Issues in Mental Health Nursing, 36:35–43, 2015 Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.932872

Clinical Use of Sensory Gardens and Outdoor Environments in Norwegian Nursing Homes: A Cross-Sectional E-mail Survey Marianne Thorsen Gonzalez, RPN, MNS, PhD University of Oslo, Institute of Health and Society, Oslo, Norway, and Diakonhjemmet University College, Institute of Nursing and Health, Oslo, Norway

Marit Kirkevold, RN, MA, EdD University of Oslo, Institute of Health and Society, Oslo, Norway

Outdoor areas are reported to be highly appreciated by nursing home residents (Cohen-Mansfield, 2007), and having access to surrounding outdoor life seems to be an essential issue for nursing home residents (Bengtsson & Carlsson, 2005). Several authors have reported that nature seems to be beneficial for patients suffering from dementia (Lovering, Cott, Wells, Taylor, and Wells, 2002; Ottosson & Grahn, 2005), with observing nature and plants, and experiencing fresh air as important experiences (Kearney & Winterbottom 2005). Joseph, Zimring, Kojetin, and Kiefer (2005) reported that the number of residents in retirement communities participating in physical activities depended on the attractiveness of both the indoor and outdoor environments. Easy access to outdoor environments has been emphasised (Mooney & Nicell, 1992). The nursing home’s gardens and outdoor surroundings offer multiple possibilities for multisensory experiences and light exposure (Burns, Byrne, Ballard, & Holmes, 2002), engagement in pleasant activities (MacDonald, 2002) and degrees of involvement in physical and social activities. Going outside daily is reported to be a good predictor of functional and health-related issues for older people (Jacobs et al., 2008; Sugiyama & Thompson, 2005). Despite these benefits, outdoor environments seem to be an overlooked resource for nursing home residents (Cutler & Kane, 2005).

Gardens and outdoor environments offer multiple therapeutic possibilities for the residents in nursing homes. Web-based questionnaires were sent to 488 nursing home leaders and 121 leaders responded. The clinical impressions of the leaders and staff regarding the benefits of sensory gardens (SGs) to the residents were consistent with previous research. SGs facilitated taking residents outdoors, offered convenient topics for communication and facilitated social privacy for relatives. For improved clinical use of SGs and outdoor environments, systematic assessment of residents’ interests, performance and experiences when outdoors, implementation of seasonal clinical programmes and educational programmes for leaders and staff are recommended.

INTRODUCTION Aging and moving from one’s home to a nursing home often results in a considerable change in a person’s contact and experiences with nature, as well as their participation in outdoor activities (Rodiek & Schwarz, 2005). Being outdoors and participating in diverse nature-related activities is often limited for nursing home residents (Chalfont, 2007; Cox, Burns, & Savage, 2004), and despite easy access, outdoor activities seem to be underused (Kearney & Winterbottom, 2005; Mather, Nemecek, & Oliver, 1997). Cutler and Kane (2005) reported that only onethird of the nursing home residents who were physically able to go outdoors actually did so. Nursing home residents tend to report a lower quality of life (QoL) than older patients who still live at home (Drageset et al., 2009; Drageset et al., 2008), and outdoor environments might play a significant role in the QoL of older people (Sugiyama & Thompson, 2005).

SENSORY GARDENS Therapeutic Environments in Dementia Care Sensory gardens (SGs) have been introduced as appropriate therapeutic outdoor environments in dementia care (Chalfont, 2007; Cooper Marcus & Barnes, 1999). The label ‘sensory garden’ (SG) refers to the idea that the garden may stimulate the senses (e.g. sight, vision, hearing, smell and touch). SGs are gardens arranged in a manner that provides a therapeutic environment for patients suffering from dementia. The gardens

Correspondence regarding this article should be directed to Marianne Thorsen Gonzalez, Institute of Health and Society, University of Oslo, Box 1130 Blindern, Norway. Tel: +47 22 45 18 07/ +47 93224285. E-mail: [email protected]

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are often walled and shielded, and they allow exposure to light, wandering, exercise, multisensory experiences and enjoyable activities. Therapeutic use of SGs may be passive and/or active. Passive use refers to being in the garden or outdoors and experiencing a variety of sensory stimulations, such as fragrances, colours, birdsong, fresh air, sunshine and various sights. Active use refers to doing and participating in a variety of activities, such as gardening, picking flowers and berries, taking care of birds, socialising and walking (Hernandez, 2007). A range of theories might be used to underpin the benefits of SGs. The benefits of nature experiences and gardening activities might be explained by the attention restoration theory (ART) (Kaplan & Kaplan, 1989; Kaplan, 1995). This theory holds that two key, active components are necessary to restore cognitive resources when overloaded or stressed; a qualitative change in environment (being away), and the allowing of attentional absorption (fascination) by qualities in the environmental features. Moving from indoors to outdoors causes an important change in environment and stimuli. Similarly, being outdoors allows for passive nature experiences and pleasant meaningful activities that are often followed by multisensory experiences and, hopefully, cognitive engagement and fascination. Being confused and disoriented, as is a frequently experienced situation for the person suffering from dementia, is a cognitively demanding experience that might lead to attentional fatigue. In this perspective, nature-based clinical practice might contribute to the regular restoration of attentional resources in patients suffering from dementia. Consistent with ART, Ottosson and Grahn (2005) have reported that the capacity to concentrate greatly improved in geriatric care residents after resting outdoors, compared with those who rested indoors. The fact that stimulation in general is a significant factor related to thriving and wellbeing for individuals with dementia (Bergland & Kirkevold, 2011), further strengthens this issue. Considering that engagement and stimulation also seem to reduce wandering, pacing and agitation (Cohen-Mansfield & Werner, 1998), it is reasonable to assume that the multisensory outdoor experiences also facilitate a reduction in this behavior. In a recent review that addressed interventions using SGs and/or horticultural activities in dementia care, Gonzalez and Kirkevold (2013) reported that improvements in behavior, sleep and sleep patterns, well-being, affect, cognition and falls, as well as the reduced use of psychotropic medication, are benefits of exposure to SGs. In Norway, SGs have become increasingly popular, despite the short summer seasons and the challenging weather conditions. Currently however, we do not know how these gardens or outdoor environments are used. Nursing homes in Norway mainly have public owners, and all counties have one Teaching Nursing Home (TNH). This study assessed the clinical use of the available SGs and outdoor environments in Norwegian nursing homes from the perspective of the leaders and healthcare staff.

