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Gardens In Healthcare Facilities: Uses, Therapeutic Benefits, And Design Recommendations


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Gardens In Healthcare Facilities: Uses, Therapeutic Benefits, And Design Recommendations

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  • 2. Copyright © 1995 by The Center for HealthDesign, Inc. All rights reserved. No part of thiswork covered by the copyright herein may be repro-duced by any means or used in any form withoutwritten permission of the publisher.The views and methods expressed by the authors donot necessarily reflect the opinions of The Centerfor Health Design, Inc. or its Board or staff.Published by: The Center for Health Design, Inc.Publisher: Wayne Ruga, AIA, IIDAResearch Consultants:Clare Cooper Marcus, MA, MCPCollege of Environmental DesignUniversity of California at BerkeleyMarni Barnes, MLA, LSCWCollege of Environmental DesignUniversity of California at BerkeleyPrinter: Eusey PressDesign and Composition: Visual CommunicationsThe Center for Health Design, Inc.4550 Alhambra WayMartinez, CA 94553-4406United States of AmericaTel: (510) 370-0345Fax: (510) 228-4018Email: CTR4HD@aol.comClare Cooper Marcus, MA, MCP2721 Stuart StreetBerkeley, CA 94705Tel: (510) 548-2904Fax: (510) 643-6166Marni Barnes, MLA, LCSWDeva Landscaping846 Boyce StreetPalo Alto, CA 94301Tel: (415) 326-6866First Printing November 1995ISBN: 0-9638938-2-3Printed in the United States of America
  • 3. THE CENTER FORHEALTH DESIGN, INC.VisionTo create a future where the built environ-ment supports the highest level of humanhealth, well-being, and achievement in all as-pects of life and work.MissionTo be a facilitator, integrator, and acceleratorpromoting the widespread developmentof health-enhancing environments, and thebenefits that these bring to human health andwell-being.PurposeTo advance the quality of health design by:• Supporting the needs and interests of its constituents.• Serving as the internationally recognized source of educational programs.• Supporting the development of research that will significantly advance the art and science of health design.• Developing and promoting the application of design.• Developing a worldwide network of support- ive individuals, businesses, and allied organi- zations.• Serving as a clearinghouse for resources, in- cluding: books, periodicals, articles, audio and videotapes, project data, facility tours, and product information. x iii
  • 4. ACKNOWLEDGMENTSW E WOULD LIKE to express our ap- Board of Directors preciation to the medical institu- Russell C. Coile Jr., MBA tions that support and maintain Ann Dixthe beautiful outdoor spaces observed during Kathryn E. Johnsonour research. Although many more people Roger K. Leib, AIAhelped to point the way and grease the wheels Jain Malkinduring this study than we could mention here, Robin Orr, MPHsome of the good souls are: Derek Parker, FAIA, RIBA Wayne Ruga, AIA, IIDAAlan Kinet, Bill Peters, and Gloria Rodriguez; Blair L. Sadler, J.D.San Francisco General Hospital; Roger S. Ulrich, Ph.D.Gail Uchiyama and Burton Presberg; Alta Research CommitteeBates Medical Center; Janet R. Carpman, Ph.D.Irwin Fisch, Pat Mariani, Gabriel Escobar, Uriel Cohen, D.ArchBob Eisenman, and Priscilla Minn; Kaiser Syed V. Husain, FAIAPermanente Walnut Creek; Debra J. LevinKaren Graham, Vicki Williams, and Francia Donald F. LopezDeAsis; California Pacific Medical Center; M.P. MacDougallTom Piazza at the University of California, Jain MalkinBerkeley, Survey Research Center, for his Wayne Ruga, AIA, IIDAknowledge and advice; Mardelle Shelpley, D.Arch Karen TetlowThe homeless and HIV-positive man who di- Roger Ulrich, Ph.D.rected us to healing gardens in San Francisco; SponsorsEileen Lemus, at Laguna Honda Hospital, for This Research Report has been exclusivelyher knowledge and belief in innovative forms sponsored by: Armstrong World Industries,of therapy; Inc.; Interface Flooring Systems, Inc.; JCMFinally, we are deeply indebted and offer our Group; and Jain Malkinheartfelt thanks to The Center for Health De- Research Consultantssign and its Research Committee for sponsor- Clare Cooper Marcus, MA, MCPing and supporting this study. and Marni Barnes, MLA, LCSWThe Center for Health Design would like to University of California at Berkeleyacknowledge the following individuals and or-ganizations for making this research projectpossible.iv x
  • 5. TABLE OF CONTENTS1 Introduction 12. Review of Relevant Research 23. Methods 34. Historical Overview of the Provision of 7 Outdoor Gardens in Medical Settings5. Typology of Outdoor Spaces Provided in 11 Contemporary Healthcare Facilities6. Case Study: San Francisco General 23 Hospital,The Comfort Garden7. Case Study: Alta Bates Medical Center, 31 Berkeley, The Roof Garden8. Case Study: Kaiser Permanente, 39 Walnut Creek, Central Garden9. Case Study: California Pacific Medical 47 Center, Garden Campus, The Garden10. Aggregate Data Analysis of the 53 Case Study Sites11. Design Recommendations 5912. Conclusion 6513. Appendix: Questionnaire 67 Bibliography 69 xv
  • 6. 1. INTRODUCTIONT HIS STUDY WAS conducted between Laguna Honda and San Francisco General — January and August 1995, and its are housed in 19th-century or early-20th-centu- goal was to investigate the use and ry pavilion-style buildings where open spacespossible benefits of gardens in hospitals by between wings have been landscaped and devel-evaluating a number of case studies. Its intent oped as gardens. Both of these hospitals also runwas not to propose theories of how or why on low budgets, serving the needy, and seem tocertain environments are therapeutic, but to make use of everything at their disposal, includ-discover which specific elements and qualities ing the outdoor space. Private hospitals seemedin hospital gardens seem to be — in the users’ more concerned with cosmetic landscaping toeyes — most related to a change of mood. enhance their image but not necessarily to fill This report consists of 12 parts: introduc- the therapeutic needs of patients or staff.tion; literature review; methods; brief histori- As we conducted interviews, we becamecal overview of hospital gardens; a typology of aware, too, of the pivotal importance of onehealth facility outdoor spaces; four case studies person or a few people in creating and makingincluding user-responses; a set of design rec- known the benefits of gardens at specific facili-ommendations based on observations and in- ties. The gardeners at San Francisco Generalterviews; and a conclusion. created the Comfort Garden, a space that Our consciousness regarding this topic was eventually became one of our case study sites.raised as we searched for case study sites. Hos- The director of the hospice at Laguna Hondapital architects we contacted knew of few such Hospital was responsible for promoting theexamples. When we started to visit hospitals, development of a garden in a formerly emptywe were surprised to find few that had outdoor courtyard. (The timing of the installation ofspaces, and where we found some that did, the this garden precluded our selecting it as a casestaff at the information desk frequently had no study.) Nurses at California Pacific Gardenknowledge of the garden or its location. Thus, Campus were responsible for encouragingearly on we sensed that this was a type of space long-term care patients and their families tothat is considered unimportant in the contem- use the garden.porary medical center. We are convinced that with more persua- In all, we looked at 24 hospitals, almost all of sive information as to their benefits, manythem in Northern California. From this admit- more hospital administrators and medical stafftedly small sample we sensed that public hospi- would encourage the use of outdoor spaces fortals are more aware of and supportive of gardens healing and stress reduction. We hope this re-in their environment than are private hospitals. port will be one tool in raising consciousnessTwo public hospitals in San Francisco — in this important area. x1
  • 7. 2. REVIEW OF RELEVANT RESEARCHT HE THEORETICAL UNDERPINNINGS of 1990). These psychological changes are often this project arise from four differing reflected in both short- and long-term changes bodies of research on emotional re- in functioning and behavior (R. Greenway,sponse to the natural environment: (1) viewing 1990, 1993). A fourth area of research looks atnatural scenes; (2) horticultural therapy, or where people go outdoors when emotionallyworking in a natural setting; (3) the experience upset. Two studies in which people were askedof simply being in a natural wilderness; and (4) what kind of place they went to when feelingoutdoor environments chosen by people as troubled, upset, or in grief revealed that naturalstress-reducing settings. There is a consider- settings were predominantly cited (Francis andable range of research where subjects in a labo- Cooper Marcus, 1991, 1992). A further studyratory setting evaluate pictures of natural related the process of emotional change to spe-scenes after a stressful experience and are then cific qualities of the outdoor environmenttested for emotional and physiological recov- (Barnes, 1994).ery. These studies indicate that the presence of Though there are many studies evaluatingnatural greenery in a scene has a high correla- the success of housing schemes, there are manytion with stress reduction (R. Ulrich, 1979, fewer of healthcare facilities, and almost none1984, 1986; M. Honeyman, 1987; T. Hartig et of hospital gardens. The one exception of theal., 1990). latter is a Master of Landscape Architecture One significant study monitored hospital- thesis by Robert Paine (University of Califor-patient recovery when looking out at vegeta- nia, Berkeley, 1984), which was re-written andtion as opposed to buildings, and found that summarized in the book People Places (Francisthose with a view to nature recovered more and Paine, 1990). Also important to mention isquickly (Ulrich, 1984). The second body of the tireless work by designer Vince Healy inwork reveals that participants in gardening ac- promoting the inclusion of gardens in hospicetivities report positive mood shifts. “Nature facilities (Healy, unpublished).fascination,” sensory joy, peacefulness, and Given the existing research on nature-as-tranquillity receive the highest ratings from the healer and the garden/gardening experience, itparticipants (R. Kaplan, 1973, 1983). Third, is clear that the need for more documented,there is documentation of the influence of nat- empirical research on gardens in healthcare fa-ural wilderness use, where people are asked to cilities is critical. Case study evaluations of ex-evaluate a place-experience. This research indi- isting outdoor sites and their therapeutic usescates that marked psychological benefits arise need to be conducted to enable the develop-from being in a natural environment (Kaplan ment of appropriate and specific design recom-and Talbot, 1983; R. Kimball, 1983; A. Ewert, mendations.2 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 8. 3. METHODSD ESIGNED TO MEET the need for prelim- SCALE: Map 3–1: ➝ inary empirical data and applicable de- 0 50 100 150 200 The Comfort sign recommendations, this research LEGEND: N Garden, = Locations San Franciscoproject undertook the documentation and General Hospital,analysis of exterior hospital gardens and their Context Mappossible therapeutic benefits. For a number ofreasons this study must be described as ex- TREET 22nd Sploratory rather than definitive. First, there areno strictly comparable studies in the published EWAYliterature, so there was no groundwork to draw T ONT Son; and the necessity for breadth required by the E 101 FRE RO AVdiscovery process precluded the exhaustive con-trol of variables. Second, the time span of the VERM POTREproject itself (January–August 1995) was verybrief. Third, inordinate bureaucratic hurdlesand wet and cold weather into May delayed thefieldwork. Hence, the bulk of the work — ob-servations, interviews, site and statistical analysis REET 23rd ST— was carried out in a shorter time frame thanwas initially anticipated. case study — resulted in minimal use of the garden. It is reported as a descriptive ratherSites than an evaluative case study (see Map 3– 4).The central focus of this research is on case Canvassing potential research sites revealedstudies of four hospitals in the San Francisco that there are actually very few healthcare facili-Bay area. Additionally, observations at 13 ties that have gardens that are utilized. This wasother hospitals in Northern California and at surprising, especially in a part of the worldone in England were incorporated into the where the climate could hardly be more con-study. The three primary case study sites were ducive to outdoor activities. However, four sitesSan Francisco General Hospital in San Fran- were found that met the stated goal of attainingcisco (see Map 3–1); Alta Bates Medical Cen- variation among the patient population types.ter in Berkeley (see Map 3–2); and KaiserPermanente Medical Center in Walnut Creek • San Francisco General Hospital’s Comfort(see Map 3–3). Extensive remodeling at Cali- Garden encompasses the entry and lawnfornia Pacific Medical Center Garden Campus area outside an outpatient medical buildingin San Francisco — intended as our fourth (see Map 3–1). x3
  • 9. • The roof garden at Alta Bates mates within the garden; (5) sensory qualities; ASH BY AVE Medical Center is adjacent to (6) opportunities for social interaction; (7) op- the maternity ward (see Map portunities for privacy; and (8) aesthetic and 3–2). spatial elements. WE BST ER • Kaiser Permanente’s central The behavioral observation data focused on EN T garden is bordered by both in- who used the space and what they used it for. patient and outpatient facilities This data revealed patterns of use that were REG LBY and by the cafeteria (see Map analyzed to understand: (1) traffic flow; (2) CO 3–3). user activities; (3) gender and age distribu- ➝SCALE: • California Pacific Medical tions; and (4) user type (patient, staff, visitor).0 50LEGEND: 100 150 200 N Center’s garden serves all of Each site was observed, and its uses record- = Locations the long-term-care patients in ed, for a total of eight hours: 11am–1pm and residence there (see Map 3–4). 1–3pm divided between two weekdays and twoMap 3–2: However, due to various hospital policies and weekend days. Each session was divided intoThe Roof Garden, six 20-minute observation periods. To record construction projects, the results presented areAlta Bates MedicalCenter, Context not necessarily typical of facilities within their the frequency of uses, if a given individual’sMap respective patient population types. (See discus- stay in the garden spanned one of the transi- sions in the individual case study accounts.) tions between the 20-minute observation peri- ods, his or her activities were recorded more Data Collection than once. (A person playing on the lawn for In order to begin to understand the people- 25 minutes, for example, would be recorded as place transactions that occur in these types of two user-observations.) environments, a multimethod approach was During the 32 hours of observations at all of employed, incorporating visual analysis of the the sites, a total of 2140 user-observations were physical site, systematic nonintrusive behav- recorded: 139 at Garden Campus, 154 at Alta ioral observation, and information gathering Bates, 596 at San Francisco General, and 1251 atMap 3–3: through interviews. Kaiser Walnut Creek. The recordings at SanThe Central The visual physical analysis of the site incor- Francisco General and Kaiser Walnut Creek un-Garden, Kaiser derrepresent the number of people passing porated: (1) mapping of the physical designPermanente through the space, as the frequency of use ex-Walnut Creek, features; (2) circulation and orientation; (3)Context Map views into and out of the garden; (4) microcli- ceeded the human limitations of accurate record- ing. The fluctuation of activity levels at these two sites created periods during which it was impos- RI IFO ➝ AVE . sible for one researcher to record all of the activi- CAL LL NEWE ty. Note, however, that the people missed were N the people moving through the space, and that this population was subsequently found to be less AIN significant in this study than stationary users. H M The user interviews explored what people SOUT liked about the space, what effects they felt it had on their psychological well-being, which qualities and characteristics of the garden they identified as contributing to their well-being, SCALE: impediments to use of the garden, and recom- 0 50 100 150 200 LEGEND: mended improvements to the garden. (See the = Locations: 68 questionnaire in the Appendix.) 0F RE EW Some questions, such as “How often do you AY Y C WA come here?” were pre-coded into ordered cat- LILA egories: my first time; occasionally/sometimes; once or twice a week; every day; several times a day. Others were pre-coded according to in- 4 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 10. formation that had emerged from the system- first was designed into the program, as it wasatic observations of use during behavior map- anticipated that due to the length of the inter-ping. For instance, when asking “What do you view, approaching people who were movinggenerally do out here?” the interviewer read through the space would be problematic.out 10 options and the interviewees were Thus, all of the interviews were conductedasked to indicate which activities applied to with stationary users and the responses ofthem, and to add any others not listed. How- those passing through were not captured.ever, the bulk of the questions were open- Another limitation was discovered duringended, allowing the interviewees to respond in the course of the study. Although all individu-their own words, and necessitating content als were approached, it was noted that individ-analysis of responses during the analysis phase. uals in some locations were more likely toThese were questions such as “What do you refuse to participate than individuals in otherlike best about this place?” and “Do you feel locations. Those less likely to participate tend-any different after you’ve spent time in the ed to be in the most secluded seating” Questions were asked in this way be- Twelve hours were devoted to interviewingcause there is no prior research that would at each site. It was hoped that 50 individualssuggest what an exhaustive range of responses could be interviewed in this time span. Thismight be. was achieved at San Francisco General Hospi- When addressing people’s feelings or tal and Kaiser Walnut Creek. Slightly fewerchange of mood, three approaches appear in (37) were interviewed at Alta Bates because ofthe literature, each with a different level of reli- relatively light usage, and very few (7) were in-ability. The most accurate is monitoring physi- terviewed at Garden Campus because of build-ological changes as an indicator of emotional ing renovation and hospital downsizing duringshifts (galvanic skin response, blood pressure, the course of the study. Although the drop inheart rate, etc.). Self-reports are considered use at Garden Campus prohibits any statisticalsecond in reliability, with the third, behavior analysis at this site, it is reported with the caseobservation, seldom used due to the extremely studies due to its value as a description of ahigh level of interpretation required. This long-term care drew upon self-reports because the needfor a breadth of information and the fact thatthe cost and time limitations of monitoring Analysisphysiological responses on hundreds of sub- The behavioral observation data were tabulat-jects precluded the use of this more reliable ed and prevalence estimates were established Map 3–4:recording of mood change. for each site and for the aggregate analysis of The Garden, Although self-reports lead some subjects to the combined sites. The open-ended narrative California Pacificanswer in a way that they think is pleasing to interview questions were analyzed for content Medical Centerthe interviewer, the overall reliability of this clusters. For example, in analyzing the re- Garden Campus, Context Mapmethod is nonetheless acceptable. Questions sponses to what people liked best about theon other topics relied on self-report because it garden, the two researchers scanned Ewas the only way to access the information. For the range of answers, then read LUPIN SCALEexample, the only way to learn what people like each response and assigned it to an 0 50 100 150 200 : LEGENDbest about a particular garden is to ask them. appropriate category. In analyzing = Locations The interview consisted of 25 questions and the question about a change oftook approximately 15–20 minutes. The inter- mood, the selection of categories SONviews were all conducted by the same person. drew upon the work of Russell and ➝ WOOD EMERAt each hospital the interviewer made a con- Snodgrass (1987). Emotional re- Ntinual circuit through the garden so that the sponses were clustered into thoseentire site was canvassed. At the end of one in- that indicated a rise in energy levelterview, the next stationary person on the (felt rejuvenated, stronger) and D. Y BLV“route” was approached. Two limitations of those that indicated a drop in ener- GEARthis sampling procedure should be noted. The gy level (felt calmer, more relaxed). Methods x 5
