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GARDENS IN HEALTHCARE FACILITIES:USES, THERAPEUTIC BENEFITS, AND DESIGN RECOMMENDATIONS

by Clare Cooper Marcus, MA, MCPand Marni Barnes, MLA, LCSWUniversity of California at Berkeley

®

Copyright © 1995 by The Center for Health Design, Inc. All rights reserved. No part of thiswork covered by the copyright herein may be repro-duced by any means or used in any form withoutwritten permission of the publisher.

The views and methods expressed by the authors donot necessarily reflect the opinions of The Centerfor 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, MCPCollege of Environmental DesignUniversity of California at Berkeley

Marni Barnes, MLA, LSCWCollege of Environmental DesignUniversity of California at Berkeley

Printer: Eusey Press

Design and Composition: Visual Communications

The Center for Health Design, Inc.4550 Alhambra WayMartinez, CA 94553-4406United States of AmericaTel: (510) 370-0345Fax: (510) 228-4018Email: [email protected]

Clare Cooper Marcus, MA, MCP2721 Stuart StreetBerkeley, CA 94705Tel: (510) 548-2904Fax: (510) 643-6166

Marni Barnes, MLA, LCSWDeva Landscaping846 Boyce StreetPalo Alto, CA 94301Tel: (415) 326-6866

First Printing November 1995ISBN: 0-9638938-2-3Printed in the United States of America

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VisionTo create a future where the built environ-ment supports the highest level of humanhealth, well-being, and achievement in all as-pects of life and work.

MissionTo be a facilitator, integrator, and acceleratorpromoting the widespread development of health-enhancing environments, and the benefits that these bring to human health and well-being.

PurposeTo advance the quality of health design by:

• Supporting the needs and interests of its constituents.

• Serving as the internationally recognizedsource of educational programs.

• Supporting the development of research that will significantly advance the art and scienceof 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, audioand videotapes, project data, facility tours,and product information.

THE CENTER FOR HEALTH DESIGN, INC.

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W E WOULD LIKE to express our ap-preciation to the medical institu-tions that support and maintain

the beautiful outdoor spaces observed duringour research. Although many more peoplehelped to point the way and grease the wheelsduring this study than we could mention here,some of the good souls are:

Alan Kinet, Bill Peters, and Gloria Rodriguez;San Francisco General Hospital;

Gail Uchiyama and Burton Presberg; AltaBates Medical Center;

Irwin Fisch, Pat Mariani, Gabriel Escobar,Bob Eisenman, and Priscilla Minn; KaiserPermanente Walnut Creek;

Karen Graham, Vicki Williams, and FranciaDeAsis; California Pacific Medical Center;

Tom Piazza at the University of California,Berkeley, Survey Research Center, for hisknowledge and advice;

The homeless and HIV-positive man who di-rected us to healing gardens in San Francisco;

Eileen Lemus, at Laguna Honda Hospital, forher knowledge and belief in innovative formsof therapy;

Finally, we are deeply indebted and offer ourheartfelt thanks to The Center for Health De-sign and its Research Committee for sponsor-ing and supporting this study.

The Center for Health Design would like toacknowledge the following individuals and or-ganizations for making this research projectpossible.

Board of DirectorsRussell C. Coile Jr., MBAAnn DixKathryn E. JohnsonRoger K. Leib, AIAJain MalkinRobin Orr, MPHDerek Parker, FAIA, RIBAWayne Ruga, AIA, IIDABlair L. Sadler, J.D.Roger S. Ulrich, Ph.D.

Research CommitteeJanet R. Carpman, Ph.D.Uriel Cohen, D.ArchSyed V. Husain, FAIADebra J. LevinDonald F. LopezM.P. MacDougallJain MalkinWayne Ruga, AIA, IIDAMardelle Shelpley, D.ArchKaren TetlowRoger Ulrich, Ph.D.

SponsorsThis Research Report has been exclusivelysponsored by: Armstrong World Industries,Inc.; Interface Flooring Systems, Inc.; JCMGroup; and Jain Malkin

Research ConsultantsClare Cooper Marcus, MA, MCPand Marni Barnes, MLA, LCSWUniversity of California at Berkeley

ACKNOWLEDGMENTS

1 Introduction 1

2. Review of Relevant Research 2

3. Methods 3

4. Historical Overview of the Provision of 7Outdoor Gardens in Medical Settings

5. Typology of Outdoor Spaces Provided in 11Contemporary Healthcare Facilities

6. Case Study: San Francisco General 23Hospital,The Comfort Garden

7. Case Study: Alta Bates Medical Center, 31Berkeley, The Roof Garden

8. Case Study: Kaiser Permanente, 39Walnut Creek, Central Garden

9. Case Study: California Pacific Medical 47Center, Garden Campus, The Garden

10. Aggregate Data Analysis of the 53Case Study Sites

11. Design Recommendations 59

12. Conclusion 65

13. Appendix: Questionnaire 67

Bibliography 69

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TABLE OF CONTENTS

THIS STUDY WAS conducted betweenJanuary and August 1995, and itsgoal was to investigate the use and

possible benefits of gardens in hospitals byevaluating a number of case studies. Its intentwas not to propose theories of how or whycertain environments are therapeutic, but todiscover which specific elements and qualitiesin hospital gardens seem to be — in the users’eyes — most related to a change of mood.

This report consists of 12 parts: introduc-tion; literature review; methods; brief histori-cal overview of hospital gardens; a typology ofhealth facility outdoor spaces; four case studiesincluding user-responses; a set of design rec-ommendations based on observations and in-terviews; and a conclusion.

Our consciousness regarding this topic wasraised as we searched for case study sites. Hos-pital architects we contacted knew of few suchexamples. When we started to visit hospitals,we were surprised to find few that had outdoorspaces, and where we found some that did, thestaff at the information desk frequently had noknowledge of the garden or its location. Thus,early on we sensed that this was a type of spacethat is considered unimportant in the contem-porary medical center.

In all, we looked at 24 hospitals, almost all ofthem in Northern California. From this admit-tedly small sample we sensed that public hospi-tals are more aware of and supportive of gardensin their environment than are private hospitals.Two public hospitals in San Francisco —

Laguna Honda and San Francisco General —are housed in 19th-century or early-20th-centu-ry pavilion-style buildings where open spacesbetween wings have been landscaped and devel-oped as gardens. Both of these hospitals also runon low budgets, serving the needy, and seem tomake use of everything at their disposal, includ-ing the outdoor space. Private hospitals seemedmore concerned with cosmetic landscaping toenhance their image but not necessarily to fillthe therapeutic needs of patients or staff.

As we conducted interviews, we becameaware, too, of the pivotal importance of oneperson or a few people in creating and makingknown the benefits of gardens at specific facili-ties. The gardeners at San Francisco Generalcreated the Comfort Garden, a space thateventually became one of our case study sites.The director of the hospice at Laguna HondaHospital was responsible for promoting thedevelopment of a garden in a formerly emptycourtyard. (The timing of the installation ofthis garden precluded our selecting it as a casestudy.) Nurses at California Pacific GardenCampus were responsible for encouraginglong-term care patients and their families touse the garden.

We are convinced that with more persua-sive information as to their benefits, manymore hospital administrators and medical staffwould encourage the use of outdoor spaces forhealing and stress reduction. We hope this re-port will be one tool in raising consciousnessin this important area.

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1. INTRODUCTION

2 ◆ Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations

THE THEORETICAL UNDERPINNINGS ofthis project arise from four differingbodies of research on emotional re-

sponse to the natural environment: (1) viewingnatural scenes; (2) horticultural therapy, orworking in a natural setting; (3) the experienceof simply being in a natural wilderness; and (4)outdoor environments chosen by people asstress-reducing settings. There is a consider-able range of research where subjects in a labo-ratory setting evaluate pictures of naturalscenes after a stressful experience and are thentested for emotional and physiological recov-ery. These studies indicate that the presence ofnatural greenery in a scene has a high correla-tion with stress reduction (R. Ulrich, 1979,1984, 1986; M. Honeyman, 1987; T. Hartig etal., 1990).

One significant study monitored hospital-patient recovery when looking out at vegeta-tion as opposed to buildings, and found thatthose with a view to nature recovered morequickly (Ulrich, 1984). The second body ofwork reveals that participants in gardening ac-tivities report positive mood shifts. “Naturefascination,” sensory joy, peacefulness, andtranquillity receive the highest ratings from theparticipants (R. Kaplan, 1973, 1983). Third,there is documentation of the influence of nat-ural wilderness use, where people are asked toevaluate a place-experience. This research indi-cates that marked psychological benefits arisefrom being in a natural environment (Kaplanand Talbot, 1983; R. Kimball, 1983; A. Ewert,

1990). These psychological changes are oftenreflected in both short- and long-term changesin functioning and behavior (R. Greenway,1990, 1993). A fourth area of research looks atwhere people go outdoors when emotionallyupset. Two studies in which people were askedwhat kind of place they went to when feelingtroubled, upset, or in grief revealed that naturalsettings were predominantly cited (Francis andCooper Marcus, 1991, 1992). A further studyrelated the process of emotional change to spe-cific qualities of the outdoor environment(Barnes, 1994).

Though there are many studies evaluatingthe success of housing schemes, there are manyfewer of healthcare facilities, and almost noneof hospital gardens. The one exception of thelatter is a Master of Landscape Architecturethesis by Robert Paine (University of Califor-nia, Berkeley, 1984), which was re-written andsummarized in the book People Places (Francisand Paine, 1990). Also important to mention isthe tireless work by designer Vince Healy inpromoting the inclusion of gardens in hospicefacilities (Healy, unpublished).

Given the existing research on nature-as-healer and the garden/gardening experience, itis clear that the need for more documented,empirical research on gardens in healthcare fa-cilities is critical. Case study evaluations of ex-isting outdoor sites and their therapeutic usesneed to be conducted to enable the develop-ment of appropriate and specific design recom-mendations.

2. REVIEW OF RELEVANT RESEARCH

DESIGNED TO MEET the need for prelim-inary empirical data and applicable de-sign recommendations, this research

project undertook the documentation andanalysis of exterior hospital gardens and theirpossible therapeutic benefits. For a number ofreasons this study must be described as ex-ploratory rather than definitive. First, there areno strictly comparable studies in the publishedliterature, so there was no groundwork to drawon; and the necessity for breadth required by thediscovery process precluded the exhaustive con-trol of variables. Second, the time span of theproject itself (January–August 1995) was verybrief. Third, inordinate bureaucratic hurdlesand wet and cold weather into May delayed thefieldwork. Hence, the bulk of the work — ob-servations, interviews, site and statistical analysis— was carried out in a shorter time frame thanwas initially anticipated.

SitesThe central focus of this research is on casestudies of four hospitals in the San FranciscoBay area. Additionally, observations at 13other hospitals in Northern California and atone in England were incorporated into thestudy. The three primary case study sites wereSan Francisco General Hospital in San Fran-cisco (see Map 3–1); Alta Bates Medical Cen-ter in Berkeley (see Map 3–2); and KaiserPermanente Medical Center in Walnut Creek(see Map 3–3). Extensive remodeling at Cali-fornia Pacific Medical Center Garden Campusin San Francisco — intended as our fourth

case study — resulted in minimal use of thegarden. It is reported as a descriptive ratherthan an evaluative case study (see Map 3–4).

Canvassing potential research sites revealedthat there are actually very few healthcare facili-ties that have gardens that are utilized. This wassurprising, especially in a part of the worldwhere the climate could hardly be more con-ducive to outdoor activities. However, four siteswere found that met the stated goal of attainingvariation among the patient population types.

• San Francisco General Hospital’s ComfortGarden encompasses the entry and lawnarea outside an outpatient medical building(see Map 3–1).

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3. METHODS

Map 3–1:The ComfortGarden, San FranciscoGeneral Hospital,Context Map

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• The roof garden at Alta BatesMedical Center is adjacent tothe maternity ward (see Map3–2).

• Kaiser Permanente’s centralgarden is bordered by both in-patient and outpatient facilitiesand by the cafeteria (see Map3–3).

• California Pacific MedicalCenter’s garden serves all ofthe long-term-care patients inresidence there (see Map 3–4).

However, due to various hospital policies andconstruction projects, the results presented arenot necessarily typical of facilities within theirrespective patient population types. (See discus-sions in the individual case study accounts.)

Data CollectionIn order to begin to understand the people-place transactions that occur in these types ofenvironments, a multimethod approach wasemployed, incorporating visual analysis of thephysical site, systematic nonintrusive behav-ioral observation, and information gatheringthrough interviews.

The visual physical analysis of the site incor-porated: (1) mapping of the physical designfeatures; (2) circulation and orientation; (3)views into and out of the garden; (4) microcli-

mates within the garden; (5) sensory qualities;(6) opportunities for social interaction; (7) op-portunities for privacy; and (8) aesthetic andspatial elements.

The behavioral observation data focused onwho used the space and what they used it for.This data revealed patterns of use that wereanalyzed to understand: (1) traffic flow; (2)user activities; (3) gender and age distribu-tions; and (4) user type (patient, staff, visitor).

Each site was observed, and its uses record-ed, for a total of eight hours: 11am–1pm and1–3pm divided between two weekdays and twoweekend days. Each session was divided intosix 20-minute observation periods. To recordthe frequency of uses, if a given individual’sstay in the garden spanned one of the transi-tions between the 20-minute observation peri-ods, his or her activities were recorded morethan once. (A person playing on the lawn for25 minutes, for example, would be recorded astwo user-observations.)

During the 32 hours of observations at all ofthe sites, a total of 2140 user-observations wererecorded: 139 at Garden Campus, 154 at AltaBates, 596 at San Francisco General, and 1251 atKaiser Walnut Creek. The recordings at SanFrancisco General and Kaiser Walnut Creek un-derrepresent the number of people passingthrough the space, as the frequency of use ex-ceeded the human limitations of accurate record-ing. The fluctuation of activity levels at these twosites created periods during which it was impos-sible for one researcher to record all of the activi-ty. Note, however, that the people missed werethe people moving through the space, and thatthis population was subsequently found to be lesssignificant in this study than stationary users.

The user interviews explored what peopleliked about the space, what effects they felt ithad on their psychological well-being, whichqualities and characteristics of the garden theyidentified as contributing to their well-being,impediments to use of the garden, and recom-mended improvements to the garden. (See thequestionnaire in the Appendix.)

Some questions, such as “How often do youcome here?” were pre-coded into ordered cat-egories: my first time; occasionally/sometimes;once or twice a week; every day; several timesa day. Others were pre-coded according to in-

4 ◆ Gardens in Heal thcare Fac i l i t i e s : Use s ,Therapeutic Benefits, and Design Recommendations

Map 3–3:The Central Garden, KaiserPermanente Walnut Creek, Context Map

Map 3–2:The Roof Garden,Alta Bates MedicalCenter, ContextMap

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formation that had emerged from the system-atic observations of use during behavior map-ping. For instance, when asking “What do yougenerally do out here?” the interviewer readout 10 options and the interviewees wereasked to indicate which activities applied tothem, and to add any others not listed. How-ever, the bulk of the questions were open-ended, allowing the interviewees to respond intheir own words, and necessitating contentanalysis of responses during the analysis phase.These were questions such as “What do youlike best about this place?” and “Do you feelany different after you’ve spent time in thegarden?” Questions were asked in this way be-cause there is no prior research that wouldsuggest what an exhaustive range of responsesmight be.

When addressing people’s feelings orchange of mood, three approaches appear inthe literature, each with a different level of reli-ability. The most accurate is monitoring physi-ological changes as an indicator of emotionalshifts (galvanic skin response, blood pressure,heart rate, etc.). Self-reports are consideredsecond in reliability, with the third, behaviorobservation, seldom used due to the extremelyhigh level of interpretation required. Thisstudy drew upon self-reports because the needfor a breadth of information and the fact thatthe cost and time limitations of monitoringphysiological responses on hundreds of sub-jects precluded the use of this more reliablerecording of mood change.

Although self-reports lead some subjects toanswer in a way that they think is pleasing tothe interviewer, the overall reliability of thismethod is nonetheless acceptable. Questionson other topics relied on self-report because itwas the only way to access the information. Forexample, the only way to learn what people likebest about a particular garden is to ask them.

The interview consisted of 25 questions andtook approximately 15–20 minutes. The inter-views were all conducted by the same person.At each hospital the interviewer made a con-tinual circuit through the garden so that theentire site was canvassed. At the end of one in-terview, the next stationary person on the“route” was approached. Two limitations ofthis sampling procedure should be noted. The

first was designed into the program, as it wasanticipated that due to the length of the inter-view, approaching people who were movingthrough the space would be problematic.Thus, all of the interviews were conductedwith stationary users and the responses ofthose passing through were not captured.

Another limitation was discovered duringthe course of the study. Although all individu-als were approached, it was noted that individ-uals in some locations were more likely torefuse to participate than individuals in otherlocations. Those less likely to participate tend-ed to be in the most secluded seating spots.

Twelve hours were devoted to interviewingat each site. It was hoped that 50 individualscould be interviewed in this time span. Thiswas achieved at San Francisco General Hospi-tal and Kaiser Walnut Creek. Slightly fewer(37) were interviewed at Alta Bates because ofrelatively light usage, and very few (7) were in-terviewed at Garden Campus because of build-ing renovation and hospital downsizing duringthe course of the study. Although the drop inuse at Garden Campus prohibits any statisticalanalysis at this site, it is reported with the casestudies due to its value as a description of along-term care facility.

AnalysisThe behavioral observation data were tabulat-ed and prevalence estimates were establishedfor each site and for the aggregate analysis ofthe combined sites. The open-ended narrativeinterview questions were analyzed for contentclusters. For example, in analyzing the re-sponses to what people liked best about thegarden, the two researchers scannedthe range of answers, then readeach response and assigned it to anappropriate category. In analyzingthe question about a change ofmood, the selection of categoriesdrew upon the work of Russell andSnodgrass (1987). Emotional re-sponses were clustered into thosethat indicated a rise in energy level(felt rejuvenated, stronger) andthose that indicated a drop in ener-gy level (felt calmer, more relaxed).

Methods ◆ 5

Map 3–4:The Garden, California PacificMedical CenterGarden Campus,Context Map

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Three additional categories were developedin order to incorporate the full range of re-sponses recorded: those that indicated a cogni-tive shift (find answers, think things through);those that indicated a spiritual or religiousconnection; and a residual category of thoseresponses that were less definitive (felt better,pleased).

Descriptive results of the observations andinterviews were presented both in the contextof the individual case study and in the aggre-gate data analysis chapter. Comparative analy-ses were performed on the aggregate interviewdata, and noteworthy associations were report-ed. Several of the interview questions allowedfor more than one response. This allowed for adiscussion in terms of both the number of re-spondents and the number of responses. Theassociations made enable the comparative eval-uation of the perceived beneficial effects of thegarden on the user’s psychological health, andthe connections drawn by each, to the variousrelevant aspects of the garden. While rigorousstatistical analyses were not appropriate, we be-

lieve these data do provide results that are aninitial step in pursuing this line of inquiry.

Recommendations have been formulated foruse in guiding the design of future gardens thatare attached to healthcare facilities. These rec-ommendations have been worded to be immedi-ately usable by clients and professionals in theplanning and creation of the next generation oftherapeutic outdoor environments.

Overall, there are pros and cons to themethodology adopted. Among the advantages— given its exploratory nature — are thebreadth of data gathered, the intersection ofdata from observation and interviews, the rich-ness provided by open-ended questions, andthe depth of researcher understanding via insitu data collection. Disadvantages include lackof experimental control of the interview envi-ronment, possible interviewee bias in self-re-ports, lack of a temporal perspective, absenceof data from nonusers, and a relatively highdegree of analytical interpretation (e.g., con-tent analysis of open-ended questions).


WHILE THE MAIN focus of this re-port is to look at the use andmeaning of outdoor gardens in

contemporary hospitals, it is important toplace this account in historical context. We aregrateful to Sam Bass Warner Jr., who kindlyallowed us to read and quote from his unpub-lished paper, “Restorative Gardens: Recover-ing Some Human Wisdom for ModernDesign.” This brief overview owes much to hiswork, as well as to a major published work byJohn D. Thompson and Grace Goldin, TheHospital: A Social and Architectural History(New Haven: Yale University Press, 1975).

