HEALING LANDSCAPING
IN HEALTHCARE ENVIRONMENT
Final Draft Document
30 April 2020
Shalini Agarwal
Roll no. 164408
Department of Architecture
Dayalbagh Educational Institute
Prof.: Nidhip Mehta
B.Arch. – Semester 8
ARM802 Seminar (Research Skills)
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1. Introduction
The visible landscape is believed to affect human beings in many ways. It provides aesthetic appreciation and health
as well as the whole well- being of the human. It improves the quality of life through psychological and physical
changes. Patients having a view of trees or natural environment through the window with their regular treatment
reduce the dose of medicine and they recover more quickly as compared to patients who have a view of the wall
(Taylor et al, 2001; Taylor and Kuo, 2009).
Well designed healing garden in a hospital and healthcare facilities reduce stress, improve clinical outcomes,
provide opportunities for escape from stressful clinical settings, heighten patient/consumer satisfaction with
healthcare providers, increase care quality, and consequently improve economic outcomes by reducing the cost of
care (Ulrich 2002).
Hospitals are places that are meant to heal, but today’s hospital's environments are not appropriate for healing. The
physical environment of hospitals is more like a corporate office environment that is confusing, intimidating thus
became stressful for patients, their families, visitors, and hospital staff. A person who is ill has compromised coping
skills to deal with stress and tension. Excessive stress increases blood pressure, heart rate, and respiratory rate.
Sometimes stress leads to sleeplessness, anger, passiveness, and disobedience with the medical treatment. Thus the
stress arising from the healthcare environment itself causes adverse effects on a patient’s physical and mental health
and counter the inherent purpose of healing. Modern medicine focuses on the illness in isolation rather than a whole
person, on the other hand, the historical medical models cared for a patient’s body, mind, and spirit as well by using
a holistic approach by integrating nature with the healing process.
Even though nature has an effective role in healing and promoting the well-being of human beings from ancient
times and several modern researches prove the importance of these healing landscapes in a hospital environment, no
statutory guidelines have been produced worldwide. Thus, this fact is overlooked in the modern world and this
practice is not adopted universally in the hospitals and healthcare centers. The healthcare centers completely depend
on medical technologies and advancements. As a result, the hospital environments have turn into bland and lifeless
spaces which are unsuited to the emotional needs of patients, their families, and even healthcare staff.
This research paper aims to understand the importance of these healing landscaping and therapeutic spaces in the
hospitals of India. This paper raises the question to the public that with the acceptance of the nature influence on
human health's healing aspects, shouldn't a hospital environment which meant to be a healing environment proposes
healing gardens as a supportive way for patients, and staff seeking restoration from the stress which arises in the
hospitals itself. Shouldn't healing landscaping be an essential part of the planning and designing of future hospitals
in India as a holistic approach to provide as a de-stressing environment?
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2. Background
2.1 Historical Overview of Healing Gardens in Hospital Settings: The concept of healing from nature
is not new at all. In the western civilization during the middle ages, Aesculapius in the ancient Epidaurus was one of
the first places in which nature used was not only for relaxation, but for treating patients. The monastic hospital was
established in the middle ages in western Europe to accommodate and take care of pilgrims. These spaces helped
people regain the health of their bodies and soul through presence in nature. During this period, the gardens were
formed alongside religious places, and nature, like the religious spaces, was a source of human tranquility and
spiritual well being (Souter- Brown 2015).
Within this enclosure many and various trees…make a veritable grove… The sick man sits upon
the green lawn… he is secure, hidden, shaded from the heat of the day…; for the comfort of his
pain, all kind of grass are fragrant in his nostrils. The lovely green of herb and tree nourishes his
eyes…. The choir of painted birds caresses his ears… the earth breathes with fruitfulness, and the
invalid himself with eyes, ears, and nostrils, drinks in the delights of colors, song, and perfumes
(quoted in Warners, 1995, p. 8)
However, monasticism demolished gradually, the significance of these healing/restorative gardens also declined.
During the 18th century the most famous theories about the healing character of nature were presented by a german
theorist; he believed that gardens should be built adjacent to hospitals. The viewpoint observed from the window
and the motivating natural scenes enhance the patient’s healing process and encourage them to be physically active.
In the 18th century the inclusion of the outdoor environment become important again in the medical setting.
However in the 20th-century things changed yet again within the healthcare world, the healing value of nature is
disappeared from hospitals as the high rise hospitals built in the international style which resembled corporate office
buildings. The relationship between nature and health began to dwindle as new medical technologies become
available. “The idea that nature could assist in healing was all but lost” (Cooper Marcus and Barnes 1999)
Figure 1: The medieval cloister garden. (source: wordpress.com)
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3. Methodology
LITRATURE STUDY (books, journals, researches,
interviews, etc.)
CASE STUDIES (online)
SURVEY (questionnare)
DATA ANALYSIS
CONCLUSION
Figure 2:: Methodology framework. (source: author)
3.1 Scope: This research paper aims to understand the importance of these healing landscaping and therapeutic
spaces in the hospitals of India. This paper raises the question to the public that with the acceptance
acceptan of the nature
influence on human health's healing aspects, should healing landscaping be an essential part of the planning and
designing of future hospitals in India? This research will focus on the very famous private multi
multi--specialty hospitals
of the national
ational capital region(NCR) of India.
3.2 limitations: 1. This paper will not propose any guidelines and measures for hospitals to incorporate healing
gardens into their settings.
2. Due to this current COVID-19
19 pandemic lockdown, all the research and case studies are done via the internet
only.
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4. Literature Review
4.1 What Is Healing Garden or Landscaping: The term “healing garden” most often applied to the green
spaces in hospitals and other healthcare facilities that specifically aim to improve health outcomes. These gardens
provide a place of wellbeing and promote healing in patients, families, and staff. The term consists of two words:
“healing” and “garden.” According to the Oxford Dictionary, the verb “heal” means “cause (a wound, injury, or a
person) to become sound or healthy again” and the noun “garden” a piece of ground adjoining a building, in which
grass, flowers and shrubs may be grown. There are a large number of definitions as every researcher’s perspective
for the term “healing gardens” varies.
Ulrich (1999) defined healing gardens as “a variety of garden features that have in common a consistent tendency to
foster restoration from stress and have other positive influences on patients, visitors and staff or caregivers. To
qualify as a “garden” the feature should contain prominent amounts of real nature such as green vegetation, flowers,
and water.” Eckerling (1996) defined such gardens as “a garden in a healing setting designed to make people feel
better.”
Cooper Marcus and Barnes (1999a) referred to healing gardens as “a space to look out at, and a space for passive or
quasi-passive activities such as observing, listening, strolling, sitting, exploring, and so on.” According to these two
leaders in this field, healing comes because the gardens promote:

