sign in sign up
<<
Home , Garden design

JAD June 2012, no.2 Art and Discourse

RESTORATIVE DESIGN: Enhancing wellness through healing spaces

M. Susan Erickson RLA, PLaCE Program Coordinator, College of Design, Iowa State University

Abstract Creating 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 questions—what kind of contact with nature? How much? Are there certain types of which are more therapeutic than others? A look at the existing knowledge base reveals a complexity of variables which prohibits a formulaic approach to 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. , which provides accessibility to the greatest possible range of garden users, should also be a consideration of any restorative garden .

Furthermore, architects and other garden 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 consult the therapists who will use the garden space for patient activities. Bringing together the expertise of therapist and 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.

89

JAD June 2012, no.2 Art and Design Discourse

Health is defined as “a state of complete physical, mental, and proceeding on to examine in detail Ulrich’s Theory of social well-being and not merely the absence of disease or Restorative Garden Design and its implications for gardens infirmity”. (World Health Organization, 1946) in healthcare facilities. The paper finishes with a recent survey that yielded puzzling results and a call for additional Introduction areas of research. Throughout history, contact with nature has been viewed as Health and wellness beneficial for health and well-being in widely different cultures. From ancient healing springs to medieval monastic The World Health Organization defines health as “a state of cloisters and continuing on to tuberculosis sanatoria in the complete physical, mental, and social well-being and not early twentieth century, contact with nature was believed to merely the absence of disease or infirmity” (Organization, be beneficial for individuals who were troubled in body, mind, 1946). This holistic definition of health provides a suitable or spirit. However, during the twentieth century the platform for beginning a discussion of restorative garden connection between healing and nature was gradually design. Because the creation of literature relating to severed, as technology took on a greater role in the medical restorative gardens is in its infancy, the field has not yet community — indeed, in Western culture as a whole. come to authoritative definitions for its component parts. For Healthcare designers and administrators became the purposes of this paper, the following working definitions preoccupied with creating environments that were functional will be used. A new student of restorative and therapeutic and efficient. The need to accommodate modern garden design will gain greater conceptual understanding of technologies in healthcare facilities overshadowed the field by keeping these definitions in mind. previously-held beliefs about the importance of providing therapeutic elements such as gardens. As a result, this new z Curing: is defined as eliminating all evidence of disease. functional emphasis produced environments that were efficient but starkly institutional. These types of environments z Healing is a natural process. Healing goes deeper than are now considered stressful and unsuited to the emotional curing and must always come from within. Healing and psychological needs of patients, visitors, and staff involves “becoming whole”. (Horsburgh, 1995; Malkin, 1992; Ulrich, 1992). Dimensions of wellness By the late twentieth century, however, a growing awareness appeared in regards to the benefits of patient-centered A state of wellness is achieved when the many dimensions of healthcare facilities. In addition, a body of research began to a person’s life are in balance — when a person is whole. be published relative to environmental characteristics that Many models exist which portray dimensions of wellness -- a help patients cope with psychological and physical effects of detailed discussion of models of wellness is beyond the sickness. Some of these environmental characteristics scope of this paper. This particular model portrays a balance related to design of the healthcare facility itself, but other between six dimensions of life and health — physical, social, characteristics related to contact with nature, such as in a environmental, emotional, spiritual, and intellectual. The healing garden or nature views through a window (Ulrich, wheel portrays each area in balance with the others, calling 1995). Researchers investigated a broader concept of health attention to the importance of nurturing all dimensions of life and wellness, addressing other incidents of contact with in order to achieve wellness. When one (or more) area nature and its benefits to a larger audience. Much of this becomes out of balance, wellness is compromised. One research focused on the ways contact with nature provided common result of being out of balance is experiencing stress. stress mitigation for everyday situations, and did not focus Modern society and life styles are full of stressful events at solely on healthcare environments (Hartig et al., 1991; home and at work; these events result in new states of ill Kaplan, 1995; Ulrich et al., 1991b; Wilson, 1984). health (Annerstedt & Wahrborg, 2011). Stress interferes with wellness in a myriad of ways. Stress, and ways to mitigate its Current knowledge relative to restorative garden design has effects, has been well-studied over the last several decades. progressed. This paper will begin with a cursory overview of a broad concept of health and wellness and proceed to look at Kellert and Wilson’s work on biophilia and biophilic design, 90

JAD June 2012, no.2 Art and Design Discourse

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 Wilson’s biophilia hypothesis (Wilson, 1984).

