'You don't bring me flowers anymore'

The Daily Mail reports that “hospitals 'are wrong to ban flowers as a health threat'”. It said, “hospitals that ban flowers in an attempt to stop infections spreading are actually slowing patients' recovery”.

This news article is based on a light-hearted discussion in the BMJ about flowers in hospital wards. The researchers did not intend to assess the evidence in a systematic way, and it may not have necessarily identified all the relevant evidence. The Mail ’s suggestion that the flower ban is “slowing patients' recovery” is not supported by this article. No details were given for how the survey was conducted, so the views of the nurses and patients expressed in the article may not be representative.

Hospital wards are likely to continue making decisions about flowers in wards based on the associated possible risks and implications for staff. The good flower guide that the authors of this research provide (listed below) seems a sensible way to assess whether sending flowers to a person in hospital is appropriate, and how to choose these flowers.

Where did the story come from?

This article was written by Giskin Day, a course director in the medical humanities, and Naiome Carter, a medical student, from Imperial College London. No sources of funding were reported, and the authors had no competing interests. The article was published as a feature article in the Christmas issue of the British Medical Journal .

What kind of research was this?

The article discusses some of the background on the debate about whether flowers should be allowed in hospital wards. It also examines the results of a cross-sectional survey looking at attitudes of patients and medical staff towards hospital flowers.

This is a light-hearted discussion of the issues and a survey of people’s attitudes. The researchers did not intend to assess the evidence in a systematic way, and so it has not necessarily identified all the relevant evidence. No details were provided about how the survey was conducted, so the views of the nurses and patients may not be representative.

What did the research involve?

The researchers asked patients and staff at the Royal Brompton Hospital and the Chelsea and Westminster Hospital in London about their attitudes to flowers in hospitals. They discuss the reasons why many hospital wards have banned flowers on wards, and what the benefits of flowers might be. They provide references to studies cited in support of these discussions.

The Daily Mail and Daily Telegraph covered the article. Although the researchers cite one study that found health benefits of flowers, the Mail’s suggestion that researchers have found that the flower ban is “actually slowing patients' recovery” is not supported by this article. Both newspapers failed to point out that this article was not a systematic review and therefore may miss important pieces of evidence.

What were the basic results?

Many hospitals have long accepted policies of not permitting flowers in high-dependency units. The authors say that since 1996, hospitals have reportedly banned flowers from general wards. They were motivated by the need “to show they were taking hospital acquired infections seriously”.

The authors say that hospitals have justified the ban on the grounds that flower water contains dangerous bacteria. They say that although a 1973 study found high counts of bacteria in flower water, subsequent research “found that there was no evidence that flower water has ever caused hospital acquired infection”. In a letter to the British Florist Association in 2007, the Department of Health said that it was “not aware of any instance of healthcare-associated infection being traced to cut flowers in the hospital ward setting”.

The authors’ survey found that hospital staff were “more concerned about the practical implications of managing flowers than risks of infection”. One nurse claimed that the biggest problem was curtains knocking over vases resulting in broken glass and water on the floor. Another nurse was “adamantly opposed” to flowers on the ward, saying that staff don’t have time to change the flowers’ water, spillages were responsible for falls and pollen caused hay fever. The authors say that “procedures for dealing with flowers vary from ward to ward”.

They say that staff tended to be more receptive to flowers on private wards. One nurse on such a ward said that flowers were welcome as long as there weren’t too many and they weren’t too smelly. On this ward, rooms had space for flowers, and cleaners tended to them, therefore they didn’t consume nurses’ time.

One patient said that flowers made her feel better, while another said that they had “enhanced his experience of his hospital stay”. The authors also cite a study which found that flowers could elicit a smile and improved mood in women. They also cited a small randomised controlled trial (RCT) which found that patients in rooms with plants needed fewer post-operative analgesics, had reduced blood pressure and heart rate, less pain, anxiety and fatigue, and more positive feelings than patients in a control group without flowers.

The researchers say that “florists need to be aware of the practical implications of providing flowers for patients”.

How did the researchers interpret the results?

The researchers added that bedside lockers “could be better designed to hold vases in such a way as to prevent spillages”. They also say, “the giving and receiving of flowers is a culturally important transaction”. They also supply a “Good flower guide” for giving flowers to people in hospital:

• Check whether the ward accepts flowers before sending them.
• If you are a regular visitor take responsibility for changing the water in the flowers.
• If it is only a short hospital stay, send the flowers to the patient’s home, as transporting the flowers is an extra complication.

• Bouquets are more likely to be accepted if they are:

• not too big and unwieldy,

• arranged in florists’ foam rather than in a glass vase or in no vase at all,
• placed on a firm base that is unlikely to tip over,
• composed of flowers that do not shed pollen, and
• not too heavily scented.

Conclusion

This research didn't assess this issue in a systematic manner, so it may not have identified all the relevant evidence. No details were provided about how the survey was conducted, so the views of the nurses and patients may not be representative.

Hospital wards are likely to continue making decisions about whether to accept flowers based on the associated risks and workload implications. The good flower guide provided by the authors seems a sensible way to assess whether sending flowers is appropriate, and how to choose them.