evaluating a children's hospital garden environment ... · evaluating a children’s hospital...

Journal of Environmental Psychology (2001) 21, 301^314 0272-4944/01/030301+ 14$35.00/0# 2001 Academic Pressdoi:10.1006/jevp.2001.0224, available online at http://www.idealibrary.com on

EVALUATING A CHILDREN’S HOSPITAL GARDEN ENVIRONMENT:UTILIZATION AND CONSUMER SATISFACTION

SANDRA WHITEHOUSE1, JAMES W. VARNI

1,2, MICHAEL SEID1, CLARE COOPER-MARCUS

3, MARY JANE ENSBERG,4

JENIFER R. JACOBS1 AND ROBYN S. MEHLENBECK1

1Center for Child Health Outcomes, Children’s Hospital and Health Center, San Diego, U.S.A.2Department of Psychiatry, University of California, San Diego, School of Medicine, U.S.A.

3College of Environmental Design, University of California, Berkeley, U.S.A.4Patient and Family Services, Children’s Hospital and Health Center, San Diego, U.S.A.

Abstract

The Leichtag Family Healing Garden at Children’s Hospital and Health Center, San Diego was planned andbuilt as a healing environment space for patients, families, and sta¡. A Post-Occupancy Evaluation (POE) wasconducted to determine whether the garden was meeting the goals of reducing stress, restoring hope andenergy, and increasing consumer satisfaction. Results from behavioral observations, surveys, and interviewsindicated a number of bene¢ts of the garden. The garden was perceived as a place of restoration and healing,and use was accompanied by increased consumer satisfaction. However, the garden was not utilized as oftenor as e¡ectively as intended. Children, parents and many sta¡ members recommended changes for the garden,such as the inclusion of more trees and greenery, and more interactive ‘things for kids to do’. In addition, themajority of family members surveyed throughout the hospital did not know about the garden. Based on the¢ndings, recommendations for changes were developed to promote better use of the garden. These research¢ndings can be used to guide the future planning, design, building, and subsequent evaluation of garden en-vironments in children’s hospitals and pediatric settings. # 2001 Academic Press

Introduction

The bene¢ts that individuals can derive from plantsand contact with nature have been discussed forthousands of years. Historical accounts suggest thatthis belief was an organizing principle for the ex-emplary hospitals of the past, where a primary goalwas making patients more comfortable (Stein, 1990).As early as the Middle Ages, hospitals within mon-asteries utilized the garden cloister as a place ofhealing (Warner, 1995). Patients’ rooms typically bor-dered courtyards that o¡ered sunlight, a lawn, sea-sonal plants and places to sit or walk. A signi¢cantchange in the treatment of illness occurred in the19th century, when biologists Louis Pasteur andClaude Bernard developed the germ theory of dis-ease. This theoryöthat disease is caused by patho-genic agents and that the host’s resistance and thegerm’s virulence determine the disease’s severityögave medicine a systematic, organized, and much

more successful way to treat and research disease(Lindheim & Syme, 1983). This also caused a changein the way hospitals were designed, from a focus onpatient comfort to a focus on disease treatment. Inaddition, engineering advances of the late 19th cen-tury, such as the elevator and the steel skeletonbuilding, made the high-rise hospital possible. Lay-outs of new hospitals were determined by the newdiscoveries in medical technology, and any lack ofattention to patient comfort seemed unimportantcompared to the dramatically improved patientrecovery rates in the new, technologically drivenhospitals.

In the United States, new hospitals or substan-tially remodeled structures are being built primar-ily to replace outdated facilities and to serve areasof population growth, as the healthcare marketplacehas become increasingly competitive (Horsburgh,1995). There is the hope that pleasant, user-friendlyfacilities will attract patients and improve their

302 SandraWhitehouse et al.

healthcare satisfaction (Hutton & Richardson, 1995).In addition, healthcare specialists, architects, andlandscape designers, among others, have come tobelieve that the hospital environment can a¡ectthe mood, stress level, and well-being of patientsand their families.With increased focus on the over-all hospital healing environment, a renewed inter-est in using the restorative aspects of nature to aidin the healing process has emerged.

Cooper-Marcus and Barnes (1999) have indicatedpotential healing processes that may be supportedby gardens, from reducing stress to achieving per-spectives about life and death. A small but growingbody of empirical research supports the healing po-tential of gardens in hospital settings. For example,several studies have found reductions in stress le-vels and health-related complaints among patients(Ulrich, 1984) and sta¡ (Verderber, 1986) who wereprovided with windows overlooking gardens, andthere has been indirect evidence that access to hos-pital gardens increases patient and sta¡ satisfactionwith the overall hospital experience (Paine & Fran-cis, 1990; Cooper-Marcus & Barnes, 1995). Several in-vestigations have provided preliminary evidenceabout the physical features of gardens that facilitatethe healing process (Cooper-Marcus, 1995; Olds,1989). The provision of gardens and access to natureseems especially important for hospitalized children(Strain & Grossman, 1975; Horsburgh, 1995). In addi-tion, the hospitalization of a child can be extremelystressful to parents and family members, who mayalso bene¢t from the availability of gardens onhospital grounds (Carpman & Grant, 1993)

Such gardens, however, put economic pressureson hospitals and have been criticized by some whobelieve that ¢nancial resources are better spent onmore direct patient care (e.g., Forman, 1996). In fact,many hospital gardens are paid for by donors afteryears of fund-raising e¡orts, and are maintained byvolunteers. There is often little training providedfor hospital sta¡ in terms of how to integrate com-plementary therapies, such as healing gardens, intooverall patient healthcare. In an era where ¢nancialconsiderations dictate so many hospital decisions, itis essential to empirically assess the contributionsthat gardens might make to the healing process inhospital environments.