METHODS Design The present study used a cross-sectional web survey design. Sample and Setting The respondents were the leaders and staff of Norwegian nursing homes. Data were collected using web-based questionnaires. The web-based questionnaires were used to facilitate communication during the recruitment and data collection stage and to facilitate responses from leaders and staff. Data Collection Two web questionnaires (UiO, Nettskjema, Version 2.0) were developed (one for the leaders and one for the staff). Except for the introductory items addressing demographic data and the data related to the nursing homes, the two questionnaires were identical. Both questionnaires were divided into two sections. The first section was related to the general clinical use of the outdoor environments and was answered by leaders and staff of nursing homes with and without an SG. The second section of the questionnaire was specifically for the nursing homes that had an SG. The items were developed according to the benefits reported in the literature (Gonzalez & Kirkevold, 2013) and were used to assess the leaders’ and staff’s clinical experiences. Items were divided into three categories: closed, closed with several alternatives and open, in which the respondent could include his, or her, own response. Procedure A short web-based questionnaire was sent via personal e-mail to 488 nursing home leaders across the Norwegian counties; this questionnaire asked for their name, nursing home address, and willingness to participate and distribute questionnaires to the staff. From these initial e-mails, 140 leaders chose to participate in the survey and were sent the complete web questionnaire developed for the leaders. Of these, a total of 121 leaders responded. A total of 97 leaders were also willing to distribute the questionnaires to their staff. A total of 302 staff respondents completed the web-based questionnaires developed for the staff. Two reminders to complete the questionnaire were sent to both leaders and staff. Data Analysis Descriptive statistics were used to analyse the data. The results are presented as percentages. However, the percentages between the leaders and staff cannot be directly compared, as the questionnaires did not link the leaders, staff or nursing homes. Ethical Considerations The project was registered and approved by the Norwegian Social Science Data Services (NSD). Responses to the initial

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USE OF SENSORY GARDENS AND OUTDOOR ENVIRONMENTS IN NORWEGIAN NURSING HOMES

invitational questionnaire were not anonymous and included names, e-mail addresses and the name and address of the nursing home. This information was needed for later distribution of selfreport questionnaires to the next of kin. However, the responses on the following web-based questionnaires were anonymous and could not be linked to any identifiable information of the leaders or staff. RESULTS Response and Response Rate A total of 121 leaders from the 488 leaders initially approached by e-mail responded to the questionnaire, which demonstrates a response rate of 25%. We do not know if the leaders distributed the web-based questionnaires to the staff via personal e-mail addresses or whether the questionnaire was available as a web-link on their home site. Because of this, the response rate of the staff cannot be estimated. Demographics of the Nursing Homes, Leaders and Staff Of the 121 nursing homes, 114 (94%) were public nursing homes; of these, five (4%) were TNH. Seven nursing homes (6%) were run by private owners. A dedicated dementia unit was available in 74% of the nursing homes. In 33% of the nursing homes, there was a short-term unit and 55% had a rehabilitation unit. The sizes of the nursing homes varied. However, in 59% of the nursing homes, the number of beds ranged between 20 and 59, implying that they were smaller than the USA and perhaps other larger countries. According to the Center for Medicare and Medicaid Services (CMS), about 70% of nursing homes in the US are larger than 100 beds (Williams et al., 2010). Further demographic information about the nursing homes is presented in Table 1. The leaders and staff respondents represented all of the Norwegian counties, with a large number of respondents from the southern and eastern parts of Norway, which mirrored the actual distribution of the inhabitants. Both leaders (87%) and staff (95%) were women, and 93% of the leaders were nurses. Further demographic information of the leaders and staff are presented in Table 2. Sensory Gardens and Outdoor Environments Clinical Use SGs were established in 62% of the nursing homes, and of those nursing homes without SGs, 48% had concrete plans of establishing a SG. Both the leaders (64%) and staff (54%) reported that they regarded the use of the SGs as part of the nursing homes’ overall therapeutic milieu programme. The gardens were on average small, with nearly 60% smaller than 500 square metres and 72% of them were established in between 2001 and 2012. The SGs were in use year round (Table 3). More than 90% of the staff regarded the SGs as important for the residents, and both the leaders (99%) and staff (83%) reported that the SGs seemed

