healing gardens in hospitals - clare cooper marcus

HEALING GARDENS IN HOSPITALS

Clare Cooper MarcusUniversity of California, Berkeley

The Architecture of HospitalsApril 2005

Outline of Presentation

• History of outdoor spaces in hospitals and why healing gardens have recently become of interest

• Design guidelines• Precedents drawn upon by designers of

contemporary healing gardens

History and Recent Developments

• Medieval monastic cloister garden

• Early example of restorative outdoor space for sick patients

1.MIDDLE AGES

2. RENAISSANCE

• 17th-18th century : Period of large municipal hospitals

• Buildings surround courtyards for exercise and air circulation

3. PAVILION-STYLE HOSPITALS

• Mid-19th-early 20th century

• Pavilion hospital, providing fresh air, sunlight and views to nature inspired by work of public health reformer,Florence Nightingale

Johns Hopkins Hospital,Baltimore

3.PAVILION-STYLE HOSPITALS

• Early 20th century

• TB sanitoria and mental asylums provide maximum exposure to sun, fresh air, and gardens to assist in healing

4. MEGA HOSPITALS

• Mid-20th century• Neo-classical style

thrown out in favor of International Style

• High rise buildings with emphasis on efficiency

• Nature succumbs to cars and parking lots

Nebraska Methodist Hospital,Nebraska Methodist Hospital,Omaha,Nebraska,USAOmaha,Nebraska,USA

4. MEGA HOSPITALS

• 1980s

• Hospitals resemble corporate office buildings

• Little concern for usable outdoor space

KirklinKirklin Clinic, Birmingham, Alabama,USAClinic, Birmingham, Alabama,USA

5. PATIENT CENTERED CARE

• 1990 - Present

• Negative reactions to institutional environments

• Competition between hospitals in US

• Greater concern for patient needs

• Slow shift to more welcoming , familiar imagery in interiors

Monterey Community Hospital,Monterey Community Hospital,Monterey,CaliforniaMonterey,California

5.PATIENT CENTERED CARE

• Designers look to familiar icons that may feel comfortable for patients and staff

• The shopping mall

Dartmouth-Hitchcock Medical Center,Lebanon, New Hampshire,USA (1992)


• Designers look to regional context for more appropriate styles, forms, colors and materials

San Diego Children’s Hospital, San Diego,California( 1990-93)


• 1984: Significant study by Roger Ulrich finds views to nature have positive influence on health outcomes

• Patients recovering from gall bladder surgery with view to trees had fewer post-surgery complications, required fewer doses of strong pain drugs, went home sooner…

Compared to those looking out at a brick wall

• At last…credible scientific evidence that nature has healing properties

5.PATIENT CENTERED CARE • Important research by

Roger Ulrich, Terry Hartig et al

• Viewing - or being in -nature causes physiological and psychological changes

• Body/mind returns to state of balance, and contributes to state of wholeness and health

• Medical authorities see nature/trees in hospital setting as not just cosmetic extras--may speed recovery, save $$$St Michael’s Medical Center, Texarkana

Texas


• Hospital clients commission art with nature images

Scripps Mercy Hospital,San Diego, California


• Product designers create features for hospitals with nature themes

HOSPITAL GARDEN RESEARCH

• 1994 - First systematic post-occupancy study of hospital outdoor space in US

• 4 hospital gardens in San Francisco Bay area studied using visual analysis, behavior mapping, and interviews

Roof garden, Alta Bates Hospital,Berkeley,California

(Cooper Marcus and Barnes, 1994)(Cooper Marcus and Barnes, 1994)

Sample

• 2,140 people observed

• 143 people interviewed– 73 female– 70 male

staff59%

visitors15%

patient26%

User categories:

• 2,140 people observed

• 143 people interviewed

–73 female

–70 male

Activities in the Gardens94%

73% 73%68%

61%

53%

38% 36%

12% 11%

0%

50%

100%

Relax Eat Talk Pass by Stroll Therapy Wait Visit Play Meeting

How do you feel after spending time in the garden?