Relief from symptoms

Stress reduction

Improvement in an overall sense of well being and hopefulness.
The Importance of Landscape in Hospitals:

It allows interaction with nature and other people.

Connects with nature by allowing sensory experiences.

Serve as a supplement to treatment.

Accelerates the recovery process in patients.

It creates an environment that will bring positive changes for patients.

Serves as a relaxation space for employees and family members.

Increases the staff efficiency.

It can save the cost by reducing the hospital stay of the patient.
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Figure 3:: Concept of Healing Through Landscape. (Source: Ingrid Belčáková, Pavla Galbavá and Martina Majorošová,2018)
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Figure 4, 5: Healing Garden in Rochester General Hospital, New York. (source:zaretskyassociates.com)
Improves
mood
Reduces
stress
Boost
positivity
Slow
heart rate
Benefits
of
Healing
Gardens
Relieves
depressio
n
Improve
immune
system
Reduces
anxiety
Improves
self esteem
Calmness
&
Relaxatio
n
Figure 5: Benefits of Healing Gardens. (source: Fundacion cosmos) Redrawn by Author
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Clare Cooper Marcus is Professor Emerita of Architecture and Landscape Architecture at the University of
California, Berkeley. In a book by Marcus and Barnes’ (1999) Healing Gardens: Therapeutic Benefits and Design
Recommendations which was published for the Wiley Series in Healthcare and Senior Living Design. In Healing
Gardens, particular chapters Marcus and Barnes establishing three broad conditions that structure how they would
identify a healing or restorative landscape. The first condition is that the garden helps to achieve a “level of relief
from physical symptoms”. Secondly, the garden allows for “stress reduction and increase levels of comfort for the
individual dealing with emotionally and physically trying experiences”. The third benefit is an “improvement in
overall sense of well-being and hopefulness that an individual is experiencing and assisting in his physical
improvement” (Marcus & Barnes, Eds., 1999). Even if there is agreement to the necessity of these three conditions,
it remains ambiguous as to how a designer attempts to create these conditions.
In 2017 an interview with Clare Cooper Marcus was conducted by Jared Green at the ASLA 2017 Annual Meeting
in Los Angeles. She said, “Many hospitals are now providing gardens and that is good. However, in their
marketing, some use the term “healing garden” as a buzz word. Sadly, in some cases I see in the trade magazines,
there’s a photo of a chaise lounge on a roof with two potted plants, and it’s labeled a “ healing garden.” Some of us
in the field are beginning to say perhaps there’s a need for a certification of healing gardens, although, just how that
would work is very complicated.”
Dr. Roger S. Ulrich, who is a professor of Architecture at the Center for Healthcare Building Research at Chalmers
University of Technology in Sweden. One of his researches, he focuses on nature as a positive natural distraction
that reduces stress and fosters restoration of individuals (Ulrich, 1992; Marcus & Barnes, Eds., 1999). Ulrich’s
retrospective study, spanning 1972 to 1981, examined records of cholecystectomy (gall bladder surgery) patients
from a suburban hospital in Pennsylvania to assess if a room with a view to nature had any effect on length of stay
and request for pain medication. The conclusion of his study demonstrated that patients with window views of
nature had shorter postoperative hospital stays, less negative evaluative comments from nurses, used less analgesic
medication, and had slightly lower scores for postoperative complications than those patients with views of an urban
brick wall. Ulrich recommended that “hospital design and siting decisions should take into account the quality of
patient window views” (Science, Vol. 224, 1984, p.421). This study renewed interest in nature as a restorative
element that positively contributes to the healing process within a hospital setting.
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Figure 6: Image Showing The Recovery Speed Of Patient Through Window View. (Source:)
4.2 Present Scenario of Healing Landscaping in the Healthcare Environment: As it has
