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Healing gardens in healthcare facilities : linking restorative value and design features Barnes, Debra 2004

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Healing Gardens in Healthcare Facilities: Linking Restorative Value and Design Features  Debra Barnes Bachelor of Landscape Architecture, University of British Columbia, 1999  A T H E S I S S U B M I T T E D IN P A R T I A L F U L F I L M E N T O F T H E REQUIREMENTS FOR T H E D E G R E E OF M A S T E R O F A D V A N C E D S T U D I E S IN A R C H I T E C T U R E in T H E F A C U L T Y OF G R A D U A T E STUDIES  We accept this thesis as conforming to the required standard  T H E U N I V E R S I T Y OF BRITISH C O L U M B I A M a y 2004  © Debra Barnes, 2004  Library Authorization  In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.  Debra Barnes  11 May, 2004  Name of Author (please print)  Title of Thesis:  Degree:  Date (dd/mm/yyyy)  Healing Gardens in Healthcare Facilities: Linking Restorative Value and Design Features  Master of Advanced Studies in Architecture  Department of  Architecture  The University of British Columbia Vancouver, BC Canada  Year:  2004  ABSTRACT  For most o f the previous century, the program and design o f healthcare facilities supported the dominant cure-based medical model o f illness treatment.  In the closing  decades o f the twentieth century increasing interest in a holistic approach to patient care that acknowledges a connection between mind, body and spirit supported the inclusion o f healing gardens in healthcare facilities.  Empirical evidence suggests that patient support requires the provision o f access to nature and outdoor spaces. If space in healthcare facilities is to be programmed for outdoor use, what design features o f this setting cares for patients, both psychologically and emotionally while supporting their physiological needs?  Further, does the therapeutic  benefit and significance o f discrete garden features vary depending on the illness and healing processes o f a particular patient population?  This thesis begins to answer the above-noted questions by reviewing the literature on the historical approach to patient care based both on documented anecdotal information and as evidenced by the design o f healthcare facilities and their adjacent outdoor spaces. Current multi-disciplinary research and empirical evidence supporting the link between nature and restorative benefit is also presented. Finally, the healing gardens supporting three special patient populations (Alzheimer's, AHDS, and Pediatrics) are reviewed, endeavoring to link specific design features to restorative value.  The result o f this investigation is a matrix synthesizing the relative benefit o f discrete garden design features to specific patient populations.  The matrix lists over fifty design  features o f a healing garden and groups each feature into one o f three categories: experiential, functional, and contextual.  In terms o f restorative benefit, generally, the  matrix rates experiential design features as essential for all patient population types and identifies contextual features as highly desirable.  Variation in the importance o f the  functional design features o f a healing garden begins to emerge when considering the particular needs o f special patient populations.  ii  This study may be used to guide a design process for the provision o f healing gardens in a healthcare facility that recognizes both the therapeutically beneficial experiential design features and significant contextual features o f a healing garden, while acknowledging that the functional characteristics o f the garden will be informed by the needs o f particular user groups and special patient populations.  iii  \  T A B L E of CONTENTS  Abstract Table of Contents List of Tables and Matrixes List of Figures  ii iv vi vii  Acknowledgements  viii  Preface  Chapter 1  ix  History of Patient Care and Healthcare Facility Design  1  1.1  The Medieval and Monastery Hospice Garden o f the Twelfth Century  2  1.2  Healthcare Facility Design o f the Fourteenth to Seventeenth Century  5  1.3  The Romantic Movement's Influence on the Healthcare Environment  6  1.4  Nineteenth Century Pavilion Hospitals  8  1.5  Twentieth Century Healthcare Trends  10  Chapter 2  Current Research: The Restorative Value of Nature  16  2.1  Psychological Perspectives on Nearby Nature  17  2.2  Nature's Effect on the Rate o f Recovery  23  2.3  The Restorative Benefits o f Horticulture Therapy  26  2.4  Biophilia Hypothesis  29  2.5  People-Plant Relationships  30  2.6  Conclusion: Review o f Science-Based Evidence  31  Chapter 3 3.1  Guiding Principles and Design Feature  A l l Patient Populations (Clare Cooper Marcus, Marni Barnes,  33 35  Cheryl E . Ware) 3.2  Patients with Dementia and Alzheimer's Disease (Elizabeth C . Brawley)  39  3.3  Pediatric Patients (Robin C . Moore)  42  Chapter 4 4.1 4.2  Healing Gardens for Special Patient Populations  Leichtag Family Healing Garden, San Diego, California (Children) Joel Schnaper Memorial Garden, Manhattan New York (AIDS Patients)  47 47 54  iv  Chapter 5  Healing Garden Design Features, Restorative Value, and Patient Populations  61  5.1  Healing Garden Matrix  62  5.2  Synthesis  63  5.3  Conclusion  72  Bibliography  78  Figure Credits  85  Appendix I Toxic Plant List. Canadian Standards Association. Children's Playspaces and Equipment.  87  v  L I S T of T A B L E S and M A T R I X E S  Table 1 - Leichtag Family Healing Garden Evaluation. Features of  52  Garden Most Enjoyed by Garden Users Table 2 - Matrix of Restorative Value o f Design Features versus  62  Healthcare Facility Population  vi  LIST of FIGURES Figure 1 . 1 -  Medieval Cloister Garden  4  Figure 1.2 -  Walled Medieval Restorative Garden  5  Figure 1 . 3 -  Example o f a pavilion-style hospital - Heather Pavilion  9  at Vancouver General Hospital Figure 2 . 1 -  1905  V i e w through a Window to Nature  24  Figure 2 . 2 - Horticulture Therapy Figure 2.3 - Garden in Healthcare Facility  27 33  Figure 3 . 1 -  37  Healthcare facility staff take a break in the garden  Figure 3.2 - Wayfinding features at the Joel Schnaper Memorial Garden,  42  New York, New York, United States Figure 3.3 -  The garden is a place where family and friends can visit loved ones  46  Figure 4.1 -  Plan of Leichtag Family Garden  48  Figure 4.2 -  Play element for children at Leichtag Family Healing Garden  50  Figure 4.3 -  Leichtag Family Healing Garden Brontosaurus Sculpture  50  Figure 4.4 -  Sea-horse fountain at Leichtag Family Garden  51  Figure 4.5 - Plan of Joel Schnaper Memorial Garden  55  Figure 4.6 - Universal design guidelines  56  Figure 4.7 -  57  Sound of water provides sensory stimulation and wayfinding clues  Figure 4.8 - Planter height suitable for tending by patients  58  Figure 4.9 -  58  Overhead trellis provides shade on rooftop in Joel Schnaper Memorial Garden  Figure 4.10 - Bright flowers, wayfinding elements and visual connection  60  from the patients' rooms to the garden at the Joel Schnaper Memorial Garden Figure 5 . 1 -  Example of dining room with views to nature at St. Michael  70  Rehabilitation Hospital, Texarkana, Arkansas, United States Figure 5.2 - Views from Heather Pavilion Vancouver General Hospital 1905  73  Figure 5.3 - Heather Pavilion Vancouver General Hospital 1928  74  Figure 5.4 - Aerial Photo of Heather Pavilion Vancouver General Hospital 2002  75  ACKNOWLEDGEMENTS  I am extremely thankful for the insights and contributions that a variety o f people have made to this thesis.  In particular, I am indebted to my academic advisors Dr. Sherry M c K a y and A l a n Duncan for their very much appreciated insight and guidance. Also, I am forever grateful to K a y Macintosh for her encouragement to pursue both undergraduate and graduate studies at U B C as well as her on-going interest in my progress. I am grateful, as well, for the patience and support Robert Leupen and my supervisors, colleagues and friends at the Vancouver Board o f Parks and Recreation extended me, particularly during the final stages o f this process.  Christina Sestan helped make the road to completion a pleasant  and memorable one and the staff in the School o f Architecture, Theresa Juba and Trish Poehnell simplified the academic administrative process — for this I am very thankful.  Finally, I would like to thank m y daughter Kristy for her inspiration, assistance and understanding.  viii  PREFACE  Healthcare facilities can be one o f the more stressful environments we enter. Ironically, stress is often considered a major causative factor in today's more prevalent diseases and illnesses (heart disease, diabetes, cancer) and can inhibit the rate and extent o f recovery. Apart from the inherent emotional stresses associated with illness and emergency care, healthcare environments often include unfamiliar technology and apparatus, unusual and unpleasant smells, artificial light, visual disconnection with the outside world, and lack o f privacy and personal control.  There is often a paradox between the function o f a  healthcare facility and the design response o f its interior and exterior environment. This thesis will mainly focus on the exterior o f the healthcare facility environment and the potential o f that environment to assist in the function o f health care.  There appears to be an intuitive understanding and considerable anecdotal information suggesting that access to nature and gardens can provide a degree o f relief from the symptoms and stresses associated with illness. Research supports what has perhaps been known for centuries, that calming the mind supports healing the body (Kaplan and Kaplan, Restorative Experience). David Singleton (lecturer in architecture and landscape design at the Welsh School o f Design), however, considers empirical evidence in this area lacking. "There is a clear need to further the guidance to more accurately define the qualities and particularities o f the external hospital environment that are most valued and are perceived as beneficial by patients and staff (Radley 21). This investigation attempts to extrapolate  a set o f restoratively beneficial design features  for special patient  populations emerging from the literature on healing gardens and restorative landscapes in the healthcare facility environment.  In western civilizations, belief in the healing power o f nature was reflected in the design o f healthcare facilities dating back as far as the medieval monasteries with their cloister  ix  gardens filled with therapeutic herbs and sunlight.  1  A t the turn of the previous century,  however, a new medical model emerged which revered science and technology and rejected natural remedies.  The clinical and often sterile high-rise hospital design of the  twentieth century reflected this abrupt change in medical procedures and approach to patient care.  In the past two decades, however, western medicine has slowly begun to rediscover that overall health and well-being are dependent on the strength o f the mental, emotional, physical and spiritual aspects of human health. This shift in thinking has coincided with the inclusion o f design features in healthcare facilities such as views to nature, natural lighting, homey interiors, access to pets and healing gardens.  In considering a number of academic perspectives healthcare environments, repeatedly articulated.  regarding the role of nature in  a distinction between the terms healing and curing was  Enhancing the patient's physical and emotional sense of well  being was described as healing, while curing referred to a focus on treating the symptoms of an illness or disorder. This distinction consistently appears to be the point of departure for discussions on the perceived therapeutic benefits of gardens and nature in general.  Modern scientific medical treatments  are intended to cure illness while a holistic  approach to healing acknowledges and responds to the connection between mind and body.  In response to this holistic approach to healing, the programs o f healthcare  facilities committed to providing a healing environment often include gardens and views of nature.  2  During the medieval period, many monasteries in Western Europe provided physical and spiritual comfort to pilgrims, the homeless, the sick and dying. These hospices included an enclosed courtyard garden that was divided into four squares radiatingfromthe central well or fountain. Patients' rooms looked out into the garden that provided the viewer with a contrived perspective onto nature. In a 2001 survey of hospital garden users at Children's Hospital and Health Center in San Diego, USA, Sandra Whitehouse, et al reported that ninety percent of the respondents were of the opinion that it is important for hospitals to include healing gardens. 2  x  The purpose o f this investigation is to explore the relationship between the design o f outdoor environments in healthcare facilities and health benefits.  I will demonstrate that  consideration o f the healing process has historically informed the design o f outdoor environments in healthcare facilities and will identify design features perceived as beneficial to the healing process.  A matrix o f design features will be synthesized from  the material reviewed.  The first chapter o f this paper consists of a historical survey (from medieval times to present day) briefly outlining trends in western healthcare epistemology and the provision of outdoor environments in healthcare facilities. This chapter focuses on healthcare facilities with landscapes and gardens perceived as promoting a sense o f well-being, reduced stress and beneficial health outcomes. The historical overview highlights the relationship between the approach to patient care and the approach to site and garden design in healthcare facilities throughout Europe and North America.  Distinctions  between the treatment and care needs o f various patient populations (depending on the particular disease process or illness) and the respective design implications begin to emerge from the historical overview.  Chapter Two reviews current science-based research-providing evidence o f a connection between contact with (and views of) nature to improved health outcomes for hospitalized patients. A n explanation for these positive health outcomes will be explored by drawing on theories  interpreting the relationship between nature and human responses as  developed over the past three decades by a number o f recognized researchers from a variety o f disciplines.  The literature review will include research in the areas o f  environmental psychology, environmental preference theories, therapeutic landscapes, people-plant relations, healthcare management,  universal design, design for social  interaction, behavioural science, horticulture, landscape architecture and biology.  Chapters Three and Four presents and reviews prescriptions for healing garden design as articulated by a number o f prominent design professionals involved in the design and evaluation o f healing gardens in healthcare facilities. This phase o f m y enquiry reviews  xi  and analyzes documented environmental design responses and features that attempt to address the distinct and particular needs of various patient populations in an outdoor setting.  The specific design requirements of several healthcare facility and patient  populations types are considered.  The final chapter summarizes the outdoor environmental design features identified as beneficial to human health and well-being and perceived as therapeutic in the healthcare environment.  This investigation concludes with a matrix developed to illustrate the  relationship between garden design and the healing requirements of a number o f different patient types.  The matrix identifies and summarizes environmental design features o f  outdoor spaces and gardens in healthcare facilities, ranking each feature in terms o f its relative benefit to a particular patient population. Emerging from this investigation is a design sensibility informed by the healing process for developing outdoor spaces that promote and enhance healing, positive human interaction and an increased sense o f wellbeing. ,  •  .  xii  Healing Gardens in Healthcare Facilities: Linking Restorative Value and Design Features  CHAPTER 1 - History of Patient Care And Healthcare Facility Design  Gardens today are most commonly considered picturesque places, specifically designed to please the visual sense. Various cultures throughout history have, however, created gardens to engage and  satisfy all the senses.  M a n y of these gardens were layered with spiritual symbolism,  religious significance or mysticism — depending on the social, historical and geographical context. Gardens have  also traditionally been created for pragmatic outcomes including  sustenance, medicine and climatic mitigation.  One common theme that appears to transcend  time and culture, however, is that gardens are created to enhance human-well-being. This chapter focuses on the tradition of Western European and North American healthcare facility garden design.  While recreating a pleasing glimpse of nature's beauty is often the basis of garden design, societies throughout history have intuitively recognized the value of gardens as places of healing and repose.  This observation has been supported by research demonstrating that gardens and  gardening are therapeutic and beneficial for hospital patients and institutionalized residents.  1  Dr. Sam Bass Warner Jr., urban historian at Brandeis University, Waltham, M A , United States, contends, that the historical periods in which society has viewed nature as essential for human well-being coincide with the appearance o f patient gardens in healthcare facilities.  In contrast,  those periods in history in which art, science and technology were revered by society were the periods in which innovative use o f gardens and garden therapy as a clinical aid disappeared from healthcare facilities.  Roger Ulrich (a professor in the Departments of Landscape Architecture and Architecture and Director of Health Systems and Design in the Colleges of Architecture and Medicine at Texas A & M University) demonstrated, in his 1984 research, that patients with a view of nature had a faster rate of recovery, needed less medication for pain and were ready to be discharged from the hospital sooner than patients in rooms that looked out on a brick wall (Ulrich, View Through Window 420-421). 1  1  Historically, the provision o f gardens in healthcare facilities has been related to the medical focus o f the facility. For example, when the role of a facility was to cure or treat the symptoms of an illness or disorder, gardens were usually absent.  When healing or convalescing was  considered the primary function o f the healthcare environment, gardens and views o f nature were often incorporated to enhance the healing process (Warner 5-12).  This chapter will provide a historical overview of gardens included in healthcare facilities, dating from medieval times to the present day, to illustrate the link between design features and benefits to patient care. While much o f the history (with respect to patient response to gardens) is based on observation and anecdotal information documented in the literature, the next chapter will review current empirical research on the relationship between natural environments and medical outcomes.  1.1 The Medieval and Monastery Hospice Garden of the Twelfth Century The restorative quality o f gardens for the treatment o f the ill has its intermittent historical beginnings in the twelfth century. hospices.  Restorative gardens first appeared in medieval monastery  M a n y monasteries in Western Europe provided physical and spiritual comfort to  pilgrims, the homeless, the sick and the dying.  Typically, patients' cells looked out onto a  courtyard garden. It was recognized that the healing process benefited from sunlight and a place to sit or stroll amongst seasonal plantings.  St. Bernard (1090-1153) wrote the following  description o f the sensual qualities o f the restorative courtyard garden at his monastery's hospice in Clairvaux, France:  Within this enclosure, many and various trees, prolific with every sort o f fruit, make a veritable grove, which lying next to the cells o f those who are ill, lightens with no little solace the infirmities o f the brethren, while it offers to those who are strolling about a spacious walk, and to those overcome with the heat, a sweet place for repose.  The sick man sits upon the green lawn, and while inclement  Sirus burns the earth and dries the rivers, he is secure, hidden and shaded from the heat o f the day, the leaves o f a tree tempering the heat o f that fiery star; for the comfort o f his pain, all kinds o f grass are fragrant in his nostrils. The lovely green of herb and tree nourishes his eyes and, their immense delights hanging and growing before him, well might he say, "I sat down in his shadow with great delight, and his fruit was sweet to my taste" [Song o f Songs 2:3]. The choir o f 2  painted birds caresses his ears with sweet modulation, and for the care o f a single illness the divine tenderness provides many consolations, while the air smiles with bright serenity, the earth breathes with fruitfulness, and the invalid himself with eyes, ears, and nostrils, drinks in the delights of colours, songs, and perfumes. (Spriggs9)  This understanding of the mesmerizing effect of the garden's sensorial dialogue — intended to provide patients with a spiritual sense of peace and hope ~ was reflected in the design o f the monastery courtyard gardens o f this time.  The monastery's center cloister, traditionally the most significant open space, consisted of a symbolic spiritual garden suffused with mystique.  The church typically formed the cloister's  north wall while the facades of the kitchen, living quarters, and dining hall completed the perimeter. A Romanesque peristyle arcade typically provided a sheltered passage between the rooms.  