“Some of our brain injury patients don’t have the initiation or willingness to participate. With one patient we tried everything and so I said, ‘I have to show you our new garden, it’s so beautiful,’ and sure enough he got out of his bed and walked out in the garden.”
In 2013, HGA acted on an opportunity to give back to a long-time client, ThedaCare Health, by providing pro bono design services for a healing garden space at ThedaCare Medical Center in Neenah, Wisconsin. The goal of the therapeutic garden was to improve rehabilitation care for long-term patients with a variety of brain and mobility injuries. While the design and implementation of a healing garden was a scope the design team was very familiar with, this project has proven to be particularly rewarding and insightful due to resulting improvements in patient care, the participant-informed design process, research opportunities, and, ultimately, important lessons learned.
ThedaCare Medical Center overlooks the Fox River at the outflow of Lake Winnebago. Despite its prominent surroundings, the project site—a completely barren 4,500 sf courtyard space adjacent to the helipad—faced many challenges in becoming an inspiring therapeutic landscape. Less than one-half of the space could be planted due to below-grade mechanical rooms that significantly limited additional loads. In response, this area became a multifunctional open space incorporating synthetic turf, cast-in-place porous rubberized surfacing, and geofoam landforms to define multiple program uses. Planted pockets flanked the open space to the north and south, connected by a meandering path recalling the adjacent river. The pockets acted as garden destinations and spaces of respite, including a footbridge, wooden benches, seat boulders, and a host of ornamental plantings. As a whole, the garden pockets and central open space transformed the bleak environment into an attractive hospital amenity creating many opportunities to improve patient care.
The proximity of the helipad meant the garden could only be used by trained personnel (i.e., individuals who knew what to do when a helicopter was approaching) and only for the purpose of therapy. In the end, the limitations imposed by the helipad contributed to the success of the garden. The single function of the space, as a therapy space and not a mixed-use space, meant the needs of rehabilitation patients, families, and staff were better served.
The final design direction was heavily influenced by a participatory process that engaged physical and occupational therapists, hospital leadership, physicians, nurses, and other clinical support staff—the outcome enabling designers to know what patients want and need in their therapy journey. To that end, a Lean 2P event was held during the early stages of design to elicit multiple user groups’ perspectives on the space needs for the garden.
Participants were encouraged to share their knowledge and thoughts in multiple formats including stories and sketches. The extensive, detailed information gathered from the event was subsequently used by the design team to create a successful design solution that would provide the best care possible for patients. Not only was the participatory approach intended to shape the physical space, it was also seen to empower employees to proactively engage with the space, once it was completed.
Funded by an in-house micro-grant program, a study team—made up of a landscape architect, landscape designer, and design researcher—conducted HGA’s first post-occupancy evaluation (POE) of a landscape architecture project at the ThedaCare garden site. The study aimed to evaluate the success of the garden in achieving its intended goals. A combination of interviews and an on-site evaluation tool, the Healthcare Garden Evaluation Toolkit (Sachs, 2017), were used to gather data. The evaluation tool included an assessment of garden elements and observations of patient, staff, and visitor activities in the space. Interviews with 11 staff members (7 PTs and 4 OTs), focused on whether sensory and physical elements of the garden helped patients achieve therapy goals and met psycho-social needs. Data collected during the study were analyzed using widely-accepted qualitative methods (Lincoln & Guba, 1985).
Key POE Findings
The garden succeeded in achieving its intended goals in several ways: three broad categories of findings emerged.
Met Physical, Psychological, and Emotional Needs of Users – Rehabilitation spaces (e.g., gyms) often contain features such as stairs that attempt to simulate real-world conditions but instead can feel like “steps to nowhere” for patients. In the ThedaCare garden, climbing the stairs of an actual outdoor deck gave purpose and meaning to the tasks at hand. Spending time in the garden was seen as an inspirational, and sometimes spiritual experience. Staff expressed pride in knowing their facility offered such a special space: “It makes me proud and I feel it makes patients happy.”
Patients’ families provide crucial support during the rehabilitation process, often feeling the ups and downs of therapy along with their loved ones. Seeing their loved one interact with elements of the garden and work to regain abilities was emotionally uplifting for families.
Improved Therapy Practice – The garden was seen by staff as a safe, but realistic environment, in which to test patients’ current-state skills and abilities in preparation for the transition to home. Information about how vision or balance might be affected at home could emerge during a visit to the garden. Staff suggested that having access to the garden sparked professional creativity and expanded thinking about activities that could help patients reach their therapy goals. “The garden definitely helped me be more creative.”
Family members often take on the role of caregiver as patients transition home. Staff members valued the frequent, spontaneous opportunities to teach skills to both family members and patients visiting the garden together. Staff repeatedly shared reactions of family members: “We can bring family members out with us…they are out digging in the garden with their loved ones and I can do family teaching in a realistic setting.”
Connected to Nature – Patients experienced a deep-seated, fundamental connection to nature in the garden. Many patients visiting the garden for the first time were moved to tears having been unable to be outdoors for weeks or months. Additionally, the garden often had a calming effect on patients experiencing agitation commonly associated with traumatic brain injury. Not only did the garden connect patients to nature and improve wellbeing, it did the same for staff. One staff member observed: “Getting some sunshine is a positive, if you are feeling good as a person, you are going to portray that to your patients . . . I love being out there with them.”
The ThedaCare Medical Center therapy garden has established enduring impacts on multiple levels. For the hospital and staff, it has provided a pleasant, new outdoor space where lasting, meaningful rehabilitation care can be delivered. For patients and families, the garden has become a place to connect, grow, and learn about nurturing loved ones. And, for the design team, the garden demonstrates the value of landscape architecture in creating therapeutic environments, thereby adding original insight to a growing knowledge base. Moving forward, the legacy of the garden will grow and evolve as it continues to influence the many participants touched by the rehabilitation process.
About the Authors
Trygve Hansen, ASLA, PLA, LEED APBD+C, SITES AP, is a Senior Landscape Architect at HGA, where he maximizes the positive impact site design has on local ecologies and communities.
Lou Bunker-Hellmich, PhD, is a Design Researcher and Writer at HGA, where she is involved in various research activities, from data collection, analysis, and reporting, to grant pursuits, publications, and client deliverables.
Read the full article in _Scape (pp 27 – 30).