• More relaxed,calmer 79%• Refreshed,stronger 25%• Able to think/cope 22%• Feel better, more positive 19%• Religious or spiritual connection 6%• No change of mood 5%

What is it about the garden that helps you feel better?

• Trees,plants,nature 69%

• Smells, sounds, fresh air 58%• Place to be alone or with friend 50%• Views,sub-areas,textures 26%• Practical features, benches etc 17%• Don’t know 8%

• Typical garden-user responses:

“My level of stress goes way down..I return to work refreshed.”

“I sit in the garden before my appointment; it helps me deal with what they will put me through.”

“I work in the Intensive Care Unit which is like a hell hole…sitting here in the sun is like therapy for me”

“I work underground in the Radiation Department, like one of the Mole People. If I didn’t have this garden to come to…sunlight, fresh air, birdsong, trees…I think I’d go CRAZY!”

Kaiser Permanente HospitalKaiser Permanente HospitalWalnut Creek, CaliforniaWalnut Creek, California


• Results of post-occupancy evaluations of hospital gardens, and design guidelines for future gardens, published 1999


• Some of first healing gardens in US created by patients who saw potential of wasted space and raised money to pay for design

Before

After

Cancer Clinic, St Vincent’sHospital,Santa Fe, New Mexico


• American Society of Landscape Architects begins to hold special sessions on healing gardens at its annual conference

• 2003 - School of Chicago Botanic Garden initiates first US course on Healthcare Garden Design


• Mid 1990s: Hospital staff begin to lobby for usable outdoor spaces

• Horticultural therapist lead team of hospital staff, working with landscape architect, to transform dull, useless space at this hospital into vibrant garden used for physical therapy, speech therapy and horticultural therapy

BeforeBefore

After After Good Samaritan Hospital,Good Samaritan Hospital,Portland,OregonPortland,Oregon

Factors contributing to emergence of interest in healing gardens , beginning in 1990s

• Understanding of mind-body connection

• Stress reduction enhances immune function

• Interest in alternative or complementary medicine

• Awareness that hospitals must be not only functionally efficient, but also patient-centered / psychologically supportive

• Evidence that environmental factors(light, temperature, noise, music, nature) play role in improved patient health-outcomes

• Recognition(in US) that attractive environment is good marketing tool in competitive healthcare

Alternative medicine begins to be recognized by government bodies and medical schools

• 1992 - Office of Alternative Medicine established within National Institutes of Health, Washington,DC

• 1999 - University of Minnesota offers first U.S. graduate level courses in alternative medicine

• 2005 - 26 medical schools in U.S. now offer such courses

• Nature and healing no longer viewed as a “fringe”idea

THE HEALING GARDEN: Essential design elements and environmental qualities

Guidelines based on stress research, post occupancy studies of hospital

outdoor space, and field observations at more than 100 hospital gardens in

US,UK,Canada and Australia

HEALING GARDEN

• Facilitates stress reduction, helps body reach more balanced state

• Helps person summon up own inner healing resources

• Helps patient come to terms with incurable medical condition

• Provides needed retreat for staff from stress of work

• Provides welcome setting for visitors

• Healing is not equivalent to cure

• Other terms used for healing garden: therapeutic, restorative, rehabilitative

POTENTIAL ACTIVITIES IN A HEALING GARDEN RANGE FROM PASSIVE TO

ACTIVE

• Viewing garden through window• Sitting outside• Dozing/napping/meditation/prayer• Gentle rehabilitation exercises• Walking to preferred spot • Eating/reading/doing paper work outside• Taking a stroll • Child playing in garden• Raised bed gardening• Vigorous walking• Sports

What happens ,psychologically, when a person chooses to go outdoors to a garden or natural

space to help themselves feel better?

