Creating restorative, aesthetically pleasing gardens in healthcare settings requires thoughtful consideration of current research and review of the elements of successful established designs. This essay will consider elements of both indoor and outdoor gardens. Approaching the question of plants within healthcare settings leads one to appreciate the central question of how plants can impact and change indoor air quality (IAQ). And this knowledge brings us to the realization "that our existence is interwoven into a symbiotic-mutually beneficial-relationship with the animals and plants of the living world."1 The US Environmental Protection Agency (EPA) currently ranks indoor air pollution as 1 of top 5 threats to public health.1,3

Poor air quality results from poor ventilation and humidity control, emissions from modern materials and electronic devices (such as formaldehyde, Xylene/toluene, benzene, trichloroethylene, chloroform, ammonia, alcohols, acetone), and human bioeffluents (humans release 150 volatile substances into the atmosphere).1 "People living in the industrialized societies spend as much as 90 percent of their lives indoors."1 This stark data highlights the importance of Wolverton's and NASA's combined 25 years of research on how growing plants can clean air in indoor settings.1,3 And it emphasizes what Ulrich, Relf, Cooper-Marcus, Barnes, and others have discovered: the beneficial effects of plants on people and the spaces they inhabit.4,5 Wolverton, in his recent book How to Grow Fresh Air describes the living biosphere, and just exactly how household plants purify the air. He describes in detail which household plants are most able to purify air and how to care for them organically.

Ulrich in an international symposium address noted that the positive effects of nature in nonclinical settings have been widely reported in scientific literature.6

There is considerable evidence that restorative effects of nature scenes are manifested within only three to five minutes as a combination of psychological/emotional and physiological changes. Concerning the first, psychological/emotional, many views of vegetation or garden-like features elevate levels of positive feelings (pleasantness, calm), and reduce negatively toned emotions, such as fear, anger, and sadness. Certain nature scenes effectively sustain interest and attention, and accordingly can serve as pleasant distractions that may diminish stressful thoughts. Regarding physiological manifestations of stress recovery, laboratory and clinical investigation have found that viewing nature settings can produce significant restoration within less than five minutes as indicated by positive changes, for instance, in blood pressure, heart activity, muscle tension, and brain electrical activity.6

Ulrich's and Cooper-Marcus and Barnes' research has shown that access to views of nature can measurably reduce patient's stress and improve health outcomes.5,7 Further Cooper-Marcus and Barnes found that "[horizontal ellipsis]many healthcare employees used gardens as an effective means for achieving a restorative pleasant escape from work stress and aversive conditions in the hospital."5

The literature describing the elements of restorative gardens is rich and varied. Several are already mentioned here. Of special note is Gerlach-Sprigg, Kaufman, and Bass Warner's Restorative Gardens: The Healing Landscape, which discusses in rich detail 6 American healthcare centers "that cherish the role of their gardens in the therapeutic process."7 Gerlach-Sprigg, a landscape architect and former intensive care nurse; Kaufman, a physician; and Bass-Warner, an historian, "examine the history and role of restorative gardens to show their importance to again integrate nature into the institutional-and largely factory like-setting of modern healthcare facilities."7 Gerlach-Spriggs brings her nursing experience and perspective to her work. In creating a therapeutic garden, she says, designers must know their patients and their medical conditions and understand the goals (stimulation? socialization? sanctuary?) of the garden.6 Therapeutic gardens then are designed to "relate to a particular aspect of a disease or healing process. Discernment between the therapeutic and healing gardens is important. The therapeutic landscape is designed to produce a given effect and measurable outcome upon a disease process within given patient and/or group of patients."8

"Healing gardens[horizontal ellipsis]are designed to promote recovery from illness. 'Healing' within the context of healthcare, is a broad term, not necessarily referring to the cure from a given illness[horizontal ellipsis]but rather an improvement in overall well-being that incorporates the spiritual as well as the physical."9 McDowell and Clark-McDowell in the book The Sanctuary Garden state that "the key to a (healing garden) is to honor and celebrate our broad human relationship with nature and spirit, not just plants. They propose seven design elements as a guideline for design and as a means to identify the intention of the space. That is, a marriage between the garden keeper and the spirit of nature."10 They are:

- special entrance that invites and embraces the visitor into the garden.

- The element of water for its psychological, spiritual, and physical effects.

- A creative use of color and lighting (be they plant or human-designed light sources) to elicit emotion, comfort, and/or awe in the visitor.

- The emphasis of natural features as grounding points-such as the use of rocks, wood, natural fences, screens, trellises, wind, sound, etc.

- The integration of A&T to enhance the overall mood/spirit of the garden.

- Garden features that attract wildlife and provide habitat to a diversity of wildlife.8

More than eight hundred years ago, monastic horticulturists designed gardens to inspire a spiritual transition in those who visited them. The power of mind and spirit to alter the body's course is an ancient lesson, one modern medicine first disdained, then forgot, and is only now rediscovering. Perhaps the next step, the link between human beings and the land that surrounds them, will eventually be fully recognized as well and gardens will spring up everywhere providing cool oases of solace and respite.6

Creating "oases of solace and respite" for patients, families, and staff is a most worthy endeavor and it is within our grasp.

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