PERCEPTUAL BARRIERS TO THERAPETUIC LANDSCAPES IN HEALT
HCARE 
SETTINGS IN MID-MICHIGAN 
 By 
 Emaley Baxter 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A THESIS 
 Submitted to  
Michigan State University 
in partial fulfillment of the requirements  
for the degree of  
 Environmental Design ΠMaster of Arts 
 2015  ABSTRACT 
PERCEPTUAL BARRIERS TO THERAPETUIC LANDSCAPES IN HEALT
HCARE 
SETTINGS IN MID-MICHIGAN 
 By 
Emaley Baxter 
 This thesis examines perceptual barriers to, and current use of, therapeutic
 
landscape environments in hospitals, end-of-life care, or extended care facili
ties. 
Specifically, this study investigates the factors that managers and he
althcare professionals 
identify as important in the creation of therapeutic garden areas for their pati
ent 
populations. The research also seeks to identify specific factors that prohibit inves
tment 
in this type of amenity in these institutional settings. Factors that ar
e investigated include 
variables such as prior experiences with therapeutic gardens along with cost
-benefits, 
liabilities, aesthetics, functional utilities, time commitments, and maint
enance concerns. 
The study reports on the importance of these variables in creating advocates a
mong 
managers and/or healthcare staff for this type of garden in their workplace
.  
 
 
 
 
 
 
  iii 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This thesis is dedicated to my parents, 
Charles and Mary Baxter. You instilled in me 
the drive to succeed and never stopped 
cheering me on when I reached for the stars. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  iv 
 ACKNOWLEDGMENTS 
 
 The completion of this thesis would not have been possible had it not been for the 

help of many individuals. This research has taken me on a wonderful journey full of 

many ups and downs, and seemed never-ending at times, but I have learned so much 

along the way and am pleased with the results. My sincere gratitude and apprec
iation 
goes to my major professor, Dr. Joanne Westphal, for sticking with me through this enti
re 
process. She patiently helped me brainstorm numerous ideas, finalize a topic, and 

provided much needed insight and encouragement during the months of research and 

writing. I also acknowledge and appreciate my other committee members, 
Dr. Eunsil Lee 
and Mr. Paul Nieratko, for their time and generous assistance, as well as Mr. J
ohn H. 
Schweitzer, Ph.D for his help with the statistical analysis of the collecte
d data. Without 
his knowledge, assistance, and thoughtful analysis this project would not have been 

possible.  
I would also like to thank the mid-Michigan healthcare clinics, hospitals, hospice
s 
and other care providers who graciously allowed me to administer my survey at t
heir 
locations and to the healthcare professionals who have taken an interest in the impor
tance 
of therapeutic gardens in healthcare landscapes. 

 Lastly, I offer my regards and blessings to the family and friends who sup
ported 
me in any respect during the completion of the project. Especially, Kyle Br
usveen, for 
always listening to my concerns and dispelling any worries I might have had. 
  
 Thank you all! 

 
  v  TABLE OF CONTENTS 
 
 
LIST OF TABLES––––––––––.––––.––––––––––............vi
 LIST OF FIGURES––––––––––––––––––––––––––..viii 

CHAPTER I INTRODUCTION–––––––..––––––––––––––....1 

CHAPTER II LITERATURE REVIEW–––––––––––––––––––.3 

       
Background–––––––...
––––––––––––.........–––..–.3        
History Œ Therapeutic Landscapes though the Ages–––––––
...–..–....5                   
Contemporary Medical Practice and Hospital Design of the United States
...19 CHAPTER III AIMS OF STUDY....–––..––––––––––––.–––.–.28 

  

CHAPTER IV METHODS–––––––––––––––––––––.–.–..30 

       
Study Population
–––.––.––––––––––––.....–––..–.30        
Survey Instrument
––––..–..–––––....––––––––....–....31        
Pre-Survey Data Collection Phase
...–..––––––––––––––.35 
      
Actual Data Collection Phase
––––..–––––––––––––....36         
Data Analysis
––––..––––––––––––...––..––....–....37 CHAPTER V RESULTS––––––.–––––––––––––––––.–.38 

CHAPTER IV DISCUSSION AND CONCLUSION–––––––––––––...51 

      Study Limitations–––––––––––––––––...–––––...60 

      Conclusions––––––––––––––––––––...––––... 62 

APPENDICES–––––...–––––––––––––––––––––––66 
Appendix A Cover Letter and Survey––.–––––––––––––.–.67 

Appendix B Tables of Statistical Analysis –.––.....–...–––––––.–.72 

 REFERENCES––––––––––––––––––––––––––––100 

 
 
 
  

   vi 
 LIST OF TABLES 
 
 
 
Table 1
. Name and location of eleven health care facilities located in mid-Michigan tha
t 
participated in the study along with a profile of the vocations of responding health ca
re 
workers...––––––––––––––––––––––..–––.––––.....73 

 
Table 2. 
Responses to Question 1: Agreement with the Definition of Therapeutic 
Garden–––––––––––––––––––––––––––––––....75 

 
Table 3.
  Responses to Question 2: Prior Knowledge of Therapeutic 
Gardens................................––.––..––––––––––...––––––........75 

 
Table 4.
 Responses to a given definition of a fiTherapeutic Gardenfl at a respondent™s 
workplace.––––––––––––––––––––––––––––––..76 

 
Table 5.
  Respondent™s perceived frequency of garden use for different patient groups at 
places of work having a therapeutic garden.––––––––––––––––......77 

 
Table 6.
 Respondent™s perceived frequency of garden use for patients and non-patients at 
places of work having a therapeutic garden.––––––––..––––––––....78 

 
Table 7.
 Respondent™s perceived frequency of garden use for different patient groups at 
places of work NOT having a therapeutic garden.––––––––––.–––...... 79 

 
Table 8.
 Respondent™s perceived frequency of garden use for patients and non-patients at 
places of work NOT having a therapeutic garden ––...––––––––––.........80 

 
Table 9.
 Areas of landscape improvement at a respondent™s place of work regardless of 
having or not having a Therapeutic Garden..––––––––––––.–––........81 

 
Table 10.
 Respondent™s perceived frequency on barriers to therapeutic gardens at their 
place of work regardless of having or not having a therapeutic garden...––––.........82 

 
Table 11.
 Respondent™s perceived frequency of concerns related to therapeutic gardens at 
their place of work regardless of having or not having a therapeutic garden...––..–...84 

 
Table 12.
 Respondent™s perceived frequency of agreement on barriers to therapeutic 
gardens at their place of work as well as prior knowledge of the characteris
tics of 
therapeutic gardens––––––––––––––––––––––––––....85 

 
Table 13.
 Respondent™s perceived frequency of agreement on barriers to therapeutic 
gardens at their place of work as well as the socio-demographics of the responde
nt...–87 
  vii 
  
 
Table 14.
  Respondent™s perceived frequency of agreement on barriers to therapeutic 
gardens at their place of work and the professional field of the respondent–––––..90 

 
Table 15.
  Respondent™s perceived frequency of concerns about therapeutic gardens at 
their place of work and prior knowledge of the characteristics of therapeutic
 
gardens..–––––––––––––––––––––––––––––––.92 

 
Table 16.
  Respondent™s perceived frequency of concerns about therapeutic gardens at 
their place of work and the socio-demographics of the respondent––––..––––.93 

 
Table 17.
  Respondent™s perceived frequency of concerns about therapeutic gardens at 
their place of work and the professional field of the respondent..–––––––––.95 

 
Table 18.
  Respondent™s perceived frequency of improvements caused by therapeutic 
gardens at the respondent™s place of work and their prior knowledge of the character
istics 
of therapeutic gardens–––––––––––––...––––....–––––––.96 

 
Table 19.
  Respondent™s perceived frequency of improvements caused by therapeutic 
gardens at their workplace and the age of the respondent––––––...–––..––97 

 Table 20.
 Respondent™s perceived frequency of improvements caused by therapeutic 
gardens at their place of work and the professional field of the respondent–––––..99 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  viii 
 LIST OF FIGURES 
 
 
Figure 1: Hospitals and Asylums of the World: Portfolio of Plans. Henry Burdett 

     (1891)––––––––––––––––––––––––––––.12 

Figure 2: The Royal Naval Hospital at East Stone House, Plymouth. (Author, date 
       unknown) taken from a postcard at http://www.plymouthdata.info/htm (last   

      accessed [August, 2013])..................................................................................13 

 
Figure 3: Wausau Hospital Site Plan (Kamp, 1998)...–––––––––––––...26 

Figure 4: Location of Participating Facilities in Mid-Michigan (Google M
aps)––...–38 
 
  
 
 
 
 
 
 
 
   1  CHAPTER I 
 INTRODUCTION 
 
  Over the past decade there have been numerous empirically sound studies 
conducted that have supported claims relating to personal health and societal benef
its of 
therapeutic gardens in healthcare settings. However, there remains a gap i
n the literature 
as to why, despite this evidence, therapeutic landscapes have not become commonplace 

in the healthcare delivery setting. It is not known whether this is the result of t
he failure 
to integrate the exterior grounds of a hospital with its interior spaces; traini
ng that 
influences the attitudes and beliefs of healthcare professionals; and/or a fa
ilure to 
evaluate therapeutic gardens as a contributing factor to patient well-being
 and/or the 
healing process in healthcare institution design. 
  This is an exploratory study to investigate medical professionals™ knowledge of, 
as well as perceived barriers to, the design, installation, and use of therapeutic
 landscapes 
within healthcare settings. A survey was developed that included questions on whether 

consensus exists among medical professionals as to what constitutes a therape
utic garden; 
the questions also probed whether prior knowledge of, or exposure to, a garden in a 

healthcare setting influences perceptions of use by staff and/or particula
r patient groups. 
In institutional settings where no garden is present, the survey asked respondents t
o think 
of an idealized therapeutic garden setting and to respond to which patient/staff gr
oup 
would be most likely to utilize such a garden at their place of work. The survey then 
asks 
respondents to consider possible improvements that the addition of a therapeutic garden 

could have on variables such as increased patient satisfaction, marketing opportunit
ies, 
and environmental impacts. Additional topics addressed how a therapeutic garden would 
 2  improve the healthcare institution where the respondent is employed. The questions
 were 
then directed toward gaining an understanding of the barriers and concerns perce
ived by 
healthcare professionals when conducting treatment protocols in outdoor environments. 

Finally, this thesis sought to use age and the type of healthcare setting as pre
dictive 
variables in determining the professionals most receptive to the idea of therape
utic 
gardens in healthcare settings, and how this group may become an advocacy force
 in the 
planning, design, and implementation of future gardens in their workplace.  
It is intended that the findings from this survey will spark an interest among 
healthcare professionals to learn more about therapeutic landscapes and the benefi
ts to 
healthcare delivery they can provide. Results from the survey will be used in the f
uture to 
create a healthy dialogue between design professionals, such as archite
cts and landscape 
architects, with medical professionals. This dialogue will enhance collabora
tion and the 
exchange of information about patient groups and treatment protocols from healthcare 

providers to improve the design of future therapeutic gardens.   
   
 
 
 
 
 
 
 
 
 
 
 
  
 
  3  CHAPTER II 
 LITERATURE REVIEW 
 
Background 
   Gardens, in the generic sense of the word, have existed since the Neolithic 
Revolution (10,000-5,000 BC), which was the first historically verifiable revolution in 

agriculture. The time period consisted of the wide-scale transition of human cultur
e from 
a lifestyle of hunting and gathering to one of agriculture and settlement, wh
ich in turn 
supported an expanding population (Bocquet-Appel, 2011).
 Archaeological data indicates 
that various forms of plant and animal domestication evolved in separate locations 

worldwide around 12,000 years ago, (Barker, 2009).
  
  Over time, two types of gardens evolved: those used primarily as a food source, 

and those intended for pleasure and rest. For many people, past and present, gardens hav
e 
offered relief from the burdens of everyday life (Berrall, 1978). Gardens ofte
n are seen as 
a direct link from man to the land. They serve as the physical manifestation of
 our 
connection with Earth. fiGardens have a mythology, a poetry, and a history, strongl
y 
linked to life cycles and the processes of healing, renewal, and ultimately dyi
ngfl 
(Gerlach-Spriggs et al., 1998). Among the various types of gardens that have evolved 

over time, there have always been places set aside for recovery, rest, and pl
easure. These 
places could be found in fia healing spring, a sacred grove, or a special rock or ca
vefl 
(Sternberg, 2009). They occurred anywhere individuals felt a connection to the land and 

each other. Oftentimes, a need arose to have these restorative healing places dur
ing 
difficult living conditions (Cooper-Marcus and Barnes, 1999).  
Indeed, in today™s civilization, we are still affected by the evolutionary bonds
 that 
 4  have for so long tied us to nature. We are still strongly responsive in our behavioral 

patterns and our physiological functioning to changes and situations we find in our 

environment. How we react and pay attention to the environment, influences what the 

experience of the natural landscape means to us, and ultimately how it can heal body
 and 
mind (Kellert and Willson, 1993; Kellert et al., 2008). The idea that a built space may 

affect the health outcomes of a patient could not be thoroughly understood scientificall
y 
until the late twentieth-century brought advances in the understanding of brain-imm
une 
connections, and their importance to maintaining health. This burgeoning understanding 

of a fimind-bodyfl connection has helped to explain the belief that physical places hav
e 
the ability to set the mind at ease, indeed, even contribute to overall well-being. L
ikewise, 
those situations that trouble our emotions can promote illnesses (Cooper-Marcus and 

Barnes, 1995; Sternberg, 2009). 

 For the purpose of this study, it is important that a definition of therapeutic 

gardens/landscapes is established. Such a definition will set the subject of this
 study apart 
from the numerous other definitions that strive to put a name on such places. For the 

purpose of this study, therapeutic gardens are not considered an alternative met
hod of 
therapy, but a supplementary one. As such, they do not provide cures, but rather 

contribute to a better sense of well-being and improved body function as well as provi
de 
functional space for the delivery of treatment outdoors (Gerlach-Spriggs et al
., 1998).  
 Westphal (2010) presented this definition of a therapeutic garden at the annual 

Chicago Botanic Garden Certificate Program; the definition inspired b
y an article written 
by Gerlach-Sprigs and Healy (2010): 
 fiA therapeutic garden is a designed outdoor space that uses plants
 and other 
elements of nature to promote patient care and well-being while fa
cilitating 
 5  medical staff in the delivery of standard treatment protocols comm
only used in 
health care settings. As such, the health services supported by a
 garden may be 
primarily palliative or rehabilitative, depending upon the patient populat
ion being 
servedfl (Westphal, 2010). 
 
Gardens can be highly vegetated and beautiful spaces that entice individuals to tra
vel 
from the confines of an interior space, like a rehabilitation facility, to an outdoor
 space 
with special amenities. Major and minor architectural elements and the orga
nization of 
space in a therapeutic garden is designed to support the user, regardless of persona
l 
limitations. These garden spaces should permit the user to spend time alone or wit
h 
others, to leisurely or briskly walk, to enjoy the sunshine or shade, and to address 

designed fichallengesfl that will facilitate the desired treatment
 outcome. They are capable 
of altering the mood of the patient, visitor, and care-giver while improving their sens
e of 
well-being through fiorderedfl design (Cooper-Marcus and Barnes, 1999).  Westphal 

(2001) believes that therapeutic gardens can have the capacity to address five dim
ensions 
of human health: physical, biological, social, psychological, and spiritual, if they 
are 
designed carefully to work within intended treatment protocols. 

History ΠTherapeutic Landscapes though the Ages 
It is not specifically known when man first felt there was something that caus
ed a 
difference in the ‚ambiance™ of one place versus another.  Neither is it known w
hen it was 
felt that a specific spot had a sort of mysterious and attractive quality. Howeve
r, these 
ancient ‚sacred groves™ have had many references through antiquity. The Old Te
stament 
in the Bible (English Standard Version, 2001) states that after God formed the worl
d, the 
seas and the dry land, he planted a garden in Eden (Gen. 2:8 ESV).  In the 
Odyssey 
(Book 
V), Homer depicts Odysseus as being imprisoned in a cave surrounded by a grove on t
he 
island of the goddess Calypso (Homer, 1959). Homer paints the vivid image of a lush, 
 6  natural setting for the goddess™ home, fi–in soft meadows on either side [of the cav
e] the 
iris and the parsley flourished. It was indeed a spot where even an immortal vis
itor must 
pause to gaze in wonder and delightfl (Homer, 1959).  Throughout history, the concept of 

a sacred grove has undoubtedly been given a natural, untended quality that makes it a par
t 
of the private, romantic, and natural side of garden design rather than the public, cla
ssic, 
and formal side of early garden design (Thacker, 1979).   
A juxtaposition of the natural ‚sacred grove™ with some of the earliest known 
gardens from Persia is essential to see the various sides of therapeutic la
ndscapes and the 
variety of spaces that were noted for their restorative qualities. Sixth centur
y BC 
landscapes incorporated lush green vegetation into geometrically designed space t
hat 
emphasized order in elements. The structured garden elements combined to create a 

restful place where tensions were calmed and contemplation was encouraged (B
rookes, 
1987). Persian gardens offered fithe outward and visible sign of an inward, invisible 

grace: the promise of divine order and meaning amid chaos, of ever-renewing life
 in the 
face of mortality, and of ease after travailfl (Khansari et al., 1998).  

