Contents
Foreword
Acknowledgments
Chapter 1: Introduction
References
Chapter 2: History of Hospital Outdoor Space
References
Chapter 3: Theory, Research, and Design Implications
The View through a Window
The Importance of Research
Evidence-Based Design
Research on Benefits of Nature Exposure
Theoretical and Philosophical Underpinnings
Other Pertinent Theories for Evidence-Based Healthcare Design
Next Steps
References
Chapter 4: Types and Locations of Therapeutic Landscapes in Healthcare
Extensive Landscaped Grounds
Borrowed Landscape
Nature and Fitness Trails
Landscaped Setback
Front Porch
Entry Garden
Backyard Garden
A “Tucked Away” Garden
Courtyard
The Hole-in-a-Donut Garden
Plaza
Roof Garden
Roof Terrace
A Peripheral Garden
Atrium Garden
Viewing Garden
Chapter 5: The Participatory Design Process
Legacy Health Overview
Organizing Staff to Conceptualize Needs
Benefits of the Design Team Process
References
Additional Reading
Chapter 6: General Design Guidelines for Healthcare Facilities
Overarching Design Considerations
Programming and Site Planning Considerations
Specific Physical Design Guidelines for All Therapeutic Gardens
References
Chapter 7: Children’s Hospital Gardens
Research
The Challenge of Multiple User Groups
Design Guidelines
Case Studies
References
Chapter 8: Gardens for Cancer Patients
References
Chapter 9: Gardens for the Frail Elderly
Design Guidelines
References
Chapter 10: Gardens for People with Alzheimer’s and Other Dementias
Introduction
Design Guidelines
References
Chapter 11: Hospice Gardens
Design Guidelines for Hospice Gardens
References
Chapter 12: Gardens for Mental and Behavioral Health Facilities
Design Guidelines
References
Chapter 13: Gardens for Veterans and Active Service Personnel
The Wounds of War
A Dearth of Research
Existing Research to Inform Design
Built Works
Guidelines
References
Chapter 14: Rehabilitation Gardens
References
Chapter 15: Restorative Gardens in Public Spaces
References
Chapter 16: Horticultural Therapy and Healthcare Garden Design
Types of Programs
Professional Training
Influences on the Development of HT
Roles of the Horticultural Therapist
Program Settings
Evidence Base for HT
Design Guidelines for the HT Garden
Funding
Collaboration among Therapies
Conclusion
References
Chapter 17: Planting and Maintaining Therapeutic Gardens
Introduction
Creating a Healthy Garden
Basic Requirements for Plant Growth
Plants: Assets and Costs
Plant Placement
Plant Selection: Plants to Avoid
Desirable Qualities of Plantings
Plant Selection: Desirable Plants
Special Healthcare Settings
Maintenance
References
Chapter 18: Therapeutic Landscapes and Sustainability
Complementary Approaches
Progress
Conflicts and Solutions
References
Organizations and Resources
Chapter 19: The Business Case and Funding for Therapeutic Gardens
Improved Patient Health and Well-Being
Stress Reduction
Improved Patient and Visitor Satisfaction
Funding Therapeutic Gardens
References
Chapter 20: Evaluation of Therapeutic Gardens
Evaluation
What We Can Learn from a POE
Further Resources
References
Index
Cover image: Anne’s Garden, Northeast Georgia Medical Center, Gainesville, Georgia. © The Fockele Garden Company.
Cover design: Wiley
Copyright © 2014 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
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Library of Congress Cataloging-in-Publication Data:
Marcus, Clare Cooper.
Therapeutic landscapes : an evidence-based approach to designing healing gardens and restorative outdoor spaces/Clare Cooper Marcus, Naomi Sachs.
pages cm
Includes index.
ISBN 978-1-118-23191-3 (cloth); ISBN 978-1-118-41940-3 (ebk); ISBN 978-1-118-42110-9 (ebk)
1. Medical geography. 2. Landscapes—Therapeutic use. 3. Landscape architecture—Therapeutic use. 4. Evidence-based design. I. Sachs, Naomi, 1968- II. Title.
RA792.M335 2014
614.4'2—dc23
2013007059
Foreword
The publication of this important book could not be more timely, given the great wave of healthcare facility construction and renovation overtaking the United States and other countries. Healthcare environments are changing and responding to trends and challenges as varied as new payment policies that reward quality and satisfaction, the growing importance of ambulatory care and rehabilitation, rising acuity levels of hospital inpatients, and rapid growth in the number of frail elderly and those with Alzheimer’s disease or other forms of dementia. The fast-evolving character of healthcare underscores the need to rethink the design of care environments and to create better facilities that prominently include gardens designed in evidence-informed ways to reduce stress, improve satisfaction and clinical outcomes, and enhance sustainability.
