance of healthcare decision-makers in the healthcare governance sector working with healthcare designers and clinical health experts to design and establish THG successfully. L 649-652.

Comment 11: In conclusion, an aspect which has not be stressed is the comparison between the different professionals: are there any relevant analogies or differences between the opinion of managers, clinicians, designers.. More quantitative elements would enrich the study. 

Response 11: As the next step subsequent studies can be carried out to investigate further and compare the different approaches of varying professions. L 654-656.

Reviewer 2 Report

Comments and Suggestions for Authors

This article presents the professional experiences of 12 global healthcare decision-makers in hospital administration, executive government, and senior consultancy to government on the role of therapeutic hospital gardens (THG) in creating a healthy and sustainable hospital environment. The article shows how these decision-makers have already worked with healthcare designers and clinical practitioners to design and establish THG. The qualitative analysis of these semi-structured interviews uncovered why and how these healthcare decision-makers made THG a reality in their hospitals. This study has certain research significance, and it is recommended to add the latest literature from the past three years.

Comments on the Quality of English Language

Minor editing of English language required.

Author Response

We thank Reviewer 2 for providing valuable feedback to improve our manuscript. We have revised the article to address the reviewer's comments. Our response and revised text in the revised manuscript are in dark red.

Comment 1: This article presents the professional experiences of 12 global healthcare decision-makers in hospital administration, executive government, and senior consultancy to government on the role of therapeutic hospital gardens (THG) in creating a healthy and sustainable hospital environment. The article shows how these decision-makers have already worked with healthcare designers and clinical practitioners to design and establish THG. The qualitative analysis of these semi-structured interviews uncovered why and how these healthcare decision-makers made THG a reality in their hospitals. This study has certain research significance, and it is recommended to add the latest literature from the past three years.

Response 1: Additional recent literature has been added. L 56-59.

Reference 14 includes the literature review up to 2023. L 729-730.

Comment 2: 

Comments on the Quality of English Language

Minor editing of English language required.

Response 2: The spelling and grammar for this paper have been checked.

Comment 3: Please clarify if the study was able to explicitly answer the research question. Do the steps identified turn to be significant guidelines for healthcare decision-makers?

Response 3: Yes, we have ensured that the study addressed the research question of “how THG can be established globally?” The five systematic steps identified make a significant contribution to knowledge to enable healthcare decision-makers to establish THG successfully. L 649-652.

Reviewer 3 Report

Comments and Suggestions for Authors

Congratulations to the authors for conducting this novel research, which undoubtedly adds knowledge to the existing literature on sustainable health and well-being. This research addresses how therapeutic gardens can be established globally by interviewing hospital CEOs, government executives, and senior consultants experienced in implementing them globally on how they managed to design, establish, and create healthy and sustainable hospital environments.

The authors have conceived and executed the research strictly as per the guidelines to be followed in conducting a qualitative study. The methodology has been adequately designed and the process followed for collecting data has been adequately presented.

The results of analysis and discussion have been found adequate, similarly, the way inferences are drawn from the analysis is worthy, and the conclusion has been drawn from the study results and discussion.

The following are my minor comments:

1.     How were the semi-structured interviews conducted? (Was it virtually conducted?)

2.     Categorization of all study participants country-wise (although the country-wise distribution of healthcare decision-makers is presented)

3.     Any specific policy guidelines available from concerned countries could also add value.

 

4.     Policy implications of the research needs to be added. 

Author Response

We thank Reviewer 3 for providing valuable feedback to improve our manuscript. We have revised the article to address the reviewer's comments. Our response and revised text in the revised manuscript are in dark red.

Comment 1: Congratulations to the authors for conducting this novel research, which undoubtedly adds knowledge to the existing literature on sustainable health and well-being. This research addresses how therapeutic gardens can be established globally by interviewing hospital CEOs, government executives, and senior consultants experienced in implementing them globally on how they managed to design, establish, and create healthy and sustainable hospital environments.

Response 1: Thank you for your feedback.

Comment 2: The authors have conceived and executed the research strictly as per the guidelines to be followed in conducting a qualitative study. The methodology has been adequately designed and the process followed for collecting data has been adequately presented.

Response 2: Thank you for your feedback.

Comment 3: The following are my minor comments:

1. How were the semi-structured interviews conducted? (Was it virtually conducted?)
2. Categorization of all study participants country-wise (although the country-wise distribution of healthcare decision-makers is presented)
3. Any specific policy guidelines available from concerned countries could also add value.
4. Policy implications of the research need to be added.

Response 3: 

1. The percentage of virtual and face-to-face interviews has been added. L 117-120.

2. The interview mode of the 12 semi-structured interviews has been added – refer to point 1.

3. While generic design guidelines exist for healing gardens and therapeutic landscapes and gardens, we are unaware of any specific guidelines guiding healthcare decision-makers to establish THG.

4. The policy implications of the research findings have been highlighted in 4.6 Limitations and future directions L 637-639.