 Another culture that was early to embrace the therapeutic benefits of nat
ural 
settings and gardens were those of Asia, specifically in the forms of the Japane
se Zen 
garden. Gardens and religion have been inseparable in Japanese culture from its
 
inception. Becoming prominent in the twelfth century AD, Zen gardens in partic
ular 
provide restorative qualities for their visitors who hold the belief that natural el
ements in 
the garden are manifestations of the gods. As a result, many garden elements
, with an 
attention to detail, are placed in religious institutions. These gardens are m
eant to provide 
guidance and consolation for the user, as Zen is about meditation and connecting oneself
 
 7  to the universe (Goto, 2003). This practice adds an additional dimension to Japan™s 

gardens for meditation. The Zen garden provides an opportunity for the individual to 

escape worldly afflictions and increase spirituality (Schaarschmidt-R
ichter, 1979). 
 Undeniably, the notion that nature is an important part in the healing process has 

been around for thousands of years.  Going back to classical times, we see templ
es to 
Asclepius, the Greek god of healing, built on hilltops. This strategic locatio
n enabled 
patients who were considered to be chronically or terminally ill to visit the t
emple far 
from the noise, dirt, and heat of the city. The temple was oriented around a fresh wa
ter 
source and provided a magnificent view of the sea while capturing fresh breeze
s. 
Although Asclepion were not hospitals in the modern sense of the word, during a stay at 

such a facility, patients were encouraged to fidreamfl their healing prescri
ptions, which 
then became the treatment protocol of the patient.  A healthy diet, pure water, socia
l 
interaction, fresh air and exposure to the surrounding nature, dream interpretation, and 

prayer complemented the experience. The most important aspect of healing w
as to be 
found in prayer, dreams, and social support, which generated a fiplacebo effectfl in the 

patient; all three of these activities were facilitated through expos
ure to natural forces 
(Westphal, 2000; Sternberg, 2009). 

 In the western world, other early therapeutic landscapes included the inter
ior 
courtyards of Roman Valentudia (100 BC-300 AD), which were some of the earliest 

formal military hospitals (Westphal, 2005; Thompson and Goldin, 1975).  The interior 

courtyards were used for ambulation following hospitalization as part of the recov
ery 
phase.  While the Roman physicians of the time were unaware of the physiological 

processes that sped recovery, modern medical practices of the day encourage amb
ulation 
 8  almost immediately after surgery to avoid problems with pneumonia.  Gardens during the
 
Middle Ages (400-1400 AD) in Europe were closely linked to the church and religious 

orders; monasteries were used to nurse the sick, orphans, disabled, insane, and other 

impoverished people within a town (Horden, 1988).  As cities grew and wealth was 

obtained, walls were built to define spaces and to provide needed security. As a res
ult, 
great vertical elements were constructed throughout the city and provided the pe
rfect 
structures for enclosed gardens and courtyards. These safe enclosures offered t
heir users 
the universal pleasures of shelter, sun, and shade (Clay, 1909). 

 In the Middle Ages, a time of spiritualism and mysticism, great attention w
as 
given to the energy that was derived from spending time in the monastery cloist
er garden. 
Saint Bernard (1090-1153 AD) described the influence of the therapeutic garden on his 

own being when he visited the garden. 
fiWithin this enclosure many and various trees–make a vertical gr
ove, which 
lying next to the cells of those who are ill, lightness with no 
little solace the 
infirmities of the brethren, while it offers to those who are str
olling about a 
spacious walk–a sweet place for repose. The sick man sits upon the gr
een 
lawn–he is secure, hidden and shaded from the heat of the day–for th
e comfort 
of his pain, all kinds of grass are fragrant in his nostrils. The l
ovely green of the 
herb and tree nourishes his eyes–the choir of painted birds caresse
s his ears–the 
earth breathes with fruitfulness, and the invalid himself, with the e
yes, ears, and 
nostrils, drinks in the delights of colors, songs and perfumesfl (Comito, 1978). 

 
As the core open space of the monastery, and therefore the most important 
symbolic garden, the cloister garden was an essential part of life in the Mi
ddle Ages 
(Cooper-Marcus and Barnes, 1999). The term ‚cloister™ refers to an enclosed court
yard 
within the walls of a monastery. A covered walkway often surrounded all or part of
 this 
central courtyard (Moulleron, 2001). For the attending monks, these spaces provided 

reprieve on both a mental and physical level, in addition to agrarian opportunities (Tys
on, 
 9  1998).   Monastic hospices served several major groups of people: traveling pilgrims, the
 
poor and infirm, as well as visitors who came to worship. Provided with a continuous 

flow of weary patients and visitors, the importance placed on the herbs grown in the 

monastery and used for healing and prayer were part of the foundation of all therape
utic 
procedures conducted in these monastic communities (Gale, 1967).  
Medieval Latin talks about the cloister garden as the ‚hortus conclusus,™ or 
enclosed garden. This term offered a metaphor for souls consecrated to God. The cloi
ster 
garden itself was designed so that it paralleled Biblical elements.  
The garden itself was divided into four squares, as in the Persia
n tradition and 
also according to the Garden of Eden legend. At the intersection 
of the four paths 
that divided the garden plots stood a well or fountain. Often the monks pl
anted a 
juniper or other evergreen to symbolize the Tree of Life in Genesi
s. Sometimes, 
too, they placed statues of the saints or the Holy Family in the e
nclosure. The 
plantings consisted of grass and flowers (MacDougall and Ettinghouse, 
1976; 
Meyvaert, 1986) 

 
Yet, toward the end of the Middle Ages (1300-1400 AD), the religious symbols 
that once marked the central cloister garden were replaced with secula
r symbols. This led 
to the decline of the monastic way of life; and as a result, the vitality and use of 

therapeutic courtyards and cloister space also began to vanish (Gale, 1967; Tys
on, 1998).  
With the Reformation, dissolution of Church Priories, and major epidemics, like 
the Bubonic Plague (1340-1400 AD), 30%-60% of the population in Europe succumbed 

to disease, crop failures, and population shifts.  Each of these factors contributed to 
a 
decline in the general medical care that monasteries once offered the needy
 (Hellinger, 
1967) during the fourteenth and fifteenth centuries. As changes in politics and religion 

occurred, monasteries were dissolved and many governments were ill prepared to 

administer healthcare to the flood of immigrants coming from the countryside. 
 10  Eventually, most care for the sick and needy was handled haphazardly by Catholic a
nd 
Protestant Church groups (Gerlach-Spriggs et al., 1998) 
During the eras of the Renaissance and Reformation (1400-1700), hospitals did 
not incorporate gardens in their facilities. However, not all therapeutic landsc
ape 
experiences at hospitals during this era were lost. Some Catholic institution
s continued to 
plan for, and utilize, the covered walkways and interior courtyards in their archi
tecture 
(Gerlach-Spriggs et al., 1998). In 1671, King Louis XIV had a hospital built for veterans 

that included numerous courtyards that were lined with trees. While the intent of buildi
ng 
therapeutic landscapes into various places of healing was noble, many of the Prote
stant 
and Catholic hospitals took on ficathedral-esquefl design elements such as placing 

windows so high on the wall that it was impossible to see the grounds outside (Cooper-

Marcus and Barnes, 1999), and most Protestant hospitals had no patient access to the 

gardens whatsoever (Thompson and Goldin, 1975). It was common for both hospital 

types to completely wall off patients from the outdoors, fresh air, and sunlight. The 

British pattern of hospital design, as observed by noted English prison reformer John 

Howard (1726-1790) in the 1770s and 1780s, was to design the patient™s rooms so that 

they opened out onto interior corridors (Howard, 1791). 
Then a new thought by statisticians proved helpful to the resurgence of the 
therapeutic garden during this time period. The notion that if the success of the countr
y 
could be measured by the health of the livestock, why not also judge the wealth of the 

nation on the health of its human subjects; fithe prince who took good care of his people 

would prosper mostfl (Rosen, 1974). This prompted the creation of many military 

hospitals and medical services with the goals to create a national standard f
or hospitals 
 11  and charities.  
New discoveries in the late eighteenth-century, through research in the various 
fields of medicine, brought about the return of therapeutic gardens by incorporating the
 
use of outdoor spaces in hospital design (Duncum, 1964). One common idea adopted as 

fact during this time was the importance of hygiene. These ideas lead to ninet
eenth 
century new knowledge about infections and germ transfer. These discoveries
 set the 
grounds for the work of Koch, Pasteur and Lister on germ theory in the late nineteent
h 
century (Park Talaro, K, 2008). The resulting finds on the importance of hygiene 

promoted hospital designs that focused on encouraging access to fresh air, proper cr
oss-
ventilation, and hygiene (Thompson and Goldin, 1975). Ample grounds with proper well-

drained soils allowed hospitals to maximize use of the sun™s directional patterns and w
ind 
flows for climate control (Gerlach-Spriggs et al., 1998).  
As German theorist Christian Cay Lorenz Hirschfeld (1741-1792) wrote in an 
article describing the proper union between nature and medicine, a hospital setting
 and 
garden design should: 
fi– be situated outside and away from cities, to allow for garden spac
e. Hospitals 
should  be located away from busy urban areas in a healthy and posit
ive and inspiring 
location, not in valleys–but on sunny, warm, hilltops protected from the wind 
or on 
southern slopes on dry soil–A hospital should lie open, not encased by high 
walls, not 
fenced in by looming trees. The garden should be directly connected to 
the hospital, or 
even better, surrounded [by] it. Because a view from the window onto bloom
ing and 
happy scenes  will invigorate the patient, a nearby garden also invit
es patients to take a 
walkfl  (Gerlach-Spriggs et al., 1998). 
 
Hospital design was being redefined, as seen in the Royal Infirmary of Edinbur
gh, 
a hospital built in Edinburgh, Scotland in 1729. It featured a U-shape layout, main 

corridors running East-West with wings on a North-South axis; this allowed the s
tructure 
 12 
 to best catch the sunshine and fresh southwesterly 
breezes (Figure 1).
 ˘ˇˆ
ˆ˙˝˛˚˜
Not long after in 1765, the Royal Naval Hospital at
 Stonehouse, England served 
as a model for English and French hospital design (
Figure 2). 
 13 
   ˇ!"#$%&
'ˆ˝'
()˜(*ˇ++)))
+˝
**,' -./˜
In this hospital, gardens and sunlight were incorpo
rated as a main component of its 
design. Additionally, the fipavilion hospitalfl style
 meant that the emphasis was put on the 
garden and allowed for the integration of garden an
d hospital. Hospital design called for 
two or three stories that allowed a maximum amount 
of direct sunlight and air to enter the 
patients™ rooms. The rectangular layout of the lawn
 between buildings meant that each 
ward had room for twenty-five beds in a lite and ve
ntilated room with a full row of 
windows (Risse, 1986).  
The result of military conflicts, such as the Battl
e of Waterloo (1815) and the 
Crimean War (1853-1856), allowed humanitarians, phy
sicians, and nurses to observe the 
treatment and healing progress of wounded soldiers 
under a variety of field hospital 
 14  conditions. It was noted that after these conflicts, soldiers treated in barns a
nd tents had a 
higher mortality rate than those that were taken to conventional hospitals (Churc
hill, 
1965). Commonly known as the founder of modern nursing, Florence Nightingale played 

a role in helping to re-solidify the connection between the natural and medical world. 
 fiSecond only to fresh air–I should be inclined to rank light in importance for the 
sick. Direct sunlight, not only daylight, is needed for speedy recovery–the being a
ble to 
see out of a window, instead of looking against a dead wall; the bright colors of flower
s; 
the being able to read in bed by the light of the window close to the bed-head. It is 

generally said the effect is upon the mind. Perhaps so, but it is not less so upon the body 

on that account–while we can generate warmth, we cannot generate daylightfl 

(Nightingale, 1863). 
 In short, Nightingale described the therapeutic link between sunlight and vitam
in D 
absorption. 
The new wealth of building material (i.e., lumber) that North America offered the 
world and a spurt in advancing building technologies made it possible to build smaller 

chimneys at less cost than the old masonry piles featured in early New England hous
es. 
Also, bricks were becoming more plentiful, and therefore less expensive. The chim
neys 
of houses became centered on the ridge at a distance of several feet in from t
he gables. 
This radical change in chimney location made possible a much more flexible floor
 plan. 
With a central hall, circulation of air, and people was considerably improved, and a much 

better stair arrangement could be adopted. Stairs now gave access to each additiona
l floor 
and larger windows with bigger panes balanced one another in a symmetrical faç
ade 
(Whitehead, 1977).  
In return, the ideals of Romanticism helped to spread the notion that finature and 
gardens came to be thought of once more as places of bodily and spiritual restorationfl 

(Gerlach-Spriggs et al., 1998). Outdoor gardens were considered to be a vital compone
nt 
 15  for a healing hospital environment (Cooper-Marcus and Barnes, 1999). Gardens were 

once more becoming the emotionally significant contributor to healing as they 
were in 
the Middle Ages; once again regarded as a place to escape and rest from the dail
y toils of 
life (Walpole, 1943). 
The patient group that perhaps benefitted the most from this revival of therapeutic 
environments was the mentally ill. Implementing the method called ‚
traitement moral™ 
or 
Moral Treatment, developed in part by Philippe Pinel (1794), called for fisocializi
ngfl 
patients (Weiner, 1992).  To create ways for patients to reassert themselve
s as 
individuals, building design focused on making the facility and treatments for the pat
ients 
resemble real-life situations as opposed to the often inhumane and/or solitary 

confinement to which many were often subjected (Bockoven, 1972; Thompson and 

Goldin, 1975; Zilboorg and Henry, 1941).  
For the mentally ill, small facility size, well-trained staff, and acc
ess to a rich 
environment allowed the Moral Treatment to be successful with this patient group. 
Great 
emphasis was placed on working in the outdoors. Gardening and caring for domestic 

animals became important aspects of the therapeutic routine. During the late ni
neteenth 
century, large outdoor grounds and plantings were incorporated into the mental health 

care facilities. (Zilboorg and Henry, 1941). By the 1880s, however, the United State
s 
stopped supporting mental facilities with adequate tax revenues in most states, and t
he 
wards quickly became over-crowed and under, or poorly staffed (Thompson and Goldin, 

1975). 
Mental care units were not the only facilities suffering from the ill effe
cts of 
overcrowding. During the last half of the nineteenth century, immigrants from
 Europe 
 16  and other countries flocked to newly developing American cities. This was the ti
me of 
the Industrial Revolution, and with it, a new set of social woes. Poor sanitation and 

increasingly poor air quality in the densely packed cities resulted in harmful
 and often 
deadly conditions (Fisher, 1986). Tuberculosis (also called ficonsumptionfl) was 

particularly troublesome in overcrowded tenant housing. In the metropolis of London, 1 

in 7 people died from consumption at the dawn of the 18th century; by 1750 that 

proportion grew to 1 in 5 and surged to 1 in 4 by around the start of the 19th century.
 The 
Industrial Revolution that America was experiencing, coupled with growing poverty a
nd 
squalor, created the optimal environment for the propagation of the disease, just as it ha
d 
in London (Chalke, 1959). 
As city conditions deteriorated, a new movement to improve human welfare on a 
national level was created. In America, the public parks movement of the mid to lat
e 
nineteenth century provided the public with outdoor spaces and access to nature as an 

informal healing method. At the forefront of this movement was the fifather of landsc
ape 
architecturefl, Frederick Law Olmstead. Being a first-hand observe
r of the terrible 
conditions that overcrowding had on the people of England, he became concerned about 

the deplorable living conditions in urban environments in America. He observed and 

noted that the urban-dweller often became fiovercome by physical exhaustion and 

physiological disorganizationfl due to their terrible living conditions.  In essenc
e, the 
crowded, unclean, and unsafe housing many people found themselves residing in was 

causing not only various forms of bodily harm but also degrees of mental illness and 

general fatigue (Fisher, 1986).  
As a champion of the public parks movement and creator of New York City™s 
 17  Central Park, Olmstead encouraged the creation and designation of spaces set a
side for 
nature and nature-based activities. As Fisher (1986) reports, Olmstead beli
eved that 
natural environments would provide urban residents an opportunity to revitalize their 

bodies and minds. Olmstead also saw the ability of a park to serve as an antidote to the
 
problems of congested city life by providing residents with outdoor park areas.    
The early twentieth century saw coexistence between nature and healthcar
e. A 
common practice involved nurses wheeling patient beds onto hospital balconies, 

verandas, or roofs for the benefits of fresh air and sunlight.  These practices aga
in 
recognized nature as an integral part of treatment for ailments such as tuber
culosis 
(Cooper-Marcus and Barnes, 1999).  
Alvar Aalto, a famed early twentieth century architect, was noted for de
signing 
buildings that appeared to grow out of their surroundings. As evidenced by his style of 

design, he was adamant about the importance of the explicit health benefits of wel
l-
planned architecture and about the importance of nature and natural views to healt
h and 
healing.  An example of this philosophy, Aalto built a tuberculosis sanatorium that would 

later become a standard for other hospitals. It featured a wing of south facing, li
ght-filled 
rooms for the patients to enjoy bright sunlight and views of the pine forest beyond the
ir 
windows (Sternberg, 2009). 
As the twentieth century advanced, so too did the fields of science, technology 
and design. New inventions in the fields of transportation and communication forever 

changed the way information was exchanged. Many of these new advancements lea
d to 
an increasingly complex and fast paced life for the modernized citizen. As a 

consequence, progress became measured by profit, efficiency, and productivity. Ma
ny 
 18  advancements in pharmaceutical, radiological, and surgical procedures warrant
ed a 
demand for more specialized spaces within the hospital. This changed the relationship 

between the internal and external spaces; the ideals of the pavilion hospital were
 no 
longer economically possible or medically desirable. 
During much of the early twentieth century, the hospital garden, with the 
exception of sanatoriums for tuberculosis and asylums for the mentally ill, was
 nearly 
eliminated. By the 1940s, hospitals began to function as corporate enterprises. 

