The document summarizes a study of gardens in healthcare facilities that included: 1) Reviewing relevant research on the therapeutic benefits of natural environments. 2) Conducting case studies of gardens at 4 hospitals, including observations and interviews to understand usage. 3) Developing design recommendations based on the case studies to promote the therapeutic use of gardens.

1. ®
GARDENS IN HEALTHCARE FACILITIES:
USES, THERAPEUTIC BENEFITS, AND
DESIGN RECOMMENDATIONS
by Clare Cooper Marcus, MA, MCP
and Marni Barnes, MLA, LCSW
University of California at Berkeley

2. Copyright © 1995 by The Center for Health
Design, Inc. All rights reserved. No part of this
work covered by the copyright herein may be repro-
duced by any means or used in any form without
written permission of the publisher.
The views and methods expressed by the authors do
not necessarily reflect the opinions of The Center
for Health Design, Inc. or its Board or staff.
Published by: The Center for Health Design, Inc.
Publisher: Wayne Ruga, AIA, IIDA
Research Consultants:
Clare Cooper Marcus, MA, MCP
College of Environmental Design
University of California at Berkeley
Marni Barnes, MLA, LSCW
College of Environmental Design
University of California at Berkeley
Printer: Eusey Press
Design and Composition: Visual Communications
The Center for Health Design, Inc.
4550 Alhambra Way
Martinez, CA 94553-4406
United States of America
Tel: (510) 370-0345
Fax: (510) 228-4018
Email: CTR4HD@aol.com
Clare Cooper Marcus, MA, MCP
2721 Stuart Street
Berkeley, CA 94705
Tel: (510) 548-2904
Fax: (510) 643-6166
Marni Barnes, MLA, LCSW
Deva Landscaping
846 Boyce Street
Palo Alto, CA 94301
Tel: (415) 326-6866
First Printing November 1995
ISBN: 0-9638938-2-3
Printed in the United States of America

3. THE CENTER FOR
HEALTH DESIGN, INC.
Vision
To create a future where the built environ-
ment supports the highest level of human
health, well-being, and achievement in all as-
pects of life and work.
Mission
To be a facilitator, integrator, and accelerator
promoting the widespread development
of health-enhancing environments, and the
benefits that these bring to human health and
well-being.
Purpose
To 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. ACKNOWLEDGMENTS
W
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 Dix
the beautiful outdoor spaces observed during Kathryn E. Johnson
our research. Although many more people Roger K. Leib, AIA
helped to point the way and grease the wheels Jain Malkin
during this study than we could mention here, Robin Orr, MPH
some of the good souls are: Derek Parker, FAIA, RIBA
Wayne Ruga, AIA, IIDA
Alan 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 Committee
Bates Medical Center;
Janet R. Carpman, Ph.D.
Irwin Fisch, Pat Mariani, Gabriel Escobar, Uriel Cohen, D.Arch
Bob Eisenman, and Priscilla Minn; Kaiser Syed V. Husain, FAIA
Permanente Walnut Creek; Debra J. Levin
Karen Graham, Vicki Williams, and Francia Donald F. Lopez
DeAsis; California Pacific Medical Center; M.P. MacDougall
Tom Piazza at the University of California, Jain Malkin
Berkeley, Survey Research Center, for his Wayne Ruga, AIA, IIDA
knowledge and advice; Mardelle Shelpley, D.Arch
Karen Tetlow
The homeless and HIV-positive man who di- Roger Ulrich, Ph.D.
rected us to healing gardens in San Francisco;
Sponsors
Eileen Lemus, at Laguna Honda Hospital, for This Research Report has been exclusively
her knowledge and belief in innovative forms sponsored by: Armstrong World Industries,
of therapy; Inc.; Interface Flooring Systems, Inc.; JCM
Finally, we are deeply indebted and offer our Group; and Jain Malkin
heartfelt thanks to The Center for Health De- Research Consultants
sign and its Research Committee for sponsor- Clare Cooper Marcus, MA, MCP
ing and supporting this study. and Marni Barnes, MLA, LCSW
The Center for Health Design would like to University of California at Berkeley
acknowledge the following individuals and or-
ganizations for making this research project
possible.
iv x

5. TABLE OF CONTENTS
1 Introduction 1
2. Review of Relevant Research 2
3. Methods 3
4. Historical Overview of the Provision of 7
Outdoor Gardens in Medical Settings
5. Typology of Outdoor Spaces Provided in 11
Contemporary Healthcare Facilities
6. Case Study: San Francisco General 23
Hospital,The Comfort Garden
7. Case Study: Alta Bates Medical Center, 31
Berkeley, The Roof Garden
8. Case Study: Kaiser Permanente, 39
Walnut Creek, Central Garden
9. Case Study: California Pacific Medical 47
Center, Garden Campus, The Garden
10. Aggregate Data Analysis of the 53
Case Study Sites
11. Design Recommendations 59
12. Conclusion 65
13. Appendix: Questionnaire 67
Bibliography 69
xv

7. 1. INTRODUCTION
T
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 spaces
possible 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 run
was not to propose theories of how or why on low budgets, serving the needy, and seem to
certain 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 seemed
in hospital gardens seem to be — in the users’ more concerned with cosmetic landscaping to
eyes — 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 became
cal overview of hospital gardens; a typology of aware, too, of the pivotal importance of one
health facility outdoor spaces; four case studies person or a few people in creating and making
including 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 General
terviews; 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 Honda
pital architects we contacted knew of few such Hospital was responsible for promoting the
examples. When we started to visit hospitals, development of a garden in a formerly empty
we were surprised to find few that had outdoor courtyard. (The timing of the installation of
spaces, and where we found some that did, the this garden precluded our selecting it as a case
staff at the information desk frequently had no study.) Nurses at California Pacific Garden
knowledge of the garden or its location. Thus, Campus were responsible for encouraging
early on we sensed that this was a type of space long-term care patients and their families to
that 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, many
them in Northern California. From this admit- more hospital administrators and medical staff
tedly small sample we sensed that public hospi- would encourage the use of outdoor spaces for
tals 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 consciousness
Two public hospitals in San Francisco — in this important area.
x1

8. 2. REVIEW OF RELEVANT
RESEARCH
T
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 at
natural scenes; (2) horticultural therapy, or where people go outdoors when emotionally
working in a natural setting; (3) the experience upset. Two studies in which people were asked
of simply being in a natural wilderness; and (4) what kind of place they went to when feeling
outdoor environments chosen by people as troubled, upset, or in grief revealed that natural
stress-reducing settings. There is a consider- settings were predominantly cited (Francis and
able range of research where subjects in a labo- Cooper Marcus, 1991, 1992). A further study
ratory 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 environment
tested for emotional and physiological recov- (Barnes, 1994).
ery. These studies indicate that the presence of Though there are many studies evaluating
natural greenery in a scene has a high correla- the success of housing schemes, there are many
tion with stress reduction (R. Ulrich, 1979, fewer of healthcare facilities, and almost none
1984, 1986; M. Honeyman, 1987; T. Hartig et of hospital gardens. The one exception of the
al., 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 and
tion as opposed to buildings, and found that summarized in the book People Places (Francis
those with a view to nature recovered more and Paine, 1990). Also important to mention is
quickly (Ulrich, 1984). The second body of the tireless work by designer Vince Healy in
work reveals that participants in gardening ac- promoting the inclusion of gardens in hospice
tivities 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, it
participants (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 uses
cates 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

9. 3. METHODS
D
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 Francisco
project undertook the documentation and General Hospital,
analysis of exterior hospital gardens and their Context Map
possible therapeutic benefits. For a number of
reasons this study must be described as ex- TREET
22nd S
ploratory rather than definitive. First, there are
no strictly comparable studies in the published
EWAY
literature, so there was no groundwork to draw
T
ONT S
on; and the necessity for breadth required by the
E
101 FRE
RO AV
discovery process precluded the exhaustive con-
trol of variables. Second, the time span of the VERM
POTRE
project itself (January–August 1995) was very
brief. Third, inordinate bureaucratic hurdles
and wet and cold weather into May delayed the
fieldwork. Hence, the bulk of the work — ob-
servations, interviews, site and statistical analysis REET
23rd ST
— was carried out in a shorter time frame than
was initially anticipated. case study — resulted in minimal use of the
garden. It is reported as a descriptive rather
Sites than an evaluative case study (see Map 3– 4).
The central focus of this research is on case Canvassing potential research sites revealed
studies 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 was
other hospitals in Northern California and at surprising, especially in a part of the world
one 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 sites
San Francisco General Hospital in San Fran- were found that met the stated goal of attaining
cisco (see Map 3–1); Alta Bates Medical Cen- variation among the patient population types.
ter in Berkeley (see Map 3–2); and Kaiser
Permanente Medical Center in Walnut Creek • San Francisco General Hospital’s Comfort
(see Map 3–3). Extensive remodeling at Cali- Garden encompasses the entry and lawn
fornia Pacific Medical Center Garden Campus area outside an outpatient medical building
in San Francisco — intended as our fourth (see Map 3–1).
x3