Empirical Evidence

There is a strong tendency for adults to prefer nat-ural landscape scenes to urban views, especiallywhen the urban views lack vegetation and water

(Ulrich, 1977; Balling & Falk, 1982; Orians &Heerwegen, 1995; Schroeder, 1995). In general, adultshave reported that when they are stressed or de-pressed, going to natural settings in the outdoorscan help them feel better (Cooper-Marcus, 1995). As-pects of nature such as trees, grass, water, visiblesky, rocks, £owers and birds were mentioned as par-ticularly helpful (Olds, 1989). Wilson (1984) hypothe-sized that such responses to natural settings may beof evolutionary signi¢cance, in that modern humansinnately respond to the characteristics of environ-ments favorable to premodern humans.

A main ¢nding across studies in a literature re-view on the environmental preferences of childrenwas that youngsters are mainly concerned aboutthe functional aspects of environments, such aswhether a tree a¡ords climbing, a wall can bejumped over, or an object can be thrown (Gibson,1979). In other words, they prefer opportunities foractive use of space (van Andel, 1990). For example,Francis (1988) noted that while adults consider,‘what does it look like,’ children ask, ‘what can I dohere?’ (p. 72). There are few, if any, studies looking athow children might use the outdoors for comfort oremotional healing. van Andel (1990) observed thatchildren sought safe, enclosed, and hidden placeswhere they could look out and not be seen. Appleton(1975, 1996) and Lewis (1994) suggested that settingssuch as these would have o¡ered comparative safetyto our predecessors. The presence of a refuge maybe comforting to a child (Kirkby, 1989). Moore(1999) reviewed research on children’s environmentsto generate assumptions relevant to children’s gar-dens, namely that children require outdoor play,environmental quality, opportunities for ‘play leader-ship’, and indoor-outdoor links (p. 327).

The level of stress associated with a hospital visithas been extensively documented, and perceivedstress has been associated with negative childhealth outcomes, such as physical pain and emo-tional distress (Varni & Katz, 1997; Varni et al.,1996; Kiecolt-Glaser et al., 1998). Kaplan and Kaplan(1983) proposed that hospital environments arestressful in part because they are typically complexand unfamiliar. They theorized that sustained expo-sure to the hospital environment would likely resultin mental fatigue and the experience of ‘cognitivechaos’ (p. 108). In such circumstances, Kaplan andKaplan (1983) suggested that exposure to a lesscomplex natural setting would be experienced asrelaxing because of the increased familiarity andlower information processing load.

Articles written speci¢cally about healing gar-dens have been typically found in landscape

Children’s Hospital Garden Evaluation 303

architecture journals and gardening magazines. Asin most articles on hospital design, these have beendescriptive in nature (e.g., Dannenmaier, 1995;Griswold, 1995; Hoover, 1995; McCormick, 1995;Stevens, 1995; Ware, 1995). Missing in these articleshave been accounts of how empirical studies mightinform the construction of such gardens. In fact, fewstudies have discussed how gardens are used thera-peutically, or evaluate the impact of gardens on pa-tient health outcomes and healthcare satisfaction.Since 1966, only a few dozen reports in the litera-ture contained data that related a particular designfeature to a speci¢c clinical outcome for a particu-lar study population (Rubin & Owens, 1996).

Cooper-Marcus and Barnes (1995) conducted aseries of case study evaluations of hospital gardensusing the Post-Occupancy Evaluation (POE)method, which included behavioral observations, ad-ministered survey questionnaires, and patient andsta¡ interviews about the use of the gardens. Reac-tions of adult patients and sta¡ who used the gar-dens were almost uniformly positive, with nearlyall subjects reporting positive changes in mood asa result of garden use. However, there were no expli-cit assessments of how the gardens might in£uenceindices of patient healthcare satisfaction, such asassessments of quality, intentions to return, andwillingness to recommend a healthcare provider toothers (Hutton & Richardson, 1995). In addition, be-cause participants were limited to garden users itwas not possible to assess potential barriers orconstraints to utilization.

Similarly, Paine and Francis (1990) presented ¢nd-ings from case studies of outdoor spaces at threehospitals. Data were gathered from behavioral ob-servations in the garden, and each hospital outdoorspace was described in terms of location, size, usesand users, and successful and unsuccessful features.The needs of children, both as patients and visitors,were summarized brie£y, with an emphasis on pro-viding settings for creative, imaginative, and physi-cal play. As in the Cooper-Marcus and Barnes (1995)study, subjects in the study were limited to gardenusers, as opposed to nonusers, which potentiallyconstituted a biased sample.

Rationale for the current study

Research suggests that exposure to natural settingsmay reduce stress and enhance healing. In addition,there is some evidence that the healing environmentmay in£uence patient and family perceptions oftheir healthcare provider, as measured by health-care satisfaction, quality assessments, intentions to

return, and willingness to recommend a healthcareprovider to others (Hutton & Richardson, 1995). Asthe ¢rst empirical investigation of a children’s hospi-tal garden, it was important to evaluate patient, fa-mily, and sta¡ perceptions and utilization of thegarden, and to determine whether there were bar-riers or constraints to use. It was also importantto investigate the ways in which adults’ and chil-dren’s preferences for various features of a gardenmight di¡er. Given the lack of empirical researchon children’s hospital gardens, the objective of thisevaluation was to contribute to the knowledge baseneeded to design more e¡ective gardens in pediatricsettings, to provide insights and guidelines abouthow to use such gardens to facilitate the healingprocess, and to establish a basis for further re-search in this area.

Method and design

A Post-Occupancy Evaluation (POE) was conductedto address the research questions, including a visualanalysis of the garden (to allow readers to deter-mine to what extent the ¢ndings here might gener-alize to other gardens in other settings), detailedbehavioral observations, surveys, and interviews.

