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JAD June 2012, no.

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Art and Design Discourse

RESTORATIVE GARDEN DESIGN:


Enhancing wellness through healing spaces
M. Susan Erickson
RLA, PLaCE Program Coordinator, College of Design, Iowa State University

Abstract
Creating gardens as places for restoration of good health and wellness has been observed throughout history, from ancient
times up through the present. Current research from a variety of academic disciplines reveals that contact with nature provides
stress reduction, which in turn leads to improved health outcomes. This research leads to additional questionswhat kind of
contact with nature? How much? Are there certain types of plants which are more therapeutic than others? A look at the existing
knowledge base reveals a complexity of variables which prohibits a formulaic approach to garden design for best health
outcomes. However, careful study of the field reveals factors of garden design which should be considered in order to achieve
maximum restoration for garden users.
Gardens which are designed for stress relief have four primary considerations embedded in the design: social support for
garden users; provision of privacy and control; opportunity for physical activity and movement; and provision of nature elements.
Universal design, which provides accessibility to the greatest possible range of garden users, should also be a consideration of
any restorative garden space.
Furthermore, landscape architects and other garden designers must design for the users and the anticipated uses of the garden.
Gardens in healthcare settings have three primary user groups patients, staff, and visitors. The needs of each must be
considered in the garden design. Garden designers must be aware of specialized needs of garden users. A garden which is
designed for cancer patients undergoing chemotherapy treatments will have very different design requirements from a garden
designed for patients recovering from joint replacement surgery. A garden designed for a hospice setting will have a totally
different set of design requirements altogether. In addition, it is critically important that the garden designer consult the
therapists who will use the garden space for patient activities. Bringing together the expertise of therapist and garden designer
yields tremendous value to the garden design.
A landmark study which looks at where people choose to go when stressed is examined, and new versions of the same survey
are reviewed. Results of the new surveys are puzzling, and yield new questions. Suggestions for new areas of research are also
given.

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Health is defined as a state of complete physical, mental, and


social well-being and not merely the absence of disease or
infirmity. (World Health Organization, 1946)

Introduction
Throughout history, contact with nature has been viewed as
beneficial for health and well-being in widely different
cultures. From ancient healing springs to medieval monastic
cloisters and continuing on to tuberculosis sanatoria in the
early twentieth century, contact with nature was believed to
be beneficial for individuals who were troubled in body, mind,
or spirit. However, during the twentieth century the
connection between healing and nature was gradually
severed, as technology took on a greater role in the medical
community indeed, in Western culture as a whole.
Healthcare
designers
and
administrators
became
preoccupied with creating environments that were functional
and efficient. The need to accommodate modern
technologies in healthcare facilities overshadowed
previously-held beliefs about the importance of providing
therapeutic elements such as gardens. As a result, this new
functional emphasis produced environments that were
efficient but starkly institutional. These types of environments
are now considered stressful and unsuited to the emotional
and psychological needs of patients, visitors, and staff
(Horsburgh, 1995; Malkin, 1992; Ulrich, 1992).
By the late twentieth century, however, a growing awareness
appeared in regards to the benefits of patient-centered
healthcare facilities. In addition, a body of research began to
be published relative to environmental characteristics that
help patients cope with psychological and physical effects of
sickness. Some of these environmental characteristics
related to design of the healthcare facility itself, but other
characteristics related to contact with nature, such as in a
healing garden or nature views through a window (Ulrich,
1995). Researchers investigated a broader concept of health
and wellness, addressing other incidents of contact with
nature and its benefits to a larger audience. Much of this
research focused on the ways contact with nature provided
stress mitigation for everyday situations, and did not focus
solely on healthcare environments (Hartig et al., 1991;
Kaplan, 1995; Ulrich et al., 1991b; Wilson, 1984).
Current knowledge relative to restorative garden design has
progressed. This paper will begin with a cursory overview of
a broad concept of health and wellness and proceed to look
at Kellert and Wilsons work on biophilia and biophilic design,
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proceeding on to examine in detail Ulrichs Theory of


Restorative Garden Design and its implications for gardens
in healthcare facilities. The paper finishes with a recent
survey that yielded puzzling results and a call for additional
areas of research.