  • 11. Three additional categories were developed lieve these data do provide results that are anin order to incorporate the full range of re- initial step in pursuing this line of inquiry.sponses recorded: those that indicated a cogni- Recommendations have been formulated fortive shift (find answers, think things through); use in guiding the design of future gardens thatthose that indicated a spiritual or religious are attached to healthcare facilities. These rec-connection; and a residual category of those ommendations have been worded to be immedi-responses that were less definitive (felt better, ately usable by clients and professionals in thepleased). planning and creation of the next generation of Descriptive results of the observations and therapeutic outdoor environments.interviews were presented both in the context Overall, there are pros and cons to theof the individual case study and in the aggre- methodology adopted. Among the advantagesgate data analysis chapter. Comparative analy- — given its exploratory nature — are theses were performed on the aggregate interview breadth of data gathered, the intersection ofdata, and noteworthy associations were report- data from observation and interviews, the rich-ed. Several of the interview questions allowed ness provided by open-ended questions, andfor more than one response. This allowed for a the depth of researcher understanding via indiscussion in terms of both the number of re- situ data collection. Disadvantages include lackspondents and the number of responses. The of experimental control of the interview envi-associations made enable the comparative eval- ronment, possible interviewee bias in self-re-uation of the perceived beneficial effects of the ports, lack of a temporal perspective, absencegarden on the user’s psychological health, and of data from nonusers, and a relatively highthe connections drawn by each, to the various degree of analytical interpretation (e.g., con-relevant aspects of the garden. While rigorous tent analysis of open-ended questions).statistical analyses were not appropriate, we be-6 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 12. 4. HISTORICAL OVERVIEW OF THE PROVISION OF OUTDOOR GARDENS IN MEDICAL SETTINGSW HILE THE MAIN focus of this re- fulness, and the invalid himself with eyes, ears, port is to look at the use and and nostrils, drinks in the delights of colors, meaning of outdoor gardens in songs, and perfumes. (Quoted in Warner, p. 80)contemporary hospitals, it is important to During the 14th and 15th centuries, a num-place this account in historical context. We are ber of trends combined to render a decline ingrateful to Sam Bass Warner Jr., who kindly the monastic provision of medical care: Period-allowed us to read and quote from his unpub- ic plagues, crop failures, waves of migrationlished paper, “Restorative Gardens: Recover- into burgeoning cities overwhelmed the facili-ing Some Human Wisdom for Modern ties that existed. According to Warner, with theDesign.” This brief overview owes much to his decline of monasticism itself the significance ofwork, as well as to a major published work by the meditative/restorative garden declined, andJohn D. Thompson and Grace Goldin, The open spaces attached to hospitals became acci-Hospital: A Social and Architectural History dents of local architectural tradition, if they ex-(New Haven: Yale University Press, 1975). isted at all (Warner, pp. 7–8). The care of the The first flowering of restorative gardens in sick fell upon civic and ecclesiastical authorities,Europe occurred during the Middle Ages and within the Roman Catholic tradition, onewhen hospitals and monasteries ministering to of the primary design incentives was to createthe sick, the insane, and the infirm often in- long wards where the priest celebrating Masscorporated an arcaded courtyard where resi- could be viewed from every bed. The influen-dents could find the degree of shelter, sun, or tial Ospedale Maggiore in Milan (1458), for ex-shade they desired in a human-scale, enclosed ample, was built in a cruciform plan like asetting. St. Bernard (1090–1153) wrote of the church nave with windows so high that no oneintentions at his hospice in Clairvaux, France; could see the formal gardens outside (Thomp-his account of its sensory delights has some re- son and Goldin, p. 31).markable parallels with the self-reported bene- Nevertheless, some hospitals did continuefits of gardens as conveyed to us by late-20th- the courtyard tradition. Les Invalides in Pariscentury users in California. (1671) incorporated a number of courts plant- ed with rows of trees. The English hospital Within this enclosure many and various trees ... and prison reformer John Howard (1726– make a veritable grove. ... The sick man sits upon the green lawn ... he is secure, hidden, 1790) described gardens for patients in hospi- shaded from the heat of the day...; for the com- tals in Marseilles, Pisa, Constantinople, Tri- fort of his pain, all kinds of grass are fragrant in este, Vienna, and Florence. “In all these his nostrils. The lovely green of herb and tree hospitals he admired the flow of fresh air, the nourishes his eyes. ... The choir of painted birds chance for patients to see gardens through caresses his ears ... the earth breathes with fruit- their windows and doorways and the opportu- x7
  • 13. nity for convalescent patients to walk in the The influential nurse and public health re-gardens” (Warner, p. 18). former Florence Nightingale (1820–1910) In the 17th and 18th centuries, the dual wrote with enthusiasm of these new hygienicemergence of scientific medicine and Romanti- hospital plans:cism fortuitously combined to encourage there-emergence of usable outdoor spaces in hos- Second only to fresh air ... I should be inclined topitals. The notion that infections were spread rank light in importance for the sick. Direct sun-by noxious vapors spawned designs that paid light, not only daylight, is necessary for speedy recovery. ... I mention from experience, as quitespecial attention to hygiene, fresh air, and perceptible in promoting recovery, the beingcross-ventilation. The so-called pavilion hospi- able to see out of a window, instead of lookingtal became the predominant form throughout against a dead wall; the bright colors of flowers;the 19th century. Two- and three-story build- the being able to read in bed by the light of theings linked by a continuous colonnade and ven- window close to the bed-head. It is generally saidtilated with large windows marked the design of the effect is upon the mind. Perhaps so, but it isthe influential Royal Naval Hospital at Ply- not less so upon the body on that account.mouth, England. The medieval Hotel Dieu in (Quoted in Warner, p. 24.)Paris was rebuilt with a series of 24-bed wardsjoined together at their ends by a service corri- Good nursing practice by the end of thedor, like the teeth of a comb (Warner, p. 23). 19th century and in the first decades of theThese new designs incorporated outdoor spaces 20th century called for wheeling hospital bedsbetween the pavilion wards, while the rise of out onto sun porches and roofs, and indeed inRomanticism prompted a reconsideration of the treatment of tuberculosis, this fresh airthe role of nature in bodily and spiritual and sunlight regimen was seen as the key torestoration. recovery. In the Catholic hospital St. Mary’s, Recommendations for hospital garden de- in San Francisco, photos in a corridor depictsign written by German horticultural theorist rows of patients in beds on the trellised roofChristian Cay Lorenz Hirschfeld at the end of garden. All that is now left of this space is athe 18th century uncannily foreshadow the decaying segment of roof with a few flowerfindings of researchers such as Roger Ulrich at boxes where staff retreat for a quick cigaretteTexas A & M University, who documented in study the healing benefits of a view onto The late 18th and early 19th centuries alsovegetation for patients recovering from saw radical reforms in the treatment of psy-surgery (Ulrich, 1984). chiatric patients and in the design of psychi- atric hospitals. Psychological nurturance A hospital should lie open, not encased by high began to replace physical punishment as the walls. The garden should be directly connected to the hospital, or even more so, surround it. Because core of treatment. New asylums were laid out a view from the window into blooming and happy with peripheral grounds and plantings to pro- scenes will invigorate the patient, also a nearby tect the patients from curious onlookers; garden encourages patients to take a walk. ... The landscape vistas were created to provide ther- plantings, therefore, should wind along dry paths, apeutic experiences; and grounds mainte- which offer benches and chairs. ... A hospital gar- nance, gardening, and farming became den should have everything to enjoy nature and to intrinsic components of the therapeutic regi- promote a healthy life. It should help forget weak- men (Warner, pp. 30–37). ness and worries, and encourage a positive out- In the 20th century, understanding of germ look. ... The spaces between could have beautiful theory, rapid advances in medical science, lawns and colorful flower beds. ... Noisy brooks could run through flowery fields, and happy wa- technical advances in high-rise construction terfalls could reach your ear through shadowy and the use of elevators, and increasing de- bushes. Many plants with strengthening aromas mands for cost-effective efficiency led to the could be grouped together. Many singing birds replacement of low-rise pavilion hospitals with will be attracted by the shade, peace, and freedom. multistory medical complexes. As Warner de- And their songs will rejoice many weak hearts. scribes this trend:8 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 14. In acute care hospitals, the design emphasis ments that might contribute to the restoration shifted towards saving steps for physicians and of health. By the 1990s, insurance companies nurses, and away from attention to the environ- and hospital administrators competing in the ments the patients experienced. Gardens disap- burgeoning “healthcare industry” have gener- peared, balconies and roofs and solaria were ated hospitals that resemble hotels or even re- abandoned, and landscaping turned into en- sorts, with elaborate entryway landscaping, trance beautification, tennis courts for the staff, plush foyers, art-filled corridors, and private and parking lots for employees and visitors. These trends which so captured the twentieth rooms. The restaurant in Monterey Communi- century American acute care hospitals spread, ty Hospital with domed skylight, interior koi after World War II, by the processes of fashion pool, and rattan furniture is so attractive that to long term and chronic care facilities, to the local business people go there for lunch. hospitals of the Veterans Administration, to Land costs and pressure from insurance mental hospitals, and to nursing homes. The companies to minimize hospital stays have prestige of the big city teaching hospitals with largely worked against the provision of gar- their gardenless patient environments set the dens in these new or refurbished medical com- styles for all the others. plexes. “Landscaping” is often seen as a In one type of hospital — catering to long- cosmetic extra — important to set the rightterm care of chronic illnesses — the garden image at the hospital entrance or in setbackwas not lost. The profession of occupational from adjacent streets, but rarely viewed as atherapy was established in the early decades of significant adjunct to patient healing or as athis century, extending a practice previously setting for stress reduction for staff and visi-limited to psychiatric patients into the rehabil- tors. Ironically, when suitable garden spacesitation of patients with physical problems. do exist, inquiries at the information desk areAfter World War I, garden work entered the often met with blank stares or an outright “Noarena in rehabilitation hospitals; after World — we don’t have a garden here.” No hospitalWar II, horticultural therapy programs with in this study provided any graphic directionsspecial-purpose garden facilities began to be to such a facility, or printed information forprovided in hospitals for veterans, the elderly, new patients. It seems as though the hospitaland the mentally ill. With rising mortality garden in late-20th-century America has be-rates from AIDS and cancer, the hospice facil- come an invisible and ignored amenity, andity has become more familiar in U.S. cities. the possible restorative benefits lost in theThese, too, have recognized the therapeutic world of high-tech machines, high-cost drugs,effect of the garden. In the specialized facili- and increasing medical specialization.ties known as Ronald MacDonald Houses, for The forgotten garden in today’s medicalchildren with cancer and their families, a arena might be thought of as analogous to thehomelike environment and adjacent garden is ignored psyche and spirit in the treatment ofthe norm. illness. The value of a garden and the role of By the 1970s, general acute-care hospitals the psyche in healing are both difficult tohad come to resemble air-conditioned office quantify or prove. But just as alternative orbuildings where the outdoor experience of complementary medicine is beginning to re-most patients and staff was confined to the examine the intricacies of the mind-body con-walk from the parking lot to the main entrance. nection, so also are the design professionsA few had garden and courtyard spaces but al- beginning to rediscover the therapeutic possi-most never were these perceived as environ- bilities of sensitive garden design. Historical Overview of the Provision of Outdoor Gardens in Medieval Settings x 9
  • 15. 5. TYPOLOGY OF OUTDOOR SPACES PROVIDED IN HEALTHCARE FACILITIEST HIS SECTION PROVIDES an overview of Photo 5–1: the different types of outdoor spaces A lake, landscaped grounds, and observed in hospitals visited during wildlife form athe study period (January–August 1995). With complete contrast tofew exceptions, these were all in Northern Cal- the hospital interi-ifornia. A definition of each type of outdoor or, provide inter-space is followed by one or two examples of ac- est, stimulate thetual places visited, observed, and critiqued in senses, and draw patients, staff, andterms of their location and design. Each garden townspeople out-was visited for 30 to 60 minutes. Photographs doors. A universal-were taken and a description of the setting and ly accessible loopits apparent use was written in situ. All these Advantages path supports en-visits were made on weekdays between 11 am joyment by people • Can tie together a variety of buildings — by with a range ofand 2 pm, during warm weather. This proved function, style, or age — into a campus-like abilities. Conserva-to be most useful, as these observations ex- setting tories at the end ofpanded the understanding of hospital outdoor • Can serve a variety of users and activities wards offer viewsspace and informed the kinds of design recom- Disadvantages to the lake. (St.mendations presented at the end of this report. Mary’s Hospital, • Maintenance may be costly Newport, Isle of Wight, England) St. Mary’s Hospital, Newport, Isle of1. Landscaped Grounds Wight, EnglandThis type of open space consists of a landscaped When a new hospital building was added to thisarea at grade that forms an outdoor area be- 19th-century medical complex, the designerstween buildings. It is often used as a walking proposed a redesign of the central outdoorroute between buildings; a setting for eating or space. It is a spacious area and contains a lakewaiting; and as a space for ambulatory patients filling a depression where building materials foror those using wheelchairs. This is the most the original Poor Law Hospital were quarried.spacious type of outdoor area reported in this The area around the lake was re-landscapedtypology, and is sometimes described by users with lawns, paths, seating, new trees, twoas “a park” or “a campus,” and is often the hub bridges, and two “pads” for the eventual loca-of the hospital complex. One good example is at tion of gazebos. It is used by outpatients waitingKaiser Permanente Walnut Creek, described in for appointments; by staff walking between de-detail in the case study section of this report. partments; by visitors or volunteers pushingAnother good example is described below. wheelchair-bound patients; and by townspeople x 11
  • 16. as a park where children are brought to feed the few trees and small flower beds. Larger streetducks and watch a family of swans who have trees cast shade on parts of the lawn. There aretaken up residence on the lake. It is a very at- no pathways, seats, litter containers, or othertractive, naturalistic space and is as different cues to suggest this might be used. This is thefrom an interior hospital environment as any only green outdoor space at this facility, andnearby space could be (see Photo 5–1). Obvi- might well be used if it were designed appro-ously the provision of such a space is a rarity priately. Ironically, on the opposite side of thisgiven the urban locations of most hospitals. building is a paved plaza, over-provided with St. Mary’s is able to incorporate this park- benches, and with none of the “green” and col-like setting because it is located on a spacious orful image provided by this Dwight Way set-site on the edge of a small country town. The back (see description on page 16).Kaiser Permanente facility at Walnut Creek isable to provide such a milieu (though much 3. The Front Porchsmaller than St. Mary’s) because two “her- Most hospitals have some features at the mainitage oaks” in the center of its property are entrance that are analogous to the front porchprotected and a much-used and well-liked of a house. These might include an overhanggarden area was developed around these ven- or porch roof, a turnaround for vehicle pickuperable trees. and drop-off, seats, directional signs, a post box, phone, bus stop, and so on.2. Landscaped Setback AdvantagesA landscaped setback is an area in front of the • Provides visual cue to main entrancemain entrance to a medical center, usually • Overhang may scale down size of buildingcomprising lawns and trees. This is a space • Sensitively located seating provides amenity forakin to the front yard of a house — to provide those waiting to be picked up or waiting for busa buffer-separation between the building and Disadvantagesthe street. Also, like a house front yard, this • May be overused if it is only outdoor seatingspace is not usually intended for use, but to area providedprovide a visually pleasing setting on ap- • May be under-used if main access to hospi-proaching the entrance. tal is via parking under buildingAdvantages• May evoke a familiar, comforting image at a Main Entry, Alta Bates Medical Center, hospital entrance Ashby Campus, Berkeley, California• Provides offices or rooms at the front of The front porch seating at this medium-sized building with some privacy community hospital is sensitively located just toDisadvantages one side of the main entrance, where there is a• While not usually intended for use, if this is lushly planted “eddy” space. People passing the only outdoor space, its lack of seating, back and forth on the adjacent sidewalk, or pathways, etc. may be frustrating for staff or walking in and out of the hospital, go by this visitors who want to use it small seating area, but do not go through it. Hence, people seated here — as if in an eddyMain Entry, Alta Bates Medical Center, off the mainstream — experience some degreeHerrick Campus, Berkeley, California of seclusion, yet can easily see if a taxi or aThe four-story stucco buildings of Alta Bates friend’s car arrives. The seating is in the formHerrick Campus face onto the busy street of of comfortable, wooden garden benches withDwight Way, a few blocks from downtown backs. “No smoking” signs ensure that non-Berkeley. A wide flight of brick steps with smokers will not be bothered by one of the fre-planters full of flowers leads up to the main en- quent uses of spaces just outside of entrances totrance. On either side of the steps an area of hospitals (and office buildings, campus build-lawn, facing south, about 25 feet deep, provides ings, etc.), that is, employees coming out for aa setback for the building. It is punctuated by a quick smoke break.12 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 17. Main Entry, John Muir Medical Center, hillsides covered with native trees and theWalnut Creek, California more distant slopes of Mt. Tamalpais. It has aA very large portico overhang clearly marks the quiet, green, parklike feeling. Nine large palmmain entrance to this medium-sized suburban trees border a small circular seating, as you approach it from one of the Around this are lawns, ivy-covered slopes, andmany surrounding parking lots. A semicircular a flower bed with every species neatly labeled.roadway loops under the portico to allow drop- Two other benches, up-slope from the circle,off and pickup at the front door. Two wooden offer a more sunny location. From the circlepark benches with backs are located on either seating, nearby parking is barely visible, andside of the entrance, facing the roadway. traffic on a street that gives access to the hos- Since a public bus route serves this hospi- pital is heard only intermittently. Due to atal, and people are being picked up by car or steeply sloped site and the configuration of thetaxi, the location of the seating is appropriate. buildings, this is the only outdoor space atHowever, the entry faces west and summer Marin General, and it appears to serve its pur-temperatures are often in the high 90s. None pose well.of the seating areas has any shade; all lookonto the glare of the adjacent road, sidewalk, 5. Courtyardand parking lots and receive the reflected heat This is a space that forms the “core” of afrom the building walls. Seating in the air- building complex like the hole in a doughnut.conditioned foyer is not close enough to the Ideally, this should be immediately visible orentrance to see when a bus or other vehicle is apparent on entering the hospital so that visi-arriving. Attention to site planning, planting, tors and patients know that it is there. When aor the creation of roofed shelters would have cafeteria occupies one or more sides of therendered this a more successful front porch. courtyard, it could function as an outdoor eat- ing place. Trees for shade, flowers for color, a4. Entry Garden water feature for pleasing auditory relief, andThis is a landscaped area close to a hospital en- movable seating are “basics” for such a space.trance that, unlike a “front porch,” is a green Advantagesspace with a garden image, and unlike a “land- • Semi-private and secure; surrounded byscaped setback,” is designed and detailed for use. hospital buildingsAdvantages • Depending on location, may be easily• Visible and accessible viewed and accessed• Makes positive use of part of site that might • Shielded from wind; buildings likely to pro- otherwise have been paved for parking vide shade• Provides a pleasing image on entering hos- • Likely to be of human scale pital environment Disadvantages• Allows use by ambulatory patients who want • Depending on its size and location, may to see a little “action” near the main entrance create a “fishbowl” experience for thoseDisadvantages using it• Without sensitive planting, may be too ex- • If too small to include adequate buffer posed to nearby parking and entry road planting, adjacent rooms may need to keep blinds drawn for privacyMain Entrance, Marin General Hospital,Greenbrae, California Cafeteria Courtyard, Novato CommunityEast of the main entrance to this medium- Hospital, Novato, Californiasized community hospital is a landscaped area This is a small, one-story community hospitalwith mature palms, live oaks, and eucalyptus, in a residential district of a small town. Theand paths zigzagging up to an upper parking courtyard is immediately visible on enteringlot. The trees screen out much of the hospital the hospital. On one side is the main corridorbuilding; the views out from this area are of with the Admitting/Registration Desk; on a Typology of Outdoor Spaces Provided in Contemporary Healthcare Facilities x 13