The interdisciplinary field of evidence-based design (EBD) has developed over the past twenty-five years in response to the need for sound knowledge to help guide healthcare design that improves care quality, outcomes, and cost-effectiveness. It makes solid sense to use the best available evidence when creating a new, long-lived healthcare environment on which so many will depend. Although the quality and amount of EBD research has rapidly increased, most studies address issues linked to the architecture and interior design of hospitals—the effects of single versus multibed patient rooms on infection transmission, for example. A smaller but growing body of EBD research has examined the influences of gardens and nature views on quality of care and outcomes in healthcare facilities. This book provides an up-to-date account of the research and theory on the effects of nature and excels in extracting and clearly explaining the design implications. Readers will gain a great deal of evidence-informed knowledge and insight concerning what garden design approaches work and which are not effective in improving healthcare quality.
It has been fifteen years since publication of the landmark volume edited by Clare Cooper Marcus and Marni Barnes, Healing Gardens: Therapeutic Benefits and Design Recommendations. Compared to that 1999 work, this new book by Marcus and Naomi A. Sachs contains much fresh material, based on recent research, plus a wealth of new knowledge derived from evaluations of several innovative and successful therapeutic gardens created in recent years by landscape architects and healthcare providers. The book begins by surveying the history of hospital outdoor space, provides a chapter covering research and theory, and follows with chapters on types and locations of therapeutic spaces in healthcare, and general design guidelines relevant across different categories of medical facilities.
Each of the following chapters focuses on a garden category designed for specific patients or user groups: gardens for children’s hospitals, for example; for patients with cancer; for persons with Alzheimer’s; and for mental and behavioral health facilities. These chapters present case studies of exemplary real-world gardens, accompanied by instructive and interesting insights obtained from postoccupancy assessments giving balanced views concerning strengths and weaknesses of the settings. Each chapter reviews research relevant to the specific user group and discusses design guidelines adjusted to meet their particular therapeutic needs. These chapters are superbly illustrated. A few examples of the many outstanding gardens featured: the Olson Family Garden at St. Louis Children’s Hospital, Alnarp Rehabilitation Garden in Sweden, and the internationally renowned Oregon Burn Center Garden at Legacy Emanuel Medical Center in Portland. Additionally, this is the first book on healing gardens with chapters on planting design and maintenance, horticultural therapy, sustainability, gardens for veterans, restorative spaces in public spaces, and the business case for healing gardens, including funding strategies.
A theme running through the book is that a participatory design process is vital to creating a successful therapeutic garden. This critical topic is the focus of a noteworthy chapter by Teresia Hazen, which describes the participatory process developed at Legacy Health in Portland, Oregon, and used to create several successful gardens at Legacy medical centers. The Legacy process begins with the premise that there is no one-size-fits-all garden design adequate to meeting the needs of varied types of patients, their families, and associated clinicians. The Legacy process instead tailors the design of each garden to ensure it directly and effectively serves the therapeutic needs of a particular category of patients (for example, stroke patients, burns cases) and their families and healthcare team.
More than any other previous book, Therapeutic Landscapes provides research-grounded yet user-friendly information that will enable readers to successfully design, fund, and build healthcare facilities that provide beneficial access to nature for patients, visitors, and staff. This book will be an indispensable resource for healthcare designers and horticultural therapists. It will also be of great value for healthcare administrators, facility managers, facility developers, and many therapists and other clinicians. The knowledge and lessons it offers will be critically important for increasing the quality and success of any healthcare project that provides gardens or other forms of access to nature.
Roger S. Ulrich, PhD, EDAC
Acknowledgments
We are deeply grateful to the many people who helped make this book a reality. We thank two colleagues who generously contributed their time and expertise by writing chapters: Teresia Hazen of Legacy Health in Portland, Oregon, who wrote chapters 5, “The Participatory Design Process,” and 16, “Horticultural Therapy and Healthcare Garden Design”; and Marni Barnes of Deva Designs in Palo Alto, California, who wrote chapter 17, “Planting and Maintaining Therapeutic Gardens.”
We greatly appreciate those colleagues who wrote or contributed to individual case studies of exemplary restorative landscapes that they designed, studied, or helped facilitate. These include Chris Garcia and Shelagh Smith (chapter 9); Chris Garcia (chapter 11); Jessy Bergeman, Victoria L. Lygum, and Ulrika K. Stigsdotter (chapter 12); Brian Bainnson (chapter 13); and Jeffrey Smith, Patty Cassidy, Kevin Aust, and David Kamp (chapter 15).
As we wrote about the business case for healing gardens and funding considerations, we asked a variety of colleagues for their experiences and drew upon their responses. For useful insights we want to thank: Brian Bainnson, Carter van Dyke, Becky Feasby, Bob Golde, Teresia Hazen, Rob Hoover, Kirk Hines, David Kamp, Deborah LeFrank, Connie Roy-Fisher, Alberto Salvatore, Jeffrey Smith, Jerry Smith, Lisa Waisath, and Daniel Winterbottom.
