A collection of writings from the proceedings of the Tenth Symposium of the Health Care Design. My article focused on the Resident Orientated Support and Evaluation System (ROSES). A way of measuring the effectiveness of the horticultural therapy programming for seniors in a healthcare facility.

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OURNAL OF
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PROCEEDINGS FROM
THE TENTH SYMPOSIUM ON
HEALTHCARE DESIGN

2. THE ANATO].4Y OF
A HEALI NG GARDEN
rated, but also that different parts of the body were
PAUL CARL ALLISON
treated by different specialists. Hospital architec-
J'IARNI BARNES, J'|.L.A., LCSW
ture became characterized by towers on a podium.
JA]'|ES BURNETT, ASLA
BARBARA CRISP
The chapel was tucked away out of sight. ln the
'1
960s, business moved into healthcare. The garden, if considered at all, became curb appeal or
TOPHER DELANEY
entry landscaping as cosmetics,
DAI/ID IG]'|B ASLA,
LF
JEAN tfiVANAGH, ASLA
DEBORAH LeFRANK
CLARE COOPER ]'IARCUS, M.A., ]'lCP
ROGER S. ULRICH, Ph.D.
arcus: The earliest healers were shamans
and priests who had links with other worlds
and brought in the spirits of plants and animals to assist in healing. The earliest healing places
were nearly always in nature
- a healing spring, a
sacred grove, a special rock or cave. The earliest
hospitals in the Western world were attached to
monasteries, where medicinal herbs and prayer
were components of healing. The cloistered garden
was an essential part of the healing environment.
With the start of the scientific era, priests and
healers separated. Hospitals became places of scientific treatment, although in the era of Florence
Nightingale-inspired pavilion hospitals, some attention was still paid to the outdoors as a source of
fresh air and sunlight. By the 20th century, medical
technology began to dominate healthcare, except in
the case of TB patients in sanitoria, where the outdoors was still seen as an important part of healing.
By the '1 940s, the rise of specialists within medicine meant not only that the body and spirit sepa-
Direct contact with the outdoors all but disappeared.
Yet all is not lost. Studies are beginning to appear
that indicate that access to nature is highly valued by
patients and staff and that it can increase positive
medical outcomes. ln certain healthcare facilities,
the garden and nature are still present. This is true in
the care of the dying in hospices, in the care of the
mentally ill, and in the care of long-term patients,
such as those with Alzheimer's disease and those in
some Veterans Administration hospitals. Those
precedents and the emerging interest in what is
being called a "healing garden" bode well for the
return of accessible nature in all medical facilities.
The healing garden movement is intimately
linked with an overall paradigm shift in society as we
move from a mechanistic and technical world view
to one that is more holistic, embracing spirit as well
as science. The interest in healing gardens is one
facet of health that looks at healing rather than treatment, and sees that healing as a combination of
the body and mind.
Healing gardens are part of a movement that also
encompasses, among other things, the opening of
clinics in Arizona and Washington State that combine
allopathic and complementary medicine; and the
enormous popularity of the work of medical doctors
who embrace complementary practices, such as
Andrew Weil and Deepak Chopra. The huge number
of American people who spend a total of $15 billion a
year on alternative medicine is further evidence that
something is changing. Clearly, these people are not
satisfied with what mainstream medicine has to offer.
a
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3. e an:
scape that harnesses the powers of nature into a
design of simplicity and order, thereby allowing a
mair-
focused environment for personal healing.
The order of the Texarkana pine forest is found
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home of this celebration in October each year by
the Sisters, staff members, and community.
The amphitheater has over-scaled steps, which
are designed at seat height and focus on the center
throughout the site in the form of bosques and allees
that enrich the quality of the built areas. The courtyard areas near the building are heavily developed
water feature. lt can accommodate a large group for
with special paving, seating, fountain f eatures,
tuated with a water feature that adds sound and
potscapes, and landscape planting. The courtyards
are designed as break areas so that people can
experience an outdoor environment more healthy
than typical medical institutions. A path system further unifies the site, reaching from the buildings to
the pond edge and throughout many of the natural
preserve areas.
The two-acre pond near the entry also functions
as an irrigation reservoir. The edge detail was a
site-adapt idea whereby we trenched a pond line
and backfilled with concrete. The soil was clayey
enough to work as a form and hold the concrete
together. Upon curing, the pond side of the trench
was excavated, leaving a four-inch pond wall intact.
The natural soil color helped to stain the concrete,
making it blend in with the natural landscape. The
complement to the pond is a decomposed granite
gravel path that winds through the woodlands, providing a porous walking path that does not damage
the tree root systems.
At the main entry to the hospital we worked very
visual interest to the court. The edge of the garden
of balance is designed with pear trees that provide
shade and seasonal color for the benches that line
the garden edge.
Committing resources and time to the proper
execution is critical to the success of the hospital
garden. Gardens, unlike buildings, are living things
and take on a life of their own. Strategies should be
developed for proper implementation as well as
long-range maintenance programs that support the
original design concepts over time.
Allison: The Oxford Dictionary describes evaluation as "assessment and appraisal." To help healing gardens reach their full potential, creative techniques for an evaluation process have been
developed to provide information about materials,
closely with architect Kirk Hamilton to keep the parking out of the way of the entry auto court. The centerpiece of this entry garden is a series of crushed
gravel paths and a fountain that offers a cool place
for people to enjoy. ln areas where we lost existing
trees for the construction process, we created an
allee of pear trees marching along the arcade,
responding to the structural grid of the building
Along this walk we notched stopping areas with
teak benches for small groups to visit or wait under
the canopy of the pear trees.