Visual analysis: site plan, description and history

The development of the Leichtag Family HealingGarden began with the idea of a garden envisionedby the Hospital’s Bereavement Committee in the late1980s. In 1993, with the creation of a Healing Envir-onment Steering Committee, the focus of the gardenshifted and it became part of an overall healing en-vironment program at Children’s Hospital andHealth Center, San Diego. The de¢nition of thehealing environment that guided these e¡orts issummarized as follows:

‘‘The Healing Environment is a term used to de-scribe the physical and cultural atmosphere createdto support families through hospitalization, medicalvisits, healing and bereavement. Guiding the Heal-ing Environment is a philosophy of caring; that is,the desire to develop a space that engenders feelingsof peace, hope, upliftment, joy, re£ection, and solaceand one which provides opportunities for relaxation,enrichment, spiritual connection, humor, and play.Motivating this philosophy is the belief, which issupported by research, that these factors play a con-siderable role in the physical, emotional, and spiri-tual healing process. The goal of the HealingEnvironment is to transform the hospital settinginto a place that addresses the human spiritand supports families to positively cope with and

FIGURE 2. Two Views of the Leichtag Family Healing Garden.


transcend illness. The cornerstones of the HealingEnvironment are building design, the arts, familysupport, and sta¡ attitudes. Physical components ofthe Healing Environment are the interior and exter-ior building designs, gardens, family spaces, and theart collection. Programmatic components of theHealing Environment are the arts and culture pro-gramsömusical performances, storytelling, artists-in-residence, and the like. Equally important to theHealing Environment are the ways in which we sup-port and treat our familiesöcustomer service, fa-mily centered care, and the Golden Rule ofcompassion and consideration.’’

After considerable fund raising e¡orts, the gar-den was completed and dedicated in July 1997. The406100 ft. garden is located in the large campus ofChildren’s Hospital and Health Center, San Diego(see Figures 1 and 2). Features included ‘Sam’ the di-nosaur (a 20640 ft. sculpted metal brontosaurus); asculpted blue-green ceramic tile sea-horse fountainwith tile murals of ¢sh swimming through sea-weed; a mauve constellation wall with colorfulstained glass disks representing the zodiac; a 14 ft.tall windmill with rainbow colored blades and me-tal birds that ‘£y’ within the structure, powered bythe wind; and a multi-colored semi-circular ‘shadowwall’ incorporating cutouts of animals. Flowers andplants selected for their medicinal value provided aborder around the garden, and shade was providedby deciduous trees and tall palms. The garden wasenclosed with curvilinear, brightly painted four toseven feet high walls, which help to de¢ne the spaceand provide a number of child-scale ‘rooms’. Seatingwas provided by seat-height planter walls and seat-ing rocks, as well as three colorful benches set onwheels to resemble £ower carts. Ground surfaces in-cluded ‘islands’ of grass surrounded by concentricovals of concrete in shades of teal, green, and blue

FIGURE 1. Two Views of the Leichtag Family Healing Garden.

reminiscent of the ocean. The overall feeling of thegarden seemed appropriate for Southern California,with a greater proportion of concrete and con-structed hardscape elements and relatively less nat-ural plants, £owers, or greenery. Instead, there weresand colored £oor surfaces, the sounds of a splash-ing fountain, palm trees, birds of paradise, shadowscast on walls, and playful and whimsical features.

Behavioral observations

Over a two week period in the month of July, 32hours of observations were collected at varioustimes of the day both during the week and on week-ends. This time period was chosen because theweather was generally sunny and it was comfortableto be outside in the garden, with temperatures ran-ging from 70^85 degrees. Over 200 people were ob-served visiting the garden. Coding sheets wereused to observe visitors to the garden in terms of:(1) demographicsöwho uses the garden?; (2) tra⁄c£owöwhere do people walk and move?; and (3) useractivitiesöwhat are people doing in the garden andhow much time are they spending? Speci¢c techni-ques used to answer these questions were BehaviorMapping (n=96) and Behavior Tracking (n=107),both of which have been used in published evalua-tions of healing gardens (see Cooper-Marcus &Francis, 1990, for more detailed discussion of theseapproaches).

Surveys and interviews

Participants. Participants were recruited fromthe total sample of patients, families, and sta¡ whovisited Children’s Hospital and Health Center, SanDiego, and selected at random from throughout the

FIGURE 3. User groups in the healing garden.

FIGURE 4. Time spent in the garden.


hospital and the garden to participate. The randomi-zation process included strati¢cation to groups toensure a representative sample of patients, families,and sta¡ from various sections of the hospital (e.g.,inpatient/outpatient, medical/surgical/critical care).Sta¡ from various disciplines were sampled (e.g.,physicians, nurses, social workers, front desk, housekeeping, grounds, and administrative personnel).Surveys and interviews were administered to adultgarden visitors (n=28), and adult family membersand sta¡ in the hospital (n=55). Adult participantsincluded 17 males and 66 females, which is approxi-mately representative of the hospital sta¡’s male : fe-male ratio. Fifty-two of the 83 adults had been tothe garden and were familiar with it (‘gardenusers’), 31 had not been and/or did not know aboutit. Children and adolescents in the garden (n=12)and in the hospital (n=10) were given a modi¢edversion of the interview. The children and adoles-cents included 12 males and 10 females, 10 were out-patients, ¢ve inpatients, one was a convalescenthospital inpatient and six were siblings of patients.Of the 22 children/adolescents interviewed, 13 hadbeen to the garden and nine had not. Of the nine,only one knew about it.