Reflecting the bible's description of Eden, the garden was divided into four squares  radiating from a central well or fountain.  2  The enclosed garden emphasized control and order,  providing the viewer with an ideal perspective of nature. Plant cycles and sky patterns marked the passing of time and the changing o f seasons. The harmony and tranquility of the garden was a deliberate design attempt to evoke a reflective mood, believed to calm and comfort the patient (see figure 1.1).  Genesis 2:8-10. "Now the Lord God had planted a garden in the east, in Eden; and there he put the man he had formed. And the Lord God made all kinds of trees grow out of the ground - trees that were pleasing to the eye and good for food. In the middle of the garden were the tree of life and the tree of the knowledge of good and evil. A river watering the garden flowed from Eden; from there it was separated into four headwaters." (Scripture taken from the Holy Bible, New International Version, International Bible Society, 1984. Used by permission of Zondervan Bible Publishers.)  2  3  Figure 1.1 Medieval Cloister Garden  Medieval society's appreciation of the garden was not confined to its ability to restore the spirit of the ill. Walled pleasure gardens were an important aspect of the well-to-do and bourgeois lifestyle (see figure 1.2).  Reading or simply pausing to meditate upon an illuminated page, playing musical instruments or board games, and dancing in the privacy of one's enclosed garden were common pastimes of a wealthy merchant wife or noble lady.  Pleasure  gardens often contained fountains, manicured lawns, orchards, and flowerbeds.  In  spring and summer, these paradise gardens provided sweet smells, shade, and birdsong, a place for playing the psaltery, harp or small organ, for reading for playing chess or backgammon, or simply for resting. (Driver 9)  These pleasure  gardens were valued as sources of enjoyment,  exchange. The enchantment  contemplation  and social  and inspiration gardens provided were recognized  throughout  medieval society; the enclosed restorative garden was a setting for pleasure and healing.  4  Figure 1.2 Walled Medieval Restorative Garden  1.2 Healthcare Facility Design of the Fourteenth to Seventeenth Century During the Renaissance and Reformation healthcare facility design ignored the benefits o f the restorative garden, providing little more than a room and a bed for patients.  The onset of the  bubonic plague in 1347 (along with crop failures) brought instability and fear to many small European towns and droves of migrants sought shelter and public care in the large urban centers. 5  The national welfare and health administrations of the fourteenth and fifteenth centuries were unable to cope effectively with the erupting demands brought about by panic and crisis; the currently familiar mix of public and private, secular and religious healthcare facilities emerged. American landscape architect Karen Kettlety notes that hospitals of this period "functioned as scientific laboratories where physicians could conduct their observations" (6).  Between the  fourteenth and seventeenth centuries, European society seemed to have lost sight of the benefits o f nature in recovery as medicine focused on finding cures rather than healing.  One notable exception to this trend appeared in 1409 at a mental hospital in Zaragoza, Spain. Regular work along with garden therapy was initiated as part of the patients' therapy regime. Patient treatment consisted of caring for the hospital's farm of vineyards, gardens and orchards. This progressive move replaced the beatings and whippings mental patients had previously received as standard, however less effective, treatment for their mental illness.  B y the late  eighteenth century, the long-term success of this innovative approach to patient care became highly regarded in Europe, influencing the work of French doctor and hospital designer, Philip Pinel, and English merchant and philanthropist, William Tuke (Warner 5-12).  1.3 The Romantic Movement's Influence on the Healthcare Environment The concept o f nature and gardens as places for bodily and spiritual restoration was reborn with the Romantic Movement in the eighteenth century (Warner 5-12). The revival of pastoralism encouraged the therapeutic connection between medical science inside the healthcare facility and the garden outside.  In the period just prior to this era, interaction between patients and the outdoor environment was usually limited to sitting in the sun and fresh air. "The Romantic Era's attitudes toward nature once again endowed garden spaces with emotional and religious powers o f high intensity" (Warner 8).  During the romantic era, it appears that commonly held beliefs in the restorative  value o f nature may have influenced healthcare facility design, as evidenced by the reappearance of gardens and outdoor spaces in veterans hospitals.  6  Healthcare facilities built in Europe during the seventeenth and eighteenth century to care for sick and injured sailors and veterans often included large centrally located open spaces, suggesting that gardens may have been viewed as an intrinsic component of the healing environment.  Louis X I V is credited with building veterans' hospitals, such as Paris' Les  Invalides, that included an outdoor open space within the compound for patients to enjoy sunlight, fresh air and regular exercise.  Les Invalides (completed in 1676) could accommodate  up to four thousand patients and set a precedent in terms of building design, ensuring that the patients' rooms had a pleasant view overlooking one of the fifteen garden courtyards. It appears that the architect of Les Invalides, Liberal Bruant, intuitively considered views of nature as beneficial in the healthcare environment and anticipated that the patients' sense o f well-being would be enhanced in a pleasant environment. This approach to patient care and the design of the physical form o f the healthcare environment was reminiscent of the medieval period's courtyard monastery hospice.  Prior to the period of Enlightenment, hospitals were often overcrowded, dark and unsanitary with very little ventilation. These unfavorable conditions led to the acknowledgement of the importance of preludes to healing: views of nature, fresh air and sunlight. Society in general became less interested in contemplating the fate of the soul and more interested in the human condition. (Kettlety 6)  New and innovative patient treatment programs (adopted during the seventeenth and eighteenth centuries) also influenced hospital design. Quaker,  William  Tuke  French doctor, Philippe Pinel (1745-1826), and the  (1732-1821) of England,  independently  lobbied their  respective  governments for the humane treatment of the mentally ill, promoting psychological nurturing rather than physical punishment (commonly practiced at the time).  This new approach was  termed the moral treatment and it quickly gained popularity in Europe and North America. Both Pinel and Tuke believed that patients could be socialized in a restful physical environment conducive to  favorable behaviour, thereby excluding the need  Occupants were considered patients rather than inmates.  for physical punishment.  Regular routine activities, resembling  those of the outside world, were prescribed for patients according to their symptoms.  This  highly successful recovery regime encouraged gardening and participation in farming activities  7  so patients could benefit from working outdoors in the fresh air.  3  New facilities were designed  and built to accommodate moral treatment; site planning reflected the value o f landscapes in the treatment of the mentally ill, often incorporating intimate courtyards, long vistas, vast natural landscapes and ornamental gardens.  These thoughtfully designed institutions provided the  environmental, recreational and occupational requirements of this style of psychiatric care. The landscape setting was central to the moral treatment and thus patient care.  1.4 Nineteenth Century Pavilion Hospitals A n awareness o f the positive effects of sunlight, views of nature and fresh air in encouraging both psychological as well as physical well-being was expressed in the architectural style of the pavilion hospital, adopted throughout Europe in the nineteenth century.  In 1853, Florence  Nightingale expounded the healing quality of nature intrinsic to the design of pavilion hospitals: 4  Second only to fresh air.. .1 should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight is necessary for speedy recovery. I mention from experience, as quite perceptible in promoting recovery, the being able to see out of a window, instead of looking against a dead wall, the bright colours of flowers...it is generally said the effect is upon the mind. Perhaps so, but it is not less so upon the body on that account.. .while we can generate warmth, we cannot generate daylight. (Warner 7).  Pavilion hospitals of the nineteenth century where modeled after such examples as the Chelsea Royal Hospital (1692) in London and the Stonehouse Royal Naval Hospital (1765) near Plymouth (see figure 1.3).  Chelsea and Stonehouse were designed with large windows to allow  plenty of light and air to circulate between the well-spaced narrow wards.  The open space  In North America, the Worcester State Hospital of Massachusetts's administration conducted a follow-up study of their psychiatric patients discharged between 1833 and 1853. This study revealed a remarkable forty-five percent of the patients who had received the moral treatment continued to conduct successful lives avoiding further hospitalization, suicide, and welfare, thus providing impressive evidence that the moral treatment in the natural environment provided patients with the positive therapy they needed (Warner 10). Considered the pioneer of modern nursing, British born Florence Nightingale (1820-1910) is particularly recognized for her contribution during the Crimean War where, through improvements to patient care in the military field hospital she managed, the mortality of the wounded was reduced by forty percent to two percent. Nightingale was awarded the Royal Red Cross medal in 1883 and the Order of Merit in 1907. Nightingale invented a diagram known as coxcomb, which she used to record statistical information on patient medical outcomes, <http://www.freedefinition.com/Florence-Nightingale.html> 8 3  4  between the two- and three-story pavilions provided an opportunity for garden viewing and tending by patients at facilities that included a horticultural therapy regime. The French Royal Commission adopted surgeon Jacques Tenon's similar hospital design guidelines for pavilion wards, thus standardizing good hospital design in the nineteenth century.  5  Tenon and his  colleagues refused to consider a hospital simply as a place of charity, and wanted to make it, above all, a place of healing (Tenon 5).  Figure 1.3 Example of pavilion-style hospital - Heather Pavilion at Vancouver General Hospital 1905  During the same period in Germany, horticultural theorist, Christian Cay Lorenz Hirschfield, wrote of hospital site and garden design commonly exemplified by the nineteenth century hospital:  A hospital should lie open, not encased by high walls. The garden should be directly connected to the hospital, or even more so, surround it. Because a view from the window into blooming and happy scenes will invigorate the patient, also  Jacques Tenon (1724-1816) was commissioned in 1785 during the reign of Louis X V I , to make recommendations for the upgrade of Parisian hospitals. Tenon visited several British hospitals and compiled a detailed account of his observations which he then used as a basis for his hospital design recommendations. 5  9  a nearby garden encourages patients to take a walk...The plantings, therefore, should wind along dry paths which offer benches and a chair.. . A hospital garden should have everything to enjoy nature and to promote a healthy life.  It should  help forget weakness and worries, and encourage a positive outlook.. .The spaces between could have beautiful lawns and colourful flower beds...Noisy brooks could run through flowery fields, and happy waterfalls could reach your ear through shadowy bushes. grouped together.  Many plants with strengthening aromas could be  M a n y singing birds will be attracted by the shade, peace, and  freedom. A n d their songs will rejoice many weak hearts. (Marcus and Barnes, Healing Gardens 12)  Hirschfield's prescription for hospital site design could well describe the grounds of Riverview Hospital in Coquitlam, British Columbia. Typical of pavilion hospital siting of this period, the views from the patients' rooms at Riverview look out onto a courtyard and beyond to the expansive picturesque grounds and surrounding rural landscape. Over the past one hundred years, as part o f their therapy program, the resident patients at this mental health facility voluntarily contributed their labour and time to establish and maintain the gardens of this two hundred and fifty acre hillside site as well as the adjacent four hundred acre riverside site known as Colony Farms.  Mental health facilities established at the turn of the previous century, commonly employed occupational and horticultural therapy in the treatment of their patients, while acute care patients enjoyed gardens strictly for fresh air, exposure to sunlight and as a pleasant environment for convalescent exercise. The extent to which therapy was provided depended largely on the patient's medical condition.  With the advent of medical scientific advancement and high-rise construction, the pavilion-style general hospital came under threat. Efficiency experts attested to the financial benefits o f the, now familiar, twentieth  century typical high-rise hospital.  Aseptic, sterile interiors and  impersonal environments replaced gardens at the expense of patients' psychological well-being. Curing and clinical therapy were assumed to be adequately provided solely within the walls of the hospital through "scientific" means.  10  1.5 Twentieth Century Healthcare Trends A significant shift in healthcare occurred in the early twentieth century. Dramatic advancements in medical research meant that healthcare facilities could offer cures where only care was previously available. The focus of healthcare changed from caring to curing and this was reflected in hospital design with the advent of the high-rise acute care hospital in North America and Western Europe. This standard acute care hospital design appeared to be adopted by all healthcare facilities regardless of their patient population. The design intent for twentieth century healthcare facilities seemed to shift from enhancing the well-being o f the patient to enhancing the efficiency o f medical staff.  Design emphasis was placed on reducing distances between  wards and thus increasing efficiency through a reduction in the amount o f time staff spent traveling between wards (Warner 5-12).  The turn of the twentieth century witnessed the beginning of laboratory medicine. Intervention therapy (which could be scientifically tested) began to replac a care regime (based on anecdotal information) that promoted healing by providing patients with views of nature, fresh air and sunlight (Kettlety 11). Kettlety asserts that the "twentieth century acute care hospital represents the high-technology, depersonalized, scientific philosophy that is the core of medical care today" (12).  The loss o f gardens and garden therapy from healthcare facilities coincided with a shift in  the approach of healthcare provision from healing individuals to curing their diseases.  However, at the beginning o f the century, after World War I, gardens began to reappear as a recognized recovery-promoting element in healthcare facility design.  Psychiatric healthcare  facilities led the way in providing gardens and access to gardening activities as a means o f promoting health. Veterans' hospitals were also built with large expanses of lawn and gardens and ensured a strong visual and physical connection between the inside and outside of the facility. A t this time, as well, garden club volunteers began assisting with occupational therapy, providing patients with horticultural education and experience (Warner 5-12).  In 1943, Indiana psychiatrist Dr. William Menninger developed a practice known as milieu therapy.  Milieu therapy recognized that a patient's well being was affected by the healthcare 11  facility environment and experience, including exposure to non-medical healthcare facility staff and fellow patients. Menninger, a believer in the restorative effects o f gardens and nature walks, was keenly interested in his staffs observations o f the link between nature and patient recovery. Interpretation o f individual patient's progress, by therapeutic staff, proved to be a significant contribution for determining appropriate therapy. Many veteran and mental hospitals throughout the United States quickly adopted milieu therapy.  Recognition o f the vital role therapeutic  caregivers provided, led to the independent profession o f the horticulture branch o f occupational therapy, now known as horticulture therapy. A s a result, much research has subsequently been undertaken in an effort to explore people-plant relationships (Warner 12).  Tubercolosis, a prevalent disease with no known cure in the first part o f the twentieth century, is an example o f patient care where survival is deemed remote.  Good nursing practice in  tuberculosis sanitariums included wheeling hospital beds outside onto sun porches and roof decks to expose patients regularly to fresh air and sunlight.  American landscape architect,  Deborah Ryan, concludes that without a cure for tuberculosis and the prevalent belief that fresh air was the only deterrent to its spread, mountain wilderness areas with forests o f pine became revered by American society (Ryan 5-8).  These particular biomes were thought to be healthy  environments, and as a result, tuberculosis sanatoriums were often sited in pine forests as this landscape setting was considered key to patient well-being and an improved chance for recovery.  Further evidence o f increasing awareness o f the benefits o f nature in maintaining wellness was also apparent in American society's attitude toward child health programs such as summer camps and nature studies, which were promoted for city children during this period. The New Deal o f the 1930s furthered American society's commitment to the improvement o f cities and acquisition o f national parks. The prominent American landscape architect o f this period and designer o f New York's Central Park, Fredrick Law Olmstead, promoted the preservation o f open green spaces in urban areas to ensure human well-being: cultural, physical and social. Olmstead was commissioned by several o f the large American cities including Boston, Chicago and Buffalo to identify and design parks for the benefit and enjoyment o f their citizens.  This  period in history illustrates Warner's contention (as did the medieval and romantic era) that when  12  society as a whole values nature, value is given to the benefits o f the restorative garden and nature in the healing process (Warner 5-12).  The last decade o f the twentieth century witnessed the beginnings o f a resurgent international interest in restorative or healing gardens in healthcare facilities. A number o f contemporary academic perspectives articulating the role o f nature in healthcare environments distinguish between the terms healing and curing.  Enhancing a patient's physical and emotional sense o f  well-being was typically described as healing, while curing usually referred to a focus on treating the symptoms o f an illness or disorder. This distinction consistently appears to be the point o f departure for discussions on the perceived therapeutic benefits o f gardens and nature. Scientific medical treatment is focused on curing the illness while healing is a holistic approach to illness and disorders that acknowledges and responds to the connection between mind and body. Access to nature and gardens is currently thought to provide a degree o f relief from the symptoms associated with illness, and as such, is considered beneficial to the healing process (Lewis, Gardening as Healing Process; Kaplan and Kaplan, Experience of Nature; Marcus and Barnes, Gardens in Healthcare Facilities; Ulrich, View through Window).  American epidemiologist  6  Dr. Richard Joseph Jackson, asserts "medicine alone will  be  inadequate to deal with the health challenges o f the twenty-first century, even with the help o f the sequenced genome and advances in robotic surgery" (Jackson 1). Jackson suggests that the prevalence o f chronic diseases in an aging population will result in escalating costs for healthcare provision.  Jackson contends that improving the quality o f our living environments could  mitigate rising medical costs. "Health for all, especially for the young, the aging, the poor, and the disabled, requires that we design health-fullness into our environments" (Jackson 1). Jackson explains that while the average American's life span doubled (from forty to eighty years o f age) during the previous two centuries, only seven o f those added years are a result o f better disease  A n epidemiologist is a medical doctor concerned with finding the causes of a disease and means for its prevention. Epidemiology is the study of the demographics of disease processes, including the study of epidemics and other common diseases, even those that are not contagious such as diabetes, coronary heart disease and high blood pressure. The founding event for the science of epidemiology was in 1854 when Dr. John Snow suppressed an outbreak of cholera in London's Soho District by identifying a public water pump as the source of the infection. <http://www.free-definition.com/Epidemiology.html> 13 6  care.  