Subsequently, hospital layouts began to resemble that of an office building. The technica
l 
advancements that were aiding in the saving of lives created many unforeseen 

consequences. Various pieces of equipment needed for medical procedures and building 

maintenance took up valuable space (Thompson and Goldin, 1975).  The use of natural 

ventilation was replaced by air conditioning. fi–outdoor terraces and balconies 

disappeared; nature succumbed to cars and parking lots; and indoor settings designed for
 
efficiency were often institutional and stressful for patients, visitors, and s
tafffl (Cooper-
Marcus, 2005).  
At the beginning of the twenty-first century, new trends in healthcare came as
 a 
result of a change in economic demands, the increased efficiencies in home heal
thcare 
delivery, and updated medical procedures for the treatment of many patient types
. No 
longer were hospitals places for those with moderate illness that needed the pr
ovision of a 
leisurely recovery. Hospitals, due to the increasing cost of healthcare delive
ry, were 
primarily for the extremely ill. As Gerlach-Spriggs et al (1998) states, 
 fi–health professionals, for very practical reasons, have tended to avoid 
the 
mystery associated with healing. Foremost is the fact that
 the battle to make medical care 
scientifically based has been hard won, and still just barely so; it is a ba
ttle that continues. 
Second, the tests, techniques, and medications of contemporary medicine a
re more easily 
 19  defined and, quite simply, the quantifiable is easier to budget for. fi 
 
The ability of the therapeutic garden to survive since the time of recorded his
tory 
quickly became an uncertainty in the span of a century–or so it seemed.  

Contemporary Medical Practice and Hospital Design of the United States
 The second half of the twentieth century saw chronic diseases replace acute 
infections as the major cause of death (Sahyoun et al., 2001). By the 1990s, heart disease
, 
cancer, and stroke accounted for 60% of all deaths in the United States, with heart di
sease 
and cancer accounting for nearly a million deaths in 1997 alone. Yet, an increase i
n the 
quality of healthcare has resulted in nearly three-fourths of all deaths happening
 at ages 
65 and older. Under existing medical conditions the typical lifespan of Americans 
has 
increased to the age of 78.9 for women and 72.5 for men, an average of 16-19 years 

longer than previous decades (Sahyoun et al., 2001). This brings up the issue of 

maintaining a high level of quality of life for the projected 70 million elderly pe
rsons by 
2030, and those tasked with providing their care. 
Although healthcare delivery protocols have advanced significantly in the past 
decades, Kaplan (1993) has shown that work environments in healthcare settings having 

a direct effect on worker efficiency, productivity, and satisfaction have c
hanged little. 
This is surprising; since research shows that healthcare settings contribute
 directly to 
patient outcomes. Aiken et al. (2011) conducted research on the effect of work 

environments on hospital outcomes across nine countries. Poor hospital work 

environments were common and associated with negative staff outcomes and poor 

quality of care. Also, staff turnover rates (specifically that of nursing st
aff) have been 
found to be a frequent occurrence in developed countries.  
 20  Reasons for high staff turnover can be complex and often depend on the context 
of the specific study and the views of the researchers (Hayes et al., 2006, Kapla
n, 1993; 
Mourshed and Zhao, 2012). What has been determined thus far concludes that the 

physical environment is linked to general staff wellbeing including injuries
 and stress 
(Kaplan and Kaplan, 2009; Trinkoff, et al, 2005; Kaplan and Kaplan, 1982). Nursing, as 

with most professions in the healthcare delivery industry, has a high incidence of ment
al 
fatigue (Wolf, 1988).  
With the technology of today, we are beginning to understand the complex 
linkages between stress, health, and nature. According to Sternberg (2009), any of
 the 
connections between healing and the environment can be explained in neurochemistry. 

She postulated that sense of sight is highly adapted to help distinguish and identify 

countless features and characteristics in the world around us.  This allows us to be
 in tune 
with our surroundings because of the complex connections and pathways located at the 

base of the brain that lead out from the visual cortex to the parahippocampal area.  

Sternberg (2009) states that the region where signals from the retina are f
irst received and 
finally constructed into a scene depends on these fipathwaysfl of nerve cells 
and increased 
receptor density that release endorphins, which are a form of morphine-like mole
cules in 
the brain.  By looking at a beautiful scene, the brain is capable of giving the body a
 
morphine-like high as more nerve cell receptors become active (Sternberg, 2009)
. Encouraging research findings have found that individuals returning from time 
spent in nature are better at proof reading than those in a control group that staye
d 
indoors (Hartig et al., 2003). fiGreen Exercise,fl or simply activity in the pres
ence of 
nature, has been show to reduce stress, improve self-esteem, and enhance mood (Bart
on  21  and Pretty, 2010). Studies also have shown that when given a choice, participants 

imagining a stressful situation choose a natural setting in which to recover 
(Herzog et al., 
1997, 2003). Hartig and Cooper-Marcus (2006) and Duvall (2011) further showed that 

affect improved and anger decreased when participants took a short walk through a for
est 
after a stressful driving assignment. This research demonstrates the a
bility of nature to 
calm the mind and improve concentration to accomplish complicated and stressful tasks
.  The work of Ulrich (2008) and Ulrich et al (2006) helped identify physical factors 
in the environment that affect staff outcome. This study recognized that well de
signed 
hospital environments had the potential to increase staff effectiveness and sati
sfaction, 
while reducing medical errors and hospital-acquired infections. The well-desi
gned 
hospital also has the ability to decrease staff stress and injuries.  Increas
ed contact with 
vegetation appears to provide a low-cost, high-gain approach for both patient and 

employee because of improved employee effectiveness (Kaplan, 1993). As Aiken e
t al. 
(2011) showed, addressing staff satisfaction and effectiveness has importance
 beyond the 
primary concern of patient care, it relates to the quality of care the health c
are institution 
is able to provide its patients.  
The Trust for Public Land sought to measure the economic value of a city park 
system to understand how park systems economically benefit cities. Working wi
th 
economists and academics, the study identified seven measurable attributes of
 parks that 
provide economic value. These attributes are property value, health, direct use, 

community cohesion, clean water and air, and increased tourism. This study shows that
 
green space imparts positive qualities to a site (Harnik and Welle, 2009).  A simil
ar study 
found that parks and natural, vegetated recreation spaces produce positive economic 
 22  outcomes for developers, homeowners, and local governments (Shoup and Ewing, 2010). 
Financial benefit to the healthcare institution also may be affected. Heal
thcare 
expenditures account for a significant share of the national budget in most countries
 
(Garrett et al, 2009). Ulrich (2002) reported in 
Health Benefits of Gardens in Hospitals, 
that the trend of spending on new and updated existing healthcare facilities in the Unit
ed 
States averaged $15 billion annually during 1992-2002. He also found that the United 

Kingdom planned to spend $4 billion on new hospital construction during 2002-2005. 

The Texas Medical Center in Houston, Texas, projected to spend $1.8 billion on new 

construction between 2002-2004. New spending for hospital buildings in the state of 

California alone has been projected to be $14 billion by the year 2010. Additions and 

renovations to existing buildings also can be very costly. Northwestern Universit
y™s main 
hospital in Chicago was renovated at a cost of $687 million. When other healthcare 

providing environments are considered, such as nursing homes, hospices, and 

rehabilitation clinics, it becomes clear that healthcare design and construct
ion directly 
accounts for large amounts of money (Ulrich, 2002). 
To judge the quality of healthcare delivery, professional practice standar
ds are 
reviewed, but seldom become a part of the physical environment of a health facility 

(Devlin & Arneill, 2003). However, the concerns of patients and staff are increas
ingly 
being heard and accepted as important input in measuring healthcare quality, e
specially 
as it affects clinical outcomes (Wolf, 1988; Woodring et al., 2004). Naturally, it i
s the 
healthcare providers, the doctors, nurses, therapists, nurses™ aides, etc and the 

administration, that encompass the user groups who spend most of their time working in 

the indoor environment of the healthcare delivery system. Due to the nature of building
 
 23  construction and renovation procedures, it is best to design for positive health delivery 

effects on occupants in the early stages of the building™s life cycle (Visc
her, 2007). The 
costly nature of modifications in later stages of construction requires earl
y decisions that 
insure improved health care delivery.  
The opinion of healthcare providers and administration on the design of a hospital 
can provide valuable information and expertise to hospital designers. These are the
 
professionals that are familiar with the physical aspects of the environment
 that affect 
various requirements of their work (Vischer, 2007). To achieve a truly fipatient cent
eredfl 
approach to care, the environment must support a team approach including medical, 

nursing, and administrative personnel (Karlin and Zeiss, 2006; Cooper-Marcus and 

Sachs, 2014). As the hospitals of the 1950-60™s are decommissioned, new opportunities 

for creating green space and/or therapeutic gardens to fienrich and improv
e the lives of 
patients and the environments of hundreds if not thousands of existing medical care 

facilitiesfl (Ulrich, 2002) are possible. 
 fi[h]ealthcare administrators everywhere are under strong pres
sures to control or 
reduce  costs yet increase care quality. Faced with imperati
ve demands such as paying for 
costly  new medical technology, administrators may often consider
 gardens as desirable 
but nonessential. Convincing the medical community to assign priority a
nd resources 
usually requires providing credible evidence that gardens and plants pr
oduce benefits yet 
are cost-effective compared to alternative, including not providing gard
ens and plants 
(Ulrich, 2002).fl 
 
However, in light of research done on clinical and economic outcomes, the most 
influential data dictating decisions in healthcare, involves patient 
satisfaction 
in patient-
centered or consumer oriented care (Ulrich, 2002). 
It was the patient centered care movement of the 1990s that re-ignited the trend of 
therapeutic landscapes in healthcare settings. During the 1980s and 1990s, research 
 24  supporting the theory that access to, direct views of, and/or exposure to nature (and its
 
sounds) had positive effects on health outcomes. There is a growing body of evidence 

that the restorative and therapeutic effects of nature scenes and sounds are 
measurable 
after only three to five minutes of exposure, as a combination of psychological/emotiona
l 
and physiological changes (Ulrich et al, 1991; Alvarsson et al., 2010). Numerous studie
s 
of various spaces have all shown that views of vegetation or garden-like features hav
e the 
ability to elevate levels of positive feelings such as being calm or having a 
sense of 
pleasantness.  Open green space also reduces negative emotions such as fear, ange
r, and 
sadness by producing measurable changes in psychological and emotional states
 (Berman 
et al., 2008; Kjellgren and Buhrkall, 2010; Gonzalez et al., 2010; Kuo and Sullivan, 2001; 

Matsuoka, 2010). 
Nature scenes successfully keep the viewer™s interest and attention, and 
accordingly, can serve as pleasant distractions that may diminish stressf
ul thoughts 
commonly associated with healthcare visits and other stressful situations and c
onditions 
(Kaplan, 2005; Kuo, 2001; Ottosson and Grahn, 2008; Wichrowski et al., 2005). Further 

research (Kuo and Taylor, 2004; Taylor and Kuo, 2009) showed that children with 

Attention Deficit Hyperactive Disorder (ADHD) concentrated better af
ter a walk in a 
park than after a walk downtown or in a highly built environment. 
Concerning the physiological component of stress recovery, filaboratory and 
clinical investigations have found that viewing nature settings can produce sig
nificant 
restoration within less than five minutes as indicated by positive changes, for i
nstance, in 
blood pressure, heart activity, muscle tension, and brain electrical activityfl 
(Ulrich, 1981; 
Ulrich et al., 1991; Kropela and Ylén, 2007). Studies such as these suggest the medical 
 25  plausibility for adding supplemental fidoses of naturefl to standard healthcare 
treatments. 
As a result of these studies, a return to nature in the medical field is on the rise. 
The Howard A. Rusk Institute of Rehabilitation Medicine in New York City, attends
 to 
the fiwhole person.fl This outlook on healthcare delivery led Dr. Howard Rusk to build 

four gardens that function as a part of integrated clinical processes and heal
ing 
environments at the facility.  In urban New York City, the garden is a welcome a
menity 
amid the skyscrapers, noise and pollution.  
Rehabilitative services required by the patients of the Rusk Institute ofte
n demand 
weeks or months of specialized high-intensity care. Therefore, the Institute
 values 
therapeutic qualities in all aspects of design in an attempt to create a ple
asant 
environment for long-term patients. The gardens specifically allow fiescape f
rom the 
clinical realm and serve as a safe means of progression from the hospital room to t
he 
outside world.fl It has been noted that fi[t]hey are often in constant use and can have gr
eat 
power and meaningfl (Gerlach-Spriggs et al., 1998). 
The Wausau Hospital in Wausau, Wisconsin, has a layout design originating in 
community values and goals. Evidence of this is seen in the abundant gardens and 

woodland areas for patients, staff, and visitors. The building plan, designed by David 

Kamp, has courtyards within the main building, allowing rooms to face outside to either 

the landscape park or inward to the courtyard. All rooms have large windows that are
 
lower than usual in order to provide views for the recumbent hospital patient. The figure 

eight layout also allows for departments to be organized within their own corridors 

(Figure 3). The system is continuous around the square, increasing efficiency w
hereby a 
less busy department could lend rooms without having to scatter patients and staff a
round 
 26  the building.  
.ˇ˘&ˆ˝0'˚˚˛˜
 This hospital™s setting is in a small community in Midwest America, but the 
tropical plantings in the enclosed courtyard atriums allow viewers the ability
 to escape 
the hospital environment and imagine themselves elsewhere. The gardens do not try t
o 
deny illness or death that is present in the hospital, but they do the job of softening, 

comforting, distracting, and inspiring observers to acknowledge that illness and de
ath are 
part of life. 
 27  Conclusion
 In light of increasingly documented physiological and psychological benefits
 of 
therapeutic landscapes on users, one might think that their presence would be 

commonplace in various healthcare settings. When a therapeutic landscape is pres
ent, 
there are positive clinical indicators such as the observable condition of a patie
nt™s blood 
pressure, heart rate, or pain medication intake. The presence of a therapeutic l
andscape 
also has shown positive patient/staff satisfaction that lead to lower recruit
ment or hiring 
costs due to staff turnover. These patient and staff benefits would seem to be suffi
cient 
cause and justification for the adoption of the therapeutic landscape in institutional 

settings, yet they are often a missing element in healthcare institutions. 
  
  
 
 
 
 
   
 
 
  28  CHAPTER III 
AIMS OF STUDY  
 This study intends to address several issues surrounding therapeutic gardens i
n 
healthcare settings: 1) perceived barriers to therapeutic landscapes ba
sed on the concerns 
of healthcare providers and administrators; and 2) a determination of whether these
 
professionals are aware of the multitude of benefits obtained through the presence 
and 
use of therapeutic garden space; and 3) does the presence of a therapeutic garde
n at work 
influence perceptions of barriers, use, and benefits.  Healthcare providers™ perce
ptions 
relating to concerns, benefits and barriers, as well as their understandings
 of what truly 
makes a landscape therapeutic, will be documented through a survey. These perceptions
 will be analyzed and reported to create a more thoughtful dialogue among healthca
re 
providers, administrators, and landscape architects.  
Because this is an exploratory study, the author decided to frame the experimenta
l 
design as a series of fiaimsfl rather than hypotheses.  The aims are intended t
o answer the 
following questions: 
1.
 Using a standard definition of a therapeutic garden, is there a strong 

consensus among healthcare workers as to what constitutes a 

therapeutic garden in healthcare settings? 
2.
 Does the prior knowledge of a therapeutic garden (as defined by 

Westphal 2010 Gerlach-Spriggs and Healy, 2009) at a healthcare 

facility influence staff perceptions of benefits, barriers and/or 

appropriate use, for different patient populations based on current 
 29  treatment protocols and intended outcomes? 
3.
 What concerns do medical staff express when asked to identify barriers 

to garden use for different patient populations irrespective of the 

presence or absence of a therapeutic garden at their place of work? 
4.
 Are perceptions relating to therapeutic gardens for use with different 

patient populations influenced by the socio-demographics and/or 

educational training of medical staff?  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  30  CHAPTER IV 
 METHODS 
  

 This study was initiated by a comprehensive review of the literature and 
was 
concluded with an analysis of data from a hand-delivered, mail-back survey. The 

literature review identified four general areas of study relative to the
 creation, location 
and user groups/patient types of therapeutic gardens. Health benefits derive
d from 
therapeutic gardens in healthcare settings also were also reviewed. One of the
 areas 
where little information on therapeutic gardens existed in the literature w
as the area 
addressing perceived barriers to the installation of gardens in contemporary hea
lth care 
settings.  This lack of information led to speculation as to cause, and eventually, to 

formulation of aims that would drive the study.  It was decided that a survey of curr
ent 
healthcare providers would be undertaken for the purpose of gathering information on 

perceived barriers to therapeutic gardens. The target group for the survey wa
s healthcare 
professionals working in the mid-Michigan area, within a one-hour to one and a half hour
 
drive of Lansing, Michigan, at various types of medical facilities (i.e., hospital
s, end-of-
life care, and extended care facilities). Conducting an internet search for
 the types of 
medical facilities listed above resulted in the contact list. 