Surveys and semi-structured interview question-naires were developed based on measures previouslydeveloped by Cooper-Marcus and Barnes (1995), pi-loted in the garden and revised. The survey includedparticipant demographic data, knowledge of the gar-den, how knowledge was obtained, impactof the garden (if any) on mood, and satisfactionwith the garden. The semi-structured interviewassessed how visitors, families, and sta¡ reacted tothe garden, what qualities and characteristics of thegarden contributed to any reported mood change,barriers and constraints to use, and what recom-mendations they would o¡er to improve the garden.The child/teen version of the interview targeted de-mographic data, use of the garden, impact of thegarden (if any) on mood, and what recommenda-tions they would make to improve the garden.Survey data was analysed for descriptive statistics.Content analysis was conducted on the interviewdata following established guidelines for qualitativeresearch (Patton, 1995; Strauss & Corbin, 1990).

Findings and discussion

Adults’ use of the garden

Aggregate data from behavioral mapping is shownin Figure 3. As can be seen, the largest percentage

of users were families. Adult family members typi-cally relaxed and talked while their children playedor more actively explored the garden. Parents notaccompanied by children would often sit quietly con-templating in the garden, or walk around looking atplants and artwork. Sta¡ used the garden for co¡eeor lunch breaks, talking quietly together or perhapsreading a book alone. On rare occasions, sta¡brought patients to the garden. In addition, specialevents such as a bimonthly celebration of life for be-reaved parents, memorial services for sta¡, andnews conferences, occurred in the garden.

Several observations about use of the garden de-serve mention. First, nearly half of all visitors ob-served in the garden spent less than ¢ve minutesthere. Typically these individuals would enter, walkquickly around, and then leave. A much smallernumber of visitors were observed to spend morethan 15 or 20 minutes in the garden (see Figure 4).Second, although the garden appeared to be wellutilized mid-day, it was often empty for long periodsof time in the morning and late afternoon. Third,some areas of the garden were more popular thanothers. Visitors typically occupied the coveredbenches, or stood looking at the seahorse or wind-mill. They rarely used the grassy areas of the gardenwhere there were no formal seating arrangements.


These issues were investigated further through thesurveys and interviews, and will be discussed subse-quently.

Survey and interview data. An explicit goal of thegarden was to help families, patients, and sta¡escape from the stressful environment of the hospi-tal. The majority of adults surveyed endorsed goingto the garden to get away from stress, relax andrest, or in some way improve their mood. Survey re-sponses from sta¡, patients, and visitors who hadbeen to the garden (including those surveyed in thegarden and the hospital) are shown in Table 1.

In the interviews following the surveys, partici-pants shared more of their perceptions of the gar-den. For example, a pediatric resident reportedcoming to the garden to get away from stress, ‘Wehad something really stressful happen just prior tocoming here, we came here to debrief. It is a goodsetting to get away from the hospital stress, to feelmore peaceful’. A father of an infant in the intensivecare unit said, ‘This is a better place to wait thanthe waiting room, we couldn’t stand being in there,wondering if she’d make it. This is quiet and peace-ful, the greenery, the colorful £owers, the sound ofthe water.’A mother who comes back to visit the gar-den periodically described how it helped her tomake sense of a very di⁄cult time, ‘My son was onlyin the hospital for 17 hours and then he died. Laterthere was a memorial service here for the childrenwho have died, for their parents. The memorial ser-vice was beautiful, very meaningful, someone hadbrought £owers, and let the petals drift gently inthe grass in the breeze. It was a way to share ourgrief with others who had also experienced this lossand it was healing, it helped with this process ofhealing.’ Most garden users reported a positivechange in mood after visiting the garden, as shown

TABLE 1Why people visit the garden.

Reason for going tothe garden

Per cent n=52

To relax and rest 28To get away from mystressful environment

24

To enjoy the garden, beengaged

18

Walk by it on my wayto work, rarely go in

12

It helps me cope withmy worries

8

To meditate, outdoortherapy

4

in survey responses in Table 2. Participants sharedmore information about speci¢c aspects of the gar-den they perceived as helpful in their responses toopen-ended interview questions following the sur-veys. Content analysis was used to determine fre-quencies of the various aspects mentioned by adultgarden users (see Table 3). Mood changes were at-tributed to combinations of the garden’s features,such as being outdoors in an enclosed naturalspace, hearing the sounds of running water, seeingthe trees, plants, and £owers, and enjoying thecolors and artwork.

One sta¡ member, for example, said ‘The water,the sound of running water in the outdoors, the dif-ferent colors, everything together, the plants, thegreenery, even the sand-like dirt, it is put togetherwell, it is relaxing.’A parent noted ‘It makes me feelmore happy, I think it is the playful colors, the feel-ing of being in a completely separate and uniqueplace. . . It takes me back to a time when there werenot so many worries.’

Increasing satisfaction. An implicit goal for the gar-den was the hope that it would increase consumersatisfaction, and providing empirical evidence tosupport or refute this belief was a second majorgoal of this research.With this in mind, several sur-vey questions speci¢cally targeted consumer satis-faction and willingness to recommend Children’sHospital to others. Survey and interview responsessuggested that the garden did increase the satisfac-tion of adult family members sta¡.

As shown in the Table 4, 50 per cent of the gardenusers reported that the garden ‘de¢nitely’ increasedtheir overall satisfaction with Children’s Hospital.Several of those interviewed made comparisons be-tween Children’s and other hospitals, and describedhow the garden in£uenced them to perceiveChildren’s as providing a higher quality of service.A mother of an outpatient explained, ‘We have been

TABLE 2Reported mood change as a result of visiting the garden.

