HEALING GARDENS IN HOSPITALS

Clare Cooper Marcus University of California, Berkeley

The Architecture of Hospitals April 2005

Outline of Presentation
History of outdoor spaces in hospitals and why healing gardens have recently become of interest Design guidelines Precedents drawn upon by designers of contemporary healing gardens

History and Recent Developments

1.MIDDLE AGES Medieval monastic cloister garden Early example of restorative outdoor space for sick patients

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

3. PAVILION-STYLE HOSPITALS

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

3.PAVILION-STYLE HOSPITALS Early 20th century TB sanitoria and mental asylums provide maximum exposure to sun, fresh air, and gardens to assist in healing

4. MEGA HOSPITALS
Mid-20th century Neo-classical style thrown out in favor of International Style High rise buildings with emphasis on efficiency Nature succumbs to cars and parking lots

Nebraska Methodist Hospital, Omaha,Nebraska,USA

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

5. PATIENT CENTERED CARE

1990 - Present Negative reactions to institutional environments Competition between hospitals in US Greater concern for patient needs
Monterey Community Hospital, Monterey,California

Slow shift to more welcoming , familiar imagery in interiors

5.PATIENT CENTERED CARE

Designers look to familiar icons that may feel comfortable for patients and staff The shopping mall

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

5. PATIENT CENTERED CARE Designers look to regional context for more appropriate styles, forms, colors and materials

San Diego Childrens Hospital, San Diego, California( 1990-93)

5.PATIENT CENTERED CARE

1984: Significant study by Roger Ulrich finds views to nature have positive influence on health outcomes Patients recovering from gall bladder surgery with view to trees had fewer post-surgery complications, required fewer doses of strong pain drugs, went home sooner Compared to those looking out at a brick wall At lastcredible scientific evidence that nature has healing properties

5.PATIENT CENTERED CARE

Important research by Roger Ulrich, Terry Hartig et al Viewing - or being in nature causes physiological and psychological changes Body/mind returns to state of balance, and contributes to state of wholeness and health Medical authorities see nature/trees in hospital setting as not just cosmetic extras--may speed recovery, save $$$

St Michaels Medical Center, Texarkana Texas

5.PATIENT CENTERED CARE Hospital clients commission art with nature images

Scripps Mercy Hospital, San Diego, California

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

HOSPITAL GARDEN RESEARCH

1994 - First systematic post-occupancy study of hospital outdoor space in US 4 hospital gardens in San Francisco Bay area studied using visual analysis, behavior mapping, and interviews
(Cooper Marcus and Barnes, 1994)

Roof garden, Alta Bates Hospital, Berkeley,California

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

staff 59%

Activities in the Gardens

100%

94% 73%

73%

68% 61% 53%

50%

38%

36%

12%
0%
Relax Eat Talk Pass by Stroll Therapy Wait Visit Play

11%

Meeting

How do you feel after spending time in the garden?

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

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

Trees,plants,nature
Smells, sounds, fresh air Place to be alone or with friend Views,sub-areas,textures Practical features, benches etc Dont know 69% 58% 50% 26% 17% 8%

 Typical garden-user responses: My level of stress goes way down..I return to work refreshed. I sit in the garden before my appointment; it helps me deal with what they will put me through.
Kaiser Permanente Hospital Walnut Creek, California

I work in the Intensive Care Unit which is like a hell holesitting here in the sun is like therapy for me I work underground in the Radiation Department, like one of the Mole People. If I didnt have this garden to come tosunlight, fresh air, birdsong, treesI think Id go CRAZY!

