Research Quadrangle, University of Miami School of Medicine, Miami, Florida (Architect of Record: Karlsberger). Courtesy of Karlsberger
Based on “Design With Nature: An Integrated Design Approach to the Environment of Care”, a presentation at HEALTHCARE DESIGN.06, November 5, 2006, in Chicago by Jerry Smith, ASLA, LEED AP, Senior Associate, The HOK Planning Group, Chicago; Geoffrey Roehll, ASLA, Vice-President, Hitchcock Design Group, Naperville, Illinois; and Laurel Macdonald Bonnell, ASLA, Principal, Macdonald Environmental Planning PC, Portland, Oregon

The phrase “design with nature” was first coined by the late Ian McHarg in his 1969 book of the same name on the environmental effects of site design and land use planning. The concept has been resonating throughout the design community since its inception and has become integrated into the basic tenets of healthcare design.

Over the past 25 years, environmental and social researchers, behavioral psychologists, and design professionals have published hundreds of research documents detailing their metrics and observations on health/nature-related outcomes. This work has been supported largely by philanthropic foundations such as the Robert Wood Johnson Foundation and the Merck Family Fund and sponsored by nonprofit organizations like The Center for Health Design. This growing body of work has provided a platform for site-design concepts and therapeutic principles of nature to become an integral part of the healthcare design process.

Recent Guidelines

Recently, two significant design guidelines have been released that provide the latest and foremost recommendations for design and construction within the healthcare design industry. These documents provide new sections and language that support incorporating direct access to nature as a recommended best practices design parameter. During the presentation at HEALTHCARE DESIGN.06, Jerry Smith, ASLA, LEED AP, of The HOK Planning Group—who is also on the Environmental Standards Council of The Center for Health Design and the Steering Committee of the Green Guide for Health Care (GGHC)—presented a brief review of these guidelines:

Defining the Healing Environment

“Therapeutic garden design” is helping shape future development for many healthcare facilities and retirement communities, yet very few understand what this phrase really means. According to Geoffrey Roehll, ASLA, of Hitchcock Design Group, “therapeutic or healing environments expand upon a holistic approach to healthcare that addresses one's physical, psychological, and emotional well-being through a commitment to the overall healing experience”. This holistic approach goes beyond the traditional method of patient-centered care and responds not only to the patient and residents, but to staff, families, and visitors. This commitment can be carried out in many forms.

“Therapeutic”, “enabling”, “restorative”, “rehabilitative”, or “spiritual” are terms often associated with these spaces, but these terms do not clearly define for whom or for what these spaces are intended. Simply stated, a healing environment is intended to elicit a positive or healthy outcome upon the user. The design and the elements incorporated will depend upon the users and how they are to interact with the space. Whatever the case, a responsible mix of elements that responds to a variety of users and program opportunities is vital to success.

Establishing the elements of a healing environment and the promotion of physical, psychological, and emotional well-being requires a basic understanding of the users and the surrounding facility. Offering amenities that provide choices and challenges within a garden may be appropriate at a rehabilitation hospital in the form of stairs and ramps that can be used for physical therapy and the restoration of body functions. The psychological health of the user is important in settings such as an ICU or skilled care where the patients, families, and staff are often subject to high levels of stress.

This scenario may be best suited by a passive environment designed for small groups or individuals to relax or disengage (figure 1). Within continuing-care settings, it is important to address the emotional health of the residents to reduce the negative effects of depression, anxiety, and boredom. These spaces should engage the residents and promote exercise and social interaction. There are no certainties though, when dealing with any one of these situations. It is this level of uncertainty that requires a responsive and knowledgeable design team to successfully implement a careful blend of elements that responds to various users and their fundamental needs.

Riverside Spiritual Healing Garden, at Riverside Hosptial, Kankakee, Illinois. Courtesy of Hitchcock Design Group, Landscape Architect.