Mood change Per cent reporting n=52

More relaxed, less stressed,content

54

Refreshed, rejuvenated,stronger

12

Pleased, more positive,better

12

No di¡erence in mood 10Able to think, ¢nd answers,cope

6

More connected in religiousor spiritual way

6

TABLE 3Features of garden most enjoyed by garden users

Adultsn=52

Childrenn=12

Feature Per cent reporting*Fountain ^ sound of running water 33 83Bright colors 25 17Being outside in a garden 23 33Flowers, trees, plants, greenery 19 33Artwork (windmill, shadow wall, con-stellation wall, dinosaur, animal tiles)

14 83

Fresh air, sunshine, breezes 12 öSense of enclosure provided by thewalls

12 ö

Multi-sensory stimulation 8 ö

*Many participants mentioned more than one aspect of the garden as helpful.

TABLE 4Consumer satisfaction with the healing garden n=52

The survey asked: De¢nitelyYes

probablyyes

noopinion

probablyno

de¢nitelyno

. Does the healinggarden increaseyour overallsatisfactionwith Children’sHospital?

50% 30% 12% 4% 4%

. Would yourecommend thatothers visit thegarden?

72% 11% 11% 6% 0%

. Does the healinggarden in£uencewhether yourecommendChildren’sHospital toothers?

20% 28% 26% 14% 12%

. In your opinion,is it importantfor hospitals toinclude healinggardens? (n=83:garden users andnonusers)

74% 16% 9% 0% 1%


to a lot of hospitals over the last three years. Noneof them have anything like this. If the hospital takesthis care, at this level, then it makes me think therewould be an emphasis, you know, on preventativemedicine at all levels, which is a very good thing’.

Regarding willingness to recommend, 72 per centof respondents reported they would ‘de¢nitely’ re-commend that other parents or sta¡ visit the gar-den, and 20 per cent said that the healing garden

‘de¢nitely’ in£uenced them to recommend the hospi-tal to others. Finally, 90 per cent of respondents(including those who had never been to the garden)expressed the view that it is important for hospitalsto include gardens. A physician commented, ‘Itmakes me feel more positive, relaxed, serene, eventhough I can only be out here for a few minutes. Itseems so removed from my work in the hospital.’ Insum, the data suggest that the garden did have a

TABLE 5Recommended changes for the healing garden

Suggestion Per cent requesting n=52

More trees, greenery,and vegetation.

50% of adult respondents

More interactive activitiesto engage children

18% adults, 66% children

More private areas forfamilies and patients

11% of sta¡

More seating 10%More water features 10%Music or wind chimes 10%Litter can(s) 2%Birdbaths or feeders 2%Drinking fountain 1%Better Maintenance 1%

FIGURE 5. Use of the garden by age group and number of partici-pants.


signi¢cant positive impact on aspects of consumersatisfaction.

Changes requested by adults. Adult garden userswere asked if they would recommend any physicalchanges for the garden, and the majority (87%)did. As can be seen in Table 5, 50 per cent requestedmore trees, vegetation, and greenery.

While only 11 per cent of sta¡ commented on theneed for privacy or refuge, these were sta¡ whoworked directly with bereaved families, or whoworked therapeutically with emotionally disturbedchildren. For example, a mental health professionalexplained, ‘Maybe there could be a planted area thatscreened o¡ a place in the gardenöa nice plantedarea, perhaps with a climbing rose bush or jasmine,something green and pleasant.’

Children’s use of the garden

Data from behavioral mapping revealed that theyounger the person (i.e., as soon as they were ableto walk), the more likely they were to be engagedin active or explorative play (see Figure 5). It is im-portant to consider the sample of children andteens obtained during this particular week of beha-vior mapping. Most were not identi¢able as patients,and appeared instead to be healthy siblings of pa-tients. This trend was also found in the interviews.Participants included seven siblings of patients,four outpatients, and one nonverbal inpatient(whose mother answered based on experiences withher daughter in the garden). All but one of thesetwelve children appeared healthy and energetic.Patients who were in more fragile condition wererarely brought to the garden.

Interview responses were consistent with beha-vioral observation data. Young children (ages two

to three) typically mentioned the water, a favoriteobject (e.g., the dinosaur), or their favorite thingsto smell. Four- to ¢ve-year-olds mentioned theirwishes to climb, run, and jump, or talked about theanimal representations (e.g., tiles, artwork) theycould ¢nd and name. Six to 10 year olds were mostlikely to request more ‘things to do’, seeming to runout of ideas for creative play and to crave morestructured or dedicated play areas. However, forspecial populations, the garden appeared to be verysuccessful. One mother explained, ‘For my son, thisgarden is wonderful. He’s autistic and the gardenseems almost built for him. He loves the waterfall.He is very visual and is also working at learningthe names of animals. He does much better out herethan in the waiting room, so it is less stressful tome, and really a lot more enjoyable, to bring him tothis hospital. I tell all kinds of people to come here.’

Themes from brief interviews with children in the hos-pital. Participants in this group included ¢ve inpa-tients (from intensive care units in hematology-oncology, orthopedic-rehabilitation, or critical care)and ¢ve outpatients (cardiology, allergy, or hematol-ogy-oncology clinics). Only one of them had actuallybeen to the garden, and only two of them knew of it.In general, they were less mobile, energetic, andhealthy than the population from the garden, andhence had di¡erent needs and di¡erent perspectiveson what is important in a garden. For example, a‘two and a half’ year old female outpatient fromhematology-oncology had not been to the garden,but very much enjoyed the other outdoor spaces atthe Hospital, ‘I am going to see the doctor becauseI am broken. And to see the ‘aminals’’. Her motheradded ‘She likes the topiary animals and can namethem in the front of the hospital, she brightens upcoming here because there are animals and placesin the hospital that she recognizes that help tomake her feel more secure here.’ In fact, it appearedthat this young patient associated the hospital more

TABLE 6Do people in the hospital know about the healing garden?