• Research suggests that unconsciously they may move through 3 or 4 stages:

• The journey

• Sensory awakening

• Personal centering

• Spiritual attunement((MarniMarni Barnes, 1994)Barnes, 1994)

EVIDENCEEVIDENCE--GROUNDED DESIGN THEORY:GROUNDED DESIGN THEORY:How Gardens Improve Outcomes How Gardens Improve Outcomes (Ulrich,1991, 1999)(Ulrich,1991, 1999)

EXERCISEEXERCISESENSESENSE OFOFCONTROLCONTROL

SOCIAL SOCIAL SUPPORTSUPPORT

ENGAGEMENT ENGAGEMENT WITH NATUREWITH NATURE

STRESS RESTORATION AND BUFFERINGSTRESS RESTORATION AND BUFFERING

IMPROVED HEALTH OUTCOMESIMPROVED HEALTH OUTCOMES(Clinical outcomes, patient satisfaction,cost of care)(Clinical outcomes, patient satisfaction,cost of care)

1. OPPORTUNITIES FOR EXERCISE

• Exercise is associated with a spectrum of health benefits -especially for those who are sedentary, depressed or elderly

• Even a few minutes of mild exercise improves mood, reduces stress

• People are more likely to walk when there is an attractive setting to walk in; paths which encourage exploration

1.OPPORTUNITIES FOR EXERCISE: Different people seek different kinds of exercise

• Opportunities for exercise for patients recovering from a stroke will be very different from…

• Those for staff who want to walk or jog for health in their lunch hour

1.OPPORTUNITIES FOR EXERCISE: Different people will seek different kinds of exercise

• Well siblings run off steam in a maze outside a pediatric out-patient clinic

• Labyrinths are becoming increasingly popular in U.S healing gardens

• Patients, staff and visitors use for contemplative walking

(Temporary labyrinth installed for healing design conference, Li(Temporary labyrinth installed for healing design conference, Liverpool,UK)verpool,UK)

Kaiser Permanente Hospital, Vallejo, CaliforniaKaiser Permanente Hospital, Vallejo, California

2.OPPORTUNITIES TO MAKE CHOICES, SEEK PRIVACY AND EXPERIENCE A SENSE

OF CONTROL

• People have need for sense of control with respect to physical and social environments

• On entering hospital, many experience loss of control: Institution decides…

-what you eat-what you wear-when doctor visits , etc

• Loss of control produces stress, worsens health outcomes

• Garden can be designed to enhance sense of control

2. SENSE OF CONTROL

• Being able to go outdoors,visit with friends, choose where to walk, where to sit subtly reinforces a sense of autonomy

St ThomasSt Thomas’’ Hospital, London, EnglandHospital, London, England

2. SENSE OF CONTROL

• Something as simple as providing mobile furniture permits this nurse to move into the shade and place her lunch on the edge of a concrete planter

• Staff working on tight schedules and perhaps under strict supervision can regain a measure of control in a garden

Alta Bates Hospital, Berkeley, CaliforniaAlta Bates Hospital, Berkeley, California

Garden of St Thomas’ Hospital,London

2.SENSE OF CONTROL

• Providing choices where people can sit -as a group or alone -can facilitate a sense of control

• Locating seating with an expansive view or a close-in view, in sun or in shade, offers welcome choices

St ThomasSt Thomas’’ Hospital, London, EnglandHospital, London, England

3.PROVIDE SETTINGS WHICH ENCOURAGE PEOPLE TO GATHER TOGETHER AND

EXPERIENCE SOCIAL SUPPORT

Research indicates that people with higher levels of social support :

-are less stressed-have better health

than those who are more socially isolated

Locate gardens close to patient rooms and waiting areas, with sub-spaces where people can find privacy

St GeorgeSt George’’s Hospital, London, Englands Hospital, London, England

3.SOCIAL SUPPORT

• Staff also need restorative places to converse with colleagues and find social support

• Post-occupancy study in California found staff were largest users of hospital outdoor space

Alta Bates Hospital, Berkeley, CaliforniaAlta Bates Hospital, Berkeley, California

3.SOCIAL SUPPORT

• “It would show that they care about us, as staff in a hospital, by having a place where we can relax..” (Nurse,London hospital)

• “…Public spaces that encourage interaction and communication influence staff retention.”