10. • 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 50'
LEGEND:
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 two
Map 3–2: However, due to various hospital policies and weekend days. Each session was divided into
The Roof Garden, six 20-minute observation periods. To record
construction projects, the results presented are
Alta Bates Medical
Center, Context not necessarily typical of facilities within their the frequency of uses, if a given individual’s
Map 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 at
Map 3–3: through interviews. Kaiser Walnut Creek. The recordings at San
The 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 design
Permanente 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

11. formation that had emerged from the system- first was designed into the program, as it was
atic 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 moving
generally 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 conducted
asked to indicate which activities applied to with stationary users and the responses of
them, 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 during
ended, 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 to
These were questions such as “What do you refuse to participate than individuals in other
like 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 spots.
garden?” Questions were asked in this way be- Twelve hours were devoted to interviewing
cause there is no prior research that would at each site. It was hoped that 50 individuals
suggest what an exhaustive range of responses could be interviewed in this time span. This
might be. was achieved at San Francisco General Hospi-
When addressing people’s feelings or tal and Kaiser Walnut Creek. Slightly fewer
change of mood, three approaches appear in (37) were interviewed at Alta Bates because of
the 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 during
shifts (galvanic skin response, blood pressure, the course of the study. Although the drop in
heart rate, etc.). Self-reports are considered use at Garden Campus prohibits any statistical
second in reliability, with the third, behavior analysis at this site, it is reported with the case
observation, seldom used due to the extremely studies due to its value as a description of a
high level of interpretation required. This long-term care facility.
study drew upon self-reports because the need
for a breadth of information and the fact that
the cost and time limitations of monitoring Analysis
physiological 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 Pacific
answer in a way that they think is pleasing to interview questions were analyzed for content Medical Center
the interviewer, the overall reliability of this clusters. For example, in analyzing the re- Garden Campus,
Context Map
method is nonetheless acceptable. Questions sponses to what people liked best about the
on other topics relied on self-report because it garden, the two researchers scanned
E
was the only way to access the information. For the range of answers, then read
LUPIN
SCALE
example, the only way to learn what people like each response and assigned it to an 0 50' 100' 150' 200'
:
LEGEND
best 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 of
took approximately 15–20 minutes. The inter- mood, the selection of categories
SON
views were all conducted by the same person. drew upon the work of Russell and
➝
WOOD
EMER
At each hospital the interviewer made a con- Snodgrass (1987). Emotional re-
N
tinual circuit through the garden so that the sponses were clustered into those
entire site was canvassed. At the end of one in- that indicated a rise in energy level
terview, 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- GEAR
this sampling procedure should be noted. The gy level (felt calmer, more relaxed).
Methods x 5

12. Three additional categories were developed lieve these data do provide results that are an
in 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 for
tive shift (find answers, think things through); use in guiding the design of future gardens that
those 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 the
pleased). 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 the
of the individual case study and in the aggre- methodology adopted. Among the advantages
gate data analysis chapter. Comparative analy- — given its exploratory nature — are the
ses were performed on the aggregate interview breadth of data gathered, the intersection of
data, 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, and
for more than one response. This allowed for a the depth of researcher understanding via in
discussion in terms of both the number of re- situ data collection. Disadvantages include lack
spondents 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, absence
garden on the user’s psychological health, and of data from nonusers, and a relatively high
the 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

13. 4. HISTORICAL OVERVIEW
OF THE PROVISION OF
OUTDOOR GARDENS IN
MEDICAL SETTINGS
W
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 in
grateful 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 migration
lished paper, “Restorative Gardens: Recover- into burgeoning cities overwhelmed the facili-
ing Some Human Wisdom for Modern ties that existed. According to Warner, with the
Design.” This brief overview owes much to his decline of monasticism itself the significance of
work, as well as to a major published work by the meditative/restorative garden declined, and
John 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, one
when hospitals and monasteries ministering to of the primary design incentives was to create
the sick, the insane, and the infirm often in- long wards where the priest celebrating Mass
corporated 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 a
setting. St. Bernard (1090–1153) wrote of the church nave with windows so high that no one
intentions 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 continue
fits of gardens as conveyed to us by late-20th- the courtyard tradition. Les Invalides in Paris
century 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

14. 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 hygienic
emergence of scientific medicine and Romanti- hospital plans:
cism fortuitously combined to encourage the
re-emergence of usable outdoor spaces in hos- Second only to fresh air ... I should be inclined to
pitals. 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 quite
special attention to hygiene, fresh air, and
perceptible in promoting recovery, the being
cross-ventilation. The so-called pavilion hospi-
able to see out of a window, instead of looking
tal 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 the
ings linked by a continuous colonnade and ven- window close to the bed-head. It is generally said
tilated with large windows marked the design of the effect is upon the mind. Perhaps so, but it is
the 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 wards
joined together at their ends by a service corri- Good nursing practice by the end of the
dor, like the teeth of a comb (Warner, p. 23). 19th century and in the first decades of the
These new designs incorporated outdoor spaces 20th century called for wheeling hospital beds
between the pavilion wards, while the rise of out onto sun porches and roofs, and indeed in
Romanticism prompted a reconsideration of the treatment of tuberculosis, this fresh air
the role of nature in bodily and spiritual and sunlight regimen was seen as the key to
restoration. recovery. In the Catholic hospital St. Mary’s,
Recommendations for hospital garden de- in San Francisco, photos in a corridor depict
sign written by German horticultural theorist rows of patients in beds on the trellised roof
Christian Cay Lorenz Hirschfeld at the end of garden. All that is now left of this space is a
the 18th century uncannily foreshadow the decaying segment of roof with a few flower
findings of researchers such as Roger Ulrich at boxes where staff retreat for a quick cigarette
Texas A & M University, who documented in break.
one study the healing benefits of a view onto The late 18th and early 19th centuries also
vegetation 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

15. 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 right
term care of chronic illnesses — the garden image at the hospital entrance or in setback
was not lost. The profession of occupational from adjacent streets, but rarely viewed as a
therapy was established in the early decades of significant adjunct to patient healing or as a
this 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 spaces
itation of patients with physical problems. do exist, inquiries at the information desk are
After World War I, garden work entered the often met with blank stares or an outright “No
arena in rehabilitation hospitals; after World — we don’t have a garden here.” No hospital
War II, horticultural therapy programs with in this study provided any graphic directions
special-purpose garden facilities began to be to such a facility, or printed information for
provided in hospitals for veterans, the elderly, new patients. It seems as though the hospital
and 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, and
ity has become more familiar in U.S. cities. the possible restorative benefits lost in the
These, 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 medical
children with cancer and their families, a arena might be thought of as analogous to the
homelike environment and adjacent garden is ignored psyche and spirit in the treatment of
the 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 to
had come to resemble air-conditioned office quantify or prove. But just as alternative or
buildings 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 professions
A 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

17. 5. TYPOLOGY OF OUTDOOR
SPACES PROVIDED IN
HEALTHCARE FACILITIES
T
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 a
the study period (January–August 1995). With complete contrast to
few 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 the
tual places visited, observed, and critiqued in senses, and draw
patients, staff, and
terms 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 loop
its 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 of
and 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 of
panded the understanding of hospital outdoor • Can serve a variety of users and activities wards offer views
space 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 of
1. Landscaped Grounds Wight, England
This type of open space consists of a landscaped When a new hospital building was added to this
area at grade that forms an outdoor area be- 19th-century medical complex, the designers
tween buildings. It is often used as a walking proposed a redesign of the central outdoor
route between buildings; a setting for eating or space. It is a spacious area and contains a lake
waiting; and as a space for ambulatory patients filling a depression where building materials for
or 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-landscaped
typology, and is sometimes described by users with lawns, paths, seating, new trees, two
as “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 waiting
Kaiser 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 pushing
Another good example is described below. wheelchair-bound patients; and by townspeople
x 11