Study Population 
Because this was an exploratory study, the study population was limited to 
actively employed healthcare workers at a variety of healthcare insti
tutions (i.e., 
hospitals, end-of-life care, and extended care facilities) in the mid-Michi
gan area.  The 
area was largely defined by a driving distance of 1.5 hours (Figure 4). Conducti
ng an 
online search for the variety of healthcare institutions listed above within the
 defined 
 31  distance, identified forty-three (43) medical facilities in the study are
a. Once a medical 
facility was found through this online search, the head administrator, the head nurse, 

volunteer coordinator or community relations representative of the facility 
was contacted 
by telephone. Eleven (11) facilities agreed to participate in the study. The
se eleven health 
care facilities included two hospitals, six nursing homes, and three extended car
e 
facilities and created a potential pool of 300 healthcare providers as partici
pants in the 
study (Table 1). 

Survey Instrument
  A survey was developed that consisted of a cover letter on Michigan State 

University letterhead and a survey instrument consisting of nine questions probing 

perceptions relating to therapeutic gardens in healthcare settings and a te
nth question that 
gather information on the respondent.  

 A standard definition of a therapeutic garden as initially described in a
n article by 
Gerlach-Spriggs and Healy (2010) and modified for widespread use by Westphal (2010) 

introduced the concept of therapeutic gardens to the respondents.  This was done to frame 

the concept of a therapeutic garden as a designed space intended for health car
e delivery 
of select treatment protocols, depending on patient audience and to establish baseline
 data 
on the respondents™ agreement with the concept.  As such, a therapeutic garden differs
 from the more popular, but less patient-targeted, designed green spaces for heal
th 
purposes like fihealingfl, fimeditationfl, fireflectivefl, and firespitefl gardens (Ty
son, 1998; 
Cooper-Marcus and Barnes, 1999; Squire, 2002). The respondent™s level of agreement 

helped the researcher determine the level of ambiguity in responses to the next que
stion 
involving fithe presence or absence of such a garden at a respondent™s place of workfl;
 
 32  without this baseline information, it would be difficult to determine the validity and 

reliability of the respondents™ subsequent answers.  The definition also helped to 

eliminate confusion emanating from unstructured, non-programmed outdoor green spaces
 at a medical facility from true therapeutic gardens with targeted pa
tient populations, 
structured treatment protocols, medical staff intervention, and medically-def
ined 
therapeutic outcomes.  The definition reads as follows: 
fiA therapeutic garden is a designed outdoor space that uses plants 
and other 
elements of nature to promote patient care and well-being while fa
cilitating 
medical staff in the delivery of standard treatment protocols comm
only used in 
health care settings. As such, the health services supported by a
 garden may be 
primarily palliative or rehabilitative, depending upon the patient populat
ion being 
servedfl (Westphal, 2010). 

 
Ten questions followed this definition that focused on respondent perception of 
therapeutic garden use by patients and other healthcare providers at their pl
ace of work; 
actual or idealized garden size; and whether the therapeutic garden is or should be 

used/designed for multiple uses, other than the delivery of treatment protocols (l
ike 
special events, staff use, etc.). 

 Based on whether a therapeutic garden existed at a participant™s place of wor
k, the 
next set of questions asked respondents to indicate their perceived frequency of use by
 
different patient groups at the healthcare facility (both in actuality if a ga
rden existed, and 
ideally, if a garden did not exist) and the perceived healthcare worker(s) m
ost likely to 
exercise use of a therapeutic garden with a patient group.  Responses for the for
mer 
question involved circling a response that ranged from finonefl to fia lotfl or finot 

applicablefl; the latter question used a 5 point, Likert-like scale, ranging f
rom fi1-very 
unlikelyfl to fi5-very likelyfl.  Size of the garden could be described in acres or
 
dimensions; and multi-use responses could be indicated with a fiyesfl or finofl, with a 
 33  fiyesfl soliciting an open response.  The purpose of this section of the survey was to see 

what patient groups were perceived as being the most appropriate users of a thera
peutic 
garden and who in the healthcare delivery system was the most likely to take pat
ients out 
into a therapeutic garden for treatment protocols.  Actual or idealized size of t
he garden 
was asked to determine if a particular patient group was tied to a certain siz
ed garden in 
reality or ideally.  The questions of multi-use were made to determine if re
spondents 
perceived a therapeutic garden as having a single function or multiple functions.
   The next section of the survey asked respondents to think about other benefits 

(beyond patient care) that therapeutic gardens might serve in health care setti
ngs.  These 
other benefits included marketing advantages for the facility, environmental prot
ection, 
staff and care-giver satisfaction, etc.  The purpose of this question was to deter
mine how 
restrictively a respondent viewed the design and ultimate use of a therapeutic garde
n in 
their health care facility. If health care workers viewed the garden as
 a single useŠi.e., 
treatment delivery for certain patient populationsŠthen designer options would focus 

singularly on that use and the patient groups identified; but if health care workers vie
wed 
the garden for use beyond patients, then a whole different array of uses could be 

incorporated into a therapeutic garden™s design, in addition to treatment.  A five-point 

Likert-like scale was use to rank various fiother benefitsfl with fi1-very unlikel
yfl to fi5-
very likelyfl.  An open-ended response for other benefits was made available to the
 
respondents with the same scaling mechanism. 

 The set of questions following benefits beyond patient care inquired about 

perceived barriers to having a therapeutic garden in healthcare facilit
ies, in general.  Most 
of these questions focused on a lack of knowledge about some aspect of therapeutic 
 34  gardens in healthcare settings.  For example, a perceived staff barrier may
 be a filack of 
knowledge about plants, about patient limitations, or about scientifically validated he
alth 
benefitsfl; others barriers may focus on budget priorities and staffing.  T
his section really 
probed the perceptual barriers held by healthcare professionals when considering
 a 
therapeutic garden in their workplace.  A five point, Likert-like scale simila
r to the other 
sub-sections of the survey was used to collect information on barriers perceived b
y 
healthcare professionals, with scaling being fi1-very unlikelyfl and fi5-ver
y likelyfl; an 
open-ended scaled blank was provided for additional perceived barriers. 

 Lastly, respondents were asked about their own professional concerns relating to 

having a therapeutic garden installed at their place of work.  This sub-section w
as 
formulated to see if some of the concerns that frequently have been mentioned 

anecdotally in the literature have merit.  Using a five-point, Likert-like
 scale, respondents 
could indicate a fi1-low concernfl to fi5- high concernfl; items included concerns of safe
ty, 
liability, maintenance, etc.  A blank was provided for a concern not listed, follow
ed by 
the same scale. Finally, a question regarding personal advocacy for therapeut
ic gardens in 
a respondent™s workplace concluded the data gathering on therapeutic gardens. 

  Question 10 was constructed to provide background information on the 
respondent and their professional training and work experience.  This battery of 

questions allowed the other responses to come into context with the respondent™s 

perceptions about therapeutic gardens and their use in healthcare settings.  A fe
w 
socio-demographic questions involving age and gender were followed by several 

questions on professional fields and degrees, workplace experience, years of 

professional service, etc.  The respondents™ were asked to report their professiona
l 
 35  field of work (N=55). Answers were grouped into fields to make up the following 

group identities:   
  Group 1 Administration: administrators, owners, coordinators, accountants 
(n=12; 21.8%).  

Group 2 fiHands-Onfl Care Givers: nurses, aides, speech and language 

pathologists, recreational therapists, occupational therapists, physical ther
apists 
(n=30; 60.0%).  
  Group 3 fiClinicalfl Care Givers: physicians, social workers, dietitians, 
     
 psychologists/psychiatrists (n=7; 12.7%).  
Group 4 Building Staff: maintenance supervisors, linens/laundry managers,  
  maintenance/janitorial staff, grounds staff, kitchen staff (n=3; 5.5%). 
The survey concluded with a note of thanks.  
Pre-Data Collection Phase  

 A pre-test survey was developed by the researcher and administered to a group of 

sixty-four (64) senior students enrolled in the nursing program at Michigan Stat
e 
University. Data from the pre-test survey was used to evaluate question ambiguity
, 
response generation, and survey organization in an effort to improve reliability
 and 
validly in responses. For questions where participant response rate was low, the
 survey 
questions were re-evaluated in their wording and/or intent.  Likewise, when survey
 
responses proved inconsistent with the response to other questions, the survey was 

revised to improve question clarity.  The resulting revised pre-test survey wa
s then 
reissued to the same group of sixty-four (64) senior nursing students to further te
st the 
quality of questions and survey organization. The same methods as above were used to 
 36  revise and amend the final survey that was to be used on professional healthcare 

employees.  The final survey, with cover letter as described above, went out to the
 
professional respondents.  All survey activities were approved by the Michigan S
tate 
University Institutional Review Board (IRB). 
 Appendix A contains the revised survey and cover letter that actually went out to 
targeted professionals in the Mid-Michigan area.   

Actual Data Collection Phase. 
While the pre-test survey was being revised, an online search of various 
healthcare facilities (i.e., hospitals, end-of-life care, extended care f
acilities) in the mid-
Michigan area was conducted. Head administrators, head nurses, volunteer coordinat
ors 
or community relations personnel of the facility was then contacted by telephone and 

solicited for employee participation in the survey.  If it was determined tha
t there may be 
administrative or medical staff interested in the survey, packets of survey
s were then 
hand-delivered to the hospital, end-of-life care, or extended care facility by
 the 
researcher; a stamped, self-addressed envelope accompanied each survey.  
An optional contact card was included with the survey; this card gave respondents 
the option to receive the overall survey results and/or to permit researchers t
o clarify any 
responses to the survey on therapeutic gardens.  Return of the card was voluntary. 

Respondent institutions received the packets in February 2013 (Table 1) and individual 

respondents had approximately 30 days to complete the survey and return it by mai
l to 
the university.  Three hundred (300) surveys were delivered to eleven institutions, and 58 

surveys were returned for a response rate of 19.33%. The distribution of healthcare 

professionals that participated in the study included 8 workers from hospitals, 45 worker
s 
 37  from fiend-of-lifefl care facilities, and 4 workers from extended-care fac
ilities. Of the 58 
surveys returned, 100% were complete and useable.  

Data Analysis  

 All data was tabulated in a standard Microsoft Excel format and analyzed u
sing 
SPSS (Statistical Package for the Social Sciences), to generate des
criptive statistics and 
cross-tabulations. Tables 2- 20 contain responses to the various questions in the survey. 

  
 
 
 
 
 
 
 
 
  
 
 
 
 
  38 
 CHAPTER V 
RESULTS 
 
 
 Eleven (11) healthcare facilities in the mid-Michi
gan area, represented by the blue 
markers (Figure 4) participated in the survey, whil
e 43 healthcare facilities (red markers) 
chose not to participate in the study. The group of
 participating facilities included 2 
hospitals, 6 end-of-life care facilities, and 3 ext
ended care facilities. Survey respondents 
included 12 administrators (facility directors, chi
ef of staffs), 33 fihands-onfl caregivers 
(nurses, nurse™s aids, and physical therapists), 7 
ficlinicalfl care-givers (doctors, 
psychologists, psychiatrists) and 3 building staff 
(building and grounds maintenance, 
culinary services) for a total of fifty-eight (58) 
surveys (Table 1). A non-response check 
of the data was not conducted because facilities we
re not tied to survey participants in 
any way due to IRB requirements; therefore, it was 
impossible to know who had or had 
not completed 
 1ˇ2*ˆ**3
43*˝53˜
 the survey at a particular healthcare facility. In 
retrospect, the use of colored surveys, 
 39  matched to specific participating facilities would have provided that type of infor
mation 
without violating anonymity.  

 Frequency of responses from the 58 surveys provided descriptive information on 

both participants and perceived garden use for patient treatment.  Tables 2-11 contain
 the 
frequency of responses to each of the questions in the survey; brief synopses of the 

responses follow. Where appropriate, tables have been constructed to illustrate t
he data. 
Tables can be found in Appendix B. 

 Questions relating to agreement with the definition, prior knowledge of 
therapeutic gardens, and prior experience with therapeutic gardens (Q 1, 2, and 3). 
The 
first question asked respondents to indicate how strongly they agreed or disagreed w
ith a 
standard definition of a therapeutic garden. Over ninety (90%) percent of the respondent
s 
said that they strongly agreed (n= 38; 65.5%) or agreed (n= 16; 27.6%) with the given 

definition while less than 7.0% said they disagreed or felt neutral (n =4; 6.9%) about the
 
definition. When asked if they had heard of, or had worked in, an environment with 

therapeutic gardens prior to the survey, 48 respondents, (n= 48; 82.8%), said that they 

had heard of, or were familiar with, gardens prior to the survey, and only 9 respondents 

(16.0%) had no previous experience with this type of garden.  

 Using the same definition of therapeutic gardens, the participants were a
sked to 
indicate whether such a garden existed at their workplace. Of the various healthca
re 
institutions participating in the survey, 54.0% of respondents (n=29) said they did not 

have a therapeutic garden available at their workplace, while 46.0% (n=25) did have a 

therapeutic garden at their workplace. Four respondents had no response.  Because the
 
perception of the gardens held by the respondent would depend largely upon their 
 40  personal interaction with such landscapes, this question divided the population into those 

that fihad therapeutic gardensfl and those that fidid not have therapeutic gardensfl at
 their 
workplace. See Tables 2-4.  
The next set of questions (Q4) was directed towards those with a therapeutic 
garden at their workplace (Q4 a-d) while those respondents with no therapeutic garden a
t 
their workplace were directed to go to Q5 a-d.  

 Responses to Question 1: Agreement with the Definition of Therapeutic Garden 
(Q4a).
 Respondents who indicated that they have a therapeutic garden at their current 
workplace (n= 25) were asked to rate their perception of the frequency of use f
or six 
various patient types. The patient types included patients under psychiatric c
are, 
orthopedic care, hospice care, oncology care, cardiac care, or dementia car
e. Hospice care 
at 31.8% (n=22), psychiatric care 17.4% (n= 23), and dementia care at 33.3% (n = 24) 

scored the highest as the most common patient groups using the gardens. The groups 

observed least likely to use the garden were the orthopedic care and cardiac care
 patients 
4.5% (n=1). The option to suggest another observed patient type found the most 

frequently mentioned fiother groupfl was long-term care patients (n=2).  See T
able 5. 
Respondent™s perceived frequency of garden use for patients and non-patients at 
places of work having a therapeutic garden (Q4b).
 The professionals rated as the most 
likely to use the gardens with patients by all respondents were the therapist
s (mean=3.45) 
followed by aids (mean=3.38) while family members were rated as the highes
t 
(mean=4.08). The most common fiother groupfl mentioned were activities and recreation 

staff members. The least likely member of staff observed to interact w
ith patients in the 
existing therapeutic garden were doctors at (mean=1.13) and nurses (mean=2.13)
.  
 41  Doctors scored the lowest standard deviation of 0.34.  See Table 6.  
Approximate size of existing therapeutic garden (Q4c).
 Survey respondents were 
asked to report on the approximate square footage of the existing therapeutic garden 
at 
their workplace location. The average existing garden was 2,500 square feet. The ra
nge 
of gardens was 100 square feet to 22,780 square feet. 

 Other uses for existing therapeutic gardens (Q4d).
 Respondents were asked to 
think about the garden in terms of its potential use for other purposes besides viewing, 

strolling, sitting, or therapeutic activities. About one-third of the respondents (32%;
 n=8) 
indicated that other activities took place in their garden space. Of those 25 respondent
s 
that indicated their work place had therapeutic gardens being used for other use
s, the 
most common use was for social events such as ceremonies, parties, and celebrat
ions. 
 Respondent™s perceived frequency of garden use for different patient groups at 
places of work NOT having a therapeutic garden (Q5a).
 Respondents who indicated that 
they did not have a therapeutic garden at their current workplace were asked to rat
e their 
perception of the anticipated frequency of use for various patient types. The sam
e set of 
patient types from Question 4 was given. All respondents scored a higher rate of
 use than 
the perceptions of those respondents at institutions with a garden present. The idealize
d 
amount of therapeutic garden use by patient groups showed that the dementia care 
group 
would be thought of as the fimost likelyfl group to use the garden at 62.5% (n= 20). 

