It’s been 30 years since the publication of Roger Ulrich’s seminal article “View Through the Window May Influence Recovery from Surgery,” which kick-started the incorporation of access to nature as an essential component of the healing environment. Much has happened in these three decades. Gardens are now less likely to be seen as cosmetic extras and eliminated through value-engineering.

Award-winning projects in Healthcare Design magazine and elsewhere frequently feature “healing gardens” and/or views to nature. The Chicago Botanic Garden offers a certification course on healthcare garden design, and the American Society of Landscape Architects’ annual conference includes sessions on healthcare design research and practice, as well as field trips to local exemplary sites. And a growing number of researchers are studying the effects of contact with nature on human health and well-being.

Useful and practical guidelines, many based on empirical research and best practices from the industry as a whole, can help designers make educated decisions with their healthcare clients. So much is now known about the needs of patients, staff, and visitors in outdoor healthcare spaces that it’s incumbent upon decision makers to focus attention on who, exactly, is likely to use that space.

While landscape designers must follow general design guidelines for all healthcare garden users, specific populations often need specific design considerations. Below, we outline design practices that are important for all populations, as well as those that address the needs of three specific patient types: the frail elderly, people with Alzheimer’s and other forms of dementia, and people with mental and behavioral health disorders.

Acute care hospitals
In acute care hospitals, the patient population is incredibly varied, including people who may also be treated at more specialized facilities. Thus, design must accommodate a wide range of users, with the needs of the most vulnerable patients coming first. Patients using the garden could include a person awaiting minor surgery; someone recovering from a hip replacement who is urged to walk and seeks smooth pathways with frequent places to stop and rest; a person who has received outpatient chemotherapy and needs to recuperate—in the shade—before driving home; or a sick child being wheeled through a garden as respite from frightening medical procedures.

Overarching considerations for gardens in all healthcare facilities include safety, security, and privacy, visual and physical accessibility to and within the garden, physical and emotional comfort, and proper maintenance. It should go without saying that gardens must feel like gardens, with a high ratio of greenery to hardscape and a great variety of vegetation appealing to all the senses. Other important design elements include plenty of choices as to where to walk, sit, or look at a view; places to sit with a family group, and places to be alone; ample shade for those who need to stay out of the sun; and walking paths of varying lengths. All of these requirements also apply to visitors and staff using the garden, the latter often being the largest group present. Unless the designer takes into account these pragmatic needs, and avoids the temptation to push the envelope with flashy design statements, the garden may fail to meet the needs of those it could help most.

Frail elderly
When we turn to the needs of the elderly in, say, assisted living or skilled nursing facilities or in a retirement community, other needs come into play. All of the basic needs mentioned above are relevant, but in addition, there are requirements that pertain particularly to those whose bodies are becoming more frail–diminished eyesight and hearing, changing posture and gait, brittle bones, and more. Older people are at greater risk of falling, and many venture out less often because they’re unsteady (especially if they have already fallen). Therefore, pathways must be smooth while at the same time offering good traction, and must be very well maintained, avoiding expansion joints between concrete pavers that are wider than 1/8-inch (which could catch a cane, crutch, or walker). As we age, we start to lose energy, which means that places to rest along a walking route must be located every 20 feet or so—the first one being clearly visible from the garden entry.

Moveable seating is important for all age and patient groups, to give people (albeit unconsciously) a sense of control. For the frail elderly, such seating must have a back and arms for comfort, be light enough to move, but also be firm enough to remain stable when a person presses the arms to get up. The Adirondack chair, popular in many gardens settings, is unsuitable for the seating posture of an older person and can be hard to get out of. Features that reflect light, such as untinted concrete and white or aluminum garden furniture, should be avoided since aging eyes have trouble adapting to glare.

Additionally, to allow people to adjust to changes in light, and to enable people to be outside even in bad weather or when they are weak, the garden entry should be covered or offer filtered shade as well as places to sit. Since many older people develop cataracts, plants with flowers that have deeply saturated blooms (red, yellow, orange, white) should be selected rather than those in the blue-mauve-purple range (which will be appear to be gray). Very elderly people move slowly and may have developed a slightly stooped posture, so it’s important to provide a variety of planting—in terms of color, texture, and visual detail—at or below eye level. No one wants to take a walk at a slow pace staring down at the edges of a lawn.

Dementia patients
The onset of Alzheimer’s disease and other forms of dementia makes a person particularly vulnerable to an environment that hasn’t been designed for his or her specific needs.  All of the design requirements of a garden for the frail elderly pertain to this group, plus a few others. As spatial cognition declines, people lose the ability to retain a “mental map” of even a familiar environment. There needs to be one entry to the garden and a simple looped or figure-eight path circling the garden, which leads people back to the entry. A fork in the path or a junction that requires the garden user to turn left or right can bring about an agony of indecision, or even agitation and anger. In late stages of the disease, people can regress to putting inappropriate things into their mouths, such as the leaves or flowers of plants. All plant material therefore must be non-toxic. It’s remarkable how many commonly used plants—such as azaleas, oleander, wisteria, daffodils, bleeding hearts, and hydrangea—have toxic elements.

Although people with dementia lose short-term memory and may forget what they did an hour ago, they often retain long-term memory, and the part of the brain that registers emotion remains viable long after other parts have declined. Designing gardens for those with dementia therefore calls for places to enjoy simple pleasures: gardening, watching birds at a feeder, and sitting in a beautiful setting which may include plants, flowers, and cultural artifacts reminiscent of earlier years.

Mental and behavioral health
Garden design for mental and behavioral health patients is a challenge because of the wide demographic range, type of disorder, and course of treatment. As with the frail elderly and people with dementia, safety and security—both actual and perceived—is paramount. Design must address the possibility of attempted escape a
nd harm of self or others. At the same time, the space and elements within the space (plants, seating, paving) should create a homelike, noninstitutional environment that offers a sense of freedom and control for the patients/residents.

Shaded areas within the garden are essential, since many psychotropic medications make people more susceptible to glare and UV exposure. Social support between staff and patients is an important component of in- and outpatient treatment, and the garden should provide spaces for one-on-one and group interaction. Much research has linked exercise—even mild exercise for short periods of time—with reduced stress, depression, anxiety, and aggression. A garden that provides walking paths and open areas for group exercise offers great physical and emotional benefits. Separate outdoor spaces for staff are encouraged for any healthcare facility, but are even more important in settings where patients may be dangerous. For facilities where patients or residents spend more than a few days and may be unable to venture outdoors, views of greenery and/or indoor planting still allow people to connect with nature.

The research on the health benefits of nature contact that began more than 30 years ago has grown and has, fortunately, become accepted by many healthcare design practitioners and administrators. The reduced demand for “proof” that nature is important allows us to focus on what specific design elements best serve specific populations. The more these elements are taken into account, the more gardens can serve as essential adjuncts to medical care, resulting in increased staff and patient satisfaction, shorter hospital stays for inpatients, better sleep patterns, decreased drug expenses, and fewer demands on staff in all types of healthcare facilities, for all types of patients and residents.

Clare Cooper Marcus is Professor Emerita in the departments of architecture and landscape architecture at the University of California, Berkeley. Naomi A. Sachs is founding director of the Therapeutic Landscapes Network (www.healinglandscapes.org) and a PhD student in architecture at Texas A&M University, focusing on access to nature in healthcare through the Center for Health Systems and Design. They are the authors of Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces (John Wiley and Sons, 2013).