( Survey of Nurses, Committee for Architecture and the Built Environment, UK, 2004)

Kaiser Permanente Hospital, Walnut Creek, CaliforniaKaiser Permanente Hospital, Walnut Creek, California

St St ThomasThomas’’HospitalHospital, London, England, London, England

3.SOCIAL SUPPORT

• For people to be attracted to relax and visit with friends or family in a hospital outdoor space it must be green, quiet, and offer places of privacy…..

• NOT THIS !

Legacy Emanuel Hospital, Portland, Oregon,USALegacy Emanuel Hospital, Portland, Oregon,USA

3.SOCIAL SUPPORT

• In considering the need for social support - the comfort of people sitting and talking together -care must be taken in the selection of furniture

• This….

• NOT THIS !

Alzheimer facility,Alzheimer facility, ChemainusChemainus, BC,Canada, BC,Canada

St MarySt Mary’’s Hospital, Isle of Wight, Englands Hospital, Isle of Wight, England

4.ENGAGEMENT WITH NATURE

• A healing garden must have a profusion of green nature , which has the effect of:+ Awakening the senses + Calming the mind+ Reducing stress+ Assisting a person to

marshall their own inner healing resources

• Nature cannot mend a broken leg or remove a tumor, but can support and strengthen us before/during/after medical procedures


• In selecting plant material, designer should consider color, texture,subtleties of green and leaf shape, grasses which more with the slightest breeze

• Frail patient may move slowly, and sit for long time in one place

• Planting design should be intricate, detailed and appeal to all the senses


• Plants and trees with distinctive seasonal changes should be considered in gardens for nursing homes, assisted living, Alzheimer’s facilities etc, where patients spend a long time and may lose track of time

• Nature attracts our attention without depleting the body of energy


• Trees can provide metaphors of solidity, strength and permanence

• Annuals can provide metaphors of growth, budding,blooming,seed-ng, decay, death, and transformation

• Perennials can provide metaphors of persistence and renewal

Kaiser Permanente Hospital, Vallejo CaliforniaKaiser Permanente Hospital, Vallejo California


• Our connection with nature can also be cognitive

• Plant labels engage our attention and can stimulate conversation

Healing Garden, Good SamaritanHealing Garden, Good SamaritanHospital, Portland,OregonHospital, Portland,Oregon


• Hospital outdoor space with little or no greenery will have little healing value

• No amount of clever paving design,sculpture or seating can make up for lack of nature


• Architects and landscape architects must work together to ensure that there are views out to gardens and landscape from patient rooms, staff offices, and corridors for post-surgery exercise

• Views to gardens and exterior landscape can assist in way-finding and reduce the stress of finding one’s way around a strange building

Hospice, Portland, OregonHospice, Portland, Oregon Victoria General Hospital,Victoria General Hospital,Victoria,BC,CanadaVictoria,BC,Canada


• Water is also an element of nature

• Views of still, reflective water; sounds and views of moving water are engaging and soothing

• Water attracts wildlife, reminding us in time of ill-health that life goes on

Trinity Trinity Hospice, Hospice, LondonLondon

West Dorset CountyWest Dorset CountyHospital, UKHospital, UK

4. ENGAGEMENT WITH NATURE

• Indoor gardens and atria are becoming more common in hospitals where:

-no outdoor space is available

-climate precludes use of outdoors for much of year

Rehabilitation Hospital ,Lake Rehabilitation Hospital ,Lake KatrineKatrine, NY, USA, NY, USA

GlenroseGlenrose Rehabilitation Hospital, Edmonton, Alberta, CanadaRehabilitation Hospital, Edmonton, Alberta, Canada

5.VISIBILITY

• Designing a healing garden to provide for exercise, sense of control, social support, and engagement with nature - though all essential - is not enough

• People have to know the garden is there!