Participants from within the hospital

Survey item: sta¡n=32

familiesn=23

patientsn=22

Have neverbeen to thehealinggarden

28% 95% 90%

Did not knowabout thehealinggarden

10% 48% 80%


with seeing the ‘aminals’ than with her treatmentfor cancer. Similarly, an eight-year-old female inpati-ent from orthopedic-rehabilitation who had been ina car accident and was wearing several casts alsowas very interested in the garden stated, ‘It’s tooloud for me in the play room and the music hurtsmy head. . . I’m tired of crutches. The garden lookspretty. Is it quiet out there?’.

In fact, the only two participants who were notinterested in going to the garden at all were se-verely ill, with advanced cases of cancer. Both hadbeen in the hospital for several months. One was aneleven-year-old female inpatient, who appeared tohave very little energy, and said, simply, ‘My handhurts too much. I don’t want to go.’ The other, a 17-year-old inpatient undergoing chemotherapy,touched her head, where she had lost all of her hair,before she answered, ‘I don’t want to go anywhere. Iwouldn’t want to go there. I don’t like to leave myroom, really. . . I will go, I guess, for the ceremonyof life for one of the guys from here who died lastmonth, with the SOMFAB [‘Some of my friends arebald’] group, I would go.’

For the other hospitalized children, it appearedthat it was important to get away from the hospitaland be in a di¡erent place, and a quiet gardenwhere there were colors and £owers, animals andwaterfalls sounded inviting to all who were well en-ough to go. For the younger patients, having child-scale places and features, such as artistic render-ings of animals, seemed especially salient in helpingthem feel secure, and in making their experiencesmore positive at the hospital. For adolescents whomay have been self-conscious about their appear-ance, privacy became more of an issue.

Changes requested by children and their adult caregi-vers. Eighteen per cent of adults and 66 per centof children (typically those who were relativelyhealthy, such as outpatients or siblings of patients)requested ‘more things for kids to do’. The literatureon children’s preferences suggests that healthy chil-dren seek places where they can be active, and en-gage in ‘manipulative play’ (e.g., digging in sand,building with blocks, moving rocks) and ‘active play’(e.g., climbing, tumbling). The garden seemed bettersuited for hospitalized children and children withdevelopmental delays and chronic health conditions.

Barriers and constraints to use

The evaluation incorporated feedback from partici-pants throughout the hospital in order to providedata addressing the issue of barriers to use. Surveys

and interviews conducted with family members ofpatients within the hospital (n=23) indicated that95 per cent (22/23) of family members had neverbeen to the garden, and 48 per cent did not knowabout it. Of the 10 children interviewed in the hos-pital, two knew of the garden, and one had visited it(see Table 6). Interviews with family members(n=23) and sta¡ in the hospital (n=32) identi¢edfour factors as major barriers to use: (1) knowledge;(2) accessibility; (3) beliefs about the garden; and (4)underlying philosophy toward treatment. Each willbe described in detail in the following paragraphs.

Knowledge of the garden. As shown in Table 6,nearly one third of sta¡ and the majority of familiesand patients had never been to the garden. Of thosefamily members who did know about the garden, themajority (54%) found out about it incidentally; forexample, they saw it through a window or walkedby it. For example, a father whose son had been inthe intensive care unit for two weeks said, ‘Wewould like somewhere else to go, to get outsideand take a break from the stress. We go back andforth from this room and the cafeteria, sometimesoutside by the rose bushes, which are nice and col-orful, the color helps . . . They may have told usabout this healing garden when we came here withmy son, but I don’t know, I can’t remember.’ In fact,families in the hospital who were surveyed aboutthe garden typically asked the interviewer for mapsand information as soon as they found out about it.Thus, informing patients and their families was onemajor di⁄culty.

Accessibility. Thirteen per cent of families in thehospital mentioned di⁄culty ¢nding wheelchairs totake their child to the garden. This was particularlyimportant for patients located farther away fromthe garden. In fact, several sta¡ noted the distanceas prohibitive and hoped that new gardens would be


constructed closer to them soon. Other sta¡ mem-bers requested better wheelchair access and IV elec-trical outlets. The sta¡ who requested these itemswere mainly those who worked in the building hous-ing the orthopedics/rehabilitation and hematology/oncology units. This building was located approxi-mately 500 yards from the garden. It had no gardensof its own at the time of the study for patients re-quiring intensive levels of care, who were morelikely to be bothered by the bumpy transition fromconcrete to decomposed granite in the garden, orrequire an IV electrical outlet. However, wheel-chair-bound patients and sta¡ from the Convales-cent Hospital, located adjacent to the garden,reported no problems with wheelchair access. Insupport of this, behavior trace analysis performedafter a wet morning showed wheelchair tracks goingall around the garden over both concrete and de-composed granite surfaces. Thus, interview re-sponses and observation data suggested wheelchairaccess was a problem for the more fragile patients,such as those who have recently had surgery, orwere receiving chemotherapy. It did not appear tobe a problem for more hardy patients. Finally,26 per cent of families in the hospital mentionedthat their children were simply too ill to go to thegarden.

Beliefs about the garden. There appeared to be someconfusion about the purpose of the garden, and ty-pical questions were, ‘Who is it for?’ and ‘What areacceptable activities for the garden?’ Fifteen percent of the sta¡ believed it was for families only(e.g., bereaved families) and that sta¡, or even chil-dren, should not go there. Other sta¡ wondered whoto ask for permission to hold special functions. Fa-milies mentioned that they saw it and thought itwas part of the playground of the nearby Children’sCenter for Child Protection, or that it was for someother type of family or patient with special needs(e.g., bereaved families or children with a particularillness). Families also were not sure if they were ‘al-lowed’ to go there, or ‘allowed’ to bring their kids(patients or well children), and did not know whoto ask for ‘permission’.