The first flowering of restorative gardens inEurope occurred during the Middle Ageswhen hospitals and monasteries ministering tothe sick, the insane, and the infirm often in-corporated an arcaded courtyard where resi-dents could find the degree of shelter, sun, orshade they desired in a human-scale, enclosedsetting. St. Bernard (1090–1153) wrote of theintentions at his hospice in Clairvaux, France;his account of its sensory delights has some re-markable parallels with the self-reported bene-fits of gardens as conveyed to us by late-20th-century users in California.

Within this enclosure many and various trees ...make a veritable grove. ... The sick man sitsupon the green lawn ... he is secure, hidden,shaded from the heat of the day...; for the com-fort of his pain, all kinds of grass are fragrant inhis nostrils. The lovely green of herb and treenourishes his eyes. ... The choir of painted birdscaresses his ears ... the earth breathes with fruit-

fulness, and the invalid himself with eyes, ears,and nostrils, drinks in the delights of colors,songs, and perfumes. (Quoted in Warner, p. 80)

During the 14th and 15th centuries, a num-ber of trends combined to render a decline inthe monastic provision of medical care: Period-ic plagues, crop failures, waves of migrationinto burgeoning cities overwhelmed the facili-ties that existed. According to Warner, with thedecline of monasticism itself the significance ofthe meditative/restorative garden declined, andopen spaces attached to hospitals became acci-dents of local architectural tradition, if they ex-isted at all (Warner, pp. 7–8). The care of thesick fell upon civic and ecclesiastical authorities,and within the Roman Catholic tradition, oneof the primary design incentives was to createlong wards where the priest celebrating Masscould be viewed from every bed. The influen-tial Ospedale Maggiore in Milan (1458), for ex-ample, was built in a cruciform plan like achurch nave with windows so high that no onecould see the formal gardens outside (Thomp-son and Goldin, p. 31).

Nevertheless, some hospitals did continuethe courtyard tradition. Les Invalides in Paris(1671) incorporated a number of courts plant-ed with rows of trees. The English hospitaland prison reformer John Howard (1726–1790) described gardens for patients in hospi-tals in Marseilles, Pisa, Constantinople, Tri-este, Vienna, and Florence. “In all thesehospitals he admired the flow of fresh air, thechance for patients to see gardens throughtheir windows and doorways and the opportu-

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4. HISTORICAL OVERVIEWOF THE PROVISION OF OUTDOOR GARDENS IN MEDICAL SETTINGS

nity for convalescent patients to walk in thegardens” (Warner, p. 18).

In the 17th and 18th centuries, the dualemergence of scientific medicine and Romanti-cism fortuitously combined to encourage the re-emergence of usable outdoor spaces in hos-pitals. The notion that infections were spreadby noxious vapors spawned designs that paidspecial attention to hygiene, fresh air, andcross-ventilation. The so-called pavilion hospi-tal became the predominant form throughoutthe 19th century. Two- and three-story build-ings linked by a continuous colonnade and ven-tilated with large windows marked the design ofthe influential Royal Naval Hospital at Ply-mouth, England. The medieval Hotel Dieu inParis was rebuilt with a series of 24-bed wardsjoined together at their ends by a service corri-dor, like the teeth of a comb (Warner, p. 23).These new designs incorporated outdoor spacesbetween the pavilion wards, while the rise ofRomanticism prompted a reconsideration ofthe role of nature in bodily and spiritualrestoration.

Recommendations for hospital garden de-sign written by German horticultural theoristChristian Cay Lorenz Hirschfeld at the end ofthe 18th century uncannily foreshadow thefindings of researchers such as Roger Ulrich atTexas A & M University, who documented inone study the healing benefits of a view ontovegetation for patients recovering fromsurgery (Ulrich, 1984).

A hospital should lie open, not encased by highwalls. The garden should be directly connected tothe hospital, or even more so, surround it. Becausea view from the window into blooming and happyscenes will invigorate the patient, also a nearbygarden encourages patients to take a walk. ... Theplantings, therefore, should wind along dry paths,which offer benches and chairs. ... A hospital gar-den should have everything to enjoy nature and topromote a healthy life. It should help forget weak-ness and worries, and encourage a positive out-look. ... The spaces between could have beautifullawns and colorful flower beds. ... Noisy brookscould run through flowery fields, and happy wa-terfalls could reach your ear through shadowybushes. Many plants with strengthening aromascould be grouped together. Many singing birdswill be attracted by the shade, peace, and freedom.And their songs will rejoice many weak hearts.

The influential nurse and public health re-former Florence Nightingale (1820–1910)wrote with enthusiasm of these new hygienichospital plans:

Second only to fresh air ... I should be inclined torank light in importance for the sick. Direct sun-light, not only daylight, is necessary for speedyrecovery. ... I mention from experience, as quiteperceptible in promoting recovery, the beingable to see out of a window, instead of lookingagainst a dead wall; the bright colors of flowers;the being able to read in bed by the light of thewindow close to the bed-head. It is generally saidthe effect is upon the mind. Perhaps so, but it isnot less so upon the body on that account.(Quoted in Warner, p. 24.)

Good nursing practice by the end of the19th century and in the first decades of the20th century called for wheeling hospital bedsout onto sun porches and roofs, and indeed inthe treatment of tuberculosis, this fresh airand sunlight regimen was seen as the key torecovery. In the Catholic hospital St. Mary’s,in San Francisco, photos in a corridor depictrows of patients in beds on the trellised roofgarden. All that is now left of this space is adecaying segment of roof with a few flowerboxes where staff retreat for a quick cigarettebreak.

The late 18th and early 19th centuries alsosaw radical reforms in the treatment of psy-chiatric patients and in the design of psychi-atric hospitals. Psychological nurturancebegan to replace physical punishment as thecore of treatment. New asylums were laid outwith peripheral grounds and plantings to pro-tect the patients from curious onlookers;landscape vistas were created to provide ther-apeutic experiences; and grounds mainte-nance, gardening, and farming becameintrinsic components of the therapeutic regi-men (Warner, pp. 30–37).

In the 20th century, understanding of germtheory, rapid advances in medical science,technical advances in high-rise constructionand the use of elevators, and increasing de-mands for cost-effective efficiency led to thereplacement of low-rise pavilion hospitals withmultistory medical complexes. As Warner de-scribes this trend:


In acute care hospitals, the design emphasisshifted towards saving steps for physicians andnurses, and away from attention to the environ-ments the patients experienced. Gardens disap-peared, balconies and roofs and solaria wereabandoned, and landscaping turned into en-trance beautification, tennis courts for the staff,and parking lots for employees and visitors.These trends which so captured the twentiethcentury American acute care hospitals spread,after World War II, by the processes of fashionto long term and chronic care facilities, to thehospitals of the Veterans Administration, tomental hospitals, and to nursing homes. Theprestige of the big city teaching hospitals withtheir gardenless patient environments set thestyles for all the others.

In one type of hospital — catering to long-term care of chronic illnesses — the gardenwas not lost. The profession of occupationaltherapy was established in the early decades ofthis century, extending a practice previouslylimited to psychiatric patients into the rehabil-itation of patients with physical problems.After World War I, garden work entered thearena in rehabilitation hospitals; after WorldWar II, horticultural therapy programs withspecial-purpose garden facilities began to beprovided in hospitals for veterans, the elderly,and the mentally ill. With rising mortalityrates from AIDS and cancer, the hospice facil-ity has become more familiar in U.S. cities.These, too, have recognized the therapeuticeffect of the garden. In the specialized facili-ties known as Ronald MacDonald Houses, forchildren with cancer and their families, ahomelike environment and adjacent garden isthe norm.

By the 1970s, general acute-care hospitalshad come to resemble air-conditioned officebuildings where the outdoor experience ofmost patients and staff was confined to thewalk from the parking lot to the main entrance.A few had garden and courtyard spaces but al-most never were these perceived as environ-

ments that might contribute to the restorationof health. By the 1990s, insurance companiesand hospital administrators competing in theburgeoning “healthcare industry” have gener-ated hospitals that resemble hotels or even re-sorts, with elaborate entryway landscaping,plush foyers, art-filled corridors, and privaterooms. The restaurant in Monterey Communi-ty Hospital with domed skylight, interior koipool, and rattan furniture is so attractive thatlocal business people go there for lunch.

Land costs and pressure from insurancecompanies to minimize hospital stays havelargely worked against the provision of gar-dens in these new or refurbished medical com-plexes. “Landscaping” is often seen as acosmetic extra — important to set the rightimage at the hospital entrance or in setbackfrom adjacent streets, but rarely viewed as asignificant adjunct to patient healing or as asetting for stress reduction for staff and visi-tors. Ironically, when suitable garden spacesdo exist, inquiries at the information desk areoften met with blank stares or an outright “No— we don’t have a garden here.” No hospitalin this study provided any graphic directionsto such a facility, or printed information fornew patients. It seems as though the hospitalgarden in late-20th-century America has be-come an invisible and ignored amenity, andthe possible restorative benefits lost in theworld of high-tech machines, high-cost drugs,and increasing medical specialization.

The forgotten garden in today’s medicalarena might be thought of as analogous to theignored psyche and spirit in the treatment ofillness. The value of a garden and the role ofthe psyche in healing are both difficult toquantify or prove. But just as alternative orcomplementary medicine is beginning to re-examine the intricacies of the mind-body con-nection, so also are the design professionsbeginning to rediscover the therapeutic possi-bilities of sensitive garden design.

Historical Overview of the Provision of Outdoor Gardens in Medieval Settings ◆ 9

THIS SECTION PROVIDES an overview ofthe different types of outdoor spacesobserved in hospitals visited during

the study period (January–August 1995). Withfew exceptions, these were all in Northern Cal-ifornia. A definition of each type of outdoorspace is followed by one or two examples of ac-tual places visited, observed, and critiqued interms of their location and design. Each gardenwas visited for 30 to 60 minutes. Photographswere taken and a description of the setting andits apparent use was written in situ. All thesevisits were made on weekdays between 11 amand 2 pm, during warm weather. This provedto be most useful, as these observations ex-panded the understanding of hospital outdoorspace and informed the kinds of design recom-mendations presented at the end of this report.

1. Landscaped GroundsThis type of open space consists of a landscapedarea at grade that forms an outdoor area be-tween buildings. It is often used as a walkingroute between buildings; a setting for eating orwaiting; and as a space for ambulatory patientsor those using wheelchairs. This is the mostspacious type of outdoor area reported in thistypology, and is sometimes described by usersas “a park” or “a campus,” and is often the hubof the hospital complex. One good example is atKaiser Permanente Walnut Creek, described indetail in the case study section of this report.Another good example is described below.

Advantages• Can tie together a variety of buildings — by

function, style, or age — into a campus-likesetting

• Can serve a variety of users and activitiesDisadvantages• Maintenance may be costly

St. Mary’s Hospital, Newport, Isle ofWight, EnglandWhen a new hospital building was added to this19th-century medical complex, the designersproposed a redesign of the central outdoorspace. It is a spacious area and contains a lakefilling a depression where building materials forthe original Poor Law Hospital were quarried.The area around the lake was re-landscapedwith lawns, paths, seating, new trees, twobridges, and two “pads” for the eventual loca-tion of gazebos. It is used by outpatients waitingfor appointments; by staff walking between de-partments; by visitors or volunteers pushingwheelchair-bound patients; and by townspeople

◆ 11

5. TYPOLOGY OF OUTDOOR SPACES PROVIDED IN HEALTHCARE FACILITIES

Photo 5–1: A lake, landscapedgrounds, andwildlife form acomplete contrast tothe hospital interi-or, provide inter-est, stimulate thesenses, and drawpatients, staff, andtownspeople out-doors. A universal-ly accessible looppath supports en-joyment by peoplewith a range ofabilities. Conserva-tories at the end ofwards offer viewsto the lake. (St.Mary’s Hospital,Newport, Isle ofWight, England)

as a park where children are brought to feed theducks and watch a family of swans who havetaken up residence on the lake. It is a very at-tractive, naturalistic space and is as differentfrom an interior hospital environment as anynearby space could be (see Photo 5–1). Obvi-ously the provision of such a space is a raritygiven the urban locations of most hospitals.

St. Mary’s is able to incorporate this park-like setting because it is located on a spacioussite on the edge of a small country town. TheKaiser Permanente facility at Walnut Creek isable to provide such a milieu (though muchsmaller than St. Mary’s) because two “her-itage oaks” in the center of its property areprotected and a much-used and well-likedgarden area was developed around these ven-erable trees.

2. Landscaped SetbackA landscaped setback is an area in front of themain entrance to a medical center, usuallycomprising lawns and trees. This is a spaceakin to the front yard of a house — to providea buffer-separation between the building andthe street. Also, like a house front yard, thisspace is not usually intended for use, but toprovide a visually pleasing setting on ap-proaching the entrance.

Advantages• May evoke a familiar, comforting image at a

hospital entrance• Provides offices or rooms at the front of

building with some privacyDisadvantages• While not usually intended for use, if this is

the only outdoor space, its lack of seating,pathways, etc. may be frustrating for staff orvisitors who want to use it

Main Entry, Alta Bates Medical Center,Herrick Campus, Berkeley, CaliforniaThe four-story stucco buildings of Alta BatesHerrick Campus face onto the busy street ofDwight Way, a few blocks from downtownBerkeley. A wide flight of brick steps withplanters full of flowers leads up to the main en-trance. On either side of the steps an area oflawn, facing south, about 25 feet deep, providesa setback for the building. It is punctuated by a

few trees and small flower beds. Larger streettrees cast shade on parts of the lawn. There areno pathways, seats, litter containers, or othercues to suggest this might be used. This is theonly green outdoor space at this facility, andmight well be used if it were designed appro-priately. Ironically, on the opposite side of thisbuilding is a paved plaza, over-provided withbenches, and with none of the “green” and col-orful image provided by this Dwight Way set-back (see description on page 16).

3. The Front PorchMost hospitals have some features at the mainentrance that are analogous to the front porchof a house. These might include an overhangor porch roof, a turnaround for vehicle pickupand drop-off, seats, directional signs, a postbox, phone, bus stop, and so on.

Advantages• Provides visual cue to main entrance• Overhang may scale down size of building• Sensitively located seating provides amenity for

those waiting to be picked up or waiting for busDisadvantages• May be overused if it is only outdoor seating

area provided• May be under-used if main access to hospi-

tal is via parking under building

Main Entry, Alta Bates Medical Center,Ashby Campus, Berkeley, CaliforniaThe front porch seating at this medium-sizedcommunity hospital is sensitively located just toone side of the main entrance, where there is alushly planted “eddy” space. People passingback and forth on the adjacent sidewalk, orwalking in and out of the hospital, go by thissmall seating area, but do not go through it.Hence, people seated here — as if in an eddyoff the mainstream — experience some degreeof seclusion, yet can easily see if a taxi or afriend’s car arrives. The seating is in the formof comfortable, wooden garden benches withbacks. “No smoking” signs ensure that non-smokers will not be bothered by one of the fre-quent uses of spaces just outside of entrances tohospitals (and office buildings, campus build-ings, etc.), that is, employees coming out for aquick smoke break.


Main Entry, John Muir Medical Center,Walnut Creek, CaliforniaA very large portico overhang clearly marks themain entrance to this medium-sized suburbanhospital, as you approach it from one of themany surrounding parking lots. A semicircularroadway loops under the portico to allow drop-off and pickup at the front door. Two woodenpark benches with backs are located on eitherside of the entrance, facing the roadway.

Since a public bus route serves this hospi-tal, and people are being picked up by car ortaxi, the location of the seating is appropriate.However, the entry faces west and summertemperatures are often in the high 90s. Noneof the seating areas has any shade; all lookonto the glare of the adjacent road, sidewalk,and parking lots and receive the reflected heatfrom the building walls. Seating in the air-conditioned foyer is not close enough to theentrance to see when a bus or other vehicle isarriving. Attention to site planning, planting,or the creation of roofed shelters would haverendered this a more successful front porch.

4. Entry Garden This is a landscaped area close to a hospital en-trance that, unlike a “front porch,” is a greenspace with a garden image, and unlike a “land-scaped setback,” is designed and detailed for use.

Advantages• Visible and accessible• Makes positive use of part of site that might

otherwise have been paved for parking• Provides a pleasing image on entering hos-

pital environment• Allows use by ambulatory patients who want

to see a little “action” near the main entranceDisadvantages• Without sensitive planting, may be too ex-

posed to nearby parking and entry road

Main Entrance, Marin General Hospital,Greenbrae, CaliforniaEast of the main entrance to this medium-sized community hospital is a landscaped areawith mature palms, live oaks, and eucalyptus,and paths zigzagging up to an upper parkinglot. The trees screen out much of the hospitalbuilding; the views out from this area are of

hillsides covered with native trees and themore distant slopes of Mt. Tamalpais. It has aquiet, green, parklike feeling. Nine large palmtrees border a small circular seating plaza.Around this are lawns, ivy-covered slopes, anda flower bed with every species neatly labeled.Two other benches, up-slope from the circle,offer a more sunny location. From the circleseating, nearby parking is barely visible, andtraffic on a street that gives access to the hos-pital is heard only intermittently. Due to asteeply sloped site and the configuration of thebuildings, this is the only outdoor space atMarin General, and it appears to serve its pur-pose well.

5. CourtyardThis is a space that forms the “core” of abuilding complex like the hole in a doughnut.Ideally, this should be immediately visible orapparent on entering the hospital so that visi-tors and patients know that it is there. When acafeteria occupies one or more sides of thecourtyard, it could function as an outdoor eat-ing place. Trees for shade, flowers for color, awater feature for pleasing auditory relief, andmovable seating are “basics” for such a space.

Advantages• Semi-private and secure; surrounded by

hospital buildings• Depending on location, may be easily

viewed and accessed• Shielded from wind; buildings likely to pro-

vide shade• Likely to be of human scaleDisadvantages• Depending on its size and location, may

create a “fishbowl” experience for thoseusing it

• If too small to include adequate bufferplanting, adjacent rooms may need to keepblinds drawn for privacy

Cafeteria Courtyard, Novato CommunityHospital, Novato, CaliforniaThis is a small, one-story community hospitalin a residential district of a small town. Thecourtyard is immediately visible on enteringthe hospital. On one side is the main corridorwith the Admitting/Registration Desk; on a

Typology of Outdoor Spaces Provided in Contemporary Healthcare Facilities ◆ 13

second side is the cafeteria. The courtyard isaccessed via sliding glass doors from both ofthese public and well-used spaces. The othertwo sides are administrative offices with win-dows that look into the courtyard; the win-dows usually have their blinds drawn.

The courtyard is small, approximately 40 x40 feet. In one corner, the one sizable tree inthe space shades a 9 x 9-foot pool with a centrallow fountain jet. The space is furnished withround tables shaded by umbrellas, lightweightmovable chairs, and three garden benches nearthe pool. Color is provided by warm brickpaving, some evergreen shrubs, a Japanesemaple, and flower boxes of petunias and impa-tiens bordering the pool. The overall ambienceis of a restful urban patio. The only aesthetical-ly jarring elements are three large, hummingvending machines against one wall and threenewspaper vending machines. However, theformer do offer a service for visitors and staffsince the cafeteria is only open at certain times.Waiting for a relative who is in surgery; takinga coffee break; doing some paperwork awayfrom the office; eating lunch with colleagues —this courtyard offers many users of this hospitala quiet outdoor respite (see Photo 11–5).

Linnaeus Physik Garden, Santa RosaCommunity Hospital, Santa Rosa, CaliforniaThe Linnaeus Physik Garden at Santa RosaCommunity Hospital is a good example ofwhat can be done in a long, narrow, leftoverspace in the midst of a medical complex of oldand new buildings. It is bounded on threesides by older, two-story hospital buildings,and on the fourth side by a half-open corridorproviding access to administrative offices. It isnot near the main hospital entrance, nor arethere any directional signs indicating its loca-tion. However, on approaching the cafeteria, itis glimpsed through corridor windows.