Health and wellness


The World Health Organization defines health as a state of
complete physical, mental, and social well-being and not
merely the absence of disease or infirmity (Organization,
1946). This holistic definition of health provides a suitable
platform for beginning a discussion of restorative garden
design. Because the creation of literature relating to
restorative gardens is in its infancy, the field has not yet
come to authoritative definitions for its component parts. For
the purposes of this paper, the following working definitions
will be used. A new student of restorative and therapeutic
garden design will gain greater conceptual understanding of
the field by keeping these definitions in mind.
z Curing: is defined as eliminating all evidence of disease.
z Healing is a natural process. Healing goes deeper than
curing and must always come from within. Healing
involves becoming whole.

Dimensions of wellness
A state of wellness is achieved when the many dimensions of
a persons life are in balance when a person is whole.
Many models exist which portray dimensions of wellness -- a
detailed discussion of models of wellness is beyond the
scope of this paper. This particular model portrays a balance
between six dimensions of life and health physical, social,
environmental, emotional, spiritual, and intellectual. The
wheel portrays each area in balance with the others, calling
attention to the importance of nurturing all dimensions of life
in order to achieve wellness. When one (or more) area
becomes out of balance, wellness is compromised. One
common result of being out of balance is experiencing stress.
Modern society and life styles are full of stressful events at
home and at work; these events result in new states of ill
health (Annerstedt & Wahrborg, 2011). Stress interferes with
wellness in a myriad of ways. Stress, and ways to mitigate its
effects, has been well-studied over the last several decades.

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medications, and received less negative comments from


nurses (Ulrich, 1984). Long-term overall improvement on
health and well being has also been well-documented, most
recently by a ten-year study of vacant lot greening in
Philadelphia, PA USA. In this statistically rigorous study,
residents reported less stress and increased physical activity
levels in neighborhoods where vacant lots were turned to
community garden spaces. Reduced crime rates were also
reported in these neighborhoods (Branas et al., 2011).
Long-term overall benefits of contact with nature for large
population groups were explained by Wilsons biophilia
hypothesis (Wilson, 1984).

Figure 1. Dimensions of Wellness Chart

Existing research: Access to


nature can enhance wellness
Research from many quarters, including the fields of
healthcare, psychology, design, public health, and other
disciplines indicates that access to nature can enhance
health and wellness. Annerstedt and Wahrborg (2011)
propose three main kinds of public health effects related to
nature: short-term recovery from stress or mental fatigue,
faster physical recovery from illness, and long-term overall
improvement on health and well being. Wilson (1984)
addressed the premise for using contact with nature in the
treatment of diseases more than twenty-five years ago with
his biophilia hypothesis.
Short-term recovery from stress or mental fatigue has been
well-studied. Studies agree that nature views are more
effective in reducing psychological and physiological stress
than urban views, and lead to more positive feelings in
subjects (Hartig et al., 2003; Ulrich et al., 1991b). Faster
recovery from illness has also been documented. The
best-known study included surgery patients in a hospital,
some having a view of a tree from their bed, and others
having a view of a brick wall. The patients with a view of a
tree had shorter hospital stays, needed less severe pain

The biophilia hypothesis suggests that there is an instinctive


bond between human beings and other living systems. In
further exploration of this concept, Stephen Kellert (2008)
investigated the idea of biophilic design, which he defined as
the deliberate attempt to translate an understanding of the
inherent human affinity to affiliate with natural systems and
processes into the built environment. He noted that people
living in proximity to open spaces report fewer health and
social problems, and that even the presence of grass and a
few trees has been correlated with enhanced coping and
adaptive behavior. Individual conditions are ameliorated by
contact with nature, but benefits translate to the greater
community as well. Communities with higher-quality
environments report more positive valuations of nature,
superior quality of life, greater neighborliness, and a stronger
sense of place than communities of lower environmental
quality. These findings were found to apply in poor urban as
well as more affluent and suburban neighborhoods.
Biophilic designs are based on six elements or attributes.
These designs generally include:
z Environmental features
z Natural shapes and forms
z Natural patterns and processes
z Light and space
z Place-based relationships, and
z Evolved human-nature relationships (Kellert, 2008).