18. as a park where children are brought to feed the few trees and small flower beds. Larger street
ducks and watch a family of swans who have trees cast shade on parts of the lawn. There are
taken up residence on the lake. It is a very at- no pathways, seats, litter containers, or other
tractive, naturalistic space and is as different cues to suggest this might be used. This is the
from an interior hospital environment as any only green outdoor space at this facility, and
nearby 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 this
given 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 is
able to provide such a milieu (though much
3. The Front Porch
smaller than St. Mary’s) because two “her-
Most hospitals have some features at the main
itage oaks” in the center of its property are
entrance that are analogous to the front porch
protected and a much-used and well-liked
of a house. These might include an overhang
garden area was developed around these ven-
or porch roof, a turnaround for vehicle pickup
erable trees.
and drop-off, seats, directional signs, a post
box, phone, bus stop, and so on.
2. Landscaped Setback Advantages
A landscaped setback is an area in front of the
• Provides visual cue to main entrance
main entrance to a medical center, usually
• Overhang may scale down size of building
comprising lawns and trees. This is a space
• Sensitively located seating provides amenity for
akin to the front yard of a house — to provide
those waiting to be picked up or waiting for bus
a buffer-separation between the building and
Disadvantages
the street. Also, like a house front yard, this
• May be overused if it is only outdoor seating
space is not usually intended for use, but to
area provided
provide a visually pleasing setting on ap-
• May be under-used if main access to hospi-
proaching the entrance.
tal is via parking under building
Advantages
• 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 to
Disadvantages 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 eddy
Main Entry, Alta Bates Medical Center, off the mainstream — experience some degree
Herrick Campus, Berkeley, California of seclusion, yet can easily see if a taxi or a
The four-story stucco buildings of Alta Bates friend’s car arrives. The seating is in the form
Herrick Campus face onto the busy street of of comfortable, wooden garden benches with
Dwight 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 to
trance. 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 a
a setback for the building. It is punctuated by a quick smoke break.
12 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations

19. Main Entry, John Muir Medical Center, hillsides covered with native trees and the
Walnut Creek, California more distant slopes of Mt. Tamalpais. It has a
A very large portico overhang clearly marks the quiet, green, parklike feeling. Nine large palm
main entrance to this medium-sized suburban trees border a small circular seating plaza.
hospital, as you approach it from one of the Around this are lawns, ivy-covered slopes, and
many 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 circle
park benches with backs are located on either seating, nearby parking is barely visible, and
side 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 a
tal, and people are being picked up by car or steeply sloped site and the configuration of the
taxi, the location of the seating is appropriate. buildings, this is the only outdoor space at
However, 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 look
onto the glare of the adjacent road, sidewalk,
5. Courtyard
and parking lots and receive the reflected heat
This is a space that forms the “core” of a
from 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 or
entrance 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 a
or the creation of roofed shelters would have
cafeteria occupies one or more sides of the
rendered this a more successful front porch.
courtyard, it could function as an outdoor eat-
ing place. Trees for shade, flowers for color, a
4. Entry Garden water feature for pleasing auditory relief, and
This 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
Advantages
space with a garden image, and unlike a “land-
• Semi-private and secure; surrounded by
scaped setback,” is designed and detailed for use.
hospital buildings
Advantages • 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 those
Disadvantages 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 privacy
Main Entrance, Marin General Hospital,
Greenbrae, California Cafeteria Courtyard, Novato Community
East of the main entrance to this medium- Hospital, Novato, California
sized community hospital is a landscaped area This is a small, one-story community hospital
with mature palms, live oaks, and eucalyptus, in a residential district of a small town. The
and paths zigzagging up to an upper parking courtyard is immediately visible on entering
lot. The trees screen out much of the hospital the hospital. On one side is the main corridor
building; 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

20. second side is the cafeteria. The courtyard is trees, and in a few other locations, are simple
accessed 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 carry
two sides are administrative offices with win- food out from the nearby cafeteria. During
dows that look into the courtyard; the win- peak-use hours, some of these tables are in
dows 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 of
movable 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 small
paving, 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 use
tiens bordering the pool. The overall ambience both before and after the lunch-time users have
is of a restful urban patio. The only aesthetical- left the picnic tables. Benches are often moved
ly jarring elements are three large, humming from one of the picnic tables so that users of
vending 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 great
since the cafeteria is only open at certain times. sensitivity. The maples provide needed shade
Waiting 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 soothing
from the office; eating lunch with colleagues — background sounds. Planters beneath the
this courtyard offers many users of this hospital maples and along the edges of the court are
a quiet outdoor respite (see Photo 11–5). filled with flowers; baskets of flowers hang
from the roof of the half-open corridor. Two
Linnaeus Physik Garden, Santa Rosa of the three entries to the courtyard are down
Community 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 entrance
Community 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 the
space in the midst of a medical complex of old walls of the adjacent building so that all the
and 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 Linnaeus
and 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 long
not near the main hospital entrance, nor are sides of space filled with medicinal herbs and
there 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 China.
is 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 and
and 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 windows
trees arranged in a line along one long edge of that block out the sounds of a small corner
the court. Under each is a raised planter of fountain for all but those sitting quite close to it.
flowers 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 of
and 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

21. ments. Warm brick paving would certainly have courtyards. These trees move in a breeze and
been 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. Were
the two-story buildings of a new outpatient fa- such spaces located in an inpatient facility, or
cility. 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 benefit.
glass looking out to the greenery. The fourth
side of each is occupied by offices and exami- Children’s Courtyard, Kaiser Permanente
nation rooms with an ample boundary of trees Medical Center, Vallejo, California
separating these office windows from anyone Half of this square, 45 x 45 feet courtyard is
seated 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-high
window 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 (or
outdoors. The staff at registration desks face their siblings) try to find their way out of the
out across the corridors, and they also have maze, climb over its walls, chase each other
good 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 audible
terra cotta planters; long lines of trees (cherries from inside. This is an excellent use of a small
and ornamental pears in one, Lombardy space, allowing children to let off steam in a
poplars in another); comfortable wooden gar- hospital environment (see Photo 11–1).
den benches and individual garden chairs with
backs and armrests. Though these features are
repeated, other elements are unique to each 6. Plaza
courtyard. 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 in
need not be mowed and provides a lovely, wavy planters, though the overall image is not of a
texture. 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 Advantages
tables with dark green market umbrellas. • Low plant maintenance and irrigation costs
These all represent very successful court- • A small place can be designed for relatively
yard spaces; they are highly visible, easily ac- heavy use
cessible, 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 space
etc.), and all provide a true garden experience. Disadvantages
The only criticism would be that there are al- • May have few of the qualities that people
most 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, a
that flowers and color are highly valued in gar- garden or oasis image
dens used for relaxation and stress-reduction. A • May evoke the image of a shopping mall or
specially sensitive aspect of planting was the corporate office plaza rather than a space for
choice of Lombardy poplar in three of the four peaceful, stress-reducing, passive enjoyment
Typology of Outdoor Spaces Provided in Contemporary Healthcare Facilities x 15

22. Seating Plaza, Alta Bates Medical Center, 7. Roof Terrace
Herrick Campus, Berkeley, California Unlike a roof garden, which is located on top of
This is an L-shaped seating plaza located out- a building or is usually open on all sides, a roof
side the Oncology waiting area. The space can terrace is an accessible outdoor area that is
be entered from one of three doors in the On- bounded on one side by a building and often
cology 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; a
street 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- Advantages
signed, probably expensive, but rather cold • Captures space that might otherwise go un-
urban plaza. There is a predominance of hard used
surfaces: travertine paving, now stained by • Potential for expansive views
water draining from the planters; 12 concrete, Disadvantages
box-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 shaded
sides; the sloping glazed roof of a below- Promenade, St. Mary’s Hospital,
ground waiting area; steel benches; and a row San Francisco, California
of 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 large
These latter, in particular, create a disturbing glazed lobby wall opposite the main doors into
sense of imbalance in the space, and — unfor- the hospital. Its outer edge is bounded by a long
tunately — 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 a
offset the overall hard appearance. Twelve long walkway used for strolling and bounded by
small Japanese maples are delicate and appro- planters with seat-high concrete ledges. Off the
priate 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 seating
building and the dominant hard-scape. Eight clusters, bounded by planters filled with shrubs
small 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 wood
to 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 colorful
tween 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 by
numbers of strangers at a bus terminal or shop-
people working in offices looking out onto the
ping mall. Considering the stressful nature of
terrace. The terrace seating is far enough away
waiting in an Oncology Department, it would
from the windows that the privacy of neither
have been more appropriate to provide short
space is compromised (see Photo 11–3).
wooden benches or movable chairs, so that a
person alone, or with a friend, could sit in a Perimeter Terrace, Davies Medical
semi-private location. The eight benches could, Center, San Francisco, California
theoretically, seat 32 people — an obvious This is an unfortunate example of this type of
over-provision in this location. Unfortunately, open space. It wraps around the south and east
sitting alone in such a space evokes a lonely sides of a central high-rise hospital building
feeling, with so many empty benches in view. and is accessible by steps and a ramp adjacent
16 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations

23. • 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 and
to 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. Large
ing in it to tempt people to stay. There are a • Users can expect that some thought has
bicycle storage
number of small, poorly maintained trees in been given to creating an environment that lockers bisect the
concrete tubs, completely out of scale with the is therapeutic space and block a
space, or with the size of the building looming • Possibly disruptive activities, such as chil- dramatic view of
above it. A few round concrete planters with dren playing or groups eating and laughing, downtown San
seating 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 is
that 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, transitional
has 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 Medical
round 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 for
This is an area on top of a hospital building Oncology Radiation, with floor-to-ceiling
that is designed and landscaped for use by pa- glass so that even when not in the garden, it
tients, 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

24. The short paths leading to two seating places for people to look down on from above, rather
at 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 used
down into a hollowed rock — provides a for decoration, rather than a garden space that
soothing 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 outdoor
very small area in a sensitive way. space design that extends the theme of a build-
ing to the outside may be appropriate in some
The Healing Garden, Kaiser Permanente settings (for example, a downtown office
Medical 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 particularly
the 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 feet
in 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 is
entered from a — presently — little used corri- Advantages
dor 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 contemplative
crete 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 Disadvantages
a decomposed granite path to the highest • If it is visible from indoor spaces, one might
point in the garden, the northeast corner, feel self-conscious, in a fishbowl. It is quite
where a cork oak is planted on a gravel-based probable that only one person at a time
terrace. The three terraces are planted with might use such a space, depending on its size
forsythia, white roses, and orange-blossomed • Given its designation, one might feel self-
dwarf pomegranate. The slopes are planted conscious about using it for other legitimate
with star jasmine and ivy, and heavily mulched quiet activities that are not meditation
with redwood bark. The flat, central section of (reading, writing)
the garden consists of a path looping around
an 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 space
plants were being put in when we visited, and be- entirely enclosed by two-story cedar-shingled
sides one litter container, no garden furniture walls and windows of the building. The garden
had been installed, and no one was using it. has low planting around its edges, an attractive
Given the results of the case studies, this garden stone wall, a fountain trickling into a bed of
does 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 they
the 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 of
the terraced section seems to have been designed falling water set the stage for what may serve at
18 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations

25. 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 unit
a 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-angled
conversations and occasional laughter are intru- arrangements, suggesting socializing rather than
sive. There is also something of a “fishbowl” lone contemplation. There is one additional
feeling while seated in such a small space. short metal bench with back and arms in which
sits, incongruously, a green-metal, sculpted frog
Meditation Garden, El Camino Hospital, — a whimsical element more suited to a chil-
Mountain View, California dren’s garden than to a place of meditation. The
This new garden in a community hospital was presence of an outdoor porch with tables and
donated by two couples — each of whom had chairs off a staff recreation room at one end of
lost a family member and had yearned for the garden is also unfortunate, as the laughter
some place to go and sit quietly while in the and conversation of staff on breaks may conflict
hospital 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 that
buildings on 21⁄2 sides. The entry is from a feels separate from the hospital. Though not far
landscaped 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 that
ings 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 therapeutic
weeping 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 colors
the willows are shade-loving shrubs and ferns, while in the garden. Some movable garden
scattered rocks, a dry streambed of pebbles, chairs and paths to quiet, green corners would
and a Japanese lantern. enable those who want to be completely alone
A concrete pathway — wide and smooth and surrounded by nature to enjoy this space
enough for a wheelchair or gurney — leads more fully.
from the garden entry to seating under a
wooden-roofed gazebo in the center of the
11. Viewing Garden
garden. 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 cannot
ful amenity in this area of hot summer nights.
be entered but can be viewed from inside the
Windows from the Dialysis Unit on one side
building.
permit views out for the patients and staff in-
side. Reflecting glass in these windows creates Advantages
an impression that the garden is larger than it • Green space in a small area
is and eliminates the feeling of being in a fish- • Can be viewed from comfortable indoor
bowl when in the garden. Two bird feeders seating area — sheltered from rain; heated/
hanging outside these windows encourage air-conditioned
birds into the garden, which are then visible • Low maintenance costs
from inside and outside. There are also views Disadvantages
into the garden from a staff lounge and a pa- • Greenery, flowers, etc. cannot be viewed up
tient waiting room. Half-closed blinds in these close or their fragrances enjoyed
windows permit someone sitting in the garden • Fountain, birds — if present — cannot be
not to feel stared at. heard
Typology of Outdoor Spaces Provided in Contemporary Healthcare Facilities x 19

26. • 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 of
Central Atrium, John Muir Medical Center, this new community hospital could be charac-
Walnut Creek, California terized as viewing gardens. One has seating in
A small, square (approximately 32 x 32 feet) it and is thus described in this section.
garden can be viewed through floor-to-ceiling A door opens off the corridor and one steps
windows from a large, plushly furnished foyer- into a space that is approximately 60 x 60 feet
atrium and from three adjacent corridors in in size. Almost half the total area comprises
this modern, suburban medical center. Flowers tiled paving in a wavelike design, echoing a
and ferns grow in square concrete planters of water theme used throughout the interior and
varied heights. There is a small fountain in the landscape design of this hospital, located as it is
center and two 2-story-high trees. The garden on an island (Isle of Wight). Beyond the paving
was designed by — and is maintained by — a (as you view it on entering) is low shrubbery
local 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 on
people 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 two
The fountain, with a number of very thin floors above, the detailing and furnishing of this
falling 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 a
ter choice, considering that people cannot hear sociofugal design (i.e., the seats face out, away
it. More lush, colorful, and varied planting from each other). This means that any more
would 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-families
This 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 by
at 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 the
Such a space is usually viewed or entered from
use of this space. Also limiting the use of this
a waiting area or corridor.
garden is an inordinately high and awkward
Advantages 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

27. 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 in
ceiling 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 and
Thus, this garden can easily be enjoyed by pathway — the other two sides are faced by the
numbers 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 variety
and is accessed by doors off the corridor-waiting of planting ensure complete privacy for those
area. The garden is approximately 115 feet long inside. Although a distant air-conditioning unit
and 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 hospital
paving 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 leaves
litter 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 true
concrete 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 reading
vide 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) looking
most 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 look
white roses, white and blue petunias, white at the therapeutic potential of outdoor gardens
cosmos, 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

29. 6. SAN FRANCISCO
GENERAL HOSPITAL:
The Comfort Garden
T
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 clinics
influenza epidemic of 1918 brought about se-
main entry to
vere overcrowding in this and many other San
Francisco hospitals. Most of the present build-
ings were constructed during 1915–20, de-
lawn
signed by city architect Newton Tharp in an
Italianate style, laid out “with green lawns and
22nd Street
bright flowering plants to add to the attrac-
tiveness of the structures.” Early photographs
out-patient clinic’s back door
depict 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 was
established in June 1990 as a “living memori-
al” to hospital employees who had died. A
name plaque in the garden, recording its in-
and Child Abuse. All of these are outpatient
ception, concludes with the words: “It is
clinics; none of the buildings adjacent to the
meant to be a place of solace where nature’s
Comfort Garden contains inpatient beds. The
beauty can bring you comfort.”
garden is bounded on two sides by these build-
ings and on the other two sides by fences that
Physical Elements and Site separate it from 22nd Street and a parking lot.
Layout The feeling of this residential-scale garden
The garden is located adjacent to Buildings 80 is of a green and colorful retreat (see Map
and 90 — imposing six-story brick buildings 6–1). Three very large trees — one cedar and
with many operable windows looking out over two Monterey pines — are almost as tall as the
the outdoor space. These buildings house a buildings. Five lawn areas are bounded by
variety of clinics, including those for TB, concrete paths and flower beds. Most of the
HIV, methadone maintenance, Family Health, paths are designed for easy, direct pedestrian
x 23

30. Photo 6–1: Richards, is entitled “Companion Place — a
Main entry path complement to the Comfort Garden.” It com-
to Building 90 — prises a curvilinear path bounded by granite
the 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 bed
Photo 6–2: where shrubs and flowers can be viewed at
Strolling path and
close quarters (see Photo 6 –2).
secluded bench in
the 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