  • 18. second side is the cafeteria. The courtyard is trees, and in a few other locations, are simpleaccessed via sliding glass doors from both of wooden picnic tables with movable benches,these public and well-used spaces. The other popular with groups of two or more who carrytwo sides are administrative offices with win- food out from the nearby cafeteria. Duringdows that look into the courtyard; the win- peak-use hours, some of these tables are indows usually have their blinds drawn. deep shade, some in dappled shade, and some The courtyard is small, approximately 40 x in full sun — providing plenty of choice de-40 feet. In one corner, the one sizable tree in pending on people’s tolerance for the sun.the space shades a 9 x 9-foot pool with a central Since summers in Santa Rosa can be very hot,low fountain jet. The space is furnished with the provision of shade is essential. On the op-round tables shaded by umbrellas, lightweight posite, long side of the court are three sets ofmovable chairs, and three garden benches near wooden garden seats with upholstered cush-the pool. Color is provided by warm brick ions — each set is a pair of chairs, with a smallpaving, some evergreen shrubs, a Japanese table between and an adjustable umbrella over-maple, and flower boxes of petunias and impa- head. These are very popular and are in usetiens bordering the pool. The overall ambience both before and after the lunch-time users haveis of a restful urban patio. The only aesthetical- left the picnic tables. Benches are often movedly jarring elements are three large, humming from one of the picnic tables so that users ofvending machines against one wall and three these padded chairs — reading, eating, chat-newspaper vending machines. However, the ting, smoking — can sit with their feet up.former do offer a service for visitors and staff This courtyard has been planted with greatsince the cafeteria is only open at certain times. sensitivity. The maples provide needed shadeWaiting for a relative who is in surgery; taking and — not incidentally — attract a lot of birds,a coffee break; doing some paperwork away whose songs and chirping provide soothingfrom the office; eating lunch with colleagues — background sounds. Planters beneath thethis courtyard offers many users of this hospital maples and along the edges of the court area quiet outdoor respite (see Photo 11–5). filled with flowers; baskets of flowers hang from the roof of the half-open corridor. TwoLinnaeus Physik Garden, Santa Rosa of the three entries to the courtyard are downCommunity Hospital, Santa Rosa, California flights of six steps; beside these are overflow-The Linnaeus Physik Garden at Santa Rosa ing planters of star jasmine, so one’s entranceCommunity Hospital is a good example of into this space is marked by strong scent. Else-what can be done in a long, narrow, leftover where in the plaza, star jasmine climbs thespace in the midst of a medical complex of old walls of the adjacent building so that all theand new buildings. It is bounded on three upholstered seating areas are “perfumed.”sides by older, two-story hospital buildings, This court was dedicated as the Linnaeusand on the fourth side by a half-open corridor Physik Garden in 1986, when the hospital aux-providing access to administrative offices. It is iliary installed six planters along the two longnot near the main hospital entrance, nor are sides of space filled with medicinal herbs andthere any directional signs indicating its loca- plants from Central and South America, Eu-tion. However, on approaching the cafeteria, it rope, North America, Africa, India, and glimpsed through corridor windows. The negative features of this space are the The courtyard is approximately 40 feet wide view at one narrow end onto dumpsters andand 120 feet long. The dominant aesthetic ef- storage bins, and the ever-present sound of air-fect is provided by five, two-story-high maple conditioning units attached to adjacent windowstrees arranged in a line along one long edge of that block out the sounds of a small cornerthe court. Under each is a raised planter of fountain for all but those sitting quite close to bordered by a square bench. These The black asphalt surface of this court is not es-provide seating places with a variety of views pecially pleasing, particularly where the roots ofand varying degrees of shade. Between the maples have caused cracks and uneven seg-14 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 19. ments. Warm brick paving would certainly have courtyards. These trees move in a breeze andbeen aesthetically preferable. their leaves make a soothing, rustling sound. One oversight is a public address or beeper sys-Medical Building Courtyards, Kaiser tem that would allow people waiting for an ap-Permanente Medical Center, Vallejo, pointment to spend time in the courtyard.California As attractive as these courtyards are, our im-Three rectangular courtyards are bounded by pression is that they are quite underused. Werethe two-story buildings of a new outpatient fa- such spaces located in an inpatient facility, orcility. Three sides of each courtyard are corri- near a cafeteria, we surmise that they would re-dors and waiting areas with floor-to-ceiling ceive greater use and provide greater looking out to the greenery. The fourthside of each is occupied by offices and exami- Children’s Courtyard, Kaiser Permanentenation rooms with an ample boundary of trees Medical Center, Vallejo, Californiaseparating these office windows from anyone Half of this square, 45 x 45 feet courtyard isseated or passing by in the courtyard. Some of taken up with an attractive and well-used chil-the corridors are punctuated by cushioned dren’s maze, constructed of four-foot-highwindow seats allowing patients waiting for ap- wooden walls, topped by thick padding. Chil-pointments to have an even closer view to the dren waiting for pediatric appointments (oroutdoors. The staff at registration desks face their siblings) try to find their way out of theout across the corridors, and they also have maze, climb over its walls, chase each othergood views to the courtyard. around the perimeter paths, romp on the lawn Although each courtyard is unique, they all (which makes up the other half of the court),have certain common elements: pathways of or climb the sturdy live oak tree. They are eas-concrete pavers; geometrically shaped areas of ily visible to their parents in the waiting areas,lawn; low boxwood hedges; shrubs in very large but any noise that they make is not audibleterra cotta planters; long lines of trees (cherries from inside. This is an excellent use of a smalland ornamental pears in one, Lombardy space, allowing children to let off steam in apoplars in another); comfortable wooden gar- hospital environment (see Photo 11–1).den benches and individual garden chairs withbacks and armrests. Though these features arerepeated, other elements are unique to each 6. Plazacourtyard. One has a circle of poplar trees, a Plaza spaces in hospitals are outdoor areas, fur-semicircular, seat-height wall feature, and is nished for use, and predominantly hard-surfaced.planted with a grass (clumping hard fescue) that They may include trees, shrubs, or flowers inneed not be mowed and provides a lovely, wavy planters, though the overall image is not of atexture. Another has “beds” of black, river- green space, but of a paved urban plaza.eroded pebbles, a mounded lawn, and a speci-men live oak tree. Two have wooden garden Advantagestables with dark green market umbrellas. • Low plant maintenance and irrigation costs These all represent very successful court- • A small place can be designed for relativelyyard spaces; they are highly visible, easily ac- heavy usecessible, provide choices of seating, include • Patients using wheelchairs, walkers, or crutch-high-quality details (seats, lighting, planters, es may be able to move easily in this spaceetc.), and all provide a true garden experience. DisadvantagesThe only criticism would be that there are al- • May have few of the qualities that peoplemost no flowers and there is limited seasonal perceive as therapeutic in outdoor spaces —color. Interviews at case study sites indicate an overall green and/or colorful setting, athat flowers and color are highly valued in gar- garden or oasis imagedens used for relaxation and stress-reduction. A • May evoke the image of a shopping mall orspecially sensitive aspect of planting was the corporate office plaza rather than a space forchoice of Lombardy poplar in three of the four peaceful, stress-reducing, passive enjoyment Typology of Outdoor Spaces Provided in Contemporary Healthcare Facilities x 15
  • 20. Seating Plaza, Alta Bates Medical Center, 7. Roof TerraceHerrick Campus, Berkeley, California Unlike a roof garden, which is located on top ofThis is an L-shaped seating plaza located out- a building or is usually open on all sides, a roofside the Oncology waiting area. The space can terrace is an accessible outdoor area that isbe entered from one of three doors in the On- bounded on one side by a building and oftencology Department, or via steps and ramp forms a long narrow “balcony” to that building.from Haste Street. It is about four feet above The basics of such a space are plantings; astreet level. Each “arm” of the “L” is approxi- choice of seating types; a choice of seating lo-mately 75 feet long; one is 50 feet wide, and cations with regard to privacy and sun/shade;the other is 25 feet wide. and accessibility/visibility to potential users. The feel of this space is of a highly de- Advantagessigned, probably expensive, but rather cold • Captures space that might otherwise go un-urban plaza. There is a predominance of hard usedsurfaces: travertine paving, now stained by • Potential for expansive viewswater draining from the planters; 12 concrete, Disadvantagesbox-shaped tree planters; the windows and • Depending on location, may be too windy,stucco walls of five-story buildings on three too hot, or too shadedsides; the sloping glazed roof of a below- Promenade, St. Mary’s Hospital,ground waiting area; steel benches; and a row San Francisco, Californiaof seven travertine slabs that tilt up into the This is an excellent example of a roof terrace.plaza and down into the waiting area beneath. First, it is immediately visible through the largeThese latter, in particular, create a disturbing glazed lobby wall opposite the main doors intosense of imbalance in the space, and — unfor- the hospital. Its outer edge is bounded by a longtunately — are reminiscent of tombstones. concrete planter filled with blue agapanthus and The planting in this space does nothing to trailing rosemary. Just inside the terrace is aoffset the overall hard appearance. Twelve long walkway used for strolling and bounded bysmall Japanese maples are delicate and appro- planters with seat-high concrete ledges. Off thepriate to this north-facing space but are com- walkway and forming the most prominent fea-pletely overshadowed by the size of the adjacent tures of the terrace are two brick-paved seatingbuilding and the dominant hard-scape. Eight clusters, bounded by planters filled with shrubssmall pittosporum trees in planters between one and flowers and shaded by pittosporum trees.arm of the plaza and Haste Street also do little The seating, with curved backs, is made of woodto create a green setting. slats and is quite comfortable. It is arranged in right-angled clusters so that three or more peo- The seating here is also unfortunate — six- ple can sit together comfortably and converse.foot-long maroon, steel benches placed be- The overall milieu is of a green and colorfultween the maple trees in planters. Though they urban garden with attractive, semi-private set-are reasonably comfortable to sit on (with backs tings in which to sit, eat lunch, or talk with col-and arms), their size suggests seating for large leagues. The greenery can also be enjoyed bynumbers of strangers at a bus terminal or shop- people working in offices looking out onto theping mall. Considering the stressful nature of terrace. The terrace seating is far enough awaywaiting in an Oncology Department, it would from the windows that the privacy of neitherhave been more appropriate to provide short space is compromised (see Photo 11–3).wooden benches or movable chairs, so that aperson alone, or with a friend, could sit in a Perimeter Terrace, Davies Medicalsemi-private location. The eight benches could, Center, San Francisco, Californiatheoretically, seat 32 people — an obvious This is an unfortunate example of this type ofover-provision in this location. Unfortunately, open space. It wraps around the south and eastsitting alone in such a space evokes a lonely sides of a central high-rise hospital buildingfeeling, with so many empty benches in view. and is accessible by steps and a ramp adjacent16 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 21. • Heating/air-conditioning units often vent on Photo 5–2: roofs, creating an intrusive mechanical sound A roof terrace near • Unless well signed, visitors and patients may the main entrance to this urban med- not know of its existence ical complex is a One example of a roof garden is described disappointing ex- and analyzed in the case study section of this ample of outdoor hospital space. report (Alta Bates Medical Center). There is little color or greenery, the 9. Healing Garden* small trees are out This is a category that includes outdoor or in- of scale with the building, and door garden spaces in hospitals that are specif- the seating is un- ically designated as healing gardens by the comfortable andto the main entrance. Surfaced with cement, administration and/or the designer. sociofugal, discour-this is a stark, glaring space with almost noth- Advantages aging social inter- action. Largeing in it to tempt people to stay. There are a • Users can expect that some thought has bicycle storagenumber of small, poorly maintained trees in been given to creating an environment that lockers bisect theconcrete tubs, completely out of scale with the is therapeutic space and block aspace, or with the size of the building looming • Possibly disruptive activities, such as chil- dramatic view ofabove it. A few round concrete planters with dren playing or groups eating and laughing, downtown Sanseating ledges around them punctuate the will probably not be found in the space Francisco. Patient use from an adja-space but offer little shade and provide seating Disadvantages cent day room isthat is uncomfortable. • Depending on its size, location, and visibili- hampered by the So much more could have been made of ty, some people might feel self-conscious lack of a wind-pro-this space, especially since on its east side it using such a garden tected, transitionalhas a magnificent view of downtown San • If not designated as such, users may be con- space. (Davies fused as to its function Medical Center,Francisco. The relative nonuse of the terrace San Francisco,is confirmed by the fact that the hospital ad- CA) Healing Garden, Oncology Deptartment,ministration has seen fit to place two large Marin General Hospital, Outpatient Medicalround bicycle storage containers in the space Building, Greenbrae, California(see Photo 5–2). This is a small (15 x 25 feet) garden in what otherwise might have been an unused space.8. Roof Garden On one side is a restricted waiting area forThis is an area on top of a hospital building Oncology Radiation, with floor-to-ceilingthat is designed and landscaped for use by pa- glass so that even when not in the garden, ittients, staff, and visitors, and — in some cases forms a pleasing green outlook. Two-story,— for viewing from offices and hospital units. cedar-shingled walls and the windows of sev- eral offices look out and down into this space,Advantages but the feeling while seated in it is not of• Captures space that might otherwise be un- being in a fishbowl because of very lush plant- used ing that seems to surround and enfold you.• Private — unlikely that public would use it The plants — almost all shade-loving — are• Potential for expansive views mostly species that have healing properties.Disadvantages• Exposed to elements: may be more windy * Healing Gardens and Meditation Gardens are identi- than ground level, or enclosed courtyard. fied as separate categories within the garden typology. In general, meditation gardens could be considered a subset• Depending on the growth and height of ad- of healing gardens. A few hospitals studied had gardens jacent buildings, temperatures may be un- that were specifically designated as one of these types. All comfortable (too hot or too cold) of them had plaques identifying and dedicating the space. Typology of Outdoor Spaces Provided in Contemporary Healthcare Facilities x 17
  • 22. The short paths leading to two seating places for people to look down on from above, ratherat either end are made of concrete stepping- than as a setting to enjoy while in the garden.stones set in moss. An unusual water feature In conclusion, the feeling is one of an inte-— a grooved stone channeling a small stream rior, architectural space where plants are useddown into a hollowed rock — provides a for decoration, rather than a garden space thatsoothing sound. This is a very quiet and contrasts with the controlled and sterile interi-soothing space that makes wonderful use of a or medical environment. While an outdoorvery small area in a sensitive way. space design that extends the theme of a build- ing to the outside may be appropriate in someThe Healing Garden, Kaiser Permanente settings (for example, a downtown officeMedical Center, Roseville, California plaza), interviews at other hospital gardens in-This garden is part of a brand-new medical dicate that it is the contrast between “build-center that had only been open two months at ing” and “garden” that people particularlythe time of our visit (August 1995) and is specif- respond to in a medical setting.ically designated as a healing garden. It is rec-tangular in shape, approximately 75 x 120 feetin size. It is completely enclosed, on three sides 10. Meditation Garden This is a small, very quiet, enclosed space specif-by three-story buildings and on the fourth side ically labeled with a plaque as a meditation gar-by a 10-foot-high stucco wall shielding the gar- den by the administration and/or the designer.den from the parking lot beyond. The garden isentered from a — presently — little used corri- Advantagesdor in the main Medical Building. • Provides a space for those in a hospital setting The entry door opens onto a small con- who want to be very quiet and contemplativecrete plaza where seating will eventually be in- • By its name, precludes other, possibly dis-stalled. The most prominent visual feature is a tracting, activities (eating, smoking, etc.)large set of planted terraces stepping up from Disadvantagesa decomposed granite path to the highest • If it is visible from indoor spaces, one mightpoint in the garden, the northeast corner, feel self-conscious, in a fishbowl. It is quitewhere a cork oak is planted on a gravel-based probable that only one person at a timeterrace. The three terraces are planted with might use such a space, depending on its sizeforsythia, white roses, and orange-blossomed • Given its designation, one might feel self-dwarf pomegranate. The slopes are planted conscious about using it for other legitimatewith star jasmine and ivy, and heavily mulched quiet activities that are not meditationwith redwood bark. The flat, central section of (reading, writing)the garden consists of a path looping aroundan area planted with dogwoods, blue turf lily Meditation Garden, Marin General(Liriope muscari), and dwarf periwinkle (Vinca Hospital, Outpatient Medical Building,minor), and punctuated with rocks. Greenbrae, California The garden, of course, is still in its infancy; This is a small (15 x 25 feet) court/garden spaceplants were being put in when we visited, and be- entirely enclosed by two-story cedar-shingledsides one litter container, no garden furniture walls and windows of the building. The gardenhad been installed, and no one was using it. has low planting around its edges, an attractiveGiven the results of the case studies, this garden stone wall, a fountain trickling into a bed ofdoes not presently include many features or qual- black pebbles off-center, and a path of decom-ities that people reported as significant to them posed granite looping around the fountain.for relaxation. For example, the garden is not There are four comfortable wooden benches,very green or lush, nor will it ever be, based on each long enough for two people, though theythe plants selected. It has little visual variety, no do not have backs.auditory element, a limited range of colors, and The small size, greenery, and sound ofthe terraced section seems to have been designed falling water set the stage for what may serve at18 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 23. times as a contemplative space. It is close to the Some of the drawbacks of this garden in-waiting area and is labeled on the entry door as clude: the low hum of an air-conditioning unita Meditation Garden. However, the windows of that competes with the pleasing sound of mov-five offices open onto this garden and in warm ing leaves; benches that have no backs or arm-weather, with windows open, the inevitable rests and which form long right-angledconversations and occasional laughter are intru- arrangements, suggesting socializing rather thansive. There is also something of a “fishbowl” lone contemplation. There is one additionalfeeling while seated in such a small space. short metal bench with back and arms in which sits, incongruously, a green-metal, sculpted frogMeditation Garden, El Camino Hospital, — a whimsical element more suited to a chil-Mountain View, California dren’s garden than to a place of meditation. TheThis new garden in a community hospital was presence of an outdoor porch with tables anddonated by two couples — each of whom had chairs off a staff recreation room at one end oflost a family member and had yearned for the garden is also unfortunate, as the laughtersome place to go and sit quietly while in the and conversation of staff on breaks may conflicthospital setting. The garden is approximately with the need for peace and quiet in the garden.40 x 40 feet and is enclosed by two-story Overall, this is a soothing, quiet milieu thatbuildings on 21⁄2 sides. The entry is from a feels separate from the hospital. Though not farlandscaped walkway through the half side that from the main hospital building and easily ac-is open. The other end not bounded by build- cessible, the garden’s orientation off a path thatings is enclosed by trees and shrubs screening is minimally used is a drawback that has impact-the garden from lawns at the front of the hos- ed its use. Many staff are unaware of its exis-pital and a distant entry road. tence, and patients or visitors are unlikely to The garden is dominated by four large find the garden on their own. The therapeuticweeping willows, which provide a green benefits of such a space could have been en-canopy, the sound of rustling leaves, and mov- hanced with a greater variety of plant materials,ing shadow patterns on the ground. Beneath engaging the eye to explore textures and colorsthe willows are shade-loving shrubs and ferns, while in the garden. Some movable gardenscattered rocks, a dry streambed of pebbles, chairs and paths to quiet, green corners wouldand a Japanese lantern. enable those who want to be completely alone A concrete pathway — wide and smooth and surrounded by nature to enjoy this spaceenough for a wheelchair or gurney — leads more fully.from the garden entry to seating under awooden-roofed gazebo in the center of the 11. Viewing Gardengarden. Lighting in the gazebo and along the With space and budget limitations, some hos-entry path permits use after dark — a thought- pitals incorporate a small garden that cannotful amenity in this area of hot summer nights. be entered but can be viewed from inside theWindows from the Dialysis Unit on one side building.permit views out for the patients and staff in-side. Reflecting glass in these windows creates Advantagesan impression that the garden is larger than it • Green space in a small areais and eliminates the feeling of being in a fish- • Can be viewed from comfortable indoorbowl when in the garden. Two bird feeders seating area — sheltered from rain; heated/hanging outside these windows encourage air-conditionedbirds into the garden, which are then visible • Low maintenance costsfrom inside and outside. There are also views Disadvantagesinto the garden from a staff lounge and a pa- • Greenery, flowers, etc. cannot be viewed uptient waiting room. Half-closed blinds in these close or their fragrances enjoyedwindows permit someone sitting in the garden • Fountain, birds — if present — cannot benot to feel stared at. heard Typology of Outdoor Spaces Provided in Contemporary Healthcare Facilities x 19
