Refined by Need

Last month, I opened a two-part discussion on healing gardens, a trend in landscape design that’s become popular among managers at hospitals and other healthcare facilities who desire spaces where patients, visitors and staff can spend a bit of time in nature to heal, set aside stress and otherwise regenerate themselves.

In the time since I first became involved with these spaces, I’ve also seen demand for these gardens – known in other contexts as “tranquility gardens” – grow among churches and retirement homes. What I’ve noticed in all cases is that these gardens resemble lots of residential projects my firm has tackled in which the curative, relaxing powers of nature inspired my clients to give us a call.

Through the years and in the course of many such projects, we’ve learned our share of important lessons about designing these gardens and the value of always keeping the specific needs of defined, key sets of users in mind.

It doesn’t take much thought, for example, to recognize that many people who will use healing gardens at hospitals and other healthcare facilities and retirement homes will be confined to wheelchairs. Right off the top, this places importance on smooth pathways and gradual grade changes and, in some cases, deployment of appropriate ramps.

ROLLING REVIVAL

While paving materials such as concrete, pavers or brick are the most common (and obvious) choices, you don’t need to work within those restrictions if you don’t want to. Indeed, I’ve found that stone dust or crushed granite can be used instead if compacted to smoothness and sustained by adequate drainage systems.

In a garden we designed and installed about five years ago, for example, solid paving was a budget-breaker, so we used a compacted stone dust to create wheelchair-friendly pathways. To make certain all was well, I even borrowed a wheelchair and found no issues in a few test runs in which I covered the full space in both directions. My observation of the completed garden confirmed this fact: The many users I saw in wheelchairs had no difficulty at all in navigating the space.

There’s also an obvious need where ramps are involved to set them at the proper pitch. The Americans with Disabilities Act stipulates that wheelchair ramps should have no more than a one-in-twelve pitch – about eight percent. In our work, we always aim for something even more gradual than that, but space availability sometimes limits what we can do.

A far less obvious need for wheelchair-bound users is some means of access to the garden’s plants and waterfeatures. When standing, most people have no problem reaching out to touch a leaf or put a hand into a cascade, but people in wheelchairs don’t have the luxury we have of leaning over and using more than an arm’s-length reach. In addition, the chair itself is an obstacle to closer contact.

What this means is that we need to take into account such details as raised-bed walls, which shouldn’t be more than eight inches thick (a limit that can play havoc with engineering standards but is doable). We also need to position planting beds at heights at which people sitting in wheelchairs easily can reach.

I’ve had wheelchair-bound clients who are avid gardeners, and I set their planting-bed levels at 24 inches above grade. In another case, there wasn’t room for raised beds, so I used containers – a series of matching planters filled with vegetables, herbs and annuals set on a large, flat, easily accessible patio. The client tended these plants daily, and the effect it had on his general spirits was profound.

As for watershapes, they must be set up in such a way that splash-out isn’t an issue (you don’t want slick surfaces or to create situations in which anyone can get trapped in mud. And if the watershape is on the same grade as an adjoining pathway, you need to set up some sort of barrier to prevent any chance of the wheelchair entering the water.

The water’s proximity to pathways is, of course, another issue. If your aim is to create spaces where the wheelchair-bound can touch the water, you need to raise the vessel to a touchable height. And if the water’s moving, keep these effects small and subtle to prevent any issues with safety or comfort.

(It’s important to note that some healthcare facilities are adamant that their patients not be able to touch the water, with a fear of waterborne contagions outweighing the benefits of feeling the water. Indeed, we’re working with exactly that edict with a garden we’ll install this spring at Rochester General Hospital and have heard from a number of other designers we’ve contacted that this can be a key concern.)

BEYOND THE VISUAL

In several cases, we’ve been called upon to design garden spaces for people with some degree or other of visual impairment, from reduced capability to total blindness. In our practice, we don’t consider these conditions to be any sort of impediment to enjoying a healing garden because, after all, fragrance and touch are still in the picture.

For gardens intended for use by the visually impaired, we do all we can to make them accessible to users of all capabilities – but focus our choices specifically on plants with distinctive (and often familiar) smells and textures.

In fact, of all the senses, the most memories are tied to the sense of smell. Who doesn’t recall grandma’s apple pies of yesteryear when you walk past a bakery today? We all have those kinds of memories associated with aromas and fragrances, so in gardens intended for use by these folks we focus on this sort of sensory experience.

We also seek out and use textured plants, which are available in great variety just about wherever people build anything, and always use falling water both for the attractive sounds it generates and the smiles it brings to the faces of those who reach out and touch it.

In one of these “sensory gardens,” we used 75 varieties of fragrant and textured plants. To identify them, we commissioned 40 forty brass plaques with the plant names in Braille. We also set up a mailbox at the entrance to the garden in which users found sheets in Braille that identified the plants in greater detail than the plaques could convey. It’s worked out so well that this particular garden is used by the seeing public as well as the visually impaired for whom it was intended.

One of the highlights of this space is a small waterfall that drops into a stream and runs under a concrete bridge (stamped with animal footprints) and into a pond. We built the bridge to within a foot or so of the waterfall so that people with limited vision could comfortably touch the cascade without any perceived danger that might have resulted from making them lean over to reach the water. (This sort of design also works for wheelchair-bound visitors, who can roll right up and reach into the cascade.)