Jackson attributes the dramatic increase in life span to, "higher living standards and a  healthful environment, including clean water and food, and better and safer housing" (1).  The  health challenges of the twenty-first century, in Jackson's opinion are, "assuring a healthy aging population, protecting mental health, thwarting environmental threats, preventing and controlling chronic diseases such as diabetes and obesity and eliminating disparities such as diminished health among the poor."  7  Jackson believes our living environments can be designed to improve  health. Designing safe places to walk is one example Jackson cites of an environmental design feature that can contribute to improved mental and physical health for all ages particularly the institutionalized and elderly.  Over the past twenty years, a number of healthcare administrators across North America and Europe have explored the possibility that access to nature can increase a patient's sense o f wellbeing and as a result have incorporated healing gardens into their respective healthcare facilities. Increasingly, patient-centered healthcare facilities are conceived and designed to meet the specific needs of the patient by acknowledging the beneficial role o f nature in the recovery process (Warner 12).  Interest in utilizing rooftops of existing and new multilevel healthcare  facilities for therapeutic purposes has resulted in the installation of healing gardens such as the Joel Schnaper Memorial Garden (to be discussed further in Chapter 4). A s construction of longterm care facilities for our aging population is expected to rise dramatically to meet the anticipated demand over the next thirty years, understanding the guiding principles and beneficial design features o f therapeutic healing gardens for this facility type, as well as others,  Dr. Richard Jackson, M D , M P H , Director of the National Center for Environmental Health, Centers for Disease Control and Prevention in Atlanta, Georgia, United States suggests the following link between health and environmental design: A n example of a disease problem epidemic that is exacerbated by bad environmental designs is that of the epidemic of obesity in the United States. Twelve per cent of the United States' population were obese in 1991; eighteen percent were in 1998. Obesity is unhealthy, it raises risks of heart disease, high blood pressure, diabetes, stroke, and diminishes vitality. For diabetes, from 1980 to 1994 the prevalence in the population increased by 2.2 million cases, an increase of thirty-nine percent, and diabetes is the seventh leading cause of death in the United States. Type 2 diabetes (formerly only associated with older and often obese adults) has increased in every age group in the population. Lack of exercise, or any physical activity, contributes to obesity and diabetes epidemic. Despite common knowledge that exercise is healthful, fewer than forty percent of adults are regularly active, and twenty-five percent do no physical activity at all. The way we design our communities makes us increasingly dependent on automobiles for the shortest trip, and recreation has become not physical but observational. There is increasing evidence (though much more research is needed) that contributing to the obesity epidemic is the lack of safe and healthy places to pursue even the most basic physical exercise, walking. Walking is a socializing and safe exercise for everyone, and the prime exercise for the elderly (Jackson 1). 14 7  will be critical to maximizing their healing benefits. Toward identifying principles and design features, the next chapter reviews the current scientific research linking exposure to nature with positive medical outcomes.  15  CHAPTER 2 - Current Research: The Restorative Value of Nature  With the exception of the Renaissance and Reformation periods in Western history, Chapter One demonstrated that, up until the twentieth century, society intuitively recognized the restorative value o f nature. This was evidenced in the design of healthcare facilities, ensuring patients were provided with either a passive or active experience of nature.  Healthcare facility design  intentionally allowed for views of a garden from patients' rooms, easy access and mobility from the hospital interior out into and through a garden, and sometimes a place to work in the garden. Healthcare facility design appeared to be based on anecdotal information related to the benefits o f nature as scientific research linking wellness, stress-recovery, and healing to nature was lacking. The need to provide for nearby nature ceased to influence hospital design with the adoption of the science-based, twentieth century medical model and its emphasis on the need for scientific evidence. With rapid advancements in the science and technology o f medicine during the first part o f the twentieth century, emphasis was increasingly placed on providing functional environments designed to accommodate newly-developed medical apparatus and the efficient delivery o f medical-based technology (Warner 5-12).  The shift from accommodating people with illness in an environment that addressed their psycho-physiological need for the comfort of a natural setting (i.e. medieval cloister gardens) to one that strictly addresses their physical need for medical intervention (i.e. the modern high-rise hospital) has subsequently been evidenced in the program, design and administration of many North American healthcare facilities (Warner 5-12).  During the latter part of the twentieth century, however, science-based research examining the relationship between nature and human well-being was increasingly undertaken, sparking a  16  renewed awareness o f the benefit o f nature in the recovery from illness.  Anecdotal evidence  suggesting the benefit o f nature to human well-being and the healing process continues to proliferate.  This chapter, however, focuses specifically on the science-based research o f a  number o f leading researchers in this area. In this chapter I will provide an overview o f current interdisciplinary science-based evidence related to the affects o f nature on human well-being, as follows: Psychological Perspectives on Nearby Nature (Stephen and Rachel Kaplan); Nature's Affect on Recovery Rates (Roger S. Ulrich, Terry Hartig, M . J. West); The Restorative Benefits o f Horticulture Therapy (Patrick Mooney); The Biophilia Hypothesis (Edward O . Wilson, Jay Appleton, Judith Heerwagen, Gordon Orians); People-Plant Relationships (Charles A . Lewis).  The decision to review studies conducted by recognized experts from a broad range o f disciplines including environmental psychology, behavioural science, horticulture, biology and landscape architecture is based on my premise that the findings o f researchers in a variety o f disciplines are consistent and will strengthen the argument supporting the inclusion o f nature in the design o f healthcare facilities.  While the research presented in this chapter highlights the  benefits o f nearby nature for human well-being, the next chapter will elaborate on the implications we may glean from this investigation for healthcare design.  2.1 Psychological Perspectives on Nearby Nature Doctors  Stephen and Rachel Kaplan,  leading researchers in the  field o f environmental  psychology, and authors o f the 1989 and 1998 books respectively, The Experience o f Nature and With People in M i n d , have been studying the relationship between people and nature for over  In the 1990s, little research linking dysfunctional physical settings with health outcomes was published. In 1996 researchers Haya Rubin and Amanda Owens identified 270 articles of 38,000 potentially relevant titles from medical databases that appeared to describe investigations into the impact of environmental elements on health outcomes. O f the forty-three articles identified as specifically detailing the relation between patient well-being and environmental factors, many were assessed to be of limited applicability due to methodological limitations. This literature review was circulated among healthcare providers and designers resulting in a general acceptance that nature content, views, windows, and appropriate colors needed to be a priority in renovation and new construction of healthcare facilities. Healing and restorative gardens have began to reappear in the outdoor healthcare environment and there is an ongoing effort to bring nature indoors in the form of the skylit atrium, fountains, waterfalls, trees, plants, and flowers, and in various representations of nature (Verderber 345). Rubin and Owens concluded: "[Investigations] into the effect of environmental manipulations have generally supported the hypothesis that environmental features affect patients' health...Thus, improvements in health outcome are likely to be available through research on this subject, and it is an important topic to pursue" (Rubin and Owens). 17  thirty years. During this time, the Kaplans have accumulated a substantial body o f research indicating that "people prefer natural environments to other settings," and that "there are other benefits beyond the mere fact o f enjoyment" (Kaplan, Kaplan, and Ryan ix). The Kaplans assert that "nearby nature can foster well-being and nature views have been demonstrated to be related to greater physical and mental health and further that activities that are nature-related have been shown to help people go about their lives more effectively" (Kaplan, Kaplan, and Ryan 2). The following discussion summarises the Kaplans' understanding o f the psychological dimensions for healing o f having nature nearby.  The Kaplans use the word "nature" broadly.  Nature is not necessarily characterized by its  distance from human settlement, nor is it necessarily unaltered by human intervention.  The  Kaplans' definition o f nature simply describes any outdoor setting with a substantial amount o f vegetation.  The Kaplans have found, through a great deal o f research, that people's concept o f  nature is broad and inclusive, emphasizing everyday natural environments often ordinary but nearby as opposed to wild, distant, dramatic or even lush.  The Kaplans' definition o f nature  includes almost any outdoor setting including parks, vacant lots, street trees, open spaces, backyards, fields and forest. For their purposes, these places range in scope and size from tiny to expansive, from highly maintained to virtually neglected.  The Kaplans also found a great diversity o f natural settings are beneficial to human well-being. They feel the restorative environment can vary in terms o f physical space and the duration o f experience. environments  The Kaplans have and the  explored the qualities and characteristics o f restorative  psychological benefits  natural settings provide and contend  that  "restorative environments offer a concrete and available means o f reducing suffering and enhancing effectiveness" (Kaplan and Kaplan, The Experience of Nature 176).  More recently, the Kaplans have considered the concept of, as well as the potential avenues for, recovery from mental fatigue. The Kaplans suggest that stress and mental fatigue are two distinctly different concepts.  Where stress is an outcome o f preparing for a threatening or  harmful event, mental fatigue is the result o f intensely directing one's attention to a task that  18  could even be described as enjoyable.  The Kaplans have theorized that when one experiences  mental fatigue, the underlying cause is fatigue o f directed attention resulting from the struggle to pay attention in a highly-distracting environment.  The Kaplans have undertaken a number o f  studies to examine the correlation between mental fatigue and mood.  In one such study,  participants were less helpful, tolerant and sensitive, and more aggressive, after exposure to attention-demanding tasks under conditions of high distraction. The Kaplans contend that rest is needed to counter mental fatigue. While sleep is not always practical or appropriate, according to the Kaplans, time spent in an environment that does not demand directed attention could provide beneficial rest.  Environments that are conducive to resting the mentally-fatigued individual are referred to by the Kaplans as restorative environments. The concept o f the restorative experience is based on the idea that mental effort, coping with hassles, and the everyday demands o f living in the modern world, all tend to fatigue one's capacity to direct one's attention. A restorative environment is considered to be an environment that fosters this recovery.  The Kaplans have defined restorative environments as having the following four characteristics:  •  Being away - The Kaplans believe that recovering from mental fatigue requires a change o f environment from the source o f the fatigue. Being away can involve a physical change or it can be as simple as allowing the fatigued mind to wander off by gazing out through a window to a view o f nature. The Kaplans contend the "distinctiveness and separateness o f the experience from the workaday experience may be as important as the literal distance" (Kaplan and Kaplan, The Experience of Nature 190). The sense o f being away can even be experienced by casually wandering through a small garden, noticing the textures and patterns o f new growth and flower buds. This experience can provide hospital staff, volunteers and visitors with needed relief from mental fatigue, an opportunity to relax, relieving them temporarily from pressures and obligations.  19  •  Extent - The issue o f size and preference o f natural areas was explored in studies on environmental preference conducted by Bardwell (1985), and Talbot, Bardwell and Kaplan (1987) which generally found that smallness is not detrimental.  The Kaplans' study  participants identified factors that make an area seem larger (extent) as well as factors that enhance their preference.  The factors identified were similar for both extent and preference  and included: "spacious, wide-open areas," "trees, especially large and numerous," and "trails and pathways" (Kaplan and Kaplan, The Experience of Nature 152). The Kaplans suggest that while wilderness areas typically provide extent, the experiential quality o f extent can also be provided in a garden as one's mind elaborates and wanders through the garden anticipating seasonal changes.  Rachel Kaplan discovered that "a park does not need to be large to be highly valued, and creating one large space was less preferred than creating a setting with many smaller regions" (Kaplan and Kaplan, The Experience of Nature 154). The Kaplans concluded that "rather than size itself being the important issue, it may be the perception o f extent that is o f greater significance.  Areas that suggest there is more to explore than is immediately apparent, has a  special attraction" (Kaplan and Kaplan, The Experience of Nature 155). They suggest it is important to consider how the space is designed to achieve the valued qualities o f views o f trees, intimate spaces within a larger area, and hints o f more to explore.  •  Fascination - When involuntary attention is held, it is typically termed fascination. The Kaplans found that fascination is important to the restorative experience because it does not use directed attention but evokes involuntary attention, "fascination," and when individuals are functioning without directed attention they are resting their directed attention capability. Gardening research has revealed that the attention-holding power o f the garden was one o f the most highly-rated benefits o f gardening. "soft-fascination."  They feel  9  The Kaplans termed fascination in a garden as  a garden that combines  beauty  and interest  provides  In 1976, Rachel Kaplan and Charles Lewis surveyed members of the American Horticultural Society. O f the over four thousand replies received, the respondents rated "nature fascination" as the second most satisfying benefit derived from gardening. Nature fascination was described as "getting completely wrapped up in it [gardening] and never failing to hold interest [the garden/gardening], (Kaplan and Kaplan, The Experience ofNature 169). 20  9  opportunities for the mind to be distracted from any unpleasant thoughts and open to other thoughts and experiences.  Gardens that include patterns and shadows created by sunlight or  moonlight through foliage, emphasizing the changing seasons and mood o f the garden through colour, scent and a variety o f textures invite the mind to wander and contribute to the sense o f being away. Even viewed through a window, a small familiar natural environment that captures the ephemeral qualities inherent in nature can be fascinating and ease the mind.  •  Compatibility - Compatibility refers to the degree to which an environment supports the actions or desires o f an individual.  A n environment that is experienced as pleasurable can  provide rest for directed attention. Many people experience functioning in a natural setting as less effortful than functioning in an urban environment, even though their familiarity with the latter is often far greater (Cawte, 149-161); the term compatibility describes this experience. Gardening and bird watching are examples o f activities or purposes that are compatible with being in a natural environment.  T o summarize, the Kaplans describe restorative environments as natural settings that counter the effects o f mental fatigue and are characterized by enabling the viewer or participant to sense: being away, fascination, extent and compatibility. When people suffer from mental fatigue, they are prone to human error, can become irritable, experience a decreased attention span and lack peace o f mind and tranquility. Nature can play a critical role in restoration from mental fatigue. Even undramatic natural settings can be helpful in providing restoration including when viewed from a distance for a relatively short period o f time.  Similar to Ulrich's findings, the Kaplans  assert that, "many o f the benefits from restorative environments can be achieved by having a view from a window" (Kaplan and Kaplan, The Experience of Nature 76). A s noted in the previous chapter, typical medieval cloisters also supported the restorative experience by ensuring intimate views to a courtyard garden from the residents' rooms.  The Kaplans suggest "basic to human well-being is an environment that fosters understanding and provides opportunities for exploration" (Kaplan and Kaplan, With People in Mind 28). Preferred environments are those perceived as safe and hence are opportunities to rest directed attention and are referred to as restorative environments. While restorative benefits are enhanced 21  in environments that are perceived as secure, thus permitting one to become absorbed, research on preferences for various environments consistently indicates that mystery is highly rated. When mystery and charm are introduced through a view partially concealed with foliage or a winding pathway, for example, one is compelled to explore that landscape.  Further, the Kaplans contend that aesthetically pleasing natural environments give pleasure and are satisfying to experience while supporting exploration and recovery from mental fatigue. Further, the nervous system experiences pain at the exclusion of pleasure hence the experience o f pleasure can reduce or eliminate pain. The Kaplans contend that contact with pleasurable stimuli can reduce pain and the need for directed attention.  A s natural settings are preferred  environments, this provides the theoretical basis for expecting natural environments to be restorative. In addition, the benefit o f including a garden to provide pleasure in a hospital setting becomes obvious in terms o f its potential to reduce the level o f pain experienced by patients (Kaplan, Kaplan and Ryan, With People in Mind; Kaplan and Kaplan, Experience ofNature).  The Kaplans concluded that the natural environment has restorative benefits and that natural settings are preferred to most other environments because o f the aesthetically pleasing qualities of nature. The Kaplans also concluded that while extended periods o f time in natural settings may provide additional restorative effects, viewing nearby nature also provides restorative benefits.  Natural environments permit tired people to regain effective functioning and there  appears to be sufficient evidence about the benefits o f nearby natural environments to support the creation o f such settings.  The Kaplans demonstrated that mentally fatigued individuals can benefit from natural settings that allow for passive involvements such as noticing different colours in fall leaves, listening to the wind, watching the clouds go by, or delighting in the antics o f a chipmunk. The Kaplans conclude that the inclusion o f natural environments in healthcare facilities provides the setting needed for staff, volunteers, visitors and patients to find respite and recovery from their particularly demanding and often stressful circumstance.  22  2.2 Nature's Effect on the Rate of Recovery Dr. Roger Ulrich is a Professor o f Landscape Architecture and Architecture at Texas A + M University,  and serves as Director of the  Center for Health Systems  and Design, an  interdisciplinary centre housed jointly in the Colleges o f Architecture and Medicine. Ulrich, a behavioral scientist, conducts research on the effects o f healthcare gardens and buildings on patient medical outcomes and his work has influenced the resurgent international interest in restorative or healing gardens.  In 1970, while doing his doctorate studies under Stephen and Rachel Kaplan, Ulrich began exploring theories o f restoration and tranquility derived from natural settings. Ulrich measured the psycho-physiological effects o f green environments to explore the role o f plants in restoration from stress. Ulrich studied the rate o f recovery response by comparing subjects who, after watching a worker-safety film depicting violent injuries, viewed scenes o f nature with others who viewed scenes o f concrete urban environments. A l l subjects experienced increased heart rate, blood pressure and muscle tension as a result o f watching the safety film. These symptoms, however, subsided much more slowly in the group not shown the nature film afterwards.  