BREAKING OUT OF THE MODERNIST CLOISTER": 

A Restorative Approach to 

Community Health Care Facility Design 

by 

Geralyn Margaret Ann L. Hogan 

B.Sc.N., The University of British Columbia, 1984 

A THESIS SUBMITTED IN PARTIAL FULFILMENT OF 

THE REQUIREMENTS FOR THE DEGREE OF 

MASTER OF LANDSCAPE ARCHITECTURE 

in 

THE FACULTY OF GRADUATE STUDIES 

(Department of Landscape Architecture, Faculty of Agricultural Sciences) 

We accept this thesis as conforming 
to the required standard 

THE UNIVERSITY OF BRITISH COLUMBIA 

April 2002 
© Geralyn M. A. L. Hogan 



In presenting this thesis in partial fulfillment of the requirements for 
an advanced degree at the University of British Columbia, I agree that the 
Library shall make it freely available for reference and study. I further 
agree that permission for extensive copying of this thesis for scholarly 
purposes may be granted by the head of my department or by his or her 
representatives. It is understood that copying or publication of this 
thesis for financial gain shall not be allowed without my written 
permission. 

Department of nCa^^Z^r^Y^ CtsfJii '̂ le c v W < 
The University of British Columbia 
Vancouver, Canada 

Date /9o£r JO - 2 - ^ ^ 



Abstract. 

The aim for this project was to explore a more restorative manner of 
health care facility design that would manipulate the environment in order 
to reduce stress, prevent illness, and promote wellness. 'Restorative 
Design' has been applied in the public realm but is not commonly seen on 
the hospital landscape. Regional hospitals across Canada are created 
almost entirely for function. Recent studies on the potential impact of 
design, however, may prove beneficial in reducing hospital stays, reducing 
absenteeism, increasing productivity, and, quite simply, improving the 
health of the community. This project looked at available data, studies, 
and expert opinions and attempted to develop a framework for restorative 
design as applied to the hospital landscape. 

Four global principles for restorative design were identified (legibility, 
inherent familiarity, accessibility, and access to natural elements). The 
project then went further to try and delineate specific needs for specific 
groups. Visitors, staff, patients, and the surrounding community were all 
considered integral parts of the open space and figured highly in the 
final design and program. Both global and specific needs for stress 
reduction were translated into several very specific design implications 
that could be translated into design and programming. 

The project explored unconventional, "restorative" means of evaluating the 
success or failure of design moves. Most notably, an unconventional large 
open space was laid out for several reasons: it provided the best chance 
for enhancing biodiversity on the site, it was accessible (visually and/or 
physically) by a variety of users and its creation offered several 
programming possibilities. A proposal was put forth for shared management 
of the open space with a local volunteer stewardship group as a way to 
offset costs as well as enhance a sense of community ownership. 

It is important to note that only one vision for this hospital site has 
been proposed here. The developed principles and design implications, 
however, may be taken and applied to any given site (public or private) to 
develop a landscape that actively participates in the healing process. 

The following document, made up of both written text and graphic images, 
aims to explain and illustrate the design process and the design proposals 
put forth in this project. Several of the original drawings were done at 
much larger scales and many were illustrated in color. A CD-R version of 
this document has been submitted and may be useful to better visualize 
some of these graphics. 

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Table of Contents 

Abstract. ii 
Table of Contents. iii 
Table of Figures. v 
Acknowledgements. viii 

Chapter 1. Challenging the Traditional Approach to Hospital Design. 

• 1.1 Preface. 1 
• 1.2 Introduction. 2 
• 1.3 Project Goal and Objectives. 3 
• 1.4 Project Approach. 4 

• 1.5 Site Introduction. 4 

Chapter 2. Restorative Design: Literature Review. 

• 2.1 Definition. 6 

• 2.2 Inherent Familiarity: The Archetypal 
Landscape. 7 

• 2.3 Legibility: The Preferred Landscape. 9 
• 2.4 The Call to Nature: The Living Landscape. 1° 
• 2.5 Physical & Visual Connections: The 

Accessible Landscape. 12 

Chapter 3. Inquiry into Status of Hospital Design 
• 3.1 History of Hospital Design: An Overview. 15 
• 3.2 Current Trends Affecting Health-care 

Facility Design. 22 

Chapter 4. Applied Restorative Design: Principles and Implications. 

• 4.1 Global Restorative Principles & Design 
Implications. 27 

• 4.2 Specific User Requirements and Design 

Implications. 
• 4.2.1 Patients and Visitors. 3 4 

• 4.2.2 Staff and Volunteers. 4 0 

• 4.2.3 Community Members. 42 

Chapter 5. Public Process: A Discussion. 

• 5.1 The Planning Phase. 4 4 

• 5.2 Site-Specific Programs 4^ 

Chapter 6. Marshall Road Location: Existing Conditions. 

• 6.1 History of Existing Project. 4"̂  
• 6.2 Analysis: Regional Context. 48 

• 6.3 Analysis: Site Context. 51 

• 6.3.1 Focus: Mill Lake Access. 52 
• 6.3.2 Focus: Trans-Canada Highway. 53 
• 6.3.3 Focus: Regional Views/Landmarks 54 

• 6.3.4 Focus: Seniors as Neighbours 54 

• 6.4 On-Site Conditions 55 
• 6.5 Summary and Site-Specific Objectives 63 



Chapter 7. A Vision for Restorative Hospital Design. 

• 7.1 Site Narratives. 
• 7.2 Introduction of Design & Program. 

• 7.3 Design Process. 

• 7.4 Sustainable Practices. 
• 7.4.1 Biodiversity Enhancement. 

• 7.4.2 Stormwater Collection. 
Hospital Program/Site Layout. 
Key Views. 
Site Circulation. 
Open Space Organization. 
Proposal for Community Stewardship. 
Master plan Specifics. 

Chapter 8 

7.5 
7.6 
7.7 
7.8 
7.9 
7.10 

The 

8.1 
8.2 
8.3 
8.4 
8.5 
8.6 
8.7 
8.8 
8.9 

Restorative Vision: Details and Specialized Spaces 
Urban Entrance. 
Community Cafe. 
Urban Woodlot. 
Accessible Walking Loops. 
Psychiatry Design & Programming. 
Cancer Clinic Woodlot Garden. 
Staff Refuges. 
Accessible Building Perimeter. 
Open Space-'Pasture, Pond, & Production'. 

Chapter 9. Recommendations for Future Inquiry or Design 

References 

Appendix I 

Appendix II 

Principles of Universal Design 

Principles of CPTED 

64 
65 
68 
70 
71 
74 
76 
80 
82 
86 
88 
92 

95 
96 
97 

98 
102 
104 

106 
108 
110 

111 

118 

126 

128 



Table of Figures. 

Figure 1-1: Design Methodology Flow Chart 5 

Figure 3-1: Mass-Void for Monastic Cloister Design 17 
Figure 3-2: Pavilion style hospital 19 
Figure 3-3: Image of Riverview Psychiatric Hospital grounds, 19 

Port Coquitlam, B.C 
Figure 3-4: Demolition of Pruitt-Igo social housing, 1972 21 
Figure 3-5: Prototypical modernist hospital, current day 21 

Figure 4-1: African Savannah Landscape 28 
Figure 4-2: Precedent: African Savannah Project, Toronto Zoo 29 
Figure 4-3: Abbotsford Bench Art Program 30 
Figure 4-4: Restorative Interaction with Nature 31 
Figure 4-5: Creekfield Lake Nature Trail in Houston, Texas 33 
Figure 4-6: Prototypical Windowless Emergency Wards 4 0 
Figure 4-7: Approach to Restorative Hospital Design 43 

Figure 5-1: Model for Public Involvement 4 5 
Figure 5-2: Community Volunteer Activity 4 6 

Figure 6-1: Downtown Abbotsford 1907 48 
Figure 6-2: Downtown Abbotsford 1930 48 
Figure 6-3: Relationship to Local Municipalities 4 8 
Figure 6-4: 'Manzana Heritage Apple Farms', Abbotsford 49 
Figure 6-5: Winter Raspberry Canes, Abbotsford 4 9 
Figure 6-6: Baling Hay Abbotsford 1941 4 9 
Figure 6-7: Farmland at Sumas Highway Exit (view Mount Baker) 4 9 
Figure 6-8: Population Abbotsford by Age 4 9 
Figure 6-9: Abbotsford Ethnic Composition 4 9 
Figure 6-10: Aerial View over Site, 2001 50 
Figure 6-11: Immediate Site Context 51 
Figure 6-12: Highland Park east of site 50 
Figure 6-13: Menno Home and Hospital north of site 51 
Figure 6-14: Low-rise Residential 51 
Figure 6-15: Trans-Canada Highway south of site 51 
Figure 6-16: Street Context 51 
Figure 6-17: Visualization sketch Primrose Avenue Connection 52 
Figure 6-18: Marshall Road looking east 52 
Figure 6-19: Primrose Avenue looking north 52 
Figure 6-20: Mill Lake Viewpoint 52 
Figure 6-21: Mill Lake Trail 52 
Figure 6-22: Mill Lake: recreational destination 52 
Figure 6-23: Sound Protection Assessment 53 
Figure 6-24: Sound Berm Construction 53 
Figure 6-25: Proposal for vTrans-Canada Green' 53 
Figure 6-26: Current southeastern berm 53 
Figure 6-27: View of Trans-Canada Highway 53 
Figure 6-28: Existing berm as viewed from Highway 53 
Figure 6-29: Viewshed Mapping to Mount Baker 54 
Figure 6-30: View to Mt. Baker 54 
Figure 6-31: 2001 Ortho Map of Proposed Site 55 
Figure 6-32: Summary of Site Conditions 56 
Figure 6-33: Vegetation Analysis 56 
Figure 6-34: Topography Analysis 5 6 

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Figure 6-35: Restorative Opportunities 57 
Figure 6-36: Central Treed Knoll (Douglas Fir) 58 
Figure 6-37: Cow pasture, one block from site 59 
Figure 6-38: Raspberry canes, one block from site 60 
Figure 6-39: Red-tailed hawk 61 
Figure 6-40: Townsend warbler 61 
Figure 6-41: Stellar j ay 61 
Figure 6-42: Views from the Highway: Potential Green Corridor 62 

Figure 7-1: Master Plan for Fraser Valley Health Centre 66 
Figure 7-2: Conceptual design sketch 1 68 
Figure 7-3: Conceptual design sketch 2 69 
Figure 7-4: Marshland shared by human and habitat 72 
Figure 7-5: Biodiversity Analysis 73 
Figure 7-6: Stormwater Detention Calculations 7 5 
Figure 7-7: Conceptual Plan of Constructed Wetland 7 5 
Figure 7-8: Site Layout General Considerations 77 
Figure 7-9: Example of Lighting: Precedent 78 
Figure 7-10: Built Program Basics 7 9 
Figure 7-11: Built Program (Floors G-2 to 2) 79 
Figure 7-12: Built Program (Floors 3 to 6) 7 9 
Figure 7-13: Built Program (Floors 7 to 10) 7 9 
Figure 7-14: Key Views Influencing Site Design 81 
Figure 7-15: Typical Street and Lane Profiles 83 
Figure 7-16: Grass Crete Section 8 4 
Figure 7-17: Circulation: automobiles 84 
Figure 7-18: Circulation: Self-Powered 85 
Figure 7-19: Open Space Organization and Management 86 
Figure 7-20: Healing Gardeners' Staging Centre 8 9 
Figure 7-21: Community Arrival 91 
Figure 7-22: Master Plan-Proposed Changes to Grading 92 
Figure 7-23: Master Plan-Proposed Vegetation Retention 93 
Figure 7-24: Rough Worksheets as Design Process 94 

Figure 8-1: Axonometric of entrance atrium 95 
Figure 8-2: Location of Shared Entrance 95 
Figure 8-3: Detail of Shared Entrance Street Plan 95 
Figure 8-4: Section looking at Community Cafe 96 
Figure 8-5: Location of Community Cafe 96 
Figure 8-6: Multi-Faith Congregation Centre in Woodlot 97 
Figure 8-7: Collages of proposed native plants 97 
Figure 8-8: Location of Urban Woodlot 97 
Figure 8-9: Location of Designed Pathways 98 
Figure 8-10: Grass Crete 98 
Figure 8-11: Accessible Raspberry Canes 98 
Figure 8-12: Conceptual Walkway: Marsh , 99 
Figure 8-13: Conceptual Walkway: Gardens 99 
Figure 8-14: Conceptual Walkway: Orchard Rows 99 
Figure 8-15: Section-Elevation of Trail Path 99 
Figure 8-16: Holter Monitor Diagram 100 
Figure 8-17: Pathway Program: Photoshop Visualization #1 101 
Figure 8-18: Pathway Program: Photoshop Visualization #2 101 
Figure 8-19: Pathway Program: Photoshop Visualization #3 101 
•Figure 8-20: Access to Volunteer Centre: Visualization 101 
Figure 8-21: Location of Psychiatric Outdoor Programs 102 
Figure 8-22: Psychiatric Outdoor Connections 102 
Figure 8-23: Detail Psychiatric Built Program 102 

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Figure 8-25: 'Back Door Privacy': Delivery Area Smoking Nook 103 
Figure 8-26: Detail Plan of Psychiatric Unit 103 
Figure 8-27: Section-Elevation of Cancer Clinic Garden 104 
Figure 8-28: Location of Cancer Clinic Garden 104 
Figure 8-29: Planting Plan for Cancer Clinic Garden 105 
Figure 8-30: Plan of Mt. Baker Staff Retreat 106 
Figure 8-31: Plan of Emergency (with interior connections) 106 
Figure 8-32: Location of Proposed Staff Refuges 106 
Figure 8-33: Elevation of ER Staff Refuge 107 
Figure 8-34: Detail of Visitor Nook : 108 
Figure 8-35: Key to Visitor Nook Locations 108 
Figure 8-36: Outdoors Accessibility for all Users 109 
Figure 8-37: Sample Visitor Nook 109 
Figure 8-38: Axonometric of site showing open space 110 
Figure 8-39: Location Pasture, Pond & Food Production 110 

Figure 9-1: A designed, supervised play area 112 
Figure 9-2: EHS access from Trans-Canada Highway 113 
Figure 9-3: Examples of varied water features 115 
Figure 9-4: Image of 'Mountain Stream' BEDSCAPES ™ 116 
Figure 9-5: Beth Israel Cardiac Catheterization Study, 1999 117 

- vii -



Acknowledgements. 

The process of exploring the issue of health care design and attempting to 
find new, more restorative approaches to landscape design proved to be a 
far more difficult task than anticipated. The field of health care design 
is neither a glamorous nor a particularly popular area of design and I 
acknowledge all those individuals who took the time to lend their 
assistance in this at times very frustrating and challenging, but 
ultimately extremely rewarding, project. 