31. 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 more
portion 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, effectively
there is some degree of privacy. complement the rich planting to create an
oasislike effect. At its widest, the garden is just
Microclimate and Ambience under 100 feet, while it is approximately 160
On a sunny day in spring and summer during feet long. The scale of this space evokes much
the peak-use hours (11 a.m. – 2 p.m.), approxi-
Photo 6–3:
mately 85 percent of the garden is in the sun.
Garden benches
However, this part of San Francisco is quite are an ideal size for
frequently breezy, if not windy. On a sunny one individual to
and breezy day, the comfort difference be- “claim” and to
tween 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 blocks
are in the sun almost all day. The wooden-
platform seating, underneath a large Monterey
pine, is in shade most of the time. Thus, only
on the hottest and calmest days is this a com-
fortable place to rest.
A small number of those we interviewed
complained that the garden is “too noisy.” In-
deed, there is a fair degree of background noise
in this setting: cars and buses driving past on
Portrero Avenue; cars accelerating uphill on
22nd Street; and the sounds from a large air-
conditioning unit on an adjacent building.
When asked to describe the garden, some
referred to it as “an oasis.” We suspect that this
image is evoked by two things: one, the lush
San Francisco General Hospital: The Comfort Garden x 25

32. Map 6–3: staying in the garden for 30 minutes or more
Comfort Garden, when they came out. There was no significant
Users Passing difference between the use of the garden and the
Through
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 in
is created by the
hospital heating
pairs to enjoy eating a brown-bag lunch; visitors
plant, new hospital or patients who sat for a while, sometimes
building, and old smoking or drinking, or who lay dozing on the
brick 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

33. 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 Interviewees
What Happens to People in the First time
here
Comfort Garden
When asked, “Do you feel any different after 14%
you’ve spent time in the garden?,” half said
that they felt calmer, more relaxed, less 46% Up to twice
a week
stressed. These comments were made by both
40%
staff and outpatients (see Table 6–1). A signifi-
Every day
cant number reported feeling “better, and more
stronger, more positive.” These respondents
were mostly outpatients.
A middle-aged male outpatient who comes
TABLE 6–1 to the garden every day to sit, relax, stroll,
Percent of Respondents Reporting Various talk, eat, and meditate loves the solitude and
Types of Mood Changes Photo 6–5:
Percent This long path
Calmer, contented, sleepy, more relaxed, 68 leads up into the
less stressed garden from the
bus stop and a
Better, more positive, pleased 26
small employee
Refreshed, stronger 16 parking lot. Note
Helps me think through problems 10 the visual bound-
Moves me, a religious connection 6 ary created by the
houses on Potrero
Escape from work 4
Boulevard and by
No difference in mood 4 distant outline of
(Number of respondents: 50) Twin Peaks.
San Francisco General Hospital: The Comfort Garden x 27

34. the colors and leaves the garden feeling “more feelings and activities this place supported. Two
relaxed ... it’s very peaceful, an oasis ... some- outpatients remarked: “It’s a place where you
times 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 recovering
waits for a friend while he’s at an appointment — they’re in the same position as me.” A female
remarked: 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 I
What Users Liked Best About
see have died. Sometimes it seems like a place
the Garden they’d come back to if they’re coming around
By relating how they would describe the gar- to visit.” Several employees and outpatients had
den 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 drinks
in the garden once or twice a week described it
Changes and Modifications
as “... absolutely beautiful ... it’s like a rainbow Desired in the Garden
on a beautiful day, with a beautiful woman. When asked if there were anything they would
How do you describe color to a blind man?” like to see changed or added to the garden, the
Many referred to it as “an oasis in a sterile set- most frequent response was — “Nothing!” or
ting,” 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 6–3
to 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 Changes
were further confirmed when people were Percent
asked: “What do you like best about this place?” Change nothing; it is changing 36
Practical changes: more seats, tables, 32
TABLE 6–2 ashtrays, trash cans
More flowers, trees, shade 22
Percent of Respondents Who Named These
Qualities 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 14
Aesthetic attractiveness and design 92
Aesthetic changes: add arbor, water feature, 12
Flowers, plants, trees 74 wrought iron, more paths, label plants
Privacy, quiet, comfort 60 Protect/enhance the personal meaning 4
Open air, sun, seasonal change, birds, 24
(Number of respondents: 50)
butterflies
Human companionship 10
There was a desire for more places to sit and
Memories 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 since
were 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

35. ing or sitting in the garden or strolling through. and to use the space as a neighborhood park. A
Recent 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; the
is 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 path
voiced 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. Three
care 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 appears
ticularly pertinent to the kinds of outpatients as though all these are local residents, enjoying
visiting 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 Conclusion
on 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 adjacent
ciety, if not actually homeless; for them, espe- buildings, and to medical and administrative
cially, 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 setting
Weekend and Weekday Use are clearly highly appreciated by all kinds of
There is a very marked difference in the use of users, by those who pass through as well as
this garden between weekdays and weekends. those who spend more time there. Of the few
On 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 we
cent buildings. During the middle hours of the talked with had varying abilities to articulate
day, as noted, many use it for eating lunch, tak- what effect the garden seems to have upon
ing 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 various
Almost no one enters or leaves the buildings. ways, and in differing degrees, this does indeed
The 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

37. 7 CASE STUDY: ALTA BATES
.
MEDICAL CENTER,
BERKELEY, CALIFORNIA:
The Roof Garden
T
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 Alice
Miner Bates, who first settled in Berkeley in Physical Elements and Site
1904, 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 of
nity. In 1905, at the request of local physi-
the hospital complex, three floors above the
cians, and with plans drawn up by her
ground. On the north side, it is bounded by a
contractor-father, she built an eight-bed nurs-
four-story wing containing patient rooms and
ing facility and school for nurses on Dwight
offices in the maternity department. On the
Way, called Alta Bates Sanitarium. In 1908,
other three sides, the garden looks out onto
due to population growth in Berkeley after
expansive views: to the east, the wooded and
the 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 Plan
added. Care was taken through setbacks and
landscaping to ensure that the buildings
blended into the residential neighborhood.
This concern extended into the 1980s, when
the 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 new
building in 1983. It is accessed from elevators
9 and 10, which are approached via a long
corridor leading south from the main lobby.
There is no indication or sign in the main
lobby directing people to it, and inquiries at
the information desk suggest that the volun-
teers who work there do not know of its exis-
x 31

38. Photo 7–1: later section, this small “anteroom” to the gar-
This “plaza” area den proper is well used because it is near the
incorporates a cen-
tral flower bed elevators and near snack machines; on hot days
with a tiered foun- it is sheltered from the sun’s glare; on frequent
tain. The sound of windy days it is screened from the breeze.
the water and the
attraction of birds
to the fountain are Ambience and Microclimate
particularly appre- The background hum of a large air-condition-
ciated in this roof
garden. 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 more
The Roof Garden, of a garden feel to it (see Photo 7–3). A small
Experiential
Analysis 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

39. screened area offering shelter from the prevail- Map 7–3:
ing winds would have been a welcome addition. The Roof Garden,
Stationary Users
Garden Use
Compared to two other sites discussed in case
studies in this report (Kaiser Walnut Creek
and the Comfort Garden at San Francisco
General Hospital), the roof garden at Alta
Bates is relatively under-used. In eight hours of
observation at the Kaiser site, there were 251
user-observations recorded; at San Francisco
General, the number was 596. The number at
Alta Bates was 154. This relative lack of use
can be explained by a number of factors: A roof
garden is a “terminus” location — most users
go there to be there, they don’t pass through it
on the way to somewhere else; a roof garden
tends to be more exposed to the elements than
a 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 were
Talk with colleagues or friends 34 those who met each other while taking a break
Eat 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 for
Look at the view 6
those who want to choose where they sit, is the
lack of movable seating. There were only five
Sleep, doze, sunbathe 5
movable white plastic garden chairs (and three
Work 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 be
person to walk from the elevator and find a moved into the shade or sun, depending on the
place to sit while smoking a cigarette, or to weather; they could be moved to sit and look at
enjoy a soft drink purchased from a machine the view, or to join a friend at a table (see Photo
near the elevator, or to eat a brown-bag lunch. 7–2). Considering the very secure location of
Since 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 more
ple 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 through
around the vending machines beneath a build- the garden (one-fourth of the total) tended to
ing overhang; it was here that most socializing move on one route — from the maternity wing
took 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 spend
crete 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

40. Photo 7–2: therapy.” Most came alone and stayed alone
Movable chairs during their break; some joined colleagues
allow this staff
person to create a whom they encountered in the garden. There
private setting for is no lack of places to sit, though there is a lack
a 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