We greatly appreciate those colleagues who took the time to read and give valuable feedback on drafts of various chapters and case studies. These include Janet Brown, Barbara Kreski, Deborah LeFrank, Steve Mitrione, Connie Roy-Fisher, Zofia Rybkowski, Alberto Salvatore, Amy Wagenfeld, James Westwater, and Russell Wilson.
We asked colleagues for images or site plans of projects they had designed, studied, or photographed that we might include in the book, and we had an overwhelming response. We offer our thanks to the many individuals and firms who replied: Lena Welen Andersson, Kevin Aust/AECOM, Angela Milewski/BHA Design, Brian Bainnson/Quatrefoil, Marni Barnes/Deva Designs, Tom Benjamin/Wellnesscapes, Jessy Bergeman, Melissa Bierman/Legacy Health, Beverly Brown/Nazareth College, Renata Brown/Cleveland Botanical Garden, Laura Blackwell/The Plaza at Twin Rivers, Sabrina Buttitta/Plant Connection, Patrick Carey/Greenroofs.com, Jack Carman/Design for Generations, Sharon Coates/Zaretsky Associates, Tara Graham Cochrane/Design Well, Nilda Cosco/Natural Learning Initiative, Brenna Costello/SmithGroup JJR, Bob Cunningham/Arcadia Studio, Sharon Danks/Bay Tree Design, Leah Diehl/University of Florida, Henry Domke/Henry Domke Fine Art, Mark Epstein/Hafs-Epstein, Julie Evans/The Fockele Garden Company, Terri Evans/Shepley Bulfinch, Lesley Fleming, Gwenn Fried/NYU Langone Medical Center, Chris Garcia/San Diego Botanic Garden, Charlotte Grant, Teresia Hazen/Legacy Health, Ella Hilker/Haverefugiet, Kirk Hines/Wesley Woods-Emory Healthcare, Sonja Johansson/Johansson Design Collaborative, Bryan Johns/Clarke-Lindsey Village, Jennifer Jones/Carol R. Johnson Associates, Kenneth Helphand/University of Oregon, David Kamp/Dirtworks, Lydia Kimball/Mahan Rykiel Associates, Barbara Kreski/Chicago Botanic Garden, Kurisu International, Deborah LeFrank/LeFrank and Associates, Kun Hyang Lee/Asia Pacific Association of Therapeutic Horticulture, Victoria Linn Lygum, Laurel Macdonald/Macdonald Environmental Planning, Beth Matlock/Living Art Designs, Randall Metz/Grissim Metz Andriese Associates, Maja Steen Moller, Jim Mumford/Good Earth Plants, Dorinda Wolfe Murray/Independent Gardening Ltd., Upali Nanda, Danna Olsen/University of Wisconsin–Madison, Samira Pasha/Perkins+Will, Annie Pollock/Arterre Landscape Design, Mary Poole/Christian Care Community, Robert Rensel/Cleveland Botanical Garden, Annette Ridenour/Aesthetics Inc., Susan Rodiek/Texas A&M University, Geoff Roehll/Hitchcock Design Group, Connie Roy-Fisher/Studio Sprout, Alberto Salvatore/Salvatore Associates, Jan Satterthwaite/VireO Design Studio, Herb Schaal, FASLA, Becky Hoerr and Peter Schaudt/Hoerr Schaudt Landscape Architects, Giulo Senes/University of Milan, Mike Shriver/National AIDS Memorial Grove, Erin Smith/Just in Time Therapy, Jeffrey Smith/Professional Engineering Associates, Shelagh Smith/Vancouver General Hospital, Rick Spalenka/RGS Designs, Diana Spellman/Spellman Brady, Ulrika Karlsson Stigsdotter/University of Copenhagen, Tim Sturdy/Mainzeal, Christine Ten Eyck/Ten Eyck Landscape Architects, Nissa Tupper/HGA Architects and Engineers, Martha Tyson/Upland Design, Roger Ulrich/Chalmers University, Carter van Dyke/Carter van Dyke Associates, Lori Vierow/Planning Resources Inc., Amy Wagenfeld/Western Michigan University, Gary Wangler/St. Louis Children’s Hospital, Keith Watson/Gardening Leave, Steven Wells/Austin Health Royal Talbot Rehabilitation Center, Daniel Winterbottom/University of Washington, Mary Wyatt/TKF Foundation/Open Spaces Sacred Places. We extend a special thank you to Henry Domke of www.henrydomke.com for his generosity in letting us use his nature photographs.
We are grateful to all of the members of the Therapeutic Landscapes Network who submitted images, stories, and ideas as we were developing the themes encompassed in this book.
We want to thank two people who were invaluable in helping us get the manuscript into shape: Janine Baer, for computer assistance; and Laura Leone, who tirelessly checked and organized references.
Thank you to Ian Muise, Rowena Philbeck, and Sheetal Goyal Rakesh at Texas A&M University’s Technical Reference Center for technical support.