I extend my gratitude to Patrick Mooney, the Chair of my Thesis Committee, 
for his persistence that I always go that one step further to do the best 
job possible. His expertise, time, patience, excellent critiques and 
adherence to what I believe to be suitably high expectations for a 
graduate student were much appreciated. Appreciation also goes to my 
Thesis Committee members Don Luymes, Stephen Sheppard, and Alex Ostry for 
their time, advice, opinions, and also for their abilities to recognize 
and point out areas in need of more work. My committee, on the whole, 
appeared very intent of pushing me as far as possible. This is 
appreciated. 

Thanks to my fellow struggling graduate students for their support, their 
impromptu critiques and their mere presence. During marathon studio 
sessions, misery does love company. 

I would not have survived these intensive last several months without the 
social support of my family and friends (Ken and his fold-out couch, in 
particular) and the positive distraction (and restorative benefits) of my 
many four-legged companions. Going home, even once or twice a week, to my 
pastoral landscape and being surrounded by a welcoming committee of 
horses, sheep, goats, dogs, cats, ducks, geese, wild birds and visiting 
coyote families (among others) provided important instant rejuvenation. 

One final thank you to my colleagues in ER who at 0300 hours on many a 
night shift were still able to express positive opinions that there is 
hope for a health care system teetering on the edge of crisis. While few 
of them understand the scope of a landscape architect, they were always 
anxious to listen, debate, respond to questions, and ask questions. 

- v m -



CHAPTER I. 

Challenging the Traditional Approach to Hospital Design 

1.1. Preface. 

The translation of art and science into meaningful physical form 
underscores the role of landscape architecture in modern design. Drawing 
from environmental, psychological and medical research, it is possible to 
create space that can profoundly influence the collective and individual 
human condition. While a commitment to advancing aesthetics and style 
remains a,strong component of landscape architecture, there is significant 
opportunity to design for fundamental social, ecological, and economic 
health and sustainability. 

Recognition of the ability of environment to influence, negatively or 
positively, health and well-being has resulted in a surge of inguiry over 
the last forty years into the potential for restorative design. 
Restorative design takes the position that manipulation of environmental 
cues can reduce stress, promote well-being, and assist in healing both the 
physical and psychological being. Increasing awareness of the powerful 
effect of stress has triggered significant research into means by which 
form of place can reduce and manipulate stressors, and subseguently 
ameliorate human condition. 

Stress is necessary to sustain life. Both positive and negative demands 
(external and internal) intertwine to create a dynamic state of being. 
Problems arise as a result of over-exposure to stress without opportunity 
for respite and restoration. Stress is both additive and cumulative. 
Unrelenting and prolonged, a state of crisis is reached and symptoms 
(physical and/or psychological) appear. 

Stress is considered a major contributing factor not only to mental 
illness, but many physical conditions. Coronary artery disease, cancer, 
respiratory disorders, multiple sclerosis, diabetes, rheumatoid arthritis, 
alcoholism, drug abuse, and family discord and violence have all been 
linked directly or indirectly to stress. The economic burden of increased 
stress is revealed in increased health insurance outlays, burnout, 
absenteeism, and reduced productivity. 

Hospitalized patients experience considerable stress. "Apart from the 
pain and other pressures associated with illness, major stress is produced 
by poorly designed healthcare facilities that typically are noisy, invade 
privacy, or interfere with social support" (Ulrich, 1992) . The issue of 
stress in the health care facility is not limited to patients. Staff 
members (faced with lack of control and high responsibility) are also 
victim to high measures of daily stress, often leading to burnout and 
illness (Ulrich 1992). Addressing the needs of staff, in particular 
caregivers, in the hospital environment will necessarily have a strong 
impact on patients. 

Stress reduction is the primary goal of restorative design. Applied to 
both public and private situations, restorative design utilizes the 
knowledge of shared human preferences for certain conditions and 
environments to create spaces that maximize comfort, security and 

- 1 -



familiarity. Kaplan and Kaplan's model of restorative environments 
(1998), Ulrich's theory of supportive design (1992), E.O. Wilson's 
description of the human need for contact with nature (1993), and 
Appleton's theory of fundamental landscape preferences (1975) are but a 
few of the significant works giving form and direction for restorative 
design. 

Application of restorative design principles to health care facilities has 
been significant in the areas of paediatrics, geriatrics (Mooney and 
Nicell 1992), psychiatry (Paine 1998) and surgery/cardiac (Ulrich 1979, 
1984). A unique health care facility challenge that has been largely 
avoided, however, is the design for multiple users as found in community 
or tertiary hospitals. Guidelines for siting and design of larger 
facilities are almost exclusively limited to the built form as it relates 
to function (Cooper Marcus and Francis 1998) . 

"What is needed is a shift in thinking that requires hospital 
designers to re-examine the hospital environment in the same way 
that designers of playgrounds, mental health care facilities, and 
housing for the elderly might do. How can these spaces be designed 
and managed so as to maximize benefits to the intended users?" 
(Cooper-Marcus and Francis, 1998, p. 314). 

The creation of form that provides a variety of options for stress 
reduction, that spans the wellness-illness continuum, and that recognizes 
a diversity of users (patients, visitors, workers, and community members) 
is the focus of this inquiry. The goal of design will be to vision a 
health care environment that is holistic and healing at the broadest sense 
and that that provides shared opportunities for stress reduction for 
hospital staff, neighboring community members, as well as patients and 
visitors. 

1.2. Introduction. 

The awareness by designers of the power of landscape to be restorative to 
the human condition has resulted in a revisitation of the manner in which 
schools, senior's facilities, and psychiatric hospitals are designed. 
Private homes and gardens are more and more the centre of "therapeutic 
design". Western community hospitals, however, remain in the image that 
has plagued them for fifty plus years. Inward-looking and disconnected 
from the community, hospitals remain a frightening destination for most of 
society (Cooper Marcus and Francis, 1998). Token healing gardens are 
retrofitted for specific patient populations (as economics permit), but, 
society is slow to re-image the modern day hospital in a manner that is 
humanistic and socially relevant. An inwardly focused design works 
contrary to desires to move health care into the community to be embraced 
in a larger way by individuals and by communities. Designing for the 
promotion, maintenance and enhancement of health on the grounds of health 
care facilities demands a stronger connection with the surrounding 
community in order to disrupt the prevailing image of hospital as a place 
to house the sick. Modern day sensibilities and limitations require a 
more integrated, sustainable and democratic use of space; in this case a 
space that has limitless opportunities to benefit all members of the 
public as they fluctuate across the wellness-illness continuum. 

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Our modern history of hospital siting and design has focused an inordinate 
amount of time and energy on building footprints and inward-looking 
programs. The hospital landscape is largely inaccessible, secondary, 
"decorated" grounds. This thesis suggests this to be a waste, not only of 
potential public green space, but, more importantly, of missed 
opportunities to bring communities and individuals together in an 
environment where the things that divide us melt under the weight of those 
that connect. It is the contention of this inquiry that the entire 
grounds of the facility should be designed as a restorative landscape at 
the outset; a restorative landscape that maximizes the power of natural 
and community resources, and provides benefit to all members of society, 
at any stage of wellness. 

Not only have we missed opportunities to connect hospitals with schools, 
churches, and various community amenities, but also the potential 
(particularly in rural/suburban areas) to couple hospital site design with 
conservation efforts is overlooked. Health care facilities, with their 
often-generous tracts of land, can be designed to foster regional desires 
for habitat protection, stream reclamation, and landscape protection and 
enhancement. Site-specific analysis of all proposed sites (and for sites 
reviewed for retrofitting) may reveal possibilities to connect hospital 
space with bird migration routes, for example, adding not only the 
restorative capabilities of the garden, but to the betterment of the 
environment at large. 

Situated in the midst of most communities, a health care facility should 
stand as a precedent and an example of restorative site planning and 
design. Heightened used of hospital environs by community members should 
increase not only stewardship of the landscape, but also the sense of 
being "caretakers of our neighbors". If one's only exposure to those 
aging, suffering, struggling, or dying is a quick glimpse out the car 
window, how can community empathy possibly be enhanced? In contrast, if 
patients share space with schoolchildren, daily joggers, and caretakers of 
habitat and landscape, the opportunities for interaction, understanding, 
and action will necessarily increase. 

1.3. Project Goal and Objectives. 

a) Following the belief that : 

1. Design of the environment can have a powerful impact on individual 
and collective health and well-being; 

2. Health care facilities should be designed as holistic, restorative 
landscapes, not patchworks of isolated and introspective spaces, and 

3. Health care facilities should be designed as a component of the 
larger community, recognizing natural and social interrelationships; 

the goal of this project is to design and program a community health care 
facility that supports and enhances the health and well-being of all 
users. 

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b) Objectives. 

• To understand existing restorative design principles and objectives. 
• To understand the evolution of community hospital design. 

• To identify principles of restorative design that may be applied to 
health care facility design. 

• To illustrate, through design and programming, a vision for application 
of restorative design principles to the case study hospital site. 

1.4. Project Approach. 

This project began with the observation that hospitals, by design, act 
contrary in efforts to heal and promote health. This observation is the 
result of the author's 17 years working in the health care field as a 
registered nurse (primarily in emergency and trauma care, cardiac and 
intensive care, cancer, infectious diseases, and acute burns). An ever-
present barrier to good care was and continues to be the physical 
environment of the hospital itself. 

The author accepts that a strength of this project is this voice that 
draws from two worlds—health care and design. The author also accepts 
that this voice has inherent biases based on strong personal experience 
and so will rely heavily on the information supplied by multiple experts 
from varied disciplines (literature review): 

• Behavioural Sciences • Landscape Architecture 

• Ecological Sciences • Medical Sciences 
• Environmental Psychology • Planning 

Following the literature review, an effort will be made to delineate 
certain principles of restorative design that could be used to explore a 
more successful approach to hospital design. This initial part of the 
project aims to create an overall framework for design. These theoretical 
findings and assumptions were used to create a conceptual plan for the 
proposed hospital site. 

Design process and methodology is illustrated in Figure 1-1 on the 
following page. 

1.5. Site Introduction. 

In June of 2001, the Ministry of Health gave the green light to a new 
regional hospital to be built in Abbotsford, British Columbia. This 
municipality, the 5th largest in British Columbia is located approximately 
4o miles east of Vancouver. Fifteen years in the planning, the estimated 
date of completion for the new hospital is 2004. A 300-bed regional acute 
care hospital is being planned (in conjunction with a new regional cancer 
care clinic) in an effort to relieve the stress on tertiary centres in 
Vancouver, and to bring health care closer to home for the growing 
population of the Central Fraser Valley. The hospital site sits adjacent 
to the Trans-Canada Highway on a 10.4 ha lot currently surrounded 
primarily by residential and institutional buildings. 

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DESIGN T H E S I S M E T H O D O L O G Y 
"Exploring t h e Restorative H o s p i t a l L a n d s c a p e " 

P r o b l e m I d e n t i f i c a t i o n 

"Can landscape design enhance the restorative experience 
of a community hospital for patients, staff, and public?' 

R e s e a r c h - L i t e r a t u r e R e v i e w 

T I 
Restorative Design 

(stress reduction through 
environmental manipulation) 

Hospital Design 
(support of technology with high 

functional emphasis) 

Restorative design specific to the hospital environment 

Filtered through: 
1, Existing Precedents 
2. Specific User Need Analysis • 

Modified by: 
1. Health Care Experience 
2. Design Imagination 

D e s i g n I m p l i c a t i o n s 

J 
Implementation 

Site Analysis: 
Opportunities and Constraints* ' 

Program for Site: 
» Restorative and Functional 

Design Vision: The Master Site Plan 

Design Methodology Flow Chart 



CHAPTER II. 

Restorative Design: Literature Review 

2.1. Definition. 

Restorative design utilizes the healing power of landscape to improve the 
human condition. A restorative, therapeutic approach to a place assumes a 
perceived impairment of physical, mental or emotional well being and a 
desire, through design, to mend, renew, and/or heal. This approach to 
design accepts the widespread existence of stress in daily life and its 
potentially hazardous effects on health and well being. Designing in a 
manner that reduces stress and promotes well being is the primary 
objective. 

"ther-a-peu 
'pyii-tik" 

Definition: 

"re•store" 
"ri-'stOr" 

Definition: 

•tic" Function: 
Etymology: 
Date: 1646 

PROVIDE/ASSIST IN A 

Function: 
Etymology: 
Date: 14th 

GIVE BACK, RETURN, t 

adjective 
Greek therapeutikos, to attend, treat 

CURE, take part in healing process 

transitive verb 
from Latin restaurare to renew, rebuild 

century 
o bring back to a former, original state 

The hospital is utilized as a place of healing, a place to cure and mend. 
It also serves, for many, as a place to spend final years in comfort with 
the help of others. Patients have the responsibility to learn both from 
caregivers and from their inner selves independence in the face of newly 
diagnosed diseases or injuries. They have the responsibility to find 
wholeness out of broken pieces when faced with tragedies and medical 
hardships. Families and visitors affected by interactions with loved ones 
must find a new sense of balance in order to cope with tragedy or 
increased responsibilities. Health care providers, faced with crises in 
management, staffing, and patient numbers must somehow draw strength from 
the hospital environment (Cooper-Marcus and Barnes, 1999). 

It should be noted that restorative design is poorly understood by the 
public and, as well, by many designers. The assumption is that the goal 
is simply to create a serene atmosphere suitable for tranquility and 
harmony. The assumption is that restorative design is primarily concerned 
with gardens and greenery. While these may be important elements in the 
design, the active design for stress reduction ivolves far more complex 
issues, and touches on a variety of design issues including, but not 
limited to: 
• urban and rural design, community management and planning, 

sustainability issues, road and built environment construction, open 
space landscape preferences. 

Restorative health care facility design aims to create an environment that 
actively assists health care providers, visitors, and patients in 

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relieving stress, increasing comfort, reducing fears, and facilitating a 
sense of well-being across groups of users. The restorative landscape may 
occur naturally or may be designed, with varying degrees of intervention 
visible (Kaplan, Kaplan and Ryan, 1998). Key elements of restorative 
design, as derived from a review of available literature, are outlined 
below. 

A restorative landscape requires the presence of certain significant 
elements, most notably: 

• Inherent Familiarity: Designing for the restorative place demands 
recognition that across cultures, humans have an inherent connection to 
certain landscape types and forms. These archetypal landscapes can be 
utilized to create a place that is fundamentally comfortable, familiar, 
and healing (Condon, 1988) . 

