How Does your Garden Grow? The role of Therapeutic Landscapes in Design

What does landscaping mean to you?  Most likely, not nearly enough.  Too easily, we view it as decorative, a “nice to have” part of a project.  However, as we learn more about salutogenic design and the effects of the environment on wellness (everything from healing to better job performance), landscape starts to become a critical element, one which should form the basis of design.  With this in mind, I asked Naomi Sachs, Founder and Director of the Therapeutic Landscapes Network (TLN to share some insights on the power of nature.  Naomi is a landscape architect and recognized expert in therapeutic landscape design, and part of the Center for Health Design’s Environmental Standards Council working on expanding the Environment of Care section of the 2014 Guidelines for Design and Construction of Health Care Facilities.  Rather than helping afflicted people to feel less bad, her goal is to use landscape to make them feel good:
Usually, when architects think about landscaping, we think about outdoor rooms or ways to enhance areas like building entries or parking lots. What are your suggestions for getting more landscaping inside of buildings?
Nature needs to be viewed as a part of the built environment.  While being out in nature is best, bringing it indoors with interior gardens, atria, or even potted plants is the next best thing. A great recent example of nature incorporated within the building is the Stoneman Healing Garden at Dana Farber’s Yawkey Center for Cancer Care. Providing windows is an excellent way to allow visual access to nature, which is especially important when people can’t go outside. Allowing for views out also lets natural light in (one study found that patients in east facing rooms who were exposed to morning sunlight did better than other patients), and “advertises” the garden, which then encourages use.  Research has also shown that while images of nature, like artwork or videos, do help people, they are not as effective as views of nature through a window or – best yet - an experience of real nature. Using natural materials (wood, stone, etc.) is another way to “bring nature in” to an indoor space.

In terms of facilitating access to the outdoors, transitions from one to the other are critical: Architects must design to minimize barriers (providing flat thresholds, doors that are easy to open, etc.) and allow for transitional spaces, such as a paved area with an awning where people can enjoy the outdoors close to the building, even in inclement weather, and can get a sense of the space before they venture out into it.

How do you explain the link between nature and wellness?
Biophilia – our innate attraction to life and living things - is intangible, but research is working towards measurable results. The book Healing Spaces: The Science of Place and Well-Being, by the neuroscientist Esther Sternberg, addresses the role of nature not only in reducing stress, but also in eliciting positive psychological and physiological responses.  For example, Sternberg documents how seratonin receptors in the brain, when exposed to positive sensory stimuli, light up. She posits that being outside creates multiple positive stimuli (and therefore more seratonin) because it’s a multi-sensory environment.  You can hear the birds, feel the sun on your face, smell flowers or freshly mown grass.  Being outdoors also enables exercise, and tends to facilitate social connections because people are more relaxed. At the San Diego Hospice, the nurse leading my tour of the facility observed that people shared more about themselves and their situation when outside. 

Kuo and Taylor have published several studies that measure the positive impact of green settings in reducing ADHD symptoms, and the correlation of trees in a neighborhood to reduced domestic violence, lower crime rates, and higher self esteem.  These studies show, empirically, that people in environments with nature do better.  Research by Whitney Gray presented at Greenbuild 2011  focused on sick building syndrome.  Gray looked at sick days, turnover, stress, and ability to concentrate; when access to nature was provided, there was a measurable improvement in all of these factors. Debajyoti, Harvey, and Barach showed that nurses who had a view of gardens over those who just had access to natural light, or no windows at all, were better able to concentrate and had less long-term stress. When you think abut the fact that it can cost around $60,000 to train each new hire, the economic benefit of providing access to nature is huge. (Full citation is below)

Maintenance is always a concern when it comes to landscaping- I’ve actually worked with healthcare clients who wanted nothing but grass in the areas they “had” to landscape for ease of maintenance.  What kind of recommendations can you make to landscape skeptics about using plantings?
Access to nature just makes good business sense. Studies by Roger Ulrich, confirmed by others, have demonstrated less need for pain medication, improved patient satisfaction, faster recovery rates, and many other examples of improved outcomes for patients and staff. When you really look at the benefits of providing access to nature, the return on investment (ROI) justifies the initial cost and lifetime maintenance.  Hospitals need to see landscaping as a strategic investment in the same manner they would the purchase of a new MRI.