experienced, most of the hospitals and clinics built in the 20th century were not designed for the healing of patients
and the comfort of family. “It seems though the hospital garden in the 20th century has become an invisible and
ignored amenity, and awareness of its possible restorative benefits has been lost in the world of high-tech machines,
high-cost drugs, and increased medical specialization”( Marcus, 1999). When a person is ill he is not only physically
weak, but mentally and emotionally weak also and today’s hospital environment considered unacceptably stressful,
and unsuited to the emotional needs of patients, their families, and even healthcare staff. Some people have even
compared these settings to prison. Today’s medical model is technology-driven, and focusing on “cure” versus
“care”. Technology exploded into the healthcare market in the 1970’s and the design of the hospital has been to
adapt technology to the facility (Verderber, 2000). However, this approach began to change in the late 20 th century
(from 1980), the traditional attitude towards the healing process re-introduced through researches. The whole restart
of the healing gardens and therapeutic landscape movement was Roger Ulrich's famous study, “the view from the
window” published in 1984 in the prestigious magazine Science. In the modern era gardens are recognized as the
tool for healing and nature does not only contribute to human health, but also contributes to the sustainability of the
space. As a result, after so many years from the construction of the Epidaurus healing center in Greece, human
beings have returned to the first point that emphasizes the new perception of body and soul and the importance of
nature as a holistic approach in the healing process, but still, this fact is overlooked or we can say ignored by most of
the healthcare settings. There may be various converging forces for example, time, money, and real estate value,
have override the benefits of allowing patients, healthcare staff access to green spaces.
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Figure 7:Alder Hey Children’s Hospital, Liverpool, England. (Source: Parry Family Charitable Foundation)
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5. Case Studies: The case studies are done for those hospitals that include healing gardens in their treatment
process as nature’s therapy. In this paper we cover one international and two national case studies and all these case
studies are done virtually via the internet.
5.1:Fiona Stanley hospital, Australia: A Landscape for Healing
Figure 8: Aerial view of Fiona Stanley Hospital. (source: land8.com)
Project: Fiona Stanley Hospital
Location: Perth, Western Australia
Area: 320,000 sqm precinct/ 65,000 sqm planted landscape
Year: 2014
Architect: HASSELL
The hospital is supported by an innovative design that uses the latest scientific, technological and medical
developments. As a 783-bed hospital, Fiona Stanley Hospital provides a full range of medical and surgical services,
comprehensive cancer services, and emergency care. The architects wanted to generate a natural healing
environment. They create an outdoor healing environment that blends with indoor spaces of the hospital, which
allows patients to recover and exercise in both outdoor and indoor. The building not only takes benefit of natural
light but also of the views of the existing and newly designed landscapes in and around the buildings, as the building
pulled apart to create courtyards, and valleys where the landscape is allowed to lead into the hospital.
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In Perth Western Australia this hospital is changing the world-class health delivery. HASSELL create a patientcentered facility that optimizes clinical efficiency. The focus on the hospital being a place aimed at patient recovery
and on supporting the staff is what makes the design so successful.
Brenden Kelly, a principal at HASSELL said, “It was important to create an environment conducive to providing
leading healthcare and promoting healing, rather than simply a ‘treatment and recovery’ factory.” The designers
accomplished it by making full use of the 38-hectare site, with six and a half hectares of planted landscape that
includes:

