DESIGN CONSIDERATIONS FOR NATURAL THERAPEUTICS IN MITIGATION CENTER

ARCHITECTURAL DESIGN CONSIDERATIONS FOR NATURAL THERAPEUTICS IN MITIGATION CENTER

MISS ANJARI PATRA BARCH/1008/2011

A DISSERTATION SUBMITTED AS A PART OF THE REQUIREMENTS FOR THE DEGREE OF BACHELOR OF ARCHITECTURE

DEPARTEMENT OF ARCHITECTURE BIRLA INSTITUTE OF TECHNOLOGY, MESRA, RANCHI

8TH SEMESTER 2011-2016

ARCHITECTURAL DESIGN CONSIDERATIONS FOR NATURAL THERAPEUTICS IN MITIGATION CENTER

MISS ANJARI PATRA BARCH/1008/2011

A DISSERTATION SUBMITTED AS A PART OF THE REQUIREMENTS FOR THE DEGREE OF BACHELOR OF ARCHITECTURE

DEPARTEMENT OF ARCHITECTURE BIRLA INSTITUTE OF TECHNOLOGY, MESRA, RANCHI

(DR. MANJARI CHAKRABORTY)

(BANGKIM KSHETRIMAYUM)

PROFESSOR IN-CHARGE

PROFESSOR IN-CHARGE

Department of Architecture Birla Institute of Technology,Mesra

Department of Architecture Birla Institute of Technology,Mesra

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ABSTRACT Women in India have been facing violence from men, in-laws, family and people around them for years. Although Indian family as a social institution is well known for the emotional and physical support that it provides to its extended members, many a time it fails to respond to the needs of women, specially for women in difficult circumstance like widows, destitute and deserted women, women ex-prisoners, victims of sexual abuse and crimes, including those trafficked and rescued from brothels, migrant or refugee women who have been rendered homeless due to natural calamities like flood, cyclone, earthquake, mentally challenged women, women victims of terrorist violence etc.

This problems that are being faced by women presently mostly happens in places where she is expected to feel safe and secure. These places are home, hospitals, police stations, college etc. Often women have to face situations appalling in these very places. It will surely take India to change the perspective of people for these issues in a social aspect but for immediate action government of India should look forward to creating a place where she would get all kinds of facilities needed by her in the moment of crisis and feel safe at the same time.

The report explores all the areas which are vital for the women in these prospects and the requirements would be framed accordingly. The needs for such women are also included. The emphasis on this topic is through a natural therapeutic setting in architectural design of building.

The research and explorations from the above theories are directed into into various solution for the existing problems in arrangement of spaces in the buildings to increase the output of medication and environment. The natural therapeutic environment and design in the building shall enforce better place for the inmates who want to take shelter.

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ACKNOWLEDGEMENT

The report would not be possible without our professors of the subject ‘Introduction to Thesis Seminar’, Dr. Manjari Chakraborty and Bangkim sir, whose constant encouragement , supervision and support from the preliminary to concluding level enabled me to develop an understanding of project and guide through it.

I would also like to thank Saurav Prasad to help me through the various stages of the report, Neeharika Kujur to encourage me to wake up all through the night while working.

At the end I am privileged to have my parents inspiration and encouragement that I was able to finish the report successfully.

Thanking You, Yours sincerely, Anjari Patra

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CONTENTS CHAPTER

TITLE

PAGE

ABSTRACT

I

ACKNOWLEDMENT

II

CONTENTS

III

LIST OF FIGURES

IV

REFERENCES

V 1–3

Introduction 1.1 Aim and objectives 1.2 Scope limitations 1.3 Research questions Methodology Detailed review of literature 3.1 Why natural therapeutic ?

3.2 Definition 3.3 Health and well-being 3.4 Nature and comfort 3.5 Stress reducing effects of viewing plants and nature 3.6 Effects on others 3.7 Benefits of natural environments within hospitals 3.8 Qualities of effective restorative gardens 3.9 Characteristics for spaces in healthcare settings 3.10 Design considerations for gardens in the facility 3.11 Hard landscaping needed for healing gardens 3.12 Research design and principles 3.13 Women centric gardens 3.14 Relevance to my Thesis Topic Conclusion

2 2 2 3 4 – 33 4 4–5 6 6–7 7–9 9 9 – 11 11 – 12 13 – 16 16 – 22 22 – 30 30 – 31 31 31 – 33 34 – 35

IV

LIST OF FIGURES FIGURES 2.1

TITLE

PAGE

Healing Garden at Legacy Good Samaritan Hospital

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2.2

Hospital Staff in the Healing Garden at Legacy Good Samaritan Hospital

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2.3

Stenzel Healing Garden at Legacy Good Samaritan Medical Center Conceptual model of effects of garden on health outcomes

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2.5

Oregon Burn Center Garden at Legacy Emanuel Medical Center

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2.6

Oregon Burn Center Garden at Legacy Emanuel Medical Center

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2.7

McLaren Health Care Village, Clarkston The

2.8

Crown Sky Garden: Ann & Robert H. Lurie Children's Hospital of Chicago

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2.9

The Enabling Garden at Bryn Mawr Rehab Hospital Parkview Women's and Children's Hospital

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2.4

2.10

8

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2.11

Roof garden on a hospital

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2.12

Joseph's Home in Cleveland

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2.13

Meandering path at the backdrop of a rehabilitation center

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V 2.14

A staff taking rest in the garden

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REFERENCE  1- 2 - Therapeutic Responses to Natural Environments Using Gardens to Improve Health Care By Stephen Mitrione, M.D., M.L.A  3 – 4 - Nature Therapy and Preventive Medicine. By Juyoung Lee ,Center for Environment, Health and Field Sciences, Chiba University,Japan  5 - Nature Therapy and Preventive Medicine. By Juyoung Lee ,Center for Environment, Health and Field Sciences, Chiba University,Japan  6 - 7- Therapeutic Responses to Natural Environments Using Gardens to Improve Health Care By Stephen Mitrione, M.D., M.L.A  8 - Hospital Outdoor Landscape Design, Gökçen Firdevs Yücel  9 - Paper for conference, Plants for People , International Exhibition Floriade 2002 Health Benefits of Gardens in Hospitals, Roger S. Ulrich, Ph.D.  10 - Literature review: Environmental design and research on the human health effects of open spaces in urban areas, Andrew Pleasant, Director of Health Literacy and Research, Canyon Ranch Institute, Tucson, Arizona Molly M. Scanlon Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona Maura Pereira-Leon, Program and Evaluation Manager, Canyon Ranch Institute, Tucson, Arizona  Corazon, S. S., Stigsdotter, U. K., Jensen, A. G. C., & Nilsson, K. (2010).

Development of the nature-based therapy concept for patients with stress-related illness at the Danish healing forest garden Nacadia. Journal of Therapeutic Horticulture  Mazumdar, S., & Mazumdar, S. (2012). Immigrant home gardens: Places of religion, culture, ecology, and family. Landscape and Urban Planning

VI ď ś Mundel, E., & Chapman, G. E. (2010). A decolonizing approach to health promotion in Canada: The case of the urban aboriginal community kitchen garden project.