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 Figure 1. Dimensions of Wellness Chart social problems, and that even the presence of grass and a few trees has been correlated with enhanced coping and Existing research: Access to adaptive behavior. Individual conditions are ameliorated by contact with nature, but benefits translate to the greater nature can enhance wellness community as well. Communities with higher-quality environments report more positive valuations of nature, Research from many quarters, including the fields of superior quality of life, greater neighborliness, and a stronger healthcare, psychology, design, public health, and other sense of place than communities of lower environmental disciplines indicates that access to nature can enhance quality. These findings were found to apply in poor urban as health and wellness. Annerstedt and Wahrborg (2011) well as more affluent and suburban neighborhoods. propose three main kinds of public health effects related to nature: short-term recovery from stress or mental fatigue, Biophilic are based on six elements or attributes. faster physical recovery from illness, and long-term overall These designs generally include: improvement on health and well being. Wilson (1984) addressed the premise for using contact with nature in the z Environmental features treatment of diseases more than twenty-five years ago with z Natural shapes and forms his biophilia hypothesis. z Natural patterns and processes Short-term recovery from stress or mental fatigue has been z Light and space well-studied. Studies agree that nature views are more effective in reducing psychological and physiological stress z Place-based relationships, and than urban views, and lead to more positive feelings in z Evolved human-nature relationships (Kellert, 2008). 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, Ulrich’s Theory of Restorative Design 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 Dr. Roger Ulrich’s theory of restorative garden design is tree had shorter hospital stays, needed less severe pain based on theory and research in the behavioral sciences and

91

JAD June 2012, no.2 Art and Design Discourse

health-related fields. His theory proposes that gardens in Social Support healthcare situations are important stress mitigating resources for patients and staff because they foster: Social support is the first major component in the theory of restorative garden design model. Generally, social support z Social support refers to perceived emotional support or caring, and material z Sense of control or physical aid, that a person receives from others (Brannon & Feist, 1997). A large body of research has shown that z Physical movement and exercise people who receive higher levels of social support are z Access to nature and other positive distractions (Ulrich, usually less stressed and have better health status than 1999). persons who are more socially isolated (Cohen & Syme, 1985; Shumaker & Czajkowski, 1994) In fact, low social Research-based evidence exists to show that each of the support maybe as great a risk factor in mortality as is four restorative components mentioned above can reduce cigarette smoking (Berkman & Syme, 1979). 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) Figure 3. A pleasant garden setting with attractive seating increases social support, which leads to improved health SOCIAL SENSE OF PHYSICAL NATURE & outcomes. Rady's Childrens Hospital, Marlon's . SUPPORT CONTROL MOVEMENT/ DISTRACTIONS San Diego, CA USA EXERCISE Patients Privacy Plants, Flowers, Family Choices Exertion Water, Wildlife, Design considerations. Social support benefits of gardens Staff Escape Rehabilitation Nature Sounds 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. STRESS RESTORATION & BUFFERING 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 IMPROVED HEALTH OUTCOMES 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 Figure 2. Ulrich Theory of Restorative Garden Design these instances provision should be made for a large group to gather in the garden.

92

JAD June 2012, no.2 Art and Design Discourse

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 person’s ability to cope with stressful situations. Control refers to people’s 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 Figure 4. Choices in seating, both in type and location, immune functioning (Schulz, 1976; Weiss et al., 1990). provide a sense of control for patients, visitors, and staff. Methodist Hospital, Des Moines, IA USA Much of the stressfulness of hospitalization has been linked to loss of control, for example, loss of privacy, inability to Design considerations. One of the most important design choose clothing, meals, and room temperature, unfamiliarity considerations in a garden at a healthcare facility is with buildings, and complex wayfinding. In response to these accessibility. Accessibility is manifested in several ways — stressful aspects of facility design and operation, many can users find the facility without difficulty? Is the door hospitals and residential healthcare facilities have begun to unlocked? Does the garden design allow users to interact offer more patient-centered care, allowing for more choices with the garden, either actively or passively? (Cooper Marcus and autonomy for patients and visitors. Healthcare staff can & Barnes, 1999). Garden designs that allow control by also be positively affected by providing a sense of control in garden users will offer choices whenever possible. These their workplace. Greater involvement in decision-making choices may relate to seating, social grouping, and processes has been shown to improve job satisfaction and environment, to name a few. For example, seating may be reduce turnover in a study of nursing home aides (Waxman provided as individual chairs or benches, with or without et al., 1984). armrests, fixed or moveable, and alone or in small or large groups. Garden paths and seating may be located in sunny Well-designed gardens offer an opportunity for patients, staff, and shady areas. Privacy should also be a consideration, for and other garden users to increase feelings of control. This garden users as well as for patients who may have rooms phenomenon has been well-studied in parks and other with windows that look out onto the garden. recreational facilities (Ulrich et al., 1991a). However, only a small amount of research has focused directly on gardens in Physical Activity and Movement healthcare facilities. Cooper Marcus and Barnes (1995) found that garden users reported restoration from stress Providing opportunity for physical activity and movement is when they had the opportunity to exercise control over their the third major component in the theory of restorative garden situation and “escape” to the 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