• Ideally, garden is visible from main lobby, so signage is not necessary

St MarySt Mary’’s Hospital,s Hospital,San FranciscoSan Francisco

6.ACCESSIBILITY

• People of all ages and abilities need to be able to enter and move around in the garden

• Paths must be wide enough for two wheelchairs to pass (minimum 6 feet)

St ThomasSt Thomas’’ Hospital, LondonHospital, London

6.ACCESSIBILITY

• Paths should be smooth and wide enough for a patient on a bed or gurney to be wheeled into the garden

• Paving joints should be narrow enough so as not to catch a cane, the wheels of a walker or an IV-pole

Healing Garden,Healing Garden,Good Samaritan Hospital,Good Samaritan Hospital,Portland, OregonPortland, Oregon

6.ACCESSIBILITY

• WHAT NOT TO DO!

• Garden paved with pebbles for maternity ward

• Pregnant women feared they would trip

• Water/island theme of hospital interior carried to ridiculous lengths

• Courtyard surface “waves” up and down; frail patients cannot use

West Dorset County Hospital,West Dorset County Hospital,Dorchester ,UKDorchester ,UK

St MarySt Mary’’s Hospital , Isle of Wight,s Hospital , Isle of Wight,UKUK

7.FAMILIARITY

• When people are stressed, elements that are familiar in that culture are comforting - this should include the garden, its design, plants, detailing, furnishing etc

St St NicholasNicholas’’HospiceHospice,,W.Suffolk Hospital,W.Suffolk Hospital,EnglandEngland

8.QUIET

• People enjoy natural sounds in a hospital garden, such as a fountain, birdsong,rustling of leaves

• Study of 4 California hospital gardens found people most disturbed by incongruent sounds such as air conditioner,traffic, emergency helicopter

9.COMFORT

• Garden should be located close to patient areas and staff break room, with choice of seating in sun and shade, and semi-private niches where a person can feel secure

Homerton Homerton Hospital,LondonHospital,London

9.COMFORT

• A garden shelter can provide a destination point for a walk, and offer shelter from sun, wind or rain, thus extending the use of the garden throughout the day or year

Garden of Trinity Hospice,Garden of Trinity Hospice,LondonLondon

9.COMFORT

• WHAT NOT TO DO!

• Psychological discomfort in a courtyard surrounded with windows, no sense of privacy, feeling of being in a “fishbowl”

10.PANORAMIC VIEW

• Where location and topography permit, a viewpoint from a garden provides a significant place for reflection

• Research suggests that people who are stressed find a viewpoint soothing as it helps them to “get things into perspective”, and “see the big picture”

San Diego Hospice,San Diego Hospice,CaliforniaCalifornia

11. UNAMBIGUOUSLY POSITIVE ELEMENTS; Emotional Congruence Theory

• Our emotional state biases our perception of the environment

• A person who is fearful, and a person who is happy, may look at the same object and have very different reactions

• Ambiguous or abstract features may be interpreted by stressed patients as fearful or threatening (…even if the artist had no such intention…)

• Therefore…any feature that might be misinterpreted should not be located in a healing garden

Art in a Psychiatric Ward (Ulrich, 1986)

• STAFF comments:

“I think its fun..whimsical..”

“Funny little talking apple cores…”

• PATIENT comments:

“Charred skulls…Drops of blood flying..”

“Wounded people. They-re in pain and crying out.”

Duke Medical Center, Raleigh , North Carolina: The Bird Garden

• An example of the wrong kind of art being placed in a hospital

• Cancer patients, looking out onto this “garden”reacted negatively:

“Beaks tearing my flesh…”“Hands coming up to grab me…”

• The sculptures had to be removed

Inappropriate art in a cancer clinic garden?

• These concrete-slab sculptures would be quite appropriate in a museum garden…

• BUT…are they appropriate at a cancer clinic where stressed patients might interpret them as gravestones?

What art IS appropriate in a hospital?