Health Promotion International ď ś McCaffrey, R., Liehr, P., Gregersen, T., & Nishioka, R. (2011). Garden walking and art therapy for depression in older adults: A pilot study. Research in Gerontological Nursing

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CHAPTER 1 INTRODUCTION The main idea is to accommodate all the possible facilities needed by a women in need. The topic aims in providing such legal and health related help to women going from place to place as per required. This will provide help such as –      

Health Education Counseling Economic rehabilitation Legal aid and guidance Shelter

The main issue are physical, sexual and psychological violence strikes that happen to women in epidemic proportions worldwide. It crosses every social and economic class, every religion, race and ethnicity. From domestic abuse to rape as a weapon of war, violence against women is a gross violation of their human rights. Not only does it threaten women's health and their social and economic well-being, violence also thwarts global efforts to reduce poverty. The crime rates of India has increased considerably since 2008.

Year

Reported violence(1.1)

2008

195,856

2009

203,804

2010

213,585

2011

213,585

2012

244,270

Violence is, however, preventable. Although no silver bullet will eliminate it, a combination of efforts that address income, education, health, laws and infrastructure can significantly reduce violence and its tragic consequences. First and foremost, abusive behaviour towards women must be viewed as unacceptable. Communities need to have an important role in

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defining solutions to violence and providing support to victims. And men must be engaged in the process too, as agents of change standing alongside women to end violence.

If the world does not address the issue, it stands to suppress the enormous potential of women and girls. When they feel safe, when they are empowered, women and girls can be gamechangers. The catalyst for the next great innovation. The leaders of a more just world. The driving force behind stronger economies.

1.1

Aim and Objectives

The dissertation report aims towards –     

1.2

The various design guidelines that are formed for natural therapeutic treatment.

Analysis of patients reaction to various colours.

Discussion about the spatial arrangement of the building for easy and safe indoors.

Women intensive approach of the natural therapeutic design.

Discussing the safety and better treatment of every inmate needing help.

Scope Limitations

The restrictions of the report are –  

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Intensive study of the spaces that can be created to be natural therapeutic inside a building.

The response to the

Research Questions 

What is it about the design of specific open spaces within urban areas that promote improvements in human health and well-being?



What methodologies and indicators are researchers employing to document those effects?

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CHAPTER 2 METHODOLOGY Derive design criteria of indoor and outdoor environment for improving health

Hierarchial level of space - scale of site and design

Built landscape feature - art, water, vegetation and seating

Green building features in the building implemented

Calculation of energy loads and cost estimation

case study to check for the criterias provided

Existing site conditions - sun, soil, water quality , acoustics

Implementation in design of building with the criterias

Safety and security in the building

Thesis project

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CHAPTER 3 DETAIL REVIEW OF LITERATURE 3.1

Why Natural Therapeutic ?(1)

Gardens are experiencing a renaissance in health care settings as a growing body of research is showing that exposure to natural environments can improve both the patient experience and health outcomes. It shows a connection between exposure to nature and improved healing, less medication use, shorter hospitalizations, and decreased anxiety and stress among family members and staff.

Facility designers and health care providers are recognizing the effect of the physical environment on patient outcomes. Facility designers and health care providers are recognizing the effect of the physical environment on patient outcomes. Studies have shown that a facility’s design can influence the rate of nosocomial infections (A hospital-acquired infection (HAI) or nosocomial infection is an infection whose development is favoured by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff.), errors in patient care, and the cost associated with treating a given condition.

The idea of including gardens within a health care setting is an old one, dating back to medieval times. When technologies and therapies were few, hospitals were seen as places of rest and recuperation. Gardens were considered part of a patient’s therapy. Today, therapeutic landscape design is an emerging field within landscape architecture, and evidence is accumulating that demonstrates a role for gardens in improving outcomes both from a clinical and an experiential standpoint.

3.2

Definition(2)

It is important to distinguish a therapeutic garden from a healing garden. In the case of a healing garden, “healing” refers to an improvement in well-being that incorporates the spiritual as well as the physical, not a cure for a specific illness. Therefore, a healing garden may provide relief from the psychological distress associated with a disease but not alter the disease’s outcome. A therapeutic garden, however, is designed to produce a given effect or outcome. It is less focused on healing in a spiritual context (although it may have that effect), and more focused on ameliorating a disease.

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Fig – 2.1 Healing Garden at Legacy Good Samaritan Hospital The 13,000-square-foot garden in Portland, Oregon, is designed to meet the needs of people with a variety of abilities. Wide paths, raised beds, and lots of seating options make it userfriendly for people in wheelchairs or those who are ill. The garden is used informally by patients, family members, and staff, and for patients’ therapy.

Fig – 2.2 Hospital Staff in the Healing Garden at Legacy Good Samaritan Hospital The garden contains an assortment of plants designed to provide interest throughout the year and attract birds and butterflies. The pattern of the paths, seating options, and spaces for horticulture, therapy, and socializing encourage visitors to interact with each other and the environment.

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3.3

Health and well-being(3)

People have a growing interest in ways to improve their own health, which perhaps reflects the stresses of modern society. How can we achieve a sense of well-being? Obviously, being healthy does not simply mean freedom from disease.

Various definitions of well-being can be found nowadays; one understanding of the word “healthy” is “the state in which an individual fully displays the abilities he or she has or is born with.” Because it differs from one individual to another, a healthy state can be maintained even when living with a physical disability. Thus, well-being is relative rather than absolute. Even more important is the conviction that being healthy is not just an ideal “picture” in itself but rather a process through which a positive and constructive life can be led. In other words, health should be a “means” not a “goal.”

3.4

Nature and comfort(4)

“Comfort” is a common term in daily life, yet no set definition is available in the academic community. One understanding of comfort is the “harmonization of rhythm between human beings and the environment.” During everyday life, a feeling of comfort can be experienced if our rhythms are synchronized with those of the environment. This comfort is sometimes reflected in phrases such as “We hit it off immediately,” “We get on well with each other,” or “I like the atmosphere.” For example, when I feel that the audience is listening to my lecture and that our intentions are synchronized, I feel comfortable with the idea of talking some more. Humans can achieve peace in natural surroundings, gaining comfort as a result of synchronization between us and Mother Nature.

Fig – 2.3 Stenzel Healing Garden at Legacy Good Samaritan Medical Center Masao Inui categorized comfort using the terms “passive comfort” and “active comfort.”

“Passive comfort” is rooted in the desire for safety and the elimination of discomfort. When

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assessing this category of comfort, it should not be difficult to reach consensus because individual preferences are not involved. In contrast, “active comfort� is rooted in the desire for personal growth and the urge to achieve something extra. Of course, personal aims can change and it can be difficult to reach consensus even within oneself. Active comfort is needed most in today’s society.

3.5

Stress reducing effects of viewing plants and nature(5)

Several studies of nonpatient groups (such as university students) as well as patients have consistently shown that simply looking at environments dominated by greenery, flowers, or water -- as compared to built scenes lacking nature (rooms, buildings, towns) -- is significantly more effective in promoting recovery or restoration from stress. A limited amount of research suggests that viewing settings with plants or other nature for a few minutes can promote measurable restoration even in hospital patients who are acutely stressed.

There is considerable evidence that restorative effects of nature scenes are manifested within only three to five minutes as a combination of psychological/emotional and physiological changes. Concerning the first, psychological/emotional, many views of vegetation or garden-like features elevate levels of positive feelings (pleasantness, calm), and reduce negatively toned emotions such as fear, anger, and sadness. Certain nature scenes effectively sustain interest and attention, and accordingly can serve as pleasant distractions that may diminish stressful thoughts. Regarding physiological manifestations of stress recovery, laboratory and clinical investigations have found that viewing nature settings can produce significant restoration within less than five minutes as indicated by positive changes, for instance, in blood pressure, heart activity, muscle tension, and brain electrical activity.