93

JAD June 2012, no.2 Art and Design Discourse

(Emery & Blumenthal, 1991). Similar positive outcomes have Nature as Distraction been observed in younger age categories (Ulrich, 1999). It is important to note that beneficial physical exercise does not Natural distraction is the fourth and last major component in need to be rigorous -- even mild exercise has been linked to the theory of restorative garden design model. Nature can positive health outcomes (McNeil et al., 1991). engage a patient’s 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 Figure 5. Providing opportunities for physical activity and (Heerwagen, 1990; Katcher, Segal, & Beck, 1984). Although movement is an important element of restorative garden studies are rare that examine potentially favorable influences design. National Museum of the American Indian, of gardens on patient stress and other medical outcomes, it Washington DC, USA appears that even acutely stressed patients can experience significant restoration after only a few minutes of viewing Design considerations. Gardens can be effective vehicles nature settings with greenery, flowers, or water. It is also for encouraging both exertion and rehabilitation, offering a important to note that viewing gardenlike scenes apparently much more pleasant setting than facility corridors or the mitigates pain (Ulrich, 1999). physical therapy laboratory. Careful planning of garden spaces will include input from the various therapists that work with patients — art therapists, 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 Figure 6. Lush vegetation and flowers are important come to visit sick siblings or other family members at a restorative elements of nature. Bible Garden. Guthrie hospital or other care facility benefit greatly from the Center, IA USA opportunity for physical activity and movement in the garden setting. 94

JAD June 2012, no.2 Art and Design Discourse

Design considerations. It is important to note that sunlight Landscape architects and other garden designers are well can have distinctly healthful influences on many patients, but qualified to prepare garden designs and even to anticipate negative effects on others. In one study, 25% of the people ways the garden will be used. However, additional wisdom interviewed in healthcare gardens mentioned sunlight as a can be gained from therapists and nursing staff. It is critical to garden quality that helped foster improved mood and incorporate their knowledge of potential activities and garden restoration (Cooper Marcus & Barnes, 1999). Sunlight also uses into the space design. Therapists such as horticulture plays a key role in enabling humans to benefit from intake of therapists, art therapists, recreation therapists, occupational vitamin D. However, some medical conditions, as well as therapists, and physical therapists may all have unique and some prescription medications, alter the body’s response to specific ideas of therapeutic activities that might be sunshine and for these patients, sunshine must be avoided. conducted in the garden setting. As mentioned previously, better outcomes may be achieved for therapies conducted in Gardens will tend to ameliorate stress effectively if they a pleasant garden setting, as compared to the same contain verdant foliage, flowers, nonturbulent water, park-like activities conducted inside the healthcare facility. qualities (grassy spaces with scattered trees), nature sounds such as birds, breezes, and water, and visible wildlife (Ulrich, In addition to gathering input from therapists and nursing 1999). Incorporating these features into a garden, in concert staff, the or garden designer should with information about garden uses and users, will provide research specific needs of the population that will be using restorative benefits to garden users. the garden. One population group that will be requiring special design attention in the near future is the increasing Conclusion. These four factors — social support, sense of elder population. Many of the principles of universal design control, physical movement and exercise, and nature as are especially well suited to the needs of elder segments of distraction — all work together to provide restoration from the population. For example, providing wider sidewalks and stress and buffering. According to Ulrich’s theory, this walking paths with wheelchair-accessible ramps and paved restoration then leads to improved health outcomes. Any ground surfaces are helpful design strategies for those with landscape can be designed with these principles in mind, to mobility impairments. Some older garden users may want to promote the healing quality of the particular space, and participate in activities but have trouble bending promote balance and wellness for the users of the space. over to reach the ground. Raised bed planters can be a helpful solution in these cases. Raised beds provide easy Applications of Ulrich’s theory access to gardening activities for those who can’t bend over. If the edge of the bed is adequately sturdy and wide, the Ulrich’s theory of restorative garden design provides a planter can also function as a place to sit. This is a helpful workable framework for the design of healing spaces. We strategy for those who have trouble standing for long periods now turn to some practical applications of his theory in of time. Specialized gardening tools which are ergonomically specific healthcare facilities. designed may also be helpful for older patients who experience difficulty with arthritis. Container gardens are Designing for specific population groups and another easy way to offer accessibility; they can be easy to garden uses manage in a variety of locations. Containers that move about on wheeled platforms can also promote garden use by those When designing a garden for a healthcare facility, the with reduced mobility. 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.