Ulrichs Theory of Restorative Design


Dr. Roger Ulrichs theory of restorative garden design is
based on theory and research in the behavioral sciences and
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health-related fields. His theory proposes that gardens in


healthcare situations are important stress mitigating
resources for patients and staff because they foster:
z Social support
z Sense of control
z Physical movement and exercise
z Access to nature and other positive distractions (Ulrich,
1999).
Research-based evidence exists to show that each of the
four restorative components mentioned above can reduce
stress and thereby improve other health outcomes. It must
be noted that gardens at healthcare facilities serve a wider
population group than the patients / residents. Families and
visitors, as well as staff, are also important users of these
outdoor spaces. An engaging garden can provide a venue for
activity, topics of conversation, and memory cues for both
visitors and patients. These garden features can enhance
the quality of the visit, which in turn enhances health
outcomes for the patient and brings visitors back more
frequently. Staff are another important user group for outdoor
spaces at healthcare facilities. Staff often have stressful jobs
and frequently have no place to go for a break. Garden
spaces can provide a sorely needed escape from the
pressures of the job.

THEORY OF RESTORATIVE GARDEN DESIGN:


(Roger Ulrich, 1991, 1999)

SOCIAL
SUPPORT

SENSE OF
CONTROL

Patients
Family
Staff

Privacy
Choices
Escape

PHYSICAL
MOVEMENT/
EXERCISE
Exertion
Rehabilitation

NATURE &
DISTRACTIONS
Plants, Flowers,
Water, Wildlife,
Nature Sounds

STRESS RESTORATION & BUFFERING

IMPROVED HEALTH OUTCOMES


Figure 2. Ulrich Theory of Restorative Garden Design

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Social Support
Social support is the first major component in the theory of
restorative garden design model. Generally, social support
refers to perceived emotional support or caring, and material
or physical aid, that a person receives from others (Brannon
& Feist, 1997). A large body of research has shown that
people who receive higher levels of social support are
usually less stressed and have better health status than
persons who are more socially isolated (Cohen & Syme,
1985; Shumaker & Czajkowski, 1994) In fact, low social
support maybe as great a risk factor in mortality as is
cigarette smoking (Berkman & Syme, 1979).

Figure 3. A pleasant garden setting with attractive seating


increases social support, which leads to improved health
outcomes. Rady's Childrens Hospital, Marlon's Courtyard.
San Diego, CA USA
Design considerations. Social support benefits of gardens
will be increased by design that promotes social interaction
among small groups. While there may be instances when
design for larger social groups is desirable, providing spaces
for small groups should always be part of the garden design.
Garden settings that do not accommodate the need for
privacy will likely be underutilized. Consideration should also
be made for diversity in the way different ethnic groups and
cultures enjoy using outdoor spaces. For example in some
cultures it is customary for large family groups to gather as a
way of offering social support to a sick family member. In
these instances provision should be made for a large group
to gather in the garden.

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Sense of Control
Providing a sense of control is the second major component
in the theory of restorative garden design model. Much
research has shown that a sense of control is an important
factor affecting a persons ability to cope with stressful
situations. Control refers to peoples real or perceived ability
to determine what they do, and to determine what others do
to them (Gatchel et al., 1989). Generally, people who feel
they have some control over situations cope better with
stress and have better health status than people who feel
they lack control. Lack of privacy is also considered a
stressor, related to lack of control over regulation of personal
exposure. Stress related to lack of control has been shown to
have many negative effects, including depression, reduced
cognitive performance, elevated blood pressure, higher
levels of circulating stress hormones, and suppression of
immune functioning (Schulz, 1976; Weiss et al., 1990).
Much of the stressfulness of hospitalization has been linked
to loss of control, for example, loss of privacy, inability to
choose clothing, meals, and room temperature, unfamiliarity
with buildings, and complex wayfinding. In response to these
stressful aspects of facility design and operation, many
hospitals and residential healthcare facilities have begun to
offer more patient-centered care, allowing for more choices
and autonomy for patients and visitors. Healthcare staff can
also be positively affected by providing a sense of control in
their workplace. Greater involvement in decision-making
processes has been shown to improve job satisfaction and
reduce turnover in a study of nursing home aides (Waxman
et al., 1984).
Well-designed gardens offer an opportunity for patients, staff,
and other garden users to increase feelings of control. This
phenomenon has been well-studied in parks and other
recreational facilities (Ulrich et al., 1991a). However, only a
small amount of research has focused directly on gardens in
healthcare facilities. Cooper Marcus and Barnes (1995)
found that garden users reported restoration from stress
when they had the opportunity to exercise control over their
situation and escape to the garden.