• Legibility: A legible design allows the user to know instantly where 
he/she is in the world, and to feel comfort in that knowledge. This 
includes simple wayfinding and sense of safety and security, but also 
involves a greater sense of place and belonging, as will be discussed 
(Kaplan, Kaplan and Ryan, 1998, Lynch, 1960). 

• Natural elements: As the research will show, physical and visual access 
to nature (vegetation, habitat, water, etc.) has significant 
restorative properties (Kaplan, Kaplan and Ryan, 1998, Kellert and 
Wilson, 1993, Ulrich 1992, et al.). 

• Accessibility: Both perceived and actual accessibility are required for 
a design to be truly restorative. Accessibility includes universal 
design principles. It also includes issues of visual versus physical 
access (Lewis, 1996). Access by surrounding community members should be 
addressed as a means of enhancing social support (Ulrich, 1992). A 
restorative hospital site enables on-site access for patients, visitors 
and staff as well as a strong social and environmental connection to 
its surroundings, thereby enhancing the possibility for social support 
and a sense of belonging (Ulrich, 1992) . 

2.2. Inherent Familiarity: The Archetypal Landscape. 

The geographer Jay Appleton, in The Experience of Landscape, identified a 
fundamental preference in landform type: the prospect-refuge scenario. 
Landscapes that allow simultaneously an opportunity to see as well as hide 
are pleasing and comfortable. Ideally occurring in combination, prospect 
(mountain, sea) and refuge (cave, forest) were considered important givers 
of power to the individual (Appleton, 1975). 

Certain landform configurations serve as archetypes, still eliciting 
preference although largely void of their primary function. Prospect and 
refuge, important when man lived as predator and prey, remains highly 
desirable. The universal attractiveness of parkland or lawn is said to 
evolve from the savannah, man's early habitat (Fleissner et al, 1999). 
Situated on the edge of a forest, man was secure in the knowledge that 
retreat into the woods was possible, as was exploration into the savannah 
for hunting and gathering. The fertile river valley, as the cradle of 
early civilizations, is seen to give a region power and ability and 

- 7 -



abundance. Meadows, ravines, caves, and hillsides are all landform 
archetypes capable of eliciting various fundamental emotional responses. 

Christian Norberg-Schulz, an architectural theorist, referred to domain, 
path and node as archetypal elements of human settlement (Norberg-Schulz, 
1985). Kevin Lynch, an urban theorist, wrapped his assessment of 
archetypal form around the task of legibility and imageability; by 
identifying districts, paths, nodes, edges, and landmarks he was primarily 
concerned with wayfinding and memory (Lynch, 1960). Stephen and Rachel 
Kaplan (environmental psychologists), along with Robert Ryan (landscape 
architect), explained preference in terms of information gathering 
(Kaplan, Kaplan and Ryan, 1998). 

The shared belief of these authors is that man is innately drawn to 
certain landscapes: optimal conditions become hardwired in our collective 
brains and exposure elicits an expected response. Attempting to "create" 
therapeutic spaces without the recognition of powerful inherent 
preferences sets up an impossible task for a designer. 

Patrick Condon, landscape architect and professor at the University of 
British Columbia describes the volumetric open space, or clearing, as 
being perhaps the earliest constructed landscape (Condon, 1988). Allowing 
built structures (and/or mature trees) to create true spaces with depth 
and form is in sharp contrast to what Condon describes as the "typical 
Cubist leftover spaces created by situating modern buildings in the centre 
of landscapes" (Condon, 1988). Humans prefer and are more comfortable in 
landscapes that have recognizable volume and are not merely edges (Condon, 
1988). Carving out settlements in the heart of forests, western ancestors 
were able to surround themselves with natural buffers while creating an 
inward focused community. Early Medieval hospitals directed views and 
activity toward an internal cloister space, protected from the harsh 
realities of the outside world (Fairbrother, 1956). Essentially closed to 
the community, these clearings, or volumetric spaces were designed to 
maximize protection from external social and natural elements. Views were 
purposefully focused inwards (Fairbrother, 1956). 

A sheltered and protected space, whether formed by natural or built forms, 
continues to be sought out by humans seeking retreat in a variety of 
forms: the fenced backyard, the mountain cabin, the sheltered ski lodge 
and the courtyard house. Housing communities are often designed around a 
central, cloistered space. Private, internal spaces within gardens are 
favored. While the inwardly focused clearing does not meet the needs of 
all users at all times, it does present as a significant form for 
introspection, reflection, and interaction. 

A contrast to the sheltered clearing is the image of the open pastoral 
landform, derivative of hunting and gathering as well as farming 
traditions. Highly preferred across cultures by humans, this landscape 
offers comfort on a variety of levels. Apart from the inherent prospect-
refuge experience, evidence of stewardship in the pastoral landscape also 
increases preference (Sheppard, 2001) . The knowledge that this is a 
landscape that can support life appeals to our biophilic nature (Kellert 
and Wilson, 1993) . 



2.3. Legibility: The Preferred Landscape. 

In With People in Mind: Design and Management of Everyday Nature (1998), 
Kaplan, Kaplan and Ryan describe the great human contradiction: we need to 
know, but we don't want to know everything. Humans need to understand. We 
understand environments that are coherent (orderly) and legible 
(containing memorable components that help with orientation). Humans want 
to explore. We want to explore environments that are complex (richness of 
elements) and mysterious (the promise that more is out there to discover). 

People care deeply about information and the need to know. Confusion is 
rejected; exploration is embraced. Restorative environments are those 
that restore fatigued mental states through an appropriate balance of 
understanding and mystery. It is important to note, however, that the 
levels of information required by individuals vary greatly with past 
experience, age, circumstances in life and stages of health (Kaplan, 
Kaplan, and Ryan, 1998) . In the hospital setting, a range of 
"understanding" is required in design. Users under high levels of stress 
require simple, secure, and easy to read environments. A common error in 
design, however, has been to engulf the hospital in simplicity and 
transparency. Not recognizing the need for humans to explore (physically 
and/or visually) has resulted in designs that under stimulate, thereby 
heightening feelings of depression, loneliness, and hopelessness (Ulrich, 
1992). Hospital users (patients, staff, and visitors) require choices and 
options for wonderment, fascination, and visual/physical exploration 
(Ulrich 1992) . This balance of legibility is a significant challenge for 
the restorative design. 

Taking advantage of familiar, local patterns, forms and elements has been 
pointed to as a potential means of creating familiarity and legibility. 
Examination of the local, or the vernacular, offers insight into 
preferential forms for potential users of a space. 

"...But above all, work on the site, stay on the site, let the site tell you 
its secrets" (Alexander et al, 1977, p. 463) 

What of this region makes this place unique? What of this neighborhood 
exudes energy and life? What on this site references places of 
reparation, rejuvenation, and reclamation? The life-making and -
perpetuating ability of the site and its context may be found in the 
minutiae, the details, the ordinary, and the overlooked. 

Understanding the language of local life as exhibited in landforms, built 
typologies, vegetation and function of space enables the designer to 
create spaces that exude familiarity and comfort. Beautiful landscapes are 
not necessarily comforting: they may be perceived simply as recreational 
spots. Use of the everyday landscape can, however, create a beautiful as 
well as comforting and threatening image. "Thoughts stray to the normal, 
fundamentally reassuring relationships and interactions of our lives" 
(Hough, 1990, p. 23) . 

The vernacular has traditionally been described as "forms that grow out of 
the practical needs of the inhabitants of a place and the constraints of 
site and climate" (Hough, 1990, p. 34). Identifying this local "language" 
of landscape and building enables the presence of legible, understandable 
elements in the design. Through use of the vernacular, levels of 

- 9 -



legibility can be altered depending on users and surrounding function. A 
high-stress treatment area, overloaded with the unknown, in which the 
patient suffers fear and loss of control, may dictate an adjacent area 
that takes full advantage of local vernacular to create a known, 
comfortable place of reprieve. To be able to sit in a garden or room that 
"looks just like home" prior to chemotherapy is preferable to lining up in 
hallways or lounges that look "just like a hospital". In contrast, 
patients confined to beds or wards would benefit from views that offer 
intrigue or mystery to contrast with monotonous institutional walls. 
Wonderment over distant pathways or secret gardens below is preferable to 
pondering the number of ceiling tiles or watching the clock between pain 
medication dosages. 

Achieving this balance of understanding with mystery is a primary goal of 
designing for comfort and legibility. It is not enough to simply surround 
the users in familiar, easy to comprehend patterns (for example, the easy 
to read urban grid system). Designers need to ensure a significant amount 
of "mystery" in the landscape in order to allow imaginations to wander, 
fascination to build, and exploration (mental or physical) to occur. In 
With People In Mind, mystery is explained as the promise that more 
information is available as one travels farther into the scene (Kaplan, 
Kaplan and Ryan 1998, A pathway that winds off into the distance to an 
unknown destination offers gentle mystery. A roadside embankment thick 
with underbrush with no obvious entrance offers heightened mystery, 
verging on fear. Evidence of familiar, vernacular human signs (paths, 
benches, fence posts) intrigue the viewer by creating a sense of 
comforting mystery and the knowledge that others have come before. 

2.4. The Call to Nature: The Living Landscape. 

E.O.Wilson states "the urge to affiliate with other life forms is to some 
degree innate" (Kellert and Wilson, 1993) . This "biophilia" is supported 
by a variety of researchers and theorists, Kaplan being perhaps the most 
well known voice. Humans have a fundamental preference for "living 
landscapes", alive with the evidence of biological processes. Landscapes 
that feature water, food, birds and animal habitat, or open pastures 
suitable for livestock give a sense of being able to support life. We are 
reminded of our connection to the earth, and of its life-giving 
properties. Medieval hospital garden designers recognized the benefit of 
birds and water in the healing landscape (Fairbrother, 1956) . Modern day 
researchers have afforded us quantitative evidence of the healing value of 
such elements (Kaplan, Kaplan and Ryan 1998, Gold 1986, Ulrich 
1979/1984/1992, et al). 

Bringing legitimacy and urgency to the benefit of integrating the natural 
environment with hospital settings is mounting evidence that physiological 
and psychological status of patients (and staff) is highly responsive to 
their surroundings. Dr. Roger Ulrich (environmental psychologist) at the 
College of Architecture, Texas A & M University, College Station, Texas, 
has focused much of his career tracking patient responses to various 
environmental design features. Ulrich works closely with health care 
professionals to measure such patient markers as: 

• Psychological reactions (mood, well-being), 

- 10 -



• Physiological reactions (blood pressure and pulse, muscle tenseness, 
levels of stress hormones, brain wave activity, skin conductivity), 
and 

• Behavioral indicators (frequency of verbal outbursts, sleeplessness, 
alcohol and drug abuse, degree of compliance with therapies, 
requests for assistance from nursing staff, and length of hospital 
stays). 

Ulrich has observed that traditional design often works counter to both 
patient and care provider needs (Ulrich, 1992). Striving to meet the 
goals of functional efficiency, cost containment, and codes, designers 
have created "hard" and institutional-like spaces when what is needed, 
according to Ulrich, is a place that offers support and comfort. Patients 
are under varying degrees of stress. Situated in a foreign environment 
and often facing reduced physical capabilities, painful and/or unknown 
(frightening) treatments and an uncertain future, they can become 
overwhelmed with a sense of helplessness and feelings of anxiety and 
depression. Ulrich has reported a decrease in stress indicators following 
exposure to "positive distraction", primarily natural elements. 

With his colleague Russ Parsons, Ulrich has showed that absence of 
"positive distraction" and subsequent sensory deprivation can have 
deleterious health effects for the hospitalized patient and caregiver. 
Their work has shown that not only can restorative design reduce stress 
but that its very absence can increase stress and cause harm. 

Positive distraction providing the most benefit is identified as: 
1. Natural elements such as trees, plants, and water; 
2. Happy, laughing or caring human faces (opportunities for 

programming), and 
3. Birds, small habitat and domesticated animals (Ulrich and Parsons, 

1992) . 

Continuous exposure to stress has the potential over time to cause 
permanent damage, interfering with self-coping mechanisms and, in the 
extreme, further depressing immune systems, making them more vulnerable to 
illness. The incidence of nosocomial (hospital-derived) infection and 
illness has traditionally been linked to cleanliness and procedures, but 
current thought shows a significant link to stress by situations and 
surroundings (Ulrich, 1992). 

While the traditional concern in hospitals is for the patient population, 
it should be noted that staff are not immune to the effects of stress and 
anxiety. Working in difficult, emotional situations and often with little 
control or reprieve, caregivers experience high rates of stress-related 
illness with ensuing lost workdays and reduced productivity (Ulrich, 
1992). Caregivers under stress directly impact on patient well being given 
the close, dependent relationship. 

A "nature restoration hypothesis" has been proposed that natural views of 
trees and other plants tend to reduce stress and anxiety. Informal, 
natural, woodland type settings are preferred for their restorative 
benefits (Kaplan, Kaplan and Ryan 1998, Gold 1986, Ulrich 
1979/1984/1992). The use of water in healing landscapes is evident 
throughout our documented history. Recent studies indicate a measurable 
improvement in physiological well-being as a result of negative ions in 

- 11 -



the surrounding moving water molecules (Parsons, 2000). The restorative 
benefit of interfacing bird and animal habitat with patients is also well 
documented. Despite his strong work in the area of visuals, Ulrich joins 
other researchers in noting an increased therapeutic benefit if physical 
interaction, in particular with domesticated animals, is facilitated 
(Ulrich, 1992, Lewis, 1996) . 

Research into association with companion animals has shown positive 
healing results. Clinical trials have indicated an improved 5-year 
survival rate post myocardial infarct for patients with close companion 
animal contact (Bustad, 1987). In healthy individuals (control subjects), 
this same research showed lasting reduction in sympathetic (flight or 
fright) responses. In short, stress reduction through interaction with 
animals occurs regardless of stage of health. Caring for other living 
things is an important tool for warding off the inevitable helplessness 
and hopelessness that threatens to accompany ill health (Beck and Katcher, 
1984) . The reciprocal nature of the relationship allows people to be 
rewarded by feeling needed. Many times the act of feeding an animal is 
often the first real connection that a child makes with care giving, and 
the development of empathic responsibilities within the social world. As a 
person ages, the role of care giving changes. With the elderly person, a 
task as simple as setting out some crumbs for the birds may be enough to 
continue or rekindle positive, empathic feelings that come with providing 
care for another living being. 

2.5. Physical & Visual Connections: The Accessible Landscape. 

The accessible landscape is one that permits and encourages movement and 
exploration (visual and/or physical) by a wide range of users. Ensuring a 
high level of real and perceived comfort of movement for patients, staff, 
and visitors enhances the restorative benefits of the landscape (Centre of 
Universal Design, 1997). 