95

JAD June 2012, no.2 Art and Design Discourse

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 Figure 7. wide sidewalks allow plenty of space for circulation and views. in the garden., even for those in wheelchairs. Moving benches off the path enhances feelings of privacy. Methodist Patients who are undergoing chemotherapy treatment Hospital, Des Moines, IA USA 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 . Minneapolis Landscape , Minneapolis, MN USA

Universal design principles should be followed in nearly all 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 Figure 9. Gardens for patients undergoing chemotherapy restorative garden design can be beneficial. Some special treatment must use plants with minimal scents. Carolyn S. design requirements of those specialized typologies are Stolman Healing Garden. San Francisco, CA USA explored below. This list is neither comprehensive nor exhaustive but is provided as a starting point for the beginning student of healing garden design.

96

JAD June 2012, no.2 Art and Design Discourse

Figure 10. Shade and seating are important features in the garden for chemotherapy patients. Chalice Well Garden, Glastonbury, England Figure 11. Porches at this hospice facility lend a cozy feeling of home and blend the transition between indoors and Hospice Garden. A hospice facility is generally intended for outdoors. North Iowa Hospice, Mason City, IA USA 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 child’s attention and provide an invitation for activity. 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 97

JAD June 2012, no.2 Art and Design Discourse

needs of the garden users. When designing a garden of this It is extremely important for landscape architects and garden type, landscape architects and garden designers should designers to be well-educated and prepared when work closely with therapists who will bring their patients to undertaking restorative garden design. Learning should the garden for therapy activities. 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. Figure 13. This rehabilitation garden provides opportunities In addition, if human biophilic tendencies are insufficiently to practice navigation in the world outside the hospital doors. stimulated and nurtured, they will become atrophied and Here, patients can practice walking on a variety of ground dysfunctional. surfaces as well as stepping up and down a curb. Magee Rehabilitation Hospital 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 Questions about stress restoration and individual Garden, San Diego, CA USA preferences were raised in a recent survey of university

98

JAD June 2012, no.2 Art and Design Discourse

students. This survey yielded some puzzling results and contrast, 54% of the students mentioned a home setting — warrants further investigation. whether their own home, their family’s home, or their university residence. 17% chose an urban or built setting such as the gym or a coffee shop, and a very few Individual preferences relative to respondents — 3%, mentioned their car. stress responses and restoration Where do you go when stressed? Iowa 2011 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 . 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, Figure 15. Iowa 2011 study 1992). Findings from this survey align quite well with Ulrich’s theory of restorative garden design, the principles of biophilia, Where do you go when stressed? and available research about the health benefits of contact Iowa 2011 vs. Francis and Cooper Marcus 1992 with nature.

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 Figure 16. Iowa 2011 vs. Francis and Cooper Marcus 1992 administered in a sophomore-level housing class; students study were primarily from the College of Human Sciences. These students’ responses were quite different. Where in the 1992 Several factors could account for the difference between the survey, 71% preferred some type of outdoor environment, two studies. There was a twenty-year gap between the two only 29% of the 2011 survey group mentioned an outdoor studies. A new generation of university students has arrived environment — 19% mentioned a natural setting, and 10% and perhaps their biophilic tendencies have atrophied, as mentioned a designed outdoor setting such as a park. In