The courtyard is approximately 40 feet wideand 120 feet long. The dominant aesthetic ef-fect is provided by five, two-story-high mapletrees arranged in a line along one long edge ofthe court. Under each is a raised planter offlowers bordered by a square bench. Theseprovide seating places with a variety of viewsand varying degrees of shade. Between the

trees, and in a few other locations, are simplewooden picnic tables with movable benches,popular with groups of two or more who carryfood out from the nearby cafeteria. Duringpeak-use hours, some of these tables are indeep shade, some in dappled shade, and somein full sun — providing plenty of choice de-pending on people’s tolerance for the sun.Since summers in Santa Rosa can be very hot,the provision of shade is essential. On the op-posite, long side of the court are three sets ofwooden garden seats with upholstered cush-ions — each set is a pair of chairs, with a smalltable between and an adjustable umbrella over-head. These are very popular and are in useboth before and after the lunch-time users haveleft the picnic tables. Benches are often movedfrom one of the picnic tables so that users ofthese padded chairs — reading, eating, chat-ting, smoking — can sit with their feet up.

This courtyard has been planted with greatsensitivity. The maples provide needed shadeand — not incidentally — attract a lot of birds,whose songs and chirping provide soothingbackground sounds. Planters beneath themaples and along the edges of the court arefilled with flowers; baskets of flowers hangfrom the roof of the half-open corridor. Twoof the three entries to the courtyard are downflights of six steps; beside these are overflow-ing planters of star jasmine, so one’s entranceinto this space is marked by strong scent. Else-where in the plaza, star jasmine climbs thewalls of the adjacent building so that all theupholstered seating areas are “perfumed.”

This court was dedicated as the LinnaeusPhysik Garden in 1986, when the hospital aux-iliary installed six planters along the two longsides of space filled with medicinal herbs andplants from Central and South America, Eu-rope, North America, Africa, India, and China.

The negative features of this space are theview at one narrow end onto dumpsters andstorage bins, and the ever-present sound of air-conditioning units attached to adjacent windowsthat block out the sounds of a small cornerfountain for all but those sitting quite close to it.The black asphalt surface of this court is not es-pecially pleasing, particularly where the roots ofmaples have caused cracks and uneven seg-


ments. Warm brick paving would certainly havebeen aesthetically preferable.

Medical Building Courtyards, Kaiser Permanente Medical Center, Vallejo,CaliforniaThree rectangular courtyards are bounded bythe two-story buildings of a new outpatient fa-cility. Three sides of each courtyard are corri-dors and waiting areas with floor-to-ceilingglass looking out to the greenery. The fourthside of each is occupied by offices and exami-nation rooms with an ample boundary of treesseparating these office windows from anyoneseated or passing by in the courtyard. Some ofthe corridors are punctuated by cushionedwindow seats allowing patients waiting for ap-pointments to have an even closer view to theoutdoors. The staff at registration desks faceout across the corridors, and they also havegood views to the courtyard.

Although each courtyard is unique, they allhave certain common elements: pathways ofconcrete pavers; geometrically shaped areas oflawn; low boxwood hedges; shrubs in very largeterra cotta planters; long lines of trees (cherriesand ornamental pears in one, Lombardypoplars in another); comfortable wooden gar-den benches and individual garden chairs withbacks and armrests. Though these features arerepeated, other elements are unique to eachcourtyard. One has a circle of poplar trees, asemicircular, seat-height wall feature, and isplanted with a grass (clumping hard fescue) thatneed not be mowed and provides a lovely, wavytexture. Another has “beds” of black, river-eroded pebbles, a mounded lawn, and a speci-men live oak tree. Two have wooden gardentables with dark green market umbrellas.

These all represent very successful court-yard spaces; they are highly visible, easily ac-cessible, provide choices of seating, includehigh-quality details (seats, lighting, planters,etc.), and all provide a true garden experience.The only criticism would be that there are al-most no flowers and there is limited seasonalcolor. Interviews at case study sites indicatethat flowers and color are highly valued in gar-dens used for relaxation and stress-reduction. Aspecially sensitive aspect of planting was thechoice of Lombardy poplar in three of the four

courtyards. These trees move in a breeze andtheir leaves make a soothing, rustling sound.One oversight is a public address or beeper sys-tem that would allow people waiting for an ap-pointment to spend time in the courtyard.

As attractive as these courtyards are, our im-pression is that they are quite underused. Weresuch spaces located in an inpatient facility, ornear a cafeteria, we surmise that they would re-ceive greater use and provide greater benefit.

Children’s Courtyard, Kaiser Permanente Medical Center, Vallejo, CaliforniaHalf of this square, 45 x 45 feet courtyard istaken up with an attractive and well-used chil-dren’s maze, constructed of four-foot-highwooden walls, topped by thick padding. Chil-dren waiting for pediatric appointments (ortheir siblings) try to find their way out of themaze, climb over its walls, chase each otheraround the perimeter paths, romp on the lawn(which makes up the other half of the court),or climb the sturdy live oak tree. They are eas-ily visible to their parents in the waiting areas,but any noise that they make is not audiblefrom inside. This is an excellent use of a smallspace, allowing children to let off steam in ahospital environment (see Photo 11–1).

6. PlazaPlaza spaces in hospitals are outdoor areas, fur-nished for use, and predominantly hard-surfaced.They may include trees, shrubs, or flowers inplanters, though the overall image is not of agreen space, but of a paved urban plaza.

Advantages• Low plant maintenance and irrigation costs• A small place can be designed for relatively

heavy use• Patients using wheelchairs, walkers, or crutch-

es may be able to move easily in this spaceDisadvantages• May have few of the qualities that people

perceive as therapeutic in outdoor spaces —an overall green and/or colorful setting, agarden or oasis image

• May evoke the image of a shopping mall orcorporate office plaza rather than a space forpeaceful, stress-reducing, passive enjoyment


Seating Plaza, Alta Bates Medical Center,Herrick Campus, Berkeley, CaliforniaThis is an L-shaped seating plaza located out-side the Oncology waiting area. The space canbe entered from one of three doors in the On-cology Department, or via steps and rampfrom Haste Street. It is about four feet abovestreet level. Each “arm” of the “L” is approxi-mately 75 feet long; one is 50 feet wide, andthe other is 25 feet wide.

The feel of this space is of a highly de-signed, probably expensive, but rather coldurban plaza. There is a predominance of hardsurfaces: travertine paving, now stained bywater draining from the planters; 12 concrete,box-shaped tree planters; the windows andstucco walls of five-story buildings on threesides; the sloping glazed roof of a below-ground waiting area; steel benches; and a rowof seven travertine slabs that tilt up into theplaza and down into the waiting area beneath.These latter, in particular, create a disturbingsense of imbalance in the space, and — unfor-tunately — are reminiscent of tombstones.

The planting in this space does nothing tooffset the overall hard appearance. Twelvesmall Japanese maples are delicate and appro-priate to this north-facing space but are com-pletely overshadowed by the size of the adjacentbuilding and the dominant hard-scape. Eightsmall pittosporum trees in planters between onearm of the plaza and Haste Street also do littleto create a green setting.

The seating here is also unfortunate — six-foot-long maroon, steel benches placed be-tween the maple trees in planters. Though theyare reasonably comfortable to sit on (with backsand arms), their size suggests seating for largenumbers of strangers at a bus terminal or shop-ping mall. Considering the stressful nature ofwaiting in an Oncology Department, it wouldhave been more appropriate to provide shortwooden benches or movable chairs, so that aperson alone, or with a friend, could sit in asemi-private location. The eight benches could,theoretically, seat 32 people — an obviousover-provision in this location. Unfortunately,sitting alone in such a space evokes a lonelyfeeling, with so many empty benches in view.

7. Roof TerraceUnlike a roof garden, which is located on top ofa building or is usually open on all sides, a roofterrace is an accessible outdoor area that isbounded on one side by a building and oftenforms a long narrow “balcony” to that building.

The basics of such a space are plantings; achoice of seating types; a choice of seating lo-cations with regard to privacy and sun/shade;and accessibility/visibility to potential users.

Advantages• Captures space that might otherwise go un-

used• Potential for expansive viewsDisadvantages• Depending on location, may be too windy,

too hot, or too shaded

Promenade, St. Mary’s Hospital,San Francisco, CaliforniaThis is an excellent example of a roof terrace.First, it is immediately visible through the largeglazed lobby wall opposite the main doors intothe hospital. Its outer edge is bounded by a longconcrete planter filled with blue agapanthus andtrailing rosemary. Just inside the terrace is along walkway used for strolling and bounded byplanters with seat-high concrete ledges. Off thewalkway and forming the most prominent fea-tures of the terrace are two brick-paved seatingclusters, bounded by planters filled with shrubsand flowers and shaded by pittosporum trees.The seating, with curved backs, is made of woodslats and is quite comfortable. It is arranged inright-angled clusters so that three or more peo-ple can sit together comfortably and converse.

The overall milieu is of a green and colorfulurban garden with attractive, semi-private set-tings in which to sit, eat lunch, or talk with col-leagues. The greenery can also be enjoyed bypeople working in offices looking out onto theterrace. The terrace seating is far enough awayfrom the windows that the privacy of neitherspace is compromised (see Photo 11–3).

Perimeter Terrace, Davies Medical Center, San Francisco, CaliforniaThis is an unfortunate example of this type ofopen space. It wraps around the south and eastsides of a central high-rise hospital buildingand is accessible by steps and a ramp adjacent


to the main entrance. Surfaced with cement,this is a stark, glaring space with almost noth-ing in it to tempt people to stay. There are anumber of small, poorly maintained trees inconcrete tubs, completely out of scale with thespace, or with the size of the building loomingabove it. A few round concrete planters withseating ledges around them punctuate thespace but offer little shade and provide seatingthat is uncomfortable.

So much more could have been made ofthis space, especially since on its east side ithas a magnificent view of downtown SanFrancisco. The relative nonuse of the terraceis confirmed by the fact that the hospital ad-ministration has seen fit to place two largeround bicycle storage containers in the space(see Photo 5–2).

8. Roof GardenThis is an area on top of a hospital buildingthat is designed and landscaped for use by pa-tients, staff, and visitors, and — in some cases— for viewing from offices and hospital units.

Advantages• Captures space that might otherwise be un-

used• Private — unlikely that public would use it• Potential for expansive viewsDisadvantages• Exposed to elements: may be more windy

than ground level, or enclosed courtyard.• Depending on the growth and height of ad-

jacent buildings, temperatures may be un-comfortable (too hot or too cold)

• Heating/air-conditioning units often vent onroofs, creating an intrusive mechanical sound

• Unless well signed, visitors and patients maynot know of its existence

One example of a roof garden is describedand analyzed in the case study section of thisreport (Alta Bates Medical Center).

9. Healing Garden*This is a category that includes outdoor or in-door garden spaces in hospitals that are specif-ically designated as healing gardens by theadministration and/or the designer.

Advantages• Users can expect that some thought has

been given to creating an environment thatis therapeutic

• Possibly disruptive activities, such as chil-dren playing or groups eating and laughing,will probably not be found in the space

Disadvantages• Depending on its size, location, and visibili-

ty, some people might feel self-conscioususing such a garden

• If not designated as such, users may be con-fused as to its function

Healing Garden, Oncology Deptartment,Marin General Hospital, Outpatient MedicalBuilding, Greenbrae, CaliforniaThis is a small (15 x 25 feet) garden in whatotherwise might have been an unused space.On one side is a restricted waiting area forOncology Radiation, with floor-to-ceilingglass so that even when not in the garden, itforms a pleasing green outlook. Two-story,cedar-shingled walls and the windows of sev-eral offices look out and down into this space,but the feeling while seated in it is not ofbeing in a fishbowl because of very lush plant-ing that seems to surround and enfold you.The plants — almost all shade-loving — aremostly species that have healing properties.


* Healing Gardens and Meditation Gardens are identi-fied as separate categories within the garden typology. Ingeneral, meditation gardens could be considered a subsetof healing gardens. A few hospitals studied had gardensthat were specifically designated as one of these types. Allof them had plaques identifying and dedicating the space.

Photo 5–2:A roof terrace nearthe main entranceto this urban med-ical complex is adisappointing ex-ample of outdoorhospital space.There is little coloror greenery, thesmall trees are outof scale with thebuilding, andthe seating is un-comfortable andsociofugal, discour-aging social inter-action. Largebicycle storagelockers bisect thespace and block adramatic view ofdowntown SanFrancisco. Patientuse from an adja-cent day room ishampered by thelack of a wind-pro-tected, transitionalspace. (DaviesMedical Center,San Francisco,CA)

The short paths leading to two seating placesat either end are made of concrete stepping-stones set in moss. An unusual water feature— a grooved stone channeling a small streamdown into a hollowed rock — provides asoothing sound. This is a very quiet andsoothing space that makes wonderful use of avery small area in a sensitive way.

The Healing Garden, Kaiser PermanenteMedical Center, Roseville, CaliforniaThis garden is part of a brand-new medicalcenter that had only been open two months atthe time of our visit (August 1995) and is specif-ically designated as a healing garden. It is rec-tangular in shape, approximately 75 x 120 feetin size. It is completely enclosed, on three sidesby three-story buildings and on the fourth sideby a 10-foot-high stucco wall shielding the gar-den from the parking lot beyond. The garden isentered from a — presently — little used corri-dor in the main Medical Building.

The entry door opens onto a small con-crete plaza where seating will eventually be in-stalled. The most prominent visual feature is alarge set of planted terraces stepping up froma decomposed granite path to the highestpoint in the garden, the northeast corner,where a cork oak is planted on a gravel-basedterrace. The three terraces are planted withforsythia, white roses, and orange-blossomeddwarf pomegranate. The slopes are plantedwith star jasmine and ivy, and heavily mulchedwith redwood bark. The flat, central section ofthe garden consists of a path looping aroundan area planted with dogwoods, blue turf lily(Liriope muscari), and dwarf periwinkle (Vincaminor), and punctuated with rocks.

The garden, of course, is still in its infancy;plants were being put in when we visited, and be-sides one litter container, no garden furniturehad been installed, and no one was using it.Given the results of the case studies, this gardendoes not presently include many features or qual-ities that people reported as significant to themfor relaxation. For example, the garden is notvery green or lush, nor will it ever be, based onthe plants selected. It has little visual variety, noauditory element, a limited range of colors, andthe terraced section seems to have been designed

for people to look down on from above, ratherthan as a setting to enjoy while in the garden.

In conclusion, the feeling is one of an inte-rior, architectural space where plants are usedfor decoration, rather than a garden space thatcontrasts with the controlled and sterile interi-or medical environment. While an outdoorspace design that extends the theme of a build-ing to the outside may be appropriate in somesettings (for example, a downtown officeplaza), interviews at other hospital gardens in-dicate that it is the contrast between “build-ing” and “garden” that people particularlyrespond to in a medical setting.

10. Meditation GardenThis is a small, very quiet, enclosed space specif-ically labeled with a plaque as a meditation gar-den by the administration and/or the designer.

Advantages• Provides a space for those in a hospital setting

who want to be very quiet and contemplative • By its name, precludes other, possibly dis-

tracting, activities (eating, smoking, etc.)Disadvantages• If it is visible from indoor spaces, one might

feel self-conscious, in a fishbowl. It is quiteprobable that only one person at a timemight use such a space, depending on its size

• Given its designation, one might feel self-conscious about using it for other legitimatequiet activities that are not meditation(reading, writing)

Meditation Garden, Marin GeneralHospital, Outpatient Medical Building,Greenbrae, CaliforniaThis is a small (15 x 25 feet) court/garden spaceentirely enclosed by two-story cedar-shingledwalls and windows of the building. The gardenhas low planting around its edges, an attractivestone wall, a fountain trickling into a bed ofblack pebbles off-center, and a path of decom-posed granite looping around the fountain.There are four comfortable wooden benches,each long enough for two people, though theydo not have backs.

The small size, greenery, and sound offalling water set the stage for what may serve at


times as a contemplative space. It is close to thewaiting area and is labeled on the entry door asa Meditation Garden. However, the windows offive offices open onto this garden and in warmweather, with windows open, the inevitableconversations and occasional laughter are intru-sive. There is also something of a “fishbowl”feeling while seated in such a small space.

Meditation Garden, El Camino Hospital,Mountain View, CaliforniaThis new garden in a community hospital wasdonated by two couples — each of whom hadlost a family member and had yearned forsome place to go and sit quietly while in thehospital setting. The garden is approximately40 x 40 feet and is enclosed by two-storybuildings on 21⁄2 sides. The entry is from alandscaped walkway through the half side thatis open. The other end not bounded by build-ings is enclosed by trees and shrubs screeningthe garden from lawns at the front of the hos-pital and a distant entry road.

The garden is dominated by four largeweeping willows, which provide a greencanopy, the sound of rustling leaves, and mov-ing shadow patterns on the ground. Beneaththe willows are shade-loving shrubs and ferns,scattered rocks, a dry streambed of pebbles,and a Japanese lantern.

A concrete pathway — wide and smoothenough for a wheelchair or gurney — leadsfrom the garden entry to seating under awooden-roofed gazebo in the center of thegarden. Lighting in the gazebo and along theentry path permits use after dark — a thought-ful amenity in this area of hot summer nights.Windows from the Dialysis Unit on one sidepermit views out for the patients and staff in-side. Reflecting glass in these windows createsan impression that the garden is larger than itis and eliminates the feeling of being in a fish-bowl when in the garden. Two bird feedershanging outside these windows encouragebirds into the garden, which are then visiblefrom inside and outside. There are also viewsinto the garden from a staff lounge and a pa-tient waiting room. Half-closed blinds in thesewindows permit someone sitting in the gardennot to feel stared at.

Some of the drawbacks of this garden in-clude: the low hum of an air-conditioning unitthat competes with the pleasing sound of mov-ing leaves; benches that have no backs or arm-rests and which form long right-angledarrangements, suggesting socializing rather thanlone contemplation. There is one additionalshort metal bench with back and arms in whichsits, incongruously, a green-metal, sculpted frog— a whimsical element more suited to a chil-dren’s garden than to a place of meditation. Thepresence of an outdoor porch with tables andchairs off a staff recreation room at one end ofthe garden is also unfortunate, as the laughterand conversation of staff on breaks may conflictwith the need for peace and quiet in the garden.

Overall, this is a soothing, quiet milieu thatfeels separate from the hospital. Though not farfrom the main hospital building and easily ac-cessible, the garden’s orientation off a path thatis minimally used is a drawback that has impact-ed its use. Many staff are unaware of its exis-tence, and patients or visitors are unlikely tofind the garden on their own. The therapeuticbenefits of such a space could have been en-hanced with a greater variety of plant materials,engaging the eye to explore textures and colorswhile in the garden. Some movable gardenchairs and paths to quiet, green corners wouldenable those who want to be completely aloneand surrounded by nature to enjoy this spacemore fully.

11. Viewing GardenWith space and budget limitations, some hos-pitals incorporate a small garden that cannotbe entered but can be viewed from inside thebuilding.

Advantages• Green space in a small area• Can be viewed from comfortable indoor

seating area — sheltered from rain; heated/air-conditioned

• Low maintenance costsDisadvantages• Greenery, flowers, etc. cannot be viewed up

close or their fragrances enjoyed• Fountain, birds — if present — cannot be

heard


• Cannot walk, stroll, or sit in garden• May be frustrating for some —“Look, but

don’t touch”

Central Atrium, John Muir Medical Center,Walnut Creek, CaliforniaA small, square (approximately 32 x 32 feet)garden can be viewed through floor-to-ceilingwindows from a large, plushly furnished foyer-atrium and from three adjacent corridors inthis modern, suburban medical center. Flowersand ferns grow in square concrete planters ofvaried heights. There is a small fountain in thecenter and two 2-story-high trees. The gardenwas designed by — and is maintained by — alocal garden club.

