The Outdoors for an Inpatient
by Susan E. Mazer

Without a doubt, nature demonstrates itself most stunningly in the complexities and depth of its landscapes. Whether rolling hills, the outlines of tall Ponderosa Pines, the mountains of the Sierra Nevada or the deserts of Jordon and the beaches of the Mediterranean—each offers its own model of beauty, aesthetic profile, and palette of changeable colors.

Then there are the “landscapes” of a hospital room that offer only the views afforded by the patient’s acuity in determining what is accessible. Years ago, when I was first beginning to work in healthcare design, I put my head on the pillow of an empty ICU bed, closed my eyes, and then opened them to see what was directly in the line of sight. There was a wall with a clock on it, a television monitor, and, if I looked further down, a stainless steel canister that had a skull and crossbones on it and words in bold red stating:  “Danger!!  Contaminated needles!!”  The one picture to my left was at an angle such that my peripheral vision could barely see it. No hills or valleys, streams or rivers, green pastures or walkways.

The world of landscape architecture is one of great depth and diversity. And, while one thinks of landscapes as being outdoor environments, in contemporary built environments, nature has moved indoors. Further,  with the substantial studies that have considered the role of nature in recovery, the move toward providing healing gardens for patients and families has grown.
In addition, and not of great surprise, there has been confusion about the distinctions among healing gardens, therapeutic gardens, contemplative gardens, and memorial gardens. The differences are not understood easily by the layperson. Whether a garden becomes healing by intention or practice, or requires specific types of plants or sculptures, or needs the natural sounds of birds and other critters, may be determined by the experiences of the perceiver.

I borrow this perspective from my experience as a musician. Many composers/performers want to declare their music as “healing,” implying that the perception, experience, preference of the listener is irrelevant. In the same regard, the landscape architect is challenged to better define landscape architecture’s relationship to healthcare design. The current definitions of healing environments use nature elements to the degree that they are understood. This is mainly mediated or, as T. E. Adams describes it, “simulated nature or televised nature” experiences (2005). To this I would add representative and artificial nature, with nature in the form of potted plants, artificial trees and flowers, and beautiful, functional grounds. We could also expand the definition to include any natural element, design, or place that has been manipulated by human intervention to create nature where it would not grow authentically.

This is hardly a criticism of the technologies that have come so close to replicating nature. Rather, studies have shown that an experience that brings an individual closer to appreciating nature’s wonder and beauty will transfer across and between the lines of natural and artificial, representative and photorealistic (de Korta, Meijndersa, Sponseleeb, & IJsselsteijna, 2006; Hartig & Cooper-Marcus, 2006; Herzog, Chen, & Primeau, 2002; Kaplan, 1979; Tennessen & Cimprich, 1995; Ulrich, et al., 2008). At the same time, there has been a clear under-appreciation of the restorative effects of nature, albeit overwhelmed by commercial trends, and notions of popularity and convenience.

Do we want to see art in the hospital or the hospital as a work of art?  Do we want healing gardens in the hospital or should the hospital itself be a therapeutic landscape? 

These questions challenge the credibility of evidence-based design when considering the therapeutic effects of nature on patients, families, nurses, physicians, and clinical and non-clinical staff. Landscaping in hospital environments is too often and naively considered an outdoor dressing rather than a therapeutic entry purposefully designed to assist families and patients entering the hospital under duress. Marginalizing a landscape to the outdoors limits its application and relevance and implies that it is not missed by those who have little or no access to it.

What is compelling?

When I declared that the outdoors had moved indoors, I also examined the possibility that “landscape” also address the halls, corridors, overpasses, waiting rooms, etc. and that there are no built environments without a landscape, or that have form, patterns, complex subject-object relationships, and inevitably reflect the values of the organization.

A study that considered the use in advertising of natural or “green” environments as backgrounds confirmed that there were “positive behavioral effects toward visual stimuli representing nature scenes with biospheric contents as opposed to pictures of urban environments or desert settings” (Hartmann & Apaolaza-Ib•Òez, 2010). Thus, advertising has a non-nature-related message in the same way that a hospital has clinical demands seemingly unrelated to a tree, river, mountain, or flower. And yet, viewers can appreciate the context as part of their greater experience. Both Gibson (Gibson, 1967) and Kaplan (Kaplan, 1979) have pointed to the visual scene as the method by which a perceiver makes meaning of the objects both separately and as a whole. Purpose and functionality are important, but coherence and comprehensibility are equally so. Kaplan further points out that, “there is a rapid and unconscious assessment of what one would experience if one were to proceed ‘deeper’ into the scene,” offering to patients a means of reflection beyond the walls of their hospital rooms.