• A whale “diving”into the ground can be a whimsical feature in a playground, but…

• Might patients at this psychiatric hospital interpret it as a whale committing suicide?

Art in a hospital setting needs to be UNAMBIGUOUSLY POSITIVE

• This sculpture might not win an award for cutting-edge design, but…

• It is entirely appropriate in a hospital setting where it may evoke positive associations and memories, and help reduce stress

PRECEDENTS DRAWN UPON BY DESIGNERS OF CONTEMPORARY HEALING

GARDENS

1. Archetypal spaces

2. Metaphors3. Historical precedents4. Domestic precedents5. Regional attributes6. Statement art7. Medical diagnoses

1. ARCHETYPAL SPACES

• A garden used in the psychiatric treatment of children who have experienced severe trauma

• Incorporates archetypal spaces such as hill, cave, ravine, island etcTherapeutic Garden at the Institute

For Child and Adolescent Development,Wellesley,Massachusetts

2. METAPHORS

• A water course is a major feature of this garden, symbolizing The Cycle of Life which begins with a low fountain-pool(birth), feeds a rocky stream (the passage of life), and ends in a contemplative pool (the end of life).

Good Samaritan Hospital,Phoenix,Arizona

AIDS Memorial Grove, GoldenGate Park, San Francisco

• Combination of trees, flowers, lawns,winding paths

• Suitable in many healthcare settings since it provides 4 key elements in healing garden design:- opportunities for exercise- places for privacy,sense

of control- settings for social support- engagement with nature

3.HISTORICAL PRECEDENTS: English strolling garden

3.HISTORICAL PRECEDENT: The courtyard

• Provides enclosed, protected space

• Is clearly hospital territory; in-patients may feel comfortable there in their hospital gowns

• Privacy of adjacent rooms needs to be protected

• Sounds of HVAC units can be irritating

Royal Devon and Exeter Hospital, Devon, England

3.HISTORICAL PRECEDENT: The cloister garden

• Would be an ideal model for garden in nursing home, geriatric ward etc

• Smooth walking surface,sheltered seating,garden view

• No contemporary examples found in N. America or UK; perhaps in Italy, Spain ?12th century cloister, Santiago de

Compostela, Spain

4. DOMESTIC PRECEDENTS

• Front porch or front garden facing street activity preferred by elderly people in senior housing

• Older people who are not sick are faced with problem of boredom rather than stress

4.DOMESTIC PRECEDENTS

• Back garden is ideal model for frail elderly or those with Alzheimer’s disease

• Enclosed space feels secure and is familiar from home environment

5. REGIONAL ATTRIBUTES

• A garden which “echoes” the colors and forms of a southern California beach scene

• Does the familiarity create a more soothing setting for hospitalized children?

Leichtag Family Healing Garden,San Diego Children’s Hospital,San Diego, California

5. REGIONAL ATTRIBUTES

• This garden “echoes”the vegetation and landscape of local coastline

• Does this make it a more healing environment?

• Perhaps….Recent study in Australia found favorite art in hospital depicted familiar,local scenes

Harrison Memorial Hospital,Bremerton, Washington

5.REGIONAL ATTRIBUTES

• Garden appropriate to regional desert context and to preferences of local Hispanic population

• But what about preferences of retirees from north-eastern USA ?Scottsdale Memorial Hospital,

Arizona

6. STATEMENT ART

• Artist commissioned to design a hospital courtyard makes “statement” that has nothing to do with regional context and has none of the attributes of a healing space

West Dorset County Hospital, Dorchester,England

6.STATEMENT ART

• Garden for cancer center based on Russian constructivist painting

• Do steel structures and minimal planting create a healing space ?