We are deeply grateful to the following people at John Wiley and Sons: Margaret Cummins, Senior Editor, encouraged us from the very beginning to undertake this book and guided us through the process with a firm but gentle and competent hand; Mike New, Editorial Assistant, for his invaluable help with organizing images and permissions; David Sassian, Senior Production Editor, for his excellent production skills.
Finally, some personal thanks. Clare wishes to thank her family—her children Lucy Marcus and Jason Cooper Marcus, daughter-in-law Angela Laffan, and grandsons Myles and Remington Marcus—who understood her passion for this work and gave her unfailing support and love. Her thanks go also to many friends, as well as her family, who rallied around when she broke her right (dominant) arm during the process of completing the book. Naomi wishes to thank her best friend, James Westwater, for his tremendous support—including insistence on healthy eating, sleeping, and spending time in nature (“Remember, this is what you’re writing about!”); Agnes and Boo for making her take them on daily walks and providing healthy doses of positive distraction; and her parents, Benjamin and Jacqueline Sachs and mum-in-law, Nedra Westwater, for their love and encouragement.
Having spent many weeks in the hospital left an indelible imprint on the way I experience pain, suffering, and loss within the recognized healthcare environment. Surely this fear and anxiety that one feels in this controlled and somewhat clinical building can leave one feeling more vulnerable, fragile, and scared. Just by being outside and with nature, to smell and touch the plants, reduced the depression and dread. I think more positive thoughts, am hopeful, and if I cry I feel the plants understand and do not judge or cringe.
Mariane Wheatley-Miller, personal communication, 2013
HOSPITALS AND OTHER HEALTHCARE FACILITIES are some of the most difficult places for people to be. Regardless of the physical setting, they are almost invariably environments where people face a high degree of stress. Patients may be experiencing physical or emotional pain; visitors, in an alien and, for many, a threatening environment, are worried about a loved one or close friend. Healthcare providers, in many cases dealing with life and death on a daily basis, are under an enormous amount of pressure. Their hours are long and their workload is taxing.
Since the mid-1990s there has been an increasing emphasis on a patient-centered approach in healthcare and a growing understanding of the importance of evidence-based design (Cama 2009; Frampton, Gilpin, and Charmel 2003). Hospital interiors have largely changed from the white, clinical settings of decades ago to more colorful—sometimes even hotel-like—environments. Nursing homes, renamed assisted-living facilities, have largely left behind their depressing reputation and are being reborn as warm, homelike settings. The environmental needs of specific patients, such as those with Alzheimer’s disease, are increasingly understood. In short, there has been a revolution in the provision of healthcare and the recognition that the physical environment matters to people’s health and well-being and that the health and well-being of the whole person needs to be addressed rather than just the disease.
Along with these beneficial changes to healthcare buildings, there has been a growing recognition that the whole environment—including outdoor space—matters (fig. 1.1). A significant body of research confirms and sheds new light on what many people have known intuitively: that connection with nature is beneficial—even vital—for health. Walking in the woods, sitting on a park bench, tending the soil in one’s garden, and even watching the colors and movements of nature from indoors are all passive and active ways to connect with the natural world. They awaken our senses, encourage physical movement and exercise, facilitate social connection, reduce stress and depression, and elicit positive physiological and psychological response. Healthcare facilities—from hospitals to specialized medical settings to assisted-living and retirement communities—are striving to incorporate specially designed outdoor spaces that can support the health and well-being of patients, residents, visitors, and staff (fig. 1.2).
Copyright, The Fockele Garden Company
Photo by Chris Garcia
Professional magazines are increasingly mentioning praiseworthy hospitals with healing gardens or views to nature. Excellent books have been published recently that focus specifically on healthcare outdoor space (Rodiek and Schwarz 2006, 2007; Pollock and Marshall 2012). However, it is rare that journals and magazines read by designers review such books or feature articles on healthcare outdoor space. Sadly, excellent books and monographs on healthcare building design often pay scant attention to outdoor spaces. Building plans are depicted with white expanses around them as if they are floating in space.
While the evidence for the importance of access to nature is there—and growing—the actual provision of appropriate outdoor space in healthcare facilities is often less than adequate, with limited “green nature,” unmet needs for privacy and “getting away,” even poor provision of the most basic needs, such as ease of access, comfortable seating, safe walking surfaces, protection from the sun, and so on.
The goal of this book is to focus critical attention on healthcare outdoor space, to emphasize the importance of evidence-based design, to highlight exemplary case studies, and to present research-based guidelines to inform clients and designers of restorative outdoor spaces. The aim is to address two key groups of readers: the clients and funders of healing spaces and the designers (principally landscape architects) who will translate client needs into an actual environment. If clients and funders understand more about the requirements and goals of a healing garden, they can more easily communicate with the designer. If designers understand more about the research on which to base their decisions, they are more likely to meet the goals of their clients—those who provide the funding and the users who will eventually benefit from the garden (fig. 1.3).