The garden of balance for the hospital is located
between the medical office buildings and the medical/surgical bed tower. lt is a large garden area
with a raised earth court and an amphitheater court
as centerpieces for the space. The amphitheater
represents the carving out of earth, while the raised
earth is built with the carved earth, which completes
the balance one strives for when recovering from an
illness. The raised earth offers a seat wall surround
that provides a place to look outward to the other
garden areas. The earth berm is intersected with a
black granite wall that extends to the edge of the
seat wall. The wall is a sundial marker that marks the
date of the Sisters' arrival on the Texas coast from
lreland some 130 years ago. This garden is the
special events (poetry reading, musical performance, or hospital gathering). The center is punc-
methods, and the functionality of design. While evaluation is also done at predesign, design, and postconstruction phases, I have developed ROSES, the
Resident Orientated Support and Evaluation System, as a postoccupancy evaluation for therapeutic
gardens to help me assess the horticultural therapy
program for seniors living at The Lodge at Broadmead, a long-term care facility in Victoria, British
Columbia, Canada.
Some of the outcome measures I look for are a
decrease in depression, a reduction in aggression
toward other residents or staff members, a decrease
in medication requirements, as well as a measure of
people's overall well-being. ROSES is a way of
bringing all this data together in one system.
Part of this system is the gardening profile. I visit
with each resident about a week after he or she first
comes to the facility, approaching each person with
a basket of flowers, perhaps from the garden that is
nearest to his or her room. We talk about the kinds
of things the resident likes in the garden and I ask
questions such as, "Did you ever have a garden
before? Was it small or large? Did you grow up on a
farm? Did you have an orchard? What gardens or
parks did you visit?"
Paying attention to detail helps in developing an
element in the garden that could be important to the
therapeutic goals, like a piece of sculpture created
by a resident. The resident's gardening profile can
enhance the development of therapeutic gardens. For
example, an elderly woman told me, "l've always had
THE ANATOMY OF A HEALING GARDEN .(}
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Marcus: Rcge | .-,,'c' arc others have ceria taught us a lot about tne therapeutic value of natu':
But there is still much that we need to know, such as
what kinds of nature and what forms work best. D:
people with different kinds of disease and physica
problems want different kinds of gardens? We knor',
-.
Sa'::-, ss-es ancj aiiergies are also inrportant
: - - s l:'a: o.s in the residents' gardening prof iles,
,', z^: :3 maKe sure that the gardens are cus.= ?.cessicle, which rneans that the garden can be
- rlc's as well as out. Perhaps this means having
: a-:s in the roorns or having a view. Frail residents
^ -s: ce able to open the doors to the garden, There
s^o;rd be raised beds and containers that residents
ra^ reach, Paths should be wide enough for two
.',
^eeichairs to go side by side without clanking into
=ac^
other.
Fvaiuation can be done in a number of different
,', a)is including the following:
o Ocservatron is crucial, with documentation by ther-
aoists and residents in a garden journal.
that the information gathered
soecific and usable. The information can come
's
'rorn question boxes, mailed-out questionnaires,
and educational workshops, and can be input into
a computer to create databases.
Anecdotal information gives clues to the value of
:ne garden to the staff and residents and can be
used for fund-raising or promotion.
Fhotography and vrdeo production can provide a
nistorical record of changes in the gardens.
, Surveys can ensure
.
,
Evaluations should include input from residents,
friends, and volunteers, as the garden
affects all of them. The assessments can be used to
staff , family,
improve the garden's therapeutic quality, to
enhance safety and security, for administrative
accountability, to provide marketing material, and to
establish a historical context.
The gardens at The Lodge at Broadmead are a
symbol of the quality of care the community gives the
elderly residents. The gardens are well loved by the
residents and bring contentment and joy to many
people. A comprehensive multidisciplinary evaluation looking at resources, resident strengths, service
needs, and coordinated care plans can help to focus
.
Bl(
-
quite a lot now about design for people wit'
Alzheimer's, both interior design and garden desigr^
We know something about hospice garden desigr,
What about psychiatric problems and the garden?
What do children want when stressed or ill? Whar
kind of healing garden will be most therapeutic for
people on dialysis or undergoing chemotherapy?
How do different culture groups respond to
a
healing garden? We certainly need more postoccupancy evaluations,
We are beginning to see gardens called healing
gardens But how do we know if they are healing?
We cannot assume just because a designer says
they are healing, or the client expects them to be
healing, that they really are. But on the other hand,
how do we test for healing? I don't think we will be
able to test for spiritual upliftment or a sense of hope
Finally, how do we encourage hospital administrators to understand that the garden is important
and indeed necessary? lf staff members are the
prime users of the garden, we need to look at
absenteeism, health problems, and staff turnover
before and after the addition of a garden.
We need to be telling hospital CEOs that having
gardens affects whether or not staff members take a
job. lt may certainly affect their health The garden
can be as important, or more so, for staff members
than for patients in certain medical facilities such as
acute care hospitals where the patients are in and out
so fast that they barely know there is a garden there.
Finally, we need lots more stories, as well as
more data. Tell people about the presentations at
this Symposium. Use research and patient satisfaction findings to convince them that a garden is
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