TABLE 1 Demographics of the nursing homes

Number of beds 100 Number of ward units 1 2–3 4–5 6–7 >10

n

(%)

14 44 28 13 9 13

12 36 23 11 7 3

17 52 37 10 5

14 43 31 8 4

TABLE 2 Demographics of leader and staff (%) Variable Gender Women Men Age 61 Education Nurse Health-related bachelor Economy Nurse’s aide Other Further training Geriatrics Psychiatry Dementia Management Other Years employed 26

Leaders (n = 121)

Staff (n = 302)

87 13

95 5

2 13 39 36 11

19 18 28 29 7

93 8 12 – 7

32 5 – 42 17

12 7 11 79 44

9 2 – – –

20 45 22 7 2 4

16 36 21 8 10 9

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M. T. GONZALEZ AND M. KIRKEVOLD

TABLE 3 Leaders’ and staff’s reports on the seasonal use of the sensory gardens (%) Leaders

Daily Several times per week Once per week

Staff

Spring

Summer

Autumn

Winter

Spring

42 46 5

77 21 0

25 7 8

7 13 5

31 38 6

to facilitate the residents’ participation in outdoor activities. A specific outlined therapeutic programme was reported by only 8% of the leaders and 12% of the staff. The clinical use of physical activities, active gardening, and social activities, as well as more passive gardening activities, were reported by relatively similar percentages of the leaders and staff (Table 4). Text data revealed that a variety of activities were used in the SG gardens, especially social activities with or without small meals, barbecues, various outdoor games and organised exercise. The impressions were that the availability of a SG tended to ease the care of pacing and restless residents. Clinical use of the outdoor environment was generally regarded as an important part of the therapeutic milieu by both the leaders (96%) and staff (88%). Elderly patients with dementia, residents walking alone and those in short-term stay were reported to most frequently use the available outdoor environments. Walks were the most frequent activities, and the nursing home gardens and surroundings were the outdoor environments most frequently used (Table 5). Text data revealed that in addition to walking, a variety of garden-related activities, such as social gatherings, eating outdoors, snow clearing, various

TABLE 4 Leaders’ and staff’s reports on the activities in the sensory garden (SG) (%) Activities General physical activities Wandering/walking Passive gardening activities Looking at scenery, animal life and plants Active gardening activities Weeding Picking flowers and branches Harvesting Sowing and germinating Picking out and planting Social activities Socialising and eating Small group activities

Leaders

Staff

63

66

61

62

50 46 45 36 26

45 48 30 27 18

61 46

62 39

Summer 68 21 1.8

Autumn

Winter

18 46 6

1 11 7

games, feeding birds, taking care of hens and bunnies, making fireplaces and sunbathing, occurred. Leader and Staff Impressions of the Residents’ Benefits The overall impressions of both the leaders and staff were that the residents showed improvements in wellbeing and contentment (97% of leaders, 91% of staff); agitation, restlessness and pacing (89% of leaders, 80% of staff); balance and mobility (81% of leaders, 74% of staff); and sleep and sleep patterns (66% of leaders, 58% of staff). Most of the leaders (92%) and staff (87%) had an overall impression that the SGs positively influenced the residents’ relatives and next of kin when visiting the nursing home. They reported that the SGs facilitated taking the residents outdoors (91% of leaders, 86% of staff), offered convenient topics for communication (87% of leaders, 73% of staff) and facilitated social privacy (82% of leaders, 77% of staff) for the residents’ relatives and next of kin. Furthermore, text data revealed that leaders and staff experienced that, for visitors who were ageing and fragile themselves, visiting a nursing home with an SG made the idea of living in a nursing home in the future less frightening.

TABLE 5 Leaders’ and staff’s reports on the most frequent users, used environments and outdoor activities (%)

Users of the outdoor environments and activities Elderly patients with dementia Elderly patients walking alone Elderly patients in short-term stay Other Use of environments and activities Nursing home garden/surroundings Nearby parks Botanical gardens Walks Other outdoor activities

Leaders

Staff

92 51 46 11

81 43 28 9

84 19 9 82 36

79 13 8 66 24

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USE OF SENSORY GARDENS AND OUTDOOR ENVIRONMENTS IN NORWEGIAN NURSING HOMES