Photo courtesy of Thomas Benjamin, Wellnesscapes.com, on behalf of Kent Hospital
With an audience of two quite different sets of “actors,” it is inevitable that some parts of this book will speak more to one than the other. For example, some sections of the chapter on planting and maintenance may be basic knowledge for an experienced landscape architect but new and useful information for a client. The detailed design guidelines are principally aimed at the practicing designer and may be of less importance to the client or philanthropic donor. Chapters on horticultural therapy and participatory design may provide new information for many readers. The case studies of exemplary gardens throughout document existing best practices and will, the authors hope, inspire anyone using this book.
The core of the book consists of the general design guidelines presented in chapter 6. These are research-informed recommendations that need to be followed in any kind of healthcare outdoor space, whether it is a courtyard or a roof garden, whether it is at an acute-care hospital or a residential facility for the frail elderly. Beyond these basic guidelines, specific guidelines must also be followed for certain patient groups. These are explained in chapters 7 through 14—gardens for ill children, those with cancer, the mentally ill, Alzheimer’s patients, the frail elderly, returning veterans, rehabilitation patients, and those in hospice.
Different terms have emerged to refer to outdoor spaces in healthcare, and two different types can be recognized. A healing, therapeutic, or restorative garden (these terms are used interchangeably in this book) is one that users, whether residents or visitors, experience any way they want: to sit, walk, look, listen, talk, meditate, take a nap, explore. Therapeutic benefits are derived from just being in the garden. No staff is necessary, except for maintenance. Such a garden might be found at an inpatient acute-care hospital, a residential facility for the frail elderly, a hospice, or an outpatient clinic.
In an enabling garden, by contrast, activities are led by a professional horticultural therapist (HT), occupational therapist (OT), physical therapist (PT), and other allied professionals in collaboration with other clinical staff. The HT might engage recovering stroke victims in weeding, watering, and repotting plants; the PT or OT might help someone with a broken limb by encouraging reaching, grasping, and exercising. Therapeutic benefits are derived from hands-on activities and exercise in the garden (fig. 1.4). Such a garden is likely to be found at a rehabilitation hospital, some mental and behavioral health facilities, and some children’s hospitals.
Courtesy of Gardening Leave Limited
For the purposes of this book, “nature” is defined quite broadly, and while largely referring to vegetation, it also refers to wildlife, water, stone, the weather, sky, clouds, wind, and sun. “Access to nature” includes actual passive and active, indoor and outdoor engagement with nature through any or all of the senses (fig. 1.5).
Photo from www.henrydomke.com.
Indoor contact with nature can include looking out at nature through a window; viewing nature imagery (still and moving pictures); seeing, touching, and smelling indoor vegetation; and hearing nature’s sounds through an open window or through sound recordings (birds, water, and the like).
Outdoor contact with nature is likely to engage more than one of the senses and can range from passive to active: sitting just outside the entry of a building, taking a stroll, stopping to look at, touch, or smell plant material, engaging in physical or occupational therapy, gardening, watering plants, taking a brisk walk for exercise, jogging, or engaging in team sports (fig. 1.6).
Courtesy of Dirtworks, PC; photo by Bruce Buck
The word “garden” will be used throughout the book to refer to any designed outdoor space with predominant greenery, even though the term has slightly different meanings in different English-speaking countries. For example, in the United Kingdom it refers to the whole of a defined and designed cultivated space that is predominantly green, whereas in the United States it tends to refer to a planting bed, such as a flower garden (fig. 1.7).
Photo from www.henrydomke.com
“Healthcare facilities” are defined as places where people receive medical care. These include—but are not limited to—inpatient and outpatient facilities, acute-care general hospitals, rehabilitation hospitals, psychiatric hospitals, children’s hospitals, veteran’s hospitals, specialty hospitals and clinics (cancer, kidney dialysis, mental health, etc.), hospice, residential and outpatient facilities for those with special needs (the frail elderly, Alzheimer’s patients, the mentally ill, battered women).
Cama, R. 2009. Evidence-Based Healthcare Design. Hoboken, NJ: John Wiley and Sons.
Frampton, S., B. L. Gilpin, and P. A. Charmel, eds. 2003. Putting Patients First: Designing and Practicing Patient-Centered Care. San Francisco: Jossey-Bass.
Pollock, A., and M. Marshall, eds. 2012. Designing Outdoor Spaces for People with Dementia. Sydney, Australia: Hammond Press.
Rodiek, S., and B. Schwarz, eds. 2006. The Role of the Outdoors in Residential Environments for Aging. New York: Haworth Press.
————, eds. 2007. Outdoor Environments for People with Dementia. New York: Haworth Press.
THE HISTORY OF HOSPITALS AND HEALING PLACES goes back many centuries. At one time nature was seen as intrinsic to healing, but this important connection was largely lost by the twentieth century. Now, however, it is being rediscovered, in the form of healing gardens and therapeutic landscapes in healthcare settings.