Ulrich discovered that the group viewing nature showed higher levels o f stress-  recovery, concluding that viewing nature can reduce stress and therefore positively influence rates o f recovery and promote health.  In a related study, Ulrich, while a professor in the University o f Delaware's Department o f Geography, set out to determine whether "a room with a window view o f a natural setting might have restorative influences" (Ulrich, View Through Window 420).  Ulrich's landmark research  compared two patient groups recovering in a Pennsylvania hospital after gallbladder surgery. Over a nine-year period (1972 through 1981), the records o f twenty-three patients with a view to a group o f deciduous trees were compared to the records o f twenty-three patients in postoperative rooms with windows looking out on to brick walls. The patients' records were studied comparing the length o f hospital stay, strength o f the pain medication received and the number o f negative evaluative comments in the nurses' notes.  In 1984, Ulrich's findings, which were 23  published in Science, suggested that the "natural scene had comparatively therapeutic influences as the patients with the tree view had fewer negative evaluative comments from nurses, took fewer moderate and strong analgesic doses, and had slightly lower scores for minor post-surgical complications" (Ulrich, View Through Window 421).  Ulrich concluded "the results imply that hospital design and siting decisions should take into account the quality o f patient window views" (Ulrich, View Through Window 421) (see figure 2.1).  Subsequent research permitted Ulrich to build on his theory that "viewing trees, flowers,  and other vegetation reduced stress and induced a sense o f well-being that promoted health, particularly for people in confined, stressful environments such as hospitals" (Thompson 74).  The significance o f Ulrich's research is evidenced by the fact that his studies were clinically conducted on real patients in real hospitals, not on people in laboratories or simulated situations. The beneficial influences, derived from viewing nature through the patients' recovery room windows, resulted in many positive health outcomes and are thought to have a psychological component. The resulting positive health outcomes included: reduced need for pain drugs; fewer typical minor complications such as persistent headache or nausea; a decline in blood pressure; more relaxed muscles. It is also important to note that Ulrich's findings revealed that the subject patients' brain electrical activities changed, suggesting they were feeling more wakefully relaxed (Ulrich, View Through Window 420-21).  24  Figure 2.1 View through a window to nature  Ulrich's findings, suggesting clinical benefits of a greater connection to the natural environment, are also supported by a 1991 study by Terry Hartig, Associate Professor in Applied Psychology, Institute for Housing and Urban Research and Department of Psychology at Uppsala University in Sweden.  Hartig and his associates (Mang and Evans) studied stressed individuals and their  responses to a forty-minute walk in a heavily-treed urban nature area compared to stressed individuals that took a walk in an urban setting without trees. Hartig found that the individuals who walked in the natural area reported improved emotional states over those who walked in the urban area with no trees.  Also in accordance with Ulrich's findings, Joanne Westphal, a medical doctor and professor of landscape architecture in the United States conducted a study o f Alzheimer's patients in 2001 which revealed that patients with access to healing gardens for more than ten minutes a day showed marked improvements in blood pressure, heart rate, weight, aggressive behavior and requested less medication.  25  Ulrich continues to conduct research on the effects of healthcare gardens and buildings on patient medical outcomes showing that the benefits of viewing nature extend beyond aesthetics to include positive effects on emotional well-being and reduction of pain and stress. Considered internationally as the leading healthcare design researcher, I found Ulrich to be the most widely cited healthcare design researcher and it appears that his studies have influenced the site planning and architectural form of many recently- constructed healthcare facilities in the United States.  2.3 The Restorative Benefits of Horticulture Therapy  10  Patrick Mooney is an Associate Professor of landscape architecture in the Faculty o f Agricultural Sciences at the University o f British Columbia. Mooney has won research awards from both the Canadian and American Societies of Landscape Architects for his work on the effects of exterior environments for people suffering from Alzheimer's disease and related dementia.  Mooney's research, discussed in "The Design, Planning and Evaluation of Healing Landscapes," indicates that the restorative benefits of nature are most significant for individuals that are the most degenerated psychologically.  Mooney tested eighty elderly individuals in a long-term  healthcare facility in North Vancouver, British Columbia, Canada. The patients population was divided into two groups, with half participating in a horticulture therapy program for six months and the other serving as a control group. Individuals participating in horticultural therapy had test results  indicating  that  anxious/depressed scale.  they  improved  markedly  on  the  belligerence/irritability  and  Sensory-motor impairment scores also showed improvement while the  control group's (no horticulture therapy) test results indicated no change in behaviour and function.  This study by Mooney of seniors in intermediate care demonstrated that horticulture  therapy could be beneficial, offsetting the negative effects of institutionalization (see figure 2.2).  The American Horticultural Therapy Association (AHTA) www.ahta.org defines horticultural therapy as "a discipline that uses plants, gardening activities, and the natural world as vehicles for professionally conducted programs in therapy and rehabilitation." 26  Figure 2.2 Horticulture Therapy Program  Mooney suggests that residents can experience a sense of connectedness to their place of residence when they contribute to their environment. Gardening activities provide opportunities for the elderly to give something personal of themselves by caring for plants or growing fruit and vegetables to share with the other residents.  Gardening can provide the institutionalized with a  sense o f satisfaction, pride and purpose. "Horticulture therapy appears to be particularly suited to the aged since it can be tailored to a range of physical abilities and interests including flower arranging, food preparation and preserving, while providing a sense of usefulness and purpose that contributes to emotional well-being" (Mooney and Errett 6).  The success of therapeutic gardens depends, however, on their ability to meet the particular requirements o f the related patient populations. People suffering with dementia and Alzheimer's disease can find it difficult to interpret and respond to their immediate environment and as a result become anxious and overly-stimulated, resulting in difficult behavior for staff to manage.  In a previous study (Mooney and Nicell 23-29), the research team of Patrick Mooney and Lenore Nicell discovered a reduction in violent incidents resulting from redesigning a patient garden at 27  Cedarview Lodge, a special care facility for one hundred and fifty Alzheimer patients in North Vancouver,  British Columbia,  Canada.  Mooney and Nicell  (Cedarview Administrator)  discovered that the patients responded negatively to the outdoor environment at the facility, which provoked behavior that was difficult for staff to manage.  The outdoor space  was  redesigned with special attention paid to garden features such as non-glare pathways (to reduce confusion and facilitate walking, not stopping), screening the fence with plant material (to diminish distractive elements), adding a central landmark (to help orient patients), and the use o f pastel colours and soothing, softly fragrant plant material (to reduce agitation). Once the outdoor space had been modified to meet the needs o f the patients, they found the rate o f violent incidents declined by nineteen percent over two years. The rate o f violent incidents, however, increased by six hundred and eighty-one percent over the same period in a similar facility without the benefit o f a restorative garden, used as a control for that study.  Mooney and Nicell's findings provide further evidence that environmental design affects health outcomes and o f the positive benefits and need for appropriately designed restorative gardens to improve the quality o f life o f people living in healthcare facilities with Alzheimer's and other dementias.  2.4  Biophilia Hypothesis  In his 1984 book, Biophilia, Edward O . Wilson, Harvard Science professor and two-time Pulitzer Prize winner, describes and defines the study of the human response to the natural environment as biophilia. Wilson theorizes that biophilia is the force that connects us to nature and is defined as a love for nature. Wilson argues that "Modern humans innately respond to natural content and configurations that characterize environments favorable to pre-modern humans.  A frequently-  cited example is that modern humans feel comfortable in replicas o f the African savanna, such as the trees and lawn setting o f an urban park" (Dannenmaier 60).  The biophilia hypothesis states  that our innate affiliation with nature results in positive responses promoting health and benefiting emotional states. Roger S. Ulrich summarizes this concept in his essay on biophilia and natural landscapes:  28  The speculation that positive responses to natural landscapes might have a partly genetic basis  implies that such responses had adaptive significance  during  evolution. In other words, i f biophilia is represented in the gene pool it is because a predisposition in early humans for biophilic responses to certain natural elements and settings contributed to fitness or chances for survival. (Ulrich, Biophilia 75)  Wilson's biophilia hypothesis was developed nine years after British geographer Jay Appleton suggested that humans prefer landscapes with elements o f prospect (extent or view) and refuge (protection from danger). It should be noted here that Stephen and Rachel Kaplan's work in the field o f environmental preferences also examined the human response to landscapes that offered both prospect and refuge.  The Kaplans discovered, as did Wilson and Appleton, that humans  prefer natural environments that consist o f an expanse o f lawn with single trees dotted throughout, consistent with the ancestral habitat of the African savanna landscape.  I should also note that Dr. Judith Heerwagen,  environmental psychologist, and Professor  Emeritus Gordon Orians, professor in the Department o f Biology at the University o f Washington, similarly describe the Biophilia Hypothesis as preferred landscapes consisting o f "habitability cues, resource availability, shelter and predator protection, hazard cues, wayfinding and movement" (Heerwagen and Orians 142-146).  Heerwagen and Orians surveyed people in a  variety o f countries around the world,, discovering remarkable similarities amongst cultures, with respect to preferred landscapes.  Heerwagen and Orians found that regardless o f culture,  preferred landscapes consisted o f natural elements consistent with landscapes that are a potential  Judith Heerwagen, Ph.D. works with the Pacific Northwest National Laboratory and has her own consulting practice, J.H. Heerwagen & Associates, Inc. based in Seattle Washington, U S A . Heerwagen provided this abstract of her presentation at Green World, May 18, 2000 in Seattle: Human Resource Sustainabilitv: Toward a Theory of Congenial Environments This talk will look at sustainable building design from a human factors focus, linking building features and attributes to physical, psycho-social, and neuro-cognitive functioning. At the present time, green building research focuses on the physical aspects of health associated with indoor air quality and improved thermal environments. However, sustainable design has strong philosophical and theoretical links to human-nature relationships. There is strong emerging evidence that buildings which incorporate nature and natural processes may have far reaching impacts on psychological, social and cognitive functioning. Drawing upon theories of habitability, biophilia, and natural design, Dr. Heerwagen will look at how features and attributes of interior spaces - including aesthetics - can inhibit or facilitate a wide range of work behaviors and outcomes highly valued by organizations, including creativity, collective intelligence, and social networks. In this perspective, the building is viewed as a habitat for people and as an investment in human resource sustainability. The presentation will identify basic "habitability" features of built environments and will link variation in these features to variation in human well-being and performance. And finally, sustainable design will be linked to other environmental factors to develop a theory of "congenial environments." 29 11  source o f food, shelter and places to explore, such as copses of trees with horizontal canopies, water, elevation changes, distant views, and flowers.  The Kaplans, Appleton, Heerwagen and  Orians' findings all support Wilson's work in this area.  2.5 People-Plant Relationships After thirty years o f studying the relationship between people and plants, in 1996 horticulturist Charles A . Lewis, published Green Nature, Human Nature: The Meaning o f Plants in our Lives. Lewis concurs with Wilson that the strong human response nature elicits must have an evolutionary basis.  Lewis draws this conclusion from numerous studies o f the human species'  affinity for nature, independent of social, economic, and cultural variables. Lewis believes that "humans seek out nature as a refuge because we evolved in nature" (Dannenmaier 60).  This  natural human instinct to seek the comfort and protection of the natural environment emphasizes the need to address this requirement of those suffering from illness. opportunity to interact with nature, nurtures a basic human need.  Allowing patients an  12  The role o f plants in human healing is based on ancient natural remedies for illness.  Herbalists recorded the healing properties of plants.  gardens were established for the enlightenment o f physicians.  The first botanical Today, however,  we seek a healing quality in gardens and gardening that acts primarily on mind, not body - medicine not to be taken orally but rather perceived sensually, to heal scars on the human psyche. (Lewis, Gardening as Healing Process 244)  In 1976, Charles Lewis and Rachel Kaplan prepared and distributed the 'People Plant Survey' to members o f the American Horticultural Society.  O f the four thousand replies received, sixty  percent o f the respondents indicated that the greatest satisfactions derived from gardening were a "feeling o f peacefulness" and a "source of tranquility." Kaplan revealed that a number o f what she has termed "satisfaction factors" are experienced from being in nature:  "sensory joy, the  feeling o f peacefulness, quiet and tranquility derived from walking or being in the garden, and  Stephen Scharper, an assistant professor of religious ethics and environmental studies at the University of Toronto suggests that the human urge to get back to the garden is primal; at its root is a longing to choose life. (Scharper, Stephen. Interview with Mary Hynes. "Back to the Garden". Tapestry. Canadian Broadcasting Corporation. 12 Apr. 2004.) 12  30  soft fascination experienced when one becomes so engrossed in the work of gardening that rest is provided from stresses plaguing the mind" (Mooney and Errett 4). Kaplan asserts:  The capacity to direct one's attention is a fragile resource. It is worn down by distraction, confusion, and by other hassles of various kinds. A s this capacity is worn down, or more accurately, fatigued, there can be numerous unfortunate consequences. A m o n g these are impatience, irritability, proneness to error, the inability to focus, and a generalized state of discomfort or pain. Ultimately the decline  in the ability to direct attention can challenge  the integrity of an  individual's mental or physical health. Given the potential damage created by the hassles and pressures of everyday life, both large and small, the restorative experience has the potential of playing a vital healing role. (Kaplan and Kaplan, Restorative Experience 243)  Lewis and Kaplan's research indicates that gardens can provide an ideal, natural healing environment. Their research results have inspired the adoption of horticulture therapy programs in many healthcare facilities in the United States and Canada.  2.6 Conclusion: Review of Science-Based Evidence The work of several researchers studying the affects of nature on human well-being is presented in this chapter. While the researchers represent a variety of disciplines, including environmental psychology,  behavioural science, horticulture, biology and landscape  architecture, similar  conclusions are being drawn. Each researcher reports science-based evidence that supports the notion that humans benefit mentally and physically from either passive or active interaction with the natural environment including contact with plants and viewing nature and landscapes.  Roger Ulrich's work suggests that patients recovering from surgery in a room with a view o f nature have a more positive medical outcome and healing process than those with a view of brick walls.  Edward Wilson developed the biophilia hypothesis  stating that the innate human  affiliation with nature results in positive psycho-physiological responses promoting health and benefiting emotional states.  Charles Lewis and Stephen and Rachel Kaplan established that  people derive feelings o f peacefulness and tranquility from gardening and being in nearby nature. 31  Patrick Mooney's research indicated that dementia patients benefit  psychologically  from  participating in horticulture therapy programs. The work o f these researchers provides a broad multidisciplinary base for the assertion that natural outdoor environments and contact with nature can contribute positively to health and well-being.  The human need for and benefit o f nearby nature, confirmed by the researchers discussed in this chapter, substantiates the assertion that outdoor natural environments and healing gardens need to be considered in healthcare facility design. The next chapter will review the implications this and other research has for the design o f outdoor environments adjacent to healthcare facilities (see figure 2.3).  Figure 2.3 Garden in healthcare facility  32  C H A P T E R 3 - G u i d i n g Principles a n d Design Features  This chapter examines the design principles and features o f restorative, therapeutic and healing gardens emerging from the literature reviewed in previous chapters. In this chapter I compare the work o f several design professionals and researchers, highlighting reoccurring themes that appear to guide and inform the design o f outdoor space in healthcare facilities to benefit human health and well-being.  Specific design requirements for special patient populations and user  groups will be articulated through this exercise.  Roger Ulrich suggests that the specific characteristics, needs, and disabilities o f the particular patient groups must be taken into account [when designing a healing garden]. One group may need a lot o f social interaction. Others may need passive restoration.  Others may need great variety, including some stimulation.  It is  imperative, i f one is dealing with very stressed, emotionally upset people, to be unambiguously positive in the garden context. (Thompson 74)  This awareness  that specific garden features may elicit a positive or negative  response,  depending on the symptoms o f the patient's illness, infers a key design consideration ~ the patient. Ulrich contends "health care is clearly headed toward patient-centered or often familycentered healing-oriented design" (Thompson 74).  The one garden feature that appears to consistently evoke a positive response is green plants. "Anything green makes patients feel better...any plant any tree," claims Nancy Chambers (a horticultural therapist at the Rusk Institute o f Rehabilitation Medicine, in New York, New York, United States). Chambers has witnessed firsthand how plants can relieve stress and improve a patient's mood, and how simple, repetitive gardening procedures such as propagating a plant can serve as a form of physical therapy for severely traumatized patients" (Thompson 55). 33  A s noted in the previous chapter, the Kaplans' research suggests the healing power o f the restorative experience can be experienced in nearby and undramatic natural environments. Although the restorative effect o f such environments may be less profound than that o f the wilderness, the Kaplans conclude that their far greater accessibility gives them a significant role. The Kaplans contend that the quintessential micro-restorative environment, the one that most closely brings together the multiple themes o f the restorative experience into a single, small, intensely meaningful space is the garden (Kaplan and Kaplan, Restorative Experience 241, 243).  