Oncology and hospice care also were thought of as fivery likelyfl to use the garden 
at 
36.7% (n= 11) and 39.4% (n= 13) respectively. The least likely patient groups thought to 

use the garden were those in cardiac care at 16.7% (n= 5) and orthopedic 16.7% (n= 5) 

care. Two respondents indicated that fipatients in rehabilitation programsfl wer
e fiother 
 42  groupsfl likely to use a therapeutic garden (Table 7). 
Respondent™s perceived frequency of garden use for patients and non-patients at 
places of work NOT having a therapeutic garden (Q5b).
 In an idealized therapeutic 
garden, respondents believed that family, staff or non-medical care givers wer
e the most 
likely to use a therapeutic garden. Family members were viewed as the most
 likely to use 
a therapeutic garden informally with a patient at 58.8% (n= 20); however, thera
pists 
42.4% (n= 14) and aids 39.4% (n= 13) were the most likely to use a garden with patients 

undergoing a treatment regiment. Family members and therapists had the highe
st mean 
value, 4.32 (sd=.98) and 4.03 (sd=1.05), respectively. The group perceived to be the least 

likely to interact with patients in a therapeutic garden for medical purposes wer
e the 
doctors 64.5% (n= 20) and nurses 21.9% (n= 7). The mean value for doctors was 1.58 

(sd=.96) and the nurses was 2.72 (sd=1.37). fiOther groupsfl identified as being fivery 

likelyfl to use the garden with patients were volunteers (n=2), social service
 workers 
(n=2), therapeutic recreation professionals (n=2), and activities managers 
(n=3).  See 
Table 8. 
Approximate size of an idealized therapeutic garden (Q5c).
 Survey respondents 
indicated that the approximate square footage for an idealized therapeutic gar
den at their 
workplace location ranged from 36 square feet to 3,600 square feet; the mean value was 

1,000 square feet.  

 Other uses for idealized therapeutic garden (Q5d).
 When asked to think about 
potential uses for a therapeutic garden beyond its use for therapy, seventy-nine perc
ent 
(79.3%; n=23) envisioned the garden being used for other uses.  Thirty-four percent 

(34.5%; n= 10) stated the garden could be used for social events such as ceremonies, 
 43  parties, and celebrations.  Another seventeen percent (17.2%; n= 5) thought the garden 

could be used for community engagement activities such as garden clubs and herb/ 

vegetable gardens for the healthcare facilities™ use. Other suggested poss
ible uses 
included increased marketing opportunities, wildlife habitat, and group exercise spa
ce. 
The following questions brought the survey respondents back together regardless 
of the fact that their workplace had, or did not have, a therapeutic garden on-location.
 The next set of questions asked respondents to rate the likelihood of various 
benefits derived at a healthcare workplace if a therapeutic garden was a
dded.  
Conditions that would improve at a respondent™s place of work if a therapeutic 
garden were provided (N=58) (Q6).
 Seven possible improvements and one open-ended 
variable were listed as possible areas of improvement if a therapeutic gar
den was 
available in a healthcare setting. All seven received an average score above (
3.0).  The 
highest mean score was assigned to the fienvironmentfl (4.57; sd=0.62) and figeneral 

appearancefl (4.59; sd=0.65). The variable with the lowest mean score for improving a 

person™s place of work was for improved fidaily patient carefl (x=3.60; sd=1.00). Of the 

listed variables for improvement, the 58 survey respondents indicated that an 

improvement in the environment (n= 36; 62.1%) and general appearance (n= 38; 65.5%) 

would be fivery likelyfl to occur. See Table 9. 
Frequently cited barriers to therapeutic gardens at one™s place of work 
(regardless of having or not having a therapeutic garden) (N=58) (Q7). 
The next set of 
questions (Q7) asked respondents to rate the perceived barriers to the implementati
on of 
therapeutic gardens in healthcare settings. There were 58 respondents but on occa
sion 
only 57 participants chose to respond to this section of questions. In that circumstance, 
 44  the N value was reduced by one. 
 Fifteen possible barriers were provided in the survey.  Respondents were asked to 
rate them on a scale of 1= strongly disagree that this would be a barrier to 5= str
ongly 
agree that this would be a barrier. The barrier most likely to prevent the adopt
ion of 
therapeutic gardens in one™s institutional setting was filack of all-weathe
r equipment for 
delivering therapy outdoorsfl (65.5% (n=38)fistrongly agreefl; 29.3% (n= 17) fiagree
fl). 
This variable also received the highest mean value of 4.59 (sd=0.65). Two-thirds (n=38
) 
of the respondents said that they fiagreedfl or fistrongly agreedfl that both fia l
ack of time 
in work schedulesfl and fihigher priorities for operating budgetsfl (N=57) were a
 barrier. 
Variables that did not appear to be a barrier to the creation of therapeutic gar
dens 
in healthcare settings were filack of family appreciationfl (x=2.26; sd= 1.00) and fil
ack of 
patient knowledgefl (x=2.19; sd= 1.00). Only one (1.7%) of the 58 respondents indicated 

that these two variables would be barriers to a therapeutic garden in their healt
hcare 
setting. See Table 10 for a full summary. 

 Level of perceived concern about the implementation of therapeutic gardens in 
healthcare settings, regardless of having or not having a therapeutic garden at one™s 
work place (N=58) (Q8). 
The next set of questions asked respondents to rate variables of concerns, relating t
o a 
therapeutic garden at one™s workplace (Table 11).  Respondents indicated a fihighfl t
o 
fivery highfl concern about fimaintenance costsfl (n= 34; 59.6%), and fistaffing costs to 

work the gardenfl (n= 33; 57.9%). The variables with the lowest rating for concern wa
s  
fiutility limitationsfl (n=5; 8.8%) and fisecurity issuesfl (n=4; 7.0%). Other conce
rns 
indicated by respondents included fiwildlife destruction to the gardenfl (n=3) and fip
atient 
 45  accessfl (n=1). The range of concern values averaged from 2.60-3.63, and all variables 

had standard deviations above 1.1. A ranking of these variables can be found  on Table 

11.  Finally, a series of questions asked respondents to provide demographic data to 
better understand the survey population.  
Likelihood of advocacy. When asked if their workplace was provided with a 
series of comprehensive plans, design details, and guidelines for their faci
lity to use, 
would the 58 respondents be more inclined to become an advocate for therapeutic 

landscapes in healthcare settings. Of the population that agreed, 77.8% (n= 42) said the
y 
would become an advocate for a therapeutic garden and 22.2% (n= 12) said they would 

not become an advocate. The most common reasons for not being a therapeutic garden 

advocate were cited as fitoo costly to implement,fl filack of time,fl and filack 
of 
commitment and interest by administration.fl  
Age. The average age of the respondents was 46 years old (sd=13.37). The 
youngest person was 24 and the oldest was 73. 
Gender. 84.5% (n= 49) of the population was female and 15.5% (n= 9) was male 
(N= 58). 

  Professional Fields. The respondents™ were asked to report their professiona
l field 
of work (N=55). Answers were grouped into fields to make up the following group  

identities:   

  Group 1 Administration: administrators, owners, coordinators, accountants 
(n=12; 21.8%).  
Group 2 fiHands-Onfl Care Givers: nurses, aides, speech and language 
 46  pathologists, recreational therapists, occupational therapists, physical 

therapists (n=30; 60.0%).  
  Group 3 fiClinicalfl Care Givers: physicians, social workers, dietitians, 
     
  psychologists/psychiatrists (n=7; 12.7%).  
Group 4 Building Staff: maintenance supervisors, linens/laundry managers,  
   maintenance/janitorial staff, grounds staff, kitchen staff (n=3; 5.5%). 
Professional Education Degrees. The respondents were asked to report their 
professional degrees in the survey. Answers were grouped into Associate, Bachel
or™s, 
Master™s, PhD, and multiple degrees. Of the 51 respondents who responded with this 

information, two had Associate Degrees (3.9%); thirty-nine had Bachelor™s D
egrees 
(76.5%); seven had Masters Degrees (13.7%); three had PhDs (5.9%). 
Workplace Type. The respondents™ were asked to report their type of workplace. 
Answers were grouped into three groups: Group 1: Hospital (hospitals, private clinic
s, 
and multi-service clinic); Group 2: End-of-Life Care (hospice, nursing home, and ass
isted 
living); Group 3: Extended-Stay Clinic (rehabilitation centers, independent living
, and 
adult foster care).  The breakdown of those that responded with this information (N=57), 

Group 1: Hospital = 8 (14.0%); Group 2: End-of-Life Care= 45 (79.0%), Group 3: 

Extended Stay Care= 4 (7.0%). 

  Department. The respondents (N=53) were asked to report their assigned 
department. Answers were grouped into three groups: Group 1: Administration = 11  

(20.7%), Group 2: Healthcare Professional = 36 (67.9%), Group 3: Building Staff = 6  

(11.3%). 

  Years at this institution.  The 57 survey participants answering this ques
tion  
 47  ranged in value from 1 to 50 years at their current place of employment. The
 average  
number of years at their current place of employment was 7.86 years of work; the
 standard deviation was 9.75 years. 

  Years of service in current profession. The 57 survey participants answering
 this 
question ranged from 1 to 49 years in their current profession, plus or minus 10.9 years  

(standard deviation). The average value was 14.33 years of work. 

  Length of working hours per week. Participants (N=58) answering this questi
on  ranged from 8 to 90 hours worked per week, plus or minus 10.46 hours (standard  

deviation); the average number was 41.12 hours per week of work. 

 Study Update Card Returned with Survey? All participants (N=58) were given t
he 
choice to request a study update upon completion of the project. Eleven (19.0%) 

responded fiyesfl while 47 (81.0%) did not return a card. 

Correlations (Cross-Tabulations) 

 
 In order to answer the main questions posed in the aims of this study, a series of 

cross tabulations were preformed to understand the statistical correlation, if
 any, between 
select variables.   

 Respondent™s perceived frequency of agreement on barriers to therapeutic 
gardens at their place of work as well as prior knowledge of the characteristics of 
therapeutic gardens (N=58)
. No perceived barrier to therapeutic gardens was found to 
have a statistically significant correlation with a respondent™s prior knowled
ge of such 
gardens (Table 12). 

 Respondent™s perceived frequency of agreement on barriers to therapeutic 
gardens at their place of work as well as the socio-demographics of the respondent 
 48  (N=58).
 There appeared to be strong correlations between the age of a respondent and 
several variables relating to perceived barriers to having a therapeuti
c garden in a health 
care setting.  Some of these correlations included: filack of knowledge about patie
ntsfl 
(p=.010). for respondents in the 31-40 (n=9; 16.4%) and the 51-60 (n=9 16.4%) year age 

groups;. filack of knowledge about family appreciationfl and respondents at 31-40 (n=9; 

16.4%) year old (p=.004); filack of published health-benefit information in reputable 

medical journalsfl and respondents in the 51-60 (n=14; 25.6%) age group (p=.022); filack 

of advocatesfl for garden areas for respondents 51-60 (n=14; 25.6%) year olds (p=.034). 

Table 13 lists all of the other correlations found between age and perceived barriers
 by 
respondents. 

 Respondent™s perceived frequency of agreement on barriers to therapeutic 
gardens at their place of work and the professional field of the respondent (N=58).
 The 
only barrier that had a statistically significant correlation with the prof
essional field of the 
respondent was filack of time in work schedulesfl (p=.013). Of the 55 respondents for this 

question, 16 (29.0%) respondents in the administrator group view a lack of time as a 

barrier (Table 14). 

 Respondent™s perceived frequency of concerns about therapeutic gardens at their 
place of work and prior knowledge of the characteristics of therapeutic gardens (N=58).
 No variables addressing possible concerns about therapeutic gardens were f
ound to have 
a statistically significant correlation with a respondent™s prior knowled
ge of such gardens 
(Table 15). 

 Respondent™s perceived frequency of concerns about therapeutic gardens at their 
place of work and the socio-demographics of the respondent (N=58).
 Only two socio-
 49  demographic variables had a statistically significant correlation; those
 included the age of 
the respondent and fimaintenance costsfl (p=0.013 for respondents 51-60 years old; n=14; 

25.5%) and fiseasonal usagefl (p=.038 for respondents 51-60 years old; n=11; 20.0%). 

Table 16 lists this data. 

 Respondent™s perceived frequency of concerns about therapeutic gardens at their 
place of work and the professional field of the respondent (N=58).
 A variable of concern 
that had a statistically significant correlation with the professional fie
ld of the respondent 
was fisafety issuesfl (p=.032); building staff (n=3) rated this concern fihigh t
o very highfl, 
while hands-on care givers (n=10; 18.2%) and administrators (n=9; 16.4%) rated this 

issue filow to very lowfl as a concern (Table 17). 

 Respondent™s perceived frequency of improvements caused by therapeutic 
gardens at the respondent™s place of work and their prior knowledge of the 
characteristics of therapeutic gardens (N=58
). None of the variables listed as possible 
fiimprovementsfl in patient care and supported by therapeutic gardens were found to have 

a statistically significant correlations, with a respondent™s prior knowle
dge of such 
gardens (Table 18). 

 Respondent™s perceived frequency of improvements caused by therapeutic 
gardens at their workplace and the age of the respondent (N=58).
 Improvement variables 
that had a statistically significant correlation with the age of the responde
nt included 
fimarketing advantagesfl (p=.013), fithe environmentfl (p=.004), and figeneral appearanc
efl 
(p=.006); these correlations occurred in the 51-60 age group.  Respondents who were 31-

40 (n=11; 20.0%) year olds, thought figeneral appearancefl was a statistically s
ignificant 
improvement (Table 19). 
 50   Respondent™s perceived frequency of improvements caused by therapeutic 
gardens at their place of work and the professional field of the respondent (N=58).
 The 
professional field of the respondent appeared to be statistically correlated 
for several 
variables.  These included figeneral appearancefl (p=.039) and fithe environmentfl 

(p=.029), with 100.0% of the building staff (n=3) and the clinical staff (n=8) indicating 

that a therapeutic garden was filikelyfl to fivery likelyfl to make an impr
ovement in the 
health care facility (Table 20). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  51  CHAPTER VI 
 DISCUSSION & CONCLUSION  
 
 This chapter summarizes the most salient findings from the data and draws some
 
conclusions and recommendations for future study.  
fiAim 1fl sought to find if there was a strong consensus among health care workers 
as to what constitutes a therapeutic garden. There was strong overall agree
ment with the 
definition of a therapeutic garden, which initiated the survey activity. This is s
ignificant 
to the study because a general consensus with the meaning and application of the 

definition focuses the respondents on this type of garden and eliminates confusion 

between a therapeutic garden and common gardens or green space. While all lands
cape 
types have proven to be beneficial to health and wellbeing in various capacities
, the 
therapeutic garden definition helps to clarify purpose related to treatment 
outcomes in 
healthcare. Over half (65.5%, n=38) the responding population strongly agreed and 

another 27.6% (n= 16) agreed with the definition (Table 2). This data is encouraging 

because the first step in increasing the acceptance of, and benefit provided by
, a 
therapeutic garden in healthcare settings is the education of the healthcare
-providing 
sector.  
Additionally, the very high occurrence of prior knowledge (Table 3) about 
therapeutic gardens (82.8%, n=48) also is very encouraging and suggests that healt
hcare 
professionals presently are aware of the concept that nature can be used in conjuncti
on 
with traditional medicine to achieve a higher rate of positive patient treat
ment outcomes. 
Because of the high agreement with the definition and the amount of healthcare 

professionals indicating that they have a prior knowledge of such spaces, it is 
not
 felt that 
 52  these areas will pose a barrier to therapeutic landscapes in healthcare set
tings. 
As expected, more healthcare locations reported an absence of a therapeutic 
garden (Table 4). What was not expected was that 43.1% (n=25) of locations 

participating in the survey had a therapeutic garden at their facility. How
ever, the 
researcher did not physically visit and assess each location; this fact wil
l remain a 
weakness in the data set.  Because of this fact, it is difficult to confidently 
report the 
accuracy of the presence of a therapeutic garden even when indicated by survey 

respondents. What is significant about the reported presence of therapeutic gardens is t
he 
perception of the respondent that gardens and landscapes at their work places were
 
thought to be a therapeutically beneficial and useful space for patient care.  
fiAim 2fl of this study asked if prior knowledge of a therapeutic garden at a 
healthcare facility influences staff perceptions of benefits, barriers
 and/or appropriate use 
for different patient populations based on current treatment protocols and intended 

outcomes. Data collected about various patient types using the garden in the presence
 of 
an 
existing
 space showed that certain patient groups are perceived to be more likely to 
use the garden than other patient groups. For example, the Orthopedic and Cardiac Care
 
patients are about 6% likely to use the garden compared to the 40% and 50% likely use 

by dementia and long term care patients, respectively (Table 5). The liter
ature supports 
the use and the derived benefit of therapeutic landscape exposure for all four patie
nt 
groups, but clearly some groups are perceived to be underutilizing the spaces. This
 may 
be due to the perceptual view of therapeutic garden use as a fipassive-palliati
ve care 
experiencefl rather than fiactive-rehabilitative care experiencefl.  Ps
ychiatric patients have 
a long history of being associated with healthcare facilities that value 
the outdoors as seen 
 53  with the asylum design of the late 19
th
 and early 20
th
 centuries. Oncology care patients, 
who were perceived to have limited use of the existing therapeutic gardens (n=
1 among 
respondents), are reported to be good candidates for using therapeutic gardens (as 

reported in the literature).  Both of these patient groups also have potential to experie
nce 
the garden in a reflective, non-structured manner.  Meanwhile, cardiac and stroke 

rehabilitation treatment protocols easily could be accommodated in a therapeut
ic garden 
with appropriate design, including dedicated fiwork-out stationsfl or use areas crea
ted for 
therapies commonly found in their rehabilitation facilities (e.g., for stationa
ry bicycles, 
etc.) 
The survey populations without an existing garden were asked to fithink about an 
idealized therapeutic gardenfl; in this group, respondents anticipated that all pati
ent 
groups would use the garden at a much higher frequency than those patient groups 

currently having physical access at other facilities having an existing
 garden (Table 7). 
The three patient groups that reported low use in the existing gardens--orthopedi
c, 
oncology, and cardiac care--also were reported to have lower use in the idealiz
ed garden; 
however the anticipated frequency of use for these groups was higher as report
ed by the 
survey population without a garden in their workplace. In the cases of psychological a
nd 
dementia care, the frequency of high use surpassed the frequency of low use. This 

suggests that when thinking about an 
ideal
 therapeutic garden, healthcare professionals 
are more receptive to the use of the garden by different patient groups compare
d to 
patient groups in locations with 
existing
 gardens and who may be experiencing 
undocumented difficulties with patients in their gardens. 
Concerning the frequency of staff interaction with patients in locations with a
 