Assessments of the Residents’ Experiences, Activities and Performance Less than half of the leaders (43%) and staff (38%) reported that the residents’ interests in gardening was part of the ordinary clinical assessment, and less than half of the leaders (39%) and staff (41%) reported that performance in the SGs was part of the clinical observations and documentation. However, the observations that to some degree were systematically assessed, included positive experiences (27% of leaders, 38% of staff), physical activity (22% of leaders, 34% of staff) and mobility and the tendency to fall (23% of leaders, 32% of staff). Evaluations of Staff Knowledge, Attitudes and Benefits Leaders and staff evaluations of their own knowledge and attitudes differed; more leaders than staff stated satisfactory knowledge of dementia (leaders 86%, staff 76%), awareness of research findings on SG benefits (leaders 55%, staff 38%) and knowledge of the degree to which staff had participated in educational programmes on the use of SGs (leaders 52%, staff 22%). The leaders’ evaluations of their own, or their staff’s attitudes, on the use of their SGs showed the same tendency (Table 6). Most of the leaders (91%) and staff (84%) reported that the outdoor environments positively influenced their working environment. However, 63% of the leaders reported that the staff had personal interests in gardening and plants, whereas only 50% of the staff themselves reported an interest. Both the leaders (61%) and staff (57%) reported that the SGs seemed to facilitate restorative breaks. Regarding the improved use of the SGs, less than half of the leaders and staff reported that improved knowledge was important, and approximately one-quarter of leaders and staff reported that engaged leaders were important (Table 6). DISCUSSION General Clinical Use The most frequent users of the outdoor environments and SGs in Norwegian nursing homes were reported to be elderly patients with dementia who were able to walk alone. Additionally, these residents were the most likely to participate in other outdoor activities. This issue highlights the need for further investigation into the amount and type of access that the elderly in need of comprehensive care and those with low mobility actually have to the outdoors and how access and outdoor activities may be facilitated, independent of function levels. Overall, the leaders and staff reported that the SGs were beneficial for the residents. They also regarded the use of the SGs as part of the overall therapeutic programme for their nursing homes. However, these impressions were not accompanied by reports on clinical assessments. This finding might reflect poor assessment practice in general or demonstrate that being outdoors is beyond the daily care and self-care activities. This finding might also be interpreted in terms of a lack of knowledge, skills or a deeper understanding of the complete therapeutic po-

TABLE 6 Evaluation of knowledge, skills and attitudes (%)

Knowledge and skills of staff Staff satisfactory knowledge of dementia Aware of research on the benefits of sensory gardens Participated in educational programme on the therapeutic use of sensory gardens in dementia Attitudes about the sensory gardens Leaders are generally positive Staff are generally positive Sensory garden is a matter of priority What is needed for improved use of the sensory garden Improved knowledge Engaged leaders

Leaders

Staff

86

76

55

38

52

22

90 89 72

84 78 54

41 26

40 25

tential of SGs and outdoor environments. From this perspective, it is interesting that staff seem to lack information regarding the reported benefits of SGs. However, less than half of the leaders and staff reported that increased knowledge might improve the clinical use of the SGs. Despite this finding, educational programmes based on theories, research, appropriate literature, films and practice models are recommended to improve this clinical practice. Furthermore, it is interesting that, despite that most of the leaders and staff appraised the use of the SGs as part of the units’ overall therapeutic programme, seasonal therapeutic programmes for their use were not developed. Because of the variety of reported benefits of SG use (Gonzalez & Kirkevold, 2013), their increasing popularity and the cost of establishing and maintaining SGs, seasonal programmes for optimal therapeutic use might be appropriate. Grant and Wineman (2007) recommend their own Garden-use Model as a guide for optimal use of SGs. This model describes how organisational and programming policies interrelate with spatial and physical attributes. A seasonal programme should include relevant activities that achieve specific clinical aims. Considering the challenging temperatures and weather conditions in Norway, it is both impressive and inspiring that SGs are in use all year round, despite the oscillating frequencies across the seasons. The SGs seemed to facilitate taking the residents outdoors, and the year round use of the SGs may encourage the residents to go outdoors more frequently. Both the leaders and staff reported having garden interests and skills and stated that going outdoors facilitated restorative breaks during the busy workdays, all of which might motivate the leaders and staff to bring the residents outdoors. Facilitating and

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M. T. GONZALEZ AND M. KIRKEVOLD

acknowledging that going outdoors is a part of clinical practice for the elderly is underpinned by reported findings related to improved physical benefits (Jacobs et al., 2008; Joseph et al., 2005; Sugiyama & Thompson, 2005), cognitive benefits (Plassman, Williams, Burke, Holsinger, & Benjamin, 2010; Spector et al., 2003; Woods, Aguirre, Spector, & Orrell, 2012) and behavioral improvements (Woodhead, Zarit, Braungart, Rovine, & Femia, 2005). Similarly, continuous activity programming has been reported to reduce staffing needs, increase the time involved in activities, decrease the use of psychotropic medication, improve nutrition and increase family satisfaction (Volicer, Simard, Pupa, Medrek, & Riordan, 2006). From this perspective, it is encouraging that these gardens are increasing in popularity. Being Outdoors Change in Environmental and Multisensory Stimulation The fact that the staff were interested in gardening and experienced that taking residents outdoors facilitated involving residents in outdoor activities, as well as ease agitated behavior, might have strengthened the staff’s motivation and inspiration to encourage residents to change environment and go outdoors. Activities related to nature in the nearby surroundings and the SGs, were reported by both leaders and staff to a large degree. The activities involved both passive and active experiences of nature, and the experienced positive benefits of these activities might be explained by ART (Kaplan & Kaplan, 1989; S. Kaplan, 1995). The positive benefits and influence of nature and outdoor environments, the significance of the features in the environments and the value of access to nature, gardens and the outdoors are, however, only slightly reflected in the standardised-measures related to therapeutic programmes in dementia care (Bicket et al., 2010; Lawton, 2001; Lawton et al., 2000; Parker et al., 2004; Sloane et al., 2002). These factors need to be developed to better understand and systematically assess the effects from various theoretical positions. Physical Activity Walking seemed to be a core activity both in the nursing home environment in general and in the SGs. The data further revealed that gardening in the SGs, being outdoors and using the nearby surroundings involved a variety of physical, social and mental activities. This complex clinical practice is supported by Kolanowski, Buettner, Litaker, and Yu (2006) who reported that complex activity programmes aimed at simultaneously improving physical and cognitive status have the potential to maximise engagement, resulting in optimal benefits in dementia care. The leaders and staff reported that the SGs positively influenced agitation, restlessness, pacing, balance and mobility, as well as improved sleep, and these findings are supported by relevant research. Salguero, Mart´ınez-Garc´ıa, Molinero, and M´arquez (2011) reported that outdoor physical activity is associated with both physical and mental components of quality of life in community-dwelling and institutionalised older adults. Exer-