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Restorative and coping Resources

Provided by gardens in Healthcare facilities

Movement & Exercise Mild exertion Physical Rehabilitation

Control (actual and perceived) Temporary escape access to privacy

Social support Among patients, visitors and staff

Natural Distractions Plants , flowers, water Natural sounds Wildlife

STRESS RESTORATION AND BUFFERING (Enhanced copying) IMPROVED HEALTH OUTCOMES Fig 2.4 Conceptual model of effects of garden on health outcomes Experiment 1 - One controlled experiment, for example, measured a battery of physiological responses in 120 stressed persons (non-patients) who were randomly assigned to a recovery period consisting of one of six different videotapes of either nature settings (vegetation or vegetation with water) or built settings lacking nature.

Findings from four continuously recorded physiological measures (blood pressure, heart rate, skin conductance, muscle tension) were consistent in indicating that recuperation from stress was faster and much more complete when individuals were exposed to the nature settings rather than any of the built environments. The quickness of nature-induced restoration was manifested as significant changes in all physiological measures within about three minutes.

The pattern of physiological data further supported the interpretation that nature, compared to the built settings, more effectively lowered activity in the sympathetic nervous system. (Heightened sympathetic nervous system activity involves energy consuming mobilization or arousal and is central in stress responding.)

Moreover, data from self-reports of feelings indicated that the nature environments likewise produced substantially more recuperation in the psychological component of stress. Persons exposed to the settings with plants and other nature, in contrast to the

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built environments, had lower levels of fear and anger, and reported far higher levels of positive feelings.

Experiment 2(6) - In a study of patients with a variety of medical conditions from throughout the United States, respondents indicated almost universally that they preferred facilities that provided access to nature either through a garden, views out windows, balconies, pictures, or indoor plants. Simulated natural environments have been shown to have a similar effect. In a study of patients recovering from heart surgery, panels were mounted at the foot of their beds with 1 of 3 scenes: a nature scene with a view of open water or an enclosed forest, an abstract design with curvilinear or rectilinear forms, or a blank, white panel. Patients viewing the nature scenes used less pain medication. Anxiety levels were significantly lower among those who saw the image of open water as opposed to the enclosed forest, indicating that different scenes had different effects. Conversely, the abstract scenes actually produced higher reported levels of anxiety in patients than the plain, white panel, which was used as a control. Burn patients undergoing dressing changes also reported experiencing less pain and anxiety when they watched a videotape of nature scenes accompanied by music as compared with those who did not.

3.6

Effects on others(7)

In addition to patients, family members and hospital staff benefit from being around nature. Health care environments can be stressful places for family to visit and staff to work. Burnout among health care providers, particularly nurses, is high. In a study of 3 healing gardens at the Children’s Hospital of San Diego Pediatric Cancer Center, Sherman et al. noted that the majority of users were not children but rather visiting adults and staff. Another study of a garden at a pediatric hospital found similar usage by adults, despite the fact that the garden had clear design features that would attract children. Ninety percent reported a positive change in mood after visiting the garden.

Although not directly related to patient outcomes, it is reasonable to conclude that by relieving stress among adult caregivers and staff, the care of pediatric patients would also improve. It is also reasonable to extrapolate this finding to the adult inpatient setting, where stressed family members and staff could find relief in a garden.

3.7

Benefits of natural environments within hospitals(8)

3.71

Physical benefits

Research shows that rehabilitative structures and procedures enhance both the physical endurance and the physical well-being of patients. Interaction with a natural environment has a positive effect on patients’ feeling of well-being, which in turn has a salutary effect on their physical health. In addition to anecdotal evidence, there are theoretical and practical studies

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illustrating the positive effects of interaction with nature on blood pressure, cholesterol levels and stress-reduction : a study by Robert Ulrich concluded that patients recovering from operations were discharged earlier, took fewer analgesics and were evaluated less negatively by nurses when they had windows in their rooms overlooking nature, compared to patients in similar rooms facing brick walls ; and a study of the home environment similarly found that a living context with windows overlooking a natural scene produced “micro-restorative experiences� that enhanced a sense of well-being, as against a context with views of built elements .

Fig- 2.5 Oregon Burn Center Garden at Legacy Emanuel Medical Center 3.72

Psychological benefits

Being able to choose between having privacy and interacting socially may assist in the process of recovery of patients, for most of whom the rigid regulation of time and activity in the hospital can have negative psychological effects, such as loss of self-esteem or the feeling of control, and a resulting increase in stress.

Research shows that high blood pressure and heart activity caused by stress can be decreased if patients are exposed to natural scenes, because such scenes engage them, draw their focus away from themselves and disturbing thoughts, and so contribute to their recovery. Research conducted in London by the Bow Centre has used flower and cutting gardens for horticultural therapy; patients are overwhelmingly in favour of well designed hospital landscapes, because of their positive psychological effects and the chance to pass time there 3.73

Social benefits

Everyone, regardless of age or ailment, needs recreation and social support; participation in social activities may also be the only means of family and community interaction and integration, and of sharing similar experiences, for the physically disabled. Studies have shown that patients with strong social support networks typically experience less stress and better health, as well as better recovery and survival rates for various conditions, than those who are isolated. Social support improves immune functions and moods, and results in better

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compliance with treatment. Natural environments in health care facilities contribute to social integration by providing spaces for social interaction and support; evidence indicates that they significantly help increase access to social support for patients, families, and staff.

3.74

Benefits of Healthcare Gardens for Staff

Healthcare staffing problems are a critical issue in most countries. It has been known for decades that healthcare occupations such as nursing are stressful because they often involve overload from work demands, lack of control or authority over decisions, and stress from rotating shifts. Workloads and pressures have mounted further, however, as healthcare providers everywhere have been forced to control or cut costs. These conditions have in many locations lowered lower job satisfaction, increased absenteeism and turnover, contributed to shortages of qualified personnel, increased providers’ operating costs, and eroded the quality of care that patients receive.

These serious staff related problems imply major importance for the aforementioned finding that healthcare staff heavily use gardens for positive escape from workplace pressures and to recuperate from stress. Additionally, it should be emphasized that evidence has begun to appear showing that hospital gardens increase staff satisfaction with the workplace, and may help hospital administrators in hiring and retaining qualified personnel.

3.8

Qualities of effective restorative gardens(9)

The limited evidence to date suggests that gardens will likely calm or ameliorate stress effectively if they contain verdant foliage, flowers, water (not tumultuous), congruent or harmonious nature sounds (birds, breezes, water), and visible wildlife (birds). Additionally, nature settings with savanna like or park like qualities (grassy spaces with scattered trees) are known to foster restoration. In their study of users of four hospital gardens, Cooper-Marcus and Barnes found that the most frequently mentioned positive garden qualities were visual nature elements, especially trees, greenery, flowers, and water. Respondents strongly associated these nature features with restorative influences on their moods.

By contrast, a characteristic that usually worsens garden effectiveness in reducing stress is predominance of hardscape (concrete, for example) or other starkly built content .

Whitehouse and her associates (2001) found that users of a children’s hospital garden disliked and avoided areas having a high percentage of concrete ground surface and/or starkly built features. Persons interviewed in this study consistently recommended that the garden should have “more greenery and flowers” and less concrete . Based on this evidence the administration of the hospital directed that the garden be reconstructed to include many more plants and less hardscape, in order to become more effective in promoting restoration.