Underlying philosophy toward treatment. It ap-peared that there was a value system driving the be-liefs cited above. For example, several nursesmentioned that there was insu⁄cient sta¡ to takepatients to the garden (e.g., volunteers) or that itwas too time consuming to explain to families aboutthe garden and how to get there. Their priority wason more direct, mainstream patient care.

Summary

The ¢rst major goal of this research was to investi-gate whether patients, families, and sta¡ used thegarden to reduce stress, and to determine the waysin which children’s use of the garden di¡ered fromadults. Surveys of garden users revealed that mostadult family members and sta¡ went to the gardento escape the stresses of the hospital and enjoy therelaxing and restorative elements of nature. Ninetyper cent of adult garden users reported a positivechange in mood after spending time in the garden.In interviews, many parents and sta¡ mentionedthat the garden was a particularly meaningful andspecial type of place to them for a variety of perso-nal reasons. These included coping with bereave-ment, processing stressful work situations, sharingquality time with children away from the hospitalroom, and working with patients. In contrast toadults’ sedentary and passive use of the garden, chil-dren tended to be more involved in active explora-tion and play. Most of the children observed werehealthy siblings of patients, or outpatients. Very fewhospitalized patients were brought to the garden.All children surveyed in the garden said they wouldlike to come back again.

The second goal of this research involved the is-sue of consumer satisfaction. The data suggest thatthe garden was associated with increased satisfac-tion. The majority of adult garden users speci¢callyreported increased satisfaction with Children’s Hos-pital, and many also indicated increased willing-ness to recommend Children’s Hospital to others.

The third major goal of this research was to iden-tify any constraints that might limit use of the gar-den. Most sta¡, family members, adult visitors, andpatients surveyed and interviewed in the hospitalreported that they did not use the garden, and manyfamilies did not know of its existence. Content ana-lysis of interview data revealed the following con-straints to use: lack of knowledge about thegarden; access di⁄culties, such as being too faraway or di⁄culty getting a wheelchair; confusionover the purpose of the garden; and philosophy to-ward traditional biomedical treatment.

Recommendations

Garden users identi¢ed speci¢c physical features ofthe garden that helped them to relax or feel morepositive. These data were used to subsequently im-prove the Leichtag Family Healing Garden, andmay provide empirical guidelines for the design of


future children’s hospital gardens. Adult gardenusers identi¢ed the following features as helpful, inorder of most to least mentioned: (1) the sound ofrunning water; (2) the presence of bright colors;(3) being outside in a garden; (4) the £owers, plants,and greenery; (5) artwork speci¢c to the gardensuch as the windmill, shadow wall, dinosaur, con-stellation wall, and animal tiles; (6) feeling freshair, sunshine, and breezes, (7) the sense of enclosureprovided by the walls; and (8) the opportunity formultisensory stimulation.

When this same group of participants was askedif they would recommend changes for the garden,the vast majority of them did. Recommended physi-cal changes included adding trees and greenery, andusing a vegetation screen to create a private corneror refuge (e.g., for teens, grieving parents). Otherrecommendations included building a wheelchairpath to link the entry to the center paved area,and posting the location of IV electrical outlets.Many of these recommended changes are consistentwith the design review checklist for hospital out-door spaces provided by Paine and Francis (1990),supporting the importance of using empiricallybased guidelines in the design of hospital gardens.

Recommendations related to children. Results fromthis research indicate that healthy children andhospitalized and ill children have di¡erent needsfor a hospital garden. Aspects of the existing gardenfavored by children, from most to least frequentlymentioned, included (1) the fountain, with runningwater they could play in; (2) novel features such asthe dinosaur, windmill, shadow wall, and animaltiles; (3) the £owers and trees, (4) being outside;and (5) the bright colors. The vast majority ofhealthy children (e.g., siblings of patients, outpati-ents without physical health problems) who were in-terviewed said they would like ‘more things to do’ inthe garden (e.g., for active or manipulative play),and many parents and sta¡ also recommended thisfor the children. This ¢nding is consistent with theliterature on children’s preferences for outdoorspaces, which suggests that the value of a place isnot determined by its appearance or aesthetic quali-ties, but by its potential for a¡ording di¡erent activ-ities (e.g., Gibson, 1979; van Andel, 1990).

Children, adolescents, and adult participantswere encouraged to share their ideas for activitiesthat would be harmonious with the needs of othergarden users. Children suggested the following: (1)allow ‘healthy kids,’ or siblings of patients, to bringtheir hospitalized counterparts to the garden tohelp them feel better; (2) encourage children to

garden, plant £owers, weed, water plants, trim £ow-ers (e.g., lavender) by picking them, sweep up, andrake; (3) make potpourri with £ower petals; (4) pick£owers to give to kids in the hospital; and (5) makethings, such as signs to identify the plants.

Adult caregivers also generated ideas for chil-dren’s activities in the garden: (1) put signs aroundthat invite kids to touch some of the plants, or smellthem, or pick them, for example, ‘touch me, I amsoft’, or ‘smell me, I am lavender’, and have the kidsin occupational therapy make the signs, or paint thesigns; (2) have kids ¢nd plants with healing proper-ties, or make it into a scavenger hunt with a sur-prise discovery at the end; (3) make a coloringbook of things from the garden and hand it out witha few crayons; (4) have a section where kids couldactually garden, and ‘touch’ everything; (5) for theplants that need constant pruning, invite kids topick a £ower to give someone; (6) add a sand box;(7) have a potting area and get kids involved inplanting; and (8) allow kids to make things to bedisplayed in the garden while they are in the hospi-tal, maybe with the theme of getting better.