Ideally, design should be equitable and democratic. The same means are 
provided all users: identical when possible/equivalent when not. The 
widely accepted principles of universal design ensure that no single user 
is made to feel like an afterthought (Centre of Universal Design, 1997). 
A balance of easy wayfinding and access with opportunities for challenge 
and mystery should be incorporated in the design for all users, 
accommodating a wide range of individual preferences and abilities. The 
Principles of Universal Design are outlined in Appendix I. 

Providing options and choices of movement within the landscape (within 
small gardens as well as within the larger open space) is important to 
give users a sense that the space was designed with them in mind. Patrick 
Mooney, landscape architect and professor at the University of British 
Columbia, well known for an influential 1992 study that measured 
Alzheimer's patients responses to the exterior environment (Mooney, 1992) 
is quoted as stating that "giving people choice gives them dignity" 
(Stevens, 1995). A restorative landscape not only allows entry, but 
encourages exploration (Kaplan, Kaplan and Ryan, 1998). 

Access to and through a landscape is also dependent on a sense of safety 
and security. Designing for real and perceptual security without 
resorting to widespread target hardening (lock and key) presents a unique 

- 12 -



challenge. Crime Prevention through Environmental Design (CPTED) is a 
means of exploring this challenge that was developed in the 1960's for use 
by architects, city planners, landscape architects, interior designers, 
and law enforcement personnel. CPTED contends that by designing the 
physical environment in a manner that positively influences human 
behaviour, it is possible to create a climate of safety at a community or 
site level. As a 24-hour facility, the hospital requires a design strategy 
that allows for safe passage by staff and visitors to and from 
cars/buses/buildings/programs at every hour of the night. The principles 
of CPTED contend that, while there are occasions in which locked gates and 
fences become necessary, much can be done to heighten safety and security 
through manipulation of the external environment and its components (RCMP, 
2002). CPTED hinges on the belief that if a place appears under good 
stewardship and measures are taken to promote legitimate activity, this 
will have the dual impact of discouraging unwanted behaviour and 
heightening existential security. The CPTED principles are outlined 
further in Appendix II. 

Designing for accessibility and security should not be limited to the site 
level. At the broader, open space planning, scale, clustering hospitals 
with schools, community parks, daycares, and civic buildings increases 
visibility and accessibility. The connection of schools and seniors' 
housing seems a logical and sustainable method of crossing age barriers 
and breaking down destructive mythologies. A more concerted effort to 
program "private" hospital grounds for use by the public (and, likewise, 
to facilitate use of surrounding amenities by hospitals) would have the 
added benefits of enhancing stewardship and offsetting long-term 
maintenance costs. Connecting hospital open space programs with community 
greenways, cycling routes or pedestrian walkways will enhance stewardship, 
positive use and a sense of belonging. 

If an open space is to satisfy the needs of the community at large, the 
physical form becomes an important consideration (Wright, Braithwaite and 
Forster, 1976). Too often public open space is designed as patchy, 
disconnected units with little continuity: a soccer field at the end of a 
block, a fenced school yard, an isolated skateboard park, a distant 
bicycle trail. For open space to be successful it must be close and 
accessible. "Whenever possible, these smaller spaces should be linked to 
larger park areas through the use of open space corridors to form a 
complete network system of open space within the community" (Wright, 
Braithwaite and Forster, 1976, p. 40) . 

Accessibility: An Evaluation Process. 

Private places are often filled with remarkable staircases and grade 
changes that, although visually appealing, are inaccessible to a large 
portion of our population: the aged and mobility impaired. Public space 
designers too often take the unimaginative route of integrating obvious 
ramps and paths that are not only lifeless, but that draw attention to the 
fact that the less-abled are "different". Confidence and comfort are 
chipped away every time a less abled person is "told" by designers that 
they are different, and require special equipment only for them, and 
special entrances only for them. If unique equipment is required to 
enable users, a design that traverses ability should be utilized. The 
challenge for hospital design is to create a place that combines desired 

- 13 -



elements of entrance, transition, and movement without second-thought 
additions for access. 

Questions to be asked during the design process may include: 

• Is the place accessible to all people, regardless of age or ability? 
Are paths accessible for walkers, wheelchairs, persons with limited 
mobility, and the very young to very old? Does the design create 
special places on the site that relegate the less able to status of 
observer only? 

• Are pathways connected in such a manner as to allow short, protected 
walks (patients requiring health care provider supervision) as well as 
more expansive walk experiences (psychiatric patients)? 

• Are ground plane features —plantings, water features- accessible (for 
touch, sight, and smell)? Garden features may include vertical 
structures with plantings that climb up to people. Beds may be raised 
for hands-on interaction. Are color palettes accessible to those with 
limited vision? Color massings are more visible to aged retinas. 

• Are there areas easily accessible by hospital staff that permit the 
combination of landscape and therapy programs (physiotherapy, cardiac 
rehabilitation programs, occupational therapy, horticultural therapy, 
etc) ? 

• Is there sufficient above ground support for users, and places to rest? 
The lack of rest stops and/or hand supports can create unpleasant and 
uncomfortable experiences for users that will prevent repeat use. 

• Does the design accept that all areas of the hospital grounds must be 
accessible to emergency caregivers, fire services and maintenance 
workers? 

• Is accessibility negated by exposure? Are open areas protected from the 
elements? Several conditions or stages of health demand extra 
protection from ultraviolet light exposure (psychiatric, pregnant, 
paediatric, cancer, burns, etc). 

Conclusion. 

Wrapping a hospital landscape in restorative benefits while still 
maintaining a functional, realistic program is the challenge for 
designers. Despite the increasing abundance of restorative design theory 
and data, modern hospital precedents all too often get lost behind the 
purely functional, leading to lifeless, cold, controlling places filled 
with signage that compound rather than reduce stress (Ulrich, 1992) . The 
expanding field of restorative design seeks to take advantage of the 
healing power of landscape in order to improve human condition. Four 
primary elements have been identified as contributing in a large way to 
the restorative nature of a place: inherent familiarity, legibility, 
natural elements, and accessibility. Finding ways to incorporate these 
elements into a design, whether in the public or private realm, will 
facilitate stress reduction and healing for humans at all stages of the 
health continuum. In the hospital environment, this means improved well 
being for patients, staff, and visitors as well as visiting community 
members taking part in outpatient programs, volunteer/stewardship programs 
or recreational opportunities. 

- 14 -



CHAPTER III. 

Inquiry into Status of Hospital Design 

Introduction. 

Many acute care health care facilities are designed according to a cookie 
cutter image of the functional institution situated on a generally 
lackluster tract of land. Function and economics continue to be the 
overriding motivators behind any new facility with little to no 
exploration into imaginative or creative design solutions, despite the 
growing body of research into restorative design (Cooper Marcus and 
Francis, 1998). A review of the literature (or lack thereof) reveals a 
submissive tolerance of the status quo on the part of designers. Society 
has rejected the image of large-scale, block social housing and yet we 
continue to build similar blocks to "house" the sick. Programs aimed at 
health prevention, maintenance and promotion, based within the confines of 
existing modernist hospital structures, struggle under the weight of the 
surrounding architecture and "dead" landscape space. 

The increasing awareness of the effect of exterior environment on health 
would seem to demand a strong attention to landscape design for health 
care facilities. This, however, has not been the case. In an issue of 
Landscape Architecture that focused on "Healing Gardens" (January 1995), 
Roger Ulrich is quoted as follows: "Interior designers have taken the lead 
and architects are coming up to speed. That's not been the case for 
landscape architects" (Dannenmaier, 1995). In the seven years since that 
statement was made, it is arguable that landscape architects continue to 
lag behind in terms of both inquiry and design. 

Claire Cooper Marcus, an important voice calling for a revisitation of 
tired hospital design guidelines, laments the difficulty of affecting 
change in a system that is unwilling to allocate funds for unquantified 
benefits to patient recovery (Cooper Marcus and Francis, 1998) . As 
discussed in the previous chapter, these benefits are being quantified by 
an increasing amount of research. 

Understanding the direction, or arguably lack of direction, for health 
care facility design by landscape architects demands an awareness of the 
historic evolution and the current factors affecting change and growth. 

3.1. History of Hospital Design: An Overview 

(a) Monastic Cloisters: Early Recognition of Landscape Power. 

Historically, the first western "hospitals" took great advantage of their 
physical layout, assuming a strong connection between the healing process 
and the natural environs. The early Benedictine monasteries situated 
patient care rooms around a central cloister garden with easy views to the 
physics gardens planted with roses, lilies, sage, rosemary and other 
herbaceous plants used to concoct early cures (Fairbrother, 1956) . The 

- 15 -



cloister 

connection between rehabilitation and a view to life-giving nature was 
deemed vital and necessary. These early medieval hospitals generally 
featured a healing walkway, designed and choreographed to provide specific 
restorative experiences along the way: exposure to water, to wildlife, to 
fall color, to spring blooms. Water was an 
important and vital component of medieval 
monastic gardens. In the earliest 
cloisters, the centrally located well was 
used for sustenance, bathing and religious 
purposes. The central location also eased 
the labor of irrigation. Over time, these 
water features took on greater prominence 
and decoration with the lines between 
symbolism, function, and aesthetics 
blurring (Fairbrother, 1956). 

Walks in the connecting gardens were 
prescribed as diligently as were crushed 
herbs and ill-tasting tonics. "The 
experience of walking around the edges of 
the garden, enjoying it from the covered 
space, smelling the fragrance of herbs, 
feeling the warmth of the sun, and hearing 
the trickle of a central water feature 
contributed to the serenity of these sanctuaries" (Parsons, 2000, p. 

:•»-<!* /#-try- ,;•-.-~r'~, \..,r—— " "•;>;' 

V S . V, 

5) . 

The Dark Ages moved the study and practice of science and technology 
behind monastic walls. Medicine and, subsequently, care of the sick and 
dying fell to the religious orders. Physic gardens, referring to the 
combined planting of flowers and medicinal herbs, became a central and 
important component of the monastic garden space. Throughout the Middle 
Ages, monasteries gave sanctuary to native plants and introduced herbs. 
The Abbey of St. Gall in Switzerland (AD 830) is characterized by Ruth 
Wrensch in The History of Herbs as a vital protector of special and 
medicinal plants, preventing mass depletion and extinction of several 
species (Wrensch, 1992) . It is recorded that the monastery of St. Gall 
had a medical herb garden, rooms for 6 sick people, a pharmacy, and 
special lodging for a physician. This is considered the first Western 

example of a hospital 
(Mayeaux, 2 0 0 0 ) . Under the 
Benedictine order, 
monasteries quickly 
expanded the trend and by 
the 10t h Century many 
monasteries in Europe had 
attached hospitals 
(Mayeaux, 2000) . 

An important building in 
medieval monasteries was 
the early isolation 
hospital with an attached 
chapel, bathhouse, kitchen, 
rectory and medicinal 
garden. The physician's 
house was located nearby 

- 16 -



with its own physic garden of essential medicinal herbs, new 
introductions, and several small sick rooms for the acutely ill. 

Medicinal plants such as sage, fennel and rosemary, were situated outside 
the infirmary widows and entrances in order to encourage patients to 
connect the "cure" with nature and therefore a higher power (Wrensch, 
1992). The use of "man-made" medicine was given religious approval 
through this ever-present and very visual connection with the earth. 
Fragrant and visually aesthetic flowers and shrubs were included in the 
early physic gardens. Debate over possible medicinal use of roses, 
lilies, peonies, and gladioli may hide the possibility that medieval man 
simply felt the sensorial impact itself was worthy of inclusion in a 
healing garden. 

As originators of Botany, the early Greek states produced tremendous 
writings on common plants and specified or hypothesized medicinal purposes 
(Wrensch, 1992). Behind medieval monastic walls, this field of Botany 
became one and the same with the field of Medicine. Plants were mandatory 
in the attempt to cure any illness. Indeed, there were remedies for many 
complaints not treated today. Medieval herbal concoctions existed not 
only for such complaints as fever, headache, insomnia, and more serious 
illnesses, but also for "immoderate laughing, forgetfulness, excessive 
crying, and fleshy lust" (Fairbrother, 1956). Written manuscripts 
produced during the Middle Ages outline specific planting schemes and 
arrangements of buildings, indicating a strong belief in the power of 
landscape to affect outcome of patient care. This perceived power is 
further illustrated in written instructions for patient programs and 
activities. 

"The sick are encouraged to spend time in the orchard, breathing the 
scent of fruit and flowers, so that their senses can be refreshed. 

Where the orchard ends, the garden begins. 
Here too a lovely prospect presents itself to 
the infirm brethren; they can sit on the 
green edge of the great fountain, and watch 
the little fishes challenging one another, as 
it were, to war-like encounters, as they meet 
and play in the water." (Talbot, Alice-Mary, 
n.d. ) 

It is interesting to note that a study 
conducted by Cooper Marcus and Barnes (1995) 
revealed very similar requisites for healing 
gardens as those utilized in early monastic 
cloister gardens: greenery, fragrance, bird 
sounds and privacy (Cooper Marcus and Barnes, 
1995) . 

The cloister design of these first hospitals 
had a purpose: to direct patients and healers 
toward the cures of nature. The connection 
between mind and spirit and body was clear. 
The connection between man and nature was 
clear. Monastic reforms following the 11th C 
saw a dramatic decline in gardens produced by 
non-secular entities. And, certainly, as the 

Figure 3-1: Mass-Void for 
Monastic Cloister Design 

- 17 -



domain of health care found its way to a medical profession infatuated 
with the provability of science and technology, natural settings for 
treatment diminished. 

(b) Community-based Treatment: Hospital as Death House. 

Prior to the mid 19th Century, the focus of health care was decidedly home 
and community-based. With good reason, patients were treated outside the 
hospital as much and for as long as possible. The role of the hospital 
was primarily to prolong life and ease the pain of dying. Admission to 
hospital rarely included a discharge to home: the concept of designing for 
"healing" was largely non-existent. Hospitals were forbidden, segregated 
dark corners of the community (Cooper Marcus and Francis, 1998). 

The radical revision of medical theory and practice that followed the 
discovery of germ theory gave hospital designers an entirely new focus and 
purpose. It became possible to treat, and even cure illness and injury 
rather than simply prolong life. Health care, rather than palliative care 
alone, was born. 

Nurse Florence Nightingale put forth the concept of antisepsis in 1859 in 
her "Notes on Hospitals". She showed that hospital mortality rates were 
three to five times higher for hospitalized patients than those who had 
been treated at home. Her work with reform of sanitation and cleanliness 
in hospitals spurred a new awareness that the form of structure in which 
health care was undertaken was vital (Bynum, 1994). 

