Design Guidelines for Effective Hospice Gardens Using Japanese Garden Principles

This proposal is submitted in partial fulllment of the Masters of Landscape Architecture Capstone Design Project for the Faculty of Landscape Architecture at the State University of New York College of Environmental Sciences and Forestry.

CHARLES KING SADLER FACULTY OF LANDSCAPE ARCHITECTURE SUNY COLLEGE OF ENVIRONMENTAL SCIENCES AND FORESTRY SYRACUSE, NEW YORK JANUARY 2007

Approved: ______________________________ Kathleen Stribley, Major Professor ______________________________ Timothy Toland, Committee Member _________________ Date _________________ Date

TABLE OF CONTENTS
LIST OF FIGURES ........................................................................................... ii ABSTRACT ...................................................................................................... iv I. II. INTRODUCTION ..............................................................................................1 BACKGROUND & CONTEXT a. Literature Review i. Principles of Restoration ............................................................ 3 ii. Healthcare Garden Design ........................................................ 5 iii. Brief Hospice History ................................................................. 6 iv. Japanese Gardens..................................................................... 8 v. Sukiya Architecture .................................................................... 10 b. Summary of Literature Review ................................................................... 12 c. Precedent Reviews 1. Hospicare, Ithaca, New York ...................................................... 13 2. Lebanon Community Hospital, Lebanon, Oregon ........................... 16 i. Summary & Conclusion of Findings .............................................. 17 SITE SELECTION CRITERIA & PROCESS a. Criteria ........................................................................................................ 17 b. Evaluation ................................................................................................... 18 c. Summary & Conclusion of Findings ........................................................... 19 d. Site Selection & Site Background ............................................................... 19 c. History and Background of the Site ............................................................ 19 METHODS ........................................................................................................ 20 CONCLUSION a. Contribution to the Discourse or Practice of Landscape Architecture .........24 b. Dissemination of Findings ...........................................................................24 PROJECT TIMELINE ........................................................................................26 APPENDIX.........................................................................................................27 BIBLIOGRAPHY ...............................................................................................30

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V. VI. VII.

List of Figures
- Photos by author unless credited under photo Figure 1 Path at Yaddo Saratoga Springs, NY ........................................................ 4 Figure 2 Road at Yaddo Saratoga Springs, NY .......................................................5 Figure 3 Pines at Shugakuin Imperial Villa Kyoto, Japan ........................................8 Figure 4 Murin an garden Kyoto, Japan ..................................................................8 Figure 5 Dry landscape garden Adachi Museum Yasugi-city, Japan .......................9 Figure 6 Juryu-an garden Adachi Museum Yasugi-city, Japan ................................11 Figure 7 Juryu-an garden Adachi Museum Yasugi-city, Japan ...............................11 Figure 8 Front door Hopsicare Ithaca, NY ...............................................................13 Figure 9 Front garden Hopsicare Ithaca, NY ...........................................................14 Figure 10 Plan of Lebanon Hospital Lebanon, OR ....................................................15 Figure 11 Garden of Lebanon Hospital Lebanon, OR .............................................16 Figure 12 Rochester, NY Site Location Map ............................................................18 Figure 13 Syracuse Site Location Map ...................................................................18 Figure 14 Hospice Site Review Chart ......................................................................19 Figure 15 Front Door Francis House Syracuse, NY .................................................20 Figure 16 Side Garden Francis House Syracuse, NY ...............................................20 Figure 17 Project Timeline Chart ...............................................................................26

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Abstract
This project will create hospice garden design guidelines using Japanese garden and architectural principles and apply them to an actual site for the purpose of creating a restorative hospice garden. To support this research study a literature and precedent review will determine what has been done. The literature review will investigate healthcare design, hospice garden design, principles of restoration, and Japanese garden/architectural principles. Then the study will show why a Japanese garden is a preferred garden type and is applicable to a restorative garden. This project will also illustrate what constitutes a restorative landscape, using guidelines from the literature review. A precedent review of existing healthcare gardens will bring to light what criteria creates a restorative Healthcare garden design and what design pitfalls to avoid. From the precedent review and literature view design guidelines for creating restorative hospice gardens will be created. These guidelines will then be applied to an exisiting hospice site to create an informed design solution.

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I. Introduction
The motivation for this research and design project is to test the theory that Japanese residential garden design principles can be used to create a superior restorative Hospice garden design. Having worked in a Japanese garden, studied them and traveled to Japan for further investigation and to experience them rst hand, the positive restorative effects are apparent to the author. Spending time in a Japanese garden gives one a sense of being away and a sense of connection with nature, these feelings alleviate mental fatigue, or stress, and bring about mental restoration, or serenity. Simply, one feels mentally refreshed after viewing a Japanese residential garden. The author would like to bring this experience to the hospice environment. The main areas of investigation for this project are to understand explicitly the mechanics of Japanese gardens/architecture, and Healthcare garden design. Design guidelines that are a hybrid of hospice garden guidelines and Japanese garden principles may be a means to deliver more effective healthcare garden designs. These guidelines will be applied to create a hospice garden design on an existing site. This project will include literature searches and precedent reviews to reveal what has been done in the areas of healthcare and Japanese garden principles. This project will review research on what constitutes a restorative landscape as well as research the reasons why a Japanese garden is a preferred garden type and is restorative. Finally the research project will show how Japanese garden principles can be implemented to create a superior Restorative Hospice Garden. The research question for this project is: can Japanese garden/architectural principles be applied in conjunction with existing hospice garden guidelines, to create a more effective restorative hospice garden? The literature on mental restorative will guide this project, especially the Kaplans (1995) four properties of restoration, being away, extent, fascination, and compatibility. These if used in concert produce successful restorative landscapes. The sense of being away, fascination and connectedness to a greater whole are feelings one has in Japanese gardens. This experience of restoration is especially important for the terminally ill, their families and staff in residential hospices. Mental fatigue causes stress, examples of this are: a protracted meeting, intense effort to complete a project, a period of worry and anxiety, or even just a period of trying to do too many things at the same time (Kaplan 178, 1995). Residents in a hospice are likely to experience worry and anxiety, as are family members and staff. In addition staff are likely to experience the other examples of mental fatigue. 1