The garden provides a green outlook forpeople waiting in the foyer or passing by in thecorridor. The trees are well selected, with deli-cate foliage that moves in even a slight breeze.The fountain, with a number of very thinfalling jets, offers a view of water, but a fountainwith more visible water would have been a bet-ter choice, considering that people cannot hearit. More lush, colorful, and varied plantingwould have made this a more attractive feature.

12. The Viewing/Walk-In GardenThis is a variation of the viewing garden inwhich a space that is predominantly (in termsof spatial extent and use) a garden to look outat from inside the hospital can also be enteredand sat in by a very limited number of people.Such a space is usually viewed or entered froma waiting area or corridor.

Advantages• Provides a soothing green outlook for peo-

ple waiting or passing by• Provides a very quiet sitting place since few

people are present• The relative lack of use ensures that users of

any adjacent offices or patient rooms willnot feel that their privacy has been undulyintruded upon

Disadvantages• People sitting in the space may feel that

they are in a “fishbowl,” being stared at

Internal Gardens, St. Mary’s Hospital,Newport, EnglandThree small courtyard spaces seen throughwindows off the main ground-level corridor ofthis new community hospital could be charac-terized as viewing gardens. One has seating init and is thus described in this section.

A door opens off the corridor and one stepsinto a space that is approximately 60 x 60 feetin size. Almost half the total area comprisestiled paving in a wavelike design, echoing awater theme used throughout the interior andlandscape design of this hospital, located as it ison an island (Isle of Wight). Beyond the paving(as you view it on entering) is low shrubberythat acts as a buffer between the garden andthe windows of offices/patient exam rooms onthe other three sides of the square.

While the paving design is an attractive fea-ture viewed from the corridor or from the twofloors above, the detailing and furnishing of thisspace are less successful. There is one seating el-ement comprising a circle of seats arranged in asociofugal design (i.e., the seats face out, awayfrom each other). This means that any morethan two people entering the space togethercannot easily converse while seated. Such a seat-ing arrangement is suitable where strangers aresitting next to each other (e.g., a subway stop)but might be questioned where visitor-familiesor co-worker colleagues are the likely users.The absence of seating in several other half-moon-shaped paved areas that are bounded byshrubs and would have made very private seat-ing spaces for one or two people curtails theuse of this space. Also limiting the use of thisgarden is an inordinately high and awkwardstep up/step down entrance sequence. This,combined with the undulating paving (on avertical scale), renders use by elderly or infirmpeople very difficult, if not impossible.

Flower Gardens, Stanford UniversityMedical Center, Stanford, CaliforniaAt ground level in a new building complex ofthis large medical center and medical school,there are two walk-in/viewing gardens ac-cessed from a major corridor at grade andviewed from three corridors, open stairways,


and small waiting areas above. The gardensare very visible from inside through floor-to-ceiling glass. Beside one of these gardens, thecorridor widens out to a spacious, tiled waitingarea with comfortable leather armchairs.Thus, this garden can easily be enjoyed bynumbers of people sitting inside.

The garden is roughly triangular in shapeand is accessed by doors off the corridor-waitingarea. The garden is approximately 115 feet longand 45 feet wide at its widest point. There aretwo seating clusters, each floored with concretepaving and furnished with five handsome wood-en garden benches with backs and arms, plus alitter container. The two clusters at either endof the garden are linked by a narrow, windingconcrete path that enables a brief walk throughthe garden. Around each cluster are a number ofsilver birch trees, three stories high. These pro-vide some sense of enclosure to those seated,and the soothing sound of leaves rustling. Atmost times of the day, there is a choice of seat-ing in the shade or in the sun. The birches alsoprovide a green outlook for those in offices andpatient rooms in the floor above the garden.

The planting in the gardens is exemplary:underplanting of shade-loving ferns, camellias,azaleas, and impatiens beneath the birches;massed plantings of blue agapanthus, pink andwhite roses, white and blue petunias, whitecosmos, white and pink dahlias, pink penste-mon, blue lobelia, and blue delphiniums. The

effect is of a very colorful “cottage garden”with the birches in two corners and cherries inthe third, acting as backdrop.

While one side (nearest the corridor) is ob-viously planned for use — seating clusters andpathway — the other two sides are faced by thewindows of offices and patient rooms. Thedepth of the garden and the height and varietyof planting ensure complete privacy for thoseinside. Although a distant air-conditioning unitcan be heard, the overall experience in this gar-den is of being very remote from the hospitalatmosphere, in a human-scale, secure, and en-closed setting, with the sound of moving leavesand views onto a wonderful variety of plants,flowers, leaves, shadows, and textures — a trueoasis experience (see Photo 11–4).

Smoking is not permitted in either garden.Generally both were used by lone people readingand eating, groups of visitors talking, elderly pa-tients in wheelchairs (with a companion) lookingat the flowers and dozing, small children explor-ing in the shrubbery.

Having categorized, described, and cri-tiqued a variety of types of hospital outdoorspace that were briefly visited and observed,the next sections of this report comprise de-tailed case studies where systematic observa-tion and user interviews provide a closer lookat the therapeutic potential of outdoor gardensin hospital settings.


THE FIRST BUILDINGS designated asSan Francisco General Hospital wereerected on this site in 1872. Out-

breaks of bubonic plague, the spread of tuber-culosis, the earthquake of 1906, and theinfluenza epidemic of 1918 brought about se-vere overcrowding in this and many other SanFrancisco hospitals. Most of the present build-ings were constructed during 1915–20, de-signed by city architect Newton Tharp in anItalianate style, laid out “with green lawns andbright flowering plants to add to the attrac-tiveness of the structures.” Early photographsdepict lawns, shrubs, paths, and palm trees be-tween the buildings, formally designed, but —apparently — with no seats or benches to en-courage use by staff or patients.

The Comfort Garden is a small but well-used outdoor space in the sprawling contem-porary “campus” of the hospital. It wasestablished in June 1990 as a “living memori-al” to hospital employees who had died. Aname plaque in the garden, recording its in-ception, concludes with the words: “It ismeant to be a place of solace where nature’sbeauty can bring you comfort.”

Physical Elements and SiteLayoutThe garden is located adjacent to Buildings 80and 90 — imposing six-story brick buildingswith many operable windows looking out overthe outdoor space. These buildings house avariety of clinics, including those for TB,HIV, methadone maintenance, Family Health,

and Child Abuse. All of these are outpatientclinics; none of the buildings adjacent to theComfort Garden contains inpatient beds. Thegarden is bounded on two sides by these build-ings and on the other two sides by fences thatseparate it from 22nd Street and a parking lot.

The feeling of this residential-scale gardenis of a green and colorful retreat (see Map6–1). Three very large trees — one cedar andtwo Monterey pines — are almost as tall as thebuildings. Five lawn areas are bounded byconcrete paths and flower beds. Most of thepaths are designed for easy, direct pedestrian

◆ 23

6. SAN FRANCISCO GENERAL HOSPITAL:The Comfort Garden

Map 6–1:Comfort Garden,Illustrative Plan

lawn

lawn

mai

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try

toou

t-pa

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clin

ics

22nd

Str

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out-patient clinic’s back door

SCALE:

movement (see Photo 6–1), but one made ofdecomposed granite and another formed with“steppingstone” blocks of wood are clearly de-signed for more casual strolling. The latterwinds through a lushly planted garden bedwhere shrubs and flowers can be viewed atclose quarters (see Photo 6–2).

This is clearly a garden that has been cre-ated — and is maintained — with love andcare: Tree stumps have been arranged to bor-der flower beds; an arbor has been created outof thin branches pruned from nearby trees;rocks have been placed among the flowers;annuals are planted out in colorful displays.There are no weeds, nor is there any litter;yet the garden has a casual rather than a man-icured appearance.

When this study was conducted — May–June 1995 — there were no fewer than 35 dif-ferent species of plants and shrubs in bloom.No wonder one of our interviewees, whenasked what she would like to see changed,asked for plant labels.

While most of the Comfort Garden has acasual, “country cottage” garden image, a por-tion of it was changed in 1994 to add a moreformal sculptural element. This area, by Peter

Richards, is entitled “Companion Place — acomplement to the Comfort Garden.” It com-prises a curvilinear path bounded by graniteblocks and surfaced with decomposed granite;five large granite blocks that function as casualseating; and two granite-bordered flower bedsplanted more formally than the rest of the gar-den, with African marigolds and lobelia.

Within and beside the informal flower bor-der that runs the length of the garden on itssouthwest side, there are a variety of places to sit(see Map 6–2). Two wooden benches with backsand arms are a perfect size for two people to oc-cupy for a private conversation, or for one per-son to “claim” by sitting lengthwise with feet up.These are ideal choices for this garden consider-ing its size and image. Being of small scale, andof more delicate construction, they are clearlygarden benches rather than park benches (seePhoto 6–3). Under one of the large pine treesthe gardeners have built a simple wooden plat-form. This enables two to four people to sit,backs against the tree, their feet up, their lunchor coffee or book beside them. It is pleasantlyinformal, flexible in use, and far enough awayfrom a path to be relatively private.

Also providing informal seating are a rowof large tree stumps forming the border of a


Photo 6–1: Main entry path to Building 90 — the busiest routethrough the gar-den on weekdays

Photo 6–2:Strolling path andsecluded bench inthe long flowerborder

portion of the long flower border. Thoughright next to a path, this is one of the least-used walkways in the garden, and thereforethere is some degree of privacy.

Microclimate and AmbienceOn a sunny day in spring and summer duringthe peak-use hours (11 a.m. – 2 p.m.), approxi-mately 85 percent of the garden is in the sun.However, this part of San Francisco is quitefrequently breezy, if not windy. On a sunnyand breezy day, the comfort difference be-tween sitting in the sun and sitting in theshade is quite marked. Fortunately, both gar-den benches and all the granite seating blocksare in the sun almost all day. The wooden-platform seating, underneath a large Montereypine, is in shade most of the time. Thus, onlyon the hottest and calmest days is this a com-fortable place to rest.

A small number of those we interviewedcomplained that the garden is “too noisy.” In-deed, there is a fair degree of background noisein this setting: cars and buses driving past onPortrero Avenue; cars accelerating uphill on22nd Street; and the sounds from a large air-conditioning unit on an adjacent building.

When asked to describe the garden, somereferred to it as “an oasis.” We suspect that thisimage is evoked by two things: one, the lush

and colorful planting, particularly in contrastto adjacent streets and tall brick buildings; two,the relatively enclosed feeling when in the gar-den. On one long side, it is bounded by thefour- to six-story wings of Buildings 80 and 90.On the opposite long side, its immediateboundary is a 10-foot iron fence, densely cov-ered in parts by a flowering vine. Beyond this,on the other side of 22nd Street, the space isvisually bounded by the three and four storiesof another brick hospital wing.

The top southeast end of the garden is de-fined by a low laurel hedge, but is visuallybounded by the concrete end wall of the hospi-tal heating plant viewed through trees, and by alarge modern addition to the hospital (seePhoto 6–4). At the downhill, narrow north-west end of the garden, an iron fence formsan edge along Portrero Avenue, but the two-story row houses across the street and moredistant hills of Twin Peaks form a more effec-tive visual boundary. These enclosing ele-ments, together with its modest size, effectivelycomplement the rich planting to create anoasislike effect. At its widest, the garden is justunder 100 feet, while it is approximately 160feet long. The scale of this space evokes much

San Francisco General Hospital: The Comfort Garden ◆ 25

Map 6–2: Comfort Garden,ExperientialAnalysis

Photo 6–3: Garden benches are an ideal size forone individual to“claim” and to provide some pri-vacy for reading or eating.

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cottagegarden

intimatescale

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woodlandgarden

SEMIPRIVATE SEATINGSOCIAL SEATINGMAJOR TRAFFIC FLOWSECONDARY TRAFFIC FLOW

more of a garden feeling than, say, the experi-ence of a park (see Photo 6–5).

Garden UseA central path in the garden leads to one ofthe main entrances to this wing of the hospital(see Photo 6–1). Not surprisingly, walking toand from this and three lesser-used doorwayscomprises four-fifths of the use of this space(see Map 6–3). While only one-fifth of thetotal of 297 observed users comprised peoplestanding, sitting, or lying down, the signifi-cance of these users should not be underesti-mated: They stayed much longer than thewalkers-through, and they seemed to enjoy thegarden more — pointing out plants, smellingthe roses, lying on the lawn on warm days, eat-ing lunch, chatting with friends or colleagues(see Photo 6–3).

The typical stationary users were staff mem-bers who came out to stand or sit while smok-ing; staff members who came out alone or inpairs to enjoy eating a brown-bag lunch; visitorsor patients who sat for a while, sometimessmoking or drinking, or who lay dozing on thelawn (see Map 6– 4). It was not uncommon atlunch time to see staff members come out andlook around for a vacant bench and find them allfull. Two-fifths of those interviewed reported

staying in the garden for 30 minutes or morewhen they came out. There was no significantdifference between the use of the garden and thelength of time people stayed between staff andoutpatients or visitors.

Interviews with Users of the Comfort GardenIn all, a total of 50 people who were spendingtime in the garden were interviewed. Of these,31 were men and 19 were women; 24 werestaff and employees, 20 were outpatients, 5were visitors, and 1 was an inpatient. Whenasked how often they used the garden, close tohalf said “up to twice a week.” A substantialnumber use the garden at least once a day (seeFigure 1). Not only did a considerable numberuse the garden frequently, but also almost halfof the users reported that on some visits theystayed 30 minutes or longer.

We showed interviewees a list of possibleactivities in the garden and asked them tocheck as many as were relevant. Every personinterviewed said that he or she came to thegarden to relax. Three-quarters of the usersreported that they also came into the gardento eat. More than half said that they came hereto talk, stroll along the paths, partake of theirown “outdoor therapy,” or to wait.

Two-thirds came into the garden alone,and just under a third came with one otherperson. This confirms that the scale of seatingprovided appears to accommodate the needs of many users — short benches and graniteblocks that can be “claimed” by a person sit-ting alone or can comfortably accommodatetwo friends.


Map 6–3: Comfort Garden,Users PassingThrough

Photo 6–4: Visual boundary attop end of gardenis created by thehospital heatingplant, new hospitalbuilding, and oldbrick wing.

SCALE:

What Happens to People in theComfort GardenWhen asked, “Do you feel any different afteryou’ve spent time in the garden?,” half saidthat they felt calmer, more relaxed, lessstressed. These comments were made by bothstaff and outpatients (see Table 6–1). A signifi-cant number reported fee l ing “better ,stronger, more positive.” These respondentswere mostly outpatients.

TABLE 6–1

Percent of Respondents Reporting VariousTypes of Mood Changes

PercentCalmer, contented, sleepy, more relaxed, 68less stressedBetter, more positive, pleased 26Refreshed, stronger 16Helps me think through problems 10Moves me, a religious connection 6Escape from work 4No difference in mood 4

(Number of respondents: 50)

Clearly, for most people who spent time init, the garden facilitated a change in mood thatwas positive. They left after a medical appoint-ment, or returned to work in the hospital, feel-ing less stressed, refreshed, more content.

For example, a middle-aged male outpa-tient who comes to the hospital once or twicea week reported:

It’s a good escape from what they put methrough. I come out here between appoint-ments. I enjoy the air, the feel of the sun, theprivacy — everyone inside knows me; I don’tknow anyone out here. It gives me the strengthto deal with things. I feel much calmer, lessstressed.

A young female employee reported:

My level of stress goes way down. I’m a lot morerelaxed; I go back to work refreshed. ... It feelslike something is alive here in the middle of acity that seems dead.

A middle-aged male outpatient who comesto the garden every day to sit, relax, stroll,talk, eat, and meditate loves the solitude and


Map 6–4: Comfort Garden,Stationary Users

Photo 6–5: This long pathleads up into thegarden from thebus stop and asmall employeeparking lot. Notethe visual bound-ary created by thehouses on PotreroBoulevard and bydistant outline ofTwin Peaks.

FIGURE 1

Frequency of Use Reported by Interviewees

First timehere

Up to twicea week

Every dayand more

14%

40%

46%

SCALE:

the colors and leaves the garden feeling “morerelaxed ... it’s very peaceful, an oasis ... some-times I come here all wound up and then I feelrelaxed.”

A female visitor who comes once a week andwaits for a friend while he’s at an appointmentremarked:

It’s pretty, it’s relaxing ... visual beauty lifts myspirits. I feel that any plant life has a big effect onpeople. ... I’ve come out here and picked flowersfor a friend who was dying because I didn’t haveany money, and it made her feel better.

What Users Liked Best Aboutthe GardenBy relating how they would describe the gar-den to someone who had never been here, theinterviewees revealed what was significant tothem about its design and image. One middle-aged male patient who relaxes, eats, or drinksin the garden once or twice a week described itas “... absolutely beautiful ... it’s like a rainbowon a beautiful day, with a beautiful woman.How do you describe color to a blind man?”Many referred to it as “an oasis in a sterile set-ting,” or “a little bit of heaven,” “a paradise.”People seemed to appreciate especially its well-tended yet casual atmosphere; several referredto it as being “like an English country garden,”or “like a garden in someone’s home.”

These very positive responses to the gardenwere further confirmed when people wereasked: “What do you like best about this place?”

TABLE 6–2

Percent of Respondents Who Named TheseQualities as What They Liked Best

PercentAesthetic attractiveness and design 92Flowers, plants, trees 74Privacy, quiet, comfort 60Open air, sun, seasonal change, birds, 24butterfliesHuman companionship 10Memories of friends who have died 4


The flowery, lush, and oasislike qualitieswere again emphasized, but so too were the

feelings and activities this place supported. Twooutpatients remarked: “It’s a place where youcan come and think without a whole lot of peo-ple around”; “I feel more comfortable when I’maround other people who are ill or recovering— they’re in the same position as me.” A femaleemployee who works in a child abuse clinicbrings children out to the garden: “It relaxesthem, if they had a traumatic experience. Ipoint out the flowers, let them play.” A maleemployee who works in HIV research likes thecolorfulness, the variety, and “the fact thatthere are plants in memory of some of my co-workers who have died. A lot of the patients Isee have died. Sometimes it seems like a placethey’d come back to if they’re coming aroundto visit.” Several employees and outpatients hadtears in their eyes as they described the memor-ial or spiritual significance of the garden.

Changes and Modifications Desired in the GardenWhen asked if there were anything they wouldlike to see changed or added to the garden, themost frequent response was — “Nothing!” or“It’s changing all the time — flowers, the sea-sons, what the gardeners do.”

TABLE 6–3

Percent of Respondents Who Desired TheseChanges

PercentChange nothing; it is changing 36Practical changes: more seats, tables, 32ashtrays, trash cansMore flowers, trees, shade 22Make larger and more private; add kids’ 20play area, cut out noiseBan dogs and smokers; improve maintenance 14Aesthetic changes: add arbor, water feature, 12wrought iron, more paths, label plantsProtect/enhance the personal meaning 4


There was a desire for more places to sit andfor picnic tables; also for things to improvemaintenance such as additional trash cans, ban-ning dogs and smokers. The latter — if en-forced — would certainly decrease use sincemany users were observed smoking while stand-


ing or sitting in the garden or strolling through.Recent bans on smoking in public buildings inCalifornia have meant that public outdoor spaceis increasingly used for this activity.

While some desired improvements werevoiced in response to this question, the overalltone of those we spoke with was of strongly feltappreciation and love for this place, and for thecare of the gardeners who created and maintain it.

Two comments regarding changes are par-ticularly pertinent to the kinds of outpatientsvisiting clinics in the adjacent buildings. A pa-tient with AIDS, beginning to lose weight, re-marked on the need for padded seating. Patientson methadone maintenance used the garden to“space out” and wanted nothing changed.“Where else would I go?” one asked. It wasclear that some users were on the fringe of so-ciety, if not actually homeless; for them, espe-cially, the garden was a nurturing setting wherethey felt comfortable and at home.