cise has been reported to have a positive influence on cognition (Plassman et al., 2010). Two review articles have reported that physical exercise has the potential to reduce both the severity of psychological symptoms and cognitive symptoms (Knochel et al., 2012; Vogel et al., 2009). Knochel et al. (2012) strongly recommended physical exercise as an innovative approach in therapeutic programmes for dementia. Salami, Lyketsos, and Rao (2011) have also reported that the best treatment for sleep disturbances in dementia care appears to be exposure to light. Whereas this study reports that physical and social activities were experienced with equal frequency, Cohen-Mansfield (2007) reported that eating and social activities undoubtedly were the most frequent activities that occurred outdoors. This difference might be due to the strong Norwegian tradition of going on scenic nature walks on the weekends. Both the leaders and staff were cautious in their impressions of residents’ benefits related to a reduction in falls. Chen and Janke (2012) reported that participation in SGs contributed to the prevention of falls, whereas Detweiler, Murphy, Kim, Myers, and Ashai (2009) reported that the introduction of a SG was associated with a reduction in the frequency of falls in general, particularly serious falls. Improved knowledge of research findings and how to prevent falls might improve the clinical practice regarding this issue. Social Activities Social activities were reported as the core activities, and this finding was consistent with the findings from the CohenMansfield (2007) survey. These clinical practices are supported by Sadowsky and Galvin (2012), who recommended increased social activities and group communication in dementia care. The leaders and staff suggested that being outdoors in the SGs also facilitated communication and social privacy for the visitors, which might also contribute to improved contact, communication, and social privacy with relatives, as well as more frequent visits due to meaningful communication and meaningful experiences. Similarly, activities with the staff and contact with their social network tend to reduce experiences of loneliness (Drageset 2004). Improvement in cognition related to the social aspect of gardening activities (Gigliotti & Jarrott, 2005; Lee & Kim, 2008) has also been reported. Socialising has been reported as a benefit of using outdoor environments, and SGs and can provide, at least, short-term positive effects on wellbeing and quality of life (Ciechanowski et al., 2004). The possibilities of complex cognitive stimulation seem to positively influence communication and social interaction, according to a recent review by Aguirre, Woods, Spector, and Orrell (2013). Leaders’ and Staff’s Knowledge, Skills and Attitudes The leaders, to a large degree, had positive attitudes towards the being outdoors. Positive leader attitudes (Grant & Wineman, 2007; Hernandez, 2007) and institutional policy and culture (Chapman, Hazen, & Noell-Waggoner, 2005, 2007) have been reported by several authors to positively influence the clinical

USE OF SENSORY GARDENS AND OUTDOOR ENVIRONMENTS IN NORWEGIAN NURSING HOMES

use of the SGs. The leaders and staff reported equal levels of satisfactory knowledge about dementia. However, it is striking that the leaders participated in education programmes related to the use and benefits of SGs to a much larger degree than the staff. Only a modest number of the leaders and staff responded that they were in need of education. These results are in contrast with Chapman and colleagues (2007); in that study, the participants reported that educational training might contribute to both the increased facilitation of outdoor environments and improved therapeutic use in dementia care. The general positive attitudes of the leaders and staff and the impressions of the residents’ benefits are, however, consistent with the reported findings of non-pharmacological interventions to prevent wandering in dementia patients (Robinson et al., 2006) and the reported benefits of SGs and gardening activities (Gonzalez & Kirkevold, 2013).

Study Limitations and Strengths This study has several limitations. First, calculating the exact response rate (RR) was not possible. The calculated RR of 25% from the initial 488 leaders was considerably lower than the RR of the 48% reported by Cohen-Mansfield (2007), who used a similar procedure. Sheehan (2001) reported a falling tendency in the use of web surveys, and Kongsved, Basnov, HolmChristensen, and Hjollund (2007) reported that paper and pencil questionnaires are better than web-based questionnaires; however, others have reported that web-based questionnaires have higher RRs (Wang et al., 2005), and Gosling, Vazire, Srivastava, and John (2004) state that the RRs in psychology studies are consistent with other data collection methods. An explanation of the only moderately satisfactory RR might be that the initial questionnaire addressed SGs in the heading and might have potentially misled the leaders that do not have a SG; for this reason, they may have felt that they were not qualified to respond. Additionally, the survey was administered during the winter, when outdoor activities and the use of SGs in Norway seem to have the lowest priority, and for this reason, the survey might have been regarded as uninteresting. Second, the skewness in responses across Norway obviously reduces the possibility of introducing a representative picture of how leaders and staff in Norwegian nursing homes experience the clinical use of the outdoor environments and SGs. Third, the fact that the leaders and staff, for ethical reasons, cannot be traced back to the exact nursing home or county reduced the ability to calculate the associations between the leader and staff responses in a distinct nursing home, district or county. This study also has some important strengths. The overall study strength is that it addresses a growing clinical practice in dementia care in nursing homes across Norway. Furthermore, this study focusses on outdoor and nature-based activities in nursing homes in general and in dementia care in particular. Despite the skewness in the geographical response, all of the Norwegian counties and various climate zones were represented,