Some results of mental fatigue are: difculty focusing, impatience, human error due to fatigue, rash, uncooperative, less competent, irritable, more aggressive, less likely to help someone in need and less sensitive to socially important cues (Kaplan 181, 1995). A startling conclusion is that when staff are mentally fatigued they are less likely to help a patient in need. Prolonged directed attention, or focusing on a task for an extended time, by staff also leads to mental fatigue (Kaplan 182, 1995). The solution for mental fatigue is activities that cause involuntary attention, or capture ones imagination spontaneously. An example would be watching birds splash in a birdbath, or leaves falls from a tree in Fall. Viewing this captures ones attention and takes ones mind off any worries or anxieties, thus allowing for mental restoration. Hospice Gardens When available, the Hospice garden is a safe and protected refuge which surrounds the hospice residence and provides garden views for those indoors and outdoors. This garden facilitates mentally restorative experiences for the patients, family and staff that spend time in the hospice. A stressful setting such as a hospice is ideal for a restorative garden (stress reducing). The residential scale of hospices and the fact that the residents are often bed-ridden makes a Japanese residential garden, the perfect landscape. By developing design guidelines for a hospice garden, using Japanese garden principles this landscape solution will be available and can be applied and/or adapted to many hospice settings. Japanese gardens Japanese residential gardens interpret wilderness landscapes; they do this by recreating the visual patterns seen in the regional wilderness, into a residential garden design. The gardens are easily visible from inside the residence, which is of paramount importance to enjoying the garden everyday of the year, for the residents.

II. Background & Context

Literature Review
PRINCIPLES OF RESTORATION Everyday living causes stress - we have all experienced some form of anxiety or tension in our lives, restoration is the relief from this mental fatigue or stress (Kaplan 177, 1995). Wilderness as the Oxford English dictionary (www.oed.com) denes it is a wild or uncultivated region or tract of land. The exposure to wilderness, or land unaltered by humans, creates a highly restorative experience (Kaplan 1995). A psychological denition of wilderness is made up of three components 1) There is a dominance of the natural; 2) there is a relative absence of civilized resources for coping with nature; and 3) there is a relative absence of demands on ones behavior that are articially generated or human-imposed (Kaplan 148-49, 1995). In addition to restoration from mental fatigue, the exposure to wilderness has been found to have deep spiritual effects. The sense of peace and tranquility often comes to individuals exposed to wilderness. Serenity is also gained from a wilderness experience, it has been found that the same individuals achieved a feeling of contentedness and self-acceptance from their time in the wilderness (Kaplan 127, 1995). This is another instance of a spiritual connection from being exposed to wilderness or nature. Restoration is not limited to true wilderness experiences but can be achieved by viewing nearby nature (Kaplan 147, 1995). Many of the benets of the wilderness experience can be replicated by viewing gardens. This is a practical matter since human populations are generally not in wilderness areas, but the restorative effects can be replicated in gardens. Gardens can be created in dense urban areas, indoors, on rooftops and in many other settings easily accessible to human populations. Restoration can occur by being physically in the landscape or by viewing it remotely from indoors (Kaplan 512, 1995). Views of nature are preferred in urban settings and create positive emotional and psychological conditions in individuals (Ulrich 1986). If wilderness is mentally restorative, how does one create that same effect in a garden or other landscape context? The Kaplans four properties being away, extent, fascination, and compatibility are guides to creating a restorative landscape (186, 1995). These properties if used in concert for landscape design, can create a restorative effect similar to the wilderness experience, even in small garden areas. This experience can take place just about wherever plants can be grown. 3

PROPERTIES OF RESTORATION EXPLAINED These four properties, being away, extent, fascination, and compatibility, provide guidance for the creation of a restorative landscape. Being Away We have all been away at some point in our lives, whether it was a far away exotic place or a local visit to a park or shopping center. These are examples of physical travel to be away. Another type of being away is psychological. Any experience that takes ones mind off the everyday can constitute as being away. As stated before viewing nature has universal appeal and constitutes a psychological sense of being away. The distance one travels is not important in having a restorative experience. Seeing a beautiful ower out ones ofce window or in a garden, can offer a mental respite from ones everyday thoughts and concerns. Extent Extent is a sense of being surrounded by vast nature or wilderness, feeling that the landscape one is in or is part of a greater whole (see Figure 1). We may think we are in the wilderness if the landscape fullls the above criteria. Wilderness or nature can be simulated in a constructed garden giving one the illusion of a boundless landscape, one with no end, when in fact the landscape may terminate at the property line, unbeknownst to the viewer. The Japanese Garden is very successful in creating the illusion of extent (Kaplan 191, 1995). Fascination Nature is full of fascination, trees, rocks, other plants, and wildlife, never ceasing to intrigue and captivate the viewer (Kaplan 192, 1995). These elements when combined into a garden can simulate the heighten fascination one has in a wild landscape. Nature sets a stage for contemplation and wonder to take place, within this frame the mind can wander, giving one a further sense of being away (Kaplan 193, 1995). Compatibility A compatible environment is one in which humans feel at ease and comfortable being themselves, a nature setting may provide this more so than a man-made setting (Kaplan 193, 4
Figure 1

1995). There is a unity of materials and spatial relationships in a nature setting generally and a minimum of distractions or demands like signs, social etiquette to follow, or trafc rules to obey (Kaplan 149, 1995). The setting does not need not be wilderness for compatibility to be experienced. Many areas with nature fulll the requirement for compatibility. People when exposed to most nature settings, experience a similar sense of ease and familiarity.
Figure 2