Weekend and Weekday UseThere is a very marked difference in the use ofthis garden between weekdays and weekends.On weekdays, the clinics are open and staff areon duty. There is barely a moment between 10AM and 5 PM when people (often many at atime) are not streaming in and out of the adja-cent buildings. During the middle hours of theday, as noted, many use it for eating lunch, tak-ing a break, lying in the sun, etc.

On weekends, however, clinics are closed.Almost no one enters or leaves the buildings.The few who walk through tend to follow thelong path running from one end to the other,

and to use the space as a neighborhood park. Acouple with a small boy walk slowly through,stopping frequently to look at the flowers; theboy balances on a log-wall, holding his father’shand. A little girl on a bike rides down the pathcalling out to her father, who walks behind car-rying a baseball bat and mitt and leading a dog.A young man walks two small dogs. Threeyouths on mountain bikes bump along the“rustic” path made of logs and chips. It appearsas though all these are local residents, enjoyingthe garden as a neighborhood outdoor space.

ConclusionThe Comfort Garden at San Francisco Gener-al Hospital is a remarkable, well-loved oasisthat brings joy, contentment, and peace to visi-tors and outpatients visiting clinics in adjacentbuildings, and to medical and administrativestaff who work nearby. Its informal design,lush plant growth, and loving maintenance bythe gardeners who created this oasislike settingare clearly highly appreciated by all kinds ofusers, by those who pass through as well asthose who spend more time there. Of the fewchanges requested, some — more seats, tables,and so on — could conceivably be effected,while others — less noise, larger size, etc. —are of a more structural nature. While those wetalked with had varying abilities to articulatewhat effect the garden seems to have upontheir feelings, there seems no doubt that all buta few were affected very positively. In variousways, and in differing degrees, this does indeedappear to be a “healing garden.”


THIS IS A complex of three- to six-story buildings set in a neighbor-h o o d o f s i n g l e - f a m i l y h o m e s ,

apartments, and medical office buildings inSouth Berkeley. It is named for Alta AliceMiner Bates, who first settled in Berkeley in1904, and nursed patients in her parents’home as there was no hospital in the commu-nity. In 1905, at the request of local physi-cians , and with plans drawn up by hercontractor-father, she built an eight-bed nurs-ing facility and school for nurses on DwightWay, called Alta Bates Sanitarium. In 1908,due to population growth in Berkeley afterthe 1906 earthquake, the facility moved tolarge three-story buildings at its present siteon Webster Street.

In 1928, its name was changed to AltaBates Hospital and six-story buildings wereadded. Care was taken through setbacks andlandscaping to ensure that the buildingsblended into the residential neighborhood.This concern extended into the 1980s, whenthe old buildings were replaced by modern fa-cilities and set back from Ashby Avenue be-hind lawns and trees. The roof garden —dedicated to the Alta Bates Volunteer Auxil-iary — was opened on the third floor of a newbuilding in 1983. It is accessed from elevators9 and 10, which are approached via a longcorridor leading south from the main lobby.There is no indication or sign in the mainlobby directing people to it, and inquiries atthe information desk suggest that the volun-teers who work there do not know of its exis-

tence or assume it is not for public use. Uponfinding one’s way to remote elevators 9 and10, only an enigmatic “R” button in the eleva-tor indicates its presence.

Physical Elements and SiteLayoutThe roof garden is located on the south side ofthe hospital complex, three floors above theground. On the north side, it is bounded by afour-story wing containing patient rooms andoffices in the maternity department. On theother three sides, the garden looks out ontoexpansive views: to the east, the wooded andpartly residential Berkeley Hills; to the south,Berkeley residential neighborhoods of single-

◆ 31

7. CASE STUDY: ALTA BATESMEDICAL CENTER, BERKELEY, CALIFORNIA:The Roof Garden

Map 7–1:The Roof Garden,Illustrative Plan

family houses; to the west, a panoramic viewof San Francisco Bay, the city of San Francis-co, the Golden Gate Bridge, and the hills ofMarin County.

The garden consists of several distinct sub-areas. Upon emerging from the elevator, onewalks out onto a square, brick-paved plazabounded by flowered planters with seat-heightconcrete edges, and eight small carob trees inconcrete boxes. In the middle of the plaza is asquare flower bed with a small fountain at itscenter (see Photo 7–1). On a wall bounding theeastern edge of this plaza, two ornate columnsand a crest that formed the entrance to thehospital in 1928 were saved and placed hereafter the building was demolished in 1983. Thefeeling of this sub-area is of an urban plaza,with users sitting around the edge, exposed toeach other.

The second major section of the roof gar-den is four steps below the plaza and has moreof a garden feel to it (see Photo 7–3). A smallbrick- and concrete-paved plaza accessed froma door in the maternity wing is bounded byseat-height concrete planters and a large raisedlawn. Three maple trees offer some shade onhot days, and a lush expanse of red and purpleclimbing bougainvillaea has grown to the thirdfloor of the adjacent building (see Photo 7–5).

A third, small and hidden section of the gar-den consists of a walkway behind the planterson the west and south sides of the roof. Mov-able garden chairs have been carried here for avery private sitting, viewing, and conversationsetting (see Photo 7–4).

A fourth sub-area is under a building over-hang by the elevators where a drink and asnack machine are located. As discussed in a

later section, this small “anteroom” to the gar-den proper is well used because it is near theelevators and near snack machines; on hot daysit is sheltered from the sun’s glare; on frequentwindy days it is screened from the breeze.

Ambience and MicroclimateThe background hum of a large air-condition-ing/heating unit is ever-present as one entersthe garden, though it is not unduly intrusiveeverywhere, depending on where one sits. Oneis aware of bird-song, and in the large plazaarea, of the sounds of the fountain. On a breezyday, the rustle of trees and vines is a soothingbackdrop for garden-users. The garden is highenough off the ground so that traffic cannot beheard. Apart from the sounds of an occasionalplane or helicopter, the roof garden is veryquiet and peaceful. When seated in most partsof the garden, the views over the city arescreened by planting, and one has the sense ofbeing in a secluded city garden.

A design factor that may inhibit use is thelack of elements to ameliorate the wind orbright sun. For perhaps half of the year, it iswarm enough to sit outside, and, depending onthe time of day, many would prefer to sit in theshade. The choice of planting in the main plaza— short, squat carob trees — was a poor one;they create very little shade. The roof tends tobe more windy than the adjacent streets. A


Photo 7–1: This “plaza” areaincorporates a cen-tral flower bedwith a tiered foun-tain. The sound ofthe water and theattraction of birdsto the fountain areparticularly appre-ciated in this roofgarden.

Map 7–2: The Roof Garden,ExperientialAnalysis

screened area offering shelter from the prevail-ing winds would have been a welcome addition.

Garden UseCompared to two other sites discussed in casestudies in this report (Kaiser Walnut Creekand the Comfort Garden at San FranciscoGeneral Hospital), the roof garden at AltaBates is relatively under-used. In eight hours ofobservation at the Kaiser site, there were 251user-observations recorded; at San FranciscoGeneral, the number was 596. The number atAlta Bates was 154. This relative lack of usecan be explained by a number of factors: A roofgarden is a “terminus” location — most usersgo there to be there, they don’t pass through iton the way to somewhere else; a roof gardentends to be more exposed to the elements thana garden at grade; the garden at Alta Bates isnot publicized and is out of the way.

TABLE 7–1

Percentage of User-Observations Recorded forEach Activity

PercentTalk with colleagues or friends 34Eat and/or drink 24Smoke 21Read, write 8Look at the view 6Sleep, doze, sunbathe 5Work 2

(Total number of user-observations: 154)

The most frequent pattern of use was for aperson to walk from the elevator and find aplace to sit while smoking a cigarette, or toenjoy a soft drink purchased from a machinenear the elevator, or to eat a brown-bag lunch.Since the cafeteria is three floors down and al-most a block away, it was very rare to see peo-ple arrive with their meal on a tray. Thosearriving for a short break tended to clusteraround the vending machines beneath a build-ing overhang; it was here that most socializingtook place. Those coming to the garden for alonger period tended to sit alone on the con-crete seating bounding the main, brick-pavedplaza or to walk very purposefully to what ap-

pears to be a favorite seat or bench in more re-mote and hidden corners of the garden. Thelatter clearly came to be alone and often dozed,sunbathed, looked at the view, or meditated.Sixty percent came to the garden alone; 21 per-cent came in pairs, usually to eat lunch togeth-er. The 18 percent observed in groups werethose who met each other while taking a breakor stopped to chat for a while.

One of the disadvantages of the garden de-sign for people in groups of two or more, or forthose who want to choose where they sit, is thelack of movable seating. There were only fivemovable white plastic garden chairs (and threemovable round tables), whereas there was morethan 300 linear feet of concrete planter-edgeseating. Not only were the chairs with backsmore comfortable, but also they could bemoved into the shade or sun, depending on theweather; they could be moved to sit and look atthe view, or to join a friend at a table (see Photo7–2). Considering the very secure location ofthe roof garden and the unlikelihood of any-thing being stolen, it is surprising that moremovable seating has not been provided.

Those who were observed walking throughthe garden (one-fourth of the total) tended tomove on one route — from the maternity wingexit to the vending machines, or from the eleva-tor to the maternity wing — and not to spendany time in the garden.

Case Study: Alta Bates Medical Center, Berkeley, California: The Roof Garden ◆ 33

Map 7–3: The Roof Garden,Stationary Users

Interviews with Users of theRoof GardenThirty-six people who were spending time inthe garden were interviewed, half men and halfwomen. Of these, 29 were staff, 3 were visitors,2 were outpatients and 2 inpatients. It was dis-appointing to see so few in- and outpatientsusing this attractive facility. This is due in partto lack of information about its existence and inpart to security measures following the kidnap-ping of a newborn baby several years ago. Themain door onto the garden is now inaccessibleto all but maternity patients and their visitors.

The garden was used predominantly by staff.A third of those we interviewed reported usingthe garden several times each day, and one-fourth came once a day. The primary use of thegarden was either for a quick break with coffee,soft drink, or cigarette (almost one-half usedthe garden at some time for this less-than-10-minute break); or for a lunchtime or longer visitof 10–30 minutes.

When asked what they did in the garden,the most frequently cited activities were relax-ing, talking, eating, strolling, and “outdoor

therapy.” Most came alone and stayed aloneduring their break; some joined colleagueswhom they encountered in the garden. Thereis no lack of places to sit, though there is a lackof movable chairs, which people liked to taketo a preferred location — into the shade, intothe sun, to a more secluded setting.

What Happens to People onthe Roof GardenWhen asked, “Do you feel any different afteryou’ve spent time in the garden?” all but one ofthe 36 interviewed reported a positive change inmood (see Table 7–2).

TABLE 7–2

Percent of Respondents Reporting VariousTypes of Mood Change

PercentCalmer, more contented, more relaxed, 80less stressedRefreshed, stronger 33Better, more positive 22Escape from work 22Moves me, a religious connection 8Helps me think through problem 5Time passes more quickly 3No difference in mood 3


Many respondents referred to the pleasingcontrast between the garden — open, sunny,colorful, “natural” — and the environment in-side the hospital. For example, a man whosewife had just given birth had come to the gar-den three times that day: “I feel more relaxed.It’s mostly because there aren’t too many peo-ple out here. I’m a solitude kind of person. Thesunlight is nice. The waiting room with fluores-cent light sucks the energy out of you.” Manyfelt the garden helped them calm down or relaxfrom stressful situations at work. A female em-ployee who uses the garden every day respond-ed: “It’s a place for meditation and relaxation.It’s real tranquil. Because I work in the radia-tion department in the basement, I feel like oneof the Mole People; I come out for sun. It’s abig mental, emotional lift.”

For many people, the garden provides a wel-


Photo 7–2: Movable chairsallow this staffperson to create aprivate setting fora lunch break.

come relief from the stress of constant interac-tion with people. A female employee who visitsthe garden two or three times a week re-marked: “I’m at peace — you can see the birdsand the water. I feel a sense of meditation; Ifeel better. Breathing the fresh air helps clearmy head even if I need to scream or run inplace. It’s getting away from people, fromwork. The air itself helps me revive.”

Many employees thought of the garden as“an escape.” A male employee who uses thegarden every day said: “It’s an excellent areafor relaxation even if it’s only for a short time.Five minutes out here is better than an hour inthe cafeteria. Its calming influence creates asense of separation from the hospital that arecreation room wouldn’t provide. It’s a com-plete getaway.”

Though relatively few patients used the gar-den, responses from two who did are indicativeof what such a space can mean to someone whois sick or in recovery. A female inpatient re-sponded: “I feel more normal here. I felt reallydepressed in there; I was getting real teary.You go from having control of your life to lesscontrol. Out here you’re on your own; there’stime to forget about it. You feel relieved fromall the medical aspects of your case. You comeout here and it’s more holistic, more natural.”

A female outpatient was waiting for an ap-pointment and recalled practicing walking onthe lawn as an inpatient recovering from an ac-

cident: “When you’re in the hospital it’s easyto get caught up in that whole sick vibe. Whenyou come out here it’s life, a surrender — thatyou’re still breathing, you’re still alive.”

For all but one of the 36 people inter-viewed, the garden helped evoke a positivechange in mood. Staff members returned towork feeling more relaxed; in- and outpatientsfelt calmer outside the normal hospital envi-ronment.

What Specific Characteristicsof the Garden Helped BringAbout a Mood ChangeMost people were quite forthright about what— in particular — in the garden helped themfeel better. Overall, aspects of planting (flow-ers, “greenery,” colors, seasonal changes) wereby far the most often cited (see Table 7–3). In-deed, it is the flowers, lawn, trees, shrubs thatmake this a garden and not just a rooftopspace. The fountain, though small, is centrallyplaced and audible from seating places in themain plaza section. Importantly, it also offerswater to birds, which frequently come to drinkand bathe. Some have made nests and raisedtheir young in the roof garden.

TABLE 7–3

Percent of Respondents Who Name TheseQualities as Helpful in Attaining a MoodChange

PercentFlowers, colors 67Openness, views 36Greenery, seasonal change, “nature” 33Water, fountain 31Peacefulness, no traffic noise 31Escape, privacy, secret places 28Sun, light, fresh air 28Birds 25Design features (textures, shapes) 19Sounds, smells 14Management policy (smoking okay) 8Places to sit, companionship 5Don’t know 3No answer 3

(Number of respondents: 36)Features that are specifically characteristic


Map 7–4: The Roof Garden,Users PassingThrough

of a roof garden were also important — views,openness, fresh air, breezes, and being awayfrom traffic noise.

A female employee who uses the roof gardenseveral times a day responded enthusiastically:

It’s a whole different environment. The birds,the flowers, the sunshine, the fresh air, beingaway from the work environment. It helps buildrelationships. Everyone who comes up, we’vegotten to know each other. It’s a place to meetpeople. I feel very fortunate to have this. Some-times, in the evening, the sun is setting. It’s awonderful experience. I have a lot of pride inthis garden. I tell patients about it, and new em-ployees when I’m orienting them.

An outpatient who was in the garden forthe second time in one day also appreciatedthe birds, the fresh air, the greenery, the windblowing, but especially the colorful flowers: “Ido energy work with colors and chakras. Dif-ferent colors arouse different emotions. Youhave all the colors of the chakras out here. Itsoothes you down. ... I can come out here andbe still.” A woman employee said that some ofthe flowers took her back to her childhood andtheir colors made her think about dress mater-ial for her granddaughters.

A female employee who comes to the gar-den to relax, stroll, eat, and “center myself”was especially articulate about which charac-teristics helped change her mood.

The most important thing for me is the fountainbecause I love the sound of water and it attractsbirds. Then, there’s the greenery and flowers.And a third component — the design is pleasingto the eye: There’s a combination of shapes andsizes; the brick gives a warm feel. ... I like thenooks and crannies so you can have a place to be

alone. As an employee in healthcare, you’re con-stantly giving, interacting. It’s important to havea place to recharge.

TABLE 7–4

Percent of Respondents Who Named TheseImpediments to Using the Garden

PercentWork schedule 44Weather 33No impediments 28Distance, difficult access 8Didn’t know it was here 5


It was primarily work schedules and theweather that inhibited people from coming tothe garden as much as they would like. Wesuspect, however, that many nonusers do notcome to the garden because they don’t knowof its existence.

TABLE 7–5:


PercentPractical changes 52

More movable chairs 25More tables 8Food cart 5Drinking fountain 5Shelter 5Outdoor pager 3

Change nothing 50Planting changes 11Aesthetic improvements 8Better maintenance and access 8


When asked if there was anything theywould like to see changed on the roof garden,one-half said, “Nothing!” But a similar propor-tion voiced a variety of pragmatic changes thatwould make the space more usable. Principalamong those was the desire for more movabletables and chairs, particularly the latter. Thiswas very apparent as we observed peoplesearching for a chair so they could join others


Photo 7–3: The “garden”area provides anexpanse of lawn for more casualuse, and children’splay.

at a table or sit with their feet up on one of theplanting edges. With only five movable chairs,they were in great demand. Observations madeby William Whyte in his film on the use ofManhattan plazas (The Social Use of SmallUrban Spaces) suggest that people just like to beable to move a chair in a public space, even ifonly a foot or two, perhaps to have a sense ofcontrol over their environment. Apart fromthese movable chairs, all the seating on theroof garden comprised concrete edges toplanters without backs.

The fact that people often clustered around

the vending machines under a concrete build-ing overhang was in part due to lack of shadein the garden and — on windy days — lack ofshelter. Several people requested shelter andmore shade trees. A drinking fountain, a foodcart, and an outdoor pager (for medical staff oncall) were other practical suggestions. For themost part, however, users were well pleasedwith the garden. Aesthetic improvements werevoiced by relatively few, but were worded quitevehemently.

A man visiting his wife in the hospital want-ed “a pond with koi or goldfish where you canwatch something methodical, take your mindoff things.” A young male outpatient visitingthe garden for the first time had a lot to say:

I would have made the area around the fountainround — there are a lot of rough edges. It wouldbe nice to have an herbal section since we’re inBerkeley, maybe a fragrance section. It would alsobe nice to have some unusual trees. It looks like someone went to the nursery and said, ‘I’llhave six of those.’ It needs a canopied section forshade ... and some healing sculptures — man-dalas, Buddha, Gaia — something relevant tohealing.

ConclusionThere is no doubt that for those who use it, theroof garden at Alta Bates facilitates relaxationand reduces stress. It was particularly beneficialto hospital employees, who reported returningto their work refreshed and more centered. Amale employee who uses the garden every dayas a “getaway for stress relief” reported: “Youcan come out here and meditate whether it’swork related or stuff I’m dealing with at home.I can come out here and think about things andthen go back in and be more productive.” A fe-male employee who occasionally visits the gar-den to eat lunch or talk with colleagues feltstrongly that “all workplaces should have some-thing like this — a place to go outside where it’squiet and pleasing to the eye, and sheltered. Ithink gardens are beneficial. I don’t think fluo-rescent light and artificial air are healthy. If yougo out and get away from that environment,you’re more productive.”

The fact that many of our respondents usedthe words “more productive,” or implied suchan outcome, is an indication that such outdoorspaces are not merely “cosmetic extras” butshould be intrinsic components of every work-ing environment. The health of the staff is asimportant as that of the patients. One maledoctor who worked part time at another hospi-tal remarked that at the other facility, therewere plants but no places to sit. “Here I sit andsmoke one cigarette and I don’t need anotherto relax me.” While smoking is not beneficial tohealth, if the garden enables an employee torelax with one cigarette rather than two, that iscertainly a benefit.


Photo 7–4: A private spot witha view is oftensought out by staff.

Photo 7–5: Magenta andorange bougain-villaea climbingthe wall providesa very colorfulbackdrop for thegarden, and is anattractive featurefor the patientsconfined to theirbeds in the adja-cent rooms.

While staff were certain of its benefits tothemselves, they also felt strongly about thevalue of a garden for patients. A female employ-ee who thought of the garden as a “naturalhaven in an unnatural setting” remarked at theend of her interview: “I’ve worked in long-term-care settings for the past eight years. Of

all the places that need cost-effective gardens,those are crying out for something like this —for patients and staff. With the aging of Ameri-ca and increased use of convalescent facilities, itis important for those places to have gardens.”