One of the first healing places for which we have evidence was the Aesclipion at Epidaurus in ancient Greece—one of a network of healing places functioning from the fourth century BCE to the sixth century CE. Natural spring water was used in cleansing rituals; a library, museum, theater, marketplace, and groves of trees provided for people’s entertainment as they waited until the auguries were favorable and they could enter the most important building, the abaton (Gesler 2003). Here, dream-healing took place, for it was believed that when people were asleep, the soul left the body and could communicate with the gods. Sleeping patients received prescribed cures from the god Asclepius, and when they awoke, his injunctions were administered by physician-priests (ibid.).
Among the first hospitals as we know them were Roman military hospitals with naturally lit and cross-ventilated wards separated from each other to avoid cross-infection, although this was long before any understanding of germ theory (Heathcote 2010). Throughout the Middle Ages in Western Europe, monastic hospices and infirmaries cared for pilgrims and others who were sick as part of the Christian obligation to offer charity and show mercy to the poor. A major figure in this era was Hildegard von Bingen, a remarkable twelfth-century German mystic, theologian, and medical practitioner who—along with Hippocrates—did not imagine the body as a machine or disease as a mechanical breakdown. She embraced the concept of greenness, or viriditas, gleaned from the practical concerns of gardening. Just as plants put forth leaves, flowers, and fruit, so the human body has the power to grow, give birth, and heal (Sweet 2012).
Monastic settings were the first instances where a garden, usually enclosed by an arcaded cloister, was specifically incorporated as part of a healing environment (fig. 2.1). Bernard of Clairvaux (1090–1153) wrote of the intentions of this space at the hospice at Clairvaux, France: “Within this enclosure many and various trees . . . make a veritable grove which lying next to the cells of those who are ill, lightens with no little solace the infirmities of the brethren, while it offers to those who are strolling about, a spacious walk. . . . The sick man sits upon the green lawn. . . . He is secure, hidden, shaded from the heat of the day . . . for the comfort of his pain, all kinds of grasses are fragrant in his nostrils. The lovely green of herb and tree nourishes his eyes. . . . The choir of painted birds caresses his ears. . . .” (Gerlach-Spriggs, Kaufman, and Warner 1998, 9). This passage indicates the remarkable intuitive insights of early Christian leaders regarding the significance of sensory awakening in nature as a component of healing, an understanding that was for a long time lost, and only now, almost a thousand years later, is being rediscovered.
Photo by Clare Cooper Marcus
As monasticism declined in the fourteenth and fifteenth centuries, care of the sick fell to civic and ecclesiastical authorities. Within the Roman Catholic tradition, one of the primary design requirements of a hospital was the provision of long wards, where the priest celebrating Mass could be seen from every bed. The influential Ospedale Maggiore of Milan (1458), for example, was built in a cruciform plan with windows so high that no one could see the formal gardens outside (Thompson and Golden 1975, 31).
Some hospitals continued the courtyard-garden tradition exemplified in the monastic cloister gardens. The English hospital and prison reformer John Howard (1726–90) reported hospitals in Marseilles, Pisa, Constantinople, Trieste, Vienna, and Florence that had gardens where patients could see through windows and doorways, and where convalescing patients could stroll (Warner 1995, 18) (fig. 2.2).
Photo by Clare Cooper Marcus
In England, by the seventeenth century, wealthy merchants and philanthropic nobility were willing their grand homes and grounds to act as hospitals. Soon architects were building hospitals in the style of grand houses, such as Christopher Wren’s Royal Chelsea Hospital in London with its spacious lawns and courtyards (Darton 1996, 91). But for most, the hospital was still a refuge of last resort. Birth, sickness, convalescence, and death were mostly experienced at home (ibid., 70).
Among the first set of recommendations for hospital garden design were those written by the German horticultural theorist Christian Cay Lorenz at the end of the eighteenth century: “The garden should be directly connected to the hospital. . . . A view from the window into blooming and happy scenes will invigorate the patient . . . [and] encourages patients to take a walk. . . . The plantings should wind along dry paths, which offer benches. . . . The spaces between could have beautiful lawns and colorful flower beds. . . . Noisy brooks could run through flowery fields. . . . A hospital garden should have everything to enjoy nature and to promote a healthy life” (Warner 1995). These suggestions uncannily foreshadow the findings of researchers in the late-twentieth century who offered credible empirical evidence that viewing or being in nature reduces stress (see chapter 3).
The next major shift in hospital design and the provision of outdoor space was the development of the pavilion hospital. In Western Europe, the seventeenth century saw an emphasis on the systematic collection of data on births and deaths and the careful observation of patients in hospitals. New hospital designs paid special attention to hygiene and ventilation, since it was then believed that infections were spread by noxious vapors or miasmas in the air emanating from swamps, stagnant water, and rotting waste. For example, a new hospital in Edinburgh constructed in 1729 was built in a U-shape on a hill to catch the air and sun, and two acres were set aside for a garden (Gerlach-Spriggs, Kaufman, and Warner 1998, 15).