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Fig – 2.6 Oregon Burn Center Garden at Legacy Emanuel Medical Center In addition to predominance of hardscape rather than vegetation, other garden qualities that can hamper recovery or even aggravate stress include: cigarette smoke; intrusive, incongruent urban or machine sounds (traffic, for example); crowding; perceived insecurity or risk; prominent litter; and abstract, ambiguous sculpture or other built features that can be interpreted in multiple ways. Regarding abstraction and ambiguity, there is mounting evidence that designers of hospital gardens should exercise considerable caution before including abstract art works or ambiguous design features. It appears that acutely stressed patients may be vulnerable to having stressful rather than positive reactions to ambiguous art or design. Current evidence suggests that the safest, most consistently effective general strategy for designers of hospital gardens is simply to feature the restorative, unambiguously positive qualities of greenery, flowers, and most other nature content.

A documented example of adverse patient reactions to ambiguous features occurred when a major university hospital installed a large-scale series of sculptures and other artworks to form a “bird garden” in a rooftop space overlooked on all sides by rooms for cancer patients. Although called a “garden,” the space actually contained no greenery, flowers, or other nature. Soon after this sculpture garden was installed, administrators and physicians began to receive many anecdotal reports of strong negative reactions by patients.

Accordingly, a questionnaire study was conducted of patient reactions to the artwork. The study showed that more than 20% of the cancer patients reported having a negative emotional or psychological reaction to the “garden.” Several patients had strongly negative responses, interpreting some rectilinear metal bird sculptures, for instance, as frightening predatory animals. The administration and medical staff decided that the rate and intensity of negative effects on patient outcomes was too high, so the art installation was removed for medical reasons.

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3.9

Characteristics for spaces in healthcare settings(10)

The review identified six overarching design criteria that contribute to the fundamental attributes of creating an open space in an urban area conducive to health and healing. The following are descriptions of the criteria discovered in the literature review.

3.91 Create open spaces in urban areas that are compatible with and encourage human activities Louis Sullivan, a world-renowned American architect who lived from the mid-19th century into the early 20th century, is commonly attributed with the phrase “form follows function”.

Similarly, 22 articles emphasized that in order to produce positive effects on human health and well-being, open spaces should be designed to be compatible with human activities. For example, if an open space was intended to increase physical exercise, it would require a different design than an open space intending to promote local horticulture activities.

Activities targeted by the open spaces described in the literature consisted of exercise, horticulture, journaling, mindfulness journeys (pathways, labyrinths, and reflection), observation of nature or art (sensory perceptions), and socialization (formal, informal, games and playfulness). Essentially, this criterion for successful design of an open space in an urban area calls for mindfulness on the part of the designers and planners involved in the project. Without a clear intent, the outcomes desired seemed to be less forthcoming.

3.92

Construct a setting for sensory stimulation

Twenty-one articles include specific mention of four human senses as critical targets for designs of open spaces in urban areas. Hearing is reflected in the sounds of water, birds, and animals. Sight is mentioned as a visual sense of beauty, color, and fascination with surroundings. Sense of smell helps humans become aware of fresh air and flowers in bloom.

Touch is articulated in feeling plants, working in the soil, and breeze upon the skin. Taste, the fifth sense, is not specifically mentioned in the articles reviewed, yet is at times implied through the horticulture activities of harvesting fruits and vegetables from community gardens. Sensory stimulation was also found to encourage interaction and socialization. 



Sherman et al. (2005) concluded that art sculptures and water fountains in a healing garden at a children’s hospital were responsible for boosting person-to environment interaction, as well as person-to-person interaction.

Whitehouse et al. (2001) conducted a post-occupancy evaluation in the same children’s hospital, and found that interactions with art, sculpture, water, and vegetation made it easier for healthy siblings to visit a sick brother or sister, and engage in family activities during the healing process.

The design goal of constructing a setting to stimulate the human senses encourages designers and planners of open spaces in urban areas to promote multi-sensory interaction and

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stimulation within those spaces in order to promote human health and well-being. We experience the world through our senses and that experience is a source of development and growth. This requires planners and designers to consciously reinforce sensory stimuli to promote human health and well-being in their designs of open spaces in urban places.

3.93

Develop the space for safety and security

Sixteen articles included discussion that an important attribute within an effective open space in an urban area must be that participants feel safe and secure. Sometimes this feeling is associated with the calmness of the environment. In other situations, the authors associated safety and security with macro scale items such as site location and its surrounding context.

Safety was also associated with micro scale garden features like the width of walking paths, threshold heights, curbs, stairs, and benches. Even the sharpness of leaves, thorns, and toxicity of plants were cited as contributing to safety. This design criterion essentially necessitates that planners and designers of open spaces in urban areas who have the goal to promote human health and well-being to be aware of the totality of the context in which they are designing. Simply designing a beautiful pocket park in an unsafe neighbourhood will not promote human health. Conversely, designing a beautiful but unsafe pocket park, even if in the safest of neighborhoods, will not promote human health and well-being.

3.94

Encourage present moment awareness

Thirteen studies found that successful open spaces in urban areas were used to separate people from daily stress for extended periods of. Participants used mindfulness activities consisting of walking a labyrinth, observing the surrounding natural setting, and writing thoughts in a journal to focus awareness on the present moment. In Scandinavian countries, both public and private insurance companies are investing in research related to therapeutic gardens for patients who cannot work due to stress-induced diseases (Corazon et al., 2010).

For example, Nacadia, a Danish healing forest garden, focuses on mindfulness activities designed into a 99-acre setting. Program activities range from chopping wood in the forest to slow walking and meditation along garden pathways. Corazon et al. (2010) described patients at Nacadia who participated in nature-based therapy. The therapy and research team developed a psychological framework around the treatment activities based on evidencebased theories: acceptance and commitment theory, and mindfulness-based cognitive therapy.

The six elements of acceptance and commitment theory (present moment, acceptance, diffusion, self as context, values, and committed action) were woven into the nature-based therapy concept. Essentially, the theory that Corazon et al. (2010) explicated is that there is greater utility and potential for positive and healthy effects from designing an open space not just to be open and available but so that the space encourages mindfulness and contemplation in its visitors.

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In a similar mode, McCaffrey et al. (2010) described the “Stroll,” a series of 12 themed walks mapped out within a Japanese garden in Delray Beach, Florida. The walks were designed to focus on reflection of topics including awareness, possibilities, transitions, connections, journey, trust, joy, freedom, forgiveness, reflection, gratitude, and fulfilment. The reflection walks were a way to experience present moment activities while “being forced to spend time away from pressure of the day” (McCaffrey et al., 2010, p. 256).Just as the first design criterion encouraged mindfulness in planners and designers, this design criterion encourages those same designers and planners to build in opportunities to promote mindfulness among visitors to the open space in an urban area in order to promote human health and well-being.

3.95

Consider the culture of the population using the space

Nine articles encourage designers to take the cultural background of the local population into account when designing an open space in an urban area with the goal of promoting human health and wellFor example, Mazumdar and Mazumdar (2012) indicated that immigrants crossing boundaries leave behind a significant sense of place from their native homeland. This can include different homes, neighborhoods, and landmarks. In the process of colonization by predominantly white Anglo- Saxon Christian civilizations throughout history, indigenous peoples were often forced to abandon their concepts of environmental holism (Mundel & Chapman, 2010). Elders may have valued the land and considered it a form of mental, emotional, physical, and spiritual health. Mundel and Chapman (2010) further stated that separating an indigenous population from its environmental beliefs has negatively affected health at individual and community levels, especially related to native food as agricultural lands, personal food choices, and offerings at ceremonial feasts changed over time. As part of an effort to reduce public health problems related to obesity and diabetes, indigenous cultures frequently re-examined their connections to native gardens for health promotion. Therefore, this design principle urges designers and planners to consider the cultural heritage of the population who will become the primary users of an open space in an urban area. Residents of urban areas may well be immigrants or simply not reflect the dominant cultural paradigm.