HEALTHCARE GARDEN DESIGN Restorative gardens have existed since the Middle Ages, they have been part of healthcare settings since healthcares beginning (Spriggs 1, 1998). The rst healthcare centers were in Medieval monasteries, the prescribed treatment being herbal remedies from the garden and prayer (Marcus 1, 1999). Exposure to the gardens was also part of this healthful regime, as was being secluded in a monastic setting, which gave one the feeling of being away (Marcus 1, 1999). Since then, and over the course of the 20th century, technology has grown in the care of patients, such that it has eclipsed previous garden-oriented restorative measures (Marcus 1, 1999). As technology has grown, exposure to gardens/nature has diminished, by the late 20th century it had nearly disappeared. Gardens for patients, family and staff are lacking in many modern healthcare settings. Healthcare Garden Design is simply the reintroduction of restorative gardens to healthcare settings, for the benet of the patients, family and staff. Because of their mobility, staff are usually the primary users of these gardens. Patients may not be well enough to visit the gardens. It is important that patients have views of the garden from their room, this way they can enjoy it year round even if they are not able to be in the garden. Contemporary Healthcare Garden Design is guided primarily by the Kaplans four properties of restoration, being away, extent, fascination, and compatibility as well as by Marcuss Healthcare garden design recommendations and the work of others in this and related elds (Marcus 1999; Kaplan 190-193, 1995). Clare Cooper Marcus has written in masterly detail design recommendations for landscape professionals in her book Healing Garden Therapeutic Benets and Design Recommendations.

BRIEF HOSPICE HISTORY The modern Hospice movements mission is to provide Palliative care, which includes pain and symptom management, to people who are expected to live six months or less (Tomer 2000). This is a much different mission than other healthcare facilities where the goal is curative care. No curative treatment is given to hospice patients currently in the United States. Hospice care is inclusive, it includes the whole family as dened by the patient. Close friends or partners may constitute the family and/or blood relatives. Residential Hospice care began in the Middle Ages in monasteries to care for travelers from the Crusades, some of who were sick or wounded (Tomer 229, 2000). This concept was used to start the modern hospice movement, which began outside of London in the 1960s (Tomer 2000). By the 1970s it had spread to the United States. Today there are over 3,100 residential hospices in the United States. Cancer is the most prevalent disease of those in hospice care (Tomer 2000). In hospice care the family units (including the patient) needs are assessed and services are offered such as medical, social/psychological, and spiritual (Tomer 2000). The family decides what services they want. These services are delivered by a medical director, doctors, nurses, social workers, chaplains, and volunteers. Hospice care is not for everyone but it is generally available to everyone, regardless of their ability to nance. Hospice gardens have a more specic program than some healthcare garden design such as acute care hospitals that deals with many types of patients and have a more open-ended program. Hospice gardens have a specic patient group with specic requirements. A successful hospice garden creates a safe and welcoming environment, full of vegetation for the patients, family and staff to enjoy (Marcus 509, 1999). By following the properties of being away, extent, fascination, and compatibility, the garden clears ones mind and allows a restorative experience to take place, thus reducing anxiety and tension. A familiar landscape is important in hospice gardens as it is comforting at the end of life (Marcus 1999). Traditional Japanese pruning techniques create tree forms that are familiar and preferred in visual surveys (Summit 553, 1999). The use of Japanese garden principles, such as aesthetic tree pruning, can aid in creating familiar landscapes, which is of the utmost importance for end of life hospice patients. The familiar is comforting and reassuring, especially for emotionally strained patients (Appendix A). Using native plants and recreating patterns seen in the regional landscape can help to create this familiar landscape. 6

In a hospice garden the family members are the primary garden users (Marcus 515, 1999). A secluded spot for the family will allow for quiet prayer and meditation; slowly moving or still water can also facilitate this activity (Marcus, 1999). The staff are the second most frequent users of the garden so it is important for them to have a private area, separate from the families, in which they can relax and let their mind wander thereby alleviating work related stress (Marcus, 1999). It is also important that the staff can view the garden while working indoors. It is vital that the garden be visible to the patients while in bed, since this may be the closest they get to the garden on many days. At the end of life individuals are particularly sensitive to cold, heat and wind. A shielded outdoor area, or covered veranda, will extend the use of the garden; protection from wind, rain and sun will allow frail patients more use of the outdoor space (Marcus 516-517, 1999). While it important to use recognizable plants so the garden is familiar, an occasional unique specimen plant can add wonder and fascination (Appendix A). Since the patients will view the garden primarily from inside, it is essential the landscape have year-round interest. Choosing plants that attract select wildlife, such as birds or butteries, can add value and interest to the garden. Thoughtful plant selection will keep the ora intriguing in all four seasons. The use of some evergreens plants will aid in sustained winter interest. In addition to plants, secondary elements such as water features, chimes and bird feeders can help animate the garden with life and bring sound to the patients, family members and staff both inside and outdoors (Marcus, 1999). JAPANESE GARDENS Japanese architecture and gardens surround one with nature giving one a sense of Being Away. The interpretation of wilderness in the Japanese Garden creates Extent (see Figure 3), or a sense of being surrounded by a vast wilderness, part of a greater whole, Japanese gardens are particularly effective in such suggestion (Kaplan 191, 1995). Illusion is a signicant component of Japanese gardens. An example of bringing the feel of wilderness into a residential garden would be to plant a group of cedars at the rear of the garden to give the impression of a deep forest, creating shadows and hiding some of the view out of the garden. Not an actual forest but a facsimile 7

of one, enough so that ones mind thinks of a forest when viewing the grove of trees. Another example is that large tall rocks could be set vertically, partially buried in a slope to connote the essence of a waterfall, even though there is no running water. Again the garden builder tricks the viewers mind by simulating the wilderness, just enough so that the viewer can have a restorative experience from viewing the landscape. Figure 4 (Murin an in Kyoto, Japan) illustrates how an garden set in an urban area can still give the illusion Brian Resor Figure 3 of a vast wilderness. Within the garden many opportunities for Fascination occur, such as plants, rocks, wildlife, the sky, sun, moon, and water features. Japanese traditional garden text instructs to represent the local landscape patterns in your garden and to use native materials to construct the garden (Slawson 1987), doing so creates a familiar landscape. Japanese gardens interpret the local wilderness landscapes thus creating a Compatible environment for humans, one in which we feel comfortable and at peace (Slawson 1987). This is logical since we originate from the wilderness ourselves.

