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SANITARNO INŽENIRSTVO / International Journal of Sanitary Engineering Research
2023;16(1): 4-13. DOI: 10.2478/ijser-2023-0002
Advantages of greenery in
hospital environment 
- a literature review
   Angela Boškin Faculty of Health Care
Spodnji Plavž 3
4270 Jesenice, Slovenia
   University of Ljubljana
Faculty of Civil and Geodetic Engineering
Chair of Buildings and Constructional Complexes
Slovenia
*Corresponding author:
Assoc. Prof. Mateja Dovjak, PhD, BSc Sanitary Engineering
University of Ljubljana
Faculty of Civil and Geodetic Engineering
Chair of Buildings and Constructional Complexes
Jamova 2
1000 Ljubljana, Slovenia 
Email: mateja.dovjak@fgg.uni-lj.si
© 2023 Sedina KALENDER - SMAJLOVIĆ, Mateja DOVJAK. This
is an open access article licenced under the Creative Commons
Attribution NonCommercial- NoDerivs license as currently
displayed on http://creativecommons.org/licenses/by-nc-
nd/4.0/.
Sedina Kalender – Smajlović    and Mateja Dovjak*  
Keywords: Room plants; Hospitals; Vegetation; Green systems; Greenery;
Plants
ABSTRACT
Background: Incorporating greenery into hospital environment contributes
to the sustainable development goals by mitigating health, environmental
and economic problems. Despite the increasing interest in plants, gardens
and green roofs in general built environments, the benefits of greenery in
hospital environment are still under-researched. The aim of this review was
to summarize the relevant literature and describe the benefits of greenery
in hospital environment. 
Methods: The PubMed, Springer Link and CINAHL databases were searched
to identify relevant studies and articles published between 2012 and 2023.
The keywords used were hospitals, greenery, green systems, vegetation,
and room plants. The language restriction was that articles were published
in English. 
Results: Following the PRISMA methodology, seven eligible studies were
included in the literature review. Evidence shows that the presence of
greenery affects patient health outcomes and the well-being of healthcare
staff. Moreover, the healing and therapeutic effects greenery in the hospital
environment have been identified. Greenery also has a positive
psychological effect on healthcare workers and visitors. Humanizing
healthcare spaces and connecting them with nature empowers patients,
reduces stress and pain, and improves emotional well-being. 
Conclusion: The biophilic design concept increases occupant connectivity
to the natural environment through vegetation at the location, including
implemented green building envelope systems (green walls and roofs) and
the introduction of indoor plants. It should be incorporated into the
established steps of hospital design. In summary, more research is needed,
particularly on the potential impact of plants on hospital-acquired
infections.
Literature Review article
Received: 21. 2. 2023
Accepted: 3. 11. 2023
Published: 31. 12. 2023 
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Revija Sanitarno inženirstvo / International Journal of Sanitary Engineering Research Vol. 16 | Issue 1 | 2023
S. Kalender - Smajlović, M. Dovjak
5
 
A lot of space is lost in positioning buildings at location areas. »Camouflage
architecture« is based on rationalization, where land is draped over the building
envelope. Green building systems (i.e. green roofs, green walls and green
building envelopes) are passive techniques that can be used to solve the
problems of modern cities. Such an approach contributes to the sustainable
development of an urban environment [1]. With the Industrial Revolution, urban
space expanded much faster and with greater changes than in previous
evolutionary periods. 
The large areas that modern cities occupy, their structure, materials, and the
general lack of vegetation have inevitably altered the climatic characteristics of
urban spaces. These changes directly affect the local climate of urban areas,
especially the central parts of cities, leading to a significant increase in urban
temperature and other changes, known as the urban heat island effect [2]. 
Greenery contributes to sustainable development with environmental,
economic and health benefits. Environmental benefits include i. rainwater
allocation and purification [3], ii. improvement of air quality, iii. sound
insulation and improved acoustics [4], iii. reduction of the urban heat island
effect [5], iv. increasing energy efficiency (on global, regional, and local levels)
[6, 7], v. green roofs as a substitute for lost landscape areas [3] and natural
habitat for animals and plants [8]. In addition to economic benefits in terms of
lower renovation costs [2], lower energy costs [9,10], lower
wastewater/meteoric water management costs and space use [3], several
benefits of green systems are reflected in all health determinants. These
include social, psychological and physical health. An experimental study on the
effects of green roofs on the built environment [9] highlights the contribution of
green roofs to the reduction of mortality and morbidity as a result of minimizing
the harmful effects of excessive heat and air pollution in urban environments.