A male employee used to bring patients outfor certain therapies, but now time doesn’tallow it. He felt the garden was an importantsetting for people who are dying: “We’vebrought patients out here to die because thefamily asked for it. They were able to die inpeace without the critical-care setting. Whenthe family decides to ‘let go,’ we’ll jumpthrough hoops to let a patient come out here todie.”

A female employee who uses the gardenevery day to relax, eat, meditate, and exercisesummed it up by saying, “It’s like time hasstopped, like a vacuum, a quiet space. I’m reallyglad it’s here, it gives me an ‘out.’ I close myeyes and listen to the water as if I’m hearing astream or a brook. ... I can get away from thedownstairs hustle and bustle. It’s the best thingabout Alta Bates.”

Or, as a male employee who was too busy tobe interviewed remarked as he made his way tothe elevator, “I’ll tell you this ... if it weren’t forthe garden, we’d all be on Prozac.”


Photo 7–6: The absence ofshade and windprotection is ap-parent in thisoverview of theroof garden.

Physical Elements and SiteLayout

The central garden at Kaiser, WalnutCreek, is the largest of the landscapesin this study. Designed around two

heritage valley oaks, the garden is spaciousenough to accommodate in addition severalmature sycamores, pines, box elders, sweetgums, and olive trees. Under the tree canopiesare undulating borders of shrubbery and largeexpanses of lawn punctuated with movablepicnic tables as well as fixed benches.

The garden is crisscrossed with paths,being anchored at one corner by the main hos-pital entrance while the multistory parkingstructure is situated diagonally opposite. Thehospital extends its single-story arms out toencompass the east and south sides of thespace with sliding glass doors and windowsthat lead directly into patient rooms. Thesewings house post-op patients and some pedi-atric and orthopedic patients. The length ofstay is sometimes as long as three weeks; how-ever, the average stay was reported to be threedays. One of the wings is being shut down forrenovations and was at 50 percent occupancyat the time of the study. These patients’ roomsare buffered from the larger lawn areas by awide, covered arcade, low shrubs, and semipri-vate seating areas.

The other two sides of the garden are filledin with a four-story outpatient medical buildingto the north, and the two-story cafeteria build-ing and single-story outpatient EKG center tothe west. Due to the layout of the perimeter

buildings, people traverse the space almost con-tinually, even in the rain and the near 100-de-gree temperatures common here, nearCalifornia’s Central Valley.

Atmosphere and AmbiencePredictably idyllic weather through most of theyear, though tending toward hotter tempera-tures, makes this open and airy garden space aninviting place. The evergreen plantings at eyelevel and below serve to provide a psychologicalscreen from the low buildings. The trees combthe open sky, blowing in the breeze and provid-ing homes for the birds that are always chirping.Squirrels scamper across the grass and chatter atpassers-by from overhead limbs. The spreading

◆ 39

8. CASE STUDY: KAISER PERMANENTE MEDICAL CENTER, WALNUT CREEK, CALIFORNIA:Central Garden

Map 8–1:The Central Garden,Illustrative Plan

oaks lend their grand dignity to the space, pro-viding a beautiful focal point from afar and thecomfort of protected seating beneath. Visitorswere observed bringing their dogs to visit withinpatients on the lawn, and the feeling is trulyone of an enjoyable suburban park.

Many seating options are provided, withbenches located along the walkways, some inthe sun and others in dappled shade. Thereare permanent stone tables and stool-like seatsin clusters, and wooden picnic tables thatchange orientation with the lawn-mowingschedule. There is a well-used covered patiowith tables and chairs directly outside of thecafeteria’s plate glass windows. There are twomaps for newcomers, and a pay phone. Ash-trays and trash cans abound, and the groundshave a clean and tidy appearance.

Garden UseMovement through the garden was constantand of such an intense rate (see Map 8–3) thatthe speed of the observer in tracking andrecording this activity became a limiting factorduring the first phase of the study. The passers-by are underrepresented perhaps by 15 percent.However, of the 1251 people recorded duringthe two mornings and two afternoons of obser-

vation, 745 either stopped to talk, or sat eating,waiting, smoking a cigarette, or purposefullypassing the time by strolling the grounds orplaying.

The high number and diversity of the ser-vices surrounding the garden made it difficultto differentiate among visitors, outpatients,and nonmedical staff. However, we recordedthat 29 percent of the users were medical staff,uniformed employees, or construction work-ers. Less than 2 percent were inpatients andthe remaining 69 percent appeared to be visi-tors, outpatients, or nonmedical employees.

The proximity of the cafeteria contributedto the high number of people recorded eatingor drinking (33 percent of the stationaryusers), in the same way that the overall hospi-tal site planning dictated the large number ofpeople moving through it.

Interviews with Users of theGardenA total of 50 people were interviewed in thegarden; two-thirds of them were women. Ofthose interviewed, 27 were staff, 11 were visi-tors, 8 were outpatients, and 4 were inpatients.Almost half reported using the garden everyday or several times a day; a third used it “occa-sionally.” With the presence of picnic tables,ample seating (see Map 8–2), and an adjacentcafeteria, it is not surprising to find that one-fifth reported spending periods of more than


Photo 8–1:The presence ofthese magnificent150-year-old valley oaks dictatedthe location of thiswell-used garden.They provide adramatic focalpoint and have become a favoriterendezvous spot.

Map 8–2: The Central Garden,ExperientialAnalysis

30 minutes in the garden, and nearly three-fourths took breaks of 10 to 30 minutes. Thiscontrasts with Alta Bates’ roof garden, in whichrelatively few used the garden for 5- to 10-minute breaks.

TABLE 8–1

Percent of Respondents Using Gardens for Various Activities

PercentRelaxing 88Walking through 84Eating 82Talking 70Strolling 54Waiting 52Outdoor therapy 46Visiting with a patient 42Kids playing 18Attending a meeting 16


While “relaxing” appeared high on the listhere and at all the case study gardens, at thisKaiser facility a higher proportion than else-where reported using the garden for eating,visiting with a patient, watching their kidsplay, and attending an outdoor meeting. Al-most half reported there were no impedimentsto their using the garden, and most of the re-mainder — as at other sites — reported weath-er and work as the only serious impediments.

The garden was highly regarded and appre-

ciated by everyone we spoke with, especiallyby staff, who were thankful for the contrastbetween the indoor and outdoor environ-ments. A female employee who comes outonce or twice a day to relax, talk, eat, stroll orvisit with a patient responded, “You can getaway from the fluorescent lights, sounds, andsmells of a hospital; listen to the birds, thebreeze. It’s a tremendous place to unwind.”

TABLE 8–2

Percent of Respondents Who Named TheseQualities as What They Liked Best

PercentTrees, plants, flowers 82Aesthetic attractiveness and design 72Serenity, quiet, “escape” 54Birds, squirrels, open air, sun 50Expansiveness, open space 8Human companionship 4


Another employee uses the garden severaltimes a day and loves the trees, plants, and ani-mals: “I feed the squirrels and birds. I havetwo blue jays who come down to eat peanuts— and there’s George the squirrel (I speak flu-ent squirrel!). I can recognize the baby squir-rels even though they’re now grown. I’ve evencome here on my day off!”

Several people felt it looked like a park or“a country club.” Employees especially appre-ciated its tranquillity:

I like the openness, the grass, birds, the breeze.Although there’s a lot of people around, there’sa quietness about it. It reminds me of a campus.

Case Study: Kaiser Permanente Medical Center, Walnut Creek, California: Central Garden ◆ 41

Map 8–3:The Central Garden,Users PassingThrough

Photo 8–2:This walking routefrom the parkingstructure to themain hospital lobbyis highly used. Themultistory buildingis dwarfed by thetree and recedes,while the lawnscreate a soothinggreen milieu.

I like it when I do swing shift; at dusk you couldimagine this is your backyard. I like the tranquil-lity. It has a certain peace about it.

Visitors and outpatients appreciated havinga relaxing place in which to wait, and a femaleinpatient remarked:

I really hate hospitals a lot. I get tired of myroom. It’s so much nicer out here — I like see-ing the grass and hearing the birds. I come outseveral times a day to sit or stroll or have asmoke. My favorite time is the evening wheneverything is really quiet. ... It’s much betterthan sitting inside and watching the boob tube.

TABLE 8–3

Percent of Respondents Reporting VariousTypes of Mood Changes

PercentCalmer, more relaxed 86Stronger, refreshed 24Escape from work 18Moves me, a religious connection 6Better, positive 6No difference in mood 6Helps me think through problems 4


When we asked if people felt any differentafter spending time in the garden, the mostfrequent and consistent response was: “Yes —more relaxed.” A garden and a hospital are al-most polar opposites on a continuum fromcontrolled to natural, from stressful to relax-ing. It is small wonder that staff and employ-ees felt so passionately about this garden in themidst of their work environment:

I work in the operating room. We have no win-dows; it’s very cold with artificial light. This isthe complete opposite — it gives me a lift tocome out in the natural light.

I feel more calm, more relaxed. If you want toget away from things, just sit under a tree andreflect — things usually get better.

It’s very soothing because it’s so different fromthe interior of the building, which is stressful.This is a complete opposite.

I’m back to being me again. This is absolutelymy little spot to get centered and heal myself.

I work in ICU, which is like a hellhole. For thefirst four hours I just run. Sitting out in thewarm sun is like therapy to me. I can relax, gath-er my thoughts. I feel like I have my headscrewed on straight.

Visitors and patients who used the gardenfelt strongly about how this place facilitated achange in mood. An outpatient who told us shebrought visitors from Europe to show themwhat a nice hospital looks like remarked:

It doesn’t feel, smell, or look like a hospital.Coming to a hospital scares and worries people.Being in the garden before or after visiting thedoctor is good, regardless of what you find out. Ifeel more relaxed.

A woman waiting in the garden while herhusband was at an appointment responded, “Ifeel more peaceful out here. I get very tiredwaiting for them to tell me how he’s doing.I’m not as tired outdoors.”

A woman in labor was strolling through thegarden, waiting for the birth of her child.“This is my first time here. I’ve been admiringthe trees, the landscape, the quietness, thebirds. It’s really relaxing — when I’m not hav-ing a contraction.”

A male inpatient was occupying one of therooms that open out onto the garden:

I really hate hospitals, but having this room — itdoesn’t bother me so much. I feel a little easier,a little more relaxed outdoors. When peoplecome to see me, we can sit out here and it makesa much nicer visit. It’s really relaxing to knowthat other people enjoy it, too.

People had no trouble “connecting” theirchange in mood with specific characteristics ofthe garden, even if — as some said — they


Photo 8–3:Wide walkwaysoutside patientrooms provide abuffer from gardenactivities, and en-able patients inbeds or wheelchairsto be brought out-side. Seating con-venient to therooms is often uti-lized by visitingfamilies.

hadn’t consciously thought about this before.For many, it was a whole range of elements.For a male employee who used the garden atleast once a day it was “the shade from thetrees, the breeze, the birds, the colors, thesounds of the leaves, the squirrels running upand down the trees, no litter in sight.”

TABLE 8–4

Percentage of Respondents Who Named TheseQualities as Helpful in Attaining MoodChange

PercentTrees and Plants 86

Trees 36Greenery 18Nature 14Colors 10Flowers 6Seasons 2

Features involving auditory, 60olfactory, or tactile sensations

Birds, squirrels 24Fresh air 12Shade 10Light and sun 8Sounds, smells 6

Psychological/social aspects 64Peaceful 18Openness, largeness 14Escape 10Oasis 8Privacy 6Watching others, companions 6No traffic noise 2

Visual qualities relating to more 26than plant materials

Visually attractive design 14Variety 10Texture 2

Practical features 26Places to sit 12Good maintenance 6Accessible 4Pathways and amenities 4

Don’t know; no answer 10


A female inpatient interviewed near herroom particularly liked “listening to the birds;it’s quiet here. I like to see other people sittingand relaxing on the benches. I can’t get outthere, but it’s neat; it’s really relaxing.”

A visitor to the hospital who occasionallyuses the garden liked “the landscaping, thebirds. You can get a cup of coffee, sit back, andlook at the trees. Every time I come, it’s a dif-ferent season. It takes your mind off whateveryou’re here for.”

The huge oak trees elicited a lot of positivecomment, particularly their size, their greatage, the wildlife they harbored, and, for some,the memories they evoked. A male securityguard who patrols the garden liked the tran-quillity and peace “... and the large trees, whenthe wind blows through the branches. It’s asound I got used to as a kid growing up in theArizona countryside.”

For others it was the oasislike quality of thespace that helped evoke a change in mood. Amale employee who comes out to sit and eatseveral times a day feels calmer as a result andattributes that to “the trees, the grass, birds,animals — its like an oasis among the con-crete, yet it’s close to whatever you need. Youhave to stay conscious because you can getinto a mood and forget about the time.”

A male outpatient also liked the enclosedfeeling: “I liked the fact that it’s surrounded bybuildings ... it’s kind of nestled, protected. Butit’s not too close to the buildings; you don’tfeel you’re in an urban park.”


Map 8–4:The Central Garden,Stationary Users

Though this space is not large by park stan-dards, we got the sense that people experiencedit as spacious because of the planting thatscreened some of the surrounding buildings;because — by hospital standards — it is a largeopen space; and because for some, it is such acontrast to the small spaces in which they liveand work.

A female employee confided:

When I work evenings, I come here two hoursearly and just sit here! In my life, this is a vastspace. I live in a little condo, work in a little of-fice in surgery. This is like a vast open space tome! The patients come out here all the time —pregnant women waddle around. They say,“This is such a great space, so soothing. Who’dbelieve this was here?”

Finally, for a few people, it is not so muchthe trees, the fresh air, animals, and opennessthat help change their mood, but the compan-ionship and good spirits of other people in thegarden, particularly, it seems, the gardeners.One employee who admitted, “I’d be out hereall day long if I could,” added, “The gardenerskeep us laughing all the time. They do such agood job, keeping the garden. It’s a joy to havethem out there.” In creating a garden for ther-apeutic outcomes it would pay not only to de-sign it with care, but also to select maintenancestaff for their sensitivity and good humor.

Just under half wanted no changes made tothe garden. Others wanted to see planting im-provements — especially more flowers, the addi-tion of a water feature, a drinking fountain, moretables and seating. Compared with the othersites we observed, Kaiser has provided well forsmokers. A small three-sided, roofed structurewith comfortable chairs inside was erected in

spring 1995 for the convenience of smokers whoneed to come outside. While this looks onto thegarden, the smokers don’t annoy nonsmokers bysitting next to them on a garden bench.

TABLE 8–5


PercentChange nothing 46Planting changes 22

More flowers, color 16More trees, shade 6

Aesthetic and planning improvements 16Add a water feature 8Make it larger 4Create a Japanese garden 2Move freeway 2

Practical changes 14Drinking fountain 4More tables 2More seating 2A shelter for rainy weather 2More designated smoking 2Add sports facilities 2

Policy changes 12Better maintenance 6Ban smoking 2Stop removing trees 2Less construction 2


ConclusionHospitals are obviously associated in mostpeople’s minds with illness, accidents, anddeath. It is clear from observing — and talkingwith — people in the garden at Kaiser WalnutCreek that the presence of life just outside isenormously therapeutic. The trees, the birds,the squirrels, children playing — all remindpeople that “life goes on.” An outpatient wait-ing for her appointment felt “rested spiritual-ly” in the garden: “It’s a privilege to be here.Look at this incredible oak tree — it’s a uni-verse in itself.” Several patients and employeesmentioned the fact that the garden made thisKaiser facility unique and that they used (orhad taken a job at) Walnut Creek specifically


Photo 8–4:Casual seatingalong the walkwayprovides a conve-nient resting spot.Wood decking anda circular benchprotect the roots ofone heritage oakwhile providingseating with anarray of vistas andinformal playspace for children.

because of its soothing milieu. One of the gar-deners told us, “They call this Kaiser ‘thecountry club.’ ”

One employee who had worked in manymedical facilities since 1959 rated this — be-cause of the garden — as one of the best. Anda male employee who uses the garden everyday, sometimes to do work-related reading,summed it up with:

I work in the operating room — no windows.The diurnal cycle is interrupted. Out here, it’sopen to the sky. It fits with the holistic idea ofwhat I think healthcare is. It’s not only medicineand physical treatment; you also have that partthat’s unique to the individual called the soul.This garden helps to revive that.


Photo 8–5:A covered patio off the cafeteriaprovides shade andshelter for an out-door eating areawithin the garden.

RESPONDING TO THE need to rehousethe many patients displaced by the1906 earthquake, the Home for the In-

curables was opened on this site in 1915. In1938 the facility changed hands, was renamedthe Garden Nursing Home, and began provid-ing an array of rehabilitative services rangingfrom cardiac and respiratory therapy throughphysical therapy and vocational counseling.Today this small private hospital for patientsof moderate means is in transition. It currentlyoffers post-acute care and hospice services toAIDS and other chronically ill patients. Theaverage length of stay at Garden Campus isaround 30 days.

The garden is now an important feature ofthis facility, but it also played a prominent rolein the history of this site. Several photo al-bums kept by the administration track the var-ious changes and momentous events. The staffhere are proud of the garden, and it is an inte-gral part of the hospital’s identity.

Physical Elements and SiteLayoutThe original garden was a formally laid outherb garden with lawns, circular paths, andlarger shrubbery and trees around the perime-ter. The plan has been modified several timesand now incorporates two glazed shelters withtables and chairs, two larger patio areas, one inthe sun and one predominantly in the shade,and a volleyball/basketball court (see Photo

9–1). The garden has a mature feel, as much ofthe original perimeter planting has been re-tained. A large camphor tree dominates, alongwith other gnarled fruit trees and the vestigesof the formal yew and boxwood plantings. Anaddition to the west wing of the hospital addeda long balcony off the day room on the thirdfloor, which meets grade and leads down intothe garden. In view of the balcony’s locationdirectly over the garden, and the direct path-way down to ground level, the balcony was in-cluded in our observations as part of thegarden (see Photo 9–5). This sunny elevatedspot proved to be the most used area, offering

◆ 47

9. CASE STUDY: CALIFORNIA PACIFIC MEDICAL CENTER, GARDEN CAMPUS, SAN FRANCISCO1:The Garden

Map 9–1:The Garden, Illustrative Plan

1 Due to hospital remodeling during the research period,this case study is descriptive only.

accessibility, wind protection, and a view ofthe entire garden.

There are four main access points in thegarden: a gate to the physicians’ parking lot,one door off each of the second-floor wings ofthe building (see Photo 9–2), and the pathdown from the balcony off the third-floor dayroom (see Photo 9–3). Due to current renova-tion, the hospital houses only 18 patients, allon the third floor of this west wing. Accessingthe ground level of the garden from this wardnecessitates either descending 17 concretesteps down the slope adjacent to the balcony,or using the main interior elevator and passingthrough the empty second floor to the gardendoors. The garden is approximately 95 feet by135 feet, with about one-third of the areabeing a heavily planted embankment.

Atmosphere and AmbienceLocated between a residential and retail/smallcommercial neighborhood, the 21⁄2-story, L-shaped hospital building nestles into thesouthwestern slope of Laurel Heights in SanFrancisco. The garden is on the uphill side,behind the building; while breezes eddythrough the space, the prevailing winds arethwarted by the hospital itself. The freshnessof the salt sea air is a reminder of the proximi-ty of the ocean, and even on sunny days therhythmic sound of a nearby foghorn remindsone of the preciousness of this secluded andrelatively protected spot.

This entire facility has an intimate feeling,with the street facade resembling an old ex-pensive hotel rather than a medical center.The garden in turn creates a feeling of intima-

cy, being bounded by the building on twosides and steep slopes of mature planting onthe north and eastern edges. The small num-ber of patients and the temporarily emptyfloors, as well as the mix of design styles andutilitarian functions within the garden, con-tribute to the timeless and almost “forgotten”feeling of this space.