The discovery of bacteria by Louis 
Pasteur revolutionized the medical 
field, and with it, the image and 
requirements of the hospital as 
place. As the "architect of germ 
theory", his discovery of 
vaccinations found immediate 
success in the treatment of such 
devastating illnesses as anthrax, 
chicken pox, and cholera. Robert 
Koch continued this inquiry and in 
1882 was able to prove the 
infectious nature of the 
tuberculosis bacillus, another 
important milestone. Now, 
individuals could understand that 
they became sick for a reason, not 
just by chance. And, most 
importantly, that health care 
could prevent, treat, and cure 
illness (Bynum, 1994). 

(c) The Birth of "Health Care": Design Reform. 

The realization that everyday persons could actually recover from the 
ravages of infection and injury brought new reform to the design of 
facilities for patients. The value of creating a homey experience replete 

- 18 -



with fresh air, sunlight, proximity to nature and strong indoor - outdoor 
relationships found its way to late 19th C hospitals. 

Figure 3-2: Pavilion style hospital. In the early 
20 C , wheeling patients outside the pavilion 
for "afternoon sun and fresh air" was considered 
a mandatory nursing function. 

Generally two-three storey 
buildings connected by 
open walkways, this 
"pavilion-style" dominated 
new hospital construction 
well past the major world 
wars. It is no small 
wonder that the desire to 
surround the ill with lush 
exposure to nature 
coincided with attempts by 
park designers (most 
notably, Frederick Law 
Olmstead) to "heal" the 
public with spacious, 
heavily designed parks. 

Turn of the century reforms are perhaps most evident in British Columbia 
on the grounds of Riverview (Psychiatric) Hospital in Port Coquitlam, B.C. 

Early administrators of 
this large provincial 
psychiatric facility saw, 
in 1912, an opportunity to 
create a unique facility 
that would benefit not 
only patients but the 
community as well (City 
Trees, 2001). The design 
included built structures 
as well as a working farm, 
gardens, orchards and an 
arboretum of over 1800 
trees. With the help of 
patients, they created a 
living heritage by 
planting trees from seven 
continents. Today, with 
buildings closed or in 
limbo, Riverview has a 
greater role as a 
backdrop for the film 
industry than as an 

institution for psychiatric care, but there is little doubt that the site 
is a unique gem to be protected. Riverview's trees comprise western 
Canada's most significant arboretum and the site is a vital link in a 
green corridor between the Fraser River and Burrard Inlet with outstanding 
habitat and educational value. 

Figure 3-3: Image of Riverview Psychiatric 
Hospital grounds, Port Coquitlam, B.C. 

- 19 -



Unfortunately, these reforms to hospital design did not survive past the 
Second World War. A western world dealing with rapid changes in 
technology put health care reforms secondary to cost-efficiency and 
functionality. 

"In acute care hospitals, the design emphasis shifted towards 
saving steps for physicians and nurses, and away from attention to 
the environments patients experienced. Gardens disappeared, 
balconies and roofs and solaria were abandoned, and landscaping 
turned into entrance beautification, tennis courts for the staff, 
and parking lots for employees and visitors. The prestige of the big 
city teaching hospitals with their gardenless patient environments 
set the styles for all the others" (Gerlach, Kaufmann and Warner, 
1997) . 

(d) Modernist Domination: The Health Care "Machine". 

Certainly the modernist fascination with the machine affected more than 
hospital design. It is curious, however, that while the form of modernism 
has been soundly rejected in other areas of public design it continues to 
mold the way in which communities perceive and approach health care. 

Early skyscraper designers battled with European Bauhaus adherents to 
create the perfect monuments to technology and man's power over nature. 
Expensive, monumental, enclosures of space, these buildings were copied in 
a hundred cities and more, not only as office towers but in the modern 
design of all commercial and public structures, including supermarkets, 
motels, and institutions. While on the one hand, perfect expressions of 
medical science's desire to thwart and dominate nature, they stand as the 
purest contradictions of the very fundamentals of health care. 
Disconnected and segregated they loom dangerously over the community with 
acres of concrete, stone and glass. The living nature is relegated to a 
struggle for life in geometrically spaced gratings. In the Modernist 
world, more is more. More is power. More is better. 

Jane Jacobs launched an attack on modernist city planning, and design in 
her book The Death and Life of Great American Cities (Jacobs, 1961) . She 
criticized the modernist abandonment of the traditional relationship of 
houses, sidewalks, and street and their replacement with high-rise 
apartment blocks set in 'parks'. These new forms of design broke down the 
traditional control of criminal behaviour and destroyed the sense of 
community identity and stewardship. The ability of residents to watch the 
street and the presence of people using the street diminished as built 
structures turned inwards and upwards. 

CasB in Point: Social Housing. 

Several sociologists have agreed that the end of the modernist domination 
in public architecture and construction occurred in 1972 when the crime-
infested, vandalized, urine-soaked Pruitt-Igo housing development in St. 
Louis was blown up. Once standing as a classic example of social 
engineering, the realities of life in this modernist structure caused its 

- 20 -



demise: high crime, the difficulty of policing, raging substance abuse, 
spiraling levels of morbidity and mortality among residents. 

The Pruitt-Igo towers, in East St. Louis, consisted of 11 story-high 
buildings with grounds on the first floor for community activities. 
Because the grounds were common and disassociated from units, residents 
could not identify with them. The complex never achieved more than 60% 
occupancy and was destroyed only 10 years after construction (Brossman et 
al, 2001). Pruitt-Igo was replaced with duplexes, row houses and single-
family structures. A renewed social sense of responsibility in the late 
60's-70's resulted in a rejection by many designers and planners of the 
modernist typology once thought the tool for social change in impoverished 
communities. 

Unfortunately, this belief in 
the ineffectiveness of modernist 
architecture and landforms is 
slow to cross into the realm of 
health care facility design. 
Pruitt-Igo versions of community 
hospitals exist across the North 
American landscape. 

Above- Figure 3-4: Demolition of 
Pruitt-Igo modernist social 
housing structures in 1972. 
http://www.eslarp.uiuc.edu/ 

Left- Figure 3-5: Prototypical 
modernist hospital structure, 
current day. 

- 21 -

http://www.eslarp.uiuc.edu/


3.2. Current Trends Affecting Health-care Facility Design. 

After a decade of slow growth, health-care design and construction is 
poised to expand substantially in this first decade of the new millennium. 
The baby boom generation, now ranging in age from 35 to 55 years, is 
influencing a wave of new and remodeled facilities. Several factors are 
influencing, or are poised to influence, the shape of future health care 
facility design. 

"Another building boom in health care will occur within the next five 
years, expanding capacity to meet the needs of the Baby Boomers and their 
aging parents." - Futurescan 2001: A Millennium Forecast of Healthcare 
Trends 2001-2005 

3.2.1. Expanding Definition of Health 

The World Health Organization, the United Nations specialized agency for 
health, was established on 7 April 1948. WHO's objective is the 
attainment by all peoples of the highest possible level of health. 

• "Health is a state of complete physical, mental, and social well-being, 
not merely the absence of disease or infirmity. Health involves 
emotional, social (cultural, environmental) , and physical well-being 
and is determined by the social, political, and economic context of 
lives as well as by biology" (World Health Organization, 1948). 

Over the past twenty-five years, the understanding of what is meant by 
health has evolved and continues to evolve. The WHO constitutional 
definition has not been amended since 1948, however, in 1986, the WHO 
further ^refined' its definition in the following manner: 

• "Health is seen as a resource for everyday life, not the objective of 
living; it is a positive concept emphasizing social and personal 
resources, as well as physical capacity" (World Health Organization, 
2002). 

The Federal Ministry of Health in Canada adheres to this definition in 
prepared documentation regarding promotion of public health as well as 
programming of institutional treatment. Social isolation, poverty, 
ethnicity/cultural diversity are all noted as significantly related to 
quality of health. Social support during times of illness or wellness 
has, in particular, been recognized as vital to health promotion. 

• "All families who are having and rearing children need support--from 
friends, relatives, neighbours, and more formal services. For parents, 
particularly women, who are isolated and facing a number of other 
stresses, support is invaluable" (Health Canada, 2002a). 

Health Canada is also becoming more open in acknowledging that the natural 
environment is a key influence on health. 

• "Many factors, including family history, social or financial status, 
physical environment and personal lifestyle choices influence 
individual health. By making Canadians more aware of dangers to their 
health, protecting them from avoidable risks and encouraging them to 
take a more active role in their health, Health Canada fosters a 

- 22 -



healthier population and contributes to a more productive country" 
(Health Canada, 2002b). 

This holistic definition describes the ideal state on which health policy, 
programs and dollars should be focused. Acceptance that health is more 
than just the absence of disease is a significant move towards more 
community-based programs as well as higher levels of public participation 
in the planning of health care facilities. "Healthy Community" programs 
are becoming integral parts of the municipal wheel. 

3.2.2. Acceptance of Therapeutic Research 

In 1988, an informal, annual forum of professionals was created to explore 
how the design of the physical environment can positively contribute to 
the quality of health care. The goal was to enhance awareness of the 
impact environment has on health as well as actively envision new, 
creative possibilities for the health care landscape. In November of 
1993, Leland R. Kaiser, Ph.D. (a professional consultant and self-
professed 'futurist') was the keynote speaker for the sixth symposium 
entitled "Design: Contributing to the Quality of Health Care'. He observed 
that health care facilities have traditionally been designed to encourage 
passivity and non-involvement, and to reinforce the idea of sickness over 
regeneration. Too often, Kaiser stated, the hardware—the machines, the 
diagnostic devices, even the doors (with their "keep out" messages 
everywhere) set the tone of a treatment area in a way that cannot help but 
make patients define themselves as "...sick, dependent, and far removed 
from everything that seems comfortable and nurturing" (Centre for Health 
Design, 1997) . 

Kaiser focused his priorities for reform on the need to involve 
communities, including patients in the planning and design phase. He 
encouraged designers to become 'advocates' for the hospital landscape. At 
this same conference, the formation of 'The Centre for Health Design' was 
announced, a non-profit organization established to guide and direct the 
symposium's activities and spread the message of reform to a broader 
audience (Centre for Health Design, 1997). 

The Centre continues to this day with over 25,000 members (design 
professionals, health care executives, practitioners and product 
manufacturers) committed to the use of design to improve the quality of 
health care. Annual speakers range from Ralph Nader, Dr. Patch Adams, 
landscape architects Marni Barnes and Claire Cooper Marcus, futurist 
Russell Coile and other high profile individuals (Centre for Health 
Design, 1997) . 

A strong emphasis is on the advancement of evidence-based design, such as 
the work being done by Roger Ulrich and others. "Evidence-based design is 
research-informed and its results not only affect patient medical 
outcomes, but also staff satisfaction and facility operations. It looks at 
building design not only as the physical space, but includes the total 
sensory environment of sight, sound, touch, and smell" (Centre for Health 
Design, 2002) . 

"We are convinced that with more persuasive information as to their 
benefits, many more hospital staff would encourage the use of outdoor 
spaces for healing and stress reduction" (Cooper Marcus and Barnes, 1995) . 

- 23 -



3 . 2 . 3 . E m e r g e n c e o f i n f o r m e d c o n s u m e r s 
The current British Columbia government is "discussing" the possibility of 
closing and/or modifying several community hospitals in the province. 
Hospitals, in kind, are responding with vigorous defenses. The 
implication for designers in both instances is a need to create hospitals 
that are wanted, are welcoming, and that give evidence at first glance of 
their "healing capacity". In the new health care environment, hospitals 
and health systems may discover a need for simple competition on quality, 
exemplary facilities and centers of excellence. A hospital's very 
survival may be dependent on how well it competes in the "market". 

3.2.4. Changing Demographic 

An aging demographic in North American, coupled with health care 
technology that is expanding life expectancy is changing the face of our 
communities. As well, medical advances are transforming acute illnesses 
into chronic illnesses with near to normal life expectancy. Disability 
that often accompanies chronic illness (heart disease, arthritis, 
diabetes, AIDS, CHF, etc.) must be accommodated for in the design of 
public and private spaces. 

The field of health-care design is also responding to society's increasing 
cultural diversity. This is already evidenced physically in signage, the 
use of icons and symbols for communication. Creating spaces that address 
the complex needs of a wide range of users will be an increasing 
challenge. 

3.2.5. Industry consolidation/Changing Decision-Makers 

In the American system, the independent free-standing hospital is unique. 
In the face of current financial challenges, health-care facilities are 
resorting to consolidations, acquisitions and mergers to achieve their 
goals, and are creating a corporate health-care model. Canada is faced 
with its own challenges as governments vacillate between regional and 
centralized models of control. 

The threat of privatization of health care in Canada will have significant 
impacts on new hospital design. The site of this thesis project is a 
unique political test case in British Columbia. Private rather than 
public contractors are being utilized in the early stages of construction 
(demolition, at this point) with significant ensuing uproar within public 
sector unions. Discussion has also revolved around the possibility of 
sharing responsibility for the hospital operations between the government 
and private sector. 

3.2.6. Consumerism and Retailing 

In the coming years, a continued rise in the population, combined with the 
idiosyncrasies of older and better educated baby boomers, will drive the 
demand for health-care facility construction. Physicians will be 
confronted by information-laden patients who have done their research on 
the Internet and will want to cross-reference with medical experts. The 
hospitals of the future will provide areas where doctors and patients 
together can utilize electronic access to the latest medical knowledge. 

- 24 -



At the same time, baby boomers are a group of individuals who seek 
personal choice and a sense of control over their environments. They are 
not satisfied with sharing a room with 2 or more other patients. An 
increase in the demand for private rooms, and rooms that enable family 
members to sleep over will change the architecture of hospitals. 

Retailing is becoming key to the delivery of health care. The inclusion of 
commercial opportunities within the hospital complex is attractive to 
patients as well as health care professionals. Visitors to the hospital 
also take advantage of pharmacies, convenience stores, restaurants and 
coffee shops within the hospital complex. A greater focus on the power of 
retail outlets to draw "clients" will expand the existing, traditional 
amenities: cafeterias will become cafes open to the public, the 
traditional gift shop will feature local work by artists and craftspeople, 
and visitor business centers and child-care services will be provided. 
Finally, hospitals increasingly will be valued for connecting to their 
communities in ways similar to the police and fire departments. Community-
centered hospitals will reach out to serve their patients and neighbors, 
contributing directly to their surroundings. Lecture halls once reserved 
for teaching and medical rounds will be the site of community instruction 
on health care issues (Futurescan, 2000) . 