24,000 msq streetscapes

16,500 msq public open space

10,000 msq building zone setting spaces and courtyards

5,000 msp roof gardens
Figure 7: Roof Garden, Fiona Stanley Hospital.
(Pc: Peter Bennetts)
Figure 9: Outdoor Garden, Fiona Stanley Hospital.
(Pc: Peter Bennetts)
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Figure 10: Outdoor Landscaping with Artworks, Fiona Stanley Hospital. (Pc: Peter Bennetts)
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5.2: Medanta Medicity, Gurgaon India:
Figure 11: Aerial view of Medanta Hospital. (source: Dipesh Anand)
Project: Medanta Medicity
Location: Gurgaon, India
Area: 43 acres
Architect: Cardinal Hardy Architects / Jodoin Lamarre Pratte architects/ group Arcop
Year: 2009
Medanta Medicity is a multi-specialty medical institute based in Gurgaon in the national capital region (NCR) of
India. It was started in 2009. As a 1200 bed hospital, Medanta provides 10 super specialty services. On its campus,
there will be a medical college and a paramedical college, as well as a diagnostics and research and development
facility. The prestigious Medicity project, an institute of integrated medical sciences and holistic therapy, combine
different streams of medical science such as Allopathy, Ayurveda, Homeopathy, Naturopathy, and Unani, to find a
holistic treatment for modern ailments and diseases. The architecture of this hospital considered the healing source,
although factors like daylight, room atmosphere, natural landscape, gardens, sound, music, and art, overall are
believed to help in creating carefully designed environments that affect and support the psychological and physical
healing of the patients.
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Figure 12: Site Plan. (source: Dipesh Anand)
Figure 13: Medanta Hospital. (source: Dipash Anand
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Medanta turn up with the design resolution to provide natural views to visitors waiting area and lounge area through
floor to ceiling windows. It is verified that visitors having a view of nature remain calm. Outside the building there
is also a meeting area for the visitors where visitors walk and talk with each other, which develops social support
among them.
Figure 14: Stepped terrace landscaping in front of the window.
landscaping
(source: Dipesh Anand)
Figure 15: visitors having view of terrace
through the window. (source: Dipesh Anand)
Figure 16: Green lawn in front of the hospital entrance for
Social gathering. (source: Dipesh Anand)
Figure 17: Systematic arrangement of shrubs and trees.
(source: Dipesh Anand)
Green entrance and landscaping in a systematic pattern arouses a sense of control among the patient and visitors,
which realizes the patient a sense of security ultimately increases the coherence factor among the staff and patient.
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Healing garden on the 5th-floor level: Medanta provides unique facilities for quick recovery of patients and a
healing garden is one of them which has been created with native Indian ayurvedic plants on the 5 th floor. In the
below mention plan green color represent the healing garden, as it is enclosed between the buildings, which acts as a
secure central green court or we can say a healing garden for the long-staying patients to increase common activity
arouses the sense of coherence among the patient and the staff.
Figure 18: View of Healing Garden. (source: www.medanta.org)
Figure 19: Plan of 5th floor. (source: Dipesh Anand)
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Figure 20: Schematic diagram showing the interaction of patient’s rooms and healing gardens adjacent to each other on the 5th
floor. (source: Dipesh Anand)
The above figure shows the spatial consideration of Medicity based on the green approach, which shows the
arrangement of bedrooms along the healing garden which increases the physical interaction between nature and
patient helps in reducing the stress level among patients, ultimately. There has been provided such access control for
the visitors, only patients are allowed in the healing garden with nurses during the daytime.
Figure 21: Healing Garden view from the patient's ward.
(source: Dipesh Anand)
Figure 22: Healing Garden view. (source: Dipesh Anand)
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5.3: Fortis Hospital, Gurgaon India:
Figure 23: Aerial view of Fortis Hospital. (source: Dipesh Anand)
Project: Fortis Hospital
Location: Gurgaon, India
Architect: Rajinder Kumar Associates, New Delhi
Area: 43,303 sq. m.
Year: 2012
Fortis hospital is a multi-specialty hospital in Gurgaon, India. It has 430 functional beds with a further plan to
increase beds to 1000. The hospital’s main aim is to create an environment that should not give a sense of boring
hospital. The design philosophy after this hospital to offer the health and well being of the people they serve through
integrated, innovative, and compassionate care, also creates spaces that allow for privacy, rejuvenation, choice,
humanistic scale, feel and experience, communication, and collaboration. The Hospital includes new trends like
wellness, technology and creates a Gen Next Medical Center which sets new standards for healthcare focusing on
healing & fostering vigorous health. At the south-west corner is a quiet & sun-filled healing garden for patients,
recuperation & areas of respite for staff and families. All major areas in the hospital will have natural light for a
healthy and sustainable environment.
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Figure 24: Site Plan of Fortis Hospital. (Source:slideshare.net/mayunk50)