Norris Cancer Center garden, University of Southern California, Los Angeles

7. MEDICAL DIAGNOSES

• Hospital gardens for specific populations are now being designed to meet the medical needs of patients and their care-givers

• Gardens are becoming the location of, and means of treatment for, certain patients

• While some successful gardens in this category have been created, more research is needed

7. MEDICAL DIAGNOSIS

• REHABILITATION garden designed for physical therapists, speech pathologists, and horticultural therapists to work with patients who have had strokes,or suffered brain damage

• Varied surfaces and slopes for learning to walk again

• Varied planter edge heights for sitting, leaning

• Variety of labeled plants for color and shape recognition, reading etcHealing Garden, Good SamaritanHealing Garden, Good Samaritan

Hospital,Portland,OregonHospital,Portland,Oregon


• Before and after views of a rooftop garden for HIV/AIDS patients

• Special attention to levels of shade because patients on certain medications must not be in sun

Joel Schapner MemorialGarden,Cardinal CookHospital,New York City

BeforeBefore

AfterAfter


• Courtyard garden at a CANCER clinic with soothing sound of water, engaging plant material, and varied degrees of shade because patients on chemotherapy drugs must stay out of sun

• Cancer patients and relatives at workshop to inscribe their stories on tiles to decorate corridor beside garden

Cancer Clinic Garden, Mount ZionHospital, San Francisco,California

7.MEDICAL DIAGNOSIS

• Garden-courtyards for patients with ALZHEIMER’S DISEASE

• Looped pathway to aid orientation

• Tinted concrete to reduce glare

• Low planting for stooped posture

• Non-toxic plants

• Features to evoke earlier memories: prairie grass and garden shed

The Lodge at The Lodge at Broadmead,Victoria,BC,CanadaBroadmead,Victoria,BC,Canada

ChemainusChemainus Health Care Health Care Center,ChemainusCenter,Chemainus,,BC, CanadaBC, Canada


• Garden at a children’s hospital must provide for sometimes conflicting needs of sick children, well siblings, worried or grieving parents, and stressed-out staff

Prouty Terrace and Garden,Children’s Hospital, Boston,Massachusetts


• Garden/playground for children with BRAIN INJURIES/mobility problems designed to encourage physical activity and re-use of limbs

• Range of topography, surfaces,features to manipulate

• Encourages interaction with natural world, and taking risks

Rusk Institute of RehabilitativeRusk Institute of RehabilitativeMedicine, New YorkMedicine, New York


• Garden for children with severe HANDICAPS who live at home or in a hospital and come to facility each day

Sensory Garden , Lucas Gardens School, Canada Bay, Sydney,Australia


• Garden for BURN PATIENTS and families

• Paths wide enough for beds

• Shade is essential

• Grade changes to practice walking

• Different textures for touch

• Separate,private staff area

Legacy Burn Center Garden,Legacy Emanuel Hospital,Portland,Oregon


• Garden for patients in DRUG AND ALCOHOL rehabilitation unit based on 12-Step Alcoholics Anonymous program

• Each step a different sub-space in garden with inspiring words inscribed on paving stone

Serenity Garden, Drug and AlcoholRehabilitation Center, ScrippsMemorial Hospital, San Diego,California

SUMMARY OF HEALING GARDEN DESIGN CONSIDERATIONS

Supportive of stress reduction and healing:• Convenient way-finding to garden• Accessibility• Places of privacy• Seating encouraging interaction• Contact with nature (green vegetation,nature

sounds,wildlife)Hindering stress reduction and healing:• Predominance of hardscape• Ambiguous, abstract art• Intrusive mechanical sounds• Lack of privacy, places to sit• Lack of choice• Lack of shade• Feeling of insecurity or risk

• Crowding• Cigarette smoke

GARDEN OFFERS COMPLETE CONTRAST TO HOSPITAL INTERIOR

HOSPITAL INTERIOR• Institutional scale• Man-made• Evoking anxiety• Limited sensory detail• Straight lines,ordered• Controlled air• Few places to be alone• Not conducive to calming

the mind• Evoking thoughts of

illness,death

GARDEN• Domestic scale• Natural• Evoking good memories• Rich,sensory detail• Varied shapes,organic• Fresh air• Places to be alone• Conducive to positive

feelings, introspection• Links to wider world of

nature, on-going cycle of life

ADVANTAGES TO HEALTHCARE FACILITIES( Roger Ulrich, 1999)

