Accessibility Assessment of Four Hospital Gardens in Texas

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Research Paper
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Accessibility Assessment
of Four Hospital Gardens
in Texas
Samira Pasha
(Texas A&M University)
Abstract
This paper represents a multi method study on usability
of garden spaces in pediatric hospitals. Four gardens in
two Children’s Hospitals in Texas were selected .Interviews,
Space Syntax analysis and environment evaluation were
incorporated to evaluate gardens accessibility and design
characteristics. The findings of the study suggest that
gardens’ location within the hospital layout impacts their
usability.
Introduction
Most contemporary hospitals have dedicated areas for
healing gardens and outdoor spaces. This concept is backed
by both the long history of healing gardens and the recent
body of research elaborating on the positive effect of nature
on patients, staff and family members’ health and mood.
Researchers argue that views to gardens from patient rooms
or garden visitation can cut costs directly or indirectly, by
reducing length of stay, fewer pain medication requests, and
higher patient and staff satisfaction (e.g., Ulrich, 1999).
However, case studies and reports reveal that not all of
the gardens or outdoor spaces in hospitals are being used
to their fullest capacity (Cooper Marcus, 2005; Sherman et
al., 2005, Whitehouse, et al., 2001). While usability of the
outdoor spaces is still uncertain, creation and maintenance
of such spaces are being criticized for the economic pressure
they place on hospitals. For example, Forman (1996) argues
that financial resources are better spent on direct patient
care than garden construction and maintenance.
To date few researchers have studied the obstacles to
garden use in hospitals. Whitehouse and colleagues (2001)
found four factors to be major barriers to the use of healing
gardens in hospitals: knowledge of existence of the garden,
accessibility of the garden, beliefs about the intended groups
of users, and staff’s ignorance about benefits of access to
healing outdoor spaces. Cooper Marcus and Barnes (1995)
suggested design factors such as visibility, accessibility,
familiarity, quietness and comfort to be considered to help
the garden reach its full potential of usability.
Hospital Garden’s Accessibility and Visibility
Although the layout and design characteristics of a garden
play a crucial role in attracting visitors, these features can’t
guarantee garden use, if people aren’t aware of its existence,
or are reluctant to pass trough various corridors to reach
there. As suggested by Whitehouse et al. (2001), one reason
gardens might be under utilized is that few people walk
by and find out about them. Cooper Marcus (2005) noted
that the outdoor spaces located at the building entrance or
visible from the main foyer have the chance to be noticed by
more people without the use of signage.
Literature on hospital gardens suggest that having views
to outdoor spaces from patient rooms, waiting areas, staff
offices, and corridors, can increase the chance of knowing
about the existence of the garden, and help with wayfinding
(Cooper Marcus, 2005). Visibility from indoor areas can
also make staff supervision and assistance to garden users
possible (Davis, 2002). Cooper Marcus et al. (1995) reported
that, with views to the outdoor play spaces, parents felt
comfortable about being able to both stay with their ill child
in the patient room and have the opportunity to keep an eye
on their other children playing outside.
Haq and Zimring (2003) conducted wayfinding research
in three hospitals. They found that when exploring an
unfamiliar setting, people tend to go to spaces with higher
connectivity. By connectivity they take into account
the relationship of one space to other immediate spaces.
A higher level of public connectivity suggests more
opportunities for exploration because of being connected
to a high number of immediate spaces. Haq and Zimring
noted that once people gain some familiarity with the
setting, they tend to use spaces with higher integration.
Integration conveys the same concept as connectivity, but
June 2010 Policy & The Environment edra41 13