41. 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) were
come 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 that
the garden two or three times a week re-
make this a garden and not just a rooftop
marked: “I’m at peace — you can see the birds
space. The fountain, though small, is centrally
and the water. I feel a sense of meditation; I
placed and audible from seating places in the
feel better. Breathing the fresh air helps clear
main plaza section. Importantly, it also offers
my head even if I need to scream or run in
water to birds, which frequently come to drink
place. It’s getting away from people, from
and bathe. Some have made nests and raised
work. 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 7–3
garden every day said: “It’s an excellent area
Percent of Respondents Who Name These
for relaxation even if it’s only for a short time.
Qualities as Helpful in Attaining a Mood
Five minutes out here is better than an hour in Change
the cafeteria. Its calming influence creates a Percent
sense of separation from the hospital that a Flowers, colors 67
recreation room wouldn’t provide. It’s a com- Openness, views 36
plete getaway.” Greenery, seasonal change, “nature” 33
Though relatively few patients used the gar- Water, fountain 31
den, responses from two who did are indicative Peacefulness, no traffic noise 31
of what such a space can mean to someone who Escape, privacy, secret places 28
is sick or in recovery. A female inpatient re- Sun, light, fresh air 28
sponded: “I feel more normal here. I felt really Birds 25
depressed in there; I was getting real teary. Design features (textures, shapes) 19
You go from having control of your life to less
Sounds, smells 14
control. Out here you’re on your own; there’s
Management policy (smoking okay) 8
time to forget about it. You feel relieved from
Places to sit, companionship 5
all the medical aspects of your case. You come
Don’t know 3
out 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

42. Photo 7–3: alone. As an employee in healthcare, you’re con-
The “garden” stantly giving, interacting. It’s important to have
area provides an a place to recharge.
expanse of lawn
for more casual
use, and children’s TABLE 7– 4
play.
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

43. at a table or sit with their feet up on one of the
planting edges. With only five movable chairs,
they were in great demand. Observations made
Conclusion
There is no doubt that for those who use it, the
by William Whyte in his film on the use of
roof garden at Alta Bates facilitates relaxation
Manhattan plazas (The Social Use of Small
and reduces stress. It was particularly beneficial
Urban Spaces) suggest that people just like to be
to hospital employees, who reported returning
able to move a chair in a public space, even if
to their work refreshed and more centered. A
only a foot or two, perhaps to have a sense of
male employee who uses the garden every day
control over their environment. Apart from
as a “getaway for stress relief” reported: “You
these movable chairs, all the seating on the
can come out here and meditate whether it’s
roof 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” but
the 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 as
in the garden and — on windy days — lack of
important as that of the patients. One male
shelter. 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, there
cart, and an outdoor pager (for medical staff on
were plants but no places to sit. “Here I sit and
call) were other practical suggestions. For the
smoke one cigarette and I don’t need another
most part, however, users were well pleased
to relax me.” While smoking is not beneficial to
with the garden. Aesthetic improvements were
health, if the garden enables an employee to
voiced by relatively few, but were worded quite
relax with one cigarette rather than two, that is
vehemently.
certainly a benefit.
A man visiting his wife in the hospital want-
ed “a pond with koi or goldfish where you can
watch 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

44. 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 important
Photo 7–6:
The absence of setting for people who are dying: “We’ve
shade and wind brought patients out here to die because the
protection is ap- family asked for it. They were able to die in
parent in this
peace without the critical-care setting. When
overview of the
roof 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

45. 8. CASE STUDY:
KAISER PERMANENTE
MEDICAL CENTER,
WALNUT CREEK, CALIFORNIA:
Central Garden
Physical Elements and Site Map 8–1:
The Central
Layout Garden,
T
he central garden at Kaiser, Walnut Illustrative Plan
Creek, is the largest of the landscapes
in this study. Designed around two
heritage valley oaks, the garden is spacious
enough to accommodate in addition several
mature sycamores, pines, box elders, sweet
gums, and olive trees. Under the tree canopies
are undulating borders of shrubbery and large
expanses of lawn punctuated with movable
picnic 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 parking
structure is situated diagonally opposite. The
hospital extends its single-story arms out to
encompass the east and south sides of the
space 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, near
atric 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 three
days. One of the wings is being shut down for Atmosphere and Ambience
renovations and was at 50 percent occupancy Predictably idyllic weather through most of the
at 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 an
wide, covered arcade, low shrubs, and semipri- inviting place. The evergreen plantings at eye
vate 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 comb
in 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 chirping.
ing and single-story outpatient EKG center to Squirrels scamper across the grass and chatter at
the west. Due to the layout of the perimeter passers-by from overhead limbs. The spreading
x 39

46. Photo 8–1: vation, 745 either stopped to talk, or sat eating,
The presence of waiting, smoking a cigarette, or purposefully
these magnificent passing the time by strolling the grounds or
150-year-old
playing.
valley oaks dictated
the location of this The high number and diversity of the ser-
well-used garden. vices surrounding the garden made it difficult
They provide a to differentiate among visitors, outpatients,
dramatic focal and nonmedical staff. However, we recorded
point and have
that 29 percent of the users were medical staff,
become a favorite
rendezvous 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 than
Map 8–2:
in clusters, and wooden picnic tables that
The Central
Garden, change orientation with the lawn-mowing
Experiential schedule. There is a well-used covered patio
Analysis 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

47. 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 72
30 minutes in the garden, and nearly three- Serenity, quiet, “escape” 54
fourths took breaks of 10 to 30 minutes. This Birds, squirrels, open air, sun 50
contrasts with Alta Bates’ roof garden, in which Expansiveness, open space 8
relatively few used the garden for 5- to 10-
Human companionship 4
minute breaks.
(Number of respondents: 50)
TABLE 8–1
Another employee uses the garden several
Percent 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 peanuts
Relaxing 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 even
Talking 70 come here on my day off!”
Strolling 54 Several people felt it looked like a park or
Waiting 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’s
Attending 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 route
here and at all the case study gardens, at this from the parking
Kaiser facility a higher proportion than else- structure to the
main hospital lobby
where reported using the garden for eating,
is highly used. The
visiting with a patient, watching their kids multistory building
play, and attending an outdoor meeting. Al- is dwarfed by the
most half reported there were no impediments tree and recedes,
to their using the garden, and most of the re- while the lawns
mainder — as at other sites — reported weath- create a soothing
er 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

48. Photo 8–3: I work in the operating room. We have no win-
Wide walkways dows; it’s very cold with artificial light. This is
outside patient the complete opposite — it gives me a lift to
rooms provide a come out in the natural light.
buffer from garden
activities, and en- I feel more calm, more relaxed. If you want to
able patients in get away from things, just sit under a tree and
beds or wheelchairs reflect — things usually get better.
to be brought out-
It’s very soothing because it’s so different from
side. 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 absolutely
families.
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

49. hadn’t consciously thought about this before. A female inpatient interviewed near her
For 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 sitting
least once a day it was “the shade from the and relaxing on the benches. I can’t get out
trees, 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 occasionally
and down the trees, no litter in sight.” uses the garden liked “the landscaping, the
birds. You can get a cup of coffee, sit back, and
TABLE 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 whatever
Qualities 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 great
Trees 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 the
Features involving auditory, 60 space that helped evoke a change in mood. A
olfactory, 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 get
Psychological/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 Users
than plant materials
Visually attractive design 14
Variety 10
Texture 2
Practical features 26
Places to sit 12
Good maintenance 6
Accessible 4
Pathways and amenities 4
Don’t know; no answer 10
(Number of respondents: 50)
Case Study: Kaiser Permanente Medical Center, Walnut Creek, California: Central Garden x 43

50. 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 talking
Photo 8–4: with — people in the garden at Kaiser Walnut
Casual seating Creek that the presence of life just outside is
along the walkway
enormously therapeutic. The trees, the birds,
provides a conve-
nient resting spot. the squirrels, children playing — all remind
Wood 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 here.
one heritage oak Look at this incredible oak tree — it’s a uni-
while providing
verse in itself.” Several patients and employees
seating with an
array of vistas and mentioned the fact that the garden made this
informal play Kaiser facility unique and that they used (or
space for children. had taken a job at) Walnut Creek specifically
44 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations

51. because of its soothing milieu. One of the gar- Photo 8–5:
deners told us, “They call this Kaiser ‘the A covered patio
country 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 area
cause of the garden — as one of the best. And within the garden.
a male employee who uses the garden every
day, 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