  • 24. • Cannot walk, stroll, or sit in garden Internal Gardens, St. Mary’s Hospital,• May be frustrating for some —“Look, but Newport, England don’t touch” Three small courtyard spaces seen through windows off the main ground-level corridor ofCentral Atrium, John Muir Medical Center, this new community hospital could be charac-Walnut Creek, California terized as viewing gardens. One has seating inA small, square (approximately 32 x 32 feet) it and is thus described in this can be viewed through floor-to-ceiling A door opens off the corridor and one stepswindows from a large, plushly furnished foyer- into a space that is approximately 60 x 60 feetatrium and from three adjacent corridors in in size. Almost half the total area comprisesthis modern, suburban medical center. Flowers tiled paving in a wavelike design, echoing aand ferns grow in square concrete planters of water theme used throughout the interior andvaried heights. There is a small fountain in the landscape design of this hospital, located as it iscenter and two 2-story-high trees. The garden on an island (Isle of Wight). Beyond the pavingwas designed by — and is maintained by — a (as you view it on entering) is low shrubberylocal garden club. that acts as a buffer between the garden and The garden provides a green outlook for the windows of offices/patient exam rooms onpeople waiting in the foyer or passing by in the the other three sides of the square.corridor. The trees are well selected, with deli- While the paving design is an attractive fea-cate foliage that moves in even a slight breeze. ture viewed from the corridor or from the twoThe fountain, with a number of very thin floors above, the detailing and furnishing of thisfalling jets, offers a view of water, but a fountain space are less successful. There is one seating el-with more visible water would have been a bet- ement comprising a circle of seats arranged in ater choice, considering that people cannot hear sociofugal design (i.e., the seats face out, awayit. More lush, colorful, and varied planting from each other). This means that any morewould have made this a more attractive feature. than two people entering the space together cannot easily converse while seated. Such a seat-12. The Viewing/ Walk-In ing arrangement is suitable where strangers are sitting next to each other (e.g., a subway stop)Garden but might be questioned where visitor-familiesThis is a variation of the viewing garden in or co-worker colleagues are the likely users.which a space that is predominantly (in terms The absence of seating in several other half-of spatial extent and use) a garden to look out moon-shaped paved areas that are bounded byat from inside the hospital can also be entered shrubs and would have made very private seat-and sat in by a very limited number of people. ing spaces for one or two people curtails theSuch a space is usually viewed or entered from use of this space. Also limiting the use of thisa waiting area or corridor. garden is an inordinately high and awkwardAdvantages step up/step down entrance sequence. This,• Provides a soothing green outlook for peo- combined with the undulating paving (on a ple waiting or passing by vertical scale), renders use by elderly or infirm• Provides a very quiet sitting place since few people very difficult, if not impossible. people are present• The relative lack of use ensures that users of Flower Gardens, Stanford University any adjacent offices or patient rooms will Medical Center, Stanford, California not feel that their privacy has been unduly At ground level in a new building complex of intruded upon this large medical center and medical school,Disadvantages there are two walk-in/viewing gardens ac-• People sitting in the space may feel that cessed from a major corridor at grade and they are in a “fishbowl,” being stared at viewed from three corridors, open stairways,20 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 25. and small waiting areas above. The gardens effect is of a very colorful “cottage garden”are very visible from inside through floor-to- with the birches in two corners and cherries inceiling glass. Beside one of these gardens, the the third, acting as backdrop.corridor widens out to a spacious, tiled waiting While one side (nearest the corridor) is ob-area with comfortable leather armchairs. viously planned for use — seating clusters andThus, this garden can easily be enjoyed by pathway — the other two sides are faced by thenumbers of people sitting inside. windows of offices and patient rooms. The The garden is roughly triangular in shape depth of the garden and the height and varietyand is accessed by doors off the corridor-waiting of planting ensure complete privacy for thosearea. The garden is approximately 115 feet long inside. Although a distant air-conditioning unitand 45 feet wide at its widest point. There are can be heard, the overall experience in this gar-two seating clusters, each floored with concrete den is of being very remote from the hospitalpaving and furnished with five handsome wood- atmosphere, in a human-scale, secure, and en-en garden benches with backs and arms, plus a closed setting, with the sound of moving leaveslitter container. The two clusters at either end and views onto a wonderful variety of plants,of the garden are linked by a narrow, winding flowers, leaves, shadows, and textures — a trueconcrete path that enables a brief walk through oasis experience (see Photo 11–4).the garden. Around each cluster are a number of Smoking is not permitted in either garden.silver birch trees, three stories high. These pro- Generally both were used by lone people readingvide some sense of enclosure to those seated, and eating, groups of visitors talking, elderly pa-and the soothing sound of leaves rustling. At tients in wheelchairs (with a companion) lookingmost times of the day, there is a choice of seat- at the flowers and dozing, small children explor-ing in the shade or in the sun. The birches also ing in the shrubbery.provide a green outlook for those in offices and Having categorized, described, and cri-patient rooms in the floor above the garden. tiqued a variety of types of hospital outdoor The planting in the gardens is exemplary: space that were briefly visited and observed,underplanting of shade-loving ferns, camellias, the next sections of this report comprise de-azaleas, and impatiens beneath the birches; tailed case studies where systematic observa-massed plantings of blue agapanthus, pink and tion and user interviews provide a closer lookwhite roses, white and blue petunias, white at the therapeutic potential of outdoor gardenscosmos, white and pink dahlias, pink penste- in hospital settings.mon, blue lobelia, and blue delphiniums. The Typology of Outdoor Spaces Provided in Contemporary Healthcare Facilities x 21
  • 26. 6. SAN FRANCISCO GENERAL HOSPITAL: The Comfort GardenT HE FIRST BUILDINGS designated as Map 6–1: San Francisco General Hospital were Comfort Garden, Illustrative Plan erected on this site in 1872. Out-breaks of bubonic plague, the spread of tuber-culosis, the earthquake of 1906, and the lawn out-patient clinicsinfluenza epidemic of 1918 brought about se- main entry tovere overcrowding in this and many other SanFrancisco hospitals. Most of the present build-ings were constructed during 1915–20, de- lawnsigned by city architect Newton Tharp in anItalianate style, laid out “with green lawns and 22nd Streetbright flowering plants to add to the attrac-tiveness of the structures.” Early photographs out-patient clinic’s back doordepict lawns, shrubs, paths, and palm trees be-tween the buildings, formally designed, but —apparently — with no seats or benches to en-courage use by staff or patients. SCALE: The Comfort Garden is a small but well-used outdoor space in the sprawling contem-porary “campus” of the hospital. It wasestablished in June 1990 as a “living memori-al” to hospital employees who had died. Aname plaque in the garden, recording its in- and Child Abuse. All of these are outpatientception, concludes with the words: “It is clinics; none of the buildings adjacent to themeant to be a place of solace where nature’s Comfort Garden contains inpatient beds. Thebeauty can bring you comfort.” garden is bounded on two sides by these build- ings and on the other two sides by fences thatPhysical Elements and Site separate it from 22nd Street and a parking lot.Layout The feeling of this residential-scale gardenThe garden is located adjacent to Buildings 80 is of a green and colorful retreat (see Mapand 90 — imposing six-story brick buildings 6–1). Three very large trees — one cedar andwith many operable windows looking out over two Monterey pines — are almost as tall as thethe outdoor space. These buildings house a buildings. Five lawn areas are bounded byvariety of clinics, including those for TB, concrete paths and flower beds. Most of theHIV, methadone maintenance, Family Health, paths are designed for easy, direct pedestrian x 23
  • 27. Photo 6–1: Richards, is entitled “Companion Place — aMain entry path complement to the Comfort Garden.” It com-to Building 90 — prises a curvilinear path bounded by granitethe busiest route blocks and surfaced with decomposed granite;through the gar-den on weekdays five large granite blocks that function as casual seating; and two granite-bordered flower beds planted more formally than the rest of the gar- den, with African marigolds and lobelia. Within and beside the informal flower bor- der that runs the length of the garden on its southwest side, there are a variety of places to sit (see Map 6–2). Two wooden benches with backs and arms are a perfect size for two people to oc- cupy for a private conversation, or for one per- son to “claim” by sitting lengthwise with feet up. These are ideal choices for this garden consider- ing its size and image. Being of small scale, and of more delicate construction, they are clearly garden benches rather than park benches (see Photo 6–3). Under one of the large pine trees the gardeners have built a simple wooden plat- form. This enables two to four people to sit, backs against the tree, their feet up, their lunch or coffee or book beside them. It is pleasantly movement (see Photo 6–1), but one made of informal, flexible in use, and far enough away decomposed granite and another formed with from a path to be relatively private. “steppingstone” blocks of wood are clearly de- Also providing informal seating are a row signed for more casual strolling. The latter of large tree stumps forming the border of a winds through a lushly planted garden bedPhoto 6–2: where shrubs and flowers can be viewed atStrolling path and close quarters (see Photo 6 –2).secluded bench inthe long flower This is clearly a garden that has been cre-border ated — and is maintained — with love and care: Tree stumps have been arranged to bor- der flower beds; an arbor has been created out of thin branches pruned from nearby trees; rocks have been placed among the flowers; annuals are planted out in colorful displays. There are no weeds, nor is there any litter; yet the garden has a casual rather than a man- icured appearance. When this study was conducted — May– June 1995 — there were no fewer than 35 dif- ferent species of plants and shrubs in bloom. No wonder one of our interviewees, when asked what she would like to see changed, asked for plant labels. While most of the Comfort Garden has a casual, “country cottage” garden image, a por- tion of it was changed in 1994 to add a more formal sculptural element. This area, by Peter 24 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 28. and colorful planting, particularly in contrast Map 6–2: to adjacent streets and tall brick buildings; two, Comfort Garden, the relatively enclosed feeling when in the gar- Experiential remote Analysis den. On one long side, it is bounded by the expansive/open four- to six-story wings of Buildings 80 and 90. On the opposite long side, its immediate hihg level GLIMPSES INTO GARDEN THROUGH WROUGHT IRON FENCE of activity cottage boundary is a 10-foot iron fence, densely cov- garden wind ered in parts by a flowering vine. Beyond this, protected abstract/formal on the other side of 22nd Street, the space is visually bounded by the three and four stories of another brick hospital wing. intimate scale The top southeast end of the garden is de- fined by a low laurel hedge, but is visually SCALE: bounded by the concrete end wall of the hospi- tal heating plant viewed through trees, and by a SEMIPRIVATE SEATING large modern addition to the hospital (see remote SOCIAL SEATING woodland MAJOR TRAFFIC FLOW garden SECONDARY TRAFFIC FLOW Photo 6 – 4). At the downhill, narrow north- west end of the garden, an iron fence forms VIEW TO HILLS an edge along Portrero Avenue, but the two- story row houses across the street and moreportion of the long flower border. Though distant hills of Twin Peaks form a more effec-right next to a path, this is one of the least- tive visual boundary. These enclosing ele-used walkways in the garden, and therefore ments, together with its modest size, effectivelythere is some degree of privacy. complement the rich planting to create an oasislike effect. At its widest, the garden is justMicroclimate and Ambience under 100 feet, while it is approximately 160On a sunny day in spring and summer during feet long. The scale of this space evokes muchthe peak-use hours (11 a.m. – 2 p.m.), approxi- Photo 6–3:mately 85 percent of the garden is in the sun. Garden benchesHowever, this part of San Francisco is quite are an ideal size forfrequently breezy, if not windy. On a sunny one individual toand breezy day, the comfort difference be- “claim” and totween sitting in the sun and sitting in the provide some pri-shade is quite marked. Fortunately, both gar- vacy for reading or eating.den benches and all the granite seating blocksare in the sun almost all day. The wooden-platform seating, underneath a large Montereypine, is in shade most of the time. Thus, onlyon the hottest and calmest days is this a com-fortable place to rest. A small number of those we interviewedcomplained that the garden is “too noisy.” In-deed, there is a fair degree of background noisein this setting: cars and buses driving past onPortrero Avenue; cars accelerating uphill on22nd Street; and the sounds from a large air-conditioning unit on an adjacent building. When asked to describe the garden, somereferred to it as “an oasis.” We suspect that thisimage is evoked by two things: one, the lush San Francisco General Hospital: The Comfort Garden x 25
  • 29. Map 6–3: staying in the garden for 30 minutes or moreComfort Garden, when they came out. There was no significantUsers Passing difference between the use of the garden and theThrough length of time people stayed between staff and outpatients or visitors. Interviews with Users of the Comfort Garden In all, a total of 50 people who were spending time in the garden were interviewed. Of these, 31 were men and 19 were women; 24 were staff and employees, 20 were outpatients, 5 were visitors, and 1 was an inpatient. When asked how often they used the garden, close to half said “up to twice a week.” A substantial number use the garden at least once a day (see SCALE: Figure 1). Not only did a considerable number use the garden frequently, but also almost half of the users reported that on some visits they stayed 30 minutes or longer. We showed interviewees a list of possible more of a garden feeling than, say, the experi- activities in the garden and asked them to ence of a park (see Photo 6–5). check as many as were relevant. Every person interviewed said that he or she came to the Garden Use garden to relax. Three-quarters of the users A central path in the garden leads to one of reported that they also came into the garden the main entrances to this wing of the hospital to eat. More than half said that they came here (see Photo 6–1). Not surprisingly, walking to to talk, stroll along the paths, partake of their and from this and three lesser-used doorways own “outdoor therapy,” or to wait. comprises four-fifths of the use of this space Two-thirds came into the garden alone, (see Map 6–3). While only one-fifth of the and just under a third came with one other total of 297 observed users comprised people person. This confirms that the scale of seating standing, sitting, or lying down, the signifi- provided appears to accommodate the needs cance of these users should not be underesti- of many users — short benches and granite mated: They stayed much longer than the blocks that can be “claimed” by a person sit- walkers-through, and they seemed to enjoy the ting alone or can comfortably accommodate garden more — pointing out plants, smelling two friends. the roses, lying on the lawn on warm days, eat- ing lunch, chatting with friends or colleagues (see Photo 6–3).Photo 6– 4: The typical stationary users were staff mem-Visual boundary at bers who came out to stand or sit while smok-top end of garden ing; staff members who came out alone or inis created by thehospital heating pairs to enjoy eating a brown-bag lunch; visitorsplant, new hospital or patients who sat for a while, sometimesbuilding, and old smoking or drinking, or who lay dozing on thebrick wing. lawn (see Map 6– 4). It was not uncommon at lunch time to see staff members come out and look around for a vacant bench and find them all full. Two-fifths of those interviewed reported 26 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 30. Clearly, for most people who spent time in Map 6– 4: it, the garden facilitated a change in mood that Comfort Garden, was positive. They left after a medical appoint- Stationary Users ment, or returned to work in the hospital, feel- ing less stressed, refreshed, more content. For example, a middle-aged male outpa- tient who comes to the hospital once or twice a week reported: It’s a good escape from what they put me through. I come out here between appoint- ments. I enjoy the air, the feel of the sun, the privacy — everyone inside knows me; I don’t know anyone out here. It gives me the strength to deal with things. I feel much calmer, less stressed. A young female employee reported: My level of stress goes way down. I’m a lot more relaxed; I go back to work refreshed. ... It feels SCALE: like something is alive here in the middle of a city that seems dead. FIGURE 1 Frequency of Use Reported by IntervieweesWhat Happens to People in the First time hereComfort GardenWhen asked, “Do you feel any different after 14%you’ve spent time in the garden?,” half saidthat they felt calmer, more relaxed, less 46% Up to twice a weekstressed. These comments were made by both 40%staff and outpatients (see Table 6–1). A signifi- Every daycant number reported feeling “better, and morestronger, more positive.” These respondentswere mostly outpatients. A middle-aged male outpatient who comesTABLE 6–1 to the garden every day to sit, relax, stroll,Percent of Respondents Reporting Various talk, eat, and meditate loves the solitude andTypes of Mood Changes Photo 6–5: Percent This long pathCalmer, contented, sleepy, more relaxed, 68 leads up into theless stressed garden from the bus stop and aBetter, more positive, pleased 26 small employeeRefreshed, stronger 16 parking lot. NoteHelps me think through problems 10 the visual bound-Moves me, a religious connection 6 ary created by the houses on PotreroEscape from work 4 Boulevard and byNo difference in mood 4 distant outline of(Number of respondents: 50) Twin Peaks. San Francisco General Hospital: The Comfort Garden x 27
  • 31. the colors and leaves the garden feeling “more feelings and activities this place supported. Tworelaxed ... it’s very peaceful, an oasis ... some- outpatients remarked: “It’s a place where youtimes I come here all wound up and then I feel can come and think without a whole lot of peo-relaxed.” ple around”; “I feel more comfortable when I’m A female visitor who comes once a week and around other people who are ill or recoveringwaits for a friend while he’s at an appointment — they’re in the same position as me.” A femaleremarked: employee who works in a child abuse clinic brings children out to the garden: “It relaxes It’s pretty, it’s relaxing ... visual beauty lifts my spirits. I feel that any plant life has a big effect on them, if they had a traumatic experience. I people. ... I’ve come out here and picked flowers point out the flowers, let them play.” A male for a friend who was dying because I didn’t have employee who works in HIV research likes the any money, and it made her feel better. colorfulness, the variety, and “the fact that there are plants in memory of some of my co- workers who have died. A lot of the patients IWhat Users Liked Best About see have died. Sometimes it seems like a placethe Garden they’d come back to if they’re coming aroundBy relating how they would describe the gar- to visit.” Several employees and outpatients hadden to someone who had never been here, the tears in their eyes as they described the memor-interviewees revealed what was significant to ial or spiritual significance of the garden.them about its design and image. One middle-aged male patient who relaxes, eats, or drinksin the garden once or twice a week described it Changes and Modificationsas “... absolutely beautiful ... it’s like a rainbow Desired in the Gardenon a beautiful day, with a beautiful woman. When asked if there were anything they wouldHow do you describe color to a blind man?” like to see changed or added to the garden, theMany referred to it as “an oasis in a sterile set- most frequent response was — “Nothing!” orting,” or “a little bit of heaven,” “a paradise.” “It’s changing all the time — flowers, the sea-People seemed to appreciate especially its well- sons, what the gardeners do.”tended yet casual atmosphere; several referred TABLE 6–3to it as being “like an English country garden,”or “like a garden in someone’s home.” Percent of Respondents Who Desired These These very positive responses to the garden Changeswere further confirmed when people were Percentasked: “What do you like best about this place?” Change nothing; it is changing 36 Practical changes: more seats, tables, 32TABLE 6–2 ashtrays, trash cans More flowers, trees, shade 22Percent of Respondents Who Named TheseQualities as What They Liked Best Make larger and more private; add kids’ 20 play area, cut out noise Percent Ban dogs and smokers; improve maintenance 14Aesthetic attractiveness and design 92 Aesthetic changes: add arbor, water feature, 12Flowers, plants, trees 74 wrought iron, more paths, label plantsPrivacy, quiet, comfort 60 Protect/enhance the personal meaning 4Open air, sun, seasonal change, birds, 24 (Number of respondents: 50)butterfliesHuman companionship 10 There was a desire for more places to sit andMemories of friends who have died 4 for picnic tables; also for things to improve(Number of respondents: 50) maintenance such as additional trash cans, ban- ning dogs and smokers. The latter — if en- The flowery, lush, and oasislike qualities forced — would certainly decrease use sincewere again emphasized, but so too were the many users were observed smoking while stand-28 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 32. ing or sitting in the garden or strolling through. and to use the space as a neighborhood park. ARecent bans on smoking in public buildings in couple with a small boy walk slowly through,California have meant that public outdoor space stopping frequently to look at the flowers; theis increasingly used for this activity. boy balances on a log-wall, holding his father’s While some desired improvements were hand. A little girl on a bike rides down the pathvoiced in response to this question, the overall calling out to her father, who walks behind car-tone of those we spoke with was of strongly felt rying a baseball bat and mitt and leading a dog.appreciation and love for this place, and for the A young man walks two small dogs. Threecare of the gardeners who created and maintain it. youths on mountain bikes bump along the Two comments regarding changes are par- “rustic” path made of logs and chips. It appearsticularly pertinent to the kinds of outpatients as though all these are local residents, enjoyingvisiting clinics in the adjacent buildings. A pa- the garden as a neighborhood outdoor space.tient with AIDS, beginning to lose weight, re-marked on the need for padded seating. Patients Conclusionon methadone maintenance used the garden to The Comfort Garden at San Francisco Gener-“space out” and wanted nothing changed. al Hospital is a remarkable, well-loved oasis“Where else would I go?” one asked. It was that brings joy, contentment, and peace to visi-clear that some users were on the fringe of so- tors and outpatients visiting clinics in adjacentciety, if not actually homeless; for them, espe- buildings, and to medical and administrativecially, the garden was a nurturing setting where staff who work nearby. Its informal design,they felt comfortable and at home. lush plant growth, and loving maintenance by the gardeners who created this oasislike settingWeekend and Weekday Use are clearly highly appreciated by all kinds ofThere is a very marked difference in the use of users, by those who pass through as well asthis garden between weekdays and weekends. those who spend more time there. Of the fewOn weekdays, the clinics are open and staff are changes requested, some — more seats, tables,on duty. There is barely a moment between 10 and so on — could conceivably be effected,AM and 5 PM when people (often many at a while others — less noise, larger size, etc. —time) are not streaming in and out of the adja- are of a more structural nature. While those wecent buildings. During the middle hours of the talked with had varying abilities to articulateday, as noted, many use it for eating lunch, tak- what effect the garden seems to have uponing a break, lying in the sun, etc. their feelings, there seems no doubt that all but On weekends, however, clinics are closed. a few were affected very positively. In variousAlmost no one enters or leaves the buildings. ways, and in differing degrees, this does indeedThe few who walk through tend to follow the appear to be a “healing garden.”long path running from one end to the other, San Francisco General Hospital: The Comfort Garden x 29