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

5. PATIENT CENTERED CARE

Before

After

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

Cancer Clinic, St Vincents Hospital,Santa Fe, New Mexico

5.PATIENT CENTERED CARE

American Society of Landscape Architects begins to hold special sessions on healing gardens at its annual conference 2003 - School of Chicago Botanic Garden initiates first US course on Healthcare Garden Design

5.PATIENT CENTERED CARE

Mid 1990s: Hospital staff begin to lobby for usable outdoor spaces Horticultural therapist lead team of hospital staff, working with landscape architect, to transform dull, useless space at this hospital into vibrant garden used for physical therapy, speech therapy and horticultural therapy
Good Samaritan Hospital, Portland,Oregon

Before

After

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

Understanding of mind-body connection Stress reduction enhances immune function Interest in alternative or complementary medicine Awareness that hospitals must be not only functionally efficient, but also patient-centered / psychologically supportive Evidence that environmental factors(light, temperature, noise, music, nature) play role in improved patient health-outcomes Recognition(in US) that attractive environment is good marketing tool in competitive healthcare

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

1992 - Office of Alternative Medicine established within National Institutes of Health, Washington,DC 1999 - University of Minnesota offers first U.S. graduate level courses in alternative medicine 2005 - 26 medical schools in U.S. now offer such courses Nature and healing no longer viewed as a fringe idea

THE HEALING GARDEN: Essential design elements and environmental qualities

Guidelines based on stress research, post occupancy studies of hospital outdoor space, and field observations at more than 100 hospital gardens in US,UK,Canada and Australia

HEALING GARDEN
Facilitates stress reduction, helps body reach more balanced state Helps person summon up own inner healing resources Helps patient come to terms with incurable medical condition Provides needed retreat for staff from stress of work Provides welcome setting for visitors Healing is not equivalent to cure Other terms used for healing garden: therapeutic, restorative, rehabilitative

POTENTIAL ACTIVITIES IN A HEALING GARDEN RANGE FROM PASSIVE TO ACTIVE

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

What happens ,psychologically, when a person chooses to go outdoors to a garden or natural space to help themselves feel better? Research suggests that unconsciously they may move through 3 or 4 stages: The journey Sensory awakening Personal centering Spiritual attunement
(Marni Barnes, 1994)

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

EXERCISE SENSE OF CONTROL SOCIAL SUPPORT ENGAGEMENT WITH NATURE

STRESS RESTORATION AND BUFFERING

IMPROVED HEALTH OUTCOMES

(Clinical outcomes, patient satisfaction,cost of care)

1. OPPORTUNITIES FOR EXERCISE Exercise is associated with a spectrum of health benefits especially for those who are sedentary, depressed or elderly Even a few minutes of mild exercise improves mood, reduces stress People are more likely to walk when there is an attractive setting to walk in; paths which encourage exploration

1.OPPORTUNITIES FOR EXERCISE: Different people seek different kinds of exercise Opportunities for exercise for patients recovering from a stroke will be very different from Those for staff who want to walk or jog for health in their lunch hour

1.OPPORTUNITIES FOR EXERCISE: Different people will seek different kinds of exercise
Well siblings run off steam in a maze outside a pediatric outpatient clinic
Kaiser Permanente Hospital, Vallejo, California

Labyrinths are becoming increasingly popular in U.S healing gardens Patients, staff and visitors use for contemplative walking

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

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

People have need for sense of control with respect to physical and social environments On entering hospital, many experience loss of control: Institution decides -what you eat -what you wear -when doctor visits , etc Loss of control produces stress, worsens health outcomes Garden can be designed to enhance sense of control

2. SENSE OF CONTROL

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

St Thomas Hospital, London, England

2. SENSE OF CONTROL
Something as simple as providing mobile furniture permits this nurse to move into the shade and place her lunch on the edge of a concrete planter Staff working on tight schedules and perhaps under strict supervision can regain a measure of control in a garden
Alta Bates Hospital, Berkeley, California

2.SENSE OF CONTROL

Providing choices where people can sit as a group or alone can facilitate a sense of control Locating seating with an expansive view or a close-in view, in sun or in shade, offers welcome choices

Garden of St Thomas Hospital, London

St Thomas Hospital, London, England

3.PROVIDE SETTINGS WHICH ENCOURAGE PEOPLE TO GATHER TOGETHER AND EXPERIENCE SOCIAL SUPPORT
Research indicates that people with higher levels of social support : -are less stressed -have better health than those who are more socially isolated Locate gardens close to patient rooms and waiting areas, with sub-spaces where people can find privacy