Figure 4. Choices in seating, both in type and location,


provide a sense of control for patients, visitors, and staff.
Methodist Hospital, Des Moines, IA USA
Design considerations. One of the most important design
considerations in a garden at a healthcare facility is
accessibility. Accessibility is manifested in several ways
can users find the facility without difficulty? Is the door
unlocked? Does the garden design allow users to interact
with the garden, either actively or passively? (Cooper Marcus
& Barnes, 1999). Garden designs that allow control by
garden users will offer choices whenever possible. These
choices may relate to seating, social grouping, and
environment, to name a few. For example, seating may be
provided as individual chairs or benches, with or without
armrests, fixed or moveable, and alone or in small or large
groups. Garden paths and seating may be located in sunny
and shady areas. Privacy should also be a consideration, for
garden users as well as for patients who may have rooms
with windows that look out onto the garden.

Physical Activity and Movement


Providing opportunity for physical activity and movement is
the third major component in the theory of restorative garden
design model. Regular physical activity goes beyond
benefitting the physical dimension of wellness, and in
addition contributes significantly to other dimensions. Many
psychological or emotional benefits of exercise have been
recorded in scientific literature. For example, exercise has
been linked to alleviating depression and producing other
positive psychological changes in physically impaired older
adults, such as patients with chronic obstructive lung disease
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(Emery & Blumenthal, 1991). Similar positive outcomes have


been observed in younger age categories (Ulrich, 1999). It is
important to note that beneficial physical exercise does not
need to be rigorous -- even mild exercise has been linked to
positive health outcomes (McNeil et al., 1991).

Figure 5. Providing opportunities for physical activity and


movement is an important element of restorative garden
design. National Museum of the American Indian,
Washington DC, USA
Design considerations. Gardens can be effective vehicles
for encouraging both exertion and rehabilitation, offering a
much more pleasant setting than facility corridors or the
physical therapy laboratory. Careful planning of garden
spaces will include input from the various therapists that work
with patients art therapists, horticulture therapists,
recreational therapists, and occupational therapists, perhaps.
These professionals have great wisdom to offer relative to
the movements and exercises that are desirable for their
patients. In areas with cold winters or extremely hot summers,
viewing opportunities may be important to consider as well.
For example, a corridor with windows looking out on the
garden may entice a longer walk than a corridor with no
outside views.
Other garden user groups should also be considered when
designing opportunities for physical activity and movement in
the garden. As mentioned previously, the garden is an
important place for staff to escape from the rigors of their
work. Another important user group is visitors usually
friends and family members of a patient. Well children who
come to visit sick siblings or other family members at a
hospital or other care facility benefit greatly from the
opportunity for physical activity and movement in the garden
setting.
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Nature as Distraction
Natural distraction is the fourth and last major component in
the theory of restorative garden design model. Nature can
engage a patients interest (thereby distracting from pain,
stress, or feelings of sickness), without requiring energy input
(Kaplan, 1995). Others agree, yet caution that a
well-designed garden with optimal restorative design
features will engage all the senses, and not just visual
sensations (Stigsdotter & Grahn, 2002). Garden designers
will do well to heed her caution.
Ulrich (1992) notes that positive distractions, such as those
found in nature, may block or reduce worrisome thoughts,
and foster beneficial changes in physiological systems such
as lowered blood pressure and stress hormones. Even views
of certain nature scenes can significantly reduce stress.
Stressed patient groups in a variety of settings from a dental
office to a pre-surgery ward all experienced more positive
health indicators when exposed to serene nature scenes
(Heerwagen, 1990; Katcher, Segal, & Beck, 1984). Although
studies are rare that examine potentially favorable influences
of gardens on patient stress and other medical outcomes, it
appears that even acutely stressed patients can experience
significant restoration after only a few minutes of viewing
nature settings with greenery, flowers, or water. It is also
important to note that viewing gardenlike scenes apparently
mitigates pain (Ulrich, 1999).