  • 33. 7 CASE STUDY: ALTA BATES. MEDICAL CENTER, BERKELEY, CALIFORNIA: The Roof GardenT HIS IS A complex of three- to six- tence or assume it is not for public use. Upon story buildings set in a neighbor- finding one’s way to remote elevators 9 and hood of single-family homes, 10, only an enigmatic “R” button in the eleva-apartments, and medical office buildings in tor indicates its presence.South Berkeley. It is named for Alta AliceMiner Bates, who first settled in Berkeley in Physical Elements and Site1904, and nursed patients in her parents’home as there was no hospital in the commu- Layout The roof garden is located on the south side ofnity. In 1905, at the request of local physi- the hospital complex, three floors above thecians, and with plans drawn up by her ground. On the north side, it is bounded by acontractor-father, she built an eight-bed nurs- four-story wing containing patient rooms anding facility and school for nurses on Dwight offices in the maternity department. On theWay, called Alta Bates Sanitarium. In 1908, other three sides, the garden looks out ontodue to population growth in Berkeley after expansive views: to the east, the wooded andthe 1906 earthquake, the facility moved to partly residential Berkeley Hills; to the south,large three-story buildings at its present site Berkeley residential neighborhoods of single-on Webster Street. Map 7–1: In 1928, its name was changed to Alta The Roof Garden,Bates Hospital and six-story buildings were Illustrative Planadded. Care was taken through setbacks andlandscaping to ensure that the buildingsblended into the residential neighborhood.This concern extended into the 1980s, whenthe old buildings were replaced by modern fa-cilities and set back from Ashby Avenue be-hind lawns and trees. The roof garden —dedicated to the Alta Bates Volunteer Auxil-iary — was opened on the third floor of a newbuilding in 1983. It is accessed from elevators9 and 10, which are approached via a longcorridor leading south from the main lobby.There is no indication or sign in the mainlobby directing people to it, and inquiries atthe information desk suggest that the volun-teers who work there do not know of its exis- x 31
  • 34. Photo 7–1: later section, this small “anteroom” to the gar-This “plaza” area den proper is well used because it is near theincorporates a cen-tral flower bed elevators and near snack machines; on hot dayswith a tiered foun- it is sheltered from the sun’s glare; on frequenttain. The sound of windy days it is screened from the breeze.the water and theattraction of birdsto the fountain are Ambience and Microclimateparticularly appre- The background hum of a large air-condition-ciated in this roofgarden. ing/heating unit is ever-present as one enters the garden, though it is not unduly intrusive everywhere, depending on where one sits. One is aware of bird-song, and in the large plaza area, of the sounds of the fountain. On a breezy family houses; to the west, a panoramic view day, the rustle of trees and vines is a soothing of San Francisco Bay, the city of San Francis- backdrop for garden-users. The garden is high co, the Golden Gate Bridge, and the hills of enough off the ground so that traffic cannot be Marin County. heard. Apart from the sounds of an occasional The garden consists of several distinct sub- plane or helicopter, the roof garden is very areas. Upon emerging from the elevator, one quiet and peaceful. When seated in most parts walks out onto a square, brick-paved plaza of the garden, the views over the city are bounded by flowered planters with seat-height screened by planting, and one has the sense of concrete edges, and eight small carob trees in being in a secluded city garden. concrete boxes. In the middle of the plaza is a A design factor that may inhibit use is the square flower bed with a small fountain at its lack of elements to ameliorate the wind or center (see Photo 7–1). On a wall bounding the bright sun. For perhaps half of the year, it is eastern edge of this plaza, two ornate columns warm enough to sit outside, and, depending on and a crest that formed the entrance to the the time of day, many would prefer to sit in the hospital in 1928 were saved and placed here shade. The choice of planting in the main plaza after the building was demolished in 1983. The — short, squat carob trees — was a poor one; feeling of this sub-area is of an urban plaza, they create very little shade. The roof tends to with users sitting around the edge, exposed to be more windy than the adjacent streets. A each other. The second major section of the roof gar-Map 7–2: den is four steps below the plaza and has moreThe Roof Garden, of a garden feel to it (see Photo 7–3). A smallExperientialAnalysis brick- and concrete-paved plaza accessed from a door in the maternity wing is bounded by seat-height concrete planters and a large raised lawn. Three maple trees offer some shade on hot days, and a lush expanse of red and purple climbing bougainvillaea has grown to the third floor of the adjacent building (see Photo 7–5). A third, small and hidden section of the gar- den consists of a walkway behind the planters on the west and south sides of the roof. Mov- able garden chairs have been carried here for a very private sitting, viewing, and conversation setting (see Photo 7–4). A fourth sub-area is under a building over- hang by the elevators where a drink and a snack machine are located. As discussed in a 32 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 35. screened area offering shelter from the prevail- Map 7–3:ing winds would have been a welcome addition. The Roof Garden, Stationary UsersGarden UseCompared to two other sites discussed in casestudies in this report (Kaiser Walnut Creekand the Comfort Garden at San FranciscoGeneral Hospital), the roof garden at AltaBates is relatively under-used. In eight hours ofobservation at the Kaiser site, there were 251user-observations recorded; at San FranciscoGeneral, the number was 596. The number atAlta Bates was 154. This relative lack of usecan be explained by a number of factors: A roofgarden is a “terminus” location — most usersgo there to be there, they don’t pass through iton the way to somewhere else; a roof gardentends to be more exposed to the elements thana garden at grade; the garden at Alta Bates is pears to be a favorite seat or bench in more re-not publicized and is out of the way. mote and hidden corners of the garden. The latter clearly came to be alone and often dozed,TABLE 7–1 sunbathed, looked at the view, or meditated.Percentage of User-Observations Recorded for Sixty percent came to the garden alone; 21 per-Each Activity cent came in pairs, usually to eat lunch togeth- Percent er. The 18 percent observed in groups wereTalk with colleagues or friends 34 those who met each other while taking a breakEat and/or drink 24 or stopped to chat for a while.Smoke 21 One of the disadvantages of the garden de-Read, write 8 sign for people in groups of two or more, or forLook at the view 6 those who want to choose where they sit, is the lack of movable seating. There were only fiveSleep, doze, sunbathe 5 movable white plastic garden chairs (and threeWork 2 movable round tables), whereas there was more(Total number of user-observations: 154) than 300 linear feet of concrete planter-edge seating. Not only were the chairs with backs The most frequent pattern of use was for a more comfortable, but also they could beperson to walk from the elevator and find a moved into the shade or sun, depending on theplace to sit while smoking a cigarette, or to weather; they could be moved to sit and look atenjoy a soft drink purchased from a machine the view, or to join a friend at a table (see Photonear the elevator, or to eat a brown-bag lunch. 7–2). Considering the very secure location ofSince the cafeteria is three floors down and al- the roof garden and the unlikelihood of any-most a block away, it was very rare to see peo- thing being stolen, it is surprising that moreple arrive with their meal on a tray. Those movable seating has not been provided.arriving for a short break tended to cluster Those who were observed walking througharound the vending machines beneath a build- the garden (one-fourth of the total) tended toing overhang; it was here that most socializing move on one route — from the maternity wingtook place. Those coming to the garden for a exit to the vending machines, or from the eleva-longer period tended to sit alone on the con- tor to the maternity wing — and not to spendcrete seating bounding the main, brick-paved any time in the garden.plaza or to walk very purposefully to what ap- Case Study: Alta Bates Medical Center, Berkeley, California: The Roof Garden x 33
  • 36. Photo 7–2: therapy.” Most came alone and stayed aloneMovable chairs during their break; some joined colleaguesallow this staffperson to create a whom they encountered in the garden. Thereprivate setting for is no lack of places to sit, though there is a lacka lunch break. of movable chairs, which people liked to take to a preferred location — into the shade, into the sun, to a more secluded setting. What Happens to People on the Roof Garden When asked, “Do you feel any different after you’ve spent time in the garden?” all but one of the 36 interviewed reported a positive change in mood (see Table 7–2). TABLE 7–2 Percent of Respondents Reporting Various Types of Mood Change Percent Calmer, more contented, more relaxed, 80 less stressed Refreshed, stronger 33 Better, more positive 22 Escape from work 22 Interviews with Users of the Moves me, a religious connection 8 Helps me think through problem 5 Roof Garden Time passes more quickly 3 Thirty-six people who were spending time in the garden were interviewed, half men and half No difference in mood 3 women. Of these, 29 were staff, 3 were visitors, (Number of respondents: 36) 2 were outpatients and 2 inpatients. It was dis- appointing to see so few in- and outpatients Many respondents referred to the pleasing using this attractive facility. This is due in part contrast between the garden — open, sunny, to lack of information about its existence and in colorful, “natural” — and the environment in- part to security measures following the kidnap- side the hospital. For example, a man whose ping of a newborn baby several years ago. The wife had just given birth had come to the gar- main door onto the garden is now inaccessible den three times that day: “I feel more relaxed. to all but maternity patients and their visitors. It’s mostly because there aren’t too many peo- The garden was used predominantly by staff. ple out here. I’m a solitude kind of person. The A third of those we interviewed reported using sunlight is nice. The waiting room with fluores- the garden several times each day, and one- cent light sucks the energy out of you.” Many fourth came once a day. The primary use of the felt the garden helped them calm down or relax garden was either for a quick break with coffee, from stressful situations at work. A female em- soft drink, or cigarette (almost one-half used ployee who uses the garden every day respond- the garden at some time for this less-than-10- ed: “It’s a place for meditation and relaxation. minute break); or for a lunchtime or longer visit It’s real tranquil. Because I work in the radia- of 10–30 minutes. tion department in the basement, I feel like one When asked what they did in the garden, of the Mole People; I come out for sun. It’s a the most frequently cited activities were relax- big mental, emotional lift.” ing, talking, eating, strolling, and “outdoor For many people, the garden provides a wel- 34 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 37. cident: “When you’re in the hospital it’s easy Map 7–4: to get caught up in that whole sick vibe. When The Roof Garden, Users Passing you come out here it’s life, a surrender — that Through you’re still breathing, you’re still alive.” For all but one of the 36 people inter- viewed, the garden helped evoke a positive change in mood. Staff members returned to work feeling more relaxed; in- and outpatients felt calmer outside the normal hospital envi- ronment. What Specific Characteristics of the Garden Helped Bring About a Mood Change Most people were quite forthright about what — in particular — in the garden helped them feel better. Overall, aspects of planting (flow- ers, “greenery,” colors, seasonal changes) werecome relief from the stress of constant interac- by far the most often cited (see Table 7–3). In-tion with people. A female employee who visits deed, it is the flowers, lawn, trees, shrubs thatthe garden two or three times a week re- make this a garden and not just a rooftopmarked: “I’m at peace — you can see the birds space. The fountain, though small, is centrallyand the water. I feel a sense of meditation; I placed and audible from seating places in thefeel better. Breathing the fresh air helps clear main plaza section. Importantly, it also offersmy head even if I need to scream or run in water to birds, which frequently come to drinkplace. It’s getting away from people, from and bathe. Some have made nests and raisedwork. The air itself helps me revive.” their young in the roof garden. Many employees thought of the garden as“an escape.” A male employee who uses the TABLE 7–3garden every day said: “It’s an excellent area Percent of Respondents Who Name Thesefor relaxation even if it’s only for a short time. Qualities as Helpful in Attaining a MoodFive minutes out here is better than an hour in Changethe cafeteria. Its calming influence creates a Percentsense of separation from the hospital that a Flowers, colors 67recreation room wouldn’t provide. It’s a com- Openness, views 36plete getaway.” Greenery, seasonal change, “nature” 33 Though relatively few patients used the gar- Water, fountain 31den, responses from two who did are indicative Peacefulness, no traffic noise 31of what such a space can mean to someone who Escape, privacy, secret places 28is sick or in recovery. A female inpatient re- Sun, light, fresh air 28sponded: “I feel more normal here. I felt really Birds 25depressed in there; I was getting real teary. Design features (textures, shapes) 19You go from having control of your life to less Sounds, smells 14control. Out here you’re on your own; there’s Management policy (smoking okay) 8time to forget about it. You feel relieved from Places to sit, companionship 5all the medical aspects of your case. You come Don’t know 3out here and it’s more holistic, more natural.” No answer 3 A female outpatient was waiting for an ap-pointment and recalled practicing walking on (Number of respondents: 36)the lawn as an inpatient recovering from an ac- Features that are specifically characteristic Case Study: Alta Bates Medical Center, Berkeley, California: The Roof Garden x 35
  • 38. Photo 7–3: alone. As an employee in healthcare, you’re con-The “garden” stantly giving, interacting. It’s important to havearea provides an a place to recharge.expanse of lawnfor more casualuse, and children’s TABLE 7– 4play. Percent of Respondents Who Named These Impediments to Using the Garden Percent Work schedule 44 Weather 33 No impediments 28 Distance, difficult access 8 of a roof garden were also important — views, openness, fresh air, breezes, and being away Didn’t know it was here 5 from traffic noise. (Number of respondents: 36) A female employee who uses the roof garden several times a day responded enthusiastically: It was primarily work schedules and the It’s a whole different environment. The birds, weather that inhibited people from coming to the flowers, the sunshine, the fresh air, being the garden as much as they would like. We away from the work environment. It helps build suspect, however, that many nonusers do not relationships. Everyone who comes up, we’ve come to the garden because they don’t know gotten to know each other. It’s a place to meet of its existence. people. I feel very fortunate to have this. Some- times, in the evening, the sun is setting. It’s a TABLE 7–5: wonderful experience. I have a lot of pride in this garden. I tell patients about it, and new em- Percent of Respondents Who Desired These Changes ployees when I’m orienting them. Percent An outpatient who was in the garden for Practical changes 52 the second time in one day also appreciated More movable chairs 25 the birds, the fresh air, the greenery, the wind More tables 8 blowing, but especially the colorful flowers: “I Food cart 5 do energy work with colors and chakras. Dif- Drinking fountain 5 ferent colors arouse different emotions. You Shelter 5 have all the colors of the chakras out here. It Outdoor pager 3 soothes you down. ... I can come out here and Change nothing 50 be still.” A woman employee said that some of the flowers took her back to her childhood and Planting changes 11 their colors made her think about dress mater- Aesthetic improvements 8 ial for her granddaughters. Better maintenance and access 8 A female employee who comes to the gar- (Number of respondents: 36) den to relax, stroll, eat, and “center myself” was especially articulate about which charac- When asked if there was anything they teristics helped change her mood. would like to see changed on the roof garden, The most important thing for me is the fountain one-half said, “Nothing!” But a similar propor- because I love the sound of water and it attracts tion voiced a variety of pragmatic changes that birds. Then, there’s the greenery and flowers. would make the space more usable. Principal And a third component — the design is pleasing among those was the desire for more movable to the eye: There’s a combination of shapes and tables and chairs, particularly the latter. This sizes; the brick gives a warm feel. ... I like the was very apparent as we observed people nooks and crannies so you can have a place to be searching for a chair so they could join others 36 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 39. at a table or sit with their feet up on one of theplanting edges. With only five movable chairs,they were in great demand. Observations made Conclusion There is no doubt that for those who use it, theby William Whyte in his film on the use of roof garden at Alta Bates facilitates relaxationManhattan plazas (The Social Use of Small and reduces stress. It was particularly beneficialUrban Spaces) suggest that people just like to be to hospital employees, who reported returningable to move a chair in a public space, even if to their work refreshed and more centered. Aonly a foot or two, perhaps to have a sense of male employee who uses the garden every daycontrol over their environment. Apart from as a “getaway for stress relief” reported: “Youthese movable chairs, all the seating on the can come out here and meditate whether it’sroof garden comprised concrete edges to work related or stuff I’m dealing with at home.planters without backs. I can come out here and think about things and The fact that people often clustered around then go back in and be more productive.” A fe- male employee who occasionally visits the gar- Photo 7–4: den to eat lunch or talk with colleagues felt A private spot with a view is often strongly that “all workplaces should have some- sought out by staff. thing like this — a place to go outside where it’s quiet and pleasing to the eye, and sheltered. I think gardens are beneficial. I don’t think fluo- rescent light and artificial air are healthy. If you go out and get away from that environment, you’re more productive.” The fact that many of our respondents used the words “more productive,” or implied such an outcome, is an indication that such outdoor spaces are not merely “cosmetic extras” butthe vending machines under a concrete build- should be intrinsic components of every work-ing overhang was in part due to lack of shade ing environment. The health of the staff is asin the garden and — on windy days — lack of important as that of the patients. One maleshelter. Several people requested shelter and doctor who worked part time at another hospi-more shade trees. A drinking fountain, a food tal remarked that at the other facility, therecart, and an outdoor pager (for medical staff on were plants but no places to sit. “Here I sit andcall) were other practical suggestions. For the smoke one cigarette and I don’t need anothermost part, however, users were well pleased to relax me.” While smoking is not beneficial towith the garden. Aesthetic improvements were health, if the garden enables an employee tovoiced by relatively few, but were worded quite relax with one cigarette rather than two, that isvehemently. certainly a benefit. A man visiting his wife in the hospital want-ed “a pond with koi or goldfish where you canwatch something methodical, take your mind Photo 7–5:off things.” A young male outpatient visiting Magenta and orange bougain-the garden for the first time had a lot to say: villaea climbing I would have made the area around the fountain the wall provides round — there are a lot of rough edges. It would a very colorful backdrop for the be nice to have an herbal section since we’re in garden, and is an Berkeley, maybe a fragrance section. It would also attractive feature be nice to have some unusual trees. It looks for the patients like someone went to the nursery and said, ‘I’ll confined to their have six of those.’ It needs a canopied section for beds in the adja- shade ... and some healing sculptures — man- cent rooms. dalas, Buddha, Gaia — something relevant to healing. Case Study: Alta Bates Medical Center, Berkeley, California: The Roof Garden x 37