3.2.7. Human Capital: Rising Competition 

The current shortage of both doctors and nurses is not a short-term 
problem. A tight labor market and the aging of the workforce make "human 
capital" all the more scarce and valuable. Incentives to recruit new 
professionals alone cannot solve this problem. Health-care designers will 
be required to envision facilities that can provide excellent care with 
less staff. As well, providers will compete by design to make new 
facilities more attractive for staff recruitment and retention. This will 
apply not only to on-site amenities but off-site connections as well (easy 
access to transit, ease of parking, nearby recreational facilities, etc.). 
Canadian nurses recruited to work in American hospitals report great 
satisfaction in the purposeful design of spaces for their professional and 
personal use, e.g. running tracks on-site, gym facilities, staff gardens, 
24-hour restaurants. 

3.2.8. Emergency Preparedness 

Hospitals have long been equipped with emergency preparedness protocols 
and disaster coordination programs. Since September 11 of 2001, however, 
the increased fear of bioterrorism has added new elements of concern: 
early detection, preparedness, and response. The designer's role in this 
process will be to plan strategically with the client for responding both 
operationally and physically to an emergency. This is not a new role but 
it will likely take on more urgency since recent events. CPTED (Crime 
Prevention through Environmental Design) issues that address personal as 
well as communal safety will be paramount in design. 

3.2.9. Flexibility and Redundancy 

Canada spends about 9% of its GNP on health care, compared with 14% in the 
U.S. The rapid rise in health care expenditures since the early 1980s is 
primarily a result of rising drug costs and the provision of more 
complicated medical interventions and technologies (Health Canada, 2001). 

- 25 -



Hospitals are increasingly faced with the need to update, and renovate in 
order to accommodate for new/expanded technologies. 

The design of new hospitals must incorporate high degrees of flexibility. 
What could be an inpatient procedure today may be an outpatient procedure 
in the (near or far) future. Any permanent change to the landscape of a 
health care facility should be able to respond to radical change in 
programming in the future. 

Conclusion. 

A strong connection with the natural environment characterised some of 
man's earliest ventures into hospital design. Monastic cloister hospitals 
relied heavily on the fruits of the landscape to supply healing sights, 
sounds, smells and experiences. As dependence on technology and science 
for treatment of illness grew, reliance on the environment, the landscape, 
and nature itself was quickly and definitely displaced. The environment 
became little more than inaccessible outdoor space, functional yet without 
healing properties. Despite an increasing trend towards community-based 
programs and an expanding definition of health, hospitals continue, in 
many cases, to stand as examples of modernist dominance of man over 
nature. An evolving population, however, has begun to demand changes in 
the manner in which health care is delivered. An economic crisis in 
health care delivery demands that any proposals for altering the design of 
facilities should be reasonable, realistic, economical, and sustainable, 
as well as restorative for all intended users. 

- 26 -



CHAPTER IV: 

Applied Restorative Design: Principles and Implications 

Introduction. 

Therapeutic design incorporates principles that aim to reduce stress, 
promote wellness, and actively facilitate the healing process. 
Restorative principles are not limited to design of health care 
facilities, however this inquiry finds its focus in the hospital setting. 
Designing in a way that enhances health and well being for patients, 
visitors, staff and visiting community members is the goal of these 
principles. Restorative design is often mistakenly thought of as designing 
for the meditative, quiet garden. In cases this may be true. A truly 
restorative design, however, is one that allows diversity in behavioral 
and experiential programs, allowing each user to move within and beyond 
their own comfort level dependent on unique needs. 

The approach to restorative design proposed here involves two major 
stages. Firstly, the landscape is viewed in its entirety and global 
restorative principles are applied. This is done either through the 
creation of new spaces and features or simply by the enhancement of 
identified opportunities. The second stage involves a review of the 
intended users of the site and their specific needs for restoration. This 
approach should create a hospital landscape that has a restorative 
"foundation" as well as opportunities for development of user specific 
spaces. 

A flowchart that simplifies this process is featured at the end of this 
chapter on page 43. 

4.1 Global Restorative Principles & Design Implications 

The four following principles, drawn directly from preceding literature 
review, are global in that they can be applied to any site, public or 
private, in the effort to design for stress reduction. These global 
principles all have at their core an ability to reduce both physical and 
physiological stress. The ultimate goal of design would be to create a 
place that is, in a connected and holistic manner, archetypal, 
preferential and compatible, living and accessible. Additional 
considerations for unique spaces will be dependent on specific users 
and/or objectives of space. 

The four identified global principles are: 
• Design for the Archetypal Landscape. 
• Design for the Compatible Landscape. 
• Design for the Living Landscape. 

• Design for the Accessible Landscape. 

4.1.1 Principle #1: Design for the Archetypal Landscape. 

Across cultures, humans have an inherent connection to certain landscape 
types and forms. These archetypal landscapes can be utilized to create a 

- 27 -



place that is fundamentally comfortable, familiar, and healing (Condon, 
1988, Appleton, 1975). 

Example: Looking out over a fertile pasture with the comfort of a forest 
at one's back: prospect beyond, refuge behind. 

Design Implications: 

1. Therapeutic design should be an early component of facility design and 
programming to influence: 

• open space configurations-avoidance of leftover open space 

• siting decisions-possible viewsheds 

• indoor/outdoor relationship (thereby influencing architectural 
form and configuration as well as interior design). 

2. Retain (and if necessary, create) open space archetypes of higher 
preference (the Savannah, the valley, the meadow, the pastoral, 
prospect and refuge scenarios); 

3. Retain (and if necessary, create) simple yet powerful natural elements 
(the single tree, the allee, the bosque, the clearing). 

4. Recognize that a pasture as open space will have higher restorative 
value than a mowed play field or built open space. 

5. Use existing or new trees and berms to enhance feelings of enclosure 
and comfort. 

Figure 4-1: African Savannah Landscape. The savannah hypotheses predicts that 
those landscapes where humans spent time in their evolutionary past are 
inherently preferred. 

The savannah provides what is needed for survival: trees that give protection 
from the sun and can be climbed to avoid predators; long, unimpeded views; and 
frequent changes in elevation to allow for orientation (Fleissner et al, 
1999). 

- 28 -



Figure 4-2: African Savannah Project at Toronto Zoo. This design by the LA 
firm of Marshall Macklin Monaghan Ltd. was chosen as a recipient of a National 
Merit Award in 2000 by CSLA. The intention was to take advantage of the human 
preference for open landscapes while at the same time providing important 
species habitat ((National Merit Awards, 2000). 

4.1.2 Principle #2: Design for the Compatible Landscape. 

Humans are most comfortable when they recognize and understand instantly 
where they are in the world. This is balanced with opportunities for 
fascination, wonderment, and mystery. In times of high stress, 
understanding should be high. At other times, a sense of the need to 
explore is desired (Kaplan et al, 1998). A design that fosters a sense of 
control by offering choices and options for and against exploration 
promotes stress reduction and wellness (Ulrich, 1992). The creation of a 
compatible landscape allows the user to interact according to his/her 
comfort level at any given time. This differs from the Archetypal 
Landscape in that interventions are more specific to the region, the 
program, and the identified users and their needs. 

Example-High Understanding: Easy wayfinding in and out of the hospital 
complex. 
Examjole—Opportunities for Mystery and Wonderment: A view to a path that 
winds mysteriously out of sight. 

Design Implications: 

1. Facilitate Control and Choices 

• Design rooms and windows to allow visual access outside for bed 
patients; 

• Balance options for privacy with options for public experiences 
(open or closed, alone or together); 

• Provide privacy for staff as well as patients; 

• Make gardens or grounds accessible to patients; 

• Give users control over exposure to outdoor elements (sun-shade, 
noise-quiet, urban-rural); 

- 29 -



• Give users control over level of participation in program elements 
(to watch, to lead, to follow, to join in); 

• Create a design that maximizes safety (real and perceptual). Refer 
to Appendix II for CPTED Principles 

2. Facilitate Range of Understanding-Mystery 

• Partially obscure or frame views to open spaces using glass atriums, 
windows, doors to promote mystery = filtered understanding; 

• Ensure views to a wide range of activities in open space. (Examples 
include: passive and active recreation, teaching sessions, 
maintenance activities such as pruning and mowing, and animal 
grazing). 

3. Facilitate Understanding. 
• Use an ordering system for the design that clearly identifies paths, 

nodes, edges, and landmarks in order to promote wayfinding and 
memory; 

• Use local customs, traditions, and aesthetics (in design or 
programming) that increase a sense of home and belonging. This may 
range from small scale design for site furniture to large regionally 
significant landscapes patterns (local grid lines, crop patters, 
rural or urban typologies); 

• Provide views to regional landmarks, large and small, that tell a 
story of place and orient users to their whereabouts; 

• Use easily understood artwork and structures on site. 

Persons under stress show a higher 
preference for regionally familiar 
forms, shapes, images and 
prototypes. This is also noted in 
reactions to artwork. Built 
structures, art, and site 
furnishings are more effective in 
reducing stress if designed using 
easily understood natural images 
and forms (versus abstract or 
ambiguous form/content) (Ulrich 
1992). 

The site of this project, 
Abbotsford, British Columbia, has 
already shown an awareness and 
acceptance of this preference for 
regional artwork. 

The Abbotsford Downtown Business 
Association launched a "Bench Art 
Project" in 1998. In conjunction 
with new streetscaping in the 
historic downtown area, this 
project was designed as a means to 
celebrate culture, history and 
dreams of the community. Local 
artists were commissioned to create 
publicly accessible art that would 
be both familiar and pleasing. 
Natural and regional forms dominate 
in the chosen benches. 

— r w i f rp-1— 1 
_-.• a v WW f • 

Figure 4-3: Abbotsford Bench Art Program. 

- 30 -



4.1.3 Principle #3: Design for the Living Landscape. 

Humans find great comfort in physical and visual access to nature-
vegetation, habitat, water, and pets. A landscape that shows evidence of 
its ability to support life reduces stress, satisfies man's need to 
nurture, and reduces feelings of helplessness and hopelessness (Kellert 
and Wilson, 1993, et al) . A landscape high in natural, living elements is 
effective in eliciting positive feelings and blocking worry (Ulrich 1992). 
Landscapes alive with, not only evidence of birds and animals but also, 
human stewardship (human signs) increase comfort (Kaplan, Kaplan, and 
Ryan, 1998) . 

Examples: 
• A woodland garden that promotes biodiversity of birds and habitat. 
' An edible landscape of orchards, gardens or crops. 

• A maintained and well-used garden tool shed. 
' An outdoor space in which patients can walk pet therapy dogs (or 

visiting pets). 
• A body of water accessible (visually and physically) by humans and 

habitat. 

Design Implications: 

1. Open space planning should consider needs of birds and mammals as well 
as humans in order to enhance biodiversity: 
• Enhance or create specific habitats for regional birds/mammals -

consider greenbelt typology, vertical stratification, planting that 
attracts birds/insects/mammals near human spaces; 

2. Views to human and habitat "daily activity" should be maximized 
(humans: gardening, maintenance-animals: grazing, foraging, nesting); 

3. Opportunities to participate in hands-on gardening/stewardship should 
be facilitated; 

4. Use domesticated animals in open spaces ("sheep to mow grass"); 
5. Water bodies and features should be included throughout the design for 

benefits to both humans and wildlife; 
6. "Edible Landscapes" (orchards, berries, community gardens) should be 

considered whenever possible to attract both humans and wildlife; 

Figure 4-4: Restorative Interaction 
with Nature Accepted in Art. 

Cassatt, Mary 
Young Women Picking Fruit 
1891/92 
Oil on canvas 
132 x 91.5 cm 
Carnegie Museum of Art, Pittsburgh 

- 31 -



7. Design for strong indoor/outdoor relationships (bringing nature 
inside): atria with greenery, roof gardens, indoor water fountains, 
aquariums, etc. 

8. Provide choices for degree of participation with natural setting. 
• Although Wilson (1993) has shown a greater therapeutic benefit if 

users are privy to "hands-on" experiences, the research of Ulrich 
and Parsons (1992) shows a definite reduction in stress resulting 
from simple visual exposure to above elements. Hospital users 
should be given choices along a hierarchy, ranging from: 

_> Views to nature 

_» Views to humans/animals in nature 

_> Participation (passive) in natural setting: e.g. outdoor 
gardens with comfortable seating, etc. 

_» Participation (active) in natural setting: e.g. gardening, 
running/walking, animal care, etc. 

4.1.4 Principle #4: Design for the Accessible Landscape. 

Humans are most comfortable in a landscape that is both visually and 
physically accessible and that recognizes the diversity of needs and 
abilities. Recognition of all user groups and their diverse needs creates 
a more inclusive and accessible design (Centre of Universal Design, 1997, 
Cooper-Marcus and Francis, 1998). A truly restorative hospital site 
enables on-site access for patients, visitors and staff as well as a 
strong social and environmental connection to its surroundings, thereby 
enhancing the possibility for social support and a sense of belonging 
(Ulrich, 1992). Welcoming community members to the hospital site may 
increase not only stewardship of the land, but also the sense of being 
"caretakers of our neighbours". As patients share space with 
schoolchildren, daily joggers, and community gardeners, the opportunities 
for interaction, understanding, and support increase. 

Examples: 
• A hospital site that welcomes visitors to its cafeteria. 
• An open space shared by patients, local schoolchildren, visiting 

families, staff, community gardeners and recreationalists. 

Design Implications: 

1. Consider comfort and needs of wide range of users on site: patients, 
visitors, staff, and range of public users: 
• Design for all users, regardless of age or ability - Refer to 

Appendix I for "Universal Design Principles"; 
• Involve as many users, in early planning stages, as possible; 

• Provide convenient/inviting overnight accommodations for family 
members; 

• Provide comfortable indoor/outdoor visitor waiting areas with 
movable seating; 

- 32 -



• Provide a variety of necessary on-site amenities for users 
(shops/restaurants); 

• Design outdoor spaces specific for staff members. 
Encourage community use of hospital site: 
• Design a friendly and welcoming street face; 

• Design a hospital cafeteria that invites local community to visit 
and use; 

• Encourage outdoor programs that foster patient /visitor/community 
member social interaction; 

• Encourage outdoor programs that integrate rather than segregate 
hospital from immediate context (Example: sharing open space with 
immediate neighbors); 

• Design and program in a manner that will actively promote 
responsible and caring stewardship of landscape by community: 

• Opportunities for interpretive trails, educational programs, 
and spontaneous place-making on site may enhance appreciation 
and protection of resources by community, 

• Sustainable on-site practices may be utilized to enhance 
healing experience (on-site water collection as habitat-
attracting marshland) and to create desired community 
destination worthy of protection. 

Figure 4-5: 
Creekfield Lake Nature 
Houston, Texas. 

Trail 

This kilometer long trail in 
Brazos Bend State Park was 
designed to maximize 
accessibility. 
The trail was designed to be 
suitable for all types of 
disabilities. 