St Georges Hospital, London, England

3.SOCIAL SUPPORT Staff also need restorative places to converse with colleagues and find social support Post-occupancy study in California found staff were largest users of hospital outdoor space
Alta Bates Hospital, Berkeley, California

3.SOCIAL SUPPORT
It would show that they care about us, as staff in a hospital, by having a place where we can relax.. (Nurse,London hospital) Public spaces that encourage interaction and communication influence staff retention. ( Survey of Nurses, Committee
for Architecture and the Built Environment, UK, 2004)
St ThomasHospital, London, England

Kaiser Permanente Hospital, Walnut Creek, California

3.SOCIAL SUPPORT
For people to be attracted to relax and visit with friends or family in a hospital outdoor space it must be green, quiet, and offer places of privacy.. NOT THIS !

Legacy Emanuel Hospital, Portland, Oregon,USA

3.SOCIAL SUPPORT
In considering the need for social support - the comfort of people sitting and talking together care must be taken in the selection of furniture This.
Alzheimer facility, Chemainus, BC,Canada

NOT THIS !

St Marys Hospital, Isle of Wight, England

4.ENGAGEMENT WITH NATURE

A healing garden must have a profusion of green nature , which has the effect of: + Awakening the senses + Calming the mind + Reducing stress + Assisting a person to marshall their own inner healing resources Nature cannot mend a broken leg or remove a tumor, but can support and strengthen us before/during/after medical procedures

4.ENGAGEMENT WITH NATURE

In selecting plant material, designer should consider color, texture,subtleties of green and leaf shape, grasses which more with the slightest breeze Frail patient may move slowly, and sit for long time in one place Planting design should be intricate, detailed and appeal to all the senses

4.ENGAGEMENT WITH NATURE

Plants and trees with distinctive seasonal changes should be considered in gardens for nursing homes, assisted living, Alzheimers facilities etc, where patients spend a long time and may lose track of time Nature attracts our attention without depleting the body of energy

4.ENGAGEMENT WITH NATURE

Trees can provide metaphors of solidity, strength and permanence Annuals can provide metaphors of growth, budding,blooming,seedng, decay, death, and transformation Perennials can provide metaphors of persistence and renewal

Kaiser Permanente Hospital, Vallejo California

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

4.ENGAGEMENT WITH NATURE

Hospital outdoor space with little or no greenery will have little healing value No amount of clever paving design,sculpture or seating can make up for lack of nature

4.ENGAGEMENT WITH NATURE

Hospice, Portland, Oregon

Victoria General Hospital, Victoria,BC,Canada

Architects and landscape architects must work together to ensure that there are views out to gardens and landscape from patient rooms, staff offices, and corridors for post-surgery exercise Views to gardens and exterior landscape can assist in way-finding and reduce the stress of finding ones way around a strange building

4.ENGAGEMENT WITH NATURE

Water is also an element of nature

Trinity Hospice, London

Views of still, reflective water; sounds and views of moving water are engaging and soothing Water attracts wildlife, reminding us in time of ill-health that life goes on

West Dorset County Hospital, UK

4. ENGAGEMENT WITH NATURE

Indoor gardens and atria are becoming more common in hospitals where:
Rehabilitation Hospital ,Lake Katrine, NY, USA

-no outdoor space is available -climate precludes use of outdoors for much of year

Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada

5.VISIBILITY
Designing a healing garden to provide for exercise, sense of control, social support, and engagement with nature - though all essential - is not enough People have to know the garden is there! Ideally, garden is visible from main lobby, so signage is not necessary

St Marys Hospital, San Francisco

6.ACCESSIBILITY

St Thomas Hospital, London

People of all ages and abilities need to be able to enter and move around in the garden Paths must be wide enough for two wheelchairs to pass (minimum 6 feet)

6.ACCESSIBILITY

Healing Garden, Good Samaritan Hospital, Portland, Oregon

Paths should be smooth and wide enough for a patient on a bed or gurney to be wheeled into the garden Paving joints should be narrow enough so as not to catch a cane, the wheels of a walker or an IV-pole