 54  therapeutic garden, it was clear that non-medical personal were most likely 
to have 
interaction with patients in the therapeutic garden. High use by family, 41.7% (n=
24), in 
existing gardens and 58.8% (n=34) in the idealized perceptual gardens, is expected w
hen 
compared to the high-perceived improvement in various positive attributes that a garde
n 
would have on visitor satisfaction (Tables 6-9). The very low potential that fia lac
k of 
family appreciationfl ranked as being a barrier to therapeutic gardens se
ems to indicate 
that family members are perceived to have a high appreciation for a therape
utic garden at 
a health care site (Table 10). The low instance of nurses and doctors using the gar
den 
with patients in both the idealized and existing therapeutic garden reflects the
 fact that a 
filack of time in schedulesfl is a significant barrier as is fihigher priori
ties for staff timefl 
for these groups in most institutional settings. This is understandable as these 

professionals are most likely to have more responsibilities throughout the workday
 that 
would interfere with time spent in a garden with their patient population. Therapist 

professionals remained equally likely to use the garden with their patients in both 

scenarios (Tables 6 and 8). It is thought that this could be due to the nature of 

responsibilities a therapist has with various patient groups. Physical and Occupa
tional 
Therapy, combined with other alternative and complementary medicines, such as 

horticultural therapy, has been found to be possible and highly beneficial to patients whe
n 
preformed outdoors.  
There were no valid correlations between the presence of perceived barriers
 and 
the prior knowledge of a therapeutic garden (Table 12).  
fiAim 3fl was directed at what concerns medical staff express when asked to 
identify barriers to garden use for different patient groups irrespective of the
 presence or 
 55  absence of a therapeutic garden at the workplace.  Tables 10 and 11 show that there was
 a 
general lack of consensus on what poses as potential barriers and concerns betw
een the 
groups that had or did not have a therapeutic garden. This in and of itself is a barrier to 

the implementation of therapeutic landscapes and gardens in healthcare setting
s. No valid 
correlations were found between the presence of perceived concerns about thera
peutic 
gardens and the prior knowledge pertaining to therapeutic gardens (Table 15).  It 
was 
hoped that those professionals whose facilities did include a therapeutic garden would 

have more decisive opinions on the topic of therapeutic gardens, but they did not.  

 fiAim 4fl looked to determine whether socio-demographics and/or the educational 

training of medical staff influence perception relating to therapeutic gar
dens for use with 
different patient populations. The correlations about possible barriers or concer
ns and the 
set of socio-demographic variables that had statistically valid correlat
ions (i.e., a Pearson 
Chi-Square test indicated a p value at the scientifically accepted level of p
=0.05) were 
filack of patient knowledgefl and filack of knowledge about family appreciationfl (
Table 
13). The 31-40 and 51-60 year old groups felt strongly that these two potential barriers 

would not affect therapeutic landscape use. It appears that respondents in the above a
ge 
groups have been in their respective professional practices for a length of ti
me long 
enough to allow them to be comfortable with their patient groups. They also have had 

more first-hand experience with family members and appear to know this group™s
 needs 
as well. It is unclear why the other age groups did not also strongly disagree wit
h these 
variables being barriers. A filack of published informationfl, filack of advocacy
 groupsfl 
and filack of appropriate patient to staff ratiosfl were viewed by 51-60 year 
olds as being a 
barrier (Table 12). A possible cause for this could be that members of this age gr
oup,  56  being the more experienced and educated professionals, place a higher value on juri
ed 
publications and work experience to gain understanding and knowledge about an 

unfamiliar topic and then apply it to their respective work environments.  A filack of tim
e 
in work schedulesfl and fiall-weather equipmentfl was felt by the 31-40 year olds to be t
he 
strongest barriers. This age group represents professionals who are likely
 to work full 
schedules, raise a family, while also beginning to take on other professional roles
 such as 
administration.  It is unclear as to why even younger professionals would not have a 

similar perception about time constraints and the lack of all-weather equipme
nt (Table 
13). 
Concerning the correlation between perceived barriers and the socio-demographi
c 
of a respondent, there were significant correlations. Perceived barriers
 to therapeutic 
gardens, (Q7) were shown to exist most strongly in medical staff ages 41-50 y
ears old.  
The only statistically valid correlation between the professional field of a
 
respondent and the agreement on a barrier to therapeutic gardens occurred for the 

variable filack-of-time in work schedulefl (Table 13). Among administrators, 29.0% 

(n=16) there was strong agreement that this was a barrier. Administrator
s are responsible 
for the proper hiring and staffing of healthcare professionals. Members of this
 work force 
could view the addition of a therapeutic garden as an unnecessary addition to the alre
ady 
rigorous and demanding norms of healthcare protocols. The fact that therapeutic garde
ns 
are features that do not currently include a set of reliable and valid performance 

standards-- based on medical outcomes that are recognized by medical profess
ionals for 
different patient groups--may be a factor as well. The group that felt the sec
ond strongest 
about filack of timefl being a barrier were the ficlinicalfl medical profe
ssionals. This group 
 57  consisted of physicians, psychologists, and other specialists, many of whom do not
 
traditionally spend large amounts of time performing fihands-on carefl for patie
nts. These 
professionals often rotate among numerous patients of different care groups. There
fore, 
they might find it difficult to devote time during their day to incorporate therapeuti
c 
garden visits with their patients into the traditional role of the health care provi
der. The 
fihands onfl medical professionals were split on filack of timefl being a barrier. Thi
s could 
be due to institutional settings, the different specializations in this group of prof
essionals, 
and/or the patient groups these nurses, aides, and therapists deal with daily at t
heir 
workplace.  
Concerning the correlation between perceived barriers and the professional f
ield 
of a respondent, there were correlations. There are perceived barriers that a
ffect the 
implementation and use of therapeutic gardens in healthcare settings that a
re significantly 
influenced by the professional field of the medical staff, but is limited to the va
riable 
described as filack of time in work schedulesfl. 
The data suggests that the filack of patient knowledgefl and filack of family 
appreciation knowledgefl are two variables with the lowest barrier potential.
 This is 
expected considering that 72.7% (n= 40) of the survey population is identified as a 

professional caregiver, and 21.8% (n= 12) are identified with being in healthcare 

administration. In particular, these are two professional groups that are e
xpected to have 
the highest level of knowledge about patients as well as have the highest level of 

interaction with families of patients on a regular basis.  
Age and concern about maintenance costs (p=.013) and seasonal usage (p=.038), 
show that a statistically valid correlation is present (Table 16). Those respo
ndents 51 to 
 58  60 years old had the highest concern (n=14; 25.5%) about maintenance costs. This age 

group also had the highest level of concern for seasonal usage (n=11; 20.0%). Overall, 

regardless of the p value, the highest areas of concern across the age groups includ
ed 
safety issues
 for 21-30 year old professionals, 
maintenance costs
 for 31-40 and 51-60 
year olds, and 
seasonal usage and maintenance
 concerns for those in the 71-80 year old 
professional group.  The 41-50 year old group did not have a strong level of concern for 

any particular variable. 

 A respondent™s professional field and the level of concern that a variable 

exhibited in relation to the addition of a therapeutic garden in a healthcare setting
 was 
seen only in the topic of fisecurity issuesfl (Table 14). Group 4: Building Mainte
nance 
(n=2; 66.7%) rated this as a high concern. In many cases, it may be the responsibilit
y of 
the building staff to maintain or ensure the proper security of a new, external
, use area. 
Conversely, Group 1: Administration professionals (n=9; 16.4%), Group 2: fiHands-Onfl 

healthcare professionals (n=10; 18.2%), and Group 3: fiClinical Carefl healthcare 

professionals (n=6; 10.9%) rated this concern filowfl to fivery lowfl.  For these t
hree latter 
groups, overall barriers (Table 10) and concerns (Table 11) relating to therapeuti
c 
gardens tended to focus on fitime commitment and fifinancial dedicationfl. 
Looking at the overall improvements made to a healthcare facility due to the 
inclusion of a therapeutic garden (Table 9), it was clear that all suggested var
iables are 
likely to be viewed as fian improvementfl to the healthcare facility. Mean values
 for 
variables that dealt with the environment (x=4.57), visitor satisfaction (x=4.36), and 

general appearance (x=4.59) of the workplace were rated as having the highes
t potential 
for improving the facility. Overall perception of improvement in the area of marke
ting 
 59  advantage also was high. This perception is important because future therapeutic
 gardens 
will depend on these gardens being seen as financially viable by all stakehol
ders in the 
healthcare delivery system.  
The suggested improvement in fistaff satisfactionfl received a mean value of x= 
3.86 in filikelihood for improvementfl. While this value is above the average, this average 

value was lower than the aforementioned variables and raises questions as to why t
he 
healthcare professionals participating in this survey would not include themselve
s in the 
population that would fivery likelyfl benefit from a therapeutic garden. Perhaps it is
 a 
result of a lack of time.   
No significant relationships between the incidence of perceived improvements 
caused by the presence of a therapeutic garden and the prior knowledge of a the
rapeutic 
garden were found (Table 18).  
The correlations asking about likelihood of therapeutic gardens providing an 
improvement and the socio-demographics of the respondent supported several 

statistically valid correlations (Table 19). Data indicating an improveme
nt in variables of 
marketing advantages, the environment, and general appearance of the workplace do 

have a significant relationship with certain socio-demographic variables in a
 population 
of healthcare workers. A therapeutic garden was seen by 30.1% of 51-60 year olds a
s 
being able to provide an improvement to the marketing advantage of the facility, al
ong 
with the environment and the general appearance of the facility. It is reasona
ble for this 
age group to agree these variables would be enhanced. These professionals are most
 
likely those practicing the longest, and know the importance of facility appearan
ce to 
customers. It is unclear, however, why the 32-40 year olds selected only general
 
 60  appearance as a benefit of the garden (to the exclusion of marketing advantage and 

environmental improvements).  
The professional field of the respondent also had a significant relationship with 
improvements in the environment (p=.029) and the general appearance (p=.039) of a 

location (Table 20) for clinical health professionals and building staff.  It is 
unclear what 
made these two groups feel so strongly while other groups of respondents ranked these
 
two variables as less likely to occur.  

Study Limitations
 While this study was exploratory, there were limitations that future projec
ts could 
address. First, the limited participation in the survey is indicative of the over
all lack of 
understanding and communication between the professional fields of medicine and 

design. Healthcare professionals are slow to recognize the importance of the bui
lt 
environment to overall patient and staff health and well-being, unless a major des
ign flaw 
disrupts daily operations.  However, the incremental decisions made by hired design 

professions affect every aspect of the functional utility and aesthetic
 appeal of their 
workplace.  In this study, over fifty mid-Michigan healthcare providing facil
ities were 
contacted about this study, and solicited for feedback that could improve the outdoor 

spaces surrounding their workplace. These facilities ranged in size from
 small, privately 
owned hospices, medium extended-stay clinics, and large regional hospitals. Only el
even 
facilities chose to participate. Within those eleven facilities, over 300 healthc
are workers 
were identified as being possible survey respondents; from this population, only 58 

completed and returned usable surveys. Limitations resulting from the small sa
mple size 
and response rates resulted in disproportional responses for some categories of workpl
ace 
 61  types and professional fields. Low response rates meant the data had to be condens
ed into 
smaller, more general populations to achieve measurable statistics. By doi
ng this, the 
study was not able to fully address perceived barriers specific to individual pr
ofessional 
fields or workplace types. It would be beneficial to conduct the survey on a larger, 

statewide or national level, by using electronic survey systems to distri
bute the surveys. 
The survey could also have been improved if the following changes occurred in 
its structure and administration. For future studies of this nature, prior to survey 

distribution, reconnaissance to a study location could be conducted to decide if the 

location has a therapeutic garden setting that adheres to the definition of such gar
dens as 
set by this study. Such a visit also would provide an opportunity to personally solicit 

involvement of the staff in the survey.  Survey results could then be checked for validity 

and reliability of data provided by respondents in regard to actual therapeutic gar
dens in 
the health-care settings (i.e., employee ratings of their garden space could t
hen be 
compared to the ratings of the researcher).  Because the survey questions addres
sed two 
possible conditionsŠperceived and actual gardensŠthe split in questions could have 

affected the ability of the respondent to accurately answer the desired intent
 of the 
question.  
Finally, the research team had intended to determine the likelihood of therapeutic 
gardens to improve fithe environmentfl in the sense of the natural surroundings and 

microclimate. However, since this distinction was not clearly made in the w
ording of the 
survey, it cannot be assumed that all respondents thought the same way as was intende
d. The responses to this question may include the entire fibuilt environmentfl on the grounds 

of their work place when considering their responses.  
 62  Conclusion  

 There was found to be a strong consensus among healthcare workers as to what 

constitutes a therapeutic garden in the healthcare setting based on the given de
finition by 
Westphal (2009) and Gerlach-Spriggs and Healy (2009) (Aim 1). This is encouraging as 

it is imperative to have agreement between those in the health care and design indust
ries 
to facilitate the proper implementation of therapeutic gardens and to establi
sh 
performance standards for such gardens. 

 The second aim of this study was to see if prior knowledge of therapeutic gardens 

had any influence on staff perceptions of appropriate use, barriers, and/or concerns fo
r 
such spaces.  No significant relationships existed between prior knowledge of the
rapeutic 
gardens and perceptions of health improvements afforded patients by the presence o
f the 
garden. Likewise, there was no correlation between prior knowledge and possible 

concerns or barriers to having such a garden in the healthcare environment. No 

correlation between these variables and the healthcare worker™s prior knowledge
 shows 
that regardless of a respondent™s prior knowledge they already formed opinions
 about 
therapeutic gardens. What this means to the success of future therapeutic gardens i
s that 
greater efforts to educate health care workers about such spaces (and exposure
 to 
thoughtfully designed gardens) can have a positive impact on health professionals 

regardless of whether they knew or heard of such spaces prior to the exposure. 
This study also found that many perceived barriers to therapeutic gardens exis
t in 
healthcare settings among staff, and many of these barriers are relat
ed to the function of 
the workplace. Specifically, the variable relating to the fiamount of timefl that s
taff could 
spend with patients in the garden always was viewed significantly higher than m
ost other 
 63  variables. Likewise, the allotment of funds to support a therapeutic garden gener
ated 
strong concerns over the actual or perceived monetary demands that a garden would 

create. Acknowledging that monetary limitations are always present in heal
thcare 
settings, the future success of therapeutic gardens will require accurate a
nd reliable data 
gathering on the costs and benefits associated with these gardens. This can be obt
ained 
from healthcare facilities that currently have therapeutic gardens. Thes
e costs must 
include the creation, maintenance, and use of these outdoor spaces, and they must be tied 

to patient outcomes, and staff/family satisfaction within the healthcare s
etting. Having 
hard data to underpin the costs and benefits of these gardens will insure that the economic 

realities of the marketplace are included in any decision affecting a ga
rden. Work by 
Ulrich (2006) suggests, that the economic benefits generated by therapeutic ga
rdens in 
large regional hospitals far outweigh the initial cost of construction and long-te
rm 
maintenance through customer satisfaction and repeat visitation.  However, simi
lar 
research on the cost-benefits of therapeutic gardens in smaller, more focused he
alth care 
facilities to date has not been done, and this presents a unique opportunity for future 

research. As a landscape architect, or any design professional, looking to posi
tively affect 
measurable health-outcomes for a variety of patient groups, staff, and familie
s, it will be 
necessary to address these deficits (Aim 3).  
What was perhaps the most interesting finding was that ‚a lack of all-weath
er 
equipment™ for use with patients in the garden was perceived to be the biggest barrie
r of 
all tested variables. This suggest that if there were all-weather options e
asily accessible or 
installed at the medical facility that the therapeutic garden would be a more via
ble option 
for patient use. If future collaborations between healthcare equipment manufa
cturers, 
 64  healthcare design professionals and the medical community were to take place
, the result 
could be a more holistic and functional therapeutic garden environment. 
The study also showed that all variables for possible areas of improvement to the
 
healthcare setting could see a positive improvement with the presence of a thera
peutic 
garden. Each variable for improvement received an average score of 3, meaning a 

therapeutic garden is over 50% likely to improve the variable in question. What is 

suggested by this data is that the respondent intrinsically knows that therapeut
ic garden 
space will be an improvement to the environment and the general appearance of the 

healthcare setting, as well as to the general health of patients, staff a
nd visitors. This idea 
follows what the literature says about the human perception of health and nature. 

