HEALING GARDENS IN HOSPITALS - Umcg

HEALING GARDENS IN
HOSPITALS
Clare Cooper Marcus
University of California, Berkeley
The Architecture of Hospitals
April 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

1.MIDDLE AGES
History and Recent
Developments
• Medieval monastic
cloister garden
• Early example of
restorative outdoor
space for sick
patients

2. RENAISSANCE
• 17th-18th century :
Period of large
municipal hospitals
• Buildings surround
courtyards for
exercise and air
circulation

3. PAVILION-STYLE HOSPITALS
Johns Hopkins Hospital,
Baltimore
• Mid-19th-early 20th
century
• Pavilion hospital,
providing fresh air,
sunlight and views
to nature inspired by
work of public health
reformer,Florence
Nightingale

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,
Omaha,Nebraska,USA

4. MEGA HOSPITALS
• 1980s
• Hospitals resemble
corporate office
buildings
• Little concern for
usable outdoor
space
Kirklin Clinic, Birmingham, Alabama,USA

5. PATIENT CENTERED CARE
Monterey Community Hospital,
Monterey,California
• 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

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)

5. PATIENT CENTERED CARE
• Designers look to
regional context for
more appropriate
styles, forms, colors
and materials
San Diego Children’s Hospital, San Diego,
California( 1990-93)

5.PATIENT CENTERED CARE
• 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
St Michael’s Medical Center, Texarkana
Texas
• 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
$$$

5.PATIENT CENTERED CARE
• Hospital clients
commission art with
nature images
Scripps Mercy Hospital,
San Diego, California

5.PATIENT CENTERED CARE
• Product designers
create features for
hospitals with nature
themes

HOSPITAL GARDEN RESEARCH
Roof garden, Alta Bates Hospital,
Berkeley,California
• 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
(Cooper Marcus and Barnes, 1994)

Sample
• 2,140 people
• 2,140 people
observed
observed
• 143 people
• 143 people
interviewed
interviewed
– 73 female
–73 female
– 70 male
–70 male
patient
26%
User categories:
visitors
15%
staff
59%

Activities in the Gardens
100%
94%
73% 73%
68%
61%
50%
53%
38% 36%
12% 11%
0%
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%

Kaiser Permanente Hospital
Walnut Creek, California
• 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!”

5. PATIENT CENTERED CARE
• Results of postoccupancy
evaluations of
hospital gardens,
and design
guidelines for future
gardens, published
1999

5. PATIENT CENTERED CARE
Before
After
• Some of first healing
gardens in US
created by patients
who saw potential of
wasted space and
raised money to pay
for design
Cancer Clinic, St Vincent’s
Hospital,Santa Fe, New Mexico

5.PATIENT CENTERED CARE
• 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

5.PATIENT CENTERED CARE
• Mid 1990s: Hospital
staff begin to lobby for
usable outdoor spaces
Before
After Good Samaritan Hospital,
Portland,Oregon
• 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

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
(Marni
Barnes, 1994)

EVIDENCE-GROUNDED DESIGN THEORY:
How Gardens Improve Outcomes (Ulrich,1991, 1999)
EXERCISE
SENSE OF
CONTROL
SOCIAL
SUPPORT
ENGAGEMENT
WITH NATURE
STRESS RESTORATION AND BUFFERING
IMPROVED HEALTH OUTCOMES
(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
Kaiser Permanente Hospital, Vallejo, California
• Well siblings run off
steam in a maze
outside a pediatric outpatient
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, Liverpool,UK)

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 Thomas’ Hospital, 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, California

2.SENSE OF CONTROL
Garden of St Thomas’ Hospital,
London
• 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 Thomas’ Hospital, London, England

3.PROVIDE SETTINGS WHICH ENCOURAGE
PEOPLE TO GATHER TOGETHER AND
EXPERIENCE SOCIAL SUPPORT
St George’s s Hospital, London, England
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

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, California

3.SOCIAL SUPPORT
Kaiser Permanente Hospital, Walnut Creek, California
• “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)
St Thomas’Hospital
Hospital, , London, England

3.SOCIAL SUPPORT
Legacy Emanuel Hospital, Portland, Oregon,USA
• 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 !

3.SOCIAL SUPPORT
Alzheimer facility, Chemainus, , BC,Canada
• 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 !
St Mary’s s 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

4.ENGAGEMENT WITH NATURE
• 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

4.ENGAGEMENT WITH NATURE
• 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

4.ENGAGEMENT WITH NATURE
Kaiser Permanente Hospital, Vallejo California
• Trees can provide
metaphors of solidity,
strength and
permanence
• Annuals can provide
metaphors of growth,
budding,blooming,seedng,
decay, death, and
transformation
• Perennials can provide
metaphors of
persistence and
renewal

4.ENGAGEMENT WITH NATURE
• Our connection with
nature can also be
cognitive
• Plant labels engage
our attention and
can stimulate
conversation
Healing Garden, Good Samaritan
Hospital, Portland,Oregon