3.96

Promote nature as a metaphor for healing

Open spaces in urban areas hoping to improve human health and well-being were interpreted in seven of the articles reviewed as metaphors for the process of healing from stressful life experiences. For example, examining gardening in everyday life and its associations with spirituality and connectedness for participants suffering distress from cancer, chronic disease, divorce, and other life challenges. The authors developed themes from participants’ qualitative responses regarding aspects of the garden being a representation of the journey of human life; how participants faced recovery from illness, dying, and death were all symbolized. Gardens signified life’s positive aspects in preparing the soil, planting seeds, witnessing germination and growth, and smelling flowers in bloom. Significant maintenance

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was required over time, demonstrating a level of nurturing that is requisite for life, through watering, fertilizing, weeding, and pruning. Noticeable changes occurred across the seasons.

Life’s challenges were represented with dying flowers, disease of plants, allowing overgrowth, and cutting vegetation to the ground for regrowth. In some cases, plants simply did not survive, requiring removal from the garden. Study participants expressed seeing the garden as a mirror of human life.

One participant saw disease as a process of living, and another found a need to face issues associated with mortality. For designers and planners, this design criterion suggests that they need to be aware that the users of an urban space in an urban area will bring their life experiences into the space and look for relevant meaning. Therefore, open spaces in urban areas should be designed to encourage visitors to see their healing process occurring metaphorically within the space in order to further their own healing process.

3.10 ď ś

Design considerations for gardens in the facility(8) Type of spaces needed in the healthcare facility –

If the garden is a foster restoration and coping by providing control, potential users must know the garden exists, be able to find their way to the settling without difficulty, and be able to use the garden in an active and passive manner. Accordingly, way finding and access are very important design and planning considerations for gardens. If patients and visitors know a garden exists in a healthcare facility, but experience difficulty or frustration in trying to find or get access to the setting, such impediments will tend to produce loss of control and engender further stress.

Control- related benefits should be increased by garden designs that facilitate on-site usage by patients, including accessibility and independence for persons in wheelchairs. A given patient will be much more likely to engage in on- site use of garden that is located close to his/her room and can be travelled to easily. Generally speaking, on-site usage rates will be higher for gardens situated adjacent to building interior spaces that are used by large number numbers of patients, visitors and/or staff, such as cafeterias or major corridors. Other examples of garden design strategies that should foster control include providing : spaces in gardens that enable users to have privacy, including visual privacy with respect to windows looking on to a garden ; variety in types of spaces, making choices possible; and an adequate number of spaces to help prevent crowding that would otherwise erode control advantages of the garden. In case of stuff, and patients in long-term facilities, feelings of control may be enhanced by involving them as participants in designing gardens.

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3.10.1 Landscaped grounds Green areas between buildings, primarily used for waiting and eating in, link the architecture with walking paths; however, they may be expensive to maintain.

Fig. 2.7 McLaren Health Care Village, Clarkston Curved Pathways and benches to sit gives an ideal garden for the people to relax 3.10.2 Landscaped setbacks These are usually planted areas in front of the main entrance, which are visually pleasant and serve to separate the hospital building from the street.

3.10.3 Front porches These may include overhangs or porch roofs, an area where vehicles can pick up or drop off passengers, sitting areas, signs with directions, a mailbox, telephone booth, bus stop, etc.

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Fig. – 2.8 The Crown Sky Garden: Ann & Robert H. Lurie Children's Hospital of Chicago The Crown Sky Garden began with contemplative spaces for stress reduction, screening spaces with sounds of water and bamboo.

3.10.4 Entry gardens These are visually pleasant green spaces designed like gardens and located near hospital entrances.

Fig – 2.9 The Enabling Garden at Bryn Mawr Rehab Hospital The beautiful entry garden acts as a calming of the patient and even maintained by the residents acting as a therapy

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3.10.5 Courtyards Courtyards are the central and most often used spaces in a hospital building complex, because of their proximity to the dining area;  they tend to be used more by visitors and patients if they are easily visible, and should be sufficiently large to prevent overcrowding.

Fig 2.10 Parkview Women's and Children's Hospital A small courtyard in the middle of the facility changes the essence of the space 

3.10.6   

3.10.7  

Courtyard features may include landscaped tree-shaded areas, water features, flowerbeds and moveable seats; for reasons of privacy and security as well as aesthetics, they may be fenced around (especially if designed for care of the mentally ill) up to a height of 4.27m .

Plazas These outdoor areas, which are typically paved and furnished, should allow easy access to wheelchairs, walkers and crutches.

They should include shade from flowering trees or spreading evergreens, and at least a quarter of the trees should be above the minimum specified size.

A plaza should have shaded seating areas decorated with plants, coloured shrubs and ground cover, and perhaps a water feature. Because these areas are largely paved, landscaping and gardening maintenance costs are low.

Roof terraces A roof terrace is usually a long, narrow balcony occupying one side of the roof of a hospital building.

The elements it is comprised of (plants and seating) and the surface finish are designed to minimize observation from from higher buildings overlooking it.

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3.10.8 

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Roof terraces are sometimes too exposed to wind, heat or shade, and for this reason care must be taken in selecting their location.

Roof gardens Gardens located on roofs are visually attractive, enabling patients to look out from their rooms and have a comforting view of grass, paving stones, benches and people, rather than roofing material or medical equipment.

Depending on how much planting material is usedand to what depth, green roofs generally weigh between 6.82kg and 22.73kg per square foot.

They are a practical and sustainable way of regulating the quantity and speed of run-off, a they retain 70-90% of the rainwater that falls on them in the summer, and 35-40% of the precipitation in winter.

Roof gardens enable major energy savings that will more than compensate, in time, for the costs of building, structure, waterproofing, and landscape maintenance; and they also minimize the environmental impact of a health care facility.

Fig 2.11 Roof gardens on a hospital When there is no setback areas for gardens roof gardens solves the purpose just the same.

3.10.9 Healing gardens Gardens which serve as safe and meditative environments for healing and recuperation date back to the medieval period, and have traditionally been features of hospitals, hospices, rehabilitation centers, and nursing homes. The wide range of activities related to healing gardens may be passive or active: looking at the garden from a window, sitting, eating reading, doing paperwork or taking a nap in the garden,

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prayer and meditation, walking to a preferred spot, gardening, exercise and sports, and children’s play. The gardens are conducive to stress relief, relieving physical symptoms, and enhancing the feeling of well-being of hospital staff and patients.

Successful healing gardens make use of certain fundamental design principles : Enhance feelings of control: People should be aware that there is a garden and be able to find, enter and use its space. The garden should have private areas which cannot be seen from overlooking windows, and different kinds of spaces so users can feel they are making choices; if users are also consulted in designing the garden, this will also add to their feeling of control. All or some of the five senses can be chosen as focal stimuli in the garden’s construction .

3.10.9.1 Have a prevalence of green material and areas: Patients’ sense of well-being is enhanced by soft landscapes, so plant material should be dominant and hardscaping reduced to a minimum: trees, shrubs and flowers should make up about 70% of the garden, with 30% in walkways and plazas.

3.10.9.2 Encourage exercise: Designs should provide easy access and independence, as well as stress reducing structural elements such as walking paths for patients to encourage exercise, and play areas for children.