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implying that the survey offers an idea of the clinical field across the country and in various climate zones.

Implications for Practice and Research Nursing homes are challenged to offer all residents the possibility of outdoor experiences and, if possible, outdoor activities. Many nursing homes do not have their own garden or SG. Therefore, nearby environments, such as public parks, botanical gardens, local nurseries, forests or any other type of natural accessible scenery, may offer a valuable replacement. To improve the clinical use of nearby outdoor environments and SGs, we recommend that leaders outline an educational programme addressing the practical, empirical, and theoretical issues to improve the understanding of this complex, nature-based clinical practice, which is especially suited for patients with dementia. Additionally, the residents’ interests, performance and pleasure in these therapeutic environments and activities should be carefully and systematically assessed and evaluated. Further research should aim to establish good practice models to help the clinical field outline therapeutic programmes for all residents, regardless of their mobility level, and to underpin their clinical practice with robust theory and research. Researchers are encouraged to develop simple assessment tools adapted for active and passive use of outdoor environments to capture the positive experiences, engagement, wellbeing and mobility of elderly residents. Similarly, the development and empirical testing of a clinical and theoretical model for the use of outdoor environments in dementia care is recommended. Finally, the researchers in this field are encouraged to develop and standardise questionnaires to capture the clinical benefits of being outdoors in dementia care.

CONCLUSION This study reports findings from a web-based questionnaire that addressed the leaders’ and staff’s reports on the clinical use of SGs and outdoor environments in Norwegian nursing homes. The data revealed that the leaders’ and staff’s impressions on the benefits of SGs were generally positive. The SGs and outdoor environments were in use year round, and the most frequent users were elderly patients with dementia who walked alone. An available SG was thought to facilitate taking the residents outdoors as well as caring for pacing residents. The most frequent activities were walking, socialising and diverse gardening activities. The clinical use of the SGs was considered part of the overall therapeutic programme; however, an outlined seasonal therapeutic programme was not reported. The residents’ positive experiences and outdoor performances were, to a minor degree, assessed and documented. Less than half of the staff were aware of the relevant research benefits of SGs for patients with dementia, and yet, the staff reported that increased knowledge would not improve the purposeful use of their SGs.

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M. T. GONZALEZ AND M. KIRKEVOLD

Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

REFERENCES Aguirre, E., Woods, R. T, Spector, A., & Orrell, M. (2013). Cognitive stimulation for dementia: A systematic review of the evidence of effectiveness from randomised controlled trials. Ageing Research Reviews, 12(1), 253–262. Bengtsson, A. & Carlsson, G. (2005). Outdoor environments at three nursing homes: Focus group interviews with staff. Journal of Housing for the Elderly, 19(3,4), 49–69. ˚ & Kirkevold, M. (2011). Which factors in the physical environment Bergland, A. promote or hinder function, thriving and well-being among persons with dementia? A literature review. Sykepleien Forskning, 6(1), 14–25. Bicket, M. C., Samus, Q. M., McNabney, M., Onyike, C. U., Mayer, L. S., Brandt, et al. (2010). The physical environment influences neuropsychiatric symptoms and other outcomes in assisted living residents. International Journal of Geriatric Psychiatry, 25(10), 1044–1054. Burns, A., Byrne, J., Ballard, C., & Holmes, C. (2002). Sensory stimulation in dementia. British Medical Journal, 325(7376), 1312–1313. Chalfont, G. E. (2007). Wholistic design in dementia care: Connection to nature with PLANET. Journal of Housing for the Elderly, 21(1,2), 153–177. Chapman, N. J., Hazen, T., & Noell-Waggoner, E. (2005). Encouraging development and use of gardens by caregivers of people with dementia. Alzheimer’s Care Quarterly, 6(4), 349–356. Chapman, N. J., Hazen, T., & Noell-Waggoner, E. (2007). Gardens for people with dementia: Increasing access to the natural environment for residents with Alzheimer’s. Journal of Housing for the Elderly, 21(3,4), 249–263. Chen, T-Y. & Janke, M. C. (2012). Gardening as a potential activity to reduce falls in older adults. Journal of Aging and Physical Activity, 20(1), 15–31. Ciechanowski, P., Wagner, E., Schmaling, K., Schwartz, S., Williams, B., Diehr, P., et al. (2004). Community-integrated home-based depression treatment in older adults – A randomized controlled trial. Journal of the American Medical Association, 291(13), 1569–1577. Cohen-Mansfield, J. & Werner, P. (1998). The effects of an enhanced environment on nursing home residents who pace. Gerontologist, 38(2), 199–208. Cohen-Mansfield, J. (2007). Outdoor wandering parks for persons with dementia. Journal of Housing for the Elderly, 21(1,2), 35–53. Cooper Marcus, C. & Barnes, M. (1999). Healing gardens: therapeutic benefits and design recommendations. New York: Wiley. Cox, H., Burns, I., & Savage, S. (2004). Multisensory environments for leisure: Promoting well-being in nursing home residents with dementia. Journal of Gerontological Nursing, 30(2), 37–45. Cutler, L. J. & Kane, R. A. (2005). As great as all outdoors: A study of outdoor spaces as a neglected resource for nursing home residents. Journal of Housing for the Elderly, 19(3,4), 29–48. Detweiler, M. B., Murphy, P. F., Kim, K. Y., Myers, L. C., & Ashai, A. (2009). Scheduled medications and falls in dementia patients utilizing a wander garden. American Journal of Alzheimer’s Disease and Other Dementias, 24(4), 322–332. Drageset, J. (2004). The importance of activities of daily living and social contact for loneliness: A survey among residents in nursing homes. Scandinavian Journal of Caring Sciences, 18(1), 65–71. Drageset, J., Natvig, G. K., Eide, G. E., Bondevik, M., Nortvedt, M. W., & Nygaard, H. A. (2009). Health-related quality of life among old residents of nursing homes in Norway. International Journal of Nursing Practice, 15(5), 455–466. Drageset, J., Natvig, G. K., Eide, G. E., Clipp, E. C., Bondevik, M., Nortvedt, M. W., et al. (2008). Differences in health-related quality of life between older nursing home residents without cognitive impairment and the general population of Norway. Journal of Clinical Nursing, 17(9), 1227–1236.