  • 40. While staff were certain of its benefits to all the places that need cost-effective gardens, themselves, they also felt strongly about the those are crying out for something like this — value of a garden for patients. A female employ- for patients and staff. With the aging of Ameri- ee who thought of the garden as a “natural ca and increased use of convalescent facilities, it haven in an unnatural setting” remarked at the is important for those places to have gardens.” end of her interview: “I’ve worked in long- A male employee used to bring patients out term-care settings for the past eight years. Of for certain therapies, but now time doesn’t allow it. He felt the garden was an importantPhoto 7–6:The absence of setting for people who are dying: “We’veshade and wind brought patients out here to die because theprotection is ap- family asked for it. They were able to die inparent in this peace without the critical-care setting. Whenoverview of theroof garden. the family decides to ‘let go,’ we’ll jump through hoops to let a patient come out here to die.” A female employee who uses the garden every day to relax, eat, meditate, and exercise summed it up by saying, “It’s like time has stopped, like a vacuum, a quiet space. I’m really glad it’s here, it gives me an ‘out.’ I close my eyes and listen to the water as if I’m hearing a stream or a brook. ... I can get away from the downstairs hustle and bustle. It’s the best thing about Alta Bates.” Or, as a male employee who was too busy to be interviewed remarked as he made his way to the elevator, “I’ll tell you this ... if it weren’t for the garden, we’d all be on Prozac.” 38 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 41. 8. CASE STUDY: KAISER PERMANENTE MEDICAL CENTER, WALNUT CREEK, CALIFORNIA: Central GardenPhysical Elements and Site Map 8–1: The CentralLayout Garden,T he central garden at Kaiser, Walnut Illustrative Plan Creek, is the largest of the landscapes in this study. Designed around twoheritage valley oaks, the garden is spaciousenough to accommodate in addition severalmature sycamores, pines, box elders, sweetgums, and olive trees. Under the tree canopiesare undulating borders of shrubbery and largeexpanses of lawn punctuated with movablepicnic tables as well as fixed benches. The garden is crisscrossed with paths,being anchored at one corner by the main hos-pital entrance while the multistory parkingstructure is situated diagonally opposite. Thehospital extends its single-story arms out toencompass the east and south sides of thespace with sliding glass doors and windows buildings, people traverse the space almost con-that lead directly into patient rooms. These tinually, even in the rain and the near 100-de-wings house post-op patients and some pedi- gree temperatures common here, nearatric and orthopedic patients. The length of California’s Central Valley.stay is sometimes as long as three weeks; how-ever, the average stay was reported to be threedays. One of the wings is being shut down for Atmosphere and Ambiencerenovations and was at 50 percent occupancy Predictably idyllic weather through most of theat the time of the study. These patients’ rooms year, though tending toward hotter tempera-are buffered from the larger lawn areas by a tures, makes this open and airy garden space anwide, covered arcade, low shrubs, and semipri- inviting place. The evergreen plantings at eyevate seating areas. level and below serve to provide a psychological The other two sides of the garden are filled screen from the low buildings. The trees combin with a four-story outpatient medical building the open sky, blowing in the breeze and provid-to the north, and the two-story cafeteria build- ing homes for the birds that are always and single-story outpatient EKG center to Squirrels scamper across the grass and chatter atthe west. Due to the layout of the perimeter passers-by from overhead limbs. The spreading x 39
  • 42. Photo 8–1: vation, 745 either stopped to talk, or sat eating,The presence of waiting, smoking a cigarette, or purposefullythese magnificent passing the time by strolling the grounds or150-year-old playing.valley oaks dictatedthe location of this The high number and diversity of the ser-well-used garden. vices surrounding the garden made it difficultThey provide a to differentiate among visitors, outpatients,dramatic focal and nonmedical staff. However, we recordedpoint and have that 29 percent of the users were medical staff,become a favoriterendezvous spot. uniformed employees, or construction work- ers. Less than 2 percent were inpatients and the remaining 69 percent appeared to be visi- tors, outpatients, or nonmedical employees. The proximity of the cafeteria contributed to the high number of people recorded eating or drinking (33 percent of the stationary users), in the same way that the overall hospi- tal site planning dictated the large number of people moving through it. Interviews with Users of the Garden oaks lend their grand dignity to the space, pro- A total of 50 people were interviewed in the viding a beautiful focal point from afar and the garden; two-thirds of them were women. Of comfort of protected seating beneath. Visitors those interviewed, 27 were staff, 11 were visi- were observed bringing their dogs to visit with tors, 8 were outpatients, and 4 were inpatients. inpatients on the lawn, and the feeling is truly Almost half reported using the garden every one of an enjoyable suburban park. day or several times a day; a third used it “occa- Many seating options are provided, with sionally.” With the presence of picnic tables, benches located along the walkways, some in ample seating (see Map 8–2), and an adjacent the sun and others in dappled shade. There cafeteria, it is not surprising to find that one- are permanent stone tables and stool-like seats fifth reported spending periods of more thanMap 8–2: in clusters, and wooden picnic tables thatThe CentralGarden, change orientation with the lawn-mowingExperiential schedule. There is a well-used covered patioAnalysis with tables and chairs directly outside of the cafeteria’s plate glass windows. There are two maps for newcomers, and a pay phone. Ash- trays and trash cans abound, and the grounds have a clean and tidy appearance. Garden Use Movement through the garden was constant and of such an intense rate (see Map 8–3) that the speed of the observer in tracking and recording this activity became a limiting factor during the first phase of the study. The passers- by are underrepresented perhaps by 15 percent. However, of the 1251 people recorded during the two mornings and two afternoons of obser- 40 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 43. ciated by everyone we spoke with, especially Map 8–3: by staff, who were thankful for the contrast The Central between the indoor and outdoor environ- Garden, Users Passing ments. A female employee who comes out Through once or twice a day to relax, talk, eat, stroll or visit with a patient responded, “You can get away from the fluorescent lights, sounds, and smells of a hospital; listen to the birds, the breeze. It’s a tremendous place to unwind.” TABLE 8–2 Percent of Respondents Who Named These Qualities as What They Liked Best Percent Trees, plants, flowers 82 Aesthetic attractiveness and design 7230 minutes in the garden, and nearly three- Serenity, quiet, “escape” 54fourths took breaks of 10 to 30 minutes. This Birds, squirrels, open air, sun 50contrasts with Alta Bates’ roof garden, in which Expansiveness, open space 8relatively few used the garden for 5- to 10- Human companionship 4minute breaks. (Number of respondents: 50)TABLE 8–1 Another employee uses the garden severalPercent of Respondents Using Gardens for times a day and loves the trees, plants, and ani-Various Activities mals: “I feed the squirrels and birds. I have Percent two blue jays who come down to eat peanutsRelaxing 88 — and there’s George the squirrel (I speak flu-Walking through 84 ent squirrel!). I can recognize the baby squir-Eating 82 rels even though they’re now grown. I’ve evenTalking 70 come here on my day off!”Strolling 54 Several people felt it looked like a park orWaiting 52 “a country club.” Employees especially appre-Outdoor therapy 46 ciated its tranquillity:Visiting with a patient 42 I like the openness, the grass, birds, the breeze.Kids playing 18 Although there’s a lot of people around, there’sAttending a meeting 16 a quietness about it. It reminds me of a campus.(Number of respondents: 50) Photo 8–2: While “relaxing” appeared high on the list This walking routehere and at all the case study gardens, at this from the parkingKaiser facility a higher proportion than else- structure to the main hospital lobbywhere reported using the garden for eating, is highly used. Thevisiting with a patient, watching their kids multistory buildingplay, and attending an outdoor meeting. Al- is dwarfed by themost half reported there were no impediments tree and recedes,to their using the garden, and most of the re- while the lawnsmainder — as at other sites — reported weath- create a soothinger and work as the only serious impediments. green milieu. The garden was highly regarded and appre- Case Study: Kaiser Permanente Medical Center, Walnut Creek, California: Central Garden x 41
  • 44. Photo 8–3: I work in the operating room. We have no win-Wide walkways dows; it’s very cold with artificial light. This isoutside patient the complete opposite — it gives me a lift torooms provide a come out in the natural light.buffer from gardenactivities, and en- I feel more calm, more relaxed. If you want toable patients in get away from things, just sit under a tree andbeds or wheelchairs reflect — things usually get be brought out- It’s very soothing because it’s so different fromside. Seating con-venient to the the interior of the building, which is stressful.rooms is often uti- This is a complete opposite.lized by visiting I’m back to being me again. This is absolutelyfamilies. my little spot to get centered and heal myself. I like it when I do swing shift; at dusk you could I work in ICU, which is like a hellhole. For the imagine this is your backyard. I like the tranquil- first four hours I just run. Sitting out in the lity. It has a certain peace about it. warm sun is like therapy to me. I can relax, gath- er my thoughts. I feel like I have my head Visitors and outpatients appreciated having screwed on straight. a relaxing place in which to wait, and a female Visitors and patients who used the garden inpatient remarked: felt strongly about how this place facilitated a I really hate hospitals a lot. I get tired of my change in mood. An outpatient who told us she room. It’s so much nicer out here — I like see- brought visitors from Europe to show them ing the grass and hearing the birds. I come out what a nice hospital looks like remarked: several times a day to sit or stroll or have a smoke. My favorite time is the evening when It doesn’t feel, smell, or look like a hospital. everything is really quiet. ... It’s much better Coming to a hospital scares and worries people. than sitting inside and watching the boob tube. Being in the garden before or after visiting the doctor is good, regardless of what you find out. I feel more relaxed. TABLE 8–3 Percent of Respondents Reporting Various A woman waiting in the garden while her Types of Mood Changes husband was at an appointment responded, “I Percent feel more peaceful out here. I get very tired waiting for them to tell me how he’s doing. Calmer, more relaxed 86 I’m not as tired outdoors.” Stronger, refreshed 24 A woman in labor was strolling through the Escape from work 18 garden, waiting for the birth of her child. Moves me, a religious connection 6 “This is my first time here. I’ve been admiring Better, positive 6 the trees, the landscape, the quietness, the No difference in mood 6 birds. It’s really relaxing — when I’m not hav- Helps me think through problems 4 ing a contraction.” (Number of respondents: 50) A male inpatient was occupying one of the rooms that open out onto the garden: When we asked if people felt any different I really hate hospitals, but having this room — it after spending time in the garden, the most doesn’t bother me so much. I feel a little easier, frequent and consistent response was: “Yes — a little more relaxed outdoors. When people more relaxed.” A garden and a hospital are al- come to see me, we can sit out here and it makes most polar opposites on a continuum from a much nicer visit. It’s really relaxing to know that other people enjoy it, too. controlled to natural, from stressful to relax- ing. It is small wonder that staff and employ- People had no trouble “connecting” their ees felt so passionately about this garden in the change in mood with specific characteristics of midst of their work environment: the garden, even if — as some said — they 42 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 45. hadn’t consciously thought about this before. A female inpatient interviewed near herFor many, it was a whole range of elements. room particularly liked “listening to the birds;For a male employee who used the garden at it’s quiet here. I like to see other people sittingleast once a day it was “the shade from the and relaxing on the benches. I can’t get outtrees, the breeze, the birds, the colors, the there, but it’s neat; it’s really relaxing.”sounds of the leaves, the squirrels running up A visitor to the hospital who occasionallyand down the trees, no litter in sight.” uses the garden liked “the landscaping, the birds. You can get a cup of coffee, sit back, andTABLE 8–4 look at the trees. Every time I come, it’s a dif-Percentage of Respondents Who Named These ferent season. It takes your mind off whateverQualities as Helpful in Attaining Mood you’re here for.”Change The huge oak trees elicited a lot of positive Percent comment, particularly their size, their greatTrees and Plants 86 age, the wildlife they harbored, and, for some, the memories they evoked. A male security Trees 36 guard who patrols the garden liked the tran- Greenery 18 quillity and peace “... and the large trees, when Nature 14 the wind blows through the branches. It’s a Colors 10 sound I got used to as a kid growing up in the Flowers 6 Arizona countryside.” Seasons 2 For others it was the oasislike quality of theFeatures involving auditory, 60 space that helped evoke a change in mood. Aolfactory, or tactile sensations male employee who comes out to sit and eat Birds, squirrels 24 several times a day feels calmer as a result and Fresh air 12 attributes that to “the trees, the grass, birds, Shade 10 animals — its like an oasis among the con- Light and sun 8 crete, yet it’s close to whatever you need. You Sounds, smells 6 have to stay conscious because you can getPsychological/social aspects 64 into a mood and forget about the time.” Peaceful 18 A male outpatient also liked the enclosed Openness, largeness 14 feeling: “I liked the fact that it’s surrounded by Escape 10 buildings ... it’s kind of nestled, protected. But it’s not too close to the buildings; you don’t Oasis 8 feel you’re in an urban park.” Privacy 6 Map 8–4: Watching others, companions 6 The Central No traffic noise 2 Garden,Visual qualities relating to more 26 Stationary Usersthan plant materials Visually attractive design 14 Variety 10 Texture 2Practical features 26 Places to sit 12 Good maintenance 6 Accessible 4 Pathways and amenities 4Don’t know; no answer 10(Number of respondents: 50) Case Study: Kaiser Permanente Medical Center, Walnut Creek, California: Central Garden x 43
  • 46. Though this space is not large by park stan- spring 1995 for the convenience of smokers who dards, we got the sense that people experienced need to come outside. While this looks onto the it as spacious because of the planting that garden, the smokers don’t annoy nonsmokers by screened some of the surrounding buildings; sitting next to them on a garden bench. because — by hospital standards — it is a large open space; and because for some, it is such a TABLE 8–5 contrast to the small spaces in which they live Percent of Respondents Who Desired These and work. Changes A female employee confided: Percent When I work evenings, I come here two hours Change nothing 46 early and just sit here! In my life, this is a vast space. I live in a little condo, work in a little of- Planting changes 22 fice in surgery. This is like a vast open space to More flowers, color 16 me! The patients come out here all the time — More trees, shade 6 pregnant women waddle around. They say, Aesthetic and planning improvements 16 “This is such a great space, so soothing. Who’d believe this was here?” Add a water feature 8 Make it larger 4 Finally, for a few people, it is not so much Create a Japanese garden 2 the trees, the fresh air, animals, and openness Move freeway 2 that help change their mood, but the compan- ionship and good spirits of other people in the Practical changes 14 garden, particularly, it seems, the gardeners. Drinking fountain 4 One employee who admitted, “I’d be out here More tables 2 all day long if I could,” added, “The gardeners More seating 2 keep us laughing all the time. They do such a A shelter for rainy weather 2 good job, keeping the garden. It’s a joy to have More designated smoking 2 them out there.” In creating a garden for ther- Add sports facilities 2 apeutic outcomes it would pay not only to de- Policy changes 12 sign it with care, but also to select maintenance Better maintenance 6 staff for their sensitivity and good humor. Ban smoking 2 Just under half wanted no changes made to Stop removing trees 2 the garden. Others wanted to see planting im- Less construction 2 provements — especially more flowers, the addi- tion of a water feature, a drinking fountain, more (Number of respondents: 50) tables and seating. Compared with the other sites we observed, Kaiser has provided well for Conclusion smokers. A small three-sided, roofed structure Hospitals are obviously associated in most with comfortable chairs inside was erected in people’s minds with illness, accidents, and death. It is clear from observing — and talkingPhoto 8–4: with — people in the garden at Kaiser WalnutCasual seating Creek that the presence of life just outside isalong the walkway enormously therapeutic. The trees, the birds,provides a conve-nient resting spot. the squirrels, children playing — all remindWood decking and people that “life goes on.” An outpatient wait-a circular bench ing for her appointment felt “rested spiritual-protect the roots of ly” in the garden: “It’s a privilege to be heritage oak Look at this incredible oak tree — it’s a uni-while providing verse in itself.” Several patients and employeesseating with anarray of vistas and mentioned the fact that the garden made thisinformal play Kaiser facility unique and that they used (orspace for children. had taken a job at) Walnut Creek specifically 44 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 47. because of its soothing milieu. One of the gar- Photo 8–5:deners told us, “They call this Kaiser ‘the A covered patiocountry club.’ ” off the cafeteria One employee who had worked in many provides shade and shelter for an out-medical facilities since 1959 rated this — be- door eating areacause of the garden — as one of the best. And within the garden.a male employee who uses the garden everyday, sometimes to do work-related reading,summed it up with: I work in the operating room — no windows. The diurnal cycle is interrupted. Out here, it’s open to the sky. It fits with the holistic idea of what I think healthcare is. It’s not only medicine and physical treatment; you also have that part that’s unique to the individual called the soul. This garden helps to revive that. Case Study: Kaiser Permanente Medical Center, Walnut Creek, California: Central Garden x 45
  • 48. 9. CASE STUDY: CALIFORNIA PACIFIC MEDICAL CENTER, GARDEN CAMPUS, SAN FRANCISCO1: The GardenR ESPONDING TO THE need to rehouse 9–1). The garden has a mature feel, as much of the many patients displaced by the the original perimeter planting has been re- 1906 earthquake, the Home for the In- tained. A large camphor tree dominates, alongcurables was opened on this site in 1915. In with other gnarled fruit trees and the vestiges1938 the facility changed hands, was renamed of the formal yew and boxwood plantings. Anthe Garden Nursing Home, and began provid- addition to the west wing of the hospital addeding an array of rehabilitative services ranging a long balcony off the day room on the thirdfrom cardiac and respiratory therapy through floor, which meets grade and leads down intophysical therapy and vocational counseling. the garden. In view of the balcony’s locationToday this small private hospital for patients directly over the garden, and the direct path-of moderate means is in transition. It currently way down to ground level, the balcony was in-offers post-acute care and hospice services to cluded in our observations as part of theAIDS and other chronically ill patients. The garden (see Photo 9–5). This sunny elevatedaverage length of stay at Garden Campus is spot proved to be the most used area, offeringaround 30 days. Map 9–1: The garden is now an important feature of The Garden,this facility, but it also played a prominent role Illustrative Planin the history of this site. Several photo al-bums kept by the administration track the var-ious changes and momentous events. The staffhere are proud of the garden, and it is an inte-gral part of the hospital’s identity.Physical Elements and SiteLayoutThe original garden was a formally laid outherb garden with lawns, circular paths, andlarger shrubbery and trees around the perime-ter. The plan has been modified several timesand now incorporates two glazed shelters withtables and chairs, two larger patio areas, one inthe sun and one predominantly in the shade,and a volleyball/basketball court (see Photo1 Due to hospital remodeling during the research period,this case study is descriptive only. x 47