The Kaplans' suggestion o f a "small, intensely meaningful space," is reminiscent o f the medieval courtyard garden ambience as described by St. Bernard in Chapter One (Kaplan and Kaplan, Restorative Experience 243).  While layered with symbolism and cultural meaning, the basic  features o f the typical medieval courtyard garden were: •  fresh air  •  plants  •  shade  •  colour  •  water  •  birds  •  soothing sounds  •  fragrance  •  views from rooms  •  sunlight  •  season variations  •  paths for strolling through the garden  In this chapter I will present emerging themes in healing garden design in healthcare facilities as they relate to specific patient populations. I will also continue to extrapolate from the literature  34  the guiding principles and garden features that appear to enhance the restorative experience and sense o f well-being derived from viewing or being in a healing garden in a healthcare facility.  Healing garden design considerations for the following special patient populations have been generated and generalized through post-occupancy evaluations o f numerous healing gardens b y the corresponding highly recognized designers, researchers and authors: A l l Patient Populations (Clare Cooper Marcus, Marni Barnes and Cheryl E . Ware); Dementia and Alzheimer's Patients (Elizabeth C . Brawley); and Pediatrics (Robin C . Moore).  In keeping with the style o f the  original text the following information is at times presented in point form.  3.1 All Patient Populations (Clare Cooper Marcus, Marni Barnes; Cheryl E. Ware) Clare Cooper Marcus is Professor Emeritus in the Departments o f Architecture and Landscape Architecture at the University o f California, Berkeley. Marcus is internationally recognized for her pioneering research on the psychological and sociological aspects o f landscape design and architecture and is concerned with distinguishing elements o f public open spaces such as gardens around healthcare facilities. Marcus is an associated partner o f Healing Landscapes, a consulting firm that specializes in user-needs analysis related to the programming, design and evaluation o f outdoor spaces in healthcare settings.  Marni Barnes is an American landscape architect and Principal o f the landscape architecture and consulting firm D E V A Designs in Palo Alto, California, United States. Marcus and Barnes have received several awards and co-authored Healing Gardens: Therapeutic Benefits and Design Recommendations, 1999.  Marcus and Barnes studied the use and therapeutic benefits o f gardens by observing and interviewing people in a number o f healing gardens in Northern California healthcare facilities. Ninety-five percent o f the people in the gardens reported a therapeutic benefit (Marcus and Barnes, Gardens in Healthcare Facilities 65).  35  Marcus and Barnes identified the following features of a healing garden as suitable for all healthcare facilities including long-term care, acute care and out-patient  facilities and as  beneficial to all patient populations (see figure 3.1): •  colourful lush plantings  •  auditory sound o f water  •  shade and sun  •  flexibility — choice of seating locations — moveable chairs  •  fragrance  •  quiet, privacy from interior — not a fishbowl  •  scale not too many big benches — comfortable benches i.e. wooden with armrest and backs, comfortable, padded seats e.g. for A I D S patients losing weight  •  rustling leaves willows or poplars  •  wide smooth paths suitable for wheelchair or gurney  •  lighting in gazebo  •  wildlife - birds  •  variety of textures and colours in plant material  •  sense of enclosure  •  deciduous trees e.g. provide green outlook for those in offices and patient rooms in the floor above the garden. (Marcus and Barnes, Gardens in Healthcare Facilities 1-65)  Marcus and Barnes' description of the Flower Garden at the Stanford University Medical Center in Palo Alto, California, United States, provides an illustration of the elements considered important to provide in a garden intended to benefit patients, staff and visitors:  The planting in the gardens is exemplary: under planting o f shade-loving ferns, camellias, azaleas, and impatiens beneath the birches; massed plantings of blue agapanthus, pink and white roses, white and blue petunias, white cosmos, white and pink dahlias, pink pentagon, blue lobelia, and blue delphiniums. The effect is o f a very colourful "cottage garden" with the birches in two corners and cherries in the third, acting as backdrop. While one side nearest the corridor is obviously planned for use - seating clusters and pathway - the other two sides are faced by the windows of offices and patient rooms. The depth of the garden and the height and variety of planting ensure complete privacy for those inside. The overall experience in this garden is of being very remote from the hospital atmosphere, in a human-scale, secure and enclosed setting, with the sound of moving leaves and views onto a wonderful variety of plants, flowers, leaves, shadows, and textures a true oasis experience. N o smoking permitted - generally used by lone people reading and eating, groups of visitors talk, elderly patients in wheelchairs with a 36  companion looking at the flowers and dozing, small children exploring in the shrubbery. (Marcus and Barnes, Gardens in Healthcare  Facilities  21)  Marcus and Barnes noted that many of the healthcare facilities they studied commonly had gardens that were unknown to staff and visitors indicating a need for adequate signage and information.  Figure 3.1 Healthcare facility staff take a break in the garden  Cheryl E . Ware is an American landscape architect with Spink Corporation, a multi-disciplinary construction and design firm in Sacramento, California, United States, and has designed Healing Gardens for California healthcare facilities.  Ware, a breast cancer survivor, suggests " A well-  designed Healing Garden should become an integral component of modern health facility planning and operation.  These gardens can help calm patients, reduce blood pressure, relieve  stress, encourage healing and host a badly needed break for harried staff or worried family members" (Ware 323).  37  Ware suggests that the following guiding principles and design features are beneficial for all patient populations in any healthcare facility including long-term care, acute care, and out-patient facilities:  •  Incorporate into or ensure the garden is adjacent to a healthcare facility that performs procedures that require a waiting and/or recovery period at the facility, including long term care such as hospices or elderly care homes.  • •  Easily accessible to patients, visitors and staff, including persons with disabilities. Create "a sense o f place," separate and distinct in style from its surroundings with a feeling of privacy and quietness.  •  Ensure space feels safe with staff able to oversee the site unobtrusively.  •  Provide shaded and sunny areas.  •  Provide seating areas for quiet reflection and physical rest.  •  Include visually-pleasing plantings that are colourful, seasonal, and interesting to explore with the eye.  •  Stimulate all senses: hearing (singing birds, trickling water), smell (fragrant flowers, fragrant trees), taste (herbs, fruits), touch (stone, wood, water, leaf textures) as well as sight (seasonal changes, flowering plants, butterfly garden).  •  Walking paths for exercise with handrails or frequent rest areas for unstable walkers.  •  Traditional medicinal herbs with educational signage.  •  Statuary or fountains.  •  Raised planting beds included to allow wheelchair-bound or unstable visitors to touch and smell low plantings.  •  Gently lit for use after dark allowing visual or physical access.  •  Planted and maintained by local volunteers, especially as part o f a horticulture therapy program.  •  Incorporate into the healing program at the facility:  group meditations, counseling  sessions, religious services, exercise programs, etc. (Ware 332-333)  38  3.2 Patients with Dementia  and Alzheimer's Disease (Elizabeth C. Brawley)  Elizabeth C . Brawley is an American Interior Designer based in Los Angeles, California and author o f the 1997 book Designing for Alzheimer's Disease. Brawley has considered the needs and symptoms o f patients with Alzheimer's Disease and has the following suggestions for a healing garden in a long-term care residential healthcare facility for seniors with dementia and Alzheimer's Disease.  While the short-term memory is the first casualty of Alzheimer's Disease, for many the ability to walk and be physically active remains intact far into the disease process. memory and ability to reason, patients  often  respond more intensely  With diminished to the  immediate  environment. Alzheimer's Disease affects a person's ability to interpret, understand and respond to the physical environment. People with dementia can be upset, aggressive or hostile by confined, monotonous and enclosed spaces lacking windows. More severely impaired people are negatively affected by glare, noise, odors and insufficient access to safe and secure outdoor areas.  Patients often experience a decrease in visual acuity, strength, endurance, balance and  coordination. The high incidence o f osteoporosis among the elderly results in impaired physical mobility and falling.  Currently four million people in the United States suffer with dementia and Alzheimer's Disease; according the National Alzheimer's Association that number will increase to fourteen million in the next thirty years.  Brawley contends that "the average facility conspires to reinforce  dependency and to immobilize residents and that the single largest missing ingredient in healthcare facilities for the elderly is light ~ affecting sight, mobility, level o f functioning and stress" (Brawley xii, xiii). Brawley believes the environment has a great impact on behavior and that designers can create spaces that provide support for residents' abilities and improve quality of life.  Dementia is the loss of intellectual function (such as thinking, remembering, and reasoning) of sufficient severity to interfere with a person's daily functioning. Dementia is not a disease in itself but a group of symptoms that characterize certain diseases and conditions. Symptoms may also include changes in personality, mood, and behavior. Dementia is irreversible when caused by disease or injury but may be reversible when caused by drugs, alcohol, hormone or vitamin imbalances or depression. Alzheimer's disease is the most common form of dementia (Brawley 290). 39  While persons in mid to late stages o f dementia respond to a peaceful, calm, quiet environment, many early stage residents delight in a more active and stimulating environment. Dull, monotonous surroundings encourage adverse reactions such as anxiety, fear, and distress; however, with beautiful gardens and a variety o f outdoor spaces available, residents able to move about during the day can be treated to a desirable and pleasing change o f pace and space.  Gardens can be a  wonderful source o f sensory stimulation ~ sight, sound, light, colour, fragrance, birds, and small domestic animals. (Brawley211) Brawley has noted through firsthand observation o f patients with dementia or Alzheimer's Disease that the following design features of a healing garden are beneficial for the users:  •  Opportunities to be outside in the fresh air and daylight light levels are essential for the well-being o f institutionalized residents.  Outdoor spaces/gardens need to provide a  connection with the natural environment and be less confining than the indoor environment to enlarge the scope o f residents' daily experiences. •  Enhance residents' physical and emotional well-being while addressing the two greatest concerns related to this patient population; the outdoor settings must be safe and secure minimizing falls and preventing exiting. A s residents experience increasing cognitive deficits and diminishing visual and auditory acuity, physical mobility, strength and endurance, the risk o f injury from hazards not seen or heard increases.  •  Residents need to be provided with opportunities to socialize and develop skills in a relaxed natural setting.  •  A n outdoor setting needs to provide institutionalized residents with places to seek needed solitude.  •  Minimize falls by providing handrails and ensuring that paving surfaces are glare-free, non-slip and uniform in texture and colour.  A s it is common for residents to shuffle,  surfaces must be gently sloped to drain well, remain non-slip in wet and dry conditions and be free o f irregularities such as cracks, potholes or uneven spots. •  Pathways should be wide enough to accommodate two-way traffic without physical contact (including walkers, wheelchairs and gurneys).  •  A high degree o f contrast is needed between paving edges and bordering areas to increase the patients' ability to distinguish between walking surfaces and non-walking surfaces.  •  Adequate level o f light is needed in the garden to assist visibility, however, glare must be minimized. Using materials o f medium to dark colour value will help reduce glare.  •  Help ensure residents are safe; the nursing station should oversee the garden.  •  The outdoor space must be a protective and secured environment surrounded by a minimum six foot high fence to prohibit climbing, vaulting, and exiting.  The secured  parameters o f the space should be softened with vines and plantings to provide enclosure yet alleviate the sense o f confinement. Trees and garden structures need to be located far enough away from the building to discourage their use as climbing aids. 40  •  Views of parking lots and facility exits should be screened from residents' view to reduce the urge to exit. Gates and locks also require camouflage to minimize attention by the residents.  •  Include space for activities to stimulate residents' long-term memory of their previous home life, e.g. mowing the lawn with a push mower, raking leaves, gardening, and hanging clothes on a clothesline.  •  Include elements o f familiar garden styles and plants popular during the 1940's and 50's to evoke memory, as this is the period in which residents may have tended their own garden.  •  Provide a variety o f spaces within the garden to increase stimulation; allow for solitude or socializing to address the range o f residents' needs from early to late stages o f the disorder.  •  Extend the use of the garden during the year by positioning the garden to maximize the southern exposure and access to the sun's warmth.  Provide covered shelter, e.g., a  gazebo, porch, pergola, awning or adjustable umbrellas to define a space for activities and provide protection from showers and the sun's seasonal heat and glare. •  Deciduous trees should be planted to provide partial shade and filtered light, however, trees and plants that drop fruit should be placed away from walking areas to avoid possible slipping and tripping hazards.  •  Seating should be provided throughout the outdoor setting to provide resting spots and places to sit and enjoy the garden. Residential lawn furniture made of non-reflective materials is suitable and flexible. Seating placed under trees or trellises can filter the sunlight and create a sense of privacy.  •  The relationship between the indoors and outdoors should be considered in terms of the transition between the outdoor and indoor ground plane. The transition should be smooth with a flow of colour leading into the garden. A porch can soften the transition from inside to outside as well as expand the interior space for sitting and walking in the outdoors in a wider range of climatic conditions.  •  Large windows overlooking the garden help to connect residents inside with the natural environment outside while increasing interior daylight and views o f the garden's flowers, trees, and birds.  •  M a n y residents  are inclined to walk and benefit  from  outdoor settings  designed  specifically to accommodate their needs. Pathways must be clearly defined and loop back to the starting point; this will help residents find their way. It is important to avoid paths that end abruptly as residents are likely to become confused and agitated in that circumstance. Providing handrails that clearly contrast with the background, ensures additional safety and security for frail residents, serves as support, and helps guide and return residents to their destination. •  While small courtyards that relate well to the interior of the facility are often successful garden spaces, roof top gardens are not recommended as residents can not be safely left unaccompanied.  41  •  Wayfinding  14  and orientation cues are vital, maximizing awareness and orientation and  reinforcing the residents' ability to exercise freedom o f choice through movement. Examples o f successful wayfinding elements in the garden setting include distinctive landmarks, familiar items from the past, and self-contained looping paths. A porch can also serve as a large visual landmark for a safe return (see figure 3.2). •  Nontoxic planting is essential in this type o f facility as patients with dementia often put things in their mouths and eat flowers and plant material. Ingesting plants is not typical of early to midstage dementia but it is more common in the later stages o f the disease (see Appendix 1).  •  Create interesting focal points within the outdoor space.  Fragrant gardens, bird feeders,  garden ornaments, weather vanes, and flower gardens provide diversion, destination goals, relief from the interior environment, and motivate residents to go outdoors.  Figure 3.2 Wayfinding features at the Joel Schnaper Memorial Garden, New York, New York, United States  3.3 Pediatrics (Robin C . M o o r e ) Robin C . Moore is a Professor in the Department o f Landscape Architecture at North Carolina State University. Moore has studied children in healthcare facilities and has provided design recommendations for healing garden features in a general hospital for children.  Moore contends that gardening, working, and playing with plants provides constant opportunities for children to participate in the processes o f life (Moore, Healing Gardens for Children 323384; Moore and Wong, Natural Learning). The following list o f guiding principles and design considerations and features were developed by Moore (Healing Gardens for Children 323-384)  "Wayfinding refers to what people see, what they think about and what they do to find their way from one place to another. Wayfinding systems are the assistive mechanisms for persons to find their way from one place to another; these may be signs, arrows or other environmental methods including person to person assistance" (Brawley 294). 14  42  as an outcome of a number of hospital garden case studies  15  undertaken to elicit design themes  supporting positive health outcomes and contributing to a restorative experience. •  The garden should provide a myriad of opportunities for children to engage with nature through hands-on activities that heighten the senses.  Natural elements, i.e., a diverse  plant palette that changes with the seasons, producing fruit and flowers can provide many activity opportunities for children. Given an appropriately designed space, a horticultural therapist can facilitate well-being through such child-nature interactions as helping children to plant seeds and harvest flowers as well as to gather pussy willows and budding forsythia branches to bring indoors. Playing in and with water is a memorable childhood experience and can be a symbolic source of life in a healing garden (Moore and Wong, Natural Learning). Natural habitats, including water, attract fauna such as birds and butterflies and can provide an additional source of discovery and fascination for children in a healing garden. •  Children's hospitals accommodate a range o f patients with a variety o f illness and disorders. A garden in a children's hospital needs to support the restorative needs of this diverse patient population.  •  Children recovering from surgery or a severe illness may seek rest in the garden while children with developmental disabilities, for example, benefit from the challenges an outdoor setting can provide (Moore, Healing Gardens for Children 378).  Opportunities  for hands-on activity in the garden can provide opportunities for manipulative play. •  Children's gardens can benefit from an artist's participation during the design and programming phase.  The Leichtag Family Healing Garden exemplifies the contribution  artistry can make to enrich a garden.  The pediatric patients' symptoms at a general hospital are diverse, and include but are not limited to pain, nausea, stress, emotional and developmental disorders. Children's hospitals often care  Moore studied a number of American healthcare facilities for children including: the Therapeutic Garden at the Institute for Child and Adolescent Development, Wellesley, Massachusetts; the Garden Court and Garden Play Progam at Children's Memorial Center, Chicago, Illinois; the Prouty Terrace and Garden, Children's Hospital, Boston, Massachusetts; the Leichtag Family Healing Garden, Children's Hospital and Health Center; San Diego, California; as well as the Gardens at Lucas Gardens School, Canada Bay, New South Wales, Australia; (Moore, Healing Gardens for Children 323-384). 15  43  for temporary and long-term resident children receiving medical services from a variety o f departments including postoperative, oncology, psychiatric, and developmental impairments. Healing gardens in children's hospitals should therefore accommodate a wide range of patient needs.  Moore developed the following design responses for children's healing gardens based on a number of case studies: •  Site Planning: The garden's orientation is important as lush plantings are a key component o f healing gardens and plants need sunlight to grow. The human comfort of the space benefits from protection from prevailing winds and the warmth of the sun throughout the year in northern climates. Conserving natural site features (mature trees, water, rock outcroppings) can enhance the potential therapeutic benefit of the garden. A s easy access to the garden is critical, site selection needs to ensure minimal topographical variation from the interior to the exterior of the hospital as well as throughout the garden.  •  Location: The garden should be located as close as possible to patient rooms and playrooms. Patient rooms should overlook the garden, enhancing the link between indoor and outdoor environments. Gardens visible from the facility entrance or dining area tend to attract more visitors.  •  Security: A children's garden should be contained, preventing children from exiting and inaccessible from any public areas surrounding the exterior of the hospital.  •  Microclimate: Shelter from wind and the intense summer sun is desirable. Exposure to the sun in the spring, fall and winter is desirable in temperate climates. Filtered sun through deciduous trees can provide shade in the summer and access to sunlight through the cooler months. Overhead shelter from rain (e.g. a translucent, ultraviolet lightresistant fabric) over part of the activity space can increase the use o f the garden.  •  Entering and Exiting: Entrances need to be welcoming to children. This may be accomplished with topiary animals, bright colours, playful water features, and childfriendly sculptures.  •  Accessibility/usability/wayfmding:  The  garden  must  be  universally  designed  to  accommodate children using wheelchairs, transporters, walkers, cots and gurneys. The height of plantings and features must relate to the height of children using these various means of mobility. For children confined to lying on their backs, consideration should be given to providing visual interest overhead such as tree canopies or kinetic sculptural elements.  The safe movement  of children with temporary and permanent  sight  impairments benefits from pathways with strongly defined edges and smooth, even surfaces (e.g. concrete is a suitable surface material as it is smooth can be coloured to enhance wayfinding and reduce glare). •  User Group Territories (Children, Adolescents, Parents, Staff, Visitors): Grieving and highly stressed families need quiet secluded places within the garden, conducive to the restorative experience, whereas adolescent inpatients may be seeking a venue for social interaction in the garden. The design of the garden needs to allow spaces for both these 44  and other uses simultaneously.  Plants that screen and help to define sitting areas are  useful and comforting as are areas that provide prospect and refuge. •  Supervision: A parent or healthcare worker most times accompanies children using the garden so comfortable seating for parents and staff needs to be provided.  •  Attracting  Trained  Volunteers: Well-designed  healing  gardens  attract  and retain  volunteers and staff. •  A Range o f High Quality Social Settings: A choice o f settings (from public to private) is needed within the garden as the desire for social exchange varies from user to user.  If  space permits, a place for special events within the garden is useful (see figure 3.3).  In summary, based on the expertise o f several design professionals and academic researchers, this chapter draws from the literature the features o f healing gardens identified as desirable for all-patient populations, children, patients with dementia and Alzheimer's Disease, as well as healthcare facility staff and visitors.  These design features are generalized and, while not site  specific, they do provide an insight into the basic features o f healing gardens that appear to benefit the quality o f life, well-being and healing process of patients, staff and visitors.  The documented work o f the individuals reviewed in this chapter, illustrates the need to consider the particularities o f the patients' disease or illness as well as the symptoms o f its progression when considering design features for a healing garden. The following chapter reviews the application o f the design features noted above in two case study healing gardens as described in the literature for children and A I D S patients.  45  Figure 3.3  The garden is a place where family and friends can visit loved ones  CHAPTER 4 - Healing Gardens for Special Patient Populations The design of the following two healing gardens for children and ADDS patients, respectively, are presented and discussed in terms of their guiding principles and design features as I was able to extrapolate from the literature.  Leichtag Family Healing Garden, San Diego, California, United States (Topher Delaney) Joel Schnaper Memorial Garden, Manhattan, New York. United States (David Kamp)  4.1 Leichtag Family Healing Garden, San Diego, California  16  (Children)  17  Topher Delaney  , an American landscape architect, designed the Leichtag Family Healing  Garden at Children's Hospital and Health Center in San Diego, California, United States. The Children's Hospital and Health Center cares for hospitalized and outpatient children from birth through adolescence; two-thirds of the patients are under four years old. The Children's Hospital accommodates over 200,000 inpatient and outpatient visits annually with the Cancer Care Center treating four hundred children each year. Completed in July 1997, the Leichtag Family Healing Garden has replaced a four thousand square foot parking lot. The guiding principles for the creation of the garden included: providing an escape for families, patients, and staff from the stressful environment inside the hospital; restoring hope and energy; reducing stress; and increasing consumer satisfaction.  The concept o f the Leichtag Family Healing Garden is to nourish the physical, emotional, mental and spiritual needs of children, their families and the hospital staff through a healing environment.  The garden is to be a place for the entire family, a refuge for them to get away  The Leichtag Family Healing Garden at Children's Hospital and Health Center, San Diego, California, United States is listed as an exemplary facility by The Center For Health Design, Pleasant H i l l , California, United States. Founded in 1988, the Center for Health Design is a non-profit, non-membership organization that is working to make people's lives better by demonstrating that using evidence-based design in hospitals and healthcare facilities can improve the quality of healthcare, <http://www.healthdesign.org/stories.html> Topher Delaney is a San Francisco landscape architect and cancer survivor. Since her breast cancer treatment experience "in a grim hospital setting," she has been on a mission designing healing gardens for hospitals (American Cancer Society 2002). 17  47  from the stress o f the high-tech environment of the hospital. The goal is for garden users to feel strengthened and renewed by visiting the garden; the theme of nature and art is intended to engender a feeling of peace.  The design includes representations o f the sky, earth, ocean and  plants as well as all kinds of animals, symbolizing the beauty and hope of life (see figure 4.1).  Dinosaur entry :  .  Lawn i . •  Figure 4.1 Plan of Leichtag Family Garden  The Children's Hospital Healing Environment Steering Committee articulated the following definition to guide the development of the  Leichtag Family Healing Garden as part o f their  healing environment program:  The Healing Environment is a term used to describe the physical and cultural atmosphere created to support families through hospitalization, medical visits, healing and bereavement.  Guiding the Healing Environment is a philosophy o f  caring; that is, the desire to develop a space that engenders feelings o f peace, 48  hope, upliftment, joy, reflection, and solace and one which provides opportunities for relaxation, enrichment, spiritual connection, humor, and play. Motivating this philosophy is the belief, which is supported by research, that these factors play a considerable role in the physical, emotional, and spiritual healing process. The goal o f the Healing Environment is to transform the hospital setting into a place that addresses the human spirit and supports families to positively cope with and transcend illness.  The cornerstones o f the Healing Environment are building  design, the arts, family support, and staff attitudes.  Physical components o f the  Healing Environment are the interior and exterior building designs, gardens, family spaces, and the art collection. Environment  Programmatic components o f the Healing  are the arts and culture programs ~  storytelling, artists-in-residence, and the like.  musical  performances,  Equally important to the Healing  Environment are the ways in which we support and treat our families — customer service,  family-centered  care,  and the Golden Rule  o f compassion and  consideration. (Whitehouse 303-304)  The Leichtag Family Healing Garden  is an example o f a healing garden typology described by  Moore {Healing Gardens for Children 323-384) as an 'informal, strolling garden,' focusing on "de-stressing, exploration, restoration, meditation, prayer, and relaxation (for children, parents, siblings and staff)."  The design features of this type o f garden accommodate walking, privacy,  sitting,  and sensory  socializing,  interest (colour, texture,  fragrance, butterflies  fluttering,  birdsong) (Moore, Healing Gardens for Children 335).  The symptoms experienced by the pediatric patients at the Children's Hospital are diverse, and include but are not limited to pain, nausea, stress, emotional and developmental disorders. Hospitalized children need outdoor play opportunities for "play leadership" and links between the indoors and outdoors (Moore, Healing Gardens for Children 327). A study conducted by Paine and Francis in 1990 observed the needs o f children (as patients and visitors) in three hospitals, indicating that children need outdoor environments supporting creative, imaginative, and physical play (see figure 4.2).  The Leichtag Family Healing Garden was selected to review in detail as it is listed as an exemplary facility by The Center For Health Design in California, United States and identified as an example of best practice in children's healing gardens for its type by Robin C. Moore (1999), Professor, Department of Landscape Architecture, North Carolina State University, Raleigh, North Carolina U S A . 49  Figure 4.2 Play element for children at Leichtag Family Healing Garden  The following are the design features of the Leichtag Family Healing Garden: •  A steel-framed brontosaurus named, "Sam," standing forty feet in height. Sam's bowed head peeks into the second floor windows of the surgery recovery area, (see figure 4.3). Covered in purple trumpet vines and soft night lighting, Sam is the garden's focal point.  •  A sea-horse fountain sculpted with blue-green ceramic tiles including murals o f fish swimming through seaweed. The soothing sound of the fountain can be heard throughout most of the garden (see figure 4.4).  Figure 4.3 Leichtag Family Healing Garden Brontosaurus Sculpture  50  Figure 4.4  • •  Sea-horse fountain at Leichtag Family Garden  Mauve constellation wall with colourful stained glass disks representing the zodiac. A fourteen foot tall windmill with rainbow coloured blades and metal birds that "fly" within the structure.  •  A multi-coloured semi-circular "shadow wall" of cutouts of animals. A s the sun moves across the sky, the animal shadows lengthen. Children, engaging their imagination, can touch the cutouts.  •  Flowers and plants in the garden were selected for their fragrance, medicinal properties, and to attract butterflies and hummingbirds. The garden's lavender flowers are cut by parents for their children's room and the geraniums give the scent of lemon, mint and chocolate.  •  Deciduous trees provide shade and a sense of enclosure.  •  A sense of enclosure and child-scale outdoor rooms were further created by providing curvilinear, brightly-painted walls four to seven feet high around the garden - creating niches of privacy.  •  Colourful six foot long benches are large enough to hold a family of five and are covered by giant shade umbrellas. The benches can be wheeled to privacy or grouped.  •  The ground plane consists of grass and rings of coloured concrete in shades of teal, green and blue - intended to resemble the ocean.  •  Sensory stimulating elements include: the sound of a splashing fountain, shadows cast on walls, whimsical features, textures of palm trees and bird of paradise plants, bright colours.  51  Table  1 below  quantifies  the features  of the garden most  enjoyed by garden users  (Whitehouse et al. Evaluating a Children's Hospital Garden Environment 307).  Table 1 Leichtag Family Healing Garden Evaluation Features of Garden Most Enjoyed by Garden Users  Adults  Children  Percent reporting*  Percent reporting*  Fountain - sound o f running water  33  Bright colours  25  83 17  Being outside in a garden  23  33  Flowers, trees, plants, greenery  19  33  14  83  Fresh air, sunshine, breezes  12  Sense o f enclosure provided by the  12  -  walls Multi-sensory stimulation  8  -  Feature  Artwork  (windmill,  shadow  wall,  constellation wall, dinosaur, animal tiles)  Many participants mentioned more than one aspect of the garden as helpful. Table 1 above and the following information is the result of a Post-Occupancy Evaluation (POE) conducted and published by Whitehouse et al (301-314). behavioral observations, surveys and interviews.  19  The P O E is based on  The garden users interviewed were asked  how they used the garden, what improvements they could suggest and whether or not the garden had any impact on their mood. The following is a list of the comments received from the garden users:  • •  The garden is perceived as a place of restoration and healing. The garden is not used as often or as effectively as intended. Eighty percent o f the family members throughout the hospital did not know the garden existed.  Several nurses  suggested that there needed to be more staff to take patients out to the garden and that there was insufficient time to direct families to the garden. "Most of the children  Sandra Whitehouse PhD, Center for Child Health Outcomes at Children's Hospital and Health Center, San Diego, California, United States. 52  observed were healthy siblings of the patients, or outpatients," (Whitehouse et al 310). The results suggest that use of the garden needs to be encouraged by educating patients, families, and staff about its location and benefits. •  Use of the garden is accompanied by an increase in patient and user satisfaction.  •  Users suggested more interactive play opportunities for active children (i.e. patients, siblings and visitors).  •  Adult family members o f the patients relaxed and visited while their children played in the garden.  •  Staff get together to spend their lunch and coffee breaks in the garden or they sit alone and read.  • •  The garden is the setting for many special events ceremonies. One garden user stated "this is a better place to wait than the waiting room, we couldn't stand being in there, wondering i f she'd make it. This is quiet and peaceful, the greenery, the colourful flowers, the sound of water" (Whitehouse et al 306).  •  Ninety percent o f the survey respondents reported a positive change in mood after visiting the garden (Whitehouse et al 310).  •  M o o d changes were attributed to the following combinations of garden features: "being outdoors in an enclosed natural space, hearing the sounds of running water, seeing the trees, plants and flowers; and enjoying the colours and artwork" (Whitehouse et al 306).  •  The most occupied areas of the garden are the covered benches. The grass areas had no benches and were only used occasionally.  •  Eighty percent of the garden users reported that the garden increased their overall satisfaction with the hospital.  •  Garden users reported that they used the garden to relax and rest, to get away from the stressful environment inside the hospital, to enjoy it and be engaged by it, to help them cope with worries (Whitehouse et al 306).  •  Fifty percent of the adult garden users recommended that the garden include more "trees, vegetation, and greenery."  •  Staff working directly with emotionally disturbed children and bereaved  families  suggested that the garden needed privacy and refuge. Staff suggested there is a need to improve wheelchair access for more fragile patients and include intravenous electrical outlets (for those that have recently had surgery or are receiving chemotherapy). •  Children said they would like more things to do in the garden. More opportunities for manipulative play (such as digging in the sand, moving and piling up blocks and rocks) could engage children for longer periods o f time.  •  Jayne Hamlet, case manager and hematology oncology nurse in the cancer care center, claims the garden aids treatment as elements in the garden generate storytelling opportunities which gently distracts the patients helping them to relax and alleviate their 20  pain without medication.  A n article by William H . Redd, PhD (professor in the program for cancer prevention and control at the Mount Sinai School of Medicine) suggests that tactics such as storytelling, guided imagery, and relaxation can mitigate the side effects of cancer treatment and that these "behavioral interventions" are effective at reducing anxiety, some types of nausea, and even pain. <http://www.cancer.org/common/images/shim.gif'\*>. Apr. 2004. 53  2 0  Whitehouse et al, concluded that future research could specifically investigate the needs and preference o f hospitalized children, particularly those o f children with severe developmental disabilities and chronic health conditions.  While eighty percent o f the hospitalized children in  their study were not aware the healing garden existed, most expressed a strong interest to go there.  4.2 Joel Schnaper Memorial Garden, Manhattan, New York (AIDS Patients) David K a m p  21  is an internationally recognized and award-winning American landscape architect  and the founding principal o f Dirtworks, P . C . Kamp's work focuses on enhancing the restorative quality o f the natural environment. Joel Schnaper Memorial Garden is located in the Terence Cardinal Cooke Health Center, in Manhattan, New York, United States. Completed nearly twenty years ago, the garden is three thousand square foot and located on the rooftop adjacent to the A I D S unit. The Center cares for one hundred and fifty-six terminally ill patients with H I V and A I D S (see figure 4.5).  David Kamp was a contributing member of the steering committee that developed Green Guidelines for Healthcare Construction, a tool for evaluating the health and sustainability of building design, construction, maintenance and operation for the healthcare industry. In 1996, Kamp co-founded Meristem, Inc. an educational not-for-profit organization dedicated to promoting nature's role in the improvement of health and well-being.  54  Figure 4.5 Plan of Joel Schnaper Memorial Garden  Guiding Principles: • • • • • • • • •  Provide patients with a therapeutic outdoor environment. Provide patients with an opportunity to "experience a sense of nurturing and a connection with nature" (McCormick 62). Provide patients with an opportunity to gain a sense of control and independence, thus reversing the pattern of being cared for, by caring for something else. Provide patients with a distraction from plaguing physical and emotional concerns, thus increasing their sense of well-being. Stimulate the senses by developing a garden rich with desirable multisensory experiences. Respond to the physical and emotional needs of the residents. Ensure opportunities for residents to experience a sense of independence and control. Provide opportunities for residents to contribute positively to their surroundings and experience the restorative benefits of the garden and gardening. Many complex symptoms typify the HrV and AIDS illness (e.g. varying abilities from one day to the next) and patients are often overwhelmed with a sense of individual crisis and feelings of vulnerability. Typically, patients with HIV and AIDS experience the following symptoms during their illness: varying degrees of strength and stamina; limited sensory functioning; sunlight sensitivity due to drug treatment; diminished level of environmental awareness; diminished orientation abilities. A Healing Garden for this  55  patient population will need to include: universally designed flexible spaces for social interaction, privacy, activity and contemplation (see figure 4.6).  Figure 4.6 Universal design guidelines  The desire to create a garden to elicit a variety of sensory responses was realized within the space constraints of the Joel Schnaper Memorial Garden by ensuring the garden elements played a multi-functional role. Several of the key design features and a description of their role and function follow: •  Plants - with varying colours and textures of the plant palette are intended to inspire a tactile response from patients in the garden and to provide beauty and a pleasant view when residents are only able to experience the garden through the window of their room. The leaf textures include: soft, rough, hairy, smooth and silky.  Universal design is environmental design intended to be useable by all people to the greatest extent possible. "The goal of universal design is to create a product, place, or service that can be used by the widest possible range of individuals. It is intended to be inclusive and not exclusive," (Covington & Hannah 1996: three cited in Mooney, Mount Pleasant Wellness Walkways). In a hospital setting outdoor spaces need to be designed for people with a wide range of abilities including children, the elderly, people using wheelchairs, walkers and intravenous trollies, and people with limited vision.  