4.ENGAGEMENT WITH NATURE
• 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

4.ENGAGEMENT WITH NATURE
Hospice, Portland, Oregon
Victoria General Hospital,
Victoria,BC,Canada
• 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

4.ENGAGEMENT WITH NATURE
Trinity
Hospice,
London
• 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
West Dorset County
Hospital, UK

4. ENGAGEMENT WITH NATURE
Rehabilitation Hospital ,Lake Katrine, , NY, USA
• 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
Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada

5.VISIBILITY
St Mary’s s Hospital,
San Francisco
• 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

6.ACCESSIBILITY
St Thomas’ Hospital, London
• 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)

6.ACCESSIBILITY
Healing Garden,
Good Samaritan Hospital,
Portland, Oregon
• 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

6.ACCESSIBILITY
West Dorset County Hospital,
Dorchester ,UK
St Mary’s s Hospital , Isle of Wight,
UK
• 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

7.FAMILIARITY
St Nicholas’Hospice
Hospice,
W.Suffolk Hospital,
England
• When people are stressed, elements that are
familiar in that culture are comforting - this
should include the garden, its design, plants,
detailing, furnishing etc

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 Hospital,London

9.COMFORT
Garden of Trinity Hospice,
London
• 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

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
San Diego Hospice,
California
• 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”

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. Metaphors
3. Historical precedents
4. Domestic precedents
5. Regional attributes
6. Statement art
7. Medical diagnoses

1. ARCHETYPAL SPACES
Therapeutic Garden at the Institute
For Child and Adolescent
Development,
Wellesley,Massachusetts
• A garden used in
the psychiatric
treatment of children
who have
experienced severe
trauma
• Incorporates
archetypal spaces
such as hill, cave,
ravine, island etc

2. METAPHORS
Good Samaritan Hospital,
Phoenix,Arizona
• 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).

3.HISTORICAL PRECEDENTS: English
strolling garden
• Combination of trees,
flowers, lawns,winding
paths
AIDS Memorial Grove, Golden
Gate Park, San Francisco
• 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 PRECEDENT: The courtyard
Royal Devon and Exeter Hospital,
Devon, England
• 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

3.HISTORICAL PRECEDENT: The cloister
garden
12th century cloister, Santiago de
Compostela, Spain
• 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 ?

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

5. REGIONAL ATTRIBUTES
Harrison Memorial Hospital,
Bremerton, Washington
• 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

5.REGIONAL ATTRIBUTES
Scottsdale Memorial Hospital,
Arizona
• Garden appropriate
to regional desert
context and to
preferences of local
Hispanic population
• But what about
preferences of
retirees from northeastern
USA ?

6. STATEMENT ART
West Dorset County Hospital, Dorchester,
England
• 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

6.STATEMENT ART
Norris Cancer Center garden,
University of Southern California,
Los Angeles
• Garden for cancer
center based on
Russian
constructivist
painting
• Do steel structures
and minimal planting
create a healing
space ?

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

Healing Garden, Good Samaritan
Hospital,Portland,Oregon
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 etc

Before
7. MEDICAL DIAGNOSIS
• Before and after views
of a rooftop garden for
HIV/AIDS patients
After
• Special attention to
levels of shade because
patients on certain
medications must not
be in sun
Joel Schapner Memorial
Garden,Cardinal Cook
Hospital,New York City

7. MEDICAL DIAGNOSIS
Cancer Clinic Garden, Mount Zion
Hospital, San Francisco,California
• 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

The Lodge at Broadmead,Victoria,BC,Canada
Chemainus Health Care Center,Chemainus,
BC, Canada
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

7. MEDICAL DIAGNOSIS
Prouty Terrace and Garden,
Children’s Hospital, Boston,
Massachusetts
• Garden at a children’s
hospital must provide
for sometimes
conflicting needs of sick
children, well siblings,
worried or grieving
parents, and stressedout
staff

7. MEDICAL DIAGNOSIS
Rusk Institute of Rehabilitative
Medicine, New York
• 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

7. MEDICAL DIAGNOSIS
• 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

7. MEDICAL DIAGNOSIS
Legacy Burn Center Garden,
Legacy Emanuel Hospital,
Portland,Oregon
• 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

7. MEDICAL DIAGNOSIS
• 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 Alcohol
Rehabilitation Center, Scripps
Memorial 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…
Good Samaritan
Hospital,Phoenix
Arizona
• 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?
Royal Brompton Heart and Lung Hospital,
London

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 patientusers
• 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 !
Royal Alexandra Children’s s Hospital, Sydney
Australia
St Rose Hospital, Las Vegas, Nevada
• 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

WE MUST DO BETTER THAN THIS
• Staff who work in this
kind of milieu deserve THIS
a place where they can
take a break that is
better than…

WE MUST DO BETTER THAN THIS !
Mental Health Clinic, Miami,Florida
Mt. Sinai Hospital, Toronto, Canada
• 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 ?!…”