53. 9. CASE STUDY: CALIFORNIA
PACIFIC MEDICAL CENTER,
GARDEN CAMPUS,
SAN FRANCISCO1:
The Garden
R
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, along
curables was opened on this site in 1915. In with other gnarled fruit trees and the vestiges
1938 the facility changed hands, was renamed of the formal yew and boxwood plantings. An
the Garden Nursing Home, and began provid- addition to the west wing of the hospital added
ing an array of rehabilitative services ranging a long balcony off the day room on the third
from cardiac and respiratory therapy through floor, which meets grade and leads down into
physical therapy and vocational counseling. the garden. In view of the balcony’s location
Today 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 the
AIDS and other chronically ill patients. The garden (see Photo 9–5). This sunny elevated
average length of stay at Garden Campus is spot proved to be the most used area, offering
around 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 Plan
in the history of this site. Several photo al-
bums kept by the administration track the var-
ious changes and momentous events. The staff
here are proud of the garden, and it is an inte-
gral part of the hospital’s identity.
Physical Elements and Site
Layout
The original garden was a formally laid out
herb garden with lawns, circular paths, and
larger shrubbery and trees around the perime-
ter. The plan has been modified several times
and now incorporates two glazed shelters with
tables and chairs, two larger patio areas, one in
the sun and one predominantly in the shade,
and a volleyball/basketball court (see Photo
1 Due to hospital remodeling during the research period,
this case study is descriptive only.
x 47

54. Photo 9–1: cy, being bounded by the building on two
This interesting sides and steep slopes of mature planting on
and eclectic garden the north and eastern edges. The small num-
offers a variety of
ber of patients and the temporarily empty
uses from active to
passive. Particu- floors, as well as the mix of design styles and
larly 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 highly
used by the chil- Garden Use
dren 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 San
Photo 9–2: Francisco. The garden is on the uphill side,
Appealing and behind the building; while breezes eddy
convenient access through the space, the prevailing winds are
at ground level
thwarted by the hospital itself. The freshness
draws people into
the garden. Wide, of the salt sea air is a reminder of the proximi-
smooth walkways ty of the ocean, and even on sunny days the
facilitate use by rhythmic sound of a nearby foghorn reminds
patients on gurneys one of the preciousness of this secluded and
or 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

55. 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 the
ground cover on the slope below the balcony
garden just before they die, so that they may
on 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 there
bin, onto the plants below, making several
were more healthy AIDS patients, “there were
trips in to the sink, to make sure that they got
always people in the garden: patients alone or
enough.
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, Users
most likely doing this as a reflection of their Passing Through
or Playing
preference for an outdoor route (see Map
9–2). Although most of the users of the garden
were stationary, a fifth of the uses recorded in
the garden were children playing. Although
playing was recorded at all of the case study
sites, this site presented not only the largest
percentage of this activity, but also children
playing for the longest time, and on their own.
Their parent-visitors were observed to come
to the balcony railing from time to time to
check on their children, and then return to the
bedside. The children, however, happy to be
playing, entertained themselves for extended
periods of time. The easy observation from
the balcony (see Photo 9–1) and the secure na-
ture of the garden both contributed to this
phenomenon.
Case Study: California Pacific Medical Center, Garden Campus, San Francisco: The Garden x 49

56. Map 9–3: responded that there was not anything. How-
The Garden, ever, one employee was quite vocal about
Stationary 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 trees
and create private and I like the sound of that.
seating areas.
Features such as
this extend the use Impediments to Use and De-
of the garden into sired Changes in The Garden
many months of Interviewees were asked if there was “anything
the 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

57. What Happens to People in Photo 9–5:
Patients on a shel-
The Garden? tered balcony off
In response to the question “Do you feel any the day room par-
different after you’ve spent time in the garden?” take of the views
all of the respondents said yes. Typical of com- and fragrances in
the garden. The
ments 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 the
or 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 of
Specifically Helpful the patients. The garden is a tremendous asset
Characteristics in allowing the residents and visitors to feel as
Several qualities of the garden were listed comfortable as possible.
specifically in connection with the mood The reports of frequent family picnics in
changes experienced by the users who were in- the garden, the intense use by children, the
terviewed. 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 spending
considered 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 can
and 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 a
in the patients when she brings them out into demanding field such as healthcare, providing
the 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 out
Conclusion here to watch and enjoy the goings-on, while
The nature of the Garden Campus, offering the proximity to the unit allows the staff to
post-acute care and hospice services with a check on them regularly. When the second
longer 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

58. Map 9–4: volleyball/basketball court is an additional
The Garden, draw for younger visitors, and is an outlet for
Experiential the release of pent-up energy by the staff (see
Analysis 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

59. 10. AGGREGATE DATA
ANALYSIS OF THE CASE
STUDY SITES
I
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 aggregate
these exterior spaces was described. In this analysis is therefore not on users moving
chapter the aggregate data is presented and through the space (though within the context
analyzed to suggest overall trends. It is some- of the individual site, this is significant).
what problematic to compile responses from
differing 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. 59
among 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. Nearly
One aspect of this is the array of differing ele-
half of the respondents use the gardens every
ments within the landscaped areas. This has
day, or several times a day.
been addressed in the analysis by focusing on
categories of elements, rather than on spe-
cifics. For example, Kaiser Walnut Creek has TABLE 10–1
two heritage oak trees that were mentioned by Frequency of Garden Use
36 percent of the people as a significant factor Percent
in their restorative process. There are relative- Several times per day 30
ly few blooming plants at Kaiser, and only 6 Occasionally/sometimes 27
percent of the respondents mentioned the
Every day 18
flowers. In contrast, San Francisco General
1-2 times per week 14
has no heritage trees, however it had 35 differ-
First time here 11
ent species of plants blooming at the time of
the study. As might be expected, 42 percent of (Number of respondents: 143) 100
those people interviewed at San Francisco
General 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 engaged
of the aggregate analysis, these two items have in from a list of 10 options. All but 8 of the
been 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 they
the four landscapes is the site layout. The gar- come to talk, eat, stroll in the garden, and/or
den’s relationship to the buildings, how many come for their own, undefined “outdoor
access points there are, and the efficiency of therapy.”
x 53

60. 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 the
Relax 94 Aggregate Data
Eat 73 When looking at the activities in relation to
Talk 73 the different types of users, there were some
Walk through 68 expected results and some associations that
Stroll in the garden 61 were not anticipated. Predictable responses
Outdoor therapy 53
were documented by those interviewees re-
porting that they came to the garden to
Wait 38
“relax,” to “stroll through,” and to engage in
Visit with a patient 36
“outdoor therapy.” Each of these activities had
Let 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, with
den reported that they “feel different” after
the visitors and patients tied at the top of the
spending 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 inquiries
laxed, and calmer. Somewhat less than a quar-
regarding “talking” in the garden. The vast
ter of the users reported that they felt
majority of employees reported that they talk
refreshed, rejuvenated, or stronger, while as
while in the garden, as did close to two-thirds
many 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 while
after being in the garden.
they were there. One explanation for this may
TABLE 10–3 be that visitors specifically come to the hospi-
tal to talk and be with a patient, and staff are
Percent of Respondents Reporting Various in a work environment where they have
Types of Mood Change friends and acquaintances, whereas patients
Percent are isolated from their social milieu and know
More 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 may
Pleased, 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 have
No 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 a
of the garden named by users as helpful to patient.” Again, the total percentage of users
them, two-thirds of the respondents men- who visit with patients was not large, but the
tioned trees, flowers, and plants. More than differences among rates of usage was revealing
half mentioned features that involve either (see Figure 10 –2). The fact that the employees
sounds or smells or tactile responses. Exactly engage in both of these activities indicates that
half of those answering this question men- the garden increases the number of options
tioned 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

61. ibility in their choices of how they work — and often provides a level of privacy otherwise
whether 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 a
ployment and their personal lives. sense of autonomy, so compromised for inpa-
tients, as well.
TABLE 10– 4 When looking at the association between
Percent of Respondents Who Named These mood changes and user types, the results con-
Qualities as Helpful In Attaining a Mood firmed our expectations. Approximately equal
Change proportions of visitors, patients, and staff felt a
Percent rise in energy and reported being refreshed
Trees 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 difference
or 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 Garden
Visual qualities relating to more than 26
plant materials Bring Kids to Play Here
attractive landscape design, views, 14%
variety of elements, textural contrast/
12%
quality, differing shapes/sizes
Practical 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 Staff
ing together in the garden. After playing with
her two children for a period of time, the
FIGURE 10–2
mother kissed them good-bye and said that
she had to “go back to work now.” Unusual The Percentages of Each User Type Who Visit
though this may be, the interviews reveal that with (Other) Patients in the Garden
this is not an isolated incident. By using the Visit with Patients
garden in this way, the staff are taking the op- 50%
portunity to satisfy their personal needs in a
way that supports their work. 40%
We also observed medical staff chatting
with patients in the garden. Some of these ap- 30%
peared to be chance meetings. However, we
did observe staff and patients coming out to- 20%
gether and having what appeared to be a seri-
10%
ous conversation. The opportunity for staff
and 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