PROBABLE ADVANTAGES• Reduction of stress in patients,staff and visitors (very likely)• Reduced pain in patients(likely)• Reduction in depression (likely, especially if garden fosters

exercise)• Higher reported quality of life for chronic and terminally-ill

patients(likely, especially if garden fosters exercise)• Improved way-finding( very likely, especially if garden in

prominent location)POTENTIAL ADVANTAGES• Reduced costs : Length of stay shorter for certain patient

categories; fewer strong pain medication doses• Increased patient mobility and independence• Higher patient satisfaction• Increased staff job satisfaction

MANY UNANSWERED QUESTIONS…

• Do people seeking calmness and peace in a hospital garden prefer a winding path, encouraging exploration? Or a straight path where they can see their destination?

• Does it depend on the type of facility?• Does it depend on culture?

MANY UNANSWERED QUESTIONS…

• Does this Native American family find comfort in the fact that all the plants in this garden are used in traditional healing?

• Are patients at this heart hospital troubled by a fountain-sculpture shaped like the human heart sliced in half, and pulsing at the rate of a normal heart-beat?

Good SamaritanGood SamaritanHospital,PhoenixHospital,PhoenixArizonaArizona

Royal Royal BromptonBrompton Heart and Lung Hospital,Heart and Lung Hospital,LondonLondon

MANY UNANSWERED QUESTIONS

• Do people find solace and peace in a zen garden, even when they don’t understand its symbolism?

• Do the residents of this London nursing home spend time in this courtyard based on a Persian paradise motif, or would they have preferred an English cottage garden like the one they left at home?

TOO MANY WASTED OPPORTUNITIES

• Courtyard designed by artists fulfills none of the requirements of a healing garden (Royal Devon and Exeter Hospital, England)

• “Front lawn” of a children’s hospital surrounded by traffic streets is not suitable for well or sick children

• (Children’s Hospital, Los Angeles, California)

DO ARCHITECTS HAVE TOO MUCH CONTROL ?

• Architects often“think”via big, computer-drawn models

• Outdoor space sometimes perceived as “…what separates buildings…”

• Architect may design outdoor space; does not have appropriate training

• Landscape architect brought into design process too late

• Minimal budget to create gardens

IDEALLY, THIS SHOULD HAPPEN:

• Designers work as team with medical personnel likely to use garden for therapy, and with potential patient-users

• Lead professional on team is landscape architect

• Team annotates plans with presumed health benefits

• Post occupancy evaluation conducted after garden in use

• Research results disseminated to peers

• Information on garden benefits disseminated to hospital staff

Clearly more research is needed but we cannot wait until such studies are completed. The evidence we DO have warrants our continuing efforts to establish healing gardens so that users may benefit, and researchers have more possibilities of evaluating their success.

WE MUST DO BETTER THAN THIS !

• Fads and fashions in design lead to hospital outdoor space that fulfills none of the needs of a healing garden

• “Stripes” of granite and gravel, lawn and gravel….anything striped = current fashion in landscape architecture

Royal Alexandra ChildrenRoyal Alexandra Children’’s Hospital, Sydneys Hospital, SydneyAustraliaAustralia

St Rose Hospital, Las Vegas, NevadaSt Rose Hospital, Las Vegas, Nevada

WE MUST DO BETTER THAN THIS

• Staff who work in thiskind of milieu deserve THISa place where they cantake a break that isbetter than…

WE MUST DO BETTER THAN THIS !

• A path that runs through a bench and terminates in a wall: What sort of message is that for a patient with a mental illness?

• Dying plants at the entrance to a hospital…”If they can’t keep the plants alive, how will they care for me ?!…”

Mental Health Clinic, Miami,FloridaMental Health Clinic, Miami,Florida Mt. Sinai Hospital, Toronto, CanadaMt. Sinai Hospital, Toronto, Canada

healing gardens in hospitals - clare cooper marcus

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