3.10.9.3 Provide positive distractions: Stress levels among patients have been shown to decrease when they are in the presence of plants, flowers, and water features as well as when they are engaged in gardening.

3.10.9.4 Minimize intrusions: Gardens should be designed to minimize negative factors like urban noise, smoke, and artificial lighting, in favour of natural lighting and sounds. Gardens that appeal to the different senses are ideal (although strongly scented flowers and other scents should be avoided for chemotherapy patients).

3.10.9.5 Minimize ambiguity: Complex or mysterious settings that provide a challenge might be of interest to the healthy, but research shows show that abstract design may be contraindicated for patients who are ill or undergoing stress. For this reason, the use of abstract art may be unsuitable, and design should focus on clearly identifiable elements.

3.10.10 Meditation gardens This type of small, enclosed, quiet garden is designed with a central focal point to help patients (often a single patient at any given time, depending on the size) concentrate and relax as part of the healing process. It is a space for quiet contemplation, removed from distractions and private – that is, not visible from other

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indoor spaces. Meditation gardens are labeled as such and purpose-designed, and their layout is usually simple and minimalist, comprising, for example, a circle representing life, a square symbolizing order, or symbols such as the Celtic knot, which represents travel . They usually have a lawn and/or a comfortable seating area with a focal point, typically a water feature, to encourage meditation. The vegetation should provide cool colours such as violets, blues and greens, rather than bright, warm or contrasting colours .

3.10.11 Viewing gardens Some health care facilities with limited space and budgets feature a small, enclosed garden that can be seen but not entered. Such gardens cost little to maintain, provide some green space, flowers, perhaps a water feature, and they can be seen from sheltered indoor seating areas; however, the elements of nature they provide are removed from the senses, as they cannot be approached smelled, heard or touched.

3.10.12 The viewing/walk-in garden In this variation on a viewing garden, the green space can actually be entered from a corridor or waiting room: because it has limited space and seating, it remains a quiet area which does not disturb the privacy of any nearby rooms or offices, and also provides a comforting view for people waiting or passing by in the corridor. The main disadvantage is that people using the space may feel a lack of privacy, as they can be watched by others .

3.10.13 Edible gardens A healing garden can be developed to a new dimension if herbs, fruit plants and vegetables are grown together with the usual planted vegetation in an easily accessible space. This “edible garden� should be simple and balanced, but designed in a repeating pattern with wandering paths demarcating public and private spaces . The vegetation would favour annuals over perennials; and the garden could feature a large number and variety of plants, such as, for example, Nasturtium spp., the flowers of which are beautiful and can also be eaten.

3.11

Hard landscaping needed for healing gardens(8)

3.11.1 Gateways and entrances Gateways and entrances welcome people on arrival and provide cues for them to find their way around the site; they can perform this function if a comprehensive network of connecting paths is planned, specified, and followed up to ensure they are properly constructed.  The main entrance should be accessed logically by the most direct path, and the entry way to the outdoor space should have no ramps or steps.

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Landscaping, artwork and detailing can prioritize the main access points and create a sense of place, and benches should be available for people arriving or waiting for rides to sit on.

Entrances must be sufficiently wide to accommodate people with special mobility requirements; for the visually impaired, different kinds of surfacing materials can be helpful, and tactile elements should indicate thresholds.

3.11.2 Parking areas  Parking areas should be sufficient to accommodate staff and employees, and parking should ideally be reserved for staff at the back of the hospital so they do not have to deal with heavy traffic when they come to work.  Parking for patients, especially those with disabilities should be as close as possible to the entrance.  Patients and visitors unfamiliar with the hospital may easily be confused if parking space is difficult to find; this can be solved by using directional signs that can be altered or moved as conditions change.

3.11.3 Paths Large hospital or medical complexes should be organized within a clear circulation hierarchy: main roads, shopping streets, neighborhood streets and service alleys. Each of these, as well as intersections and destinations, should be indicated by a consistent system of spatial cues.  This circulation in the health-care facility should be independent of public roadways, and public (nonsecured) and private (secured) zones should be distinct, preferably with patient intake and outdoor recreational areas in the private zone.  Traffic circulation should be organized so that individuals and ambulances can directly access emergency facilities.  The main circulation routes should be clearly indicated, for example by giving easily understood names to the main corridors like “Hospital Street” or “Blue Corridor” (here the walls and floor should be predominantly blue in colour); or having coloured lines along the walls or floor to designate main routes; or using lighting along a route.

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Fig 2.12 Joseph's Home in Cleveland Peaceful therapeutic garden for residents of Joseph's Home, a facility for homeless men recovering from illness. Garden beds are thick with plants that are fragrant and textured, in soothing colors such as soft blue. Meandering pathways gives an encouraging push to go forward and also provide surprising vistas and views. 

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Primary routes should be accessible to everyone; however, some people will prefer to experience the natural environment unmodified and will not expect easy access everywhere.

Minor walkways should be at least 1.5m wide, with drainage that will get rid of rainwater quickly.

One-way traffic routes should be at least 1.5m wide to allow for the turning circle of a wheelchair; while two-way traffic routes should be at least 2.1m wide. There is a risk of tripping if the edges of a path are raised ; and handrails or balustrades and wheelchair barriers will preclude people’s falling where surface levels change, or from entering uneven ground beside paths and paved areas.

In the garden, clear links with different facilities and direct routes are essential.

Right-angled corners in paths should be avoided, and slopes designed as follows: a walkway’s slope  should not exceed 5% (i.e. 30.48cm of rise for a length of 6.1m);  cross slopes should not exceed 2% (30.48cm of rise for a length of 15.24m).

Where the slope does exceed 1/20, there should be a support railing to preclude slipping.

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Fig 2.13 Meandering path at the backdrop of a rehabilitation center The garden’s position also needs to be located where it can be easily accessed from the building. Healing gardens offer many benefits to the morale and psyche of a patient, some are more impactful than others, but they all contribute to the overall goal of making patients more comfortable.  

The surfaces of paths should be firm, smooth and level, and provide traction; they should reflect the context, with “softer” materials used for informal settings.

Paving surfaces should be smooth enough to be used by wheelchairs and gurneys; but grooved paving may be unsuitable for them. Different materials have different pros and cons: concrete is suitable, but costly; asphalt absorbs and radiates heat, and may be too hot in the summer; decomposed granite may be suitable for wheelchairs, but is not for users of crutches. More recently developed rubberized paving materials are firm enough to support wheelchairs, and also absorb the force of a fall.

3.11.4 Children’s gardens Children are usually discouraged from moving around in hospital environments lest they disturb the health-care workers or patients;  there should be spaces set apart for them where they can move as freely as they need or wish to, as they need to engage in imaginative play regardless of the condition of their health.  Children need to feel they can create and make changes by interacting with their environment and moving objects and parts; as a result, flexible play areas should be designed to stimulate their imaginations and give them the pleasure and therapeutic benefit of creative activity.  A children’s area might, in addition to using primary colours and providing climbing structures, include a path maze, a chalkboard masonry wall, child-sized sculptures, or a miniature bridge traversing a faux rock stream, which can also be crossed on stepping stones.  Routes should be stable and made of surfaces like decomposed granite, asphalt, wooden boardwalk, resilient mats, and concrete, to resist slipping.

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There might be platforms so children in wheelchairs can safely move onto and off play structures; and sand play areas may be made available at different heights, so they can be used on the ground or from a wheelchair.