Figure 6. Lush vegetation and flowers are important


restorative elements of nature. Bible Garden. Guthrie
Center, IA USA

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Design considerations. It is important to note that sunlight


can have distinctly healthful influences on many patients, but
negative effects on others. In one study, 25% of the people
interviewed in healthcare gardens mentioned sunlight as a
garden quality that helped foster improved mood and
restoration (Cooper Marcus & Barnes, 1999). Sunlight also
plays a key role in enabling humans to benefit from intake of
vitamin D. However, some medical conditions, as well as
some prescription medications, alter the bodys response to
sunshine and for these patients, sunshine must be avoided.
Gardens will tend to ameliorate stress effectively if they
contain verdant foliage, flowers, nonturbulent water, park-like
qualities (grassy spaces with scattered trees), nature sounds
such as birds, breezes, and water, and visible wildlife (Ulrich,
1999). Incorporating these features into a garden, in concert
with information about garden uses and users, will provide
restorative benefits to garden users.
Conclusion. These four factors social support, sense of
control, physical movement and exercise, and nature as
distraction all work together to provide restoration from
stress and buffering. According to Ulrichs theory, this
restoration then leads to improved health outcomes. Any
landscape can be designed with these principles in mind, to
promote the healing quality of the particular space, and
promote balance and wellness for the users of the space.

Applications of Ulrichs theory


Ulrichs theory of restorative garden design provides a
workable framework for the design of healing spaces. We
now turn to some practical applications of his theory in
specific healthcare facilities.

Designing for specific population groups and


garden uses
When designing a garden for a healthcare facility, the
designer must research uses and users of the garden. The
principles of universal design -- providing accessibility for the
greatest possible range of garden users -- should be a first
consideration. Detailed specifications are available for
interior and exterior applications and new construction in the
US must conform to these specifications (Osterberg, 2010).
Design for maximum wellness, however, goes beyond the
specifications of universal design and works to engage all
the senses in experiencing the space.

Landscape architects and other garden designers are well


qualified to prepare garden designs and even to anticipate
ways the garden will be used. However, additional wisdom
can be gained from therapists and nursing staff. It is critical to
incorporate their knowledge of potential activities and garden
uses into the space design. Therapists such as horticulture
therapists, art therapists, recreation therapists, occupational
therapists, and physical therapists may all have unique and
specific ideas of therapeutic activities that might be
conducted in the garden setting. As mentioned previously,
better outcomes may be achieved for therapies conducted in
a pleasant garden setting, as compared to the same
activities conducted inside the healthcare facility.
In addition to gathering input from therapists and nursing
staff, the landscape architect or garden designer should
research specific needs of the population that will be using
the garden. One population group that will be requiring
special design attention in the near future is the increasing
elder population. Many of the principles of universal design
are especially well suited to the needs of elder segments of
the population. For example, providing wider sidewalks and
walking paths with wheelchair-accessible ramps and paved
ground surfaces are helpful design strategies for those with
mobility impairments. Some older garden users may want to
participate in gardening activities but have trouble bending
over to reach the ground. Raised bed planters can be a
helpful solution in these cases. Raised beds provide easy
access to gardening activities for those who cant bend over.
If the edge of the bed is adequately sturdy and wide, the
planter can also function as a place to sit. This is a helpful
strategy for those who have trouble standing for long periods
of time. Specialized gardening tools which are ergonomically
designed may also be helpful for older patients who
experience difficulty with arthritis. Container gardens are
another easy way to offer accessibility; they can be easy to
manage in a variety of locations. Containers that move about
on wheeled platforms can also promote garden use by those
with reduced mobility.

