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