6.ACCESSIBILITY
WHAT NOT TO DO! Garden paved with pebbles for maternity ward
West Dorset County Hospital, Dorchester ,UK

Pregnant women feared they would trip Water/island theme of hospital interior carried to ridiculous lengths Courtyard surface waves up and down; frail patients cannot use

St Marys Hospital , Isle of Wight, UK

7.FAMILIARITY

St NicholasHospice, W.Suffolk Hospital, England

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

8.QUIET
People enjoy natural sounds in a hospital garden, such as a fountain, birdsong,rustling of leaves Study of 4 California hospital gardens found people most disturbed by incongruent sounds such as air conditioner,traffic, emergency helicopter

9.COMFORT

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

Homerton Hospital,London

9.COMFORT

Garden of Trinity Hospice, London

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

9.COMFORT

WHAT NOT TO DO! Psychological discomfort in a courtyard surrounded with windows, no sense of privacy, feeling of being in a fishbowl

10.PANORAMIC VIEW

San Diego Hospice, California

Where location and topography permit, a viewpoint from a garden provides a significant place for reflection Research suggests that people who are stressed find a viewpoint soothing as it helps them to get things into perspective, and see the big picture

11. UNAMBIGUOUSLY POSITIVE ELEMENTS; Emotional Congruence Theory

Our emotional state biases our perception of the environment A person who is fearful, and a person who is happy, may look at the same object and have very different reactions Ambiguous or abstract features may be interpreted by stressed patients as fearful or threatening (even if the artist had no such intention) Thereforeany feature that might be misinterpreted should not be located in a healing garden

Art in a Psychiatric Ward (Ulrich, 1986)

STAFF comments: I think its fun..whimsical.. Funny little talking apple cores PATIENT comments: Charred skullsDrops of blood flying.. Wounded people. They-re in pain and crying out.

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

An example of the wrong kind of art being placed in a hospital Cancer patients, looking out onto this garden reacted negatively: Beaks tearing my flesh Hands coming up to grab me The sculptures had to be removed

Inappropriate art in a cancer clinic garden? These concrete-slab sculptures would be quite appropriate in a museum garden BUTare they appropriate at a cancer clinic where stressed patients might interpret them as gravestones?

What art IS appropriate in a hospital?

A whale diving into the ground can be a whimsical feature in a playground, but Might patients at this psychiatric hospital interpret it as a whale committing suicide?

Art in a hospital setting needs to be UNAMBIGUOUSLY POSITIVE

This sculpture might not win an award for cutting-edge design, but It is entirely appropriate in a hospital setting where it may evoke positive associations and memories, and help reduce stress

PRECEDENTS DRAWN UPON BY DESIGNERS OF CONTEMPORARY HEALING GARDENS

1. Archetypal spaces
2. 3. 4. 5. 6. 7. Metaphors Historical precedents Domestic precedents Regional attributes Statement art Medical diagnoses

1. ARCHETYPAL SPACES A garden used in the psychiatric treatment of children who have experienced severe trauma Incorporates archetypal spaces such as hill, cave, ravine, island etc

Therapeutic Garden at the Institute For Child and Adolescent Development, Wellesley,Massachusetts

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

3.HISTORICAL PRECEDENTS: English strolling garden

Combination of trees, flowers, lawns,winding paths Suitable in many healthcare settings since it provides 4 key elements in healing garden design: - opportunities for exercise - places for privacy,sense of control - settings for social support - engagement with nature

AIDS Memorial Grove, Golden Gate Park, San Francisco

3.HISTORICAL PRECEDENT: The courtyard

Provides enclosed, protected space Is clearly hospital territory; in-patients may feel comfortable there in their hospital gowns Privacy of adjacent rooms needs to be protected
Royal Devon and Exeter Hospital, Devon, England

Sounds of HVAC units can be irritating

3.HISTORICAL PRECEDENT: The cloister garden

Would be an ideal model for garden in nursing home, geriatric ward etc Smooth walking surface,sheltered seating,garden view No contemporary examples found in N. America or UK; perhaps in Italy, Spain ?