99

JAD June 2012, no.2 Art and Design Discourse

Kellert suggested. Also, the students from the 1992 study or June, for example. The point in time of the academic year were mostly students and were likely might also be a factor. The 2011 study in Iowa was more environmentally conscious and in tune with human performed just after Thanksgiving break, during the last week biophilic tendencies. The second study, conducted in early before final exams for fall semester. Students might have 2012, raises even more questions. been pulled emotionally towards home in their survey responses, as they were approaching their migrations home This study was conducted in Taiwan, and administered to a for holidays and the month-long break between semesters. university group. This survey population was a combination The 2012 survey responses in Taiwan were conducted in of students and faculty. Only the responses from the 18-29 early January. Their survey responses may have been age group are included here, in order to eliminate age bias in different if the survey had been given a few weeks later, as responses. This survey is very small in comparison, with 22 students were preparing for final exams, semester break, respondents. The survey questions were the same as in the and trips home to celebrate the Chinese Lunar New Year. 2011 study. Responses from this study were much closer to the 1992 survey responses. 63% of respondents recalled After looking at these three surveys, it appears that more going to an outdoor setting when they were stressed — 45% data is needed before firm conclusions can be drawn. If mentioned a natural setting and 18% mentioned a designed further surveys are undertaken, data should also be recorded outdoor setting. 32% mentioned a home environment, in about when and where the survey is administered. In spite of contrast to 54% in the 2011 survey of American students. all the questions raised above, some preliminary conclusions can nevertheless be proposed from the survey results. Where do you go when stressed? Certainly one can infer that, as Lerner proposed, a common element of places that provide healing and restoration for All studies 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

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 Figure 17. Comparison of all three studies window. These health benefits are valid for many population groups — patients in healthcare settings such as hospitals, Of course no firm conclusions can be drawn from these small medical offices, dental offices, nursing homes, and assisted studies. Questions about the surveys can be raised, however. living facilities; they are also valid for college students under Survey validity and reliability can both be called into question. stress as they prepare for a test, retail employees at the end The 1992 study was performed in California, USA, the 2011 of a mentally taxing day at work, or children on their way to study in Iowa, USA, and the 2012 study in Taiwan. The school. climates of California and Taiwan are much more moderate than Iowa’s climate. The survey was conducted in early Incorporating the principles of Ulrich’s theory of restorative December in Iowa, just when cold winter weather was garden design has many potential benefits to society in beginning. Perhaps considerations of outdoors as a diverse arenas, from gardens in healthcare facilities to public restorative place would be more prevalent in Iowa if the parks, schoolyard designs, and civic plazas. The value of survey was conducted in months of pleasant weather-- May implementing these principles is difficult to quantify, due to 100

JAD June 2012, no.2 Art and Design Discourse

the complex nature of the question. Certainly research Emery, C. F., & Blumenthal, J. A. (1991). Effects of physical shows us that benefits would accrue to society as a whole if exercise on psychological and cognitive functioning of these design features were implemented on a wide scale. older adults. Annals of Behavioral Medicine, 13, 99-107. Future research that can begin to quantify the benefits would be valuable indeed to convince decision-makers to Francis, C., & Cooper Marcus, C. (1992). Restorative places: incorporate the principles of restorative garden design in a Environment and emotional well-being. Paper presented wide range of locales — from rural communities to major at the 24th Environmental Association urban centers. Conference, Boulder, CO.

Other valuable factors for future research studies are specific Gatchel, R. J., Baum, A., & Krantz, D. S. (1989). An causal factors of therapeutic design. It will also be valuable to introduction to health psychology (2nd ed.). New York: track biophilic tendencies of future generations who have McGraw-Hill. spent much less of their childhood outdoors experiencing nature. Will they be drawn more to electronic screens for Hartig, T., Evans, G. W., Jamner, L. D., Davis, D. S., & restoration from stress? Garling, T. (2003). Tracking restoration in natural and urban field settings. Journal of Environmental The puzzling survey questions will also merit further study. Psychology, 23, 109-123. This survey likely needs a larger sampling of the population before meaningful conclusions can be drawn. Hartig, T., Mang, M., & Evans, G. W. (1991). Restorative effects of natural environment experiences. Environment References and Behavior, 23, 3-26. Heerwagen, J. (1990). The psychological aspects of Annerstedt, M., & Wahrborg, P. (2011). Nature-assisted windows and window design. Paper presented at the therapy: Systematic review of controlled and 21st Annual Conference of the observational studies. Scandinavian Journal of Public Research Association, Oklahoma City. Health, 39, 371-388. Horsburgh, C. R. (1995). Healing by design. New England Berkman, L. F., & Syme, S. L. (1979). Social networks, host Journal of Medicine, 11(333), 735-740. resistance, and mortality: A nine-year follow-up study of alameda county residents. American Journal of Kaplan, S. (1995). The restorative benefits of nature: Epidemiology, 109, 186-204. Toward an integrated framework. Journal of Environmental Psychology, 15(3), 169-182. Branas, C. C., Cheney, R. A., MacDonald, J. M., Tam, V. W., Jackson, T. D., & Ten Have, T. R. (2011). A Katcher, A., Segal, H., & Beck, A. (1984). Comparison of difference-in-differences analysis of health, safety, and contemplation and hypnosis for the reduction of anxiety greening vacant urban space. American Journal of and discomfort during dental surgery. American Journal Epidemiology. of Clinical Hypnosis, 27, 14-21.