Figure 25: View Of Landscaping At The Entrance.
(Source: Dipesh Anand)
Figure 26: View Of Water Fountain At The Entrance.
(Source: Dipesh Anand)
N
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Heavy plantation is done at site boundaries to absorb most of the noise coming from the vehicles outside.
Landscaping at the entrance gives visitors and patients a sense of calmness and decrease the stress and anxiety
among the patients, which arouses a level of coherence factor themselves. It also provides a sense of support to the
patients as plants represent Life, Growth, and Hope, for which the patients come to the hospitals. They can provide
interest and diversion from the pain as well.
Figure 27: Landscaping At The Site. (Source: Dipesh Anand)
Figure 28: Water Body At The Site.
(Source: Dipesh Anand)
Views of vegetation, and especially water, appear to sustain interest and attention more effectively than urban views
of equivalent information rate. The hospital’s landscaping and healing gardens are designed with lush greenery and
water body because most natural views elicit positive feelings, reduce fear in stressed subjects, hold interest, and
may block or reduce stressful thoughts, they might also foster restoration from anxiety or stress. Patient’s wards are
designed with big openings through which the patient can enjoy the natural greenery of the site. In the interior
corridors also the photographs and paintings of nature are displayed as nature is viewed positively and reduce stress.
Figure 29: Photographs In The Corridors.
Anand)
(Source: Dipesh Anand)
Figure 30: Photographs Of Nature. (Source: Dipesh
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Figure 31: View of Terrace Garden from Patient's Room. (Source: Dipesh Anand)
6. Survey:
As an attempt to understand the public awareness on the concept of healing effects of nature and what is their
perception on healing garden should be an essential part of hospitals or not, a public survey was conducted, the
survey was s simple questionnaire which contained very simple questions based on the basic knowledge of the
healing landscaping in the hospitals.
Q.1 Do you know that natural landscaping (greenery) helps us to recover from physical illness and mental stress?
Q.2 Do you prefer natural green spaces within hospitals in your cities?
Q.3 Do you prefer nature with medical treatment if viewing greenery from the hospital's room through window
reduces the dose of your medicine?
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Q.4 Do you prefer nature if spending time in the natural environment can reduce your hospital care cost by reducing
your staying period in the hospital?
Q.5 Do you think that natural greenery should be an essential part of future hospitals in India?
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7. Analysis:
Through the data collected from the existing literature of healing garden in healthcare settings. It can be analyzed
that the concepts of healing landscaping are not a new concept in the modern world. it Is the holistic approach to
heal people through nature which has its roots way back from the Greek civilization. But this approach is overlooked
with the time as the hospitals and healthcare centers became more advance and high-tech. the modern medicinal
model completely depends on medical technologies and advancements, which leads them to become a lifeless,
stressful environment for patients as well as staff. By the exploration of technologies in the healthcare market the
hospital spaces become more like high rise institutional buildings. The awareness towards these healing gardens
again come into existence in the late 20th century as many researchers and landscape architects have done their
research and claim that nature can be a holistic approach by integrating nature as a healing process. Nowadays this
holistic approach is adopted by very few healthcare facilities in India but and this fact is still ignored by many
hospital authorities. There may be some converging forces or factors due to which this practice is not adopted. A
public survey is also conducted to analyze the public perspective on this approach. A question was asked to the
public that do should these natural healing spaces or gardens be an essential part of the future hospitals in India.
Should Indian hospitals adopt this holistic approach of healing gardens with the medical treatment, 88.9% responded
yes, 11.1% responded maybe.
8. Conclusion:
Finding several studies and researches converge in indicating that simply viewing nature not only helps to calm
patients, divert their mind from their pain, but can also foster improvement in clinical outcomes by reducing their
pain, medicine intake, and shortening their hospital stay. These gardens are also financially beneficial for the
patients as medical treatments are very money-spinning in current time. Clare Cooper Marcus said that there just
needs to be more coverage of this information transferred from academic writing into more popular writing and
hence the need for journalists and new messengers rather than new messages. Also there are no statutory guidelines
for these gardens produced. The potential for the healing gardens in medical settings will increase the attention if the
administrators and providers feel strong pressure to increase the quality, become more patient-oriented, control cost
of the treatments by adopting this holistic approach along with the medical treatments.
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Bibliography:
Books