Figure 4

Inez & Frans Arnold

The forms created by traditional Japanese pruning techniques, achieve tree forms which are preferred by the majority of viewers in visual preference surveys of tree forms (Summit 553, 1999). This preferred tree aids in creating a compatible landscape. This tree form is generally characterized by a wide canopy and a shorter trunk (see gure 5) (Summit 550, 1999). This aesthetic of shorter broader trees, is ideal for human-scale gardens such as Japanese gardens or healthcare gardens, since the trees branches and foliage are much closer to eye level, they can be viewed and enjoyed more easily. This creates easy viewing of trees from both indoors and outdoors. This facilitates a more compatible and thus more restorative landscape. The residential Japanese garden simulates a wilderness experience by interpreting the wild landscape, creating nature as art (Nitschke 10, 2003). As humans we identity closely with wilderness and hence we identify closely with the Japanese garden type. 8

Japanese gardens have further compatibility since the gardens proportions are based on human proportions (Slawson 1987). Western gardens can dwarf the individual with monumental scale. When a garden is human scale one feels immediately comfortable and at peace because, our human proportions are reected in the gardens proportions. Human scale is achieved by selecting rocks and stepping stones in scale with our bodies, selective pruning techniques keep the plant material in proportion with our body scale. The structures and architecture in and surrounding the garden are also in harmony with Adachi Museum Figure 5 the human form. At its most effective the Japanese garden paints a picture for the viewer with the elements of the wilderness (Slawson 1987). The proper architecture plays a large roll in the success of this garden type it does this by limiting the view and focusing viewers attention. The scroll garden is generally viewed from a xed location and is usually framed by an architectural element, such as a veranda (Slawson 1987). One generally views this garden type from inside the residence and/or on the veranda. The scroll garden was an early garden type in Japan and was generally adjacent to the residence. This garden type has it roots in the paradise garden which traveled to Japan via China (Harada 1956). Early scroll gardens often contained a pond and a hill, hence the name hill and pond style. Later scroll gardens sometimes used crushed stone to represent the water, they were called kare san sui, or dry landscape gardens. The scale of the scroll garden varies but is well suited to a residential lot. A modest townhouse might have a 6x18 garden visible through sliding doors, while a royal palace or large monastery might have a viewing garden of an acre or more. The scroll garden is an ideal garden type for a hospice garden since it is meant to be viewed from a xed location, such as patients in bed. The stroll garden on the other hand is a garden that one walks through and hence has changing scenes. Each of these scenes is carefully planned out, stepping stones, framing of views, and screening help control what viewers see and when. A central element in the stroll garden is the path, it narrates the garden for the viewer, one step at a time. This technique of changing views is often called hide and reveal, as one scene is displayed the next lies hiding (Slawson 1987). This garden style is a synthesis of previous styles: primarily the scroll garden and the tea 9

garden. The stroll garden borrows the path from the tea garden and expands on the scale of garden (Harada 1956). Japanese gardens are shown to be preferred by Westerners over western gardens in Yangs study. The study took place in Korea, those surveyed were Western tourists and Koreans. They were asked to rank photos of gardens. The categories where as follows: 1) Korean style landscapes, 2) Western formal style landscapes, 3) Japanese style landscapes, 4) Informal style vegetation (consisting of both informal western landscapes and informal Japanese landscapes) (Yang 95-104, 1988). The Japanese garden had a mean ranking of 3.94, the closest was the Informal style which ranked 3.25. The Western formal style landscapes ranked even lower at 3.13. The signicance is that Japanese gardens are preferred by Westerners over their own formal and informal styles. SUKIYA ARCHITECTURE The Sukiya style has been a vernacular residential architecture style in Japan for about 400 years, and is still used today (see Figure 6) (rothteien.com):
The sukiya style Japanese house is a rened and graceful living space that employs elements of the Japanese tea house. Characteristics of the Sukiya style include delicate proportions, the ample use of natural materials, the integration of interior and exterior spaces, and a general sense of quite elegance with rustic overtones. In the traditional Japanese house, moderation is of key importance. In addition to slender wood elements and the lack of ostentation, the sukiya living environment strives, not to overwhelm, but rather to harmonize with the human scale and human sense perception. (http://rothteien.com/landing/architecture/sukiya.htm)

In western architecture ones orientation is often facing inward toward the center of the building. The Sukiya styles orientation is outward, toward the garden (see Figure 7). For restorative effects from the garden to occur, one must be facing it and have easy visual access to it. Sukiya architecture is able to maximize garden views and create comfortable environmental conditions for those indoors. Heating and cooling issues are important to maintain comfort for frail hospice patients. Adaptation of the Sukiya principles in hospice wall design could aid in keeping patients more comfortable. Passive solar heating could be utilized in the cold weather with large southern facing sliding doors, such as those produces by NanaWall (<http://www.nanawallsystems.com/>).