 The professional group thought most likely to be a prime advocate group (as 

found in this study through the combination of variables indicating low concern, streng
th 
of barrier, and high occurrence of variable-induced improvement) would be the 

healthcare professionals from Group 2: fihands-onfl medical professionals. These 

professionals will likely be between 21-40 or 51-70 years old; they are more likel
y to be 
employed in a workplace type classified as Group 1: A Hospital setting that c
urrently has 
a therapeutic garden installed. A secondary advocacy group would consist of 

professionals from Group 3: ficlinicalfl medical professionals working in a workpl
ace 
type classified as Group 2: End of Life Care.  Age was an intervening variabl
e that 
proved significant in this study. The most likely socio-demographic segment to s
erve as 
advocates would be in the age ranges of 21-40 and 51-70 years old, in a location that 

currently has a therapeutic garden installed. This group may have even stronger a
dvocacy 
potential, if further education were provided on garden history, application, and 
 65  documented benefits. Continuing medical education workshops and journal articles are 

likely outlets for disseminating this information (Aim 4).   
The ultimate lesson learned from this study is research, that enhances the va
lidity 
and reliability of therapeutic site design to achieve predictive outcomes, am
ong the 
various user groups in a garden is essential if both fields, landscape architec
ts and 
medical professionals, hope to optimize the benefits of this feature in the workplace
. This 
type of work is needed if any advancement in installation and utilization of thera
peutic 
gardens in healthcare settings is to occur. Continued interaction between design a
nd 
healthcare professionals through post-occupancy evaluations and continuing education 

requirements for both professional groups will insure that designed space evolves ove
r 
time, just as changes in personnel and/or treatment protocols evolve within healthcare 

settings.  In this manner, both the designer and the medical professional remain infor
med 
and important advocates for garden use as they seek desired health outcomes for t
heir 
clients and patients, respectively. 
 
 
 
  
 
 
   66   
 
 
 
 
 
 
 
 
 
 APPENDICES  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  67   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  APPENDIX A 
 Cover Letter and Survey 
 68    69    70    71    72   
 
 
 
 
 
 
 
 
 
 APPENDIX B 
 Tables of Statistical Analysis 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
   73
Table 1.
  Name and location of eleven health care facilities located in mid-Michigan tha
t participated in the study along with a profile 
of the vocations of responding health care workers.                             
                    
               

Name of Facility    Location of Facility   Vocations of Healthcare
 Workers   
 
1) Delta Retirement Center  Lansing, Michigan   Office Manager, A
ctivities Director, Nurse 
 
2) Wynwood of Meridian  Haslett, Michigan   Administration 

 
3) Prestige Pines   Dewit, Michigan   Executive Director 

 
4) Craft Care Homes   Holt, Michigan   Administration, Accounting 

 
5) Capital Health & Rehabilitation Lansing, Michigan   Special Educa
tion, Admissions, Dietitian, House Keeping, 
Physical Therapy, Nursing, Occupational Therapist, 

Maintenance Supervisor 
 
6) Okemos Health Rehabilitation Okemos, Michigan   Maintenance Supervisor,
 Nurse Aid, Nurse,  
Physical Therapist, Occupational Therapist 
 
7) Holt Senior Care &Rehabilitation Holt, Michigan   Administration, Nurs
e, Psychology  
 
8) Pines Healthcare   Lansing, Michigan   Recreational Therapy, N
urse, Internal Medicine (D.O.) 
     

9) Ingham County Medical Care Okemos, Michigan   Social Work, Nurse, Dietit
ian, Maintenance Supervisor,  
          Administration, Art/Recreational Therapist,  

          Human Resources, Internal Medicine (D.O.),  

          Internal Medicine (M.D.) 

 
10) Bircham Hills Retirement  East Lansing, Michigan  Recreationa
l Therapist 
  74
Table 1 (cont™d.).
  Name and location of eleven health care facilities located in mid-Michiga
n that participated in the study along with 
a profile of the vocations of responding health care workers.                              
           
               

11) McLaren Hospice Services Flint, Michigan   Nurse, Internal Medicine
 (D.O.), Bereavement/Spiritual  
          Counseling, Social Work, Psychology 

  75
Table 2.
  Responses to Question 1: Agreement with the Definition of Therapeutic Garden (N=58)
.          
 
       Range of Agreement  
   

   


      1              2                   3                    4                       5 

  Frequency 
Percent 
Valid Percent 
Cumulative Percent 
Valid 
1 
2 3.4
 3.4
 3.4
 3 
2 3.4
 3.4
 6.9
 4 
16
 27.6
 27.6
 34.5
 5 
38
 65.5
 65.5
 100.0
 Total 
58
 100.0
 100.0
   
Table 3.
  Responses to Question 2: Prior Knowledge of Therapeutic Gardens (N=58).                                       
 
  Frequency 
Percent 
Valid Percent 
Cumulative Percent 
Valid 
1 Yes 
48
 82.8
 84.2
 84.2
 2 No 
9 15.5
 15.8
 100.0
 Total 
57
 98.3
 100.0
  Missing 
3 NR 
1 1.7
   Total 
58
 100.0
    
  76
Table 4.
  Responses to a given definition of a fiTherapeutic Gardenfl at a respondent™s workpl
ace. (N=58).     
 
  Frequency 
Percent 
Valid Percent 
Cumulative Percent 
Valid 
1 Yes 
25
 43.1
 46.3
 46.3
 2 No 
29
 50.0
 53.7
 100.0
 Total 
54
 93.1
 100.0
  Missing 
3 NR 
4 6.9
   Total 
58
 100.0
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  77
Table 5.
 Respondent™s perceived frequency of garden use for different patient groups at plac
es of work having a therapeutic garden 
(N=25).                  
 
Patient User Group     Frequency of Garden Use     
     

    


        1              2                   3                    4                       5 

 
Psychiatric Care (N=23) 3 (13.0%) 4 (17.4%) 4 (17.4%) 4 (17.4%) 8 (34.8%) 

 
Orthopedic Care (N=22) 7 (31.8%) 3 (13.6%) 5 (22.7%) 1 (4.5%) 6 (27.3%) 

 
Hospice Care (N=22)  3 (13.6%) 3 (13.6%) 8 (36.3%) 7 (31.8%) 1 (4.5%) 

 
Oncology Care (N=22) 7 (31.8%) 1 (4.5%)  5 (22.7%) 1 (4.5%) 8 (36.3%) 

 
Cardiac Care (N=23)  6 (26.1%) 5 (21.7%) 5 (21.7%) 1 (4.3%) 6 (26.1%) 

 
Dementia Care (N=24) 1 (4.2%) 2 (8.4%) 9 (37.5%) 8 (33.3%) 4 (16.7%) 

 
Other Care (N=4) 

 Long Term Care (n=2)      2 (100%) 

 Garden Club (n=1)       1 (100%) 

 Rehabilitation Care (n=1)      1 (100%)      

 
 
 
 
 
  78
Table 6
.  Respondent™s perceived frequency of garden use for patients and non-patients at pla
ces of work having a therapeutic garden 
(N=24).                  
 
Staff User Group     Frequency of Garden Use     
     

                      
˘˘ˇ˘
ˇ˘
          1                  2                    3                    4                     5                 Mean (x)      St. Dev. 

 
Nurses (N=23)   10 (42.4%) 5 (21.7%) 5 (21.7%) 1 (4.3%) 2 (8.6%)       x=2.13  1.29 

 
Doctors (N=23)  20 (87.0%) 3 (13.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)       x=1.13  0.34 

 
Aids (N=24)   2 (8.3%) 4 (16.7%) 6 (25.0%) 7 (29.2%) 5 (20.8%)       x=3.38  1.25 

 
Family (N=24)  0 (0.0%) 1 (4.2%)  6 (25.0%) 7 (29.2%) 10 (41.7%)       x=4.08  0.93 

 
Therapists (N=22)  3 (13.6%) 2 (9.0%) 3 (13.6%) 10 (45.4%) 4 (18.2%)       x=3.45  1.30 

 
Other User (N=9) 

 Recreation Staff (n=6)        6 (100%) 

 Volunteers= (n=2)       2 (100%) 

 Case Managers  (n=1)       1 (100%) 

       

 
 
 
 
 
 
  79
Table 7.
  Respondent™s perceived frequency of garden use for different patient groups at pl
aces of work NOT having a therapeutic 
garden (N=32).                 
  

Patient User Group     Frequency of Garden Use     
     

    


        1              2                   3                    4                       5 

 
Psychiatric Care (N=30) 0 (0.0%) 0 (0.0%) 11 (36.7%) 12 (40.0%) 7 (23.3%) 

 
Orthopedic Care (N=30) 0 (0.0%) 7 (23.3%) 14 (46.7%) 5 (16.7%) 4 (13.3%) 

 
Hospice Care (N=33)  3 (9.0%) 3 (9.0%) 12 (36.4%) 13 (39.4%) 2 (6.1%) 

 
Oncology Care (N=30) 4 (13.3%) 0 (0.0%) 8 (26.7%) 11 (36.7%) 7 (23.3%) 

 
Cardiac Care (N=30)  3 (10.0%) 4 (13.3%) 14 (46.7%) 5 (16.7%) 4 (13.3%) 

 
Dementia Care (N=32) 0 (0.0%) 2 (6.3%) 10 (31.3%) 20 (62.5%) 0 (0.0%) 

 
Other Care (N=2) 

 Rehabilitation Care (n=2)      2 (100%)      

 
 
 
 
 
 
 
  80
Table 8.
  Respondent™s perceived frequency of garden use for patients and non-patients at pla
ces of work NOT having a therapeutic 
garden (N=24).                 
 
Staff User Group     Frequency of Garden Use     
     

    
˘˘ˇ˘
ˇ˘
          1                  2                    3                    4                     5                 Mean (x)      St. Dev. 

 
Nurses (N=32)   7 (21.9%) 9 (28.1%) 7 (21.9%) 4 (12.5%) 5 (15.6%)       x=2.72  1.37  

 
Doctors (N=31)  20 (64.5%) 6 (19.4%) 4 (13.0%) 0 (0.0%) 1 (3.2%)       x=1.58  0.96 

 
Aids (N=33)   1 (3.0%) 3 (9.1%) 7 (21.2%) 9 (27.3%) 13 (39.4%)       x=3.90  1.13 

 
Family (N=34)  1 (2.9%) 0 (0.0%) 6 (17.6%) 7 (20.6%) 20 (58.8%)       x=4.32  0.98 

 
Therapists (N=33)  1 (3.0%) 1 (3.0%) 8 (24.2%) 9 (27.3%) 14 (42.4%)       x=4.03  1.05 

 
Other User (N=14) 

 Activities Manager (n=6)      3 (50.0%) 3 (50.0%) 

 Therapeutic Recreation (n=4)      2 (50.0%) 2 (50.0%) 

 Social Services  (n=2)         2 (100%)      

 Volunteers (n=2)         2 (100%) 

 
 
 
 
 
 
  81
Table 9.
  Areas of landscape improvement at a respondent™s place of work regardless of havi
ng or not having a Therapeutic Garden 
(N=58).                  
 
Improvement Variable     Range of Improvement     
     

    
˘˘ˇ˘
ˇ˘
          1                  2                    3                    4                     5                 Mean (x)      St. Dev. 

 
Market Advantage (N=58) 0 (0.0%) 4 (6.9%) 5 (8.6%) 18 (31.0%) 31 (52.4%)       x=3.79  1.24  

 
Staff Satisfaction (N=58) 5 (8.6%) 4 (6.9%) 9 (15.5%) 20 (34.5%) 20 (34.5%)       x=3.86  1.13 

 
Patient Treatment  

Outcomes (N=58)  3 (5.2%) 5 (8.6%) 8 (13.8%) 23 (39.7%) 19 (32.8%)       x=3.86  1.13 

 
The Environment (N=58) 0 (0.0%) 1 (1.7%) 1 (1.7%) 20 (34.5%) 36 (62.1%)       x=4.57  0.62 

 
Daily Patient Care (N=58) 2 (3.4%) 4 (6.9%) 21 (36.2%) 19 (32.8%) 12 (20.7%)       x=3.60  1.00 

 
Visitor Satisfaction (N=58) 0 (0.0%) 4 (6.9%) 8 (24.2%) 9 (27.3%) 14 (24.4%)       x=4.36   0.85 

 
General Appearance (N=58) 0 (0.0%) 1 (1.7%) 2 (3.4%) 17 (29.3%) 38 (65.5%)       x=4.59   0.65 

 
Other User (N=1) 

 Spirituality (n=1)         1 (100.0%) 

          

 
 
 
  82
Table 10.
  Respondent™s perceived frequency on barriers to therapeutic gardens at their plac
e of work regardless of having or not 
having a therapeutic garden (N=58).               
 
Barrier Variable       Range of Agreement     
           

     


        1                 2                   3                    4                       5            Mean (x)(
rank
)       St. Dev.  
 
Lack of Knowledge about 

Plants (N=58)   7 (12.1%) 8 (13.8%) 15 (25.9%) 21 (36.2%) 7 (12.1%)       x=3.22 (
10
) 1.20  
 
Lack of Knowledge about 

Garden Maintenance (N=58) 4 (6.9%) 11 (19.0%) 20 (34.5%) 16 (27.6%) 7 (12.1%)       x=3.19 (
12
) 1.10 
 
Lack of Knowledge about 

Patient (N=58)   17 (29.3%) 20 (34.5%) 15 (25.9%) 5 (8.6%) 1 (1.7%)       x=2.19 (
15
) 1.00 
 
Lack of Knowledge about 

Family Appreciation (N=58) 16 (27.6%) 20 (34.5%) 18 (31.0%) 5 (8.6%) 1 (1.7%)       x=2.26 (
14
) 1.00 
 
Lack of Knowledge about 

Benefits: Cost  (N=58) 3 (5.2%) 9 (15.5%) 17 (29.3%) 20 (34.5%) 9 (15.5%)       x=3.40 (
8)  1.00 
 
Lack of Published  

Information in Health 

Journal (N=58)  6 (10.3%) 11 (19.0%) 16 (27.6%) 15 (25.9%) 10 (17.2%)       x=3.20 (
11
)  1.20 
 
Lack of Garden  

Performance  

Standards (N=58)  10 (17.2%) 9 (15.5%) 24 (41.4%) 9 (15.5%) 6 (10.3%)       x=2.86 (
13
)   1.20 
  83
Table 10
 (cont™d). Respondent™s perceived frequency on barriers to therapeutic gardens at t
heir place of work regardless of having or 
not having a therapeutic garden (N=58).              
 