Garden UseAwareness of the garden and pride in it con-tribute to the continued utilization of thisoutdoor space, despite the serious accessibilityissues. During the 12 hours of observation,131 user-observations were recorded. In addi-tion to the staff using the garden for theirbreaks, half of the reports were of patientsand guests coming out for strolls and visits.On the weekend, the space was used by chil-dren playing while family members visitedwith others inside, and during one of the ob-servation periods, the garden was being set upfor a volunteer appreciation party later thatafternoon.

The staff have commented upon the dropin the use of the garden since the reduction inthe number of patients, and the subsequentclosing of all but the third floor of one wing.However, during our observation the staffwere seen to encourage patients to spend timeoutside, and they themselves would come tothe balcony rail for a glance out and a deepbreath before returning to their tasks inside.The feeling about the garden is demonstratedby an episode that took place while three em-ployees were on a break. They became concerned about the health of the rosemary


Photo 9–2: Appealing andconvenient accessat ground leveldraws people intothe garden. Wide,smooth walkwaysfacilitate use bypatients on gurneysor in wheelchairs.

Photo 9–1: This interestingand eclectic gardenoffers a variety ofuses from active topassive. Particu-larly interesting isthe incorporationof a basketball/volleyball court,which is highlyused by the chil-dren of patientsand visitors.

ground cover on the slope below the balconyon which they were standing. They took itupon themselves to slosh water out of a plasticbin, onto the plants below, making severaltrips in to the sink, to make sure that they gotenough.

The layout of the hospital grounds is suchthat it is equally convenient to travel inside asoutside when moving between most destina-tions. The significance of this is that the peo-ple observed passing through the garden weremost likely doing this as a reflection of theirpreference for an outdoor route (see Map9–2). Although most of the users of the gardenwere stationary, a fifth of the uses recorded inthe garden were children playing. Althoughplaying was recorded at all of the case studysites, this site presented not only the largestpercentage of this activity, but also childrenplaying for the longest time, and on their own.Their parent-visitors were observed to cometo the balcony railing from time to time tocheck on their children, and then return to thebedside. The children, however, happy to beplaying, entertained themselves for extendedperiods of time. The easy observation fromthe balcony (see Photo 9–1) and the secure na-ture of the garden both contributed to thisphenomenon.

Interviews with Users of The GardenSeven people were interviewed while spendingtime in the garden at this site. Of these, fivewere women and two were men; four were staffand three were visitors. Only one patient usedthe garden during the interview periods despitethe fact that almost a fifth of the users duringthe observation period were inpatients. This pa-tient was unable to speak due to a recent stroke,but his wife did participate in the interviews.The medical staff reported that with the down-sizing of the hospital and the relocation of thepost-op patients, the general health of the pa-tient population had declined during the study.

During the interview phase of the study, themajority of patients were confined to their bedsand unable to be moved into the garden. De-spite this situation, we were able to record thecomments of several visitors and staff regardingpatient use of the garden. One nurse supervisortold of patients requesting to be moved into thegarden just before they die, so that they mayspend their last minutes outside. Another re-ported that when the hospital was full, and therewere more healthy AIDS patients, “there werealways people in the garden: patients alone orwith visitors, having barbecues and such.”

Of the seven visitors and staff that were in-terviewed, all reported that it was a relaxing en-

Case Study: California Pacific Medical Center, Garden Campus, San Francisco: The Garden ◆ 49

Photo 9–3: Old yews, boxwoodhedges, and formalstairways con-tribute to anatmosphere oftimeless elegance.

Map 9–2:The Garden, UsersPassing Throughor Playing

vironment. One staff member indicated that shewas not able to relax in the garden because herfocus was on the patients rather than on herself:

It is quiet and peaceful ... (but) if you go out withthe patient, you don’t think of yourself, you arethinking of the patient.

What Users Liked Best AboutThe Garden

The most attractive aspects of the gardenfor the users were the quiet atmosphere andthe sense of being removed from the hospital(see Photo 9–4). The plants and flowers werecredited with providing this feeling. One em-ployee commented:

It’s nice looking at the flowers, getting out ofthat claustrophobic place. It’s like a safe haven.

And another:

It is serene, tranquil. Up here (on the balcony)you can hear the wind going through the treesand I like the sound of that.

Impediments to Use and De-sired Changes in The GardenInterviewees were asked if there was “anythingthat prevents or inhibits you from cominghere as much as you would like.” Most people

responded that there was not anything. How-ever, one employee was quite vocal aboutbeing “too damn busy ... most of the time pa-tients can’t be taken out here, there isn’t time.... If I do take a patient out I can’t relax ... Ihave a lot of patients who can’t do anythingfor themselves.”

The only other impediment was mentionedby an employee who commented that he“can’t play basketball at night.”

More flowers, specifically fragrant flow-ers, followed by concerns expressed regardingthe upkeep of the garden were the two pre-dominant requests in response to the question,“Is there anything you would like to seechanged or added?”

One employee commented:

I hope they keep it up; more flowering plantswith a nice aroma. You’re dealing with a lot ofelderly patients ... I wish more of the patientscould get out here. That’s why I pick the flowersfor the patients. The jasmine is nice, the smell ifwe can get it to waft into the rooms. When youput jasmine under their nose, they just light up.

Another:

I’d like to see more flowers, (but) ... they’d haveto hire someone to take care of it.

Outdoor lighting was not directly men-tioned by the users who were interviewed;however, two of the respondents referred todrawbacks that could be solved by providingillumination at night. In addition to the com-ment about playing basketball at night quotedabove, another staff member said:

I used to work the PM shift, and I didn’t see itthat much. The flowers ... I’ve always been anoutdoors person ... it is a nice treat (to see them).


Map 9–3:The Garden, Stationary Users

Photo 9–4: Glazed shelterstrap the heat, pro-vide protectionfrom the breeze,and create privateseating areas.Features such asthis extend the useof the garden intomany months ofthe year.

What Happens to People inThe Garden?In response to the question “Do you feel anydifferent after you’ve spent time in the garden?”all of the respondents said yes. Typical of com-ments from the staff was the nurse who said:

(I feel) more relaxed, ready to go do my work. Itgives me time to plan what I’m going to dowhen I get back to work; it clears my head.”

and the doctor who said:

If I play basketball, I feel very different, (andeven) if I don’t, and just go out for a few min-utes, I feel better.

or the visitor who commented:

Because his room is so small, it is relaxing tocome out here, you catch air ... you don’t knowyou are in a hospital.

Specifically Helpful Characteristics Several qualities of the garden were listedspecifically in connection with the moodchanges experienced by the users who were in-terviewed. Getting out into “fresh air and sunshine” and the trees and greenery wereconsidered to be the major factors.

One staff member spoke of the greenery,and also of what the garden represents:

The existence of plant life in general is a relaxant.And I think just that it (the garden) exists is heart-warming; someone cared enough to put it here.

A nurse spoke about her witnessing changesin the patients when she brings them out intothe garden:

To the patients, the garden is like a pet; it justmakes them come up if they are depressed. Youshould see the expression on their faces, thebody language. They just bloom up ... or it couldmake them sad, because it makes them think oftheir garden at home ... you have to watch theirbody language, how they breathe, their eyes.Greens do make a physical change.

ConclusionThe nature of the Garden Campus, offeringpost-acute care and hospice services with alonger length of stay, directly influences the

usage of the garden. The focus of the serviceprovided here is necessarily more on “qualityof life” than on the more immediate goal ofmedical stabilization at other institutions. Pa-tients’ emotions are addressed as a necessarypart of the treatment agenda. Similarly, thesignificance of the ongoing support of visitorsincreases in proportion to the length of stay ofthe patients. The garden is a tremendous assetin allowing the residents and visitors to feel ascomfortable as possible.

The reports of frequent family picnics inthe garden, the intense use by children, theobservations recorded by nurses of the emo-tional changes in the patients after spendingtime in the garden, all speak to the increasedlevel of satisfaction and contentment that canbe gained by having access to an outdoorspace. Additionally, secondary benefits to thepatient include the facilitation of more fre-quent and longer visits from family and lovedones, and being cared for by a staff who havethe opportunity to rejuvenate themselves. In ademanding field such as healthcare, providingfor the needs of all the participants, therebymaximizing all of the potential support-ener-gy, is critically important.

The garden design and issues of accessi-bility play a significant role in the success ofthis garden space. The direct benefit of thegarden for inpatients is tremendously in-creased by the availability of the outdoor bal-cony space immediately adjacent to the dayroom (see Map 9–3). Patients are brought outhere to watch and enjoy the goings-on, whilethe proximity to the unit allows the staff tocheck on them regularly. When the secondfloor is again open, the accessibility off the

Case Study: California Pacific Medical Center, Garden Campus, San Francisco: The Garden ◆ 51

Photo 9–5: Patients on a shel-tered balcony offthe day room par-take of the viewsand fragrances inthe garden. Thenursing staff oftenpop out to check onpatients, whilestaying longer andenjoying the gar-den themselves ontheir breaks. Notethe fragrantclimbing rose onthe arbor in theforeground.

west wing will offer the same advantage. Addi-tionally, wind shelters, and patio surfaces andwalls to reflect the heat are used by patients tomoderate San Francisco’s “natural air-condi-tioning.” Thus, the patients have a way to staywarm without having to be directly exposed tothe sun’s rays. The unexpected existence of the

volleyball/basketball court is an additionaldraw for younger visitors, and is an outlet forthe release of pent-up energy by the staff (seeMap 9–4).

The garden at California Pacific’s GardenCampus is a private and secluded oasis that hasserved many purposes over the years. Today itis again in transition, and like the institution it-self is underutilized. Yet the sensitivity of thestaff to the patients’ enjoyment of the gardenand its healing benefits, as well as the ethos andpride that this institution has in its namesake,continues to enable this facility to take the bestadvantage of this asset. (Is it a coincidence thatof the units available, the one with the best ac-cess to the garden is the one remaining open?)The staff’s patient loads have increased, andthey feel overworked, yet they care for the gar-den on their breaks and come to work early tobe able to enjoy it. Everyone encountered atthis facility spoke of a desire to have the gardenkept up as a contributing aspect of the hospi-tal’s treatment services. Indeed, plans are in theworks to modify the garden to accommodate afuture Alzheimer’s unit.

(At the time of printing, the Garden Campus site ofCalifornia Pacific Medical Center has been tem-porarily closed in order to expedite the renovationsand an anticipated merger.)


Map 9–4:The Garden,ExperientialAnalysis

IN THE PREVIOUS chapters, four hospitalgarden case studies were presented. Theuse and therapeutic benefits of each of

these exterior spaces was described. In thischapter the aggregate data is presented andanalyzed to suggest overall trends. It is some-what problematic to compile responses fromdiffering sites, and there are a few qualifica-tions that should be pointed out at this time.

While the differences in physical settingsamong the research sites add to the breadth ofthe study, they limit the aggregation of data.One aspect of this is the array of differing ele-ments within the landscaped areas. This hasbeen addressed in the analysis by focusing oncategories of elements, rather than on spe-cifics. For example, Kaiser Walnut Creek hastwo heritage oak trees that were mentioned by36 percent of the people as a significant factorin their restorative process. There are relative-ly few blooming plants at Kaiser, and only 6percent of the respondents mentioned theflowers. In contrast, San Francisco Generalhas no heritage trees, however it had 35 differ-ent species of plants blooming at the time ofthe study. As might be expected, 42 percent ofthose people interviewed at San FranciscoGeneral mentioned the flowers, while only 4percent mentioned the trees. For the purposesof the aggregate analysis, these two items havebeen grouped together under the heading of“trees and plants.” A second difference amongthe four landscapes is the site layout. The gar-den’s relationship to the buildings, how manyaccess points there are, and the efficiency of

travel through the space to interior destina-tions play a role in the way the garden is per-ceived and used. The focus of the aggregateanalysis is therefore not on users movingthrough the space (though within the contextof the individual site, this is significant).

Aggregate Descriptive DataOne hundred and forty-three users were inter-viewed; 73 were female and 70 were male. 59percent were employees, 26 percent were pa-tients, and 15 percent were visitors. Nearlyhalf of the respondents use the gardens everyday, or several times a day.

TABLE 10–1

Frequency of Garden UsePercent

Several times per day 30 Occasionally/sometimes 27Every day 181-2 times per week 14First time here 11

(Number of respondents: 143) 100

We asked the users of the gardens to indi-cate one or more activities that they engagedin from a list of 10 options. All but 8 of the143 users reported that they come to “relax.”More than half of the users said that theycome to talk, eat, stroll in the garden, and/orcome for their own, undefined “outdoortherapy.”

◆ 53

10. AGGREGATE DATA ANALYSIS OF THE CASE STUDY SITES

TABLE 10–2

Percent of Respondents Using Gardens for Var-ious Activities

PercentRelax 94Eat 73Talk 73Walk through 68Stroll in the garden 61Outdoor therapy 53Wait 38Visit with a patient 36Let their children play here 12Work-related meeting 11


Ninety-five percent of the users of the gar-den reported that they “feel different” afterspending time there. Just over three-quartersof the respondents described feeling more re-laxed, and calmer. Somewhat less than a quar-ter of the users reported that they feltrefreshed, rejuvenated, or stronger, while asmany again spoke of being able to think moreclearly, find answers, and felt more capableafter being in the garden.

TABLE 10–3

Percent of Respondents Reporting VariousTypes of Mood Change

PercentMore relaxed, less stressed, calmer, contented 78Refreshed, rejuvenated, stronger 25Able to think, find answers, cope 22Pleased, better, more positive 19Religious or spiritual connection 6No difference in mood 5


Of those specific characteristics or qualitiesof the garden named by users as helpful tothem, two-thirds of the respondents men-tioned trees, flowers, and plants. More thanhalf mentioned features that involve eithersounds or smells or tactile responses. Exactlyhalf of those answering this question men-tioned the psychological or social aspects of

the space (it is peaceful; an escape from work;companionship; etc.).

Comparative Analysis of theAggregate DataWhen looking at the activities in relation tothe different types of users, there were someexpected results and some associations thatwere not anticipated. Predictable responseswere documented by those interviewees re-porting that they came to the garden to“relax,” to “stroll through,” and to engage in“outdoor therapy.” Each of these activities hada representative spread within the staff, pa-tient, and visitor types. Also, as might be an-ticipated, differences in frequency of responsearose for “work-related meetings,” “eating,”and “waiting.” The staff reported the most in-stances of meeting and eating outdoors, withthe visitors and patients tied at the top of thelist of those who choose to wait in the garden.

Less expected were the results of inquiriesregarding “talking” in the garden. The vastmajority of employees reported that they talkwhile in the garden, as did close to two-thirdsof the visitors. However, almost half of the pa-tients said that they did not converse whilethey were there. One explanation for this maybe that visitors specifically come to the hospi-tal to talk and be with a patient, and staff arein a work environment where they havefriends and acquaintances, whereas patientsare isolated from their social milieu and knowrelatively few people. However, another possi-ble explanation is that the situation of under-going treatment at a medical facility mayincrease one’s desire to get away and be alone.

The total number of interviewees who haveused the hospital gardens as a play area fortheir children was relatively small. However,the rate of usage between the user types wasnearly equal (see Figure 10–1). Similar resultswere recorded for those users who “visit with apatient.” Again, the total percentage of userswho visit with patients was not large, but thedifferences among rates of usage was revealing(see Figure 10–2). The fact that the employeesengage in both of these activities indicates thatthe garden increases the number of optionsopen to the staff. It gives employees more flex-


ibility in their choices of how they work —whether they talk with patients indoors or out-side — and also how they integrate their em-ployment and their personal lives.

TABLE 10– 4

Percent of Respondents Who Named TheseQualities as Helpful In Attaining a MoodChange

PercentTrees and plants 69

flowers, colors, greenery, heritage trees, being in nature, seasonal changes

Features involving auditory, olfactory, 58or tactile sensations

birds/squirrels, wind/fresh air, water,quiet, light/sun, shade, fragrances

Psychological or social aspects 50peaceful, escape from work, openness/large, privacy/secret places, oasis, companionship, watching others, knowing it is here

Visual qualities relating to more than 26plant materials

attractive landscape design, views, variety of elements, textural contrast/quality, differing shapes/sizes

Practical features 17seating, well maintained, accessibility, vending machines, smoking allowed, pathways

No answer or “don’t know” 8


On one occasion a family was observed eat-ing together in the garden. After playing withher two children for a period of time, themother kissed them good-bye and said thatshe had to “go back to work now.” Unusualthough this may be, the interviews reveal thatthis is not an isolated incident. By using thegarden in this way, the staff are taking the op-portunity to satisfy their personal needs in away that supports their work.

We also observed medical staff chattingwith patients in the garden. Some of these ap-peared to be chance meetings. However, wedid observe staff and patients coming out to-gether and having what appeared to be a seri-ous conversation. The opportunity for staffand patients to choose this outdoor setting fortheir meetings increases the degree of comfort

and often provides a level of privacy otherwiseunavailable. This adds variation into the work-day of the employee, and contributes to asense of autonomy, so compromised for inpa-tients, as well.

When looking at the association betweenmood changes and user types, the results con-firmed our expectations. Approximately equalproportions of visitors, patients, and staff felt arise in energy and reported being refreshedand rejuvenated. Similarly, close to even pro-portions reported a cognitive shift (they hadthought things over or had worked out a prob-lem, etc.). There was a predictable differencebetween the rates within the user types whofelt more relaxed or calmed down (a drop inenergy level) (see Figure 10–3), and also be-

Aggregate Data Analysis of the Case Study Sites ◆ 55

FIGURE 10–1

The Percentages of Each User Type Who BringTheir Children to Play in the Garden

FIGURE 10–2

The Percentages of Each User Type Who Visitwith (Other) Patients in the Garden

Patient Visitor Staff

12%

10%

8%

6%

4%

2%

0%

14%

Visitor Staff Patient

50%

0%

40%

30%

20%

10%

Bring Kids to Play Here

Visit with Patients

tween those who reported spiritual or religiousexperiences and feelings (see Figure 10–4).

The different user-patterns of these twomood shifts could be expected considering thatpatients are most probably physically ill, andthe most likely users to be depressed or sad. Itwould follow, therefore, that they would seekan uplifting experience in the garden describedby them as “religious” or “spiritual.”

It was anticipated that some differences inresponses would arise among the different sites.It was also expected that the length of timespent in the garden would be related to moodchange. However, the analysis of the data didnot support either of these assumptions. Therewere, however, differences in the proportion ofuser types at each site and these could be direct-

ly associated with location and accessibility. Atall of the sites except Alta Bates, about one-halfof the interviewees were employees, with visitorsand patients comprising the other half. In theroof garden at Alta Bates, however, more than80 percent of the users were staff members. Asdiscussed in chapter 7, this is a garden that is atone end of the hospital site, far from the mainentry. The entire interior area of that floor hasrecently been converted to a secure unit, forc-ing most users to come and go from a single el-evator at the end of the lengthy hallway thatjogs its way through the various hospital addi-tions. Volunteers at the information desk wereunable to direct us there upon our first visit andit was not shown on any maps of the site. It isonly visible from one set of patient rooms, onthe fourth floor, so even to learn of its exis-tence, one has to rely on an informal networkof communication. The staff, with their longertenure there and their relative ease of mobility,are the predominant users.

The split between the proportion of visitorand patient users was relatively even for KaiserWalnut Creek and Alta Bates. There weresubstantial differences between these groups atSan Francisco General, however, where manymore patients were interviewed than visitors.At this site, the issue is not one of accessibility;rather it is one of location. The garden is di-rectly outside two buildings that house severaloutpatient clinics that primarily serve adults(methadone maintenance, tuberculosis, HIV,family planning, etc.). The occasion for visi-tors to come here is much more limited thanat a site adjacent to an inpatient building.