Sure, a lawn is better than no landscaping at all, but when you consider the benefits of gardens and more designed landscaping, you can make the argument for the cost of maintenance. A study by Matsuoka showed that students viewing just lawn vs. a more varied view that included trees and shrubs performed better. Access to a lawn is often restricted; it may be wet or uneven, and wheelchairs cannot travel on it.  Lawns are best as one element in children’s play areas, since they – especially visiting children - need to run around and blow off steam. [In case you want the full citation: Matsuoka, Rodney (2010). “Student Performance and High School Landscapes: Examining Links.” Landscape and Urban Planning, Vol. 97]. Incidentally, lawns actually take a LOT of money to maintain: They need regular irrigation, fertilization, mowing, leaf-blowing, etc. Facilities that are using alternative landscapes such as native meadows and rain gardens are finding significant savings after the initial investment. And at the same time, they are sending a very positive message about their commitment environmental as well as human health. It’s all related.

That being said, the landscape architect needs to know the resources and capabilities the client is willing or able to put into the project – up front and for the future - and design around that. Your typical “mow and blow” crew is not qualified to handle anything more than routine maintenance, so there needs to be a funding strategy in place for an annual maintenance budget. It’s also a good idea to create a maintenance manual for staff or an outside landscaper to follow.
Some healthcare facilities, usually those with a horticultural therapy program,  integrate gardens into physical and occupational therapy.  This is a great way to provide benefit to patients while keeping the garden expertly maintained. The gardens at Legacy Health, in Portland, OR, are excellent examples of this strategy.
Healing gardens can be easy to raise money for because they are “warm and fuzzy.” The institution can also use the space for social events and to generate PR (promotional materials, events, press releases, etc.). The likelihood of assisted living facility resident referrals has been shown to increase with the quality of the grounds.

What is the difference between landscaping and a garden?  Is it only about habitation?
In general, I would say that a “landscape” is any outdoor space, wild or designed, and a “garden” is a designed space. A restorative landscape is simply an outdoor space that makes you feel good when you’re in it. To me, “landscaping” implies decorative elements like a lawn, shrubs, some trees, and is not necessarily intended for interaction.  A therapeutic (or healing) garden is a space designed for a specific population (children, cancer patients, people with Alzheimer’s) and a specific intended outcome (stress reduction, positive distraction, rehabilitation). This is not to say that landscaping isn’t important. Well-designed and maintained landscapes communicate to patients and their families that they will receive a high level of care, and this can happen from the moment you cross the property line.  Even areas such as parking lots can utilize landscape to provide and reinforce the overall image and mission of the facility.

What is landscaping’s role in wayfinding?
This goes back to the importance of views outside from indoors. As a wayfinding tool, a garden stands out as a strong landmark, something people notice and remember.  Plantings - indoors and out - can also provide visual cues or themes for a space.  Again, when well-integrated with design, views to a garden can also act as advertisement for that space.  So often, gardens are underutilized because people (even staff!) don’t know they exist.  Signage can help, but creating direct views to the garden is the best way to ensure that people use it.

Landscape is a blanket term that includes plantings, water feature, site furniture and hardscape elements like pavers and walls. How does your ideal therapeutic garden utilize these elements?
My ideal garden would focus on the needs of the user population (patients, visitors, staff) and would be designed based on evidence, but also with a heavy dose of empathy and inspiration. As with any good design, there are parameters, but we can never just tick off boxes on a checklist. All landscape elements – overall layout, paths, seating, hardscape, plantings, water features – should facilitate health and well-being. Two useful theoretical frameworks are Ulrich’s Theory of Supportive Design, in which a space supports the users by reducing stress; increasing a sense of control; encouraging social support; and facilitating physical movement and exercise. And Stephen and Rachel Kaplan’s theory of environmental preference, which calls for an emphasis on coherence, complexity, legibility, and mystery. I would add that especially in the healthcare environment, outdoor spaces must be safe and comfortable, and should provide a marked contrast to “the hospital,” which is often perceived as a very cold, alien, intimidating environment. Finally, all of the elements should contribute to that positive multisensory experience we talked about earlier to help people feel not just “not bad,” but instead “good.” That is true salutogenic design.

How does this play into prospect/refuge theory in biophilic design?
It is really important to design with this in mind.  People like to survey the space from a protected vantage point.  Creating transitional space like a covered patio at the entrance to the garden is important, especially for elderly people who may not feel safe going directly outside.  Those with certain psychiatric issues, including autism, like to be “read” a space before immersing themselves in it.  Good designs create transition spaces throughout including shade to sun and walking and seating areas, and “nooks” or nodes where people can feel a sense of security and even privacy.   