Brannon, L., & Feist, J. (1997). Health psychology (3 ed.). Kellert, S. (2008). Dimensions, elements, and attributes of Pacific Grove, CA: Brooks/Cole. biophilic design. In S. Kellert, J. H. Heerwagen & M. Mador (Eds.), Biophilic design: The theory, science, Cohen, S., & Syme, S. L. (Eds.). (1985). Social support and and practice of bringing buildings to life. Hoboken, NJ: health. New York: Academic Press. John Wiley & Sons, Inc.

Cooper Marcus, C., & Barnes, M. (Eds.). (1999). Healing Lerner, M. (1996). Choices in healing: Integrating the best gardens: Therapeutic benefits and design of conventional and complementary approaches to recommendations. New York: John Wiley & Sons, Inc. cancer: MIT Press.

101

JAD June 2012, no.2 Art and Design Discourse

Louv, R. (2005). Last child in the woods: Saving our Ulrich, R., Dimberg, S. U., & Driver, B. L. (1991a). children from nature-deficit disorder: Algonquin Books of Psychophysiological indicators of leisure benefits. In B. Chapel Hill. L. Driver, P. J. Brown & G. L. Peterson (Eds.), (pp. 73-89). State College, PA: Venture Publishing. Louv, R. (2011). The nature principle: Human restoration and the end of nature-deficit disorder: Algonquin Books Ulrich, R., Simons, R. F., Losito, B. D., Fiorito, E., Miles, M. of Chapel Hill. A., & Zelson, M. (1991b). Stress recovery during exposure to natural and urban environments. Journal of Malkin, J. (1992). Hospital . New York: Environmental Psychology, 11, 201-230. Van Nostrand Reinhold. Waxman, H. M., Carner, E. A., & Berkenstock, G. (1984). Job McNeil, J. K., LeBlanc, E. M., & Joyner, M. (1991). The effect turnover and job satisfaction among nursing home aides. of exercise on depressive symptoms in the moderately The Gerontologist, 24, 503-509. depressed elderly. Psychology and Aging, 6, 487-488. Weiss, C. S., Pato, C. S., McAllister, G., Littman, R., Brier, A., Organization, W. H. (1946). Preamble to the constitution of Paul, S. M., et al. (1990). Differential effects of the world health organization. New York. controllable and uncontrollable acute stress on lymphocyte proliferation and leukocyte percentages in Osterberg, A. O. (2010). Access for everyone: A guide to humans. Brain, Behavior, and Immunity, 4, 339-351. the accessibility of buildings and sites with references to 2010 adasad (3rd ed.). Ames, IA: Iowa State University. Wilson, E. O. (1984). Biophilia: The human bond with other species. Cambridge: Harvard University Press. Schulz, R. (1976). Effects of control and predictability on the physical and psychological well-being of the institutionalized aged. Journal of Personality and Social Psychology, 33, 563-573.

Shumaker, S. A., & Czajkowski, S. M. (Eds.). (1994). Social support and cardiovascular disease. New York: Plenum.

Stigsdotter, U. A., & Grahn, P. (2002). What makes a garden a healing garden. Journal of Therapeutic Horticulture, 60-68.

Ulrich, R. (1984, 27 april 1984). View through a window may influence recovery from surgery. Science, 224, 420-421.

Ulrich, R. (1992). How design impacts wellness. Healthcare Forum Journal, 20, 20-25.

Ulrich, R. (1995). Effects of healthcare on wellness: Theory and recent scientific research. In S. O. Marberry (Ed.), Innovations in health care design (pp. 88-104). New York: Van Nostrand Reinhold.

Ulrich, R. (1999). Effects of gardens on health outcomes: Theory and research. In C. C. Marcus & M. Barnes (Eds.), Healing gardens (pp. 27-86). New York: Wiley.

102