56  •  • • • •  •  Orientation and wayfinding cues include running water and wind chimes providing sound to assist patients needing reference points. A compass stencil and brightly coloured pots of flowers, while adding beauty to the garden, also act as an orientation devices (see figure 4.7). Kinetic wind sculpture provides a distraction and a conversation piece. Birds and butterflies are attracted to specifically selected plant material; small pets provide distraction and amusement for residents and their visitors. Planter size and location selected to ensure residents can comfortably tend plants (see figure 4.8). A number of outdoor rooms within the garden offer a range of microclimates and intimacy levels, accommodating individual choice and varying preferences depending on the time of day, weather conditions, and the mood of the resident and their visitors. Overhead trellises covered in vines and canvas awnings soften the effects of sunshine (ensuring shade and cooler temperatures) while providing a sense of enclosure and intimacy thus accommodating residents wishing to recoil into a comfortable secluded corner to meet privately with friends and relatives (see figure 4.9).  Figure 4.7 Sound of water provides sensory stimulation and wayfinding clues  57  Figure 4.8  Planter height suitable for tending by patients  Universal design guidelines were adopted during the planning phase to accommodate independent movement throughout the garden.  Figure 4.9  Overhead trellis provides shade on rooftop in Joel Schnaper Memorial Garden  Design Features of the Joel Schnaper Memorial Garden  58  Design Features o f the Joel Schnaper Memorial Garden •  The Joel Schnaper Memorial Garden acts as the center for the hospital's horticulture therapy program and provides a place for patients, families, and staff to gather, visit, recreate, celebrate and meditate.  •  The garden is a key component o f residents' daily therapy.  •  Sufficiently flexible to permit special events to be held in the garden.  •  Facilitates daily physical care o f the garden by residents.  •  Permits ease o f movement throughout the space.  •  Contains a number o f garden features, accomplishing the designer's wish to create a multi-sensory garden.  •  •  Those who know the garden believe the fragrant plants, delightful sounds and cheerful colours help to elevate the patients' spirits and increase their sense o f well-being (see figure 4.10). The hospital's vice-president for operation and nursing facility administration, Peter Karow, notes that "the garden has been received fantastically," describing it as a "morale booster for both patients and s t a f f (McCormick 62).  •  The centre's director o f therapeutic recreation, M i m i Fierle, claims "nurturing this garden has increased the patients' self-esteem and well-being; people have the chance to see the ebb and flow o f nature and that has a very calming effect" (McCormick 62).  •  Barbara Crisp, faculty associate in the School o f Architecture at Arizona State University and author o f Human Spaces, suggests that "the design for the Joel Schnaper Memorial Garden responds to the human heart and stimulates the senses, creating a life-enhancing experience for all who visit. The project reflects the cycles o f life, offering a symbolic sense o f hope" (182).  •  Nancy Chambers, horticultural therapist at the Rusk Institute o f Rehabilitation Medicine in New Y o r k City, considers the Joel Schnaper Memorial Garden an AIDS-care model.  •  The garden has inspired the initiation o f other gardens in the Terence Cardinal Cooke Health Care Centre.  In summary, the guiding principles and design features presented in this chapter represent a patient-centred approach to the design o f healing gardens in healthcare facilities.  These design  features were extrapolated from multiple sources including surveys, direct observation, user group feedback, scientific studies, designers, hospital administrators and patients.  The features  o f a healing garden common to both patient populations of the Leichtag Family Healing Garden and the Joel Schnaper Memorial Garden were greenery, sensory stimulation, fresh air, sunlight, beauty and views to nature from patient rooms. These basic and essential features o f a healing garden are noted and referenced throughout the literature.  59  The following chapter synthesizes, in the form of a matrix, the experience and findings o f the designers  and researchers presented in this and the previous chapter to help guide  the  programming and design o f a healing garden suitable for a particular patient population in a healthcare facility.  Figure 4.10 Bright flowers, w a y f i n d i n g elements and a visual connection from the patients' rooms to the garden at the Joel Schnaper Memorial Garden  60  CHAPTER 5 - Linking Healing Garden Design Features, Restorative Value, and Healthcare Facility Populations In this concluding chapter I have attempted to synthesize the material presented in the preceding chapters by collating the most general and consistently referenced design features o f healing gardens in healthcare facilities and by assigning a relative value to each. This synthesis takes the form o f a matrix and suggests a restorative value for each design feature listed -- dependent upon the healthcare facility population type.  I have used four rating categories for restorative value: essential, high, medium and low importance/benefit.  Although somewhat subjective, I have attempted to apply the ratings as I  interpret, to the extent possible, the importance inferred by the authors from the case studies, post-occupancy evaluations, and research material presented in the preceding chapters.  The Healing Garden Matrix following illustrates the varying degrees to which a number o f healing garden design features benefit or are important to the various patient populations and user groups identified.  The matrix demonstrates that the essential features o f healing gardens  common to all garden users are: beauty, sensory stimulation, lush greenery and deciduous trees, fresh air, sunlight, and views from patient rooms to nature. (See Table 2.)  The matrix may be useful in determining priorities in the design process, particularly for facilities and healing gardens with either size or budget constraints. While the matrix is not an exhaustive list o f design features for healing gardens in healthcare facilities, it could be a tool that could be expanded upon in the future.  61  5.1 Healing Garden Matrix Table 2 Matrix of Restorative Value of Design Features versus Healthcare Facility Population Legend: E=essential; H=high importance/benefit; M=moderate importance^enefit; L=low importance/benefit Special Patient Population Healing (••>!den I valines E X P E R I I " . M 1 \ I I 1 A l l RI.S Water (i.e. moving water, fish ponds, bird baths) Aesthetically pleasing/beauty Stimulates the senses Plants and flowers attracting birds and butterflies and flowers with a variety of colours and textures Plants and flowers with seasonal variation Plants and flowers with fragrance Lush greenery and deciduous trees Fresh air Sunlight Shade Peaceful and calm Soothing sounds Sense of enclosure (prospect/refuge) Elements that stimulate long-term memory (i.e. clothes line and old fashion/style plants) Small animals (i.e. kittens and rabbits) Art r i V H O N \ L F E \ T 1 RJS Safe Unimpeded access/carefully designed ramps Meets universal design standards Suitable for horticulture therapy programs Adequate, moveable, comfortable sitting and eating areas Privacy within the garden Flexibility of seating locations Places for quiet contemplation Places supporting social interaction Non-glare surfaces Planters of various heights and vertical planting elements Non-slip walking surfaces Mitigates climate (provides shade and wind protection) Pathways wide enough for 2 wheelchairs side by side Distinct from indoor environment Play opportunities Focal point/landmarks within the garden Drinking fountain Smooth pathway surfaces Enclosure/Security  1 i-rininal  \ isitors' Staff  Dementia' M/hcimi-i "s  ( hildn-n  L E E M H H H E E E E E H H H  H E E H H H H E E E M M M H L  E E H H H H E E E M E H H M  II E E H H M H E E E M H H H L  M M  H H  H M  M M  E H H H H M H M H H E H H E . H L H L H E  E H H H M M M L H M M H H E H E H M H E  E H H H H E H H H H E H H E H L Ff M H L  E H H L H E H H M L L M H E H M M M M L  /tins 11  62  Smooth ground plane transition from indoors to outdoors Lighting (i.e. inside a gazebo) Continuous looping pathways Wayfinding and orientation devices Nontoxic plants Shelter from rain Handrails along pathways C O N T E X T U A L FEATURES Visible from facility entrance Views from patient rooms to garden Suitability of rooftop space Privacy from interior of hospital Close proximity to patient rooms or dining areas Microclimate supporting maximum year round comfort Easily supervised from nursing station Close proximity to restrooms  5.2  H H E E E H H  H M M L E H L  L E L L M H E H  M E L L H H H H  H H M H L H M  1BB111HBI L E H H H H M H  M H L L L H L H H H H H H L M  Synthesis  The Healing Garden Matrix is intended to stimulate discussion and awareness during the preliminary healthcare facility program development about the value of incorporating a healing garden into the facility's program and an understanding that the program requirements o f the garden could vary depending on the patient population. The matrix could be used as a checklist o f pre-design considerations to help establish priorities and, as such, begin to inform the initial design processes from which site and client-specific programming and considerations could develop.  The following two local and contemporary examples, Mount Saint Joseph's Hospital and St. Paul's Hospital, both in Vancouver, British Columbia, Canada will be used as test studies for the use of the matrix.  It is hoped that this exercise will help illuminate the potential of the matrix  to guide and inform the preliminary programming phase of a healthcare facility development project, as well as highlight any limitations to its use.  Mount Saint Joseph Hospital on Kingsway at Prince Edward Street is a community hospital with a multi-cultural approach to service delivery, clinical programs, and community services. Mount Saint Joseph's Hospital is a two hundred and thirteen bed acute and extended care Information regarding Mount Saint Joseph's Hospital and Dr. Peter Day Center and Residence at St. Paul's Hospital obtains from their websites: <http://www.providencehealthcare.org/patient/mtstjoesp.htm> and <http://www.drpeter.org/>, respectively. 63  facility whose residents have a range of mobility and health restrictions.  The hospital has  undergone four additions since it was founded in 1946, the most recent of which was the addition of a fourth floor for the pediatric unit in 1991.  Mount Saint Joseph's Hospital exemplifies facility programming that did not adequately address the needs o f patients, staff and visitors to have contact with nature in an outdoor setting.  The  program for Mount St. Joseph's Hospital allowed for a small outdoor seating area for the facility's patients, staff, and visitors, however, the success o f the area was severely compromised by a number o f physical factors.  I will demonstrate that had the Healing Garden Matrix been  referred to at the outset o f the program development, the current site o f the outdoor seating area would not have been selected.  A n outdoor space for a garden was not considered in the original facility program at Mount Saint Joseph's Hospital. A s a result, only left over spaces around the outside o f the building remained for the facility's population wishing to go outside.  The administration subsequently installed a  gazebo in an attempt to address the desire o f patients and staff to have a comfortable place on the hospital site to be outdoors.  It appears that the architectural design o f the hospital had not  addressed the possibility o f an outdoor seating area as being important in the healing process and the potential for the seating area to be located with a southern exposure was negated by the presence o f the physical plant on the building's sunny south side. This left only a small area on the north side o f the four-storey building adjacent to a parking lot and a major traffic arterial route, as a possible site for access to the outdoors.  However, the traffic noise and lack o f  sunlight, needed for both plant growth and human comfort, meant that this space was rarely occupied. A s a consequence, the hospital staff, patients, and visitors were required to leave the hospital site in order to find a quiet place to sit outdoors comfortably and reconnect with the natural environment.  The failure o f the architectural design o f this healthcare facility to provide outdoor space to satisfy the therapeutic needs o f the hospital population resulted in the hospital administration requesting that the City o f Vancouver make changes to the streetscape between Mount Saint Joseph's Hospital and M a i n Street.  T o explore and accommodate the need for the patients at 64  Mount Saint Joseph's Hospital to have exposure to a therapeutic milieu to practice essential life skills in a safe, challenging and realistic environment, the City o f Vancouver commissioned the Mount Pleasant Wellness Walkway Design Study in 1999.  24  One o f the goals o f the Wellness Walkway was to identify design solutions to accommodate a barrier-free connection between the hospital and the shopping area o f M a i n Street.  Since the  implementation o f the Wellness Walkway Street improvements, negotiating the four blocks to the shops on M a i n Street from the hospital has enabled the patients to practice and prepare for "returning home" in a safe and comfortable environment. The Wellness Walkway also provides opportunities for the hospital population to come in contact with plants with scent, color and a variety o f textures.  A s many o f the patients at Mount Saint Joseph's Hospital suffer from arthritis and are recovering from strokes and other physically debilitating conditions, a program o f rehabilitation and therapy is part o f their daily care regime.  The design provisions o f the Wellness Walkway made it  possible for patients, often with the help o f staff or visitors, to increase their physical mobility through the exercise o f walking outdoors, and down the street to the shopping area on M a i n Street. (Mooney and Luymes 1-21)  The  Mount Pleasant Wellness Walkway Design Study recommended that the existing city  sidewalks, be widened and upgraded, smoothing the surface treatment to minimize any unevenness and bumps that would result in physical discomfort and excess noise, which could make it difficult to carry on a conversation as patients move along the route with their walkers and wheelchairs. for  Specially designed benches were located at intervals considered appropriate  individuals needing to take a rest on route, between the hospital and the shops.  The  boulevard was planted with flowers, shrubs, and trees intended to stimulate the senses and a public park at the midway point o f the walkway provides a comfortable place for family and friends of the patients to visit quietly in a natural setting.  2 4  Based on interview with Alan Duncan, City of Vancouver Planner. May 2nd, 2004. 65  The Mount Saint Joseph's Hospital example illustrates that when patients' needs and their requirement for an outdoor space as a setting for rehabilitation, sensory stimulation and social exchange is not considered in the initial facility programming and design phase, the ability o f the healthcare facility to provide a future venue for the healing process is compromised.  In this  instance the patient's needs were addressed in the public realm on the Wellness Walkway.  The Healing Garden Matrix identifies a number o f essential garden features for every patient population group as well as visitors and staff.  The unsuccessful result o f siting the existing  outdoor gazebo at Mount Saint Joseph's Hospital would have been easy to predict had the matrix been reviewed during the pre-design phase.  Further, i f the features listed on the Healing Garden Matrix as essential were applied during consideration o f the program requirements for this facility, the designers would have been aware  of, for example, the need for sunlight and a microclimate supporting year round comfort. The existing north facing outdoor space does not provide the essential light requirements to foster the  lush growth of plants or the warmth of a. microclimate supporting maximum year round comfort.  Secondly, i f the experiential features peaceful and calm andfreshair had been considered as essential in benefiting patients (as noted on the matrix), the current Gazebo location adjacent to a busy and noisy road would have been considered inappropriate for a healing garden. T h e inability o f the current Gazebo site to provide for the four features mentioned above would have eliminated this location as a suitable site for a healing garden. A t a minimum, all the features identified as essential on the matrix (e.g. sunlight, fresh air and lush greenery) need to be accommodated when considering the program for a healing garden.  A s Mount Saint Joseph's Hospital accommodates a variety o f patient groups, including longterm-residential, pediatrics, and acute care patients, reference to the matrix would highlight that there are some features o f the healing garden which are considered essential for one patient group but not for another.  66  A n example o f a feature that is essential for one patient group but rated as moderate for another is continuous looping pathways. This feature is considered essential for patients suffering from dementia, as dead ends often trigger confusion and aggressive behavior in patients with this illness. Children, however, may have no adverse reactions to a path that ends at a sand box, for instance.  Conversely, while children's play features are rated as essential for pediatric patients,  this feature is not essential in a garden designed for dementia patients.  A n awareness o f the  needs o f specific patient population groups could lead designers and administrators to consider the inclusion o f more than one garden, i f space permitted, or at least to accommodate the special needs of particular patient groups within one garden.  T o fully appreciate the features listed on the matrix and the rating that has been applied to each feature, it may be necessary for the designer/user to have a general understanding o f the various illness symptoms o f the healthcare facility populations referenced on the matrix as well as an awareness o f the significance o f the relationship between human need for contact with nature and healing.  Without this background knowledge, a group or individual could, for example,  capriciously decide that sunlight could be sacrificed for a space adequately large to allow for a greater number o f the design features to be incorporated into the garden. For example, in an effort to provide a number o f spaces that would allow for privacy within the garden and be suitable for horticulture therapy programs the programmer may opt to allocate a sizeable space along the north side o f the building. A s the Mount Saint Joseph's Hospital case exemplifies, the existing space, complete with a private area and room for horticulture therapy, is functionally and experientially unsuitable for a healing garden. Its usefulness is very limited and is not used as intended because o f the unsuitable microclimatic temperatures and inability to sustain healthy plant life, both due to a lack o f sunlight.  In summary, the matrix is a tool to help prioritize and identify the features that need to be considered in healthcare facility programming to ensure that patients benefit from the healing power o f access to nature in an outdoor setting. The specific design elements and their relative size and form have not been articulated in this matrix as the success o f a healing garden design is also dependant upon the spatial arrangement and creative insightfulness o f a designer and  67  cannot be collated in a matrix. The matrix simply suggests that there are features o f a healing garden for a healthcare facility that are important to consider and incorporate, and that these features may or may not be the same for all the user groups in a specific healthcare facility.  The second contemporary, local example selected to test the matrix is St. Paul's Hospital, located at Burrard and Comox Street in downtown Vancouver. St. Paul's Hospital was founded over one hundred years ago and has undergone eight renovations and additions during this period. Currently, St. Paul's accommodates four hundred and forty-five acute care patients and, besides being a teaching facility and general hospital, is the province's main healthcare facility for the treatment o f H r V / A I D S .  The recent addition o f the Dr. Peter Day Centre and Residence opened in 2003 is the first subacute care facility for H I V / A I D S in Canada.  This recent addition to St. Paul's Hospital eases  the pressure on the acute care beds in the main hospital as the Dr. Peter Centre offers a day health program and a twenty-four hour assisted-living residence for twenty-four inpatients. The Dr. Peter Centre is located one block off a major traffic route in a quiet residential neighbourhood to the west and rear o f the main hospital building. This facility was selected to test the matrix as it exclusively accommodates one o f the patient populations referenced on the matrix—AIDS patients.  In imagining that at the preliminary programming phase o f this project's development,  those  charged with writing a terms o f reference for the Dr. Peter Centre consulted the Healing Garden Matrix, how would the matrix be utilized? Firstly, the matrix would draw attention to the fact that the healing process for patients with H I V / A I D S is benefited by access to nature both visually, physically, passively, and interactively.  