12th century cloister, Santiago de Compostela, Spain

4. DOMESTIC PRECEDENTS

Front porch or front garden facing street activity preferred by elderly people in senior housing Older people who are not sick are faced with problem of boredom rather than stress

4.DOMESTIC PRECEDENTS

Back garden is ideal model for frail elderly or those with Alzheimers disease Enclosed space feels secure and is familiar from home environment

5. REGIONAL ATTRIBUTES A garden which echoes the colors and forms of a southern California beach scene Does the familiarity create a more soothing setting for hospitalized children?

Leichtag Family Healing Garden, San Diego Childrens Hospital, San Diego, California

5. REGIONAL ATTRIBUTES
This garden echoes the vegetation and landscape of local coastline Does this make it a more healing environment? Perhaps.Recent study in Australia found favorite art in hospital depicted familiar,local scenes
Harrison Memorial Hospital, Bremerton, Washington

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

Scottsdale Memorial Hospital, Arizona

6. STATEMENT ART Artist commissioned to design a hospital courtyard makes statement that has nothing to do with regional context and has none of the attributes of a healing space
West Dorset County Hospital, Dorchester, England

6.STATEMENT ART Garden for cancer center based on Russian constructivist painting Do steel structures and minimal planting create a healing space ?

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

7. MEDICAL DIAGNOSES Hospital gardens for specific populations are now being designed to meet the medical needs of patients and their care-givers Gardens are becoming the location of, and means of treatment for, certain patients While some successful gardens in this category have been created, more research is needed

7. MEDICAL DIAGNOSIS
REHABILITATION garden designed for physical therapists, speech pathologists, and horticultural therapists to work with patients who have had strokes,or suffered brain damage Varied surfaces and slopes for learning to walk again Varied planter edge heights for sitting, leaning Variety of labeled plants for color and shape recognition, reading etc

Healing Garden, Good Samaritan Hospital,Portland,Oregon

7. MEDICAL DIAGNOSIS
Before

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

After

Special attention to levels of shade because patients on certain medications must not be in sun
Joel Schapner Memorial Garden,Cardinal Cook Hospital,New York City

7. MEDICAL DIAGNOSIS
Courtyard garden at a CANCER clinic with soothing sound of water, engaging plant material, and varied degrees of shade because patients on chemotherapy drugs must stay out of sun Cancer patients and relatives at workshop to inscribe their stories on tiles to decorate corridor beside garden
Cancer Clinic Garden, Mount Zion Hospital, San Francisco,California

7.MEDICAL DIAGNOSIS
Garden-courtyards for patients with ALZHEIMERS DISEASE Looped pathway to aid orientation
The Lodge at Broadmead,Victoria,BC,Canada

Tinted concrete to reduce glare Low planting for stooped posture Non-toxic plants Features to evoke earlier memories: prairie grass and garden shed

Chemainus Health Care Center,Chemainus, Center,Chemainus, BC, Canada

7. MEDICAL DIAGNOSIS

Garden at a childrens hospital must provide for sometimes conflicting needs of sick children, well siblings, worried or grieving parents, and stressedout staff
Prouty Terrace and Garden, Childrens Hospital, Boston, Massachusetts

7. MEDICAL DIAGNOSIS
Garden/playground for children with BRAIN INJURIES/mobility problems designed to encourage physical activity and re-use of limbs Range of topography, surfaces,features to manipulate Encourages interaction with natural world, and taking risks

Rusk Institute of Rehabilitative Medicine, New York

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

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

7. MEDICAL DIAGNOSIS
Garden for BURN PATIENTS and families Paths wide enough for beds Shade is essential Grade changes to practice walking Different textures for touch
Legacy Burn Center Garden, Legacy Emanuel Hospital, Portland,Oregon

Separate,private staff area

7. MEDICAL DIAGNOSIS
Garden for patients in DRUG AND ALCOHOL rehabilitation unit based on 12-Step Alcoholics Anonymous program Each step a different sub-space in garden with inspiring words inscribed on paving stone
Serenity Garden, Drug and Alcohol Rehabilitation Center, Scripps Memorial Hospital, San Diego, California