The Green Roof Organisation [11] considers green roofs as elements of healthy
cities and states that horticultural therapy leads to better recovery after
surgery. Simonič and Dobrilovič [3] argue that recreational spaces improve
health and aesthetics, socializing, and positively affect the indoor climate by
increasing thermal comfort and occupant productivity as well as reducing sick
building syndrome. 
Plants and planted landscapes are known for their therapeutic benefits.
Hospitals are increasingly adopting therapeutic landscapes such as healing
gardens, horticultural therapy, and memory gardens [12]. In recent decades,
human-plant research has increasingly focused on providing empirical evidence
of the relationships between plants and health [13]. Several trial studies have
revealed that observing nature or even images of nature scenes have beneficial
effects on mood and mental health. A Japanese study [14] reports that looking
at plants altered EEG recordings and reduced stress, anxiety, anger and
sadness, and lowered blood pressure, pulse rate and muscle tension. Another
Japanese study [15] found that looking at a green hedge was physiologically
more beneficial than looking at a concrete fence. 
INTRODUCTION
Several trial studies have revealed
that observing nature or even
images of nature scenes have
beneficial effects on mood and
mental health.
Greenery contributes to sustainable
development with environmental,
economic and health benefits.
Revija Sanitarno inženirstvo / International Journal of Sanitary Engineering Research Vol. 16 | Issue 1 | 2023
  Inclusion criteria  Exclusion criteria 
Language  English All others 
Date of publishing  2012 – 2023  Before 2012 
Article category 
Original research
Systematic review
Review article 
Editorials
Professional
articles
Letters
Keywords 
Room plants and
hospitals
Vegetation, green
systems, greenery,
plants
 
S. Kalender - Smajlović, M. Dovjak
6 
The PubMed, Springer Link and CINAHL databases were searched to identify
relevant studies and articles published in the last decade (2012-2023). The
keywords used were hospitals, greenery, vegetation, green systems, outdoor
plants and room plants. The language restriction was that the articles were
published in English. Studies and review articles describing greenery were
summarised. Literature selection was made as illustrated in Table 1.
Despite the increasing interest in green plants, gardens and green roofs, the
benefits of greenery in the hospital environment are still under-researched. In
the hospital setting, environmental factors and architectural layout should be
emphasized as part of infection control measures, in addition to identifying
patients at risk for hospital-acquired infections and following standard
precautions to reduce transmission [16]. As noted by Gould et al. [17], there
are frequent discussions on hygiene and infection risks associated with cut
flowers introduced into the hospital environment. It has been reported that
this practice is no longer allowed in many wards because the flowers are
considered to be hygienically problematic, cause allergies, and harbour
bacteria in the water that can cause infections. Based on these findings, this
study aimed to summarise the relevant literature and describe the benefits of
greenery in the hospital environment.
MATERIALS AND METHODS
RESULTS
The search results are shown in Figure 1. The systematic review included
seven articles. An overview of the studies analyzed is shown in Table 2.
Table 1: Inclusion and exclusion criteria
Despite the increasing interest in green
plants, gardens and green roofs, the
benefits of greenery in the hospital
environment are still under-
researched. 
Based on these findings, this study
aimed to summarise the relevant
literature and describe the benefits of
greenery in the hospital environment.
Revija Sanitarno inženirstvo / International Journal of Sanitary Engineering Research Vol. 16 | Issue 1 | 2023
S. Kalender - Smajlović, M. Dovjak Figure 1: Flow diagram
Table 2: Index of articles included in the final analysis
Authors, year Aim  Type of study  Population  Country  Results 
Kim, Ahn [18] (2021)  
To investigate the role of green
spaces in the immediate
surroundings of a hospital on
the incidence of asthma. 
