Kathleen Bogaski has more than 25 years of professional experience working at exceptional design firms including Design Workshop, Inc., EDAW/AECOM, and Land Design Research. Her research and design practice, Bogaski Design Studios, focuses on site designs using low-water-consumption plantings and sustainable materials, landscape renovation and redesign, and creative surface-water management and reuse techniques. She has advanced training and certificates in healthcare garden design, fire-wise design, and quality management. Read more about Kathleen Bogaski here.
In fall 2015, fourth-year landscape architecture students at LSU were given the opportunity to study the evidence-based approach to designing for healthcare facilities in Portland, Oregon. The students toured a memory garden for Alzheimer patients and five Legacy Health System facilities, which included a wide variety of well-designed therapeutic gardens serving staff and users of the Oregon Burn Center, children’s hospital, birthing center, and rehabilitation facilities. Guided by Teresia Hagen, coordinator of the Legacy Gardens, students learned that the success of a healthcare garden is more likely when using a collaborative design process involving the people using and caring for the garden and a strong understanding of the patients’ health outcome goals.
The concept of nature as a restorative environment is not a new or modern idea. Since ancient times, gardens have been designed to aid in the healing process. From the first tablets of herbal medicine to the Asclepius gardens in ancient Greece, monastic cloisters to Zen gardens in Asia, and public parks to modern healthcare facilities, the garden has been proposed as a place of care, restoration, and healing of the spirit.
The idea of “nature as a healer” has waxed and waned over the centuries. Advances in modern medical science led to a dramatic decline in access to nature by the 20th century as hospitals were institutionalized and designs were driven by costs, efficiency, and infection control. By the 1980s, the AIDS epidemic, virulent new viruses, and the high cost of medical care became prominent issues and possibly compelled researchers to examine the physical and psychological benefits of nature in the healing process.
In 1984, Dr. Roger Ulrich, one of the most influential evidence-based healthcare design researchers in the world, provided the first credible scientific evidence to support what most people knew intuitively about the restorative benefits of nature. He found that surgical patients with views of nature had shorter post-operative stays, fewer negative observations from nurses, took less pain medication, and experienced fewer minor post-operative complications than those with views of only a brick wall. Ulrich’s studies in the 1990s indicated that only 5-7 minutes spent in nature or viewing natural scenes reduced the physiological indicators of stress (such as elevated heart rate, blood pressure, production of stress hormones), resulting in a calming effect that improved mood and aided in the healing process.
Similarly, Rachel and Stephen Kaplan’s research in 1999 indicated that exposure to nature and natural scenes could restore a person’s ability to concentrate after mental fatigue due to focused effort. Further research revealed a 20 percent improvement in both memory and attention span for people who walked for one hour in nature as opposed to those in an urban setting; elderly stroke patients who received as little as 15 minutes per day in sunlight had 84 percent fewer hip fractures than those not regularly exposed to sunlight; and women 50 years of age or older who gardened at least once a week had a higher bone density reading than those who performed other types of exercise.
These research findings demonstrated to the medical community that the physical environment—specifically, views of nature—had a measurable positive effect on patient health and established a business case for supporting the development of gardens and access to nature. Medical authorities began to see nature/gardens in hospital settings as not just cosmetic extras but as ways to improve health outcomes for patients that translated directly into potential cost savings for hospitals and insurance companies (Marcus, Sachs 2014).
The need for design reform became even more evident in 2000 when a report from the Institute of Medicine revealed that medical errors were involved in more than 98,000 hospital deaths per year, and in the same year, the Centers for Disease Control and Prevention reported that the annual cost for U.S. hospital-acquired infections was estimated at $5 billion (Ulrich, et al., 2008). These findings resulted in a promising new direction in healthcare design where gardens were created for specific patient populations through a collaborative design process with clinical staff, former patients, therapy occupations, and maintenance staff. But it could also be argued that any garden can have a therapeutic effect and aid in the healing process if thoughtfully designed with the users’ needs placed first and foremost at the center of the design process.
In the 21st century, the goal is to continue to train more professionals in this specialized area and gather additional evidence on how the design of therapeutic gardens can more appropriately support the healing process for specific diseases and injuries. What specific design components lead to the creation of an environment that supports health benefits? How might healing gardens become an integral part of the healthcare design process? With the recent trend toward more outpatient facilities, we may need to rely on all landscape types to provide restorative qualities. Fortunately, most of the evidence-based design guidelines for healthcare gardens can be applied to any site, as they are developed from the foundational principles of design, access for all, and creating aesthetically pleasing and sustainable landscapes designed to meet users’ needs.