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Sukiya architectures strength is that the walls are visually permeable and the conguration is exible (Ashihara 1984). This open ended program allows for full direct sun in the cold winter months and partial or no direct sunlight in the hot summer months as well as every variation in between. This enormous exibility is achieved with sliding doors or screens in tracks, some of the screens are solid, such as wood, others are translucent such as paper and wood, and still others are transparent such as mesh screens. This variation of wall types allows for maximized garden views and enjoyment during all four seasons Adachi Museum Figure 6 regardless of the weather. This author has learned from hospice staff that keeping patients and staff at a comfortable temperature and keeping cost down is difcult. The patients generally like their rooms very warm as they have poor circulation. The staff are often overheated at these temperatures and the heating costs are high. The exibility of the Sukiya styles walls and screens would allow for maximum passive solar gain in the winter months which could reduce heating costs. In the summer solar gain could be reduced by screening direct sunlit in to the building while still allowing diffused light to illuminate the rooms.
Figure 7
Adachi Museum

SYNTHESIS OF LITERATURE REVIEW

The four properties of restoration (being away, extent, fascination, compatibility) are the basis for Healthcare Garden Design, the Japanese garden meets these requirements better than other landscape types (Kaplan 191, 1995, Yang 103, 1988). The requirements of a hospice garden are within the guidelines of Healthcare Design, with the addition that the landscape be familiar, the Japanese garden model accomplishes this by specifying the garden take its inspiration and 11

materials from the local landscape (Slawson 1987). By adhering to the principles of Japanese garden design, the landscape will be familiar wherever it is constructed, since it will reect the locale in its form and materials. Sukiya or traditional Japanese architecture will seamlessly integrate the building and the garden facilitating being away, extent, fascination, and compatibility to more easily take place for those viewing the garden from inside. Research has shown the Japanese garden type to be highly compatible, so it is no surprise it is a preferred garden type among Westerners (Yang 103, 1988). This familiar and compatible garden type is really an artistic interpretation of the wilderness, so it is logical it would be preferred, since the source of its inspiration, the wilderness, it so highly compatible. Residential Japanese gardens rarely have ostentatious ornamentation but rather emulate the patterns seen in the local wild landscapes. If this principle is followed of making the garden local one can not go wrong - the garden will invariably be familiar and compatible to those in a hospice.

Precedent Reviews
The following two precedents were selected to learn rst hand what criteria creates a restorative Healthcare garden design. The rst site - Hospicare in Ithaca, New York - was a unique example of a Hospice residence and garden which was professionally designed, expressly for hospice use. The second site, Lebanon Community Hospital in Lebanon, Oregon, was unique in that Japanese garden principles were used to design this restorative hospital garden. In addition, the garden designers utilized contemporary environmental and behavior research for their restorative gardens design. Appendix A. and B. were used for guidance in the following precedent reviews. HOSPICARE, ITHACA, NEW YORK This residential hospice sits on 11-acres and was founded in the early 1990s south of Ithaca, New York (see Figure 8). It is the rst certied hospice residence in New York State. The garden was designed by Paula Horrigan, a local landscape architect and professor at Cornell University. The hospice and gardens are very appealing and well designed. The building houses six hospice patients or residents, plus the support staff and administration for Hospice of Tompkins 12

County. The building and the landscape are contemporary in design style, specically built for the needs of a hospice. From indoors the garden can be viewed from all four sides of the building. The garden contains a small pool and waterfall feature in the front garden and a two acre pond in the background of the rear garden. A wooded area lies beyond the pond. Seating and circulation is provided in most areas of the garden. The hospice is a split level building with the front entrance is at grade. The grade then drops as it rounds the building to reveal a walk out lower level.
Figure 8

Five of the patient rooms face the rear garden, while one faces the side garden. The kitchen and living room have views of the exuberant front garden. The staff and administrative ofces also face out to garden views Front Garden The circulation patterns immediately around the building are well constructed and allow for seating of both ambulatory individuals and wheelchair individuals (see Figure 9). The front garden, which faces the street, is rich in plant material having four season interest, contains an interesting water feature, and provides various seating options. Space is allowed for wheelchair mobility in and through this section of the garden. This garden has some indoor/ outdoor connection but fails to sufciently tie the garden to the interior with some plant material obstructing the view from indoors. The road is sufciently screened from view and the site offers a sense of extent from its abundant plantings and layered views. Thoughtful consideration of plant material makes this garden pleasing year-round. Side Garden The side garden links the front and rear garden areas. Aesthetically this area is successful but functionally the paved circulation path abruptly ends, due to erosion of the stone dust and timber path, creating an uneven grade and making wheelchair travel difcult. An integrated hierarchical circulation system is needed, so that wheelchairs can navigate easily through the 13

majority of the garden. Secondary paths that are not ADA accessible can offer other options, as long as no paths dead-end, leaving the mobility-challenged individual with no options. A secluded area exists in the side garden - this private area is ideal for quiet prayer and meditation for the resident or family members, or as a refuge for staff. A rock garden area allows for various seating option on boulders and interesting and varied plant material. Rear Garden The grade drops about one story as it rounds the building to the rear so this area is surrounded on two sides by a two-story building. This area offers some play options for children and various seating options. A sh bowl effect is caused by the extensive windows which face this area, while there is little plant material to screen the garden users. This may be the weakest area of the site due to this fact. More evergreen plant material would strengthen this area and provide more winter interest.
Figure 9

A second oor veranda allows residents to view the garden from their rooms through large sliding glass doors - wind chimes and hanging plants add visual interest for residents. The railing obstructs some of the view from a seated position (wheelchair). The semi-protected veranda offers great garden viewing for patients during mild weather. Pond Area This area lacks much shade or wind protection, which is vital for frail inrm residents. The two-acre pond and surrounding area offer a welcome contrast to the mowed and landscape area around the residence. One feels compatible with this apparently wild un-mowed and wooded section of the property. Some seating is available and wildlife viewing, especially waterfowl, can be enjoyed from the picnic table area. A circular path leads one around the pond allowing for restoration from nature to occur, however this dirt path would be difcult to navigate with a wheelchair. Summary This hospice garden succeeds in the major areas of layout and design, however it falls short 14