Cross-sectional study Patients with asthma California, UnitedStates of America 
Findings suggest that creating dense or clustered tree
patches and small-scale green spaces could
substantially improve air quality and reduce asthma
emergency room visits.
Beukeboom,
Langeveld, Tanja-
Dijkstra [19] (2012)
To investigate the effect of
exposure to nature or artificial
nature on reducing patients'
stress. 
Field research 
N = 457 patients (60%
women and 40% men)
in two radiology waiting
rooms
Netherland
Natural elements in the hospital environment can
reduce patients' feelings of stress. The presence of
greenery or posters of plants in waiting rooms creates
a pleasant atmosphere that has a positive effect on
patients' well-being.
Qi, Yan, Lau, Tao
[20] (2021)
To investigate the impact of
the hospital environment
(paediatric clinic) on patients
and relatives.
Case study  N = 195 persons  China 
Optimizing the design of the waiting area in pediatric
clinics, focusing on functional layout, flow
organization, supporting facilities and environmental
details, can improve overall 
satisfaction with pediatric waiting rooms.
Ali Khan, Amin, Khan,
Imtiaz, Khan, Imran,
Asad, Badshah [21]
(2016)
To investigate the therapeutic
horticultural impact of indoor
plants and floral arrangements
on health outcomes in surgical
patients.
Case study  N = 270 patients  Pakistan 
Plants and floral arrangements have an effect on
shorter postoperative length of stay, lower analgesic
intake, and lower pain intensity than a ward without
greenery.
Raanaas, Patil, Hartig
[22] (2012)  
To study the effect of looking
out of the window on the
natural environment by
patients in rehabilitation. 
Longitudinal quasi-
experiment  N = 288 patients  Norway
Looking out of the window at the natural environment
helps improve physical and mental health. Differences
were found according to gender and a diagnostic
group of patients. 
Korpela, De Bloom,
Kinnunen [23] (2014) 
To study the effects of
houseplants and looking out of
the window on recovery and
restoration.
Literature review N = 63 articles   Finland 
In a hospital setting, the view on nature is important.
Research reveals the therapeutic effects of natural
environments that reduce stress. They focus on the
effects of looking at or exercising in nature, the setting
and effects of indoor plants and views on nature
through windows. 
Song, Ikei, Nara,
Takayama, Miyazaki
[24] (2018)
To examine the effects of
viewing bonsai on autonomic
nervous system activity,
prefrontal cortex activity and
subjective ratings of
psychological relaxation in
elderly patients undergoing
rehabilitation.
Cross-sectional study N = 14 participants Japan
Viewing bonsai resulted in a significant increase in
parasympathetic nervous system activity, a
substantial decrease in sympathetic nervous system
activity, and a significant increase in the feeling
»comfortable and relaxed«.
7
Natural elements in the hospital
environment can reduce patients'
feelings of stress. 
Revija Sanitarno inženirstvo / International Journal of Sanitary Engineering Research Vol. 16 | Issue 1 | 2023
8 
DISCUSION S. Kalender - Smajlović, M. Dovjak
This review has identified the advantages of greenery in a hospital setting.
Interestingly, Kim and Ahn [18] used two spatial regression models to show
that the associations between greenery (i.e. trees/green spaces) and asthma
are highly significant. However, Ali Khan and colleagues [21] found that
patients in a ward with greenery had more vigorous psychological moods
regarding recovery from surgery and more positive emotions and feelings
about their hospital stay. They also felt that atmosphere in the ward as more
calming, pleasant and satisfying. In addition, focus group discussions with
doctors and nurses in the ward confirmed the questionnaire findings that i)
leafy plants and flower arrangements create a nurturing environment in the
ward, ii) reduce patients' stress, iii) improve patients' health and mental state
and iv) bring a pleasant atmosphere to the hospital environment. These
findings confirm the therapeutic value of horticultural activities, especially for
surgical patients in a stressful hospital environment. The study by
Beukeboom, Langeveld, and Tanja-Dijkstra [19] also confirms that patients
exposed to natural plants and those exposed to plant posters reported lower
levels of stress compared with patients who had no greenery in the hospital
environment. Further analyses showed that these small but significant effects
of exposure to nature were partly mediated by the perceived waiting room
functionality.