Gigliotti, C. M. & Jarrott, S. E. (2005). Effects of horticultural therapy on engagement and affect. Canadian Journal on Aging-Revue Canadienne Du Vieillissement, 24(4), 367–377. Gonzalez, M. T. & Kirkevold, M. (2013). Benefits of sensory garden and horticultural activities in dementia care: a modified scoping review. Journal of Clinical Nursing, 15 October. [Epub ahead of print]. Gosling, S. D., Vazire, S., Srivastava, S., & John, O. P. (2004). Should we trust web-based studies? A comparative analysis of six preconceptions about internet questionnaires. American Psychologist, 59(2), 93–104. Grant, C. F. & Wineman, J. D. (2007). The Garden-Use-Model – An environmental tool for increasing the use of outdoor space by residents with dementia in long-term care facilities. Journal of Housing for the Elderly, 21(1,2), 89–115. Hernandez, R. O. (2007). Effects of therapeutic gardens in special care units for people with dementia: Two case studies. Journal of Housing for the Elderly, 21(1,2), 117–152. Jacobs, J. M., Cohen, A., Hammerman-Rozenberg, R., Azoulay, D., Maaravi, Y., & Stessman, J. (2008). Going outdoors daily predicts long-term functional and health benefits among ambulatory older people. Journal of Aging and Health, 20(3), 259–272. Joseph, A., Zimring, C., Harris-Kojetin, L., & Kiefer, K. (2005). Presence and visibility of outdoor and indoor physical activity features and participation in physical activity among older adults in retirement communities. Journal of Housing for the Elderly, 19(3,4), 141–165. Kaplan, R. & Kaplan, S. (1989). The experience of nature: A psychological perspective. New York: Cambridge University Press. Kaplan, S. (1995). The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology, 15(3), 169– 182. Kearney, A. R. & Winterbottom, D. (2005). Nearby nature and long-term care facility residents: Benefits and design recommendations. Journal of Housing for the Elderly, 19(3,4), 7–28. Knochel, C., Oertel-Knochel, V., O’Dwyer, L., Prvulovic, D., Alves, G., Kollmann, B., et al. (2012). Cognitive and behavioural effects of physical exercise in psychiatric patients. Progress in Neurobiology, 96(1), 46–68. Kolanowski, A., Buettner, L., Litaker, M., & Yu, F. (2006). Factors that relate to activity engagement in nursing home residents. American Journal of Alzheimer’s Disease & Other Dementias, 21(1), 15–22. Kongsved, S. M., Basnov, M., Holm-Christensen, K., & Hjollund, N. H. (2007). Response rate and completeness of questionnaires: A randomized study of internet versus paper-and-pencil versions. Journal of Medical Internet Research, 9(3):e25. Lawton, M. P. (2001). The physical environment of the person with Alzheimer’s disease. Aging & Mental Health, 5(Suppl 1), 56–64. Lawton, M. P., Weisman, G. D., Sloane, P., Norris-Baker, C., Calkins, M., & Zimmerman, S. I. (2000). Professional environmental assessment procedure for special care units for elders with dementing illness and its relationship to the therapeutic environment screening schedule. Alzheimer Disease and Associated Disorders, 14(1), 28–38. Lee, Y. & Kim, S. (2008). Effects of indoor gardening on sleep, agitation, and cognition in dementia patients – A pilot study. International Journal of Geriatric Psychiatry, 23(5), 485–489. Lovering, M. J., Cott, C. A., Wells, D. L., Taylor, J. S., & Wells, L. M. (2002). A study of a secure garden in the care of people with Alzheimer’s disease. Canadian Journal on Aging-Revue Canadienne Du Vieillissement, 21(3), 417–427. MacDonald, C. (2002). Back to the real sensory world our ‘care’ has taken away. Journal of Dementia Care, 10(1), 33–36. Mather, J. A., Nemecek, D., & Oliver, K. O. (1997). The effect of a walled garden on behavior of individuals with Alzheimer’s. American Journal of Alzheimer’s Disease, 12(6), 252–257. Mooney, P. & Nicell, P. L. (1992). The importance of exterior environment for Alzheimer residents: effective care and risk management. Healthcare Management Forum, 5(2), 23–29.