In SummaryThis research has documented that people inmedical settings use available outdoor gardensfor therapy and emotional healing. Positive per-spectives and attitudes are known to supportbetter health and increased recovery rates fromillness. The beneficial emotional changes re-ported by patients after spending time in thegarden, and being cared for by staff who havethe opportunity to rejuvenate themselves andreturn to work more relaxed and refreshed,must then improve the healing environment.The increased morale of the employees con-


Visitor Staff Patient

100%

0%

80%

60%

40%

20%

Patient Visitor Staff

12%

10%

8%

6%

4%

2%

0%

FIGURE 10–4

The Percentages of Each User Type Who Report a Spiritual or Religious Mood Shift

FIGURE 10–3

The Percentages of Each User Type Who Report a Pleasing Drop in Energy Level

Drop in Energy Level

Deeper Meaning

tributes to the smooth functioning of a produc-tive and efficient work force, increasing the levelof satisfaction for the total hospital community.

Patients, visitors, and staff come to the gar-den to help themselves to feel better. They dothis consciously, and speak eloquently aboutthe gardens and their experiences there. Theycome to get away, to relax, and to think andbuild their strength. They report as significant:

• plants and growing, living things• varied sensory stimulation• facilitation of the psychological experience

of expansiveness and peacefulness

• opportunities for social interaction and ob-servation.

By examining these sites individually and inaggregate, issues of site planning, accessibility,and the need for a space that is in contrast withthe controlled and sterile internal environ-ment clearly come to the fore. In the followingchapter, design recommendations are present-ed that arise from the discussions and inter-views and the observations at both the casestudy sites and the sites presented in the typol-ogy chapter.

Aggregate Data Analysis of the Case Study Sites ◆ 57

THE FOLLOWING RECOMMENDATIONS

have emerged from the case studiesand from additional brief critical eval-

uations of outdoor spaces at other hospitalsdescribed in chapter 5. The recommendationsare divided into three groups:

A) locational, site-planning, and way-finding;B) planting, seating, aesthetic, and detail;C) policy regarding the provision and mainte-nance of gardens intended to be used for ther-apeutic benefit.

A. Locational, Site Planning, and Way-FindingRecommendationsTo truly maximize the potential of gardenspaces in hospital facilities, the design processneeds to begin with site planning. Many issuesthat we encountered in our research couldhave been mitigated or avoided if the provi-sion of potentially therapeutic garden spaceshad been considered from the beginning. Ac-cordingly, our recommendations start with anumber of steps that are often overlooked.

Principles for site planning of therapeuticgarden environments in healthcare facilities are:

• Healthcare facilities are high-stress environ-ments for staff and patients alike. Exteriorenvironments should provide a contrast tothe interior space, in order to facilitate asense of “getting away.”

• Physically ill people are a vulnerable popula-tion. They are acutely aware of their physical

comfort. Design with particular awareness ofissues of mobility and microclimate.

• People who are not well also tend to beemotionally vulnerable and sometimes intel-lectually impaired. Design for a sense of se-curity, serenity, and safety — with definedseating areas, easily readable pathways, andclear designations — and remember thesymbolic takes on increased meaning as wegrapple with our own frailties.

Specific suggestions include:1. A professional landscape architect needs

to be on the design team from the start to as-

◆ 59

11. DESIGN RECOMMENDATIONS

Photo 11–1:Children enjoy thisimaginative maze,lawn, and climb-ing tree in a court-yard adjacent tothe pediatricdepartment ofthis suburbanmedical center.Surrounded byplate-glass win-dows, this spaceallows easy moni-toring, yet providessound insulationfor children whoneed to let offsteam. (KaiserPermanente Medical Center,Vallejo, CA)

sist with the determination of outdoor spacelocation, orientation, function, and ambience,and to assess microclimates, accessibility, andanticipated user groups.

2. Since there are likely to be multipleusers (staff, inpatients, outpatients, visitors),with a range in ages, including children, theplanning of a new hospital, or hospital addi-tion, should include consideration of a varietyof outdoor spaces. These need to be varied asto type (i.e., front porch, roof garden, court-yard, etc.) and design image: for example, anentry porch where people can sit and wait fora taxi; a terrace or courtyard off the cafeteriafor outdoor eating; an attractive viewing gar-den where people waiting for appointments orfor items at the pharmacy can sit and look outat greenery; a ground-level or roof garden thathas the immediate imagery of “a garden,” andwhich is furnished and detailed for quiet con-templation, eating a brown-bag lunch, medita-tion, strolling, and so on.

3. Our field studies revealed that lack ofknowledge about the existence of a gardenspace is one of the most critical factors in itsuse. The location and visibility of such spacesis very important. One outdoor space shouldbe visible from the main entrance or thereshould be clear and prominent directions as toits location.

4. The amount of time to spend outside islimited, especially for employees of a health-care facility. A garden, courtyard, or roof ter-race next to the cafeteria can draw people intothe fresh air, offering a choice and allowingthem to take best advantage of the free time.Also, in most hospitals now, this is the onlyspace where one can eat and smoke.

5. Outdoor spaces designed to optimizetherapeutic benefits need to have a degree ofenclosure or separation from the outside world— an entry lawn or landscaped setback fromthe street is not appropriate as the only spaceavailable for use.

6. Visibility of a garden space from insidefor staff monitoring of patients is especiallycritical for long-term care facilities. Patio areasoff day rooms are a successful combination.

7. Where there is sufficient room, dividethe space so that there are sub-areas of varyingsize and levels of privacy. Some users comealone and seek a space in which to sit that iscomfortably private, while others may desiredistraction and social interaction.

8. The interior and exterior spaces shouldcomplement each other. If patients near anoutdoor space have private rooms, exteriorareas for social interaction and observationshould be a priority. If nearby units have anopen, multiple-bed floor plan, more areas forprivate conversations and withdrawing fromsocial interaction need to be provided.

9. Balconies or roof terraces with a view intoa garden can add to the use of an outdoor space,especially for those on gurneys or in wheelchairswho cannot easily access the garden proper.These spaces need to be of ample size and havewide doors — perhaps automatic — so that visi-tors and volunteers, who may not be experiencedin moving patients, feel that the space is accessi-ble, without having to worry about mobility.

10. The layout of the garden needs to beeasily “readable,” to minimize confusion forthose who are not functioning well. This is es-pecially true in nursing homes and facilities forpatients with psychological impairment.

11. Make sure that the garden is easily ac-cessible to patients and the paving surface iswide enough to accommodate wheelchairs andgurneys.

B. Planting, Seating, and DetailRecommendations In keeping with the main focus of this report,the following recommendations on design de-tails and planting refer to garden spaces wherepatients, staff, etc., are likely to go to relax, tothink and build their strength, and to get away


Photo 11–2: A covered sittingterrace with forestviews outside a dayroom offers conve-nient access to theoutdoors in allweather, as well asvisibility for moni-toring by staff.Movable chairsprovide a residen-tial feeling whileallowing for avariety of socialgroupings. (Monterey County Hospice, Monterey,CA)

from the hospital environment. Our interviewsand case studies clearly indicate that three as-pects of design details are critical in facilitatinga change of mood and lowering stress. Theseare the presence of a variety of green, grow-ing, and living things; the stimulation of thesenses; and the availability of a variety of set-tings for both social interaction and quiet in-trospection.

The following design principles can serveas guides to creating therapeutic garden envi-ronments:

• Provide sensory stimuli that is noninvasive incharacter to draw our attention away fromthe initial feeling state to an external focus.

• Facilitate physical and psychological move-ment with pathways and/or vistas through toa variety of types of spaces, thereby assistinga shift in perspective.

• Create areas for safe seclusion as well as so-cial interaction to help think and workthrough issues.

Specific suggestions to achieve these goals are:1. Lush, colorful planting that is varied and

eye-catching so as to suggest the image of a gar-den. Over and over, trees, plants, and greenerywere cited as the most significant helpful char-acteristic.

2. Appropriate plant selection, with specialattention given to cultural requirements andcorrect placement in the garden, is one of theessential elements of a therapeutic garden envi-ronment, as dying and unhealthy plants have anegative psychological impact on those observ-ing them.

3. Flowering trees, shrubs, and perennialsprovide a sense of seasonal change that rein-forces one’s awareness of life’s rhythms andcycles.

4. Trees whose foliage moves easily, even ina slight breeze, draw the user’s attention to thepatterns of color, shadows, light, and move-ment. This was described by interviewees as asoothing and meditative experience.

5. Features to attract birds — such as afountain or birdbath, a bird feeder, trees ap-propriate for roosting or nesting — stimulatethe senses and help to lift people’s spirits.

6. Contrast and harmony in texture, form,color, and arrangement of plant materials pro-vide a variety that holds the attention andhelps to draw our focus away from ourselves.

7. Plant species that attract butterflies callattention to the ephemeral, serving as a gentlereminder of the preciousness of life.

8. In addition to providing an externalfocus, sound can create a psychological screen(white noise) that serves the restorationprocess. A water feature can provide thispleasing and soothing sound. Care should betaken to place it in a wind-protected locationwhere people can sit nearby, and where air-conditioning or other irritating noises do notcreate too much competition.

9. For the comfort of users, where offices orpatient rooms border the garden, create aplanting buffer of sufficient distance and depthso that people walking or sitting in the gardendo not feel that they are intruding on the pri-vacy of those indoors.

10. Paths that meander allow for strollingand contemplation and complement moreheavily used direct routes between accesspoints. Where the space is large enough, pro-vide varying vistas, levels of shade, and tex-tures of planting along these routes.

11. Select paving surfaces that are smoothenough to accommodate wheelchairs and gur-neys.

12. In long-term facilities, arrange entrancesto the garden and width of pathways so thatvolunteers or family members can easily bring apatient on a gurney or in a wheelchair out intothe space.

Design Recommendations ◆ 61

Photo 11–3: This roof terracein a larger urbanhospital offers apromenade forstrolling (to theright of photo) andsemiprivate seat-ing clusters incor-porating the warmtextural materialsof brick and wood.The terrace offerssun or shade, andviews towardgreenery or overthe city skyline.(St. Mary’sHospital, SanFrancisco, CA)

13. Electrical outlets allow for the gardento be used for hospital parties or other spon-sored functions, extending the use to otherpeople who may not usually come.

14. Nighttime lighting maximizes the ther-apeutic benefit by allowing people to use thespace safely after dark, or to look out at thegarden from indoors.

15. Seating arranged for social interaction(right angled or centripetal benches, or mov-able chairs) near to the entrance into the gar-den adds convenience, as this area will likelybe used for quick smoking breaks by staff whoknow each other.

16. Seating partly enclosed by planting, orat the perimeter of an open space, provides adegree of privacy for those wanting to bealone, or who want to observe from a distance.

17. Fixed seating with backs for sitting incomfort is especially important for gardenusers who may be physically weak.

18. If bench-type seating is provided, selecta material that is appealing to the touch (i.e.,wood) and a size (4–6 feet) such that one ortwo people can “claim” the space. The imagemight be of a garden bench, rather than a parkor bus stop bench.

19. Increase the seating options availablewith movable seating so that users can meettheir own particular needs. These chairs canbe moved, selecting the degree of sun andshade, as well as determining the size of theseating cluster.

20. Benches, platform seating, or planter-edge seating with something to support theback allows people to sit with their feet up —or they can lie down to take a nap or sunbathe,as was frequently observed.

21. Tables with movable chairs or benchesprovide for users who want to hold a meeting

or eat, especially where the space is adjacent tothe cafeteria.

22. Adjustable umbrellas allow people tocontrol the amount of sun or shade, so impor-tant to those who feel unwell or are taking cer-tain medications.

23. Wind shelters, heat-reflecting surfaces— or alternatively, shade-producing arbors —and other structures and planting help to miti-gate the climate, and extend the use of the gar-den into several seasons.

24. Where there is a view, make sure thatsome seating faces that direction to facilitatepsychological movement out of the space. Ifthe exterior space is a roof garden or terrace,the edge rail, balustrade, or planter should besufficiently low or transparent so that peopleseated can take in the view.

25. Where there is not a ready-made view,a sense of mystery and movement can be cre-ated by designing smaller-scale glimpses andintriguing focal points within the garden, todraw the users’ attention and, sometimes, fa-cilitate a change in perspective.

26. Providing one or more eye-catchingand unique features by which people will iden-


Photo 11–4: Located off one ofthe arterial hall-ways of this majormedical center, awell-tended, dra-matic display ofcolor provides awelcome surpriseand can be enjoyedboth from the in-side and from theoutside. The pri-vate windows onthe surroundingwalls are ade-quately screenedwith shrubberyto minimize the“fishbowl” feelingthat such spacesoften create.(StanfordUniversityMedical Center,Stanford, CA)

Photo 11–5: Movable chairs,tables, and parasolsallow users to enjoythis communityhospital’s smallcourtyard in a va-riety of ways.Proximity to thecafeteria con-tributes to the useof this space. (No-vato CommunityHospital, Novato,CA)

tify a garden — such as a sculpture, windchimes, an aviary, a fish pond — serves to an-chor memories of the garden and the restora-tion achieved there.

C. Policy and Maintenance recommendationsOne of the interesting contrasts that we dis-covered during our canvassing of potential re-search sites was that we encountered whatappeared to be more emphasis on the gardenspaces and a greater awareness of potentialtherapeutic benefits at the public institutionsthan at private facilities. The older public fa-cilities take great pride in their gardens, andthere was a high level of awareness of theirplace in the healing milieu of the facility. Pri-vate institutions, on the other hand, appear toview incorporated gardens primarily as cos-metic elements. Older established gardens inthese private hospitals have gone to seed, orhave been encroached upon. Decisions madeby the hospital administration do have a directimpact on the success of exterior therapeuticgarden spaces. These are the principles andguidelines that we recommend.

• Exterior garden spaces are a resource to beused for maximum benefit; promotingawareness and facilitating use will influencethe level of benefit derived.

• Considering a garden as an essential elementwithin the therapeutic milieu of a facilitygives additional variation and support to theentire hospital community.

• Quality maintenance contributes to thehealth of the plants, which in turn providesthe maximum therapeutic benefit.

Specific recommendations:1. Our field studies revealed that awareness

of the garden space is one of the most criticalfactors in its use. We found that even wherethere was an outdoor space, people at the in-formation desk were often not aware of its ex-istence, or mistaken about accessibility. (Theextreme situation was in one hospital where ittook 45 minutes and several exasperatingtrails of misinformation before access couldbe attained to a locked roof garden that was“open to the public.”) Signs that direct people

to the space, labeling the gardens on postedmaps, and listing them in the resource hand-book at the information desk would go a longway toward promoting their use and reapingtheir rewards.

2. Educating employees about the existenceand therapeutic benefits of exterior spaces willincrease their use of the gardens and con-tribute toward a refreshed, rejuvenated, andmore productive staff.

3. Encouraging the medical staff to pro-mote the use of exterior spaces will increasethe use of gardens by patients and visitors, andextend the ripple of the beneficial effect toeveryone.

4. Scheduling events and meetings in thegarden incorporates the restorative benefits ofa garden into the work schedule.

5. Communication can be easier in an exte-rior space. Several interviewees mentionedthat the gardeners provided companionshipand were great to talk to. The head gardenerat one of the study sites remarked on the pub-lic relations service he provided, by listeningto people vent and express their dissatisfac-tions. The casual nature of being in the gardencan enhance communication; acknowledgingthis and capitalizing on it would benefit theentire organization.

6. Keep gardens open; appealing gardens,designed with seating but that are behindlocked doors, are as bad or worse than noth-ing. The frustration that rattling locked doorscreates increases the stress levels of newcom-ers to the facility (and the emotional costwould be even greater, and longer term, tothose who may be confused or disoriented).Gardens that are designed for use should bekept available.

Design Recommendations ◆ 63

Photo 11–6: In all four casestudies, a completecontrast to the in-terior environ-ment was muchappreciated by pa-tients and staff.Even in an urbanenvironment thissmall space outsidethe hospital wallswas inexpensivelytransformed byvolunteers into anintimate settingthat contrasts withthe controlled inte-rior. (LagunaHonda Hospital,San Francisco,CA)

7. In a time when money is limited, creativethinking can lead to increased benefit. Re-cruitment and use of volunteers to take pa-tients outside gives relief to the staff as well asto the patients.

8. Consider approaching volunteers or alocal garden club to raise money for, and/or tomaintain, a hospital garden.

9. Maintenance is important in terms ofboth the physical safety of the site and thetherapeutic potential. Shrubs, trees, and flow-ers are labor intensive compared to structuresand patio spaces. Yet it is these green, growingthings that appear to offer the most restorativevalue. Appropriate fertilizing, selective thin-ning rather than shearing, and the use of sea-sonal color contribute to the healthy andnatural qualities listed as significant by theusers of the study.

10. Encouraging birds, butterflies, squirrels,etc. — another aspect of the garden that ishigh on the list of significant qualities — iseasier if organic practices are employed. Un-documented but also relevant may be thedetrimental effect of the use of chemicals onthe health of the people in the garden, espe-cially those who are already physically unwell.Hand weeding, mulching, companion plant-ing, and appropriate spacing of plants all re-duce the need for the use of chemicals.

11. Interest, variety, the fact that “someonecares” about the garden were mentioned byusers of the garden; pristine lines, perfection,and aesthetic excellence were not. Mainte-nance should be geared toward providing afriendly, comfortable, welcoming space ratherthan perfection.


T HIS STUDY HAS explored the use ofhospital gardens and the therapeuticbenefits of these outdoor spaces. By

observing and interviewing people while theyare in the garden, the benefits of these spaceshave been described and documented. Ninety-five percent of the people in the gardens re-ported a therapeutic benefit. Employees saidthey were more productive, patients spoke offeeling better and having more tolerance fortheir medical procedures, and friends and rela-tives felt relief from the stress of the hospitalvisit.

Some important questions arise from thisstudy: Is there documentation for increasingthe amount of common area outside? What, ifany, are the differences in the design of gar-dens for different patient populations? Whatare the comments from people who do not usea garden, when there is one available and ac-

cessible? Why don’t they use it? Is it a ques-tion of personal preference?

The next step in the pursuit of full utiliza-tion of all space in healthcare facilities is tocompare the results of this study with a similarone examining interior spaces. What are thetherapeutic benefits of common areas such asday rooms, waiting rooms, and cafeterias? Andare there any design elements mentioned inthis research on gardens that can be applied tointerior spaces?

There is no question of the perceived ther-apeutic benefits of the garden spaces reportedin this research. Narrowing the scope of sub-sequent research to accommodate specificquantitative analysis and conducting compara-tive studies to establish the place of the gardenon the fiscal priority list of healthcare facilitiesare challenges that lie ahead.

◆ 65

12. CONCLUSION

Location

______________________________________

______________________________________

______________________________________

Date and Time ______________

Number ____________________

1) The oral consent script has been read andconsent given?

■■■■ yes■■■■ no

2) Gender is:

■■■■ female■■■■ male

3) Would you mind telling me if you are:

■■■■ employee■■■■ patient who is in the hospital■■■■ outpatient here for a doctor appointment,

test, shot, etc.■■■■ visitor

4) How often do you come out here?

■■■■ my first time■■■■ occasionally, sometimes■■■■ once or twice a week■■■■ every day■■■■ several times a day

5) What do you generally do out here? (several boxes may be checked)

■■■■ sit and wait (for an appointment, a friend, etc.)■■■■ sit and relax (smoke, read, have coffee, etc.)■■■■ sit and talk with friend(s), colleague(s)■■■■ hold a work-related meeting■■■■ visit with a patient (sit, stroll, etc.)■■■■ walk through on my way to another building■■■■ come out for a stroll (not necessarily en route

to another building)■■■■ let my kids run and play here■■■■ outdoor therapy■■■■ eat■■■■ other ________________________________

6) When you come out here, how long do yougenerally stay? (may give several answers, dependingon activity)

■■■■ just a few minutes■■■■ 5–10 minutes■■■■ 10–30 minutes■■■■ more than 30 minutes

7) Is there anything that prevents or inhibits youfrom coming here as much as you would like?

8) What do you like best about this place?

◆ 67

APPENDIXQuestionnaire

9) Is there anything you would like to seechanged or added?

10) Do you feel any different after you’ve spent time in the garden?

11) What specific characteristics or qualities ofthis place help you to feel _________________?(fill in the answer to question 10)

12) Is there anything else you would like totell me about the garden, or how you feelwhen you are out here?


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