The Healing Environment:  A Therapeutic Landscape 

There remains so much more to consider in bringing the outdoors inside, specifically for acute care and other hospital settings. Potted plants became a greater part of modern life indoors when it was easier to transport them greater distances, and this also allowed the enjoyment to cross class lines. “Passive and active engagement with nature outdoors can, for example, increase positive affect, reduce psychophysiological arousal, and renew an ability to perform tasks that require concentration. This positive affect has transferred itself indoors to the degree that the access is appropriate and to the extent that the individual is in need of restoration or stress reduction” (Bringslimark, Hartig, & Patil, 2009).

In the late 1960’s, when John Portman designed the first Hyatt Regency in Atlanta, hotels could no longer just landscape their porches and walkways. The outdoors has been invited indoors almost five decades, with inside offices having windows and skylights that offer daylight and the hour-to-hour changes in natural light.

By virtue of market pressures to mimic the hospitality industry, and with the emergence of models of care such as the Eden Alternative for elders, attention to the natural environment has become a standard of design for care environments. Newer facilities have gardens, some designed to be actively therapeutic while others to be only aesthetically pleasing. Some have walkways and security for those residents who may wander. Other gardens are only to be viewed from outside. What is meaningful and functional for a long-term care resident who is living in a building is quite different from an overnight visitor of the acute care patient.

Questions to consider:

1. How does landscape architecture serve the clinical objectives that drive a healthcare organization?
2. How can natural landscapes be integrated seamlessly between the inside of a hospital, which represents illness, confinement, challenge, and fear, and the outside, which offers health, hope, and freedom?
3. What kind of research would bring to the fore the greater depth offered by landscape architects to better inform budgetary decisions regarding nature and recovery?

This is the time to tackle these issues, as the values of healthcare organizations and the inherent stresses placed on patients and staff demand more attention to humane care. The beauty of nature, by its very character, is therapeutic. Human pain and suffering can be eased with views that are inherently hopeful, are readily accessible, offer enough complexity to engage the mind and spirit, and are appropriate to the needs of the moment. Bringing clarity and skill to how this can be accomplished is the challenge in front of each of us who works in this field.

Susan E. Mazer is the President and CEO of Healing HealthCare Systems, which produces the C.A.R.E. Channel. She can be reached at


Adams, T. E., . "Phenomenologically investigating mediated 'nature'." The Qualitative Report, 10(3), 512-532.

Bringslimark, T., Hartig, T., & Patil, G. G. (2009). "The psychological benefits of indoor plants: A critical review of the experimental literature." Journal of Environmental Psychology, 29(4), 422-433.

de Korta, Y. A. W., Meijndersa, A. L., Sponseleeb, A. A. G., & IJsselsteijna, W. A. (2006). "What’s wrong with virtual trees?
Restoring from stress in a mediated environment." Journal of Environmental Psychology, 26, 309-320. 

Gibson, J. J. (1967). "What is Perceived? Notes for a Reclassicifation of the Visible Properties of the Environment." Retrieved from: 

Hartig, T., & Cooper-Marcus, C. (2006). "Healing gardens-places for nature in health care." The Lancet, 358, 536-537.

Hartmann, P., & Apaolaza-Ib•Òez, V. (2010). "Beyond savanna: An evolutionary and environmental psychology approach to behavioral effects of nature scenery in green advertising." Journal of Environmental Psychology, 30(1), 119-128.

Herzog, T. R., Chen, H. C., & Primeau, J. S. (2002). "Perception of the restorative potential of natural and other settings." Journal of Environmental Psychology, 22(1), 295-306.

Kaplan, S. (1979). "Perception and Landscape: Conceptions and Misconceptions." Paper presented at the National Conference on applied Techniques for Analysis and Management of the Visual Resource.

Tennessen, C. M., & Cimprich, B. (1995). "Views to nature: Effects on attention." Journal of Environmental Psychology, 15(1), 77-85.

Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo, H.-B., Choi, Y.-S., et al. (2008). "A Review of the Research Literature on Evidence-Based Healthcare Design (Part I)." Health Environments Research & Design, 1(3).

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