The matrix also suggests that A I D S patients  would use an outdoor space as both a venue for social interaction and quiet reflection.  The  matrix highlights that a visual connection from the residents' rooms to natural scenery outdoors is essential. The terms o f reference and preliminary program for the facility would therefore acknowledge the requirement o f well considered outdoor spaces, suitably sited to accommodate  68  the symptoms o f the illness and the patients' healing process, as well as the need for an outdoor space suitable for a horticulture therapy program.  Secondly, referencing the matrix could confirm the importance o f taking advantage o f the preexisting site conditions and context, particularly with respect to views from patients' rooms, as the program of the Dr. Peter Centre includes residential suites. Reference to the matrix would highlight that views to nature are an essential feature o f a healing environment and a component of the healing process.  The existing opportunities for views o f nature through the windows o f  the facility could be realized and the windows could be oriented towards the adjacent park site and long range vistas of the North Shore Mountains.  The view down the back lane of a neighourhood greenway and community gardens also provides an opportunity to borrow views, providing visual access to nature from the surrounding context of the site. In fact, the current facility has taken advantage o f the views o f the neighboourhood parks, trees and gardens as well as the distance views to the natural scenery o f the North Shore Mountains. The existing centre is four stories in height and includes a terraced balcony with nature views and direct access outdoors from the community dining area. The centre provides one o f the contextual features rated as essential on the Healing Garden Matrix - views from patients rooms to the garden as well as two o f the features rated as highly beneficial - close  proximity to patient rooms or dining areas and suitability of rooftop space (see figure 5.1).  69  Figure 5.1 Example of dining area with views to nature — St. Michael Rehabilitation Hospital, Texarkana, Arkansas, United States  The new Dr. Peter Centre has a residential non-institutional ambiance. The clinic is on the main floor and is reserved for recreational activities.  The second floor accommodates the clinic,  counseling centre and library. The top two floors are reserved for the inpatient residents' suites and dining and living areas.  The residents' floor benefits from long views out over the  neighbouring gardens and to the North Shore Mountains beyond. One of the centre's stated "Comfort Care " missions includes "recognizing the broad determinants of health and quality of life, and providing innovative, integrated, flexible, community-based care.  A n on-site healing  garden at this facility would support the goal of enhancing quality o f life.  A s the site itself is  limited in terms of space for providing a number of the features listed on the Healing Garden Matrix, fortunately many o f the features have been provided in the immediate context of the facility.  For example, continuous looping paths are rated as moderately important for patients  with A I D S and while the facility's site does not accommodate this feature, the lanes and sidewalks around the facility do provide a pleasant, lushly planted green space for the residents and out-patients to benefit from exposure to nature while addressing the physical requirements of their healing process. horticulture  In addition, while the site constraints make it difficult to provide for  therapy programs,  which are rated as highly beneficial for patients with A I D S , the  community gardens in the adjacent greenway are suitably close for this activity.  70  Finally, while there is opportunity for privacy inside the facility for the residents and patients to discuss their health and concerns with friends or loved ones, the Healing Garden Matrix suggests that it is essential that space be provided in the garden context for this purpose. This may have been accomplished within the space constraints of this site i f flexible seating was included on the terraced outdoor patio or i f a bench had been provided at grade in a quiet, lushly planted corner o f the site.  While the architectural design o f the Dr. Peter Centre provides well for, and  enhances, the quality o f life of, the inpatients and out-patients, without the benefit o f its rich context in terms o f views and access to nearby nature off site, the extent o f the existing health benefits would not have been realized.  If a Healing Garden Matrix was referred to at the outset o f the Dr. Peter Centre project's programming, the importance o f views to nature would have been addressed in the architectural orientation o f the facility and large windows to the views o f nature would have been considered. A s the success o f the facility reflects, it appears that the essential features for enhancing quality o f life, well-being and promoting healing were considered and implemented on the adjacent public realm during the facility's preliminary programming phase.  Based on the two test studies discussed above, it appears most beneficial that a multi-disciplinary design  team  consisting  of  architects,  landscape  architects,  interior designers,  hospital  administrators, staff and patients participate in the program development o f future new, and renovated healthcare facilities.  In order for healing gardens to provide maximum benefits to  patients, staff, and visitors, appropriate space location and allocation is crucial.  !  71  5.3 C o n c l u s i o n Through the literature review I discovered that up until the turn o f the previous century there was considerable support for exposure to outdoor environments, gardens and gardening as part o f patient care regimes.  A s a consequence, the design o f healthcare facilities in Western Europe  and North America often reflected this approach to patient care. The medieval monasteries, for example, with their cloister gardens filled with therapeutic herbs and sunlight were believed to benefit the healing process and care for the patients needs.  For most o f the previous century, however, the program and design o f healthcare facilities supported the currently dominant cure-based medical model o f illness treatment.  A s I noted in  my preface, apart from the inherent emotional stresses associated with illness and emergency care, modern hospital environments often include unfamiliar technology and apparatus, unusual and unpleasant smells, artificial light, visual disconnection with the outside world, and a lack o f privacy and personal control.  In the closing decades o f the twentieth century an increasing interest in a holistic approach to patient care that acknowledges a connection between mind, body and spirit began to emerge. This holistic approach to patient care supports the inclusion o f healing gardens in healthcare facilities.  While this trend potentially raises a number o f questions for environmental designers, I considered the design implications o f the following.  If space in healthcare facilities is to be  programmed for outdoor use, what design features o f this setting cares for patients, both psychologically and emotionally while supporting their physiological needs? Further, does the therapeutic benefit and significance o f discrete garden features vary depending on the illness and healing processes o f particular patient populations and are there any constraints that limit the use of the garden?  72  T o find answers to these questions I began by reviewing Western European historical precedents for gardens in healthcare facilities. While gardens today are most commonly intended to be aesthetically pleasing, specifically designed to please the visual sense, I realized that various cultures throughout history have created gardens to engage and satisfy all the senses. While traditionally gardens have also been created for pragmatic outcomes including sustenance, medicine and climatic mitigation, a common theme that emerged from the literature review was that gardens are created to enhance human well-being.  For example, the siting and design of the typical nineteenth century pavilion hospital ensured views from patient rooms onto a courtyard and beyond to the expansive grounds and surrounding rural and often picturesque landscape.  It appears this design approach reflected a belief in the  benefit o f fresh air, sunlight, and views o f nature in promoting recovery (see figure 5.2).  Figure 5.2 View from Heather Pavilion Vancouver General Hospital 1905  The early photographs o f the Heather Pavilion at Vancouver's General Hospital exemplify the described nineteenth century approach to the siting and design o f healthcare facilities, while the recent aerial photograph o f the same site reflects not only contemporary urban space constraints, but perhaps as well, a lack o f appreciation for the significance a connection with nature has on  73  the hospitalized patients' physical and emotional sense o f well-being as well as the beneficial effect that it appears to have on the healing process (see figure 5.3 and 5.4).  74  Figure 5.4 Aerial Photo of Heather Pavilion Vancouver General Hospital 2 0 0 2  In reviewing the scientific-based evidence suggesting that nature is beneficial for the healing and recovery process, I noted that over the past thirty years a number of researchers from a variety o f disciplines including environmental psychology, behavioural science, horticulture, biology and landscape architecture have documented the restorative benefits o f nature.  Environmental  preference studies conducted in the United States by environmental psychologists  Doctors  Stephen and Rachel Kaplan reveal that a great diversity o f natural settings are beneficial to human well-being.  A s noted in Chapter Two, the Kaplans define nature as almost any outdoor  setting including parks, vacant lots, street trees, open spaces, backyards, fields and forest varying in size from tiny to expansive from highly maintained to virtually neglected. The Kaplans contend that the quintessential microrestorative environment, the one that most closely brings together the multiple themes o f the restorative experience into a single, small, intensely meaningful space, is the garden.  B y evaluating and synthesizing the documented empirical evidence and anecdotal support for healing gardens in healthcare facilities for three patient groups (children, Alzheimer's Disease and A I D S patients) I compiled a list o f the design features consistently referred to as beneficial 75  to the patients, staff and visitors at the healthcare facilities reviewed. It appeared to me that the design features recommended for each population group fell into one o f three categories: functional, experiential, and contextual.  Based on comparing and considering the written and  design work o f the leading experts in this area, I inferred a restorative value or relative benefit for each o f the design features listed — dependant upon the patient group or disease process.  The Healing Garden Matrix above organizes and synthesizes my interpretation o f the material extrapolated from the literature review and is a result o f exploring the link between the restorative value o f design features in a healing garden and specific patient populations. While somewhat subjective, the value I assigned to each design feature listed on the matrix (either as essential, high, moderate or low in terms o f benefit and or importance), illustrates variations depending on the population group, which highlights the need for designers to understand the particularities o f the patient group and the disease or illness.  The matrix also illustrates a consistency in terms o f the essential design features o f a healing garden needed for all patient population groups as well as visitors and staff.  These essential  design features for healing gardens fall mainly in the experiential category and include: lush greenery, fresh air, sunlight, views to nature from patients' rooms, sensory stimulation, and beauty.  I gleaned from this investigative process that even when a disease is deemed incurable, garden fragrances and lush green spaces can evoke pleasant memories and can lend patients the motivation to experience the sensory stimulus o f nature, whether alone or with loved ones. Also, that key to effective therapeutic or healing garden design is an appreciation for the relative value or importance o f design features, as they relate to the illness or disease process o f a specific patient group.  While the Healing Garden Matrix is not an exhaustive list o f design features and considerations, it is m y hope that it could be used as a check list or to guide the preliminary programming or predesign stage o f a healthcare facility development process.  The matrix could also be useful for  76  those charged with setting out a terms o f reference or a call for proposals for a healthcare facility, thereby increasing the awareness o f the importance o f the healing benefit o f access to nature. Further, the matrix is intended to provide an overview o f some o f the design considerations for a healing garden in order to begin to achieve a successful therapeutic and restorative connection between the healthcare facility population and the outdoor setting.  In addition, by reviewing during the pre-design stage the features listed on the matrix and noting that the relative importance o f individual features varies between healthcare facility population groups and diseases, there is an opportunity for the facility's program to be developed at the outset with the intention o f providing meaningful outdoor spaces that accommodate the specific needs o f the garden users in a setting that can provide another dimension to their therapy regime and healing process.  This exploration demonstrates that visual and physical access to nature can positively affect a patient's spirit, sense o f well-being and quality o f life ~ perhaps even facilitate recovery ~ and that restorative and therapeutic healing garden design responds to specific patient limitations while also responding to the disease's process and progression.  77  BIBLIOGRAPHY Adolph, V a l and Brenda Guild Gillespie.  The Riverview Lands: Western Canada's First  Botanical Garden. 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Environment:  Utilization  and  Consumer  "Evaluating a Children's Hospital Garden Satisfaction."  Journal  of  Environmental  Psychology 21 (2001): 301-314. 83  Wilson, Edward O . Biophilia. Cambridge: Harvard University Press, 1984.  FIGURE CREDITS  Figure 1-1.  Parsons, Colette. "The Cloister Garden: Historic Exemplar." Landscapes. Winter 2004:5.  Figure 1-2.  Fox, Sally.  The Medieval Women, A n Illuminated Calendar.  New  York:  Workman Publishing, 1994. [8] Figure 1-3.  City of Vancouver Archives. Vancouver General Hospital.  Figure 2-1.  Marcus, Clare Cooper and Marni Barnes. Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Dedsign Recommendations. Healthcare Design, 1995.  Martinez, C A : Center for  132-133.  Figure 2-2. <http://www.hospitalnews.com/modules/magazines/mag.asp?ID=3&IID=52«&AI D=629> Figure 2-3.  Marcus, Clare Cooper and Marni Barnes. Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations. Healthcare Design, 1995.  Figure 3-1.  132-133.  Marcus, Clare Cooper and Marni Barnes. Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations. Healthcare Design, 1995.  Figure 3-2.  Martinez, C A : Center for  McCormick, Kathleen.  Martinez, C A : Center for  132-133.  "Realm of the Senses."  Landscape Architecture  85.01  (1995): 62.  Figure 3-3.  Marcus, Clare Cooper and Marni Barnes. Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations. Healthcare Design, 1995.  Figure 4-1.  Martinez, C A : Center for  132-133.  Marcus, Clare Cooper and Marni Barnes. Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations. Healthcare Design, 1995.  Martinez, C A : Center for  132-133.  Figure 4-2. <http://www.cancer.org/docroot/FPS/content/FPS_l_Healing_Gardens_Nurture_t he_Spirit_While_Patients_Get_Treatment.asp?SiteArea=> Apr. 2004  85  Figure 4-3. <http://www.cancer.org/docroot^ he_Spirit_While_Patients_Get_Treatment.asp?SiteArea=> Apr. 2004 Figure 4-4. <http://vv^vm.cancer.org/docroot/FPS/content/FPS_l_H he_SpMt_wTiile_Patients_Get_Treatrnent.asp?SiteArea=> Figure 4-5. M c C o r m i c k , Kathleen.  "Realm of the Senses."  A p r . 2004  Landscape Architecture  85.01  (1995): 62. Figure 4-6. Crisp, Barbara. Human Spaces: Life-Enhancing Designs for Healing, Working, and Living. Massachusetts:  Rockport Publishers Inc., 1998.  (168-171).  Figure 4-7. Crisp, Barbara. Human Spaces: Life-Enhancing Designs for Healing, Working, and Living. Massachusetts: Rockport Publishers Inc., 1998.  (168-171).  Figure 4-8. Crisp, Barbara. Human Spaces: Life-Enhancing Designs for Healing, Working, and Living. Massachusetts:  Rockport Publishers Inc., 1998.  (168-171).  Figure 4-9. Crisp, Barbara. Human Spaces: Life-Enhancing Designs for Healing, Working, and Living. Massachusetts:  Rockport Publishers Inc., 1998.  Figure 4-10. Crisp, Barbara. Human Spaces: and Living. Massachusetts:  (168-171).  Life-Enhancing Designs for Healing, Working,  Rockport Publishers Inc., 1998.  (168-171).  Figure 5-1.  Leccese, Michael. "Nature Meets Nurture." Landscape Architecture 85.01 (1995): 70.  Figure 5-2.  City of Vancouver Archives.  Figure 5-3.  City of Vancouver Archives.  Figure 5-4.  City of Vancouver Archives.  86  APPENDIX 1 Toxic Plant List G.8.4 Plant List This list of plants can serve as a general guideline for identifying those plants which should be avoided in children's playspaces. Although there are toxic elements in the fruit, foliage, and roots of about 700 documented plants found in North America, children are more likely to be attracted to brightly coloured fruits rather than to other parts. A general rule of thumb is to avoid any plants with white berries, whether or not they appear on :: the following list. Botanical name  Common name(s), Type of plant  Plants with poisonous fruits Actea pachypoda  White Baneberry, Cohosh (Perennial)  Actea rubra  Red Baneberry, Red Cohosh (Perennial)  Actea spicata  Black Baneberry (Perennial)  Daphne mezereum  February Daphne (Shrub)  Euonymus arnericana  Strawberry bush, Wahoo (Shrub)  t  87  ©.Canadian  Standards Association  Botanical name  Children's Playspaces and Equipment  C o m m o n narne(s). T y p e o f p l a n t  Plants w i t h p o i s o n o u s fruits ( C o n c l u d e d ) Euonymus atropurpurea  Eastern Wahoo (Large shrub)  Euonymus europaea  Spindle Tree (Small tree, or bush)  Hedera helix  English Ivy (Vine)  Hydrangea sp.  Hydrangea (Shrub)  Ilex sp.  Holly (Shrub)  Lathyrus sp.  Sweet Pea (Annual or perennial)  Leucbthoe sp.  Leucothoe (Shrub)  Menispermum canadense  C o m m o n Moonseed (Vine)  Phoradendron serotinum  American Mistletoe (Tree parasite)  Phytolacca americana  Pokeweed, Inkberry (Perennial)  Podophyllum peltatum  Mayapple, Mandrake (Perennial)  Rhodotypos scandens  Jetbead (Shrub)  Ricinus communis  Castor Bean (Annual)  Robinia pseudoacacia  Black Locust (Tree)  Solanum dulcamara  Deadly Nightshade (Vine)  Symphoricarpos  Snowbeny, Waxberry (Shrub)  Rhamnus sp.  Buckthorn (Shrub or tree)  Rhus radicans  Poison Ivy (Vine)  Rhus vernix  Poison Sumac (Shrub)  Taxus sp.  Yews (Shrubs and small trees)  Wisteria sp.  Wisteria (Vines)  Plants w i t h p o i s o n o u s foliage Aconitum sp.  Aconite, Monkshood (Perennial)  Anemone sp.  Anemone (Perennial)  Azalea sp.  Azalea, Rhododendron (Shrub)  Buxus sp.  Box, Boxwood (Shrub)  Cicuta maculata  Water-hemlock (Perennial)  Clematis sp.  Clematis (Perennial vine)  Conium maculatum  Poison Hemlock (Biennial)  Datura stramonium  jimson-weed, Thornapple (Annual) (Continued)  88  ©Canadian  CAN/CSA-Z6U-03  Botanical name  Standards Association  Common name(s), Type of plant  Plants with poisonous foliage (Concluded) Delphinium sp.  Larkspur (Biennial)  Digitalis purpurea  Foxglove (Biennial)  Euphorbia cyparrissias  Cypress Spurge (Perennial)  Euphorbia marginata  Show-oh-the-Mountain (Annual)  Helleborus sp.  Hellebore, Christmas-rose (Perennial)  Kalmia sp.  Lambkill, Mountain Laurel (Shrub)  Ligustrum sp.  Privet (Shrub)  Lobelia sp.  Lobelia (Annuals or Perennials)  M o m s rubra  Red Mulberry (Tree)  Parthenocissus quinquefolia  Virginia Creeper (Vine)  Pieris sp.  Andromeda (Shrub)  Prunus serotina  Black Cherry, Rum Cherry (Tree)  Ranunculus sp.  Buttercup (Perennial)  Rheum rhubarbium  Rhubarb (Only leaves are toxic)  Rhus radicans  Poison Ivy (Vine)  Rhus vernix  Poison Sumac (Shrub)  Rudbeckia sp.  Coneflower, Black-eyed Susan (Perennial)  Sambucus canadensis  American Elder (Shrub)  Sanguinaria canadensis  Bloodroot (Perennial)  Shepherdia sp.  Buffalo-berry (Large shrub)  Solanum tuberosum  Potato (New shoots only)  Vinca sp.  Periwinkle (Ground cover):  Plants with poisonous roots, stems, or seeds Arisaema tryphyllum  ]ack-in-the-pulpit (Perennial)  Camassia sp.  Death Camass (Bulb)  Colchicum auturnnale  Autumn Crocus (Bulb)  Convallaria majalis  Lily-of-the-Valley (Perennial)  Dicentra sp.  Bleeding Heart (Perennial)  Endymion sp.  English Bluebell, Squill (Bulb)  Galanthus sp.  Snowdrop (Bulb) (Continued)  Children's Plqyspqces and Equipment  © Canadian Standards Association  Botanical name  Common name(s). Type of plant  Plants with poisonous roots, stems, or seeds (Concluded) Gloriosa superba  Glory-Lily (Perennial)  Gymnocladus dioica  Kentucky Coffee-Tree (Large tree)  Hyacinth sp.  Hyacinth (Bulb)  Ipomoea sp.  Morning Glory (Annual vine)  Iris sp.  Iris, Flag (Corm)  Laburnum anagyroides  Goldenchain (Tree)  Narcissus sp.  Narcissus, Daffodil (Bulb)  Ornithogalum peltatum  Star-of-Bethlehem (Bulb)  Phytolacca americana  Pokeweed (Perenniai)  Podophyllum peltatum  Mayapple, Mandrake (Perennial)  Scilla sp:  Scilla, Bluebell (Bulb)  

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