verified globally, meaning it puts the whole built project
into consideration, not only immediate spaces. Integration
and connectivity are two concepts of Space Syntax, which
convey how well the spaces are bond together. Eventually,
they suggest that a strong correlation between connectivity
and integration will result in a more comprehensible spatial
experience. Earlier, Hillier, et al. (1987) noted that in an
urban environment layout integration was a predictor of
movement.
Overall, one might suggest that the location of healing
outdoor spaces within a hospital layout might be an
important factor in its usage. The major hypothesis of this
research is that the positioning of the garden in a hospital,
its connectivity to adjacent spaces and integrity with overall
layout can raise the chance of gardens being discovered and
utilized by hospital visitors.
Research Methods
This research consists of three main parts: interviews,
site evaluation, and Space Syntax analysis. Two children
hospitals in East Texas area were selected which both had at
least two gardens available to staff, patients and visitors. The
proximity between hospitals enabled controlling for factors
such as climate and culture. Comparing gardens within a
hospital was helpful to pinpoint the effect of position and
design of the garden on its usage, by controlling for factors
such as overall design of the hospital, population, culture
and administrative policies. This also helped to understand
whether in each of these hospitals, the garden with more
connectivity and integrity is the one being visited most.
The site visits were completed based on guidelines provided
by Zimring (1994). The gardens were evaluated using
Children’s Hospital Gardens Evaluation System by Cooper
Marcus (2008). The tool was instrumental to evaluate
design qualities of the gardens as well as their location and
accessibility. This is the first time that Space Syntax analysis
is being conducted in conjunction with space evaluation.
Usability of the gardens might be affected by two groups
of design issues: design features and layout of the garden,
and garden’s location within the hospital, determining its
accessibility and visibility from interior spaces. This study
mainly focused on the second group of design aspects.
Interviews
To cast light on the original intent and philosophical goals
of the designers, interviews were conducted with a designer
representative of the gardens. During the site visits, garden
visitation habits were discussed with a child life specialist.
A variable oriented strategy was utilized to identify themes
that different cases shared or did not share (Huberman
& Miles, 1994). It was noted that each case needs to be
understood as thoroughly as possible considering the
limited number of cases examined (Stake, 1998).
Based on the interviews, major barriers of garden visitation
can be categorized in three main groups: lack of knowledge
about the garden, accessibility and proximity to patient
rooms or high traffic zones of the hospital, and finally
security, safety and privacy issues.
Knowledge about the garden: As already discussed in the
Introduction, a garden located in a low traffic zone of the
hospital, has lower chance of being discovered by visitors.
However, as suggested by designers, sometimes gardens are
completely visible, but visitors don’t know these spaces are
for them to use. Education about the garden is essential
to encourage use of outdoor spaces. Creating handbooks
and holding events in the gardens are some of the methods
practiced in these hospitals to introduce the gardens to
family members.
Accessibility and proximity: Accessibility is considered
to be a problem for all gardens especially when IV poles
and wheelchairs are involved. Gardens for physical
therapy should be adjacent to patient rooms and preferably
accessible from the unit.
Security and safety: Secure Access to the garden is the
main concern of hospital administrators. There are also
concerns of people falling (or committing suicide) from
roof top gardens and getting injured in the playgrounds.
Although children are never left unsupervised in any
outdoor spaces, some hospitals continue to lock the doors of
outdoor physical therapy or playground areas. The selected
gardens for this research all have unlocked doors; however,
the administrators preferred implementing secure access
and supervision by volunteers.
The findings of current interviews are consistent with those
of Whitehouse et al (2001). This is essentially important
since the findings are validated in a different US state.
14 edra41 Policy & The Environment June 2010

Hospital-A
Garden 1
Hospital-A
Garden 2
Location and Boundaries .64 .54 .64 .62
Layout and Pathways .51 .73 .47 .59
Planting .39 .46 .37 .43
Seating .33 .45 .35 .44
Amenities for Children .55 .59 .36 .40
Design Details .40 .40 .36 .36
Maintenance 1.00 1.00 1.00 1.00
Garden Atmosphere .90 1.00 .85 .95
Table One
Site Evaluation
The Children’s Hospital Garden Evaluation System (Cooper
Marcus, 2008) was employed to evaluate and rank the
outdoor spaces in terms of their design characteristics. For
each of the four gardens, the scores for the eight categories of
the audit form were calculated separately as shown in Table 1.
The scores show that Hospital A Garden 2, ranking best
in all design categories, scored lowest in location and
boundaries category. In contrast, Hospital B garden 1, with
relatively lower scores in design categories, has the highest
location score. One might consider the probability of
designers having a tendency to keep readily available gardens
simple to control visitors’ population.
Space Syntax Analysis
Connectivity and integration are two concepts of Space
Syntax. Space Syntax, in concordance with environment-behavior
research, is based on the notion that spatial layout
shapes patterns of human behavior, and therefore we
cab generate graphs representing relationships between
components of space, and analyze those using theoretical
measures (Turner, 2004). The theory was conceived and
developed in the late 1970s to early 1980s, and is defined
as “a set of techniques for the representation, quantification
and interpretation of spatial configuration in buildings and
settlements” (Hillier, Hanson, & Graham, 1987).
In 1979, Benedikt created maps based on visual
characteristics of a building, which showed how people
navigated the building. He theorized that these maps would
Hospital-B Garden
1
Hospital-B Garden 2
correspond to movement patterns within the space. Hiller
and Hanson (1984) generated their own version of maps
by breaking the space into its components, and drawing a
diagram demonstrating those, however, no research has
investigated the impact of little visibility on visitors’ feelings
of insecurity. In other three cases, the high traffic zone of the
garden had a good view of the garden.
Hospital B Garden 1 seemed to have the best visibility and
accessibility, as already declared by environment evaluation
tool. The highest traffic zone on this level happened to be the
lobby, adjacent to the hospital main entrance and the lobby
garden. The garden and its entrance are completely visible
and easily accessible from this area.
Components and their relationships: In 1985, Hillier
introduced the concept of depth by creating a graph showing
spaces, which needed to be passed through in order to get
from one space to a space of interest.
Space Syntax analysis has been used in various urban and
architectural studies, as well as in healthcare settings. For
example Alalouch and Aspinall (2007) used Space Syntax
analysis on six ward designs to explore the relationship
between space configuration and perceptions of privacy. In
addition to the visibility graph and depthmap analysis, they
incorporated questionnaires to assess subjective judgments of
participants.
Although a number of inconsistencies have been reported in
Space Syntax (Ratti, 2004), its application has been generally
successful in architectural and urban researches (Hillier,