Case Studies

Marianjoy Rehabilitation Hospital in Wheaton, Illinois, commissioned Hitchcock Design Group in nearby Naperville to create an open air courtyard located in the interior of the new expansion hospital (figure 2). The courtyard serves a dual purpose as a space for both relaxation and rehabilitation. Patients are challenged through the incorporation of stairs, varying slopes and ramps, and handrails. Raised planters and a vertical planting wall allow interaction with plant material. The landscape architects designed an interactive water feature to provide interest and soothing background noise within the courtyard, which includes spaces for both large social gatherings and small group interactions.

Healing Garden at Marianjoy Rehabilitation Hospital, Wheaton, Illinois. Courtesy of Hitchcock Design Group, Landscape Architect

The hospital also commissioned Hitchcock Design Group to create a spiritual space for the Wheaton Franciscan sisters and visitors to enjoy. The 1,520-square-foot Chartres Labyrinth is centered in a sunken plaza accessible from the surrounding hallway. Symbolism is threaded throughout the garden, including the use of sacred geometry to dictate the number of plantings, site furniture, and hardscape elements. Visitors enter the labyrinth facing east with a view of an unordered landscape. As they exit facing west, the view is of three ordered trees, reflecting the spiritual journey.

At the Samaritan Regional Medical Center Campus in Corvallis, Oregon, the master planning process was taken a step further. The development pressures for this 50-acre regional facility were such that the City Planning agency insisted that the hospital develop two-, five-, and 10-year development master plans that would address principles and policies for the campus, planning areas, facility needs, development standards, parking, and transportation demands and implementation schedule. To develop these plans, a team of consultants assembled to address their related disciplines including facility directors, architects, engineers, traffic consultants, and landscape architects.

The incorporation of healing environments was realized specifically in the Landscape Development Standards prepared as a part of the Development Master Plan. As a component, landscape architects Macdonald Environmental Planning developed a standard plant materials list that defined what plants were to be used in each type of landscape treatment. The treatment areas reflected various natural environments, including building entrances, major and minor roadway landscaping, parking lot landscape treatment, outdoor cafés, healing gardens, meditation gardens, and rooftop terrace areas. The standards tied to each development project ensure a unified campus appearance and access to nature regardless of when during the 10-year planning period they would be constructed.

From the standpoint of a healthcare group, Samaritan Health Services in Oregon recognized that to provide better care, there was a need to unify the access to healing environments at all of the seven facilities they manage. To accomplish this, Macdonald Environmental Planning and representatives from each facility were selected to participate in the six-month master planning process where existing conditions, questionnaires from healthcare providers/patients/community representatives, and facility development plans were evaluated to determine where the deficiencies and opportunities for healing environments existed.

Through this evaluation process, a short list of opportunities and their associated costs was developed at each facility. Laurel Macdonald Bonnell of Macdonald Environmental Planning states that “even as various facility additions at medical center campuses finally do get funded and are in the design process, there are still significant risks to having the healing environments outcome compromised”. At the very least, this prioritized list emphasized the importance of incorporating these healing environments to the front of the facility strategic planning process and to tie their funding to the capital improvement development plan.


Healthcare landscape designers are not only involved in placemaking, but also in facilitating an integrated design process. Incorporating access to nature within the healthcare facility requires a concerted and proactive effort by an integrated team of design professionals through all phases of the design and construction process. By establishing guiding principles early in the initial visioning sessions that are accepted and supported by the design team throughout the process, the built product will be one that is infused with opportunities for health benefits that interaction with nature provides.

The environment of care is distinguished by the focus on the users of these facilities—patients, family/visitors, and staff—and how the physical environment influences the way those interactions are perceived and translated. How attributes of nature are observed and perceived, how that perception is interpreted and, more specifically, how that interpretation yields positive health outcomes are the leading questions that need to be addressed. By identifying stress as a common indicator in all of the user groups in the environment of care, the answers to these questions can be more tangible and attainable. HD

Senior Associate at HOK Planning Group, Chicago.