in some of the details, especially by not offering patients easily visible nature from their beds. It fails to have an integrated circulation system that is ADA accessible, and to integrate the landscaped building area with the pond area by providing shade there. Overall more seating and shade would make this garden more user friendly and livable in the summer. Furthermore the rear garden would benet from additional screening with plant material, this would provide privacy for those using the garden and alleviate the sh-bowl effect, from the surrounding building. This site does provide restorative experiences for those in the garden. Some restoration occurs from garden views from inside but not enough, do to lack of foreground views. The main view from patient rooms is a background view of the pond, woods and distant hills. Even this background may not be visible for a patient in bed. LEBANON COMMUNITY HOSPITAL, LEBANON, OREGON This quarter acre restorative hospital garden was created in 2002. This garden was designed using Japanese garden principles by Kurisu International, a landscape architecture rm, with ofces in Portland, Oregon and Delray Beach, Florida (see Figure 10). The garden is visible from various wings including the birth center, classrooms, and the cafeteria hallway, the hospital surrounds the garden on four sides. Such a wide and democratic viewing of the garden is a success and helps the patients, family and staff to have restorative experience. This Japanese garden interprets a wilderness landscape (see gure 11), it includes three waterfalls, both evergreen and deciduous trees, circulation, lighting, a covered patio area, two japanese-style gazebos, and handmade benches (www. samhealth.org 2006). The garden has strolling paths which are designed to retain privacy for patient rooms facing the garden.

Figure 10

Kurisu International

The garden designer, Hoichi Kurisu, used environmental behavior research to create an effective Healthcare garden design that is restorative (<http://www.kurisu.com>). Without 15

following the principles of Healthcare garden design it would be difcult to create an successful restorative design. Summary This garden has many strengths as it recreates the highly restorative experience of viewing the wilderness and does so in a limited area (Kaplan 1995). To the average person it is a beautiful nature scene, not a Japanese scene. This is important, since one must feel compatible with the landscape for restoration to occur. The intent of the garden is to give one a sense of being away, as one views the hills, pines, maples, rocks, water falls, Kurisu International streams and pond areas. The Figure 11 intent is that one looks out of ones hospital room so one can experience the feeling of being in the woods. By using roughly 50% evergreen trees this garden has four season interest. The covered patio area and gazebos offer protection from the elements, the sun and extend the use of the garden. This is a very thoughtful design, as frail patients are sensitive to heat, cold and exposure. PRECEDENT REVIEWS: SUMMARY & CONCLUSION OF FINDINGS Both of the preceding garden precedents had visually appealing gardens and were well cared for. One difference between in the gardens is how the buildings interfaced with the landscape. Hospicares garden had a poor indoor/outdoor relationship with the building. This garden did not closely follow the principles of restorative gardens outlined by the Kaplans or Marcus guidelines for hospice gardens (Appendix A). The most nely detailed area of this garden (the Hospicare front garden) was for warm weather use and not viewable by many indoor viewers. In addition the patients had little or no views of the nely detailed garden areas from their beds, a critical failing. Hospicare did provide intimate 16

garden views from staff ofces, but this garden area suffered from a shbowl effect for people in the garden, due to a lack of screening. Lebanon Community Hospitals garden also had a well planned garden, with the buildings surrounding this garden intended to give patients, visitors and staff, intimate views of the garden without leaving the building. The shbowl effect was countered in this garden by screening patient rooms from people in the garden. This garden was designed to emulate a wilderness scene, hence it is very restorative. It intends to gives one great sense of being away as the garden evokes a mountain landscape. The intent of the gardens hills, plantings and water features is to interpret the wilderness and convince one they are in the wilderness. This tends to give one a strong sense of extent and compatibility.

Site Selection Criteria and Process

The site selection process began with searching for residential hospices in Upstate New York. These were found through an online search. Then Syracuse and Rochester were selected due to their close proximity to the authors home and the availability of hospices. Syracuse has only one residential hospice, Francis House, while Rochester has numerous residential hospices. From these choices, hospices were selected that had gardens or the potential for garden areas. All of these sites were visited and analyzed for suitability for a design study. Based on the hospice garden design guidelines (Appendix A and B) and the rest of the literature review, plus the authors own design training, the following site selection criteria were developed. 1) It is essential that the patient, family and staff areas of the hospice face the garden for restoration to occur. 2) In order for all patients to have easy physical access to the garden and the hospice in general, the building should be ADA accessible and have patients primarily on the rst oor. 3) The rst oor is best for intimate garden views. 4) The site will ideally be close to the authors home, for ease and convenience of access. 5) Finally, the hospice staff and administrators will be the contacts for the authors study, it is important that the staff is friendly and helpful for this design study to make progress and be successful.

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Figure 12

Figure 13

Maps: Google

The seven hospices were reviewed based on the above criteria. Francis House in Syracuse, New York met the criteria fully. All of the sites had gardens, some very well designed and sensitive to hospice design guidelines, yet many of the hospices had poor or no clear garden views to allow for restoration. Francis House was clearly designed with garden views in mind and provides garden views from all patient rooms and from some common areas such as the living room.
oo r es tor ng to S

Advent House, Victor, NY Francis House, Syracuse, NY Isaiah House, Rochester, NY Journey Home, Rochester, NY Serenity House, Victor, NY Sheppard House, Peneld, NY Sunset House, Irondequoit, NY

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Figure 14

Met Fully Met Partially Not Met

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Site Background - Francis House

After evaluating the site selection criteria Francis House in Syracuse, New York was selected for the site of the authors research and design project (see Figure 15). The majority of the buildings on this site were designed specically for hospice care. The architecture is sensitive to the hospice patients needs such as accessibility and easily visible garden views from their beds. History and Background of the Site The following history is attributed to www. Figure 15 francishouseny.org and to the authors site visit and conversations with staff and administrators. In 1991 Francis House was created by the Sisters of St. Francis on the city of Syracuses north side. Since its inception Francis House has served over 1,000 patients and over 6,000 family members. The idea for this hospice was brought to community leaders by the Sisters of St. Francis in 1989, two years later the hospice at 108 Michaels Avenue was opened. The original site, a residential home, was expanded and new residential hospice buildings now occupy property adjacent to the original site and behind the original house. The original house now houses administrative and other non-patient activities. The new hospice buildings were designed with the patients needs in mind and have large double windows in each room with low sills and clear garden views (see Figure 16). The hospice has grown from housing two patients in 1991, to eight patients in 1998 with the new addition, and in 2004 the latest building on the site raised the occupancy to 16 patients.
Figure 16