There are few reports, if any, on the environmen-tal preferences of hospitalized children. In the cur-rent study, it was di⁄cult to ¢nd hospitalizedchildren who had visited the healing gardenöeightyper cent of the children and adolescents interviewedin the hospital did not know the garden existed.Thus, an important direction for future researchwould be to speci¢cally investigate the needs andpreferences of this population. Signi¢cantly, mostof the hospitalized children expressed strong inter-est in going to the garden once they found out aboutit. Results from behavioral observations and inter-views in the garden did suggest that children whowere very young, who had been in the hospital fora long time, or those with physical or developmentaldisabilities, were responsive to and appreciative ofthe garden or other hospital outdoor spaces.

The available literature (e.g., Appleton, 1975;Balling & Falk, 1982; Kirkby, 1989) suggests thatchildren, particularly hospitalized children, wouldbe attracted to landscapes that provide opportu-nities for refuge. Although the garden in this parti-cular study did not a¡ord classic refuges (e.g.,places where children could look out and not beseen), the enclosed feeling of the garden was men-tioned by some parents as providing this sense ofrefuge for children. It also seems helpful to includefeatures in the garden likely to be highly familiar tochildren. For example, the garden in this study wasbright, colorful, and full of novel child-scaleartwork.


Recommendations to address constraints to use. Toensure that hospital gardens are used once theyare designed and built, the following guidelinesare recommended. First and perhaps most impor-tantly, sta¡ need to be educated as to the purposeof the garden, who it is for, and how to incorporateuse of the garden into patient and family care. Tokeep sta¡ informed, periodical feedback to sta¡about how families are bene¢ting from the gardenis essential. Second, to ensure that families and pa-tients know about the garden and are able to haveaccess to it, colorful brochures with pictures, infor-mation about the garden, and maps on how to getthere are needed. These informational items shouldbe included in new patient packages, and in the pa-tient information book in hospital rooms. Third, in-stalling posters about the garden in elevators orother high-tra⁄c areas could further increase thevisibility of information about the garden. Finally,assigning volunteers and hospital interns to bringpatients and families to visit the garden wouldincrease its use and accessibility.

In sum, results from this evaluation suggest thatwell-designed gardens can have a positive impact onthe sense of well being of participants in the hospi-tal environment. In addition, there is evidence thatgardens can increase consumer and sta¡ satisfac-tion with the hospital. Respondents in the presentstudy indicated that particular features of the gar-den, such as greenery and plants, shade, the soundof water, and adequate seating, were particularlyhelpful, ¢ndings that are supported in the literatureon environmental preferences for emotional healing.However, it is not enough to attend to merely thephysical design and construction of the garden. Itis equally important to attend to the human side ofthe equation: to educate patients, families and sta¡about the garden and to encourage its use.

Limitations and implications for futureresearch

The POE framework used in this study had severallimitations. First, much of the data were descriptive,thus conclusions must be considered tentative atbest, primarily useful for guiding future research.For example, data suggested that use of the gardenreduced stress and increased satisfaction for pa-tients, families, and sta¡. Future research shouldfurther evaluate these tentative conclusions using amore quantitative approach. Second, survey ques-tions may have demand characteristics, particularlyfor the assessment of satisfaction. Because the

garden was referred to as a ‘healing garden,’ this po-tentially biased participants’ responses. In addition,participants were surveyed about particular fea-tures of the garden they found healing, with re-sponse choices based on previous studies. Thisapproach answers the question of ‘what features’are healing, but does not address the question of‘why’ people ¢nd these features healing. In the fu-ture, well-designed qualitative research, with open-ended questions, could further illuminate these is-sues. Additionally, given the relatively brief expo-sure to the garden, expectations of ‘healing’ aremost likely constrained to the emotional bene¢ts ofstress reduction a¡orded by being in a pleasant en-vironmental space. Whether these brief episodes ofstress reduction can lead to sustained emotionalcoping, and resultant physical health bene¢ts, re-mains an empirical question.

The present study also had sampling limitations.The garden had a preponderance of hardscape (con-structed elements and colorful concrete), as opposedto more traditional vegetated spaces, thus, the ¢nd-ings must be considered in this context. The idealblend of built hardscape characteristics of gardenswith natural landscape is an empirical questionthat further research will need to address. In termsof time and season, the study was completed in Julyand August, thus, the weather was quite warm inSouthern California, and participants may havebeen biased to request more shade elements.Further, the climate in San Diego is typically be-nign for most of the year, even during the winterseason. Given that many parts of the world experi-ence the full spectrum of weather extremes, maymake an outdoor garden for some children’s hospi-tals in certain parts of the world of little utility oradded value for many months of the year. Future re-search will need to evaluate a diverse group of chil-dren’s hospital gardens across countries andseasons. Finally, participants who were interviewedin the garden came there because they chose to,leading to the possibility of a biased sample. Parti-cipants were also gathered from within the hospital,however, few of these had visited the garden orknew about it, thus there was insu⁄cient represen-tation of individuals who were aware of the gardenand chose not to go there. In addition, very few se-verely or chronically ill children were found who ac-tually used the garden. Thus, it is important forfuture research to further investigate the use ofchildren’s hospital gardens for children with severedevelopmental disabilities and chronic health condi-tions. As suggested by the ¢ndings of the presentstudy, chronically ill and handicapped children


may have very di¡erent requirements for a hospitalgarden environment.

Notes

This research was supported by an intramural grantfrom Children’s Hospital and Health Center, SanDiego. Address correspondence and reprints re-quests to: James W. Varni, Ph.D., Professor and Se-nior Scientist, Center for Child Health Outcomes,Children’s Hospital and Health Center, 3020 Chil-dren’s Way, MC 5053, San Diego, California USA92123. E-mail: [email protected].

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