Entrance
Garden
Figure One. Hospital A Courtyard Visibility Graph Figure Two. Hospital A Courtyard Isovist Map
Figure Three. Hospital A Main Garden Visibility Map Figure Four. Hospital A Main Garden Isovist Map
1999). The application of Space Syntax in conjunction with
other data collection techniques would increase validity of
analysis and results. Observation (Penn, Desyllas & Vaughan
,1999; Osmond, 2007) and survey (Alalouch & Aspinall, 2007;
Penn, Desyllas & Vaughan, 1999) are other frequently used
methods in combination with Space Syntax analysis.
The analysis in this study was run on the floor plans of the
hospitals where the selected gardens were located. First a
visibility graph was created for each map to find the spots
that were more visible and therefore more likely to be passed
by people. Comparing the location of the garden with these
spots can show how much the gardens are likely to be passed
by and therefore discovered. Usually this high traffic zone is
located in the intersections or the central space such as lobby
or main corridor. In the next step the spot with highest traffic
was chosen as a center point to create Isovist maps. Isovist
maps demonstrate the area visible from a single point. Figure
1 and 2 represent Hospital A Courtyard Visibility Graph and
Isovist Map.
As for the case of Hospital A main garden, no specific zone
was identified as a high traffic zone (Figure 3). Likewise, site
evaluation tool identified this garden as the least accessible
garden. The entrance of the garden was chosen to create
Isovist map.
Figure 4 shows that a section of the outdoor garden is
completely visible from the parking lot. In addition to
proximity issues, it is important to consider the role of
visibility, and visitors’ tendency to remain in the visible area
of the garden because of feelings of safety. Cooper Marcus
(2005) had already introduced negative role of fishbowl
effect on garden usage because of violating visitor’s privacy.
However, no research has investigated the impact of little
visibility on visitors’ feelings of insecurity.

Entrance
Garden
Figure Five. Hospital B Lobby Garden VIsibility Map Figure Six. Hospital B Lobby Garden Iovist Map
Figure Seven. Hospital B Dining Garden Visibility Map Figure Eight. Hospital B Dining Garden Iovist Map
Hospital B Lobby Garden seemed to have the best visibility
and accessibility, as already declared by environment
evaluation tool. The highest traffic zone on this level
happened to be the lobby, adjacent to the hospital main
entrance and the lobby garden. The garden and its entrance
are completely visible and easily accessible from this area and
will provide another minor entrance to the lobby (Figure 5
and Figure 6).
Many staff and family members pass through the garden
to reach the parking. Hospital B Dining Garden, adjacent
to hospital dining area, clearly benefited a combination of
good design and location (Figure 7). The garden is visible and
accessible from the dining area on the same level (Figure 8).
However, it is not visible from a wide range of hospital spaces
on other levels.
Discussion
During the design process of all four gardens, designers
held focus groups with family members, patients and staff.
Although the viewpoints of these groups of users were
implemented in design, unforeseen problems arose after
the hospitals started operating, which led to insufficient use
of the gardens. For example, limited number of volunteer
workers for supervising garden usage combined with
low visibility of gardens from staff stations led hospital
administration to limit use of some gardens. Insufficient
number of wheelchairs combined with long distance between
garden and patient rooms made travels for patients harder.
Gardens tucked away in a low traffic corner of the hospital
remained undisclosed and hidden.
Although holding focus groups with users during design
stage of a project can provide invaluable information, it
doesn’t guarantee meeting all design criteria. This study

suggest incorporating other methods of analyzing design
plans such as Space Syntax may reveal some of the design
issues before construction and operation of a building.
During past two decades, new tools have emerged to
support research in design. While design processes more
or less involve concerns over qualities of space, researchers
and designers have tried to create tools to quantify
characteristics of designed space to make evaluations
possible. In this study, methods of site visits, site evaluations
and plan analysis were adopted and data drawn from these
methods were in accordance with each other. Considering
the fact that Space Syntax is a relatively new science used
in few architectural studies, this study although concise,
supports the validity of this tool.
Limitations
Lack of observational data to examine the correlation
between the garden usability and its location is the major
limitation of this study. Although interviews and site visits
cast light on patterns of use at each garden, for more accurate
conclusion, quantitative observational data is required.
As for the Space Syntax analysis, only physical form of
the space is taken into account. However, function of
adjacent spaces and the different nature of the locations
might influence the usability of the gardens. Although the
evaluation system provided items to score such qualities, the
impact of the functions of the adjacent indoor spaces will still
remain unclear.
Small number of gardens under investigation and evaluating
only hospitals in Texas, which has specific climate and
culture characteristics, is another limitation of the study.
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