Pavilion-style hospitals comprised two- and three-story buildings linked by a continuous colonnade, and narrow wards with large windows that enhanced ventilation. Between the wards were courtyards and gardens, which began to be reconsidered as important components of the healing environment. Several influential hospitals designed in this style included St. Thomas’ Hospital in London, the rebuilt Hôtel Dieu in Paris, and several naval and military hospitals built at the height of Britain’s imperial power.
Florence Nightingale, British nurse and public health reformer, enthusiastically endorsed these new hygienic hospital plans, which became the predominant form in the nineteenth and early-twentieth centuries. Having cared for the wounded during the Crimean War (1854–56), Nightingale observed unexpected differences in mortality experienced by soldiers treated in tents and temporary buildings and those treated in conventional hospitals. She proposed that high mortality rates in hospitals could be solved through a combination of design, sanitation, and quality care. At the Scutari military hospital near Constantinople, she succeeded in reducing the death rate from cholera and dysentery from 42 percent to 2 percent through hygiene and careful nursing practice (Darton 1996, 93).
In one of her influential publications she wrote: “Second only to fresh air . . . I should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight, is necessary for speedy recovery, . . . being able to see out of the window instead of looking at a dead wall; the bright colors of flowers, . . . being able to read in bed by the light of the window. . . . It is generally said the effect is upon the mind. Perhaps so, but it is not less so upon the body on that account” (Warner 1995, 24) (fig. 2.3). Her insights marked a significant important return to an understanding that mind and body are intertwined and must be treated as one. With the study of anatomy in the Renaissance, when the dissection of cadavers revealed “no spirit inside the body,” that understanding had been discredited.
Photo by Clare Cooper Marcus
The rise of Romanticism prompted a reconsideration of the role of nature in bodily and spiritual restoration. Writers such as Rousseau and Goethe extolled the powers of nature to foster contemplation and an emotional connection with spirit. The landed gentry created landscapes that mimicked nature. Cities built parks for the physical and mental health of their residents. It was during this period that there was a dramatic reemergence of nature as part of the restorative environment, particularly in the treatment of the mentally ill.
Rethinking the treatment of the mentally ill began at the hospital at Zaragosa, Spain, founded in 1409. Instead of patients being confined and punished, as was the custom at the time, they followed a simple daily routine of communal meals, household chores, and work in vegetable gardens, vineyards, orchards, and on a farm (Warner 1995, 17). This method of socializing patients became known in the nineteenth century as the “moral treatment,” and was enthusiastically endorsed by the reformers Dr. Phillippe Pinel in France and William Tuke in England.
In 1792 William Tuke and the Society of Friends established The Retreat on the outskirts of the English city of York. Here, in a radical new approach to treatment, the mentally ill were treated with gentleness and kindness instead of being chained down and beaten like prisoners. Access to landscaped grounds became part of the treatment; it was believed that the mentally ill could not cope with city environments and could only recover in peaceful natural surroundings. The grounds also protected patients from being perused by the curious and served as a space for gardening and farming.
The philosophy behind these new kinds of hospitals spread to North America. The first such hospital in the United States was the Friends Asylum in Philadelphia founded in 1813. By the 1820s, asylums with natural landscaped grounds had opened in Boston and New York. The American landscape architect Andrew Jackson Downing wrote in 1848: “Many a fine intellect, overtasked and wrecked in the too ardent pursuit of power and wealth, is fondly courted back to reason and more quiet joys by the dusky, cool walks on the asylum” (Schuyler 1999, 79).
By the 1850s, it was accepted professional orthodoxy that a naturalistic landscape had a direct role in the treatment of the mentally ill and that the mind and body must be treated together. Views onto greenery were believed to “soothe shattered nerves,” while exercise and gardening were employed to restore bodily health.
The principal proponent of this restorative landscape approach in the United States was Dr. Thomas Kirkbride, who in 1851 was invited by his peers to compose a set of “propositions on the structure and arrangement of asylums” (what we would now term design guidelines). In these he proposed that asylums should be located in the countryside not less than two miles from a large city; that they have at least one hundred acres of land, or half an acre per patient; of this, at least fifty acres should be dedicated to gardens and pleasure grounds; and that wards for “the most excited class” of patients should have large windows and pleasant views. The “Kirkbride Plan” was unanimously endorsed by his peers, and by 1900, asylums built on these propositions had been created in twenty-eight states.
But paralleling this development, immigration and urban poverty in US cities mushroomed. Asylum wards soon became overcrowded, the humane treatment of patients declined, and asylums became the last resort for hopeless cases. While some of the early influential models are still in operation—for example, the Retreat at York, England, and the Friends Hospital, Philadelphia—and their beautiful landscaped grounds remain, twentieth-century labor unions opposed the policy of engaging patients in farm and garden work. Apart from occasional horticultural therapy programs, the grounds are now primarily used for passive enjoyment.