It’s not unknown for a project to get landscape elements value engineered out due to budget concerns. What’s your advice for architects regarding how to work best with landscape architects and really integrate their work into the design so that the landscape elements become less expendable to the client?
Bring the LA in right away! Landscape architects are valuable members of the interdisciplinary project team [or A/E team] and they need to be included in the conceptual design phase. LAs have so much more to offer than simply “putting the parsley around the meatloaf.” Their site planning expertise can be a great asset to preserve open space, maximize views, create walking paths, take advantage of existing natural amenities, and to create that “healing experience” that starts at the entry drive, not just in some tucked-away “healing garden” courtyard. They can assist in design of the building to maximize visual and physical access to nature, both indoors and out. They can also best address EPA standards and maximize LEED and Green Guide For Healthcare points and help make sustainable measures like stormwater management or green roofs into design features.

It is important to use a landscape architect trained in healthcare design for healthcare projects (the TLN has a directory of designers and consultants who specialize in this field). They know the research and requirements for each specific user population; they have the experience in this particular area and so they know how to do pre-occupancy evaluations and talk to the various stakeholders: Healthcare providers, facilities and maintenance staff, the C-Suite, board members and donors, patients and community members. They can be allies in your design efforts because they have the experience, examples and precedents to share with clients regarding the sustainable or evidence-based value of a design decision.

Can you talk a little bit about the book you are working on with Clare Cooper Marcus?  What kind of issues are you looking at?
Healing Gardens: Therapeutic Benefits and Design Recommendations (Eds. CLare Cooper Marcus and Marni Barnes, with eight contributing authors including Naomi Sachs) was published in 1999 and is still considered to be the "bible" on this topic. Our new book, to be published by John Wiley and Sons, NYC in 2013, will be a shorter companion volume with different material and format, and will address many of the issues we’ve talked about in this interview. The heart of the book will be design guidelines that are applicable to all patient populations and settings, as well as guidelines for specific users (hospice, cancer care, children, etc.). We will be drawing on many examples of built works to illustrate theories and practice. Other chapters will focus on history, theory, and definitions; the interdisciplinary design process; funding; planting design and maintenance; sustainability; and more. Clare and I are both very excited, and from the feedback we’re getting, others feel the same way.

I encourage all of you to explore the wonderful resource that is the TLN site ( You don’t have to be a landscape architect to take advantage of the TLN as a springboard for your sustainability and evidence based design research or as a resource for finding a great landscape architect specializing in healthcare.  How will you harness the power of  landscape and gardens on your next project?

*Citation: Debajyoti Pati, Tom Harvey Jr., Paul Barach (2008). “Relationships Between Exterior Views and Nurse Stress: An Exploratory Examination.” Health Environments Research & Design Journal, Vol. 1, No. 2, pp. 27-38.
Exterior views of nature decreased stress and increased alertness in pediatric nurses.
Objective: Examine the relationships between acute stress and alertness of nurse, and duration and content of exterior views from nurse work areas. Background: Nursing is a stressful job, and the impacts of stress on performance are well documented. Nursing stress, however, has been typically addressed through operational interventions, although the ability of the physical environment to modulate stress in humans is well known. This study explores the outcomes of exposure to exterior views from nurse work areas. 
Methods: A survey-based method was used to collect data on acute stress, chronic stress, and alertness of nurses before and after 12-hour shifts. Control measures included physical environment stressors (that is, lighting, noise, thermal, and ergonomic), organizational stressors, workload, and personal characteristics (that is, age, experience, and income). Data were collected from 32 nurses on 19 different units at two hospitals (part of Children's Healthcare of Atlanta) in November 2006.
Results: Among the variables considered in the study view duration is the second most influential factor affecting alertness and acute stress. The association between view duration and alertness and stress is conditional on the exterior view content (that is, nature view, non-nature view). Of all the nurses whose alertness level remained the same or improved, almost 60% had exposure to exterior and nature view. In contrast, of all nurses whose alertness levels deteriorated, 67% were exposed to no view or to only non-nature view. Similarly, of all nurses whose acute stress condition remained the same or reduced, 64% had exposure to views (71% of that 64% were exposed to a nature view). Of nurses whose acute stress levels increased, 56% had no view or only a non-nature view. 
Conclusions: Although long working hours, overtime, and sleep deprivation are problems in healthcare operations, the physical design of units is only now beginning to be considered seriously in evaluating patient outcomes.