The trail itself is smooth asphalt 
with a graded flat surface. 
Parking blocks line the side to 
keep users from veering off trail. 
Displays along the path are 
designed for the sight impaired 
with information printed in large 
type and in Braille. Audiotapes 
are also made available. Park 
benches have no side handrails so 
wheelchair users can easily 
transfer across. Small raised 
sections of pavement signal an 
upcoming display without impeding 
wheelchairs. 

The trail is successful at showing 
a wide range of design features 
available to expand the equitable 
nature of a park (Bondi, 2000). 

- 33 -



3. Consider physical connections to community destinations and amenities: 
• Provide easy access to hospital by foot, car or bus; 

• Ensure easy access to hospital by ambulances and persons in medical 
crisis; 

• Connect on-site walking trails to larger recreational routes; 

• Plan location of hospital open space in consideration of adjacent 
uses/resources. 

4 . 2 Specific User Requirements and Design Implications. 

While it is accepted that within the patient, staff, and community 
populations there will be diverse needs and abilities, an assumption is 
made that all individuals will benefit from stress reducing design. Given 
that, the preceding global principles and design implications should apply 
to all users. This second stage of the process encourages an in-depth 
evaluation of all intended users and their specific needs for unique and 
diverse spaces and opportunities. 

The scope of this project does not allow an in-depth evaluation of all 
user group needs. A general discussion of the various groups and possible 
specific design implications is outlined below. This is not intended to 
be inclusive but rather a means of idea generation for design. 

4.2.1 Patients and Visitors - Diverse Needs 

Patient groups have been divided into 7 primary categories that will 
facilitate visual, behavioural, functional and experiential programming 
and design: 

# 1. Critical Care. 
# 2. Outpatient Treatment/ Diagnostics. 
# 3. Outpatient Teaching/Follow-up. 
# 4. Inpatients— Medical/Surgical. 
# 5. Extreme Ages. 
# 6. Hospital Long-Stay. 
# 7. Psychiatry/ Mental Health. 

Family members and visitors are considered to be part of the "patient 
group" . This follows a strong belief that when a member of the family 
(immediate or extended) is ill, that the entire family experiences stress, 
fear, anxiety and grief. For example, a patient confined to an Intensive 
Care Unit bed is highly dependent on caregivers. In many ways, the family 
member who sits vigil is equally if not more dependent on the hospital, 
its staff, and its design. A patient will sometimes, at a peak of stress, 
submit to the caregivers as a means of relieving stress and worry. Family 
members must continue to cope and so require special attention. 

*Note: The following discussion draws strongly from the author's 
experience/education as a registered nurse-certified emergency nurse 
(bedside, research, teaching, and management) in both urban/rural 
hospitals. It is also drawn from conversations with other caregivers 
(registered nurses, practical nurses and physicians) in the Vancouver 
region. 

- 34 -



Patient/Family Grouping #1: Critical Care. 

Examples: Emergency, Intensive Care Unit, Coronary Care Unit, Surgical 
Units (O.R., Post-Anaesthetic Recovery Room, Critical Care Recovery) 

Discussion. 
This group experiences immediate and high stress and requires a high level 
of legibility, simplicity, and functional considerations. A high potential 
for boredom associated with long waits, however, mandates access to views, 
programs and outdoor space. A strong risk for sensory deprivation is 
present due to confinement to bed. Length of hospital stay ranges from 
days to months, depending on illness/injury. Prolonged stays generally 
include transfer to less acute area of hospital. 

Design Implications. 
1. Visitors/family members require strong consideration in design. For 

example: 
• Entrances and exits should be clearly marked and circulation 

between services should be direct and simple. Waiting areas 
(indoors or outdoors) should be within close proximity. 

• Cafeterias should be in close proximity for easy access and quick 
retreat/refuge. 

• Access to basic retail/commercial as well as comfortable 
overnight facilities should be available. 

• The 24-hour nature of critical illness demands design elements 
that promote a sense of safety, security, and understanding 
during day and night. Pathways and outdoor spaces require 
lighting and simple wayfinding with attention to principles of 
CPTED (refer to Appendix II) to allow visitors 24 hour escape. 

2. Confinement to beds demands that windows be low enough to provide 
visual access outdoors, height, presence of positive distraction, 
regional cues to promote sense of place. 

3. Strong views to nature, animals, positive programming should be 
maximized, especially for patients suffering from stress-related 
illness (e.g. coronary artery disease). 

Patient/Family Grouping #2: Outpatient Treatment/ Diagnostics. 

Examples: Radiology, Day Care Surgery, Outpatient Cancer Care Clinic 

Discussion. 
A fear of the unknown and potential for long waiting times creates a 
strong need for stress reduction. Depending on the feared or actual 
diagnosis, a loss of control and feelings of helplessness and hopelessness 
may be significant. Length of hospital stay ranges from hours to 
occasional overnight stay. 

Design Implications. 
1. Access to outdoor spaces should be close and easy. 
2. Strong visual positive distraction (views to nature/pets/play) are 

needed to combat helplessness/hopelessness. 
3. Physical access to positive distraction should be possible: e.g. 

nature (fragrant plantings, touchable plantings, bird/butterfly 

- 35 -



attracting plantings, access to outdoor walking routes), programming 
(commercial, cafeteria) . 

4. Providing options for easy refuge/escape and choices in 
movement/activity will combat loss of control. 

5. Potential for sensitivity to ultraviolet light 
(chemotherapy/radiation) demand shady garden spaces as an option. 

6. Potential for impaired skin integrity demands comfortable seating 
outdoors, sheltered from elements (sun/wind). 

7. Potential for impaired mobility (weakness or disability) demands 
frequent rest stops in open areas, handrails, and universal design, 
(see Appendix I) 

8. Consideration of visitor and support person needs required (also 
subject to waiting/fear of unknown). 

Patient/Family Grouping #3: Outpatient Teaching/Follow-up. 

Examples: Healthy Heart, Diabetes Clinic, Asthma Clinic, CHF Monitoring, 
CVA Rehabilitation, Health Promotion Programs 

Discussion. 
Teaching/learning and repeat visits are a strong component and therefore 
require special consideration in programming spaces. Patients may move 
through the continuum of ability (in either direction) and therefore 
options and diversity are required. The length of hospital stay is 
generally less than one day, but may occur several times weekly, monthly, 
or yearly. It is also important to note that entrance into one of these 
programs often follows an acute stay in hospital (e.g. following new 
diagnosis of diabetes or recent myocardial infaction). 

Design Implications. 
1. Ensure presence of connections between acute care portion of 

hospital and outpatient programs to enable patients early 
introduction to follow-up. 

2. Provide connections between wellness programs for outpatients and 
specialized inpatient units in order to enhance follow-up and 
compliance with after-care treatment. This will also streamline 
movement by staff between the programs (e.g. cardiologists can visit 
acute patients in Coronary Care as well as patients returning for 
stress tests). Examples of Acute Programs to Connect with Wellness 
Programs are: Healthy Heart program—Coronary Care Unit; 
Physiotherapy programs—Surgical units; Diabetic Teaching Centre-
Medical units. 

3. Provide a welcoming community street face to reduce the stress 
inherent in attending a hospital site and increase accessibility/ 
awareness. 

4. Provide access to larger open space for independent exercise 
programs. 

5. Provide access to communal open space for programs with support 
staff (physiotherapists, occupational health, horticultural 
therapists, etc.). 

6. Consider avoidance of allergens in planting (e.g. avoidance of 
London Plane-Platanus X Acerifolium) . 

7. Include programs suitable for hands-on interaction with nature (e.g. 
bird-feeding or watching, gardening, caretaking, fruit picking). 

- 36 -



8. Provide options for movement in the space to challenge persons 
during rehabilitation (e.g. wheelchair accessible paths to forest 
hiking trails to bicycle paths). 

9. Provide connections to community resources/amenities for field 
trips- programs (e.g. grocery stores for winter walking programs, 
local recreation facilities, schools). 

Patient/Family Grouping #4: Inpatients— Medical/Surgical. 

Examples: Neurology, Vascular, Orthopedics, Renal, Maternity, Infectious 
Disease, Respirology. 

Discussion. 
Patients in general medical-surgical wards encompass a tremendous variety 
of abilities, needs and ages. Their length of hospital stay may range 
from one night to several months. 

Design Implications. 
1. Both mobile patients and those confined to bed share a need for 

physical and visual access to outdoors: rooftop/outdoor gardens 
should be easily accessible by wheelchairs and stretchers with 
consideration of window height and placement. 

2. Consider outside views in siting programs within the hospital. For 
example, the dialysis unit (with potential for long hook-up times) 
should offer a view that has interest, nature, and intrigue. Views 
to areas with mystery in outdoor open space would be appreciated. 

3. Provide temporal changes in outdoor views: over days, seasons. For 
example, a program of bringing in rural pasture animals to "mow" 
open lawns would create special days of interest for patients 
confined to bed/hospital. 

4. The increase in fear, frustration, anger, and boredom with prolonged 
hospital stays demands visual and physical access to distraction. 

5. Loss of control increases with prolonged stays, demanding the 
inclusion of options and choices of spaces: a sunny cafeteria space 
(indoor-outdoor) versus a shady, sheltered refuge. 

6. Younger inpatients may desire places to meet with friends where 
noise will not disturb other patients. 

7. Patients may desire places with "extent" for meeting with family, 
friends, volunteers, and pets. Extent is described as a place away, 
a place to forget if only for a short time that current home is the 
hospital (Kaplan, Kaplan, and Ryan 1998). A waterside picnic area 
under canopy trees, for example, with views oriented away from the 
hospital might be designed for family gatherings. 

8. Creative design of indoor spaces with strong connections to outdoor 
gardens might be designed for telephone nooks. Cellular phones 
remain banned in the majority of hospitals, and so the "pay 
telephone nook" becomes a well-used place. 

Patient/Family Grouping #5: Extreme Ages. 

Examples: Paediatric population and geriatric population. 

Discussion. 
A particular requirement for this grouping is the need for supervision and 
safety, combined with positive distraction. The length of hospital stay 
may range from day(s) to week(s) for paediatric patients. For geriatrics 

- 37 -



patients, it may range up to several months, while awaiting placement in 
an extended care facility. 

Design Implications. 
1. Supervision and safety are required. 

• Outdoor programs should be accessible, defensible and in plain 
view of caretakers. 

2. Positive distraction through both design and programming is required 
to prevent sensory deprivation. 
• For geriatric patients that may be waiting for placement, the 

hospital becomes an interim home. This may be the population 
that suffers most from over designing hospitals for function and 
legibility. The absence of positive distraction and stimulation 
has disastrous effects on the fragile elderly population. A 
strong reliance on programming to provide stimulation (music 
therapy, pet therapy, horticultural therapy, and pastoral care) 
presents as a significant risk factor in an age of budgetary 
restraints and cutbacks. The role of the designer will be to 
aggressively design places that facilitate easy access to 
programs, e.g. by providing built raised garden beds and pathways 
accessible to wheelchairs and persons with impaired walking 
skills. Designing access to outdoor spaces for persons confined 
to hospital beds will be an important challenge for the designer. 

3. Consider the creation of space that can be used by both geriatric 
and pediatric populations (separate and together). 

• An option may be to combine gardens/play areas for both groups of 
patients. Placing these two groups in close proximity allows 
them to offer support, learning and positive distraction. Play 
can be combined with rehabilitative efforts. For example, 
persons learning to walk again (e.g. following a cerebrovascular 
accident) or learning to use wheelchairs require a variety of 
surfaces and materials for "practice" (gravel, rubber, concrete, 
sand, turf, etc.) . These materials can be used to create a 
garden that is playful yet instructive for both sets of patients. 

Patient/Family Grouping #6: Hospital Long-Stay. 

Examples: Palliative Care/Extended Care. May also include a variety of 
medical conditions that require prolonged hospital stay for treatment 
(e.g. renal dialysis, complicated cardiac recoveries, etc.) 
Discussion. 
The hospital environment becomes home to these users, who may seek a 
variety of programs for comfort. Length of stay may be days to years. 
Consideration of visitor and family member requirements will be vital. 

Design Implications. 
1. These patients have a strong need for imageability and legibility in 

this hospital place that becomes "home". Access to a diversity of 
programs will be beneficial. Facilitating the spontaneous creation of 
place making (allowing for discovery) will also be important. For 
example, along with defined spaces, it will be important that patients 
have opportunities to find their own special corner, path, or tree on 
the hospital landscape. 

2. Opportunities for spiritual and emotional interactions between 
patients, staff, and community should be available: e.g. a multi-
denominational chapel/area for prayer should be within easy access. 

- 38 -



3. Creating an environment that encourages community participation 
(volunteer groups and individuals) promotes social support. Measures 
taken throughout the hospital site to encourage community involvement 
and volunteerism will benefit this group. 

Patient/Family Grouping #7: Psychiatry/ Mental Health. 

Discussion. 
A diverse group of varied ages and abilities, the psychiatric population 
will benefit highly from efforts at reducing stress. Stress is, in most 
cases, a significant factor in mental illness. Their length of hospital 
stay varies from days to weeks, depending on the type and severity of 
illness. Length of stay will also be dependent on the type of psychiatric 
treatment programs offered by the proposed hospital. 

Design Implications. 
1. Provide strong natural views outside locked wards/quiet rooms. 
2. Avoid abstract art/forms in the landscape that might increase stress or 

fear. 
3. Provide well-defined, highly legible walking paths. 
4. Provide opportunities for privacy as well as social interaction. 
5. Provide legible wayfinding to private spaces, to public cafe/coffee 

shops, and to outdoor programs. 
6. Provide an outdoor space for patients to utilize that can be supervised 

by staff. 
7. Consider need for comforting, safe, outdoor area that can be supervised 

and is secure (e.g. "locked garden") for patients involuntarily 
admitted to hospital under Mental Health Act. At the very least, these 
patients should have strong views to nature. 

8. Define a smoking area that is well lit for 24-hour use, defensible and 
provides a pleasing atmosphere. 

9. Define a smoking area that is visible by patients from within the ward. 
This will act to decrease stress if patients are made aware of the 
presence of a nearby smoking area. 

Research Focus: Schizophrenia & Smoking Behaviour. 

Some readers of this project may find it unusual that there is such 
specific emphasis being placed on the design of smoking areas. A brief 
review of available medical research, however, details the importance of 
enabling this behaviour for the psychiatric population, and, in 
particular, for schizophrenic patients. 