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Figure 7. wide sidewalks allow plenty of space for circulation


in the garden., even for those in wheelchairs. Moving
benches off the path enhances feelings of privacy. Methodist
Hospital, Des Moines, IA USA

Chemotherapy
Garden.
Chemotherapy
may
be
administered in an outpatient facility where patients must sit
for several hours receiving their treatment. They may be
allowed to take their treatment in the garden, or more likely
they will view the garden through a window during their
treatment, perhaps relaxing in the garden afterwards.
Chemotherapy treatments often render patients more
sensitive to the sun, and more sensitive to smells. Gardens
that will be used by patients undergoing chemotherapy
treatments should always provide some type of shelter from
the sun. Plants should also be chosen carefully for low-odor
flowers and foliage. It is important in all healthcare gardens
to provide ongoing maintenance; poorly maintained or dead
plants can induce negative thoughts and feelings in patients
who use or view the garden. Chemotherapy patients may be
the population most in need of well-maintained garden plants
and views.
Patients who are undergoing chemotherapy treatment
usually visit the facility numerous times over a period of
several weeks or months, and a family member or caregiver
may accompany them. A pleasant garden space can also
provide a place of respite and stress reduction for caregivers,
who suffer from their own particular troubles when a loved
one is not well.

Figure 8. Raised bed gardens offer access to planting activity


for those who are unable to reach down to the ground level.
Minneapolis Landscape Arboretum, Minneapolis, MN USA
Universal design principles should be followed in nearly all
landscape design situations. Specialized gardens for the
elderly are appropriate for locations such as nursing homes
and assisted living facilities. In addition, there are many other
specialized garden typologies in which the theory of
restorative garden design can be beneficial. Some special
design requirements of those specialized typologies are
explored below. This list is neither comprehensive nor
exhaustive but is provided as a starting point for the
beginning student of healing garden design.
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Figure 9. Gardens for patients undergoing chemotherapy


treatment must use plants with minimal scents. Carolyn S.
Stolman Healing Garden. San Francisco, CA USA

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Figure 10. Shade and seating are important features in the


garden for chemotherapy patients. Chalice Well Garden,
Glastonbury, England
Hospice Garden. A hospice facility is generally intended for
patients who are no longer receiving medical treatments in
search of a cure, but who are preparing to die. Comfort in all
dimensions of wellness is the principle treatment plan for
patients. Hospice facilities are designed to be restful places
that evoke feelings of comfort and home. These facilities
often have quite lovely gardens, as feelings of home are
evoked by strong ties to the out-of-doors. Patients who are
receiving hospice care may be confined to the bed, so
doorways should be wide enough to accommodate a rolling
hospital bed. Some patients will enjoy time spent outdoors,
even from their bed. The senses of hearing and smell can be
the last senses to depart, so planting designs should
consider those senses when plants are being selected.
Places for solitary meditation and contemplation are
important at hospice facilities, as well as places for small
groups of family members to talk and gather.
A hospice facility is sure to host family members of all ages.
Hospice gardens should provide features that would engage
a young childs attention and provide an invitation for activity.

Figure 11. Porches at this hospice facility lend a cozy feeling


of home and blend the transition between indoors and
outdoors. North Iowa Hospice, Mason City, IA USA

Figure 12. Providing a grassy area to run around and a swing


set makes families with children feel welcome at a hospice
facility. San Diego Hospice, San Diego, CA USA
Rehabilitation Gardens. Rehabilitation gardens host more
vigorous activities. They provide opportunities for patients to
develop life skills and rebuild strength. Patients may be in
rehabilitation for physical, emotional, or mental disabilities.
This type of garden should be very specifically tailored to the
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needs of the garden users. When designing a garden of this


type, landscape architects and garden designers should
work closely with therapists who will bring their patients to
the garden for therapy activities.

