The importance of nature is well-known. Our indigenous ancestors lived close to and respected nature, believing humans and the elements of nature — animals, plants, natural forces and geographic features — were all members of an extended ecological family. The antelope, trees, sun, sky, lightning, rain, stones, seas, and rivers were all living things, vitally interconnected and kin. Today we know people want to be close to nature, as we hear some individuals hug trees. Human-centered design and access to the natural environment positively impact health outcomes and LTC residents’ quality of life. When people are confined, lack of access to nature, like direct sunlight, is one of the most disturbing aspects of their situation. There exists a whole literature of confinement. Harriet Jacobs, in her book Incidents in the Life of a Slave Girl Written by Herself, describes the garret where she was confined. “There was no admission of either light or air, the darkness total. The continual darkness was oppressive.” The Moroccan prisoner in This Blinding Absence of Light describes his cell thus: “A bottomless pit. If only for a moment, hope for a ray of light. Night cloaked us. No springtime. No blue sky. Above all no light. No more stars. No more moon. Endless life in extreme deprivation.” Nursing home residents are, obviously, neither slaves nor prisoners, but suffer a similar fate, often incarcerated by age and infirmities, not able to benefit from the healing power of nature. A current resident’s situation was shared with me by her friend. I quote: “Eleni was transferred from a bed next to a window with a beautiful view of trees and a landscaped area to a bed that not only is on the corridor side of the room but also doesn’t have access to a window. Her roommate keeps the divider curtain drawn 100% of the time, which blocks Eleni’s view. Her roommate is 105 years old and, understandably, no one wants to upset her. However, the situation leaves Eleni in a dark, boring atmosphere. Bad enough during a normal day schedule, but the situation becomes totally isolating whenever she is confined to her nap time, during the 1+ months she was bedridden to help a pressure sore heal, and when she was recuperating from pneumonia. The isolation contributes to her depression.” A colleague wrote that she continues to be haunted by how her mother, a lifelong gardener of peas, beans, squash, turnip greens, tomatoes and flowers, felt being cut off from the nature and plants she so loved. In her nursing home for 10 years, she rarely went outside; it was not part of her care plan. The woman’s sadness was expressed in the letter she sent to the nursery she used to frequent. I quote: “Dear Friends, I have been thinking of writing, and letting you know why I haven’t given an order for so long. I have arthritis now and live in a nursing home, where I guess I will be for as long as I live. But, I want you to know, I have really enjoyed my flowers and vegetables I have grown from the seeds and plants I got from you. I miss my gardening and flowers so much, but am thankful I was able to work with them as long as I did. I’m 81 now, so guess it’s time to stop and rest. I’ll probably order a few houseplants once in a while. I’m writing this in bed, so please excuse writing. Sincerely...” Published research studies from multiple disciplines — biology, medicine, health promotion, and environmental psychology — provide evidence to support the theory that access to nature improves physical and psychological health. Studies have shown improved observable clinical outcomes, including better heart rate and blood pressure, and less pain. Other studies have shown that the restful contemplation and calming effects of nature are restorative. Eliciting pleasant feelings reduces stress and anxiety, increases energy, and improves mental health — alertness, mood, and satisfaction with life. Windows. The nursing facility is our home where we may live the rest of our lives, rarely ever stepping foot outside, not able to come to sunlight on our own. Access to natural elements is thus a critical need that can be achieved through supportive design of the built environment. Health care architects should be asked to see that every bed has access to a window, now the law in Florida. Providers should see that windows are operable for fresh air, air exchange, comfortable temperature, and oxygen. At residents’ request, staff should open and close windows, and pull the blinds up and down. Natural light is critical to residents’ health and well-being. In many rooms the blinds are drawn, blocking the view. Nursing assistants contribute to this problem, fearing someone might look in and want windows covered. If every resident has a window, compelling views like the following can be seen. Spring — light coming sooner, trees budding yellowish-green, crocuses and daffodils pushing up, robins and sparrows flying and chirping, rain showers. Summer — bright sunshine, green green grass, soil, weeds, a warm breeze through the window. Autumn — spectacular scenery with leaves a brilliance of color, birds flying south. Winter — first flakes of snow on window panes, dazzling ice, bare branches on trees, darkening early. All year the sky — floating and ever changing clouds — white, dark, stormy, low, with lightening and colors, sunset and sunrise, night sky, twilight, stars and moon. Courtyards and Gardens. Providers should design courtyards with gardens and stable paving for walking or wheeling. Side rails are essential to avoid injury. Lots of chairs and benches with armrests should be available. Include gardens and garden containers or boxes at different heights. Provide overhangs for shade. There should be easy access to the courtyard with automatic door openers, as big heavy doors are difficult to open. Providers should assist residents in getting out, and make sure there are opportunities for both individual and group activities. Residents can experience an effortless form of nature which engages all the senses — being in sunlight, hearing sounds of rustling leaves, feeling a breeze, seeing bird life. Residents can slow down, lose a sense of time, observe, smell, play, rest, linger, relax, reflect, meditate, restore, be soothed. For those who are able, the positive effects of gardening are numerous. Since it involves moderate physical activity, it provides opportunities for exercise, improving strength and flexibility, endurance, and standing tolerance for those who are ambulatory. Cultivation of vegetables and flowers provides cognitive benefits — taking the initiative, being creative, using self-expression, taking responsibility, caring and nurturing plants, being effective as flowers and plants mature. Socially, a resident can have a private encounter or choose the opportunity to connect with others. Managements of facilities should have policies that ensure inclusion of access to nature in care plans, and sufficient staff to meet this basic need for healing. During 14 years in my facility, I have experienced the importance of nature. My window view has been essential, especially when two roommates died. I was able to look at their peaceful faces, and then at the tree outside that I follow seasonally, representing the eternal cycle of life. Outside for the first time in years, I enjoyed, with the wonder and delight of a child, snowflakes falling on my face and the soaring canopy of trees at the end of our parking lot. A letter to the editor I co-authored in Health Environments Research and Design Journal (2014;7[4]:135–39) and a lecture I gave in December 2015 on human-centered health care design describe my experiences with natural elements in more detail. The video and video text of the lecture are available on the website of the Institute for Human Centered Design Boston (www.humancentereddesign.org/news-events/diana-anderson-penny-shaw). Recently in Massachusetts, advocates won two related legislative efforts. First, a Dementia Special Care Unit law and regulations for special units now requires that windows in residents’ rooms be operable with secure locks, and that secure outdoor recreation space with walkways and secure fencing or barriers that prevent injury and elopement be provided. The regulations also require that providers help residents gain access to the outdoor space and walkways during reasonable times, with supervision appropriate to each resident. Second, a Fundamental Right to Fresh Air was added in 2015 to the existing Five Fundamental Rights law, an amendment to the existing Massachusetts mental health laws. This right added daily fresh air to other fundamental rights of patients of mental health facilities. These victories represent hope that all nursing home residents too may someday enjoy natural elements directly. Supportive design and access to nature can be powerful and consequential. Problems can be attenuated and lives changed. Sometimes it’s the smallest of environmental conditions that makes life tolerable — something as simple as windows and courtyards with gardens. Dr. Shaw is a board member of the Massachusetts Advocates for Nursing Home Reform and of the Disability Policy Consortium in Boston; a member of the Citizens Advisory Committee of the Massachusetts Executive Office of Elder Affairs; and a policy adviser to the Nursing Home Division, Survey and Certification Group, in the Centers for Medicare & Medicaid Services.