  • 49. Photo 9–1: cy, being bounded by the building on twoThis interesting sides and steep slopes of mature planting onand eclectic garden the north and eastern edges. The small num-offers a variety of ber of patients and the temporarily emptyuses from active topassive. Particu- floors, as well as the mix of design styles andlarly interesting is utilitarian functions within the garden, con-the incorporation tribute to the timeless and almost “forgotten”of a basketball/ feeling of this space.volleyball court,which is highlyused by the chil- Garden Usedren of patients Awareness of the garden and pride in it con-and visitors. tribute to the continued utilization of this outdoor space, despite the serious accessibility accessibility, wind protection, and a view of issues. During the 12 hours of observation, the entire garden. 131 user-observations were recorded. In addi- There are four main access points in the tion to the staff using the garden for their garden: a gate to the physicians’ parking lot, breaks, half of the reports were of patients one door off each of the second-floor wings of and guests coming out for strolls and visits. the building (see Photo 9–2), and the path On the weekend, the space was used by chil- down from the balcony off the third-floor day dren playing while family members visited room (see Photo 9–3). Due to current renova- with others inside, and during one of the ob- tion, the hospital houses only 18 patients, all servation periods, the garden was being set up on the third floor of this west wing. Accessing for a volunteer appreciation party later that the ground level of the garden from this ward afternoon. necessitates either descending 17 concrete The staff have commented upon the drop steps down the slope adjacent to the balcony, in the use of the garden since the reduction in or using the main interior elevator and passing the number of patients, and the subsequent through the empty second floor to the garden closing of all but the third floor of one wing. doors. The garden is approximately 95 feet by However, during our observation the staff 135 feet, with about one-third of the area were seen to encourage patients to spend time being a heavily planted embankment. outside, and they themselves would come to the balcony rail for a glance out and a deep breath before returning to their tasks inside. Atmosphere and Ambience The feeling about the garden is demonstrated Located between a residential and retail/small by an episode that took place while three em- commercial neighborhood, the 2 1⁄ 2-story, L- ployees were on a break. They became shaped hospital building nestles into the concerned about the health of the rosemary southwestern slope of Laurel Heights in SanPhoto 9–2: Francisco. The garden is on the uphill side,Appealing and behind the building; while breezes eddyconvenient access through the space, the prevailing winds areat ground level thwarted by the hospital itself. The freshnessdraws people intothe garden. Wide, of the salt sea air is a reminder of the proximi-smooth walkways ty of the ocean, and even on sunny days thefacilitate use by rhythmic sound of a nearby foghorn remindspatients on gurneys one of the preciousness of this secluded andor in wheelchairs. relatively protected spot. This entire facility has an intimate feeling, with the street facade resembling an old ex- pensive hotel rather than a medical center. The garden in turn creates a feeling of intima- 48 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 50. Interviews with Users of Photo 9–3: Old yews, boxwood The Garden hedges, and formal Seven people were interviewed while spending stairways con- time in the garden at this site. Of these, five tribute to an were women and two were men; four were staff atmosphere of timeless elegance. and three were visitors. Only one patient used the garden during the interview periods despite the fact that almost a fifth of the users during the observation period were inpatients. This pa- tient was unable to speak due to a recent stroke, but his wife did participate in the interviews. The medical staff reported that with the down- sizing of the hospital and the relocation of the post-op patients, the general health of the pa- tient population had declined during the study. During the interview phase of the study, the majority of patients were confined to their beds and unable to be moved into the garden. De- spite this situation, we were able to record the comments of several visitors and staff regarding patient use of the garden. One nurse supervisor told of patients requesting to be moved into theground cover on the slope below the balcony garden just before they die, so that they mayon which they were standing. They took it spend their last minutes outside. Another re-upon themselves to slosh water out of a plastic ported that when the hospital was full, and therebin, onto the plants below, making several were more healthy AIDS patients, “there weretrips in to the sink, to make sure that they got always people in the garden: patients alone orenough. with visitors, having barbecues and such.” The layout of the hospital grounds is such Of the seven visitors and staff that were in-that it is equally convenient to travel inside as terviewed, all reported that it was a relaxing en-outside when moving between most destina-tions. The significance of this is that the peo- Map 9–2:ple observed passing through the garden were The Garden, Usersmost likely doing this as a reflection of their Passing Through or Playingpreference for an outdoor route (see Map9–2). Although most of the users of the gardenwere stationary, a fifth of the uses recorded inthe garden were children playing. Althoughplaying was recorded at all of the case studysites, this site presented not only the largestpercentage of this activity, but also childrenplaying for the longest time, and on their own.Their parent-visitors were observed to cometo the balcony railing from time to time tocheck on their children, and then return to thebedside. The children, however, happy to beplaying, entertained themselves for extendedperiods of time. The easy observation fromthe balcony (see Photo 9–1) and the secure na-ture of the garden both contributed to thisphenomenon. Case Study: California Pacific Medical Center, Garden Campus, San Francisco: The Garden x 49
  • 51. Map 9–3: responded that there was not anything. How-The Garden, ever, one employee was quite vocal aboutStationary Users being “too damn busy ... most of the time pa- tients can’t be taken out here, there isn’t time. ... If I do take a patient out I can’t relax ... I have a lot of patients who can’t do anything for themselves.” The only other impediment was mentioned by an employee who commented that he “can’t play basketball at night.” More flowers, specifically fragrant flow- ers, followed by concerns expressed regarding the upkeep of the garden were the two pre- dominant requests in response to the question, “Is there anything you would like to see changed or added?” One employee commented: I hope they keep it up; more flowering plants with a nice aroma. You’re dealing with a lot of elderly patients ... I wish more of the patients could get out here. That’s why I pick the flowers for the patients. The jasmine is nice, the smell if vironment. One staff member indicated that she we can get it to waft into the rooms. When you was not able to relax in the garden because her put jasmine under their nose, they just light up. focus was on the patients rather than on herself: Another: It is quiet and peaceful ... (but) if you go out with the patient, you don’t think of yourself, you are I’d like to see more flowers, (but) ... they’d have thinking of the patient. to hire someone to take care of it. Outdoor lighting was not directly men- What Users Liked Best About tioned by the users who were interviewed; The Garden however, two of the respondents referred to The most attractive aspects of the garden drawbacks that could be solved by providing for the users were the quiet atmosphere and illumination at night. In addition to the com- the sense of being removed from the hospital ment about playing basketball at night quoted (see Photo 9–4). The plants and flowers were above, another staff member said: credited with providing this feeling. One em- I used to work the PM shift, and I didn’t see it ployee commented: that much. The flowers ... I’ve always been an It’s nice looking at the flowers, getting out of outdoors person ... it is a nice treat (to see them). that claustrophobic place. It’s like a safe haven.Photo 9–4:Glazed shelters And another:trap the heat, pro-vide protection It is serene, tranquil. Up here (on the balcony)from the breeze, you can hear the wind going through the treesand create private and I like the sound of that.seating areas.Features such asthis extend the use Impediments to Use and De-of the garden into sired Changes in The Gardenmany months of Interviewees were asked if there was “anythingthe year. that prevents or inhibits you from coming here as much as you would like.” Most people 50 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 52. What Happens to People in Photo 9–5: Patients on a shel-The Garden? tered balcony offIn response to the question “Do you feel any the day room par-different after you’ve spent time in the garden?” take of the viewsall of the respondents said yes. Typical of com- and fragrances in the garden. Thements from the staff was the nurse who said: nursing staff often (I feel) more relaxed, ready to go do my work. It pop out to check on gives me time to plan what I’m going to do patients, while when I get back to work; it clears my head.” staying longer and enjoying the gar-and the doctor who said: den themselves on their breaks. Note If I play basketball, I feel very different, (and the fragrant even) if I don’t, and just go out for a few min- usage of the garden. The focus of the service climbing rose on utes, I feel better. provided here is necessarily more on “quality the arbor in theor the visitor who commented: of life” than on the more immediate goal of foreground. medical stabilization at other institutions. Pa- Because his room is so small, it is relaxing to tients’ emotions are addressed as a necessary come out here, you catch air ... you don’t know part of the treatment agenda. Similarly, the you are in a hospital. significance of the ongoing support of visitors increases in proportion to the length of stay ofSpecifically Helpful the patients. The garden is a tremendous assetCharacteristics in allowing the residents and visitors to feel asSeveral qualities of the garden were listed comfortable as possible.specifically in connection with the mood The reports of frequent family picnics inchanges experienced by the users who were in- the garden, the intense use by children, theterviewed. Getting out into “fresh air and observations recorded by nurses of the emo-sunshine” and the trees and greenery were tional changes in the patients after spendingconsidered to be the major factors. time in the garden, all speak to the increased One staff member spoke of the greenery, level of satisfaction and contentment that canand also of what the garden represents: be gained by having access to an outdoor space. Additionally, secondary benefits to the The existence of plant life in general is a relaxant. patient include the facilitation of more fre- And I think just that it (the garden) exists is heart- quent and longer visits from family and loved warming; someone cared enough to put it here. ones, and being cared for by a staff who have A nurse spoke about her witnessing changes the opportunity to rejuvenate themselves. In ain the patients when she brings them out into demanding field such as healthcare, providingthe garden: for the needs of all the participants, thereby To the patients, the garden is like a pet; it just maximizing all of the potential support-ener- makes them come up if they are depressed. You gy, is critically important. should see the expression on their faces, the The garden design and issues of accessi- body language. They just bloom up ... or it could bility play a significant role in the success of make them sad, because it makes them think of this garden space. The direct benefit of the their garden at home ... you have to watch their garden for inpatients is tremendously in- body language, how they breathe, their eyes. creased by the availability of the outdoor bal- Greens do make a physical change. cony space immediately adjacent to the day room (see Map 9–3). Patients are brought outConclusion here to watch and enjoy the goings-on, whileThe nature of the Garden Campus, offering the proximity to the unit allows the staff topost-acute care and hospice services with a check on them regularly. When the secondlonger length of stay, directly influences the floor is again open, the accessibility off the Case Study: California Pacific Medical Center, Garden Campus, San Francisco: The Garden x 51
  • 53. Map 9–4: volleyball/basketball court is an additionalThe Garden, draw for younger visitors, and is an outlet forExperiential the release of pent-up energy by the staff (seeAnalysis Map 9–4). The garden at California Pacific’s Garden Campus is a private and secluded oasis that has served many purposes over the years. Today it is again in transition, and like the institution it- self is underutilized. Yet the sensitivity of the staff to the patients’ enjoyment of the garden and its healing benefits, as well as the ethos and pride that this institution has in its namesake, continues to enable this facility to take the best advantage of this asset. (Is it a coincidence that of the units available, the one with the best ac- cess to the garden is the one remaining open?) The staff’s patient loads have increased, and they feel overworked, yet they care for the gar- den on their breaks and come to work early to be able to enjoy it. Everyone encountered at this facility spoke of a desire to have the garden kept up as a contributing aspect of the hospi- tal’s treatment services. Indeed, plans are in the west wing will offer the same advantage. Addi- works to modify the garden to accommodate a tionally, wind shelters, and patio surfaces and future Alzheimer’s unit. walls to reflect the heat are used by patients to moderate San Francisco’s “natural air-condi- (At the time of printing, the Garden Campus site of tioning.” Thus, the patients have a way to stay California Pacific Medical Center has been tem- warm without having to be directly exposed to porarily closed in order to expedite the renovations the sun’s rays. The unexpected existence of the and an anticipated merger.) 52 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 54. 10. AGGREGATE DATA ANALYSIS OF THE CASE STUDY SITESI N THE PREVIOUS chapters, four hospital travel through the space to interior destina- garden case studies were presented. The tions play a role in the way the garden is per- use and therapeutic benefits of each of ceived and used. The focus of the aggregatethese exterior spaces was described. In this analysis is therefore not on users movingchapter the aggregate data is presented and through the space (though within the contextanalyzed to suggest overall trends. It is some- of the individual site, this is significant).what problematic to compile responses fromdiffering sites, and there are a few qualifica-tions that should be pointed out at this time. Aggregate Descriptive Data One hundred and forty-three users were inter- While the differences in physical settings viewed; 73 were female and 70 were male. 59among the research sites add to the breadth of percent were employees, 26 percent were pa-the study, they limit the aggregation of data. tients, and 15 percent were visitors. NearlyOne aspect of this is the array of differing ele- half of the respondents use the gardens everyments within the landscaped areas. This has day, or several times a day.been addressed in the analysis by focusing oncategories of elements, rather than on spe-cifics. For example, Kaiser Walnut Creek has TABLE 10–1two heritage oak trees that were mentioned by Frequency of Garden Use36 percent of the people as a significant factor Percentin their restorative process. There are relative- Several times per day 30ly few blooming plants at Kaiser, and only 6 Occasionally/sometimes 27percent of the respondents mentioned the Every day 18flowers. In contrast, San Francisco General 1-2 times per week 14has no heritage trees, however it had 35 differ- First time here 11ent species of plants blooming at the time ofthe study. As might be expected, 42 percent of (Number of respondents: 143) 100those people interviewed at San FranciscoGeneral mentioned the flowers, while only 4 We asked the users of the gardens to indi-percent mentioned the trees. For the purposes cate one or more activities that they engagedof the aggregate analysis, these two items have in from a list of 10 options. All but 8 of thebeen grouped together under the heading of 143 users reported that they come to “relax.”“trees and plants.” A second difference among More than half of the users said that theythe four landscapes is the site layout. The gar- come to talk, eat, stroll in the garden, and/orden’s relationship to the buildings, how many come for their own, undefined “outdooraccess points there are, and the efficiency of therapy.” x 53
  • 55. TABLE 10–2 the space (it is peaceful; an escape from work; companionship; etc.).Percent of Respondents Using Gardens for Var-ious Activities Percent Comparative Analysis of theRelax 94 Aggregate DataEat 73 When looking at the activities in relation toTalk 73 the different types of users, there were someWalk through 68 expected results and some associations thatStroll in the garden 61 were not anticipated. Predictable responsesOutdoor therapy 53 were documented by those interviewees re- porting that they came to the garden toWait 38 “relax,” to “stroll through,” and to engage inVisit with a patient 36 “outdoor therapy.” Each of these activities hadLet their children play here 12 a representative spread within the staff, pa-Work-related meeting 11 tient, and visitor types. Also, as might be an-(Number of respondents: 143) ticipated, differences in frequency of response arose for “work-related meetings,” “eating,” and “waiting.” The staff reported the most in- Ninety-five percent of the users of the gar- stances of meeting and eating outdoors, withden reported that they “feel different” after the visitors and patients tied at the top of thespending time there. Just over three-quarters list of those who choose to wait in the garden.of the respondents described feeling more re- Less expected were the results of inquirieslaxed, and calmer. Somewhat less than a quar- regarding “talking” in the garden. The vastter of the users reported that they felt majority of employees reported that they talkrefreshed, rejuvenated, or stronger, while as while in the garden, as did close to two-thirdsmany again spoke of being able to think more of the visitors. However, almost half of the pa-clearly, find answers, and felt more capable tients said that they did not converse whileafter being in the garden. they were there. One explanation for this mayTABLE 10–3 be that visitors specifically come to the hospi- tal to talk and be with a patient, and staff arePercent of Respondents Reporting Various in a work environment where they haveTypes of Mood Change friends and acquaintances, whereas patients Percent are isolated from their social milieu and knowMore relaxed, less stressed, calmer, contented 78 relatively few people. However, another possi-Refreshed, rejuvenated, stronger 25 ble explanation is that the situation of under-Able to think, find answers, cope 22 going treatment at a medical facility mayPleased, better, more positive 19 increase one’s desire to get away and be alone.Religious or spiritual connection 6 The total number of interviewees who haveNo difference in mood 5 used the hospital gardens as a play area for their children was relatively small. However,(Number of respondents: 143) the rate of usage between the user types was nearly equal (see Figure 10–1). Similar results Of those specific characteristics or qualities were recorded for those users who “visit with aof the garden named by users as helpful to patient.” Again, the total percentage of usersthem, two-thirds of the respondents men- who visit with patients was not large, but thetioned trees, flowers, and plants. More than differences among rates of usage was revealinghalf mentioned features that involve either (see Figure 10 –2). The fact that the employeessounds or smells or tactile responses. Exactly engage in both of these activities indicates thathalf of those answering this question men- the garden increases the number of optionstioned the psychological or social aspects of open to the staff. It gives employees more flex-54 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 56. ibility in their choices of how they work — and often provides a level of privacy otherwisewhether they talk with patients indoors or out- unavailable. This adds variation into the work-side — and also how they integrate their em- day of the employee, and contributes to aployment and their personal lives. sense of autonomy, so compromised for inpa- tients, as well.TABLE 10– 4 When looking at the association betweenPercent of Respondents Who Named These mood changes and user types, the results con-Qualities as Helpful In Attaining a Mood firmed our expectations. Approximately equalChange proportions of visitors, patients, and staff felt a Percent rise in energy and reported being refreshedTrees and plants 69 and rejuvenated. Similarly, close to even pro- portions reported a cognitive shift (they had flowers, colors, greenery, heritage trees, being in nature, seasonal changes thought things over or had worked out a prob-Features involving auditory, olfactory, 58 lem, etc.). There was a predictable differenceor tactile sensations between the rates within the user types who birds/squirrels, wind/fresh air, water, felt more relaxed or calmed down (a drop in quiet, light/sun, shade, fragrances energy level) (see Figure 10–3), and also be-Psychological or social aspects 50 peaceful, escape from work, openness/ FIGURE 10 –1 large, privacy/secret places, oasis, companionship, watching others, The Percentages of Each User Type Who Bring knowing it is here Their Children to Play in the GardenVisual qualities relating to more than 26plant materials Bring Kids to Play Here attractive landscape design, views, 14% variety of elements, textural contrast/ 12% quality, differing shapes/sizesPractical features 17 10% seating, well maintained, accessibility, 8% vending machines, smoking allowed, pathways 6%No answer or “don’t know” 8 4%(Number of respondents: 143) 2% 0% On one occasion a family was observed eat- Patient Visitor Staffing together in the garden. After playing withher two children for a period of time, the FIGURE 10–2mother kissed them good-bye and said thatshe had to “go back to work now.” Unusual The Percentages of Each User Type Who Visitthough this may be, the interviews reveal that with (Other) Patients in the Gardenthis is not an isolated incident. By using the Visit with Patientsgarden in this way, the staff are taking the op- 50%portunity to satisfy their personal needs in away that supports their work. 40% We also observed medical staff chattingwith patients in the garden. Some of these ap- 30%peared to be chance meetings. However, wedid observe staff and patients coming out to- 20%gether and having what appeared to be a seri- 10%ous conversation. The opportunity for staffand patients to choose this outdoor setting for 0%their meetings increases the degree of comfort Visitor Staff Patient Aggregate Data Analysis of the Case Study Sites x 55
  • 57. FIGURE 10–3 ly associated with location and accessibility. At all of the sites except Alta Bates, about one-halfThe Percentages of Each User Type WhoReport a Pleasing Drop in Energy Level of the interviewees were employees, with visitors and patients comprising the other half. In the Drop in Energy Level roof garden at Alta Bates, however, more than100% 80 percent of the users were staff members. As discussed in chapter 7, this is a garden that is at80% one end of the hospital site, far from the main entry. The entire interior area of that floor has60% recently been converted to a secure unit, forc- ing most users to come and go from a single el-40% evator at the end of the lengthy hallway that20% jogs its way through the various hospital addi- tions. Volunteers at the information desk were 0% unable to direct us there upon our first visit and Visitor Staff Patient it was not shown on any maps of the site. It is only visible from one set of patient rooms, ontween those who reported spiritual or religious the fourth floor, so even to learn of its exis-experiences and feelings (see Figure 10– 4). tence, one has to rely on an informal network The different user-patterns of these two of communication. The staff, with their longermood shifts could be expected considering that tenure there and their relative ease of mobility,patients are most probably physically ill, and are the predominant users.the most likely users to be depressed or sad. It The split between the proportion of visitorwould follow, therefore, that they would seek and patient users was relatively even for Kaiseran uplifting experience in the garden described Walnut Creek and Alta Bates. There wereby them as “religious” or “spiritual.” substantial differences between these groups at It was anticipated that some differences in San Francisco General, however, where manyresponses would arise among the different sites. more patients were interviewed than visitors.It was also expected that the length of time At this site, the issue is not one of accessibility;spent in the garden would be related to mood rather it is one of location. The garden is di-change. However, the analysis of the data did rectly outside two buildings that house severalnot support either of these assumptions. There outpatient clinics that primarily serve adultswere, however, differences in the proportion of (methadone maintenance, tuberculosis, HIV,user types at each site and these could be direct- family planning, etc.). The occasion for visi-FIGURE 10–4 tors to come here is much more limited than at a site adjacent to an inpatient building.The Percentages of Each User Type WhoReport a Spiritual or Religious Mood Shift In Summary Deeper Meaning This research has documented that people in12% medical settings use available outdoor gardens for therapy and emotional healing. Positive per-10% spectives and attitudes are known to support 8% better health and increased recovery rates from illness. The beneficial emotional changes re- 6% ported by patients after spending time in the garden, and being cared for by staff who have 4% the opportunity to rejuvenate themselves and 2% return to work more relaxed and refreshed, must then improve the healing environment. 0% Patient Visitor Staff The increased morale of the employees con-56 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 58. tributes to the smooth functioning of a produc- • opportunities for social interaction and ob-tive and efficient work force, increasing the level servation.of satisfaction for the total hospital community. By examining these sites individually and in Patients, visitors, and staff come to the gar- aggregate, issues of site planning, accessibility,den to help themselves to feel better. They do and the need for a space that is in contrast withthis consciously, and speak eloquently about the controlled and sterile internal environ-the gardens and their experiences there. They ment clearly come to the fore. In the followingcome to get away, to relax, and to think and chapter, design recommendations are present-build their strength. They report as significant: ed that arise from the discussions and inter-• plants and growing, living things views and the observations at both the case• varied sensory stimulation study sites and the sites presented in the typol-• facilitation of the psychological experience ogy chapter. of expansiveness and peacefulness Aggregate Data Analysis of the Case Study Sites x 57