As mentioned last time, we also have gotten involved in designs intended for use by patients with Alzheimer’s and other age-related issues. Here again, fragrance is a huge factor: Research has shown that the apple-pie factor mentioned above relates to these patients specifically and that fragrances recalled from youth bring happiness and occasional sparks of clarity or well-being to these often-confused patients.

With these people in particular, however, extreme caution must be taken in specifying plants. Anything the least bit toxic should be avoided, as Alzheimer’s patients have been known to ingest leaves and fruit without hesitation.

BALANCING ACTS

In all such design projects, it’s important to bear in mind that what works for one group of users might not be ideal for others.

Early in this discussion, for example, I mentioned that wheelchair users can get along quite well on compacted stone dust or crushed granite in addition to other forms of paving. With Alzheimer’s patients (or other ambulatory users with limited mobility), the choices are more limited.

Simply being outside and surrounded by nature’s beauty is a tonic not just for patients, but also for those who’ve come to visit their friends and loved ones – as well as the healthcare practitioners who work in these facilities day in and day out.

In most such gardens, the paving has to be some type of poured surface that minimizes joints and seams. Not even cost-conscious designs that use concrete pavers are truly appropriate: The beveled edges on these pavers can present trip hazards to those who walk with a shuffle, and they can topple I.V. stands that might have to go along with either an ambulatory or wheelchair-bound patient.

If poured concrete is the option of choice – and it frequently is – then it should be colored in such a way that glare is minimized. Railings are another consideration: Lots of Alzheimer’s patients, for example, are older, have limited mobility and can use the support.

As mentioned in last month’s column, it is also of paramount importance that any pathways in an Alzheimer’s garden be organized in some form of a closed loop. With their tendency to get confused, making choices among pathways can become traumatic experiences and can easily make these patients fear they’ve gotten “lost,” even when all they need to do is turn around.

In all of this, as designers we need to appreciate the fact that one of the issues that make staying in hospitals and other healthcare facilities so disquieting is the sense patients have that they’ve given up any sense of control over their lives and the environments they occupy. We go through our daily lives choosing what to wear, what to eat, when to go to work and when to shop. When hospitalized or in assisted-living situations, we’re placed on schedules based on the policies of the institution.

For the Caregivers Some neat observations came to light while I was learning about the design and installation of healthcare gardens – studies revealing the fact that facility staff, bar none, was the largest group of healing-garden users. Indeed, one such evaluation found that 75 percent of all users of a hospital’s garden were people working there. And this wasn’t about cigarette breaks or lunch outdoors, neither of which were even allowed in this particular garden. Instead, the staff – particularly the nurses and doctors – used the garden to break away from the incredible stresses they faced daily. In interviews, they reported that just a few minutes of communing with nature was enough to help them face the rest of a day – a wonderful and unintended benefit. And it gets better: One hospital administrator told me directly that it costs up to $100,000 to replace a critical-care nurse. He told me that the simple fact that his facility had a healing garden and made it available to staff increased his ability to retain top staff (and save recruitment money) because the garden had proved such an effective stress reliever. B.Z.

Think about that for a moment: These folks go from 100-percent control of their lives to almost none. They’re told when to wake up, when to eat, when to take medicine. They wear hospital gowns and are hooked up to who-knows-what contraptions. In many cases, they’re bed-ridden and lonely. Is it any wonder that one of the greatest of all life’s stresses is a stay in the hospital?

Healing gardens address that stress directly by meeting patients’ desire to be outside, in nature. While they in these spaces, they want to control where they go, what they see, what they touch and how much time they spend pursuing these simple activities. They also – and this is important – want to decide where to be, which is one of the reasons our designs almost invariably include sturdy but easily movable furnishings.

PERSONAL LIBERATION

Nobody enjoys the waiting-room experience of sitting on chairs bolted to the floor and the impossibility of enjoying a private conversation or even private thoughts.

When outside in our healing gardens, these people want to find furniture they can adjust to suit their needs and nobody else’s. Simply being able to slide a couple of chairs close together in a private location allows people to get away and have private, even intimate conversations beyond earshot or view of others who might be using the space.

It occurs to me, of course, that so much of this is exactly what we’re after in designing many of our residential gardens: What clients really want most is a private retreat in which they can escape from a day’s cares and concerns and either commune alone with nature or share the experience with a spouse, a friend or a child.

Before I ever took that course at the Chicago Botanic Garden in healthcare-related exterior design, I’d always applied common sense along with my own personal style to these types of gardens. With education, however, my sensitivity to the full range of issues involved in designing these spaces has grown and carried my work to new and more-focused levels.

As we all age (and unfortunately, it’s something we’re all doing), most of us will become, willing or not, residents of retirement communities, assisted-living centers or hospices. So where would you rather be, an antiseptic-smelling room or out in the open in a well-designed garden?

Bruce Zaretsky is president of Zaretsky and Associates, a landscape design/construction/consultation company in Rochester, N.Y. Nationally recognized for creative and inspiring residential landscapes, he also works with healthcare facilities, nursing homes and local municipalities in conceiving and installing healing and meditation gardens. You can reach him at [email protected].