USE OF SENSORY GARDENS AND OUTDOOR ENVIRONMENTS IN NORWEGIAN NURSING HOMES Ottosson, J. & Grahn, P. (2005). Measures of restoration in geriatric care residences: The influence of nature on elderly people’s power of concentration, blood pressure and pulse rate. Journal of Housing for the Elderly, 19(3,4), 227–256. Parker, C., Barnes, S., McKee, K., Morgan, K., Torrington, J., & Tregenza, P. (2004). Quality of Life and Building Design in Residential and Nursing Homes for Older People. Ageing and Society, 24, 941–962. Plassman, B. L., Williams, J. W. J., Burke, J. R., Holsinger, T., & Benjamin, S. (2010). Systematic review: Factors associated with risk for and possible prevention of cognitive decline in later life. Annals of Internal Medicine, 2010, 153, 182–193. Robinson, L., Hutchings, D., Corner, L., Beyer, F., Dickinson, H., Vanoli, A., et al. (2006). A systematic literature review of the effectiveness of nonpharmacological interventions to prevent wandering in dementia and evaluation of the ethical implications and acceptability of their use. Health Technology Assessment (Winchester, England), 10, iii, ix–108. Rodiek, K. & Schwarz, B. (2005). Introduction: the outdoors as a multifaceted resource for older adults. In K. Rodiek & B. Schwarz (Eds), The role of outdoors in residential environments for aging (pp. 1–6). New York: Haworth Press. Sadowsky, C. H. & Galvin, J. E. (2012). Guidelines for the management of cognitive and behavioral problems in dementia. Journal of the American Board of Family Medicine, 25(3), 350–366. Salami, O., Lyketsos, C., & Rao, V. (2011). Treatment of sleep disturbance in Alzheimer’s dementia. International Journal of Geriatric Psychiatry, 26(8), 771–782. Salguero, A., Mart´ınez-Garc´ıa, R., Molinero, O., & M´arquez, S. (2011). Physical activity, quality of life and symptoms of depression in community-dwelling and institutionalized older adults. Archives of Gerontology & Geriatrics, 53(2), 152–157. Sheehan, K. B. (2001). E-mail survey response rates: A review. Journal of Computer-Mediated Communication, 6(2). Sloane, P. D., Mitchell, C. M., Weisman, G., Zimmerman, S., Foley, K. M. L., Lynn, M., et al. (2002). The therapeutic environment screening survey

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for nursing homes (TESS-NH): An observational instrument for assessing the physical environment of institutional settings for persons with dementia. Journals of Gerontology Series B: Psychological Sciences & Social Sciences, 57B(2), S69–S78. Spector, A. E., Thorgrimsen, L., Woods, B., Royan, L., Davies, S., Butterworth, M., et al. (2003). Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia. British Journal of Psychiatry, 183(2), 248–254. Sugiyama, T. & Thompson, C. W. (2005). Environmental support for outdoor activities and older people’s quality of life. Journal of Housing for the Elderly, 19(3,4), 167–185. Vogel, T., Brechat, P., Leprˆetre, P., Kaltenbach, G., Berthel, M., & Lonsdorfer, J. (2009). Health benefits of physical activity in older patients: A review. International Journal of Clinical Practice, 63(2), 303–320. Volicer, L., Simard, J., Pupa, J. H., Medrek, R., & Riordan, M. E. (2006). Effects of continuous activity programming on behavioral symptoms of dementia. Journal of the American Medical Directors Association, 7(7), 426– 431. Wang, Y-C., Lee, C-M., Lew-Ting, C-Y., Hsiao, C. K., Chen, D-R., & Chen, W. J. (2005). Survey of substance use among high school students in Taipei: Web-based questionnaire versus paper-and-pencil questionnaire. Journal of Adolescent Health, 37(4), 289–295. Williams, C., Hadden, L., Mortimore, E., Nagy, F., Plotzke, M., & White, A. (2010). Measuring nursing home quality – The five star rating system. NESUG 2010, Centers for Medicare and Medicaid Services, Baltimore. Retrieved from http://www.lexjansen.com/nesug/nesug10/hl/hl09. pdf Woodhead, E. L., Zarit, S. H., Braungart, E. R., Rovine, M. R., & Femia, E. E. (2005). Behavioral and psychological symptoms of dementia: The effects of physical activity at adult day service centers. American Journal of Alzheimer’s Disease and Other Dementias, 20(3), 171–179. Woods, B., Aguirre, E., Spector, A. E., & Orrell, M. (2012). Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of Systematic Reviews (2), CD005562.

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