Barrier Variable       Range of Agreement     
         

     


        1                 2                   3                    4                       5            Mean (x)(
rank
)       St. Dev.  
Lack of Garden/ 

Medicine Training (N=57) 6 (10.5%) 6 (10.5%) 16 (28.1%) 21 (36.8%) 8 (14.0%)       x=3.33 (
9)    1.10 
 
Higher Priorities for  

Capital Investments (N=57) 2 (3.5%) 3 (5.3%) 17 (29.8%) 18 (31.6%) 17 (65.5%)       x=3.79 (
5)    1.00 
 
Higher Priorities for  

Operating Budgets (N=57) 1 (1.8%) 4 (7.0%) 14 (24.6%) 21 (36.8%) 17 (29.8%)       x=3.86 (
3)     0.99 
 
Higher Priorities for  

Staff Time (N=57)  2 (3.5%) 6 (10.5%) 9 (15.8%) 22 (28.6%) 18 (31.6%)       x=3.84 (
4)     1.00 
 
Lack of Advocacy  

Groups (N=57)  2 (3.5%) 4 (7.0%) 18 (31.6%) 22 (38.6%) 11 (19.3%)       x=3.63 (
6)     0.99 
 
Lack of Time in 

Work Schedules (N=57) 0 (0.0%) 1 (1.8%) 18 (31.6%) 22 (38.6%) 16 (28.1%)       x=3.93 (
2)     0.82 
 
Lack of All-Weather 

Therapy Equipment (N=57) 0 (0.0%) 1 (1.7%) 2 (3.4%) 17 (29.3%) 38 (65.5%)       x=4.59 (
1)     0.65 
 
Lack of Knowledge about 

Patient:Staff  

for Safety (N=57)  0 (0.0%) 10 (17.5%) 18 (31.6%) 13 (22.8%) 16 (28.1%)       x=3.61 (
7)     1.00 
 84
Table 11.
  Respondent™s perceived frequency of concerns related to therapeutic gardens at t
heir place of work regardless of having or 
not having a therapeutic garden (N=58).              
 
Concern Variable       Range of Concern     
        

              
ˇˆ˙ˇˆ˙˝
˛˙˝˛˙
       1           2                   3                    4                       5            Mean (x)(
rank
)       St. Dev. 
 
Maintenance Costs (N=57) 5 (8.8%) 3 (5.3%) 15 (26.3%) 19 (33.3%) 15 (26.3%)       x=3.63 (
1)  1.19  
 
Staffing Costs to Work 

the Garden (N=57)  4 (7.0%) 7 (12.3%) 13 (22.8%) 16 (28.1%) 17 (29.8%)       x=3.61 (
2)  1.23 
 
Seasonal Usage (N=57) 5 (8.8%) 10 (17.5%) 14 (24.6%) 18 (31.0%) 10 (17.5%)       x=3.33 (
4)  1.21 
 
Liability Issues (N=57) 6 (10.5%) 8 (14.0%) 18 (31.6%) 18 (31.6%) 7 (12.3%)       x=3.21 (
5)  1.16 
 
Security Issues  (N=57) 14 (24.6%) 12 (21.1%) 14 (24.6%) 13 (22.8%) 4 (7.0%)       x=2.67 (
6)  1.20 
 
Safety Issues (N=57)  4 (7.0%) 7 (12.3%) 19 (33.3%) 17 (29.8%) 10 (17.2%)       x=3.39 (
3)  1.10 
 
Utility Limitations (N=58) 13 (22.8%) 14 (24.6%) 17 (28.9%) 8 (14.0%) 5 (8.8%)       x=2.60 (
7)  1.20 
 
Other Concern  (N=4) 

 Wildlife Destruction (n=3)        3 (100.0%) 

 Patient Access (n=1)         1 (100.0%) 

 
 
 
  85
Table 12.
  Respondent™s perceived frequency of agreement on barriers to therapeutic garde
ns at their place of work as well as prior 
knowledge of the characteristics of therapeutic gardens (N=58).       
    
 
Barrier Variable Q7           Knowledge Q2                                         Range of Agreement     
  

    

         

˚˙˛˜ 
!"
#$
         1                    2                   3             4               5   

 
Lack of Knowledge about Plants (N=58)                      p=.383     

       

Lack of Knowledge about Garden (N=58)                        p=.445 

   

Lack of Knowledge about Patient (N=58)                      p=.754 

     

Lack of Knowledge about Family Appreciation (N=58)             p=.822 

       

Lack of Information about Benefit:Cost (N=58)             p=.531 

   

Lack of Published Health-Benefit Information in Health Journals (N=58)       
      p=.521 
 
Lack of Garden Performance Standards (N=58)               p=.133 

            

Lack of Garden/Patient Training (N=57)                   p=.530 

    

Higher Priorities for Capital Investments (N=57)                 p=.873 

   

Higher Priorities for Operating Budgets (N=57)                  p=.976 

 
Higher Priorities for Staff Time (N=57)                    p=.560 
 86
Table 12
 (cont™d). Respondent™s perceived frequency of agreement on barriers to therapeuti
c gardens at their place of work as well as 
prior knowledge of the characteristics of therapeutic gardens (N=58).    
      
 
Lack of Advocacy Groups  (N=57)                           p=.505 

 
Lack of Time in Work Schedule (N=57)                    p=.881 

 
Lack of All-Weather Equipment for Outdoor  Therapy (N=57)             p=.630 

   

Lack of Knowledge About Patient:Staff For Safety (N=57)              p=.790 

   

         

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  87
Table 13
.  Respondent™s perceived frequency of agreement on barriers to therapeutic garde
ns at their place of work as well as the 
socio-demographics of the respondent (N=58).             
 
Barrier Variable Q7           Age (years) Q10a                                  Range of Agreement 
    

                         

˚˙˛˜ !"
#$
                    1                 2                   3             4                    5   

   

     

Lack of Knowledge
     21-30   5           2    2        1       0         
p=.010
 about Patients (N=55)
  31-40    3         6           2         0             0    
      41-50   3         4           2         0             0 

    51-60   3         6           7         3             0 

    61-70   2         1           1         0             0 

    71-80   0         1           0         0             1     

 
Lack of Knowledge
     21-30   5           2    3        0       0         
p=.004
 about Family  
 31-40    4         5           2         0             0    
Appreciation (N=55)
  41-50   3         2           3         1             0 
    51-60   2         4           9         4             0 

    61-70   1         2           1         0             0 

    71-80   0         1           0         0             1       

 
Lack of Published
     21-30   0           4    4        1      1         
p=.022
 Health-Benefit   
31-40    2         3           2         3             1    
Information in Health
 41-50   4         0           2         3             0 
Journals
 (N=55)
  51-60   0         1           4         8             6 
    61-70   0         1           3         0             0 

    71-80   0         1           0         0             1 

  88
Table 13
 (cont™d). Respondent™s perceived frequency of agreement on barriers to therapeuti
c gardens at their place of work as well as 
the socio-demographics of the respondent (N=58).             
 
Barrier Variable Q7           Age (years) Q10a                                  Range of Agreement 
           

˚˙˛˜ !"
#$
                     1                    2             3                4                   5   

  
Lack of Advocates
     21-30   0           4    4        1      1         
p=.034
 (N=55)
    
31-40    1         3           2         3             1    
    41-50   0         0           2         3             0 

    51-60   0         1           4         8             6 

    61-70   1         1           3         0             0 

    71-80   0         1           0         0             1 

 
Lack of Time in 
     21-30   0           0    7        1      1         
p=.000
 Work Schedule (N=55)
 31-40    0         0           4        5             5    
    41-50   0         0           2         3             3 

    51-60   0         0           3         4             4 

    61-70   1         0           2         0             0 

    71-80   0         1           0         1             1 

    

Lack of All-Weather
    21-30   0           1    7        0      1         
p=.032
 Equipment (N=55)
  31-40    0         3           3        3             5    
    41-50   0         0           2         4             3 

    51-60   0         4           5         3             4 

    61-70   1         0           1         2             0 

    71-80   0         1           0         1             1 

 
  89
Table 13
 (cont™d). Respondent™s perceived frequency of agreement on barriers to therapeuti
c gardens at their place of work as well as 
the socio-demographics of the respondent (N=58).             
 
Lack of Knowledge about
 21-30   0           0    3        2      1         
p=.017
 Patient:Staff in Garden
 31-40    0         2           2        0             2    
(N=55)
    41-50   0         0           0         1             3 
    51-60   0         0           4         9             2 

    61-70   1         0           1         0             0 

    71-80   0         0           1         0             1 

 
Lack of Knowledge about Benefit:Cost (N=55)                p=.369 

                   

Lack of Knowledge about Plants (N= 55)                 p=.453 

           

Lack of Knowledge about Garden (N=55)                 p=.369 

  

Higher Priorities for Operating Budgets (N=55)                      p=.143 

   

Higher Priorities for Staff Time (N=55)                          p=.284 

 
Lack of Performance Standards  (N=55)                  p=.103 

 
Lack of Personal Garden Training (N=55)               p=.079 

 
Higher Priorities for Capital Investments (N=55)                   p=.087 

   

 
 
 
 
  90
Table 14.
  Respondent™s perceived frequency of agreement on barriers to therapeutic garde
ns at their place of work and the 
professional field of the respondent (N=58).              
 
Barrier Variable Q7      Professional Field Q10c              Range of Agreement 
    

           

˚˙˛˜ !"
#$
                     1                  2              3                 4                  5   

 
Lack of Time
             Administrators  0           0    1        9       7         
p=.013
 in Work Schedule
             fiHands-Onfl Care 0         0     4        6             7    
(N=55)
             fiClinicalfl Care  0         0         10         6             1 
           Building Staff  0         0           2         0             1 

     

Lack of Knowledge about Plants (N= 55)                 p=.801 

           

Lack of Knowledge about Garden (N=55)                 p=.513 

 
Lack of Knowledge about Patients (N=55)                p=.828 

 
Lack of Knowledge about Family Appreciation (N=55)             p=.776 

 
Lack of Knowledge about Benefit:Cost (N=55)                p=.092 

 
Lack of Published Health-Benefit Information in Health Journals (N=55)       
       p=.218 
     

Lack of Performance Standards (N=55)                  p=.372 

 
Lack of Personal Garden Training (N=55)               p=.183 

  91
Table 14
 (cont™d). Respondent™s perceived frequency of agreement on barriers to therapeuti
c gardens at their place of work and the 
professional field of the respondent (N=58).              
 
Higher Priorities for Capital Investments (N=55)                   p=.342 

 
Higher Priorities for Operating Budgets (N=55)                      p=.550 

   

Higher Priorities for Staff Time (N=55)                          p=.502 

 
Lack of Advocates (N=55)                              p=.365 

 
Lack of All-Weather Equipment (N=55)               p=.484 

 
Lack of Knowledge about Patient:Staff in Garden (N=55)             p=.542 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  92
Table 15.
  Respondent™s perceived frequency of concerns about therapeutic gardens at their plac
e of work and prior knowledge of the 
characteristics of therapeutic gardens (N=58).            
                              
 
Concern Variable Q8           Knowledge Q2                                         Range of Concern       
    

           

˚˙˛˜ !"
#$
         1                         2                   3             4               5  

 
Maintenance Cost (N=57)                 p=.764 

        

Staffing Costs  for Garden (N=57)                p=.686 

 
Seasonal Usage                     p=.886 

 
Liability Issues                          p=.559 

 
Security Issues                        p=.407 

 
Safety Issues                           p=.773 

 
Space Limitations                     p=.966 

 
Utility Limitations                     p=.504 

 
 
 
 
 
  93
Table 16.
  Respondent™s perceived frequency of concerns about therapeutic gardens at their plac
e of work and the socio-demographics 
of the respondent (N=58).                              
 
Concern Variable Q8           Age (years) Q10a                   Range of Concern 
    

        
ˇˆ˙ˇˆ˙˝˛˙
˝˛˙˚˙˛˜ !"
#$
          1                2              3                 4                        5   

 
     

Maintenance Costs
     21-30   0           0    6         4             0                        
p=.013
  (N=55)
    31-40    1         2           1          6                   1    
      41-50   1         1           4          1                   2 

    51-60   0         0           3          6                   8 

    61-70   1         0           0          2                   0 

    71-80   0         0           0          0                   2 

 
Seasonal Usage
     21-30   1           2    4         3             0                      
p=.038
  (N=55)
    31-40    1         4           1          5                   0    
      41-50     0         3           4          1                    1 

    51-60   3         1           4          6                   5 

    61-70   0         0           1          1                   1 

    71-80   0         0           0          0                   2 

 
Staffing Costs (N=55)                    p=.061 

                   

Liability Issues (N= 55)                    p=.272 

 
Security Issues (N= 55)                    p=.222 

 
  94
Table 16
 (cont™d). Respondent™s perceived frequency of concerns about therapeutic gardens at 
their place of work and the socio-
demographics of the respondent (N=58).                           
 
Safety Issues (N= 55)                     p=.309 

 
Space Limitations (N= 55)                    p=.203 

 
Utility Limitations (N=55)            p=.189 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  95
Table 17.
  Respondent™s perceived frequency of concerns about therapeutic gardens at their plac
e of work and the professional field of 
the respondent (N=58).             ____________ 
 
Concern  Variable Q8      Professional Field Q10c              Range of Concern 
    

                        
ˇˆ˙ˇˆ˙˝˛
˙˝˛˙˚˙˛˜ !"
#$
                 1               2              3               4                         5   

 
Security Issues
        Administrators           4        5    6        5            0                
p=.032
 (N=55)
           
fiHands-Onfl Care       7                  3     7        5                  1    
           fiClinicalfl Care           2                  4         0         1                  1 

            Building Staff          1                  0              0         2                  0 

     

 
 
Maintenance Costs (N= 55)                                     p=.519 

 
Staffing Costs (N=55)                   p=.855   

 
Seasonal Usage (N=55)                  p=.427   

 
Liability Issues (N=55)                  p=.593 

 
Safety Issues (N=55)                         p=.272 

 
Space Limitations (N=55)                  p=.444 

 
Utility Issues (N=55)                              p=.620 

  96
Table 18.
  Respondent™s perceived frequency of improvements caused by therapeutic gardens a
t the respondent™s place of work and 
their prior knowledge of the characteristics of therapeutic gardens (N=
58).         
                                
 
Improvement Variable Q6 Knowledge Q2                 Range of Likelihood       
    

               
˘˘ˇ˘
ˇ˘
      
˚˙˛˜ !"
#)                      1                  2              3               4               5    

 
Marketing Advantage (N=58)             p=.814   

 
Staff Satisfaction with Workplace (N=58)           p=.782 

 
Patient Treatment Outcomes (N=58)            p=.385    

 
The Environment (N=58)              p=.951  

   

Daily Patient Care (N=58)             p=.266 

 
Visitor Satisfaction (N=58)             p=.751 

 
General Appearance (N=58)             p=.881 

 
 
 
 
 
 
 
 
  97
Table 19.
  Respondent™s perceived frequency of improvements caused by therapeutic gardens a
t their workplace and the age of the 
respondent (N=58).                 
 
Improvement Variable Q6   Age (years) Q10a                   Range of Concern 
    

                                     
˘˘ˇ˘
ˇ˘
          
˚˙˛˜ !"
#) 
          1                  2              3               4                    5   

 
     

Marketing Advantage
  21-30   0           1    0        6       3          
p=.013
  (N=55)
    31-40    0         2           0         0             9    
      41-50   0         0           2         1             6 

    51-60   0         0           2         8             9 

    61-70   0         0           0         2             2 

    71-80   0         0           0         0             1 

 
The Environment  
  21-30   0           0    0        6       4          
p=.004
  (N=55)
    31-40    0         0           0         3             8    
      41-50   0         0           0         1             8 

    51-60   0         0           1         6             12 

    61-70   0         0           0         2             2 

    71-80   0         0           0         0             1 

 
General Appearance  
21-30   0           0    1        3       6          
p=.006
  (N=55)
    31-40    0         0           0         1             10    
      41-50   0         0           0         3             6 

    51-60   0         0           1         6             12 

    61-70   0         0           0         2             2 

    71-80   0         1           0         0             1 

 
  98
Table 19
 (cont™d). Respondent™s perceived frequency of improvements caused by therapeuti
c gardens at their workplace and the age 
of the respondent (N=58).                
 
Staff Satisfaction with Workplace (N=55)                    p=.138 

 
Patient Treatment Outcomes (N=55)                     p=.475 

 
Daily Patient Care (N=55)                        p=.600 

 
Visitor Satisfaction (N=55)                      p=.310 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  99
Table 20.
  Respondent™s perceived frequency of improvements caused by therapeutic gardens a
t their place of work and the 
professional field of the respondent (N=58).              
 
Improvement Variable Q6      Professional Field Q10c              Range of Concern 
    

                
˘˘ˇ˘
ˇ˘
      
˚˙˛˜ !"
#)                      1                  2              3               4               5   

 
The Environment
         Administrators  0           0    1        6             14             
p=.029
 (N=55)
   
        fiHands-Onfl Care 0         0     0        9            14    
                   fiClinicalfl Care  0         0         0         3            5 

           Building Staff  0         0           0         2            1 

     

General Appearance
         Administrators  0           0    1        5             15            
p=.039
 (N=55)
   
        fiHands-Onfl Care 0         0     1        7            15    
                   fiClinicalfl Care  0         0         0         2            6 

           Building Staff  0         0           0         2            1 

 
 
 
Marketing Advantage (N= 55)                                 p=.672 

 
Staff Satisfaction (N=55)                     p=.282 

 
Patient Treatment Outcome (N=55)                    p=.114 

 
Daily Patient Care (N=55)                             p=.531 

 
Visitor Satisfaction (N=55)                                p=.795 

 
   100
 
 
 
 
 
 
 
 
 
 
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   101
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