Figure 13. This rehabilitation garden provides opportunities


to practice navigation in the world outside the hospital doors.
Here, patients can practice walking on a variety of ground
surfaces as well as stepping up and down a curb. Magee
Rehabilitation Hospital

It is extremely important for landscape architects and garden


designers to be well-educated and prepared when
undertaking restorative garden design. Learning should
never end--the state of research relative to health benefits of
contact with nature is in its infancy and a wise designer will
stay abreast of new information. This saves time and money
for healthcare facilities, and provides best quality of life and
optimum wellness for those who use the garden.
As described above, a wealth of research exists which gives
convincing evidence that contact with nature is linked to
positive outcomes for human health and wellness. Kellert
(2008) writes that with humility and understanding, effective
biophilic design can potentially enrich both nature and
humanity. In addition, he maintains that human wellbeing is
highly contingent on contact with the natural environment,
which is a necessity rather than a luxury for achieving lives of
fitness and satisfaction even in modern urban society
(emphasis added). However, Kellert writes that human
affinity for contact with nature, biophilia, is a weak biological
tendency that is reliant on adequate learning, experience,
and sociocultural support for it to become functionally robust.
In addition, if human biophilic tendencies are insufficiently
stimulated and nurtured, they will become atrophied and
dysfunctional.
Modern urban society, therefore, must integrate contact with
nature into the design of places where people live, work,
learn, and play in order to achieve maximum wellness for
people individually and for society as a whole. This may be a
difficult challenge, on two fronts. People are spending more
and more time indoors in sedentary pursuits, often in front of
a screen of some type television, computer, electronic
games for example. When people do venture outdoors, they
may lack access to natural environments, or even
environments with restorative properties (Louv, 2005, 2011).
All people may not respond the same way to natural
environments. Certainly some elements, such as inner peace
and a deep experience of love are universal to nearly all
people as healing qualities. There are also common
conditions of healing, such as care from friends and family,
laughter, music, and great art. There are also unique
conditions of healing which apply to individuals and which
are based on individual personality and preferences (Lerner,
1996).

Figure 14. Patients have opportunity for active and passive


recreation at this rehabilitation garden. Sharps Recovery
Garden, San Diego, CA USA
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Questions about stress restoration and individual


preferences were raised in a recent survey of university

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students. This survey yielded some puzzling results and


warrants further investigation.

Individual preferences relative to


stress responses and restoration
A landmark study was performed in 1992 which investigated
where people choose to go when stressed. The study, by
Francis and Cooper Marcus, involved a sample of 154
university students, mostly from the department of
Landscape Architecture. They were asked to recall an
occasion when they had been feeling particularly stressed,
upset, depressed, angry, confused, or grief-stricken, and
they had gone to a particular place that helped them feel
better. They were asked to describe the place, what
happened to them there, and which specific elements or
place qualities seemed to lift their mood. In survey results,
respondents showed a marked preference for outdoor
settings 71% of the sample of 154 students. 40% of the
students described natural settings and 31% described
designed outdoor settings such as a park or college campus
(Cooper Marcus & Barnes, 1999; Francis & Cooper Marcus,
1992). Findings from this survey align quite well with Ulrichs
theory of restorative garden design, the principles of biophilia,
and available research about the health benefits of contact
with nature.

contrast, 54% of the students mentioned a home setting


whether their own home, their familys home, or their
university residence. 17% chose an urban or built setting
such as the gym or a coffee shop, and a very few
respondents 3%, mentioned their car.

Where do you go when stressed? Iowa 2011

Figure 15. Iowa 2011 study

Where do you go when stressed?


Iowa 2011 vs. Francis and Cooper Marcus 1992

Two more recent surveys, conducted in 2011 and 2012,


yielded puzzling results which raise more questions than
answers. They are included here as an invitation to further
inquiry by the scientific community.
In the first survey (Iowa, 2011), 78 American university
students were asked the same questions as in the previous
study by Francis and Cooper Marcus: Recall an occasion
when you felt particularly stressed, upset, depressed, angry,
or confused, and you went to a particular place that helped
you feel better. Respondents were asked to describe the
place, how they felt after spending time there, and what
qualities were important in the place. Students were not from
an environmental or design background. The study was
administered in a sophomore-level housing class; students
were primarily from the College of Human Sciences. These
students responses were quite different. Where in the 1992
survey, 71% preferred some type of outdoor environment,
only 29% of the 2011 survey group mentioned an outdoor
environment 19% mentioned a natural setting, and 10%
mentioned a designed outdoor setting such as a park. In