SUMMARY OF HEALING GARDEN DESIGN CONSIDERATIONS

Supportive of stress reduction and healing: Convenient way-finding to garden Accessibility Places of privacy Seating encouraging interaction Contact with nature (green vegetation,nature sounds,wildlife) Hindering stress reduction and healing: Predominance of hardscape Crowding Ambiguous, abstract art Cigarette smoke Intrusive mechanical sounds Lack of privacy, places to sit Lack of choice Lack of shade Feeling of insecurity or risk

GARDEN OFFERS COMPLETE CONTRAST TO HOSPITAL INTERIOR HOSPITAL INTERIOR

Institutional scale Man-made Evoking anxiety Limited sensory detail Straight lines,ordered Controlled air Few places to be alone Not conducive to calming the mind Evoking thoughts of illness,death

GARDEN
Domestic scale Natural Evoking good memories Rich,sensory detail Varied shapes,organic Fresh air Places to be alone Conducive to positive feelings, introspection Links to wider world of nature, on-going cycle of life

ADVANTAGES TO HEALTHCARE FACILITIES

( Roger Ulrich, 1999)

PROBABLE ADVANTAGES Reduction of stress in patients,staff and visitors (very likely) Reduced pain in patients(likely) Reduction in depression (likely, especially if garden fosters exercise) Higher reported quality of life for chronic and terminally-ill patients(likely, especially if garden fosters exercise) Improved way-finding( very likely, especially if garden in prominent location) POTENTIAL ADVANTAGES Reduced costs : Length of stay shorter for certain patient categories; fewer strong pain medication doses Increased patient mobility and independence Higher patient satisfaction Increased staff job satisfaction

MANY UNANSWERED QUESTIONS

Do people seeking calmness and peace in a hospital garden prefer a winding path, encouraging exploration? Or a straight path where they can see their destination? Does it depend on the type of facility? Does it depend on culture?

MANY UNANSWERED QUESTIONS

Does this Native American family find comfort in the fact that all the plants in this garden are used in traditional healing? Are patients at this heart hospital troubled by a fountain-sculpture shaped like the human heart sliced in half, and pulsing at the rate of a normal heart-beat?

Good Samaritan Hospital,Phoenix Arizona

Royal Brompton Heart and Lung Hospital, London

MANY UNANSWERED QUESTIONS

Do people find solace and peace in a zen garden, even when they dont understand its symbolism? Do the residents of this London nursing home spend time in this courtyard based on a Persian paradise motif, or would they have preferred an English cottage garden like the one they left at home?

TOO MANY WASTED OPPORTUNITIES

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

Front lawn of a childrens hospital surrounded by traffic streets is not suitable for well or sick children
(Childrens Hospital, Los Angeles, California)

DO ARCHITECTS HAVE TOO MUCH CONTROL ?

Architects oftenthink via big, computer-drawn models Outdoor space sometimes perceived as what separates buildings Architect may design outdoor space; does not have appropriate training Landscape architect brought into design process too late Minimal budget to create gardens

IDEALLY, THIS SHOULD HAPPEN:

Designers work as team with medical personnel likely to use garden for therapy, and with potential patientusers Lead professional on team is landscape architect Team annotates plans with presumed health benefits Post occupancy evaluation conducted after garden in use Research results disseminated to peers Information on garden benefits disseminated to hospital staff

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

WE MUST DO BETTER THAN THIS !

Royal Alexandra Childrens Hospital, Sydney Australia St Rose Hospital, Las Vegas, Nevada

Fads and fashions in design lead to hospital outdoor space that fulfills none of the needs of a healing garden Stripes of granite and gravel, lawn and gravel.anything striped = current fashion in landscape architecture

WE MUST DO BETTER THAN THIS

Staff who work in this kind of milieu deserve a place where they can take a break that is better than

THIS

WE MUST DO BETTER THAN THIS !

Mental Health Clinic, Miami,Florida

Mt. Sinai Hospital, Toronto, Canada

A path that runs through a bench and terminates in a wall: What sort of message is that for a patient with a mental illness? Dying plants at the entrance to a hospitalIf they cant keep the plants alive, how will they care for me ?!