Healing Gardens: Therapeutic Benefits and Design Recommendations
By: Clare Cooper Marcus, Marni Barnes – 1999

Gardens in Healthcare Facilities: Uses Therapeutic Benefits, and Desig Recommendations
By: Clare Cooper Marcus, Marni Barnes – 1995
Articles/Papers/Interviews

Ulrich, R. S. (1984). View through a window may influence recovery from surgery. Science, Volume 224,
420-421.

Ulrich, R. S. (1986). Human responses to vegetation& landscapes. Landscape & Urban Planning, Vol. 13,
29-44.

Ulrich, R. S., et al. (1991). Stress recovery during exposure to natural & urban environments. Journal of
Environmental Psychology, Vol. 11, 201-230.

Ulrich, R.S. (1999). Effects of gardens on health outcomes: theory and research.. In C.C. Marcus & M.
Barnes (Eds.), Healing gardens: therapeutic benefits and design recommendations (pp. 27-86). New York: John
Wiley & Sons.

Verderber, S., & Fine, D. J. (2000). Healthcare architecture. New Haven; Yale University Press.

https://www.researchgate.net/publication/303923867_What_is_a_healing_garden

https://www.sciencedirect.com/science/article/pii/S209526351830030X

https://www.takingcharge.csh.umn.edu/explore-healing-practices/healing-environment/whathappeninghealthcare-settings-today

https://www.academia.edu/36696728/Healing_Landscape_Analysing_the_Landscape_Design_of_Fiona_S
zanley_Hospital

https://land8.com/fiona-stanley-hospital-a-landscape-for-healing

https://www.researchgate.net/publication/328788657_Healing_and_therapeutic_landscape_design_
_Examples_and_experience_of_medical_facilities

https://www.slideshare.net/DipeshAnand1/healing-architecture-for-hospital?from_action=save

https://www.academia.edu/36696728/Healing_Landscape_Analysing_the_Landscape_Design_of_Fiona_St
anley_Hospital

https://www.takingcharge.csh.umn.edu/explore-healing-practices/healing-environment/what-are-healinggardens
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
https://www.takingcharge.csh.umn.edu/explore-healing-practices/healing-environment/what-are-healinggardens

The experience of nature: a psychological perspective. Cambridge University Press.

Kaplan, R., Kaplan, S., & Ryan, R.L. (1998). With people in mind: design and management of everyday
nature. Washington, D. C.: Island Press.

https://www.researchgate.net/publication/12761803_A_theory_of_supportive_design_for_healthcare_facili
ties

https://www.researchgate.net/publication/277953355_Ulrich_1979_Visual_landscapes_psych_well-being
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