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III. Methods
PROGRAM & DESIGN GUIDELINES The program will be synthesized from Marcus Desirable Hospice Garden Guidelines (Appendix A), from University of Minnesotas Hospice Garden Guidelines (Appendix B), and will be derived from design guidelines from Japanese garden literature (including The Journal of Japanese Gardening), and from Sukiya Architecture literature containing design guidelines (including The Journal of Japanese Gardening). The goal of the program is to create a restorative garden that meets the needs of hospice patients, family and staff. The intention is that the Japanese garden/architecture principles from the literature review can further articulate the rather open ended hospice garden guidelines. This further renement and sharpening of aesthetic goals will hopefully lead to a more effective restorative experience. Deliverables: Written Program - elements May have explanatory graphics: sketches Program renement matrix with dimensions, environmental requirements, materials, support elements and notes.

Hospice Garden Design Guideline Development These guidelines will be informed by the results/ndings of the program development. They will synthesize the literature review ndings including Appendix A and B. In addition these guidelines will take into account the local climate and context. The goal of these guidelines will be to clearly illustrate how to design an effective hospice garden using Japanese garden/ architectural principles in a northern climate. Deliverables: Written Design Guidelines a) Details b) Texture c) Overhead Plane d) Enclosure e) Proportions/Scale f) Layout and object relationships g) Indoor/outdoor relationships h) View relationship types 20

 Ideal spatial diagram: indoor/outdoor including garden structures Sections illustrating ideal garden grade, plant material and buildings indoor/outdoor relationships Ideal garden diagram Sketches illustrating garden details and perspectives Sketches illustrating garden view from indoors Ideal Functional Diagram Booths ideal functional diagram will be used as a guide. The site analysis information will be used to determine the best locations for the various program elements. This will be illustrated with an ideal functional diagram on a the copy of the base map. Deliverables: Ideal functional diagram

DESIGN PHASE Site Inventory and Analysis A site survey of the hospice property will be obtained, including a oor plan of the hospice. This will be used to form a basic base map of the site, on which the site inventory and analysis can be recorded. Booths ideal checklist inventory as a guide for site inventory. Staff interviews may be conducted at Francis House Hospice, depending on time schedule, to obtain site specic details, what works, what does not work, what could be improved. The site analysis will evaluate this site against the ideal program I have created. By doing this the sites strength and weaknesses will be identied. These can be then addressed in the later design steps. Deliverables: Base Map/Site Plan Site plan containing site inventory - Based on Booths ideal checklist inventory (287-289, 1990) Site plan containing site analysis Sections illustrating buildings existing indoor/outdoor relationship Sections illustrating existing grades at the site

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The Ideal Program Renement Program will be rened based on the site analysis. The limitations of the site will dictate how closely the ideal program can be followed. The program will be rened based on the new design guidelines created by the author. Concept Renement The concept renement will be an organic growth out of the ideal functional diagram and will be integrated with the Site Related Functional Diagram. The concept will be evaluated against my design guidelines and further rened. Deliverables: A rened concept drawing on a site plan

Site-related functional diagram Knowledge from the concept renement stage will be used to begin to give the diagram a sense of scale and proportion related to the site. The design will now begin to closely relate to the interior rooms of the building and their functions plus the existing grade as it relates to the program. Deliverables: A site-related functional diagram on a site plan

Preliminary Design The site-related functional diagram will be the starting point for the preliminary design. The somewhat open and ambiguous forms from the site-related functional diagram will now be converted into actual articulated forms and details in the landscape design. The landscape forms will be sensitive to and in harmony with the building forms. Deliverables: Preliminary site plan Sections showing grade change and indoor/outdoor relationship as needed

Design Development/ renement/ materials/ sections This will be an outgrowth of the preliminary design. This design will become even more specic listing materials for all the elements, specifying plant materials including their character, texture and form. The three-dimensional site characteristics will now be considered, including the height of the structures in the landscape, the size and height of the plant materials. The relative size and height of all the elements in relation to each other will be considered. 22

Deliverables:

Evaluation of preliminary design Rened site plan containing materials and plant material specications Sections showing site details and indoor/outdoor relationship

Evaluation of the Design The design will be rst evaluated against the new design guidelines. Then, time permitting, the design will be evaluated be an outside design professionals, possibly Dennis Burns, a Japanese garden designer/builder from Rochester, NY, Paula Horrigan a landscape architect and faculty member at Cornell University, as well as SUNY-ESF faculty and student comments. Deliverables: An annotated layout plan and possibly sections showing suggested renements

Final Master Plan This will be an outgrowth of the design development and will reect the feedback from the design evaluation. It will be done in a more rened manner than the preliminary master plan. It will specify all site details and materials. Will include sections to illustrate indoor/outdoor relationships and site details. Deliverables: Master Plan, rendered in a rened graphic style May include sections to show indoor/outdoor relationship and site details Plan oblique views as appropriate Perspective sketches

Evaluation The nal master plan will be evaluated against the new design guidelines. Deliverables: Final Annotated Master Plan incorporating corrections and suggestions

Final Document Deliverables: Final Master Plan and supporting graphics

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V. Conclusion/ Summary of Findings

Potential impacts: The creation of synthesized Hospice design guidelines based on hospice garden guidelines, restorative landscape guidelines, Sukiya architecture guidelines, and Japanese scroll/stroll garden guidelines will create a template combines the best of these four areas. The intent is to create a more effective hospice garden through the integration of these four areas. Creating better restorative hospice gardens will improve the quality of life for patients, their families, and staff members. This Sukiya hospice garden design will be adaptable to any hospice. Furthermore, this research will be translatable into any healthcare garden application. Appropriate to do post occupancy review on hospices designed in the future, to determine their effectiveness. Package/Production Final documents will be printed and mounted as necessary for presentation. Documentation The design process will be documented for inclusion in the nal Capstone document. Contribution to the Discourse or Practice of Landscape Architecture Dissemination of Findings

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V.