  • 59. 11. DESIGN RECOMMENDATIONST HE FOLLOWING RECOMMENDATIONS Photo 11–1: have emerged from the case studies Children enjoy this imaginative maze, and from additional brief critical eval- lawn, and climb-uations of outdoor spaces at other hospitals ing tree in a court-described in chapter 5. The recommendations yard adjacent toare divided into three groups: the pediatric department ofA) locational, site-planning, and way-finding; this suburbanB) planting, seating, aesthetic, and detail; medical center.C) policy regarding the provision and mainte- Surrounded bynance of gardens intended to be used for ther- plate-glass win- dows, this spaceapeutic benefit. allows easy moni- toring, yet providesA. Locational, Site sound insulation for children whoPlanning, and Way-Finding need to let offRecommendations steam. (Kaiser PermanenteTo truly maximize the potential of garden Medical Center,spaces in hospital facilities, the design process Vallejo, CA)needs to begin with site planning. Many issuesthat we encountered in our research couldhave been mitigated or avoided if the provi-sion of potentially therapeutic garden spaces comfort. Design with particular awareness ofhad been considered from the beginning. Ac- issues of mobility and microclimate.cordingly, our recommendations start with a • People who are not well also tend to benumber of steps that are often overlooked. emotionally vulnerable and sometimes intel- Principles for site planning of therapeutic lectually impaired. Design for a sense of se-garden environments in healthcare facilities are: curity, serenity, and safety — with defined seating areas, easily readable pathways, and• Healthcare facilities are high-stress environ- clear designations — and remember the ments for staff and patients alike. Exterior symbolic takes on increased meaning as we environments should provide a contrast to grapple with our own frailties. the interior space, in order to facilitate a sense of “getting away.” Specific suggestions include:• Physically ill people are a vulnerable popula- 1. A professional landscape architect needs tion. They are acutely aware of their physical to be on the design team from the start to as- x 59
  • 60. sist with the determination of outdoor space 5. Outdoor spaces designed to optimize location, orientation, function, and ambience, therapeutic benefits need to have a degree of and to assess microclimates, accessibility, and enclosure or separation from the outside world anticipated user groups. — an entry lawn or landscaped setback from 2. Since there are likely to be multiple the street is not appropriate as the only space users (staff, inpatients, outpatients, visitors), available for use. with a range in ages, including children, the 6. Visibility of a garden space from inside planning of a new hospital, or hospital addi- for staff monitoring of patients is especially tion, should include consideration of a variety critical for long-term care facilities. Patio areas of outdoor spaces. These need to be varied as off day rooms are a successful combination. to type (i.e., front porch, roof garden, court- 7. Where there is sufficient room, divide yard, etc.) and design image: for example, an the space so that there are sub-areas of varying entry porch where people can sit and wait for size and levels of privacy. Some users come a taxi; a terrace or courtyard off the cafeteria alone and seek a space in which to sit that is for outdoor eating; an attractive viewing gar- comfortably private, while others may desire den where people waiting for appointments or distraction and social interaction. for items at the pharmacy can sit and look out 8. The interior and exterior spaces should at greenery; a ground-level or roof garden that complement each other. If patients near an has the immediate imagery of “a garden,” and outdoor space have private rooms, exterior which is furnished and detailed for quiet con- areas for social interaction and observation templation, eating a brown-bag lunch, medita- should be a priority. If nearby units have anPhoto 11–2: tion, strolling, and so on. open, multiple-bed floor plan, more areas forA covered sitting 3. Our field studies revealed that lack ofterrace with forest private conversations and withdrawing fromviews outside a day knowledge about the existence of a garden social interaction need to be offers conve- space is one of the most critical factors in its 9. Balconies or roof terraces with a view intonient access to the use. The location and visibility of such spaces a garden can add to the use of an outdoor space,outdoors in all is very important. One outdoor space should especially for those on gurneys or in wheelchairsweather, as well as be visible from the main entrance or therevisibility for moni- who cannot easily access the garden proper. should be clear and prominent directions as to These spaces need to be of ample size and havetoring by staff.Movable chairs its location. wide doors — perhaps automatic — so that visi-provide a residen- 4. The amount of time to spend outside is tors and volunteers, who may not be experiencedtial feeling while limited, especially for employees of a health- in moving patients, feel that the space is accessi-allowing for a care facility. A garden, courtyard, or roof ter-variety of social ble, without having to worry about mobility. race next to the cafeteria can draw people intogroupings. 10. The layout of the garden needs to be the fresh air, offering a choice and allowing(Monterey County easily “readable,” to minimize confusion forHospice, Monterey, them to take best advantage of the free time. those who are not functioning well. This is es-CA) Also, in most hospitals now, this is the only pecially true in nursing homes and facilities for space where one can eat and smoke. patients with psychological impairment. 11. Make sure that the garden is easily ac- cessible to patients and the paving surface is wide enough to accommodate wheelchairs and gurneys. B. Planting, Seating, and Detail Recommendations In keeping with the main focus of this report, the following recommendations on design de- tails and planting refer to garden spaces where patients, staff, etc., are likely to go to relax, to think and build their strength, and to get away 60 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 61. from the hospital environment. Our interviewsand case studies clearly indicate that three as-pects of design details are critical in facilitatinga change of mood and lowering stress. Theseare the presence of a variety of green, grow-ing, and living things; the stimulation of thesenses; and the availability of a variety of set-tings for both social interaction and quiet in-trospection. The following design principles can serveas guides to creating therapeutic garden envi-ronments:• Provide sensory stimuli that is noninvasive in character to draw our attention away from 6. Contrast and harmony in texture, form, Photo 11–3: the initial feeling state to an external focus. color, and arrangement of plant materials pro- This roof terrace• Facilitate physical and psychological move- vide a variety that holds the attention and in a larger urban helps to draw our focus away from ourselves. hospital offers a ment with pathways and/or vistas through to promenade for a variety of types of spaces, thereby assisting 7. Plant species that attract butterflies call strolling (to the a shift in perspective. attention to the ephemeral, serving as a gentle right of photo) and• Create areas for safe seclusion as well as so- reminder of the preciousness of life. semiprivate seat- cial interaction to help think and work 8. In addition to providing an external ing clusters incor- through issues. focus, sound can create a psychological screen porating the warm (white noise) that serves the restoration textural materials of brick and wood. Specific suggestions to achieve these goals are: process. A water feature can provide this The terrace offers 1. Lush, colorful planting that is varied and pleasing and soothing sound. Care should be sun or shade, andeye-catching so as to suggest the image of a gar- taken to place it in a wind-protected location views towardden. Over and over, trees, plants, and greenery where people can sit nearby, and where air- greenery or overwere cited as the most significant helpful char- conditioning or other irritating noises do not the city skyline. (St. Mary’sacteristic. create too much competition. Hospital, San 2. Appropriate plant selection, with special 9. For the comfort of users, where offices or Francisco, CA)attention given to cultural requirements and patient rooms border the garden, create acorrect placement in the garden, is one of the planting buffer of sufficient distance and depthessential elements of a therapeutic garden envi- so that people walking or sitting in the gardenronment, as dying and unhealthy plants have a do not feel that they are intruding on the pri-negative psychological impact on those observ- vacy of those them. 10. Paths that meander allow for strolling 3. Flowering trees, shrubs, and perennials and contemplation and complement moreprovide a sense of seasonal change that rein- heavily used direct routes between accessforces one’s awareness of life’s rhythms and points. Where the space is large enough, pro-cycles. vide varying vistas, levels of shade, and tex- 4. Trees whose foliage moves easily, even in tures of planting along these routes.a slight breeze, draw the user’s attention to the 11. Select paving surfaces that are smoothpatterns of color, shadows, light, and move- enough to accommodate wheelchairs and gur-ment. This was described by interviewees as a neys.soothing and meditative experience. 12. In long-term facilities, arrange entrances 5. Features to attract birds — such as a to the garden and width of pathways so thatfountain or birdbath, a bird feeder, trees ap- volunteers or family members can easily bring apropriate for roosting or nesting — stimulate patient on a gurney or in a wheelchair out intothe senses and help to lift people’s spirits. the space. Design Recommendations x 61
  • 62. Photo 11–4: or eat, especially where the space is adjacent toLocated off one of the cafeteria.the arterial hall- 22. Adjustable umbrellas allow people toways of this major control the amount of sun or shade, so impor-medical center, awell-tended, dra- tant to those who feel unwell or are taking cer-matic display of tain medications.color provides a 23. Wind shelters, heat-reflecting surfaceswelcome surprise — or alternatively, shade-producing arbors —and can be enjoyed and other structures and planting help to miti-both from the in- gate the climate, and extend the use of the gar-side and from theoutside. The pri- den into several seasons.vate windows on 24. Where there is a view, make sure that 13. Electrical outlets allow for the gardenthe surrounding some seating faces that direction to facilitatewalls are ade- to be used for hospital parties or other spon- psychological movement out of the space. Ifquately screened sored functions, extending the use to other the exterior space is a roof garden or terrace,with shrubbery people who may not usually come. the edge rail, balustrade, or planter should beto minimize the 14. Nighttime lighting maximizes the ther-“fishbowl” feeling sufficiently low or transparent so that people apeutic benefit by allowing people to use thethat such spaces seated can take in the view. space safely after dark, or to look out at theoften create. 25. Where there is not a ready-made view,(Stanford garden from indoors. a sense of mystery and movement can be cre-University 15. Seating arranged for social interaction ated by designing smaller-scale glimpses andMedical Center, (right angled or centripetal benches, or mov-Stanford, CA) intriguing focal points within the garden, to able chairs) near to the entrance into the gar- draw the users’ attention and, sometimes, fa- den adds convenience, as this area will likely cilitate a change in perspective. be used for quick smoking breaks by staff who 26. Providing one or more eye-catching know each other. and unique features by which people will iden- 16. Seating partly enclosed by planting, or at the perimeter of an open space, provides aPhoto 11–5: degree of privacy for those wanting to beMovable chairs, alone, or who want to observe from a distance.tables, and parasolsallow users to enjoy 17. Fixed seating with backs for sitting inthis community comfort is especially important for gardenhospital’s small users who may be physically weak.courtyard in a va- 18. If bench-type seating is provided, selectriety of ways. a material that is appealing to the touch (i.e.,Proximity to the wood) and a size (4 – 6 feet) such that one orcafeteria con-tributes to the use two people can “claim” the space. The imageof this space. (No- might be of a garden bench, rather than a parkvato Community or bus stop bench.Hospital, Novato, 19. Increase the seating options availableCA) with movable seating so that users can meet their own particular needs. These chairs can be moved, selecting the degree of sun and shade, as well as determining the size of the seating cluster. 20. Benches, platform seating, or planter- edge seating with something to support the back allows people to sit with their feet up — or they can lie down to take a nap or sunbathe, as was frequently observed. 21. Tables with movable chairs or benches provide for users who want to hold a meeting 62 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 63. tify a garden — such as a sculpture, wind Photo 11–6:chimes, an aviary, a fish pond — serves to an- In all four casechor memories of the garden and the restora- studies, a complete contrast to the in-tion achieved there. terior environ- ment was muchC. Policy and Maintenance appreciated by pa- tients and staff.recommendations Even in an urbanOne of the interesting contrasts that we dis- environment thiscovered during our canvassing of potential re- small space outsidesearch sites was that we encountered what the hospital walls was inexpensivelyappeared to be more emphasis on the garden transformed byspaces and a greater awareness of potential to the space, labeling the gardens on posted volunteers into antherapeutic benefits at the public institutions maps, and listing them in the resource hand- intimate settingthan at private facilities. The older public fa- book at the information desk would go a long that contrasts withcilities take great pride in their gardens, and way toward promoting their use and reaping the controlled inte- rior. (Lagunathere was a high level of awareness of their their rewards. Honda Hospital,place in the healing milieu of the facility. Pri- 2. Educating employees about the existence San Francisco,vate institutions, on the other hand, appear to and therapeutic benefits of exterior spaces will CA)view incorporated gardens primarily as cos- increase their use of the gardens and con-metic elements. Older established gardens in tribute toward a refreshed, rejuvenated, andthese private hospitals have gone to seed, or more productive staff.have been encroached upon. Decisions made 3. Encouraging the medical staff to pro-by the hospital administration do have a direct mote the use of exterior spaces will increaseimpact on the success of exterior therapeutic the use of gardens by patients and visitors, andgarden spaces. These are the principles and extend the ripple of the beneficial effect toguidelines that we recommend. everyone. 4. Scheduling events and meetings in the• Exterior garden spaces are a resource to be garden incorporates the restorative benefits of used for maximum benefit; promoting a garden into the work schedule. awareness and facilitating use will influence 5. Communication can be easier in an exte- the level of benefit derived. rior space. Several interviewees mentioned• Considering a garden as an essential element that the gardeners provided companionship within the therapeutic milieu of a facility and were great to talk to. The head gardener gives additional variation and support to the at one of the study sites remarked on the pub- entire hospital community. lic relations service he provided, by listening• Quality maintenance contributes to the to people vent and express their dissatisfac- health of the plants, which in turn provides tions. The casual nature of being in the garden the maximum therapeutic benefit. can enhance communication; acknowledging Specific recommendations: this and capitalizing on it would benefit the 1. Our field studies revealed that awareness entire organization.of the garden space is one of the most critical 6. Keep gardens open; appealing gardens,factors in its use. We found that even where designed with seating but that are behindthere was an outdoor space, people at the in- locked doors, are as bad or worse than noth-formation desk were often not aware of its ex- ing. The frustration that rattling locked doorsistence, or mistaken about accessibility. (The creates increases the stress levels of newcom-extreme situation was in one hospital where it ers to the facility (and the emotional costtook 45 minutes and several exasperating would be even greater, and longer term, totrails of misinformation before access could those who may be confused or disoriented).be attained to a locked roof garden that was Gardens that are designed for use should be“open to the public.”) Signs that direct people kept available. Design Recommendations x 63
  • 64. 7. In a time when money is limited, creative 10. Encouraging birds, butterflies, squirrels,thinking can lead to increased benefit. Re- etc. — another aspect of the garden that iscruitment and use of volunteers to take pa- high on the list of significant qualities — istients outside gives relief to the staff as well as easier if organic practices are employed. Un-to the patients. documented but also relevant may be the 8. Consider approaching volunteers or a detrimental effect of the use of chemicals onlocal garden club to raise money for, and/or to the health of the people in the garden, espe-maintain, a hospital garden. cially those who are already physically unwell. 9. Maintenance is important in terms of Hand weeding, mulching, companion plant-both the physical safety of the site and the ing, and appropriate spacing of plants all re-therapeutic potential. Shrubs, trees, and flow- duce the need for the use of chemicals.ers are labor intensive compared to structures 11. Interest, variety, the fact that “someoneand patio spaces. Yet it is these green, growing cares” about the garden were mentioned bythings that appear to offer the most restorative users of the garden; pristine lines, perfection,value. Appropriate fertilizing, selective thin- and aesthetic excellence were not. Mainte-ning rather than shearing, and the use of sea- nance should be geared toward providing asonal color contribute to the healthy and friendly, comfortable, welcoming space rathernatural qualities listed as significant by the than perfection.users of the study.64 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
  • 65. 12. CONCLUSIONT HIS STUDY HAS explored the use of cessible? Why don’t they use it? Is it a ques- hospital gardens and the therapeutic tion of personal preference? benefits of these outdoor spaces. By The next step in the pursuit of full utiliza-observing and interviewing people while they tion of all space in healthcare facilities is toare in the garden, the benefits of these spaces compare the results of this study with a similarhave been described and documented. Ninety- one examining interior spaces. What are thefive percent of the people in the gardens re- therapeutic benefits of common areas such asported a therapeutic benefit. Employees said day rooms, waiting rooms, and cafeterias? Andthey were more productive, patients spoke of are there any design elements mentioned infeeling better and having more tolerance for this research on gardens that can be applied totheir medical procedures, and friends and rela- interior spaces?tives felt relief from the stress of the hospital There is no question of the perceived ther-visit. apeutic benefits of the garden spaces reported Some important questions arise from this in this research. Narrowing the scope of sub-study: Is there documentation for increasing sequent research to accommodate specificthe amount of common area outside? What, if quantitative analysis and conducting compara-any, are the differences in the design of gar- tive studies to establish the place of the gardendens for different patient populations? What on the fiscal priority list of healthcare facilitiesare the comments from people who do not use are challenges that lie ahead.a garden, when there is one available and ac- x 65
  • 66. APPENDIXQuestionnaireLocation 5) What do you generally do out here? (several boxes may be checked)______________________________________ s sit and wait (for an appointment, a friend, etc.)______________________________________ s sit and relax (smoke, read, have coffee, etc.) s sit and talk with friend(s), colleague(s)______________________________________ s hold a work-related meeting s visit with a patient (sit, stroll, etc.)Date and Time ______________ s walk through on my way to another buildingNumber ____________________ s come out for a stroll (not necessarily en route to another building) s let my kids run and play here s outdoor therapy1) The oral consent script has been read and s eatconsent given? s other ________________________________s yess no 6) When you come out here, how long do you generally stay? (may give several answers, depending2) Gender is: on activity)s female s just a few minutess male s 5–10 minutes s 10–30 minutes3) Would you mind telling me if you are: s more than 30 minutess employees patient who is in the hospital 7) Is there anything that prevents or inhibits yous outpatient here for a doctor appointment, from coming here as much as you would like? test, shot, etc.s visitor4) How often do you come out here?s my first time 8) What do you like best about this place?s occasionally, sometimess once or twice a weeks every days several times a day x 67
  • 67. 9) Is there anything you would like to see 11) What specific characteristics or qualities ofchanged or added? this place help you to feel _________________? (fill in the answer to question 10)10) Do you feel any different after you’vespent time in the garden? 12) Is there anything else you would like to tell me about the garden, or how you feel when you are out here?68 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations
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