62. FIGURE 10–3 ly associated with location and accessibility. At
all of the sites except Alta Bates, about one-half
The Percentages of Each User Type Who
Report 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 than
100%
80 percent of the users were staff members. As
discussed in chapter 7, this is a garden that is at
80%
one end of the hospital site, far from the main
entry. The entire interior area of that floor has
60%
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 that
20%
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, on
tween 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 longer
mood 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 visitor
would follow, therefore, that they would seek
and patient users was relatively even for Kaiser
an uplifting experience in the garden described
Walnut Creek and Alta Bates. There were
by them as “religious” or “spiritual.”
substantial differences between these groups at
It was anticipated that some differences in
San Francisco General, however, where many
responses 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 several
not support either of these assumptions. There
outpatient clinics that primarily serve adults
were, 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 Who
Report a Spiritual or Religious Mood Shift
In Summary
Deeper Meaning This research has documented that people in
12% 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

63. 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 with
this 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 following
come 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

65. 11. DESIGN
RECOMMENDATIONS
T
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 to
are divided into three groups: the pediatric
department of
A) locational, site-planning, and way-finding; this suburban
B) planting, seating, aesthetic, and detail; medical center.
C) policy regarding the provision and mainte- Surrounded by
nance of gardens intended to be used for ther- plate-glass win-
dows, this space
apeutic benefit.
allows easy moni-
toring, yet provides
A. Locational, Site sound insulation
for children who
Planning, and Way-Finding need to let off
Recommendations steam. (Kaiser
Permanente
To truly maximize the potential of garden
Medical Center,
spaces in hospital facilities, the design process Vallejo, CA)
needs to begin with site planning. Many issues
that we encountered in our research could
have been mitigated or avoided if the provi-
sion of potentially therapeutic garden spaces comfort. Design with particular awareness of
had 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 be
number 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

66. 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 an
Photo 11–2: tion, strolling, and so on. open, multiple-bed floor plan, more areas for
A covered sitting 3. Our field studies revealed that lack of
terrace with forest private conversations and withdrawing from
views outside a day
knowledge about the existence of a garden social interaction need to be provided.
room offers conve- space is one of the most critical factors in its 9. Balconies or roof terraces with a view into
nient 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 wheelchairs
weather, as well as be visible from the main entrance or there
visibility 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 have
toring 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 experienced
tial 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 into
groupings. 10. The layout of the garden needs to be
the fresh air, offering a choice and allowing
(Monterey County easily “readable,” to minimize confusion for
Hospice, 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

67. from the hospital environment. Our interviews
and case studies clearly indicate that three as-
pects of design details are critical in facilitating
a change of mood and lowering stress. These
are the presence of a variety of green, grow-
ing, and living things; the stimulation of the
senses; and the availability of a variety of set-
tings for both social interaction and quiet in-
trospection.
The following design principles can serve
as 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, and
eye-catching so as to suggest the image of a gar- taken to place it in a wind-protected location views toward
den. Over and over, trees, plants, and greenery where people can sit nearby, and where air- greenery or over
were cited as the most significant helpful char- conditioning or other irritating noises do not the city skyline.
(St. Mary’s
acteristic. 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 a
correct placement in the garden, is one of the planting buffer of sufficient distance and depth
essential elements of a therapeutic garden envi- so that people walking or sitting in the garden
ronment, 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 indoors.
ing them. 10. Paths that meander allow for strolling
3. Flowering trees, shrubs, and perennials and contemplation and complement more
provide a sense of seasonal change that rein- heavily used direct routes between access
forces 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 smooth
patterns 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 that
fountain or birdbath, a bird feeder, trees ap- volunteers or family members can easily bring a
propriate for roosting or nesting — stimulate patient on a gurney or in a wheelchair out into
the senses and help to lift people’s spirits. the space.
Design Recommendations x 61

68. Photo 11–4: or eat, especially where the space is adjacent to
Located off one of the cafeteria.
the arterial hall- 22. Adjustable umbrellas allow people to
ways of this major
control the amount of sun or shade, so impor-
medical center, a
well-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 surfaces
welcome 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 the
outside. The pri- den into several seasons.
vate windows on 24. Where there is a view, make sure that
13. Electrical outlets allow for the garden
the surrounding some seating faces that direction to facilitate
walls are ade- to be used for hospital parties or other spon-
psychological movement out of the space. If
quately 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 be
to minimize the 14. Nighttime lighting maximizes the ther-
“fishbowl” feeling sufficiently low or transparent so that people
apeutic benefit by allowing people to use the
that such spaces seated can take in the view.
space safely after dark, or to look out at the
often 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 and
Medical 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 a
Photo 11–5: degree of privacy for those wanting to be
Movable chairs,
alone, or who want to observe from a distance.
tables, and parasols
allow users to enjoy 17. Fixed seating with backs for sitting in
this community comfort is especially important for garden
hospital’s small users who may be physically weak.
courtyard in a va- 18. If bench-type seating is provided, select
riety 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 or
cafeteria con-
tributes to the use two people can “claim” the space. The image
of this space. (No- might be of a garden bench, rather than a park
vato Community or bus stop bench.
Hospital, Novato, 19. Increase the seating options available
CA) 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

69. tify a garden — such as a sculpture, wind Photo 11–6:
chimes, an aviary, a fish pond — serves to an- In all four case
chor memories of the garden and the restora- studies, a complete
contrast to the in-
tion achieved there.
terior environ-
ment was much
C. Policy and Maintenance appreciated by pa-
tients and staff.
recommendations Even in an urban
One of the interesting contrasts that we dis- environment this
covered during our canvassing of potential re- small space outside
search sites was that we encountered what the hospital walls
was inexpensively
appeared to be more emphasis on the garden transformed by
spaces and a greater awareness of potential to the space, labeling the gardens on posted volunteers into an
therapeutic benefits at the public institutions maps, and listing them in the resource hand- intimate setting
than at private facilities. The older public fa- book at the information desk would go a long that contrasts with
cilities take great pride in their gardens, and way toward promoting their use and reaping the controlled inte-
rior. (Laguna
there 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, and
these 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 increase
impact on the success of exterior therapeutic the use of gardens by patients and visitors, and
garden spaces. These are the principles and extend the ripple of the beneficial effect to
guidelines 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 behind
there 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 doors
istence, 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 cost
took 45 minutes and several exasperating would be even greater, and longer term, to
trails 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

70. 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 is
cruitment and use of volunteers to take pa- high on the list of significant qualities — is
tients 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 on
local 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 “someone
and patio spaces. Yet it is these green, growing cares” about the garden were mentioned by
things 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 a
sonal color contribute to the healthy and friendly, comfortable, welcoming space rather
natural qualities listed as significant by the than perfection.
users of the study.
64 x Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations

71. 12. CONCLUSION
T
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 to
are in the garden, the benefits of these spaces compare the results of this study with a similar
have been described and documented. Ninety- one examining interior spaces. What are the
five percent of the people in the gardens re- therapeutic benefits of common areas such as
ported a therapeutic benefit. Employees said day rooms, waiting rooms, and cafeterias? And
they were more productive, patients spoke of are there any design elements mentioned in
feeling better and having more tolerance for this research on gardens that can be applied to
their 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 specific
the 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 garden
dens for different patient populations? What on the fiscal priority list of healthcare facilities
are the comments from people who do not use are challenges that lie ahead.
a garden, when there is one available and ac-
x 65

73. APPENDIX
Questionnaire
Location 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 building
Number ____________________ s come out for a stroll (not necessarily en route
to another building)
s let my kids run and play here
s outdoor therapy
1) The oral consent script has been read and s eat
consent given? s other ________________________________
s yes
s no 6) When you come out here, how long do you
generally stay? (may give several answers, depending
2) Gender is: on activity)
s female s just a few minutes
s male s 5–10 minutes
s 10–30 minutes
3) Would you mind telling me if you are: s more than 30 minutes
s employee
s patient who is in the hospital 7) Is there anything that prevents or inhibits you
s outpatient here for a doctor appointment, from coming here as much as you would like?
test, shot, etc.
s visitor
4) How often do you come out here?
s my first time 8) What do you like best about this place?
s occasionally, sometimes
s once or twice a week
s every day
s several times a day
x 67

74. 9) Is there anything you would like to see 11) What specific characteristics or qualities of
changed or added? this place help you to feel _________________?
(fill in the answer to question 10)
10) Do you feel any different after you’ve
spent 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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