PROJECT TIMELINE
DEC
1 2 3 4 1

METHODS & OPERATIONS

week of month week of semester

JAN
2 3 1 4 2 1 3

FEB
2 4 3 5

SPRING 2007
MAR
2 8 3 9 4 6 1 7

APRIL

MAY
2 3 4

4 1 2 3 4 1 10 11 12 13 14 15

DATA COLLECTION Literature Review Proposal Refinement PROGRAM DEVELOPMENT Program Development Design Guideline Development Ideal Functional Diagram DESIGN PHASE Site Inventory & Analysis Program Refinement Concept Refinement Site-related functional diagram Preliminary Design Design Dev./Refinement/Material/Sections Evaluation/Guideline Check Final Master Plan Conclusion/Summary of Findings Package/Production DOCUMENTATION
Figure 17

SPRING 2007

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VI.

APPENDIX
APPENDIX A Desirable Hospice Garden Guidelines Desirable Hospice garden guidelines (Clare Cooper Marcus, University of California Berkeley, unpublished work, January 2006) 1. Ensure familiar building and garden design; nothing strange or challenging at end of life 2. Provide variety of walking routes 3. Create hierarchy of pathways: for wheelchair use and lone exploration on foot Avoid wheelchair accessible paths dead-ending 4. Meandering pathways provide changing viewpoints, sense of getting away 5. Create destination points 6. Series of outdoor rooms creates sense of exploration and arrival 7. Choose a predominance of plants familiar in the culture, and a lot of variety 8. Add occasional unfamiliar accent plants, which may trigger conversation 9. Provide moveable and xed garden furniture 10. Create settings where person can be alone and private Access to a secret path and lone, private bench 11. Provide places for families to meet in private Area for family privacy Choice of settings for family privacy 12. Create features in garden that will extend its use throughout year Covered outdoor area Enclosed or protected outdoor area, especially protected from the wind and sun (summer) 13. Provide soothing sounds: water, birdsong, rustling leaves, and chimes etc. Important for these sounds to be heard in the rooms, especially the sound of moving water 14. Incorporate unambiguous positive sculpture (representational artwork) 15. Create viewpoints where topography permits 16. Ensure all rooms have green (garden or nature) outlook Make sure landscape is appealing year-round 17. Provide restorative environments for the staff Numerous garden views from staff work areas indoors Private area in garden for staff 27

18. Provide distractions for visiting children Play area, sand box etc. 19. Create low-key design for donor recognition Example: Mosaic leaf design on wall, each leaf inscribed with name of donor (San Diego Hospice) Avoid plaques In Memory of beside each tree. Can remind patients family of death

APPENDIX B Hospice Garden Guidelines Additional hospice garden guidelines (http://sustland.umn.edu/design/healinggardens.html, University of Minnesota Department of Horticultural Science, Sustainable Urban Landscape Information Series, report developed by Molly Furgeson) 1. Provide transitional spaces between indoor and outdoor spaces to allow adjustment to bright outdoor light. 2. Provide soothing natural sounds in gardenhearing is often the last of the senses to leave a dying person. 3. Provide quiet places to sit and contemplate. 4. To encourage people to touch things in the garden, use plants and structures with a variety of textures. 5. Provide a view from the window for patients that cant go outside. 6. Design with materials that improve, rather than wear out with age. Provide a water feature. Water is a soothing agent. Still water can provide a setting for meditation or prayer while the sound of and view of moving water is undeniably restorative

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VII. BIBLIOGRAPHY
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Seike, Kiyoshi, Masanobu Kudo and David H. Engel, editorial consultant. A Japanese Touch For Your Garden. Tokyo: Kodansha International, 1992. SLCH Healing Garden. Lebanon Community Hospital. Samaritan Health Services. 14 Dec. 2006 <http://www.samhealth.org/shs_facilities/lch/hospital_services/ TheSLCHHealingGarden.html>. Summit, Joshua, and Robert Sommer. Further Studies of Preferred Tree Shapes. Environment and Behavior Vol. 31 No. 4 July (1999): 550-576. Tange, Kenzo. Katsura: Tradition and Creation in Japanese Architecture. New Haven: Yale University, 1960. Taniguchi, Yoshiro. The Sugakuin Imperial Villa. Tokyo: Mainichi Newspapers, 1956. Tatsui, Matsunosuke. Japanese Gardens. Japan Travel Bureau: Tokyo, 1961 Tomer, Adrian., Ph.D. Death Attitudes and the Older Adult. Philadelphia: BrunnerRoutledge, 2000. Tyson, Martha M. The Healing Landscape: Therapeutic Outdoor Environments. New York: McGraw-Hill, 1998. Ulrich, Roger S. Human Responses to Vegetation and Landscapes. Landscape and Urban Planning, 13 (1986): 29-44. Windows, Views, and Health Status in Hospital Therapeutic Environments, Stephen Verderber, D. Reuman, The Journal of Architecture and Planning Research, 4:2 (1987) 120-133. Verderber, Stephen, and J. Song, Environment and Aging in Japan A Review of Recent Research. Environment and Behavior. Vol. 37 No. 1 January (2005): 43-80. Yagi, Koji. A Japanese Touch For Your Home. Tokyo: Kodansha International, 1992. Yamagata, Saburo, and Peter Goodman, editor. The Japanese Home Stylebook: Architectural Details and Motifs. Berkeley: Stone Bridge Press1`, 1992. Yang, Byoung-E., Ph.D. A Cross-Cultural Comparison of Preference for Korean, Japanese and Western Landscape Styles. Dissertation. University of Michigan. 1988.

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