Figure 16. Iowa 2011 vs. Francis and Cooper Marcus 1992
study
Several factors could account for the difference between the
two studies. There was a twenty-year gap between the two
studies. A new generation of university students has arrived
and perhaps their biophilic tendencies have atrophied, as
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Kellert suggested. Also, the students from the 1992 study


were mostly landscape architecture students and were likely
more environmentally conscious and in tune with human
biophilic tendencies. The second study, conducted in early
2012, raises even more questions.
This study was conducted in Taiwan, and administered to a
university group. This survey population was a combination
of students and faculty. Only the responses from the 18-29
age group are included here, in order to eliminate age bias in
responses. This survey is very small in comparison, with 22
respondents. The survey questions were the same as in the
2011 study. Responses from this study were much closer to
the 1992 survey responses. 63% of respondents recalled
going to an outdoor setting when they were stressed 45%
mentioned a natural setting and 18% mentioned a designed
outdoor setting. 32% mentioned a home environment, in
contrast to 54% in the 2011 survey of American students.

Where do you go when stressed?


All studies

or June, for example. The point in time of the academic year


might also be a factor. The 2011 study in Iowa was
performed just after Thanksgiving break, during the last week
before final exams for fall semester. Students might have
been pulled emotionally towards home in their survey
responses, as they were approaching their migrations home
for holidays and the month-long break between semesters.
The 2012 survey responses in Taiwan were conducted in
early January. Their survey responses may have been
different if the survey had been given a few weeks later, as
students were preparing for final exams, semester break,
and trips home to celebrate the Chinese Lunar New Year.
After looking at these three surveys, it appears that more
data is needed before firm conclusions can be drawn. If
further surveys are undertaken, data should also be recorded
about when and where the survey is administered. In spite of
all the questions raised above, some preliminary conclusions
can nevertheless be proposed from the survey results.
Certainly one can infer that, as Lerner proposed, a common
element of places that provide healing and restoration for
some people is an outdoor space of some type. Universal
elements of places that provide healing and restoration are
not evident from this data set. Many people from 29% to
71% -- report that they are restored by immersion in an
outdoor environment, and a slight preference is seen for
natural settings over designed outdoor settings.

Conclusion

Figure 17. Comparison of all three studies


Of course no firm conclusions can be drawn from these small
studies. Questions about the surveys can be raised, however.
Survey validity and reliability can both be called into question.
The 1992 study was performed in California, USA, the 2011
study in Iowa, USA, and the 2012 study in Taiwan. The
climates of California and Taiwan are much more moderate
than Iowas climate. The survey was conducted in early
December in Iowa, just when cold winter weather was
beginning. Perhaps considerations of outdoors as a
restorative place would be more prevalent in Iowa if the
survey was conducted in months of pleasant weather-- May
100

Over the last quarter century a good deal of research has


been performed to investigate the health benefits of contact
with nature. A solid foundation of evidence exists which
confirms positive health benefits when people have access
to nature, either by immersion, such as being in a park or
garden setting, or by visual access, such as a view through a
window. These health benefits are valid for many population
groups patients in healthcare settings such as hospitals,
medical offices, dental offices, nursing homes, and assisted
living facilities; they are also valid for college students under
stress as they prepare for a test, retail employees at the end
of a mentally taxing day at work, or children on their way to
school.
Incorporating the principles of Ulrichs theory of restorative
garden design has many potential benefits to society in
diverse arenas, from gardens in healthcare facilities to public
parks, schoolyard designs, and civic plazas. The value of
implementing these principles is difficult to quantify, due to

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Art and Design Discourse

the complex nature of the question. Certainly research


shows us that benefits would accrue to society as a whole if
these design features were implemented on a wide scale.
Future research that can begin to quantify the benefits would
be valuable indeed to convince decision-makers to
incorporate the principles of restorative garden design in a
wide range of locales from rural communities to major
urban centers.
Other valuable factors for future research studies are specific
causal factors of therapeutic design. It will also be valuable to
track biophilic tendencies of future generations who have
spent much less of their childhood outdoors experiencing
nature. Will they be drawn more to electronic screens for
restoration from stress?
The puzzling survey questions will also merit further study.
This survey likely needs a larger sampling of the population
before meaningful conclusions can be drawn.

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