By the 1850s, the centuries-old belief that disease was spread by noxious-smelling miasmas began to be questioned. A turning point was Dr. John Snow’s investigation of a cholera epidemic in London, where he traced deaths from the disease to drinking polluted water from the Broad Street pump (Johnson 2006). Although this was the beginning of an understanding of germ theory, it was not until Scottish surgeon Joseph Lister’s discovery of sepsis and French chemist Louis Pasteur’s discovery of bacteria in the 1860s that it was fully accepted. This radically changed the rules of hospital design (Heathcote 2010). Since the spread of germs could now be contained by antiseptics and basic hygiene, physical separation as in the pavilion hospital was no longer necessary, though many have remained in operation up to the present time (fig. 2.4).
Photo by Clare Cooper Marcus
Land-consuming low-rise pavilion hospitals began to be replaced by highly functional compact “monoblock” and high-rise hospitals, where design was concerned with efficiency and infection control; illness was treated with the help of antibiotics, pain killers, anesthesia, and improved surgical techniques; emotions were now studied in psychology, the physical body in anatomy and medicine, thus severing any lingering belief in the mind-body connection; outdoor space was relegated to parking lots and delivery ramps; gardens disappeared, and glimpses of nature were restricted to token areas of landscaping at the main entrance. Traditional styles were thrown out in favor of the International Style, and many new urban hospitals came to resemble office blocks and corporate headquarters. Even the sanitarium, where tuberculosis had been treated with ample exposure to sunlight, fresh air, and spacious grounds, now fell into disuse as drugs were found to treat the disease. Two kinds of healthcare facility did not succumb to this loss of a connection with nature: the hospice and the nursing home. For residents and patients in these facilities, the emphasis was, and is, on care rather than cure. The buildings are often designed at a domestic scale, echoing images of home—one element of which is the garden.
Alongside the proliferation of large medical centers, several professions arose that heralded a resurgence of interest in the garden. Occupational and physical therapy (OT and PT) came into prominence in the treatment of veterans returning from World War I. By the end of the twentieth century, rehabilitation hospitals (and the rehab wards of acute-care hospitals) often included a garden or outdoor area where patients could work with physical therapists in a more normalized setting than the hospital interior.
After World War II, horticultural therapy came into prominence as a subset of occupational therapy, using gardening as a means of restoring both physical and mental health. Degree programs in this profession were established, and indoor and outdoor gardening programs were instituted in veterans hospitals, psychiatric facilities, chronic-care facilities, and rehabilitation hospitals. Trained professionals work with the clinical staff to facilitate the recovery of patients who have experienced posttraumatic stress disorder, traumas, strokes, brain injuries, and other forms of mobility impairment (see chapters 14 and 16). These professionals work as well in prisons and geriatric facilities.
By the latter decades of the twentieth century, a number of changes in society signaled the emergence of what has become known as patient-centered care. The general public began to take an interest in health and wellness, recognizing the importance of diet and exercise rather than focusing on illness and disease. There was a growing interest in alternative or complementary medicine. Tools became available to research the mind-body connection. Healthcare designers and administrators began to recognize the physical environment of the hospital as an important component in a competitive market place and strived to create more patient-friendly settings.
One of the signature events in the development of patient-centered care was the emergence of the Planetree model in the early 1980s. In the mid-1970s, San Francisco resident Angelica Thieriot was hospitalized with a life-threatening condition. Although the best of Western medicine was available, little attention was paid to her emotional, social, and spiritual needs (Frampton, Gilpin, and Charmel 2003, xxvii). Motivated by this negative experience, Thieriot founded the nonprofit organization Planetree in 1978, its name taken from the plane tree under which Hippocrates taught his students.
The entire hospital experience was evaluated from the perspective of the patient. A consumer health resource center was opened in San Francisco in 1981. In 1985 a patient-oriented thirteen-bed model hospital unit at Pacific Presbyterian Medical Center in San Francisco was designed by University of California professor Roslyn Lindheim (ibid., xxix). The emphasis was on organizational and physical changes meant to create more healing environments. Organizational changes included unrestricted visiting hours, permitting children and pets to visit, and encouraging family members to stay overnight and to cook food for the patient. Physical changes included a homelike decor; naturalizing the interior environment with plants, fish tanks, and so on; connecting the interior environment to the outdoors by providing views to attractive outdoor spaces; and stressing the importance of healing gardens for patients, family members, and staff (ibid., 237). For example, the waiting area for ambulatory surgery and endoscopy at Lakeland Hospital in Niles, Michigan was “designed to focus the attention of patients and families toward the calming and peaceful view provided by the natural setting of the St. Joseph River . . . as they mentally prepare for their procedure” (ibid., 171). For the first time since the clearly articulated value of nature in the treatment of the mentally ill in the nineteenth century, the Planetree model brought nature and gardens back into focus as important elements of a healing environment and a healthy workplace.