3.11.5 Dining areas Because the dining area is used by more people than any other hospital area, there are more potential outdoor space users in it; having an outdoor space near the dining area is essential.  There should be tables in the space for eating, reading, and writing activities, and to serve as territorial markers, as people rarely intrude on a table that is being used.  Shade and semiprivate group spaces can also be provided by umbrella tables with chairs.

3.11.6 Art Artworks form part of the healing environment, and works of art in health-care facilities  featuring images of nature have been linked with stress relief in diverse groups of people.  In hospital spaces which can easily be accessed, artworks which create inviting, habitable spaces should be incorporated into the design.  The type of artwork used is also important; it should have what is described as “emotional congruence”, which means that when confronted with a collection of environmental stimuli, the viewer will tend to focus on the parts that correspond to his or her emotional state. For example, abstract art might be seen as interesting by a relaxed person, but as frightening or threatening by a person in a state of anxiety.  As the hospital environment tends to increase stress, artworks, sculptures and other design elements should provide an unambiguously positive message; complex or abstract art is therefore not suitable for this kind of setting.  Appropriate artworks can create an engaging focal point for a hospital space. In terms of genre, Ulrich has shown that postoperative patients preferred representational pictures, which tend to incorporate the subdued colours of nature, as opposed to abstract art, which often features unexpected colour combinations; another study found that people in a state of anxiety prefer less saturated colours.  The artworks should therefore be selected with these effects in mind.

3.11.7 Water  Hearing water running in a fountain, or seeing fish in a pond or sunlight reflecting on water, can be meaningful for a patient [44]; the sound of running water in particular can mask other noises which negatively affect the therapeutic value of a space.  Such sights and sounds create sensory focal points for garden spaces which attract all ages and abilities.

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Water should be available, close to the garden site, and in a paved area to prevent muddying.

The spigot should be 61-91.5cm above ground, and hand levers (not round spigot handles) and snap connectors should be used. Soaker hoses and mulch can decrease the water requirements of the garden. “Bubble” fountains may be appropriate, as they are tactile and make use of shallow water, raising fewer health and safety issues.

3.11.8 Site furniture This term refers to free-standing elements such as seating, litter bins, lighting and signs, which should be selected to meet the needs of users. Furniture should be anchored to concrete pads or too heavy to be moved, and in cases where there is a risk of users running away, it should not be placed near fences or walls.

Fig 2.14 A staff taking rest in the garden Furnitures that gives a hide away space and privacy to the residents and staff 3.11.9 Seating  Seating should be available where people would actually want to use it, typically enclosed and towards the back, facing an attractive view or focal point, and not obstructing people on the path.  Comfortable, movable, and varied seating can increase usage of the garden, especially by hospital staff; there should be benches and chairs for individuals, and more social seating arrangements for groups.  Social seating arrangements (right-angled or centripetal benches, or movable chairs) should be conveniently located near the garden entrance, where they are most likely to be used by staff for short breaks.  In addition to semiprivate areas there should be some benches arranged in a line rather than in a group, facing a view or circulation area.

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Benches are usually situated at rest places or corridors with an exterior view .

Space should be left beside a seat to accommodate a wheelchair or electric scooter.

Raised features can help wheelchair users and people who cannot easily bend down, and should attract others as well, for example if the edge can serve as an informal seat.

The thinnest construction materials should be used as long as they are stable, to increase the area of the garden: seating ledges should be 20-45cm wide, and the sides may range from 45cm high for a child, to 60cm for a visitor sitting by a bed, to 75cm or more for those who cannot bend easily.

Seats can be artworks in themselves. The material used should not retain heat or cold, so concrete, aluminium and steel should not be used: wood or hard plastic are preferable.

Moveable chairs can be rearranged depending on the sun or shade, and to adjust the size of the seated group. In general, seats should have arm and back support, but their height and depth, as well as their supporting structure, will affect their usefulness to people with special needs, and this should be taken into consideration.

3.11.10 Signage Being able to choose whether or not to follow or avoid a route that might have rough paths is essential;  appropriate, approachable and welcoming signs are a must.  Site signage should indicate, among other things, directional or one-way traffic, restrictions, parking, deliveries, patient entry points, entrances to facilities, and so on .  Tactile signs should be fixed at a height of 150cm (120cm for children).  Other sensory indictors, such as audible water features and wind chimes may also be used to assist way finding for the visually impaired in the garden.

3.11.11 Lighting  The primary purpose of lighting is to enhance safety and security.  Exterior lighting deters thieves or vandals; while lights on stairs, walkways or approach roads both increase safety from attackers and help prevent accidental falls.

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Fig 2.16 Nationwide Children's Hospital All potted plants glow with bright colours in the evening. It's a beautiful thing for the patients to see from their windows  Parking areas, entrance and service roads, and also isolated or dark areas need to be clearly defined and lit; bollards or bulkheads are usually used for this purpose.

Fig 2.17 Lighting in the internal courtyard Interesting shapes and sceneries are generated which attracts more attention 

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Lighting along pedestrian routes should be mounted at a height where faces can be seen and recognized, and any entrances, intersections or hazards such as changes in path level, should be indicated by beacons.

An added therapeutic benefit of night-time lighting is that it enables safe use of the space at night, and viewing of the garden from indoors.

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3.11.12 Receptacles  The locations of trash containers should be considered as an essential element of health-care facility planning, as they allow for easy disposal of food and paper products outdoors.  The number of receptacles required depends on the population density and the activity level in an area, as well as how often they are emptied; overflowing litter bins indicate a need either for more of them or for more frequent service.  There should be litter containers at all transition areas such as doors, building entries, parking access points and social and pedestrian spaces.  To provide a less disturbing environment, receptacles should be placed at least 3.6m away from where people tend to socialize.

3.12

Research design and principles(9)

This literature review identified six overarching design criteria: • create outdoor spaces that are compatible with and encourage human activities; • construct a setting for sensory stimulation; • develop the space for safety and security; • encourage present moment awareness; • consider the culture of the population using the space; • promote nature as a metaphor for healing.

Further, this literature review identified three important areas of individual design elements: existing site characteristics, hierarchy of the space, and built landscape features.

A synergy between the design elements and design criteria is important to establish an open space that promotes interaction with nature and meets the goal of improving human health and well-being. On one hand, a reductionist approach could work against an open space or the accompanying research design being able to reach and identify the desired goals of improved human health and well-being through exposure to nature. For example, far too often, we found research is conducted post hoc only or the design process is conducted in a vacuum and not tailored through formative research to truly meet the needs and culture of the community of potential users of the open space. This is a key point that should be addressed by all planners, policy-makers, and researchers. We strongly recommend that researchers and practitioners give greater consideration to comparability and replicability, but not as justification for further simplification. The relationships studied and proposed by the field are complex and interrelated.

While economic pressures urge landscape designers and researchers to try to do more with less, spaces must have sufficient strength of design to allow visitors to mindfully separate themselves, at least temporarily, from sources of stress and ill health in order to reposition their lives in a healthier direction. The study of that process is, we urge, best made from a cross-disciplinary and integrated perspective with a team of researchers and environmental designers collaborating with both the internal team and the external community of users.

This argues for a more holistic approach to both the design process and the research

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design. The incentive to reduce the research design and the landscape design to a few key identifiable elements seems clear.

This approach is easy to explain, less costly to produce and conduct, and in theory will allow researchers to isolate the source of effects. However, our analysis of the literature indicates that a holistic approach that includes multiple design elements interacting with visitors simultaneously in a complex fashion and a research design that includes multiple indicators in a more complex pre/post design (hopefully including a control group) are more likely to produce and document health effects. Maintaining a successful balance is critical and seems to be possible by paying close attention to the local site configuration and the surrounding social, environmental, and economic contexts.