Patients with schizophrenia have an extremely high prevalence of smoking. 
A 1986 US study found 88% of these patients were smokers compared with 
only 33% in the general population (Hughes, et al, 1986). The increase in 
dopamine release induced by smoking has been hypothesized as being helpful 
in alleviating some of the positive schizophrenic symptoms (delusions, 
hallucinations, paranoia, etc.) Therefore, schizophrenics smoke in an 
attempt to self medicate. Smoking also interacts with neuroleptic 
treatment (a common drug treatment for schizophrenics, includes the drugs 
Haloperidol and Chlorpromazine). Neuroleptic plasma levels are reduced 
causing higher doses to be prescribed and, subsequently, leading to higher 
incidence of side effects (Goff, et al, 1992). One study actually showed 
that patients smoke more when treated with the neuroleptic Haloperidol 
than during a medication-free state (McEvoy, et al, 1995). 

- 39 -



In summary, smoking cigarettes has proved beneficial in reducing both the 
ill effects of the disease and the powerful side effects of the drugs used 
to treat schizophrenic patients. Yvonne Savard, an Emergency Psychiatric 
Clinician at Langley Memorial Hospital (Langley, B.C.) made the following 
statement in a conversation with the author (in May of 2002) : 

"The act of smoking helps them to filter out the negative thoughts 
that attack their minds and, in turn, they are much easier to deal 
with and much more open to treatment". 

Most hospitals in the Lower Mainland of British Columbia have very liberal 
smoking rules for their patients. Areas provided for smoking, however, 
are generally windowless lounges or back door entrances. This project 
proposes to design a more hospitable open space for smoking. 

4.2.2 Staff and Volunteers 

Staff and volunteers in hospitals require opportunities for stress 
reduction, for social gatherings, for education, and for meal and break 
taking. In particular, caregivers (nurses, physicians) require easy and 
immediate access to areas that offer brief respite. Emergency staff, for 
example, in many larger cities across North America are victims of extreme 
stress several times during 12-16 hour shifts. These stressors include 
violence from patients and visitors, dealing with death and dying, 
exposure to infectious diseases, etc. In personal conversations, a large 
number of nurses claim regular physical/verbal abuse in the workplace. 
Despite this, with staff shortages, breaks have become little more than 
stolen minutes outside the ambulance bay door. 

Several studies across a variety of workplaces (e.g. healthcare, office 
buildings) have found that staff members have strong feelings about the 
presence of windows and available views. Natural views are most 
preferred. Studies conducted on caregivers in hospitals show that 
employees with views to nature experience less stress and report better 
health and higher levels of job satisfaction than comparable groups who 
lack such views (Leather et al., 1997). The highest degrees of stress were 
found in environments with no windows at all (Leather et al. , 1997) . For 
the economically conscious employer, improved health and higher 
satisfaction should translate into fewer sick days, injuries and leaves of 
absence as well as higher productivity (Leather et al. , 1997) . 

An absence of windows is the current accepted status quo in a majority of 
emergency rooms in the Lower Mainland of British Columbia. If windows are 
present, they are placed above head level and are screened with 
drapery/blinds (with the excuse of a need for privacy and security). 
Illumination, night and day, is generally by harsh fluorescent overheads. 
Natural lighting is rarely considered. Many caregivers and patients will 
complain of a sense of disorientation to time due to the cocoon-like 
nature of the environment. 

Consideration of hospital staff members as important users of the design 
creates several possibilities and responsibilities: 

1. Early involvement in design and planning of the built structure should 
include consideration of window placement and access to natural views 
for staff who are confined to working indoors for several hours at a 
time. 

- 40 -



Figure 4-6: Prototypical Windowless Emergency Wards. 

2. Physical access to the outdoors should be considered with possibilities 
for easy, quick access for short or long retreats. 

3. The designer will need to pay special attention to the creation of 
spaces that promote a feeling of "being away" and of "extent" (Kaplan, 
Kaplan, and Ryan 1998). Lookouts with views to significant landmarks or 
large open space may be designed. 

4. The designer should also pay special attention to the creation of quick 
refuge areas for staff only that are accessible and defensible 24 hours 
a day. Spaces should be designed that enable staff to be human and cry, 
swear, smoke or laugh away from the public-patient eye. 

5. Programmming for recreation before, during and after work should be 
included. For example, a defined running track on the hospital grounds 
may be used to relieve stress during longer breaks. 

6. Larger, open spaces to be utilized for teaching and social gatherings 
will be important as well. An unfortunate development in many 
hospitals is the gradual relegation of teaching rooms to basements and 
windowless rooms. Indoor-outdoor relationships and views should be 
considered in early siting and programming. 

7. Security, safety, and functionality are important issues for staff 
working extended hours. Easy and safe access from parking to hospital 
entrances is especially vital for evening and night staff. Grouping 
parking together along a well-lit axis enables staff to walk together 
and facilitates monitoring of staff by security personnel. Given the 
high numbers of staff who work extended hours, designs and programs for 
after dark become an important element. 

• Administration: Monday to Friday, business hours 

• Patient Care and Treatment (physicians/nursing): extended hours 
(24 hours) 

• Support Services( security, cleaning, secretarial, medical 
records, laboratory, radiology, etc.): extended hours (24 hours) 

- 41 -



• Volunteers (both regular and ephemeral programs): extended hours 
8. In the landscape design, facility maintenance staff/gardeners will also 

be important users. Spaces should be designed for a range of 
maintenance requirements. 

4.2.3 Community Members 

Welcoming the community at large onto the site will potentiate stewardship 
of land as well as social support. The visiting public will have specific 
needs for programs not usually considered on a hospital landscape. These 
programs will include (but not be limited to): 
1. Welcoming entrance: significant street face and high visibility; 
2. Accessible pathways not dominated by autos or ambulances that enable 

joggers, cyclists, pedestrians, dog walkers, and possibly equestrians 
to use the site; 

3. Open areas for community play; 
4. Public washrooms and public rest areas: coffee shop, cafe, retail; 
5. Gardening sheds for community programs; 
6. Meeting areas on site that encourage public users to stay versus simply 

pass through the landscape; 
7. Physical connections to larger community amenities (greenway corridors, 

trail systems, etc.) . 

Conclusion. 

Following a framework of restorative design should create a health care 
facility that people want to visit, during times of illness or wellness. 
It should be a place in which people feel comfortable; a place that is 
familiar; a place that is alive with food, water and plant and animal 
life; a place that people can and want to explore. At the same time, 
however, the health care landscape must respond to very specific needs of 
specialized users. It must be functional. It must be safe. It must be 
easy to use. The challenge will be to create a restorative landscape 
without compromising functionality. Creating a place that allows harmony 
of nature and technology will be the goal of the design. 

An overall design that facilitates restoration should be applied to the 
hospital landscape with specific interventions applied whenever possible 
to meet the needs of specific populations. At the very least, the design 
should provide a framework for unique and specific places that may then be 
built as economics allow. For example, the design may program an open 
space to be shared by the extended care and the paedeatric wards. Actual 
construction of this garden that combines rehabilitation with play may 
require future fundraising by the community and the hospital in order to 
become a reality. Providing the space and the infrastructure for this and 
other gardens or open spaces increases the likelihood that they will be 
constructed. 

- 42 -



Applied Restorative Design: A Tiered Approach 

t a g e # 1 : Application of Universal Principles to Entire Project 

" enhance existing conditions and/or create new situations that satisfy human needs tor restoration (stress 

Design for: 

ARCHETYPAL LEGIBLE LIVING 

J 

ACCESSIBLE 

Goal: A Holistic Restorative Landscape 

T 
Stage #2: 

Recognition of Specific User Requirements 

ipottm ••-.••:; to meets"" 

\ 

PATIENT/FAMILY 
GROUPS 

Goal: 
To recognize the specific needs of 
various patient/family groupings 
and design a "groundwork" for 
individual spaces that can evolve 
overtime. 

Specialized groups include, but 
are not limited to: 
1. Critical Care 
2 . O u t p a t i e n t T r e a t m e n t / 
Diagnostics 
3. Outpatient Follow-up 
4. Inpatients-Medical/Surgical 

Desi gn for: 

STAFF AND 
VOLUNTEERS 

Goal: 
To not only recognize but actually 
design for stress reduction among 
caregivers. Special attention must 
be paid to the 24-hour nature of 
employment in health care facilities 
and subsequent needs for safety 
and security. 

COMMUNITY 
MEMBERS 

Goal: 
To increase use and 
s t e w a r d s h i p o f 
landscape, as well as 
facilitating a greater 
m o v e t o w a r d s 
v o l u n t e e r i s m a n d 
a l t r u i s m w i t h i n the 
hospital environs. 

1 i I 
Goal: A Holistic Restorative Landscape that Responds to All 

Figure 4 - 1 : Approach to Applied Restorative Design (Hospital Landscape) •43 



CHAPTER V. 

Public Process: A Discussion 

5.1 The Planning Phase. 

"Any attempt to create a new approach to public land or building design 
will fail miserably if the public is not consulted and does not have a 
sense of ownership, stewardship, or claim in the project." (Sommer, 1983, 
p. 122) 

It is accepted that the scope of this project does not permit the public 
input that would be required for the successful design of a community 
facility. Planning for a hospital landscape would require full and active 
participation from a wide cross section of the population. 

Actual interest groups involved in the process would require specific 
research for each individual site. Interest groups that would be called 
on to assist planners and designers would ideally include (but not be 
limited to): 

• government officials (municipal, provincial and federal), 
• health care (physicians and nursing), 
• local business associations, 
• representatives from different levels of local schools (university, 

secondary and elementary), 
• wildlife and environment stewardship groups, 
• churches and volunteer groups, and 
• various recreation interest groups. 

The accepted form of decision making in a democratic world is voting. All 
citizens would have say in where and how a health care facility is 
constructed. The demanding and complicated procedure that precedes a 
vote, however, is that of goal setting (Steiner, 1991, p. 23) . "Goal 
formulation requires public participation" (Wright, Braithwaite, and 
Forster, 1976). 

A major challenge in involving public interests in the decision-making 
process is to ensure that decisions and goal setting are based on accurate 
and complete data. The public may concede to the tried and true only for 
lack of a better approach. How does one ensure that the public not only 
has a voice in the hospital design, but is also made aware of the 
expanding and specialized body of research that directs restorative 
design? If community members are made aware of the advantages of 
designing for familiarity, compatibility, biodiversity and accessibility, 
it may be assumed that heightened pressure will be put on public 
representatives to change current traditions of construction and, more 
importantly, of resource allocation. 

An initial exposure to the restorative design approach may feature the use 
of preference testing of key potential users. This would involve showing 
visualizations of regional and archetypal landscapes to users in order to 
determine preference (and to build justification) for the ensuing design. 

- 44 -



Designers may well propose restorative landscape manipulation, but without 
public support, designs are easily slashed to a mere remnant of their 
original intention as a means of saving dollars. An adaptation of a model 
put forth by Ray McNair in 1981 and elaborated by Frederick Steiner in 
1991 is proposed here as a means of ensuring early and continued 
involvement by community interests. This model demands and facilitates an 
interactive process between planners, designers and the public. 

A g e n c y R e p r e s e n t a t i v e s 
landscape architects, 
planners, architects, 

health care consultants 

C i t i z e n O r g a n i z i n g 
core interest groups 

(e.g. recreation, volunteers. 
wildlife protection, 

seniors-schools-ch urches) 

Setting objectives 

P h a s e I 
preliminaries: 

objectives, agendas, concerns 
Organize core groups 

J 
Gathering Data 

T 
P h a s e II 
Elaboration 

J 
Selecting core 
representatives 

Identifying 
alternative plans 

I 
T 

Prepare/organize for long 
term involvement 

Setting Priorities 
i 

I P h a s e I I I Action 
Negotiating citizen 

ideas and proposals 

I 
Design of technical 
program proposals 

I 
Task Force Formation for j 
Long Term Considerations 

1 
Reformulating proposals Negotiating detailed 

recommendations 

Final N e g o t i a t e d D e c i s i o n s 

Public Process Model 
(Adapted from: Macnair, 1981) 

Continued involvement: 
Interaction with Regional Health Board 

to ensure long term goal attainment 

Figure 5-1: Model for Public Involvement 

The model suggests moving the public process away from the traditional 
open public forum, often criticised as being ineffectual and a nuisance 
(Steiner, 1991) . Rather, key personnel with both project and community 
interests are brought together in an atmosphere that encourages sharing of 
ideas, goal setting and decision-making. 

- 45 -



5.2 Site-Specific Programs. 

In times of financial constraint, it is unrealistic to expect health care 
budgets to be allocated in a large way on landscape upkeep. However, it 
may be possible to attract and encourage organized community groups that 
are now present in most cities, large and small. Locally and regionally 
directed volunteer/interest groups exist as powerful potential resources. 

Examples drawn from the City of Abbotsford, B.C. (locally and regionally) 

may include, but certainly not be limited to: 

• Central Fraser Valley Naturalist Society, 

• Local 4-H Clubs, 

• Monika's Wildlife Shelter & Friends, 

• Local groups/individuals with interest in the areas of heritage 
tree protection, native planting promotion, habitat protection, 
etc., 

• City of Abbotsford "Adopt-A-Street", 

• City of Abbotsford "Adopt-A-Park", 

• Neighborhood Block Watch, 

• British Columbia Senior's Peer Network, 

• Alzheimer's Society of B.C. Field Support Staff and Volunteers, 

• Abbotsford Hospice Society, 

• Abbotsford Big Brothers-Big Sisters, 

• Ducks Unlimited Canada-local chapter, 

• Langley Environmental Partner's Society, 

• Abbotsford Peer Support for Senior's. 

Involving the local community groups in an early phase of planning will 
increase the chance of designing a site that will be the subject of active 
and concerned stewardship. 

This design proposal will include exploration into the development of a 
local community group that will take a specific interest in the care and 
maintenance of the hospital landscape. As has been stated, the idea of 
creating hospital open space that promotes community use and care as a 
means of advancing volunteerism and altruism is an important goal of this 
exploration. 

Figure 5-2: 
Volunteers monitoring habitat 
in constructed stream-marsh. 

- 46 -



CHAPTER VI. 

Marshall Road Location: Existing Conditions 

6.1 History of Existing Project. 

On March 10, 2001, the provincial 
government gave approval to construct 
a new regional hospital in the Fraser 
Valley of British Columbia. A 350-
bed acute care hospital will be 
combined with a new regional cancer 
centre to serve residents of the 
eastern Fraser Valley. The proposed 
site for the complex is a 10.4 ha 
parcel of land on Marshall road in 
Abbotsford owned by the Fraser Valley 
Regional Health District. The 
intention of this new facility is not 
only to relieve pressure on tertiary 
care centres in Vancouver, but, more 
importantly to allow local residents to receive improved health care closer to 
their homes. The new hospital will replace an aging facility that no longer 
meets the needs of the community. "Together, 'this new facility' will provide 
a phenomenal improvement in health care and new services not now available in 
the region. Health authorities and providers need to be able to plan and 
deliver services for patients within their own region." (BC Cancer Society, 
2001) 