In the study by Qi, Yan, Lau, Tao [20] it was found that the waiting rooms in
pediatric clinics currently do not to meet the essential needs of patients in
areas such as mother and infant rooms, children's play areas and drinking
water facilities. There are widespread problems with creating natural
environments, such as views on natural scenery out of the window and indoor
green plants. Six factors were found to have significant positive impact on
overall satisfaction with the waiting area, describing 69.7% of the changes in
the respondents' level of satisfaction with the waiting environment.
Interestingly, Raanaas, Patil, Hartig [22] also found that a blocked view
appeared to negatively affect physical health change in women. In contrast,
obstructed vision appeared to negatively affect mental health in men.
Pulmonary patients with a panoramic view showed more significant
improvement in mental health than coronary patients with such a view. Those
who had a panoramic view of nature often chose to stay in their bedroom
when they wanted to be alone than those who had an obstructed view. Song et
al. [24] also found that viewing bonsai significantly increased parasympathetic
neural activity and decreased sympathetic neural activity by physiological
measurements. These results are partially consistent with the findings of
previous studies on the effects of viewing leafy plants, fresh flowers and
bonsai in a hospital setting [25].
Totaforti [26] argues that the global health challenges of the 21st century
require a new way of thinking and a change in the organization of health
services, with an approach that takes into account human needs in their
entirety rather than in a strictly therapeutic sense. Numerous studies show
that humanizing healthcare facilities and contact with nature can empower
patients and have a positive impact by reducing stress and pain and improving
emotional well-being. As healthcare facilities continue to move towards more
sustainable business models, with a focus on energy efficiency and
environmental care, the popularity of installing vegetative roofs is likely to
increase [27]. 
These findings confirm the
therapeutic value of horticultural
activities, especially for surgical
patients in a stressful hospital
environment. 
Patients who viewed the green
surface had fewer postoperative
complications, required less pain
medication and had a hospital stay
that was almost 9 % shorter than
those who viewed the brick wall.
Revija Sanitarno inženirstvo / International Journal of Sanitary Engineering Research Vol. 16 | Issue 1 | 2023
9
S. Kalender - Smajlović, M. Dovjak As has been pointed out in the past, the healing power of green spaces is a
significant advantage of installing vegetated roofs in healthcare facilities. In a
study [28] the recovery time of surgical patients looking out the window at a
brick wall was compared with those looking at green areas. Patients who
viewed the green surface had fewer postoperative complications, required less
pain medication and had a hospital stay that was almost 9 % shorter than those
who viewed the brick wall. As the Association of American Medical Colleges
[29] notes, gardens also serve the purpose of expanding the healing
environment by providing natural light, fresh air, space to move around and
space for patients to exercise. 
Howarth, Brettle, Hardman, Maden [30] found highly positive effects of gardens
and gardening on health, well-being and improved functional biometric
outcomes based on a scoping review involving 77 studies. Interventions ranged
from garden visits, gardening and therapeutic activities. Findings showed
associations between gardens and improved mental well-being, increased
physical activity and reduced social isolation. Perez, Alexander and Bailey [31]
note that the appearance of plants is beneficial: their leaves remove toxins,
dust and microorganisms from the air and produce the negative ions from their
leaves. The overall evidence that charged ions affect mood is unconvincing,
although their benefits are strongly promoted in advertising.
Thompson [32] notes that there is increasing evidence that exposure to plants
and green spaces, particularly horticulture, is beneficial for mental and physical
health and could reduce pressure on hospitals. Health professionals should
therefore encourage their patients to use green spaces and work in gardens
and should put pressure on local authorities to provide more open spaces and
more trees, which would also help prevent air pollution and climate change.