To that end, a surprising shortcoming of the field indicated by the studies we analyzed is the minimal amount of attention given to human culture and context as an important baseline consideration both for the design of the spaces and the design of the research methodologies. Only nine articles explicitly highlighted the importance of the human cultural environment to be incorporated into the design of the open space. This seems to be another weakness in the field that future efforts should strive to avoid. We are unsure why such an important consideration was seldom mentioned in the peer-reviewed literature. One possible explanation is that the environmental designers, planners, and researchers are not grounded in public health and the social science literature that demonstrates the critical importance of culture, and instead prioritize a focus on the environmental sciences or architecture and design. Alternatively, is it possible that the lack of ethnic and racial diversity among environmental design professionals contributes to a lack of cultural sensitivity. Anthony (2002) stated that out of 194,000 environmental design professionals in the United States, only 15.7% are women, 2.3% AfricanAmerican, and 4.4% Latino.

Other ethnicities such as Native American designers are even rarer. Similarly, a British study reported women designers at only 13% of the profession . A third possibility is that a fundamental error was made in assuming that nature is a universal constant to which all humans will equally respond. Whatever the explanation, it seems telling that while only nine articles explicitly indicated the importance of human culture, 22 articles identified the surrounding environment as an important consideration. We would suggest the field begin to more equally represent those two areas of critical importance in the evidence base in the future. Equally surprising in its absence is a thorough treatment of the precursors of health status and the role of social determinants of health and important considerations in health behaviour change such as health literacy and self-efficacy. These constructs have been repeatedly shown to have strong, causative influences on health status.. For the body of work reviewed in this article not to take those important determinants of health status into consideration reveals yet another dimension into which the study of human health outcomes from interactions with nature needs to expand.

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3.13 Women centric gardens As the natural therapeutic environment is to be designed for women the main focus should be on the outdoor areas that can comprise one or sometimes a combination of the following: a large, free standing healthcare centre where grounds are at least several acres; a small, specialized facility, where outdoor space is limited and is sometimes enclosed by the building that make up the facility are sometimes comfortable. Some of the basic guidelines specially for women –  More number of interactive and open spaces which are visible from a distance such that they can interact with the other inmates of the facility.  Areas with coloured flowers should be placed such that bright coloured flowers can be seen at one place and the subtle colours at another place. The inmates can accordingly decide where she wants to spend time.  Spaces for sitting should be sometimes visible and also hidden from a specific place.  Smell and sounds should play a very important role in the gardens.  The gardens works wonders for women population when it has small animals eg.rabbits, swans, fishes, birds etc . It also occupies the mind for sometimes.

3.14 Relevance to my Thesis Topic The designing of a centre that accommodates all the design characteristics and criteria that a woman needs inside a campus. These criterias will help her to reduce the level of stress and pain to a considerable level and hereby providing all the necessary duty once staff has to offer in that centre. The open spaces in urban places targeting improvements in human health and well-being should be designed and researched in the future. In that respect, our normative goal is that research should become rigorous enough to support future systematic reviews. That aggregation of evidence, if done well, can both reduce potential bias and increase confidence in the evidence. That level of evidence can further inform environmental designers and planners to increase the healthy effects of open spaces in urban areas that they create and allow policy-makers to fully support the creation of effective open spaces that can be equitably accessed and enjoyed by all members of a community. The research is targeted to provide the best practices that healthcare designers follow. The centre of women mitigation would have all the basic environment that a therapeutic environment needs –  Have a variety of spaces.

Research has shown that when individuals are stressed and perceive themselves as having some control over their situation, they are less likely to experience negative consequences of stress. 

Provide for social support.

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Having the support of family and friends is associated with improved outcomes among ill patients. By offering a quiet space for families to provide support, patients’ conditions can improve.. 

Allow for physical movement and exercise.

Exercise alleviates stress and elevates mood. Because they are pleasant places, gardens can encourage patients to move.

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Provide access to nature and positive distractions.

There is a dose-related response to nature and natural scenes; the more greenery in a garden, the greater the effect on health. Thus, it is important to make sure that the hardscape (walls, sidewalks, patios, etc.) in a garden does not dominate the greenscape (plants, trees, and shrubs).

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Minimize ambiguity.

Individuals who are stressed respond negatively to ambiguous art and objects.

Abstract images and art, which may be challenging and interesting to people who are well, have been shown to have negative effects on those who are ill.

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Minimize intrusive stimuli.

Noise, odours, and bright light can cancel out the benefits of a garden. Thus, it is important to place the garden away from these negative stimuli or to mitigate their presence in order for the garden to be effective.

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CHAPTER 4 CONCLUSION While gardens had been used in the service of health care for centuries, modern medicine, beginning in the early 20th century, disregarded their therapeutic value. In recent years, however, there has been a resurgence of interest in the contribution to healing provided by outdoor garden environments in healthcare facilities. The hours spent in a hospital or any healthcare institution can be stressful for patients, staff and visitors, and going out into a garden provides an escape; as one patient commented: “It’s a good escape from what they put me through. I come out here between appointments... I feel much calmer, less stressed.”

Easy access to a natural environment can contribute to stress management and potentially improve health outcomes: physiological studies indicate that 3-5 minutes spent in such environments reduces anger, anxiety and pain and induces relaxation. Research also shows that “positive distractions” can reduce stress, and their visual forms include gardens, scenic views and artwork, which play a critical role in modern hospital design: gardens, fountains, fish tanks, rooftop gardens, and water features provide patients, staff and visitors with restorative experiences of nature.

Sensory stimulation through design elements or atmospheric features like labyrinths and reflecting pools, seasonal vegetation that attracts birds, and found objects of art and other elements of surprise and delight, also contribute to positive distraction.

Green areas outside hospitals are today seen as both beneficial and necessary, and specialized gardens have now been designed to meet the needs of particular patient groups such as children, cancer patients, those undergoing rehabilitation, burn patients, the elderly and Alzheimer’s patients, among others. In order to afford the greatest therapeutic benefits, the health-care garden should have a broad variety of vegetation, including seasonal flowering species, plants that attract small, safe fauna (birds, squirrels, butterflies), and leaves or grasses that move in the breeze. There should be views open to the sky and clouds, and if possible to the horizon; reflecting pools with fish or water lilies; and moving water features that can be seen and heard.

The benefits of gardens in health-care facilities may be limited by various factors. The first of these is lack of information on a garden’s location, accessibility and purpose: hospital staff should be educated as to its purpose and users, and on how to make use of it in patient and family care; and continual feedback to staff from users is essential.

To ensure that patients and their visitors are aware of the garden and can access it, colorful brochures with pictures, information, and maps should be distributed, and posters about it put up in frequented areas such as elevators. Other limiting factors may include lack of sensitivity

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to patients’ specific mobility needs; disturbing sensory stimuli (e.g. noise and allergic pollens); lack of facilities for competing user needs (such as the wish to smoke or the desire for fresh air); and ambiguous design elements.

It is vital that the garden be easily maintainable, to inspire confidence in patients that they are being well taken care of by the staff. Water-efficient, low-maintenance landscaping should be used, with water conservation achieved by managing storm water runoff in the site. Keeping up and using green spaces around hospitals lowers the costs associated with recovery and also contributes positively to patients’ survival chances and quality of life during their stay. Hospitals should landscape and improve their existing green spaces, and then restructure their facilities and patient care practices to provide maximal interaction between patients, visitors, staff and these natural environments.