Therapeutic gardens have been used in hospitals for millennia and were
strongly advocated by Florence Nightingale as they help improve the
environment for patients, visitors and staff [33]. The therapeutic garden is
becoming increasingly popular as a non-pharmacological approach in the
modern healthcare system. It is a type of healing garden used primarily as a
physical therapy or horticultural therapy programme, which may include both
horticultural and non-horticultural activities. These activities are very helpful in
treating patients, reducing stress in health care workers and patients,
improving hospital outcomes, increasing work efficiency and reducing medical
costs [34]. Korpela and colleagues [23] report that evidence shows that looking
out the window at nature mitigates the negative effects of workplace stress;
the more natural elements present, the lower the negative effects of workplace
stress on intention to leave. A laboratory study that recorded brain waves and
blood volume pulses found that people were less nervous or anxious when
looking out of a window at nature than when looking out of a window at the city
or no window. The amount of contact with nature during work breaks is also
associated with less perceived stress and better self-rated health. Research
has shown that while plants in the office seem to improve creative task solving,
they interfere with simple tasks, such as proofreading or sorting, which require
constant focus on the task at hand. 
Geimer-Flanders [35] notes that complementary and alternative medical
practices can be combined with evidence-based conventional medicine to
promote an optimal healing environment and overall well-being for patients. 
The therapeutic garden is becoming
increasingly popular as a non-
pharmacological approach in the
modern healthcare system.
Research has shown that while plants
in the office seem to improve creative
task solving, they interfere with
simple tasks, such as proofreading or
sorting, which require constant focus
on the task at hand. 
Revija Sanitarno inženirstvo / International Journal of Sanitary Engineering Research Vol. 16 | Issue 1 | 2023
10 
We emphasize the transition from therapeutic gardens as curative to sensory
gardens with therapeutic elements that would address all sensory and motor
systems according to universal design principles. This ensures health
(physiological, social, psychological components), comfort and well-being. 
The results of our study provide opportunities to implement biophilic concepts in
the current design of the hospital environment [2, 36-38]. Specifically, the design
of healthy hospitals should start from site characteristics, where strengths and
weaknesses are defined. Advantages such as existing green areas, natural
habitats and water (lakes, rivers) should be preserved, optimum insolation of the
building should be ensured, and this should be linked to the building design.
Disadvantages such as proximity to industry and busy roads with increased noise
and pollutant emissions can be avoided by ensuring optimal building and room
orientation, setbacks, and by incorporating natural green barriers. Potential
excessive solar gain, and thus overheating of the building, can be regulated by
selecting trees that block the sun's rays in summer and let them pass through in
winter. 
Climbing plants and pergolas can already be part of the active living shade on the
building, as well as orientation of the building and active spaces towards the
views of greenery outside, and incorporating green systems (green roof, green
wall) into the envelope. These envelopes have numerous environmental, social,
health and economic benefits. They also have a water collection and purification
function. Parts of the building envelope functionally connect and extend to the
external surfaces and form part of the healing garden. They integrate water and
plants into the indoor environment, especially in common and communication
areas. From a sanitary technical and hygienic point of view, closed transparent
systems and indoor elements with vegetation can also be designed to let in direct
light. All this becomes part of the bioclimatic design of buildings [2, 36-39].
S. Kalender - Smajlović, M. Dovjak
CONCLUSION
To ensure the well-being of patients, healthcare staff and visitors in the
hospital environment, there has been a growing stream of research addressing
the impact of vegetation on patient health outcomes and the well-being of
occupants. Based on the evidence-based approach, the healing and
therapeutic effects of greenery in the hospital environment have been
identified. 
The recommend biophilic design concept increases occupant connectivity to
the natural environment through: i. the use of on-site vegetation, ii. with
implemented green building envelope systems (green walls and roofs), and iii)
the introduction of indoor plants. The possible risks of plants should be
considered to prevent health-related infections in the hospital environment.
From a sanitary technical and
hygienic point of view, closed
transparent systems and indoor
elements with vegetation can also be
designed to let in direct light.
The possible risks of plants should be
considered to prevent health-related
infections in the hospital
environment.
Revija Sanitarno inženirstvo / International Journal of Sanitary Engineering Research Vol. 16 | Issue 1 | 2023
JOURNALISM ETHICS CONSIDERATIONS 
Ethical issues (Including plagiarism, informed consent, misconduct, data
fabrication and/or falsification, double publication and/or submission,
redundancy, etc.) have been completely observed by the authors.
S. Kalender - Smajlović, M. Dovjak
11 
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CONFLICT OF INTEREST
The authors acknowledge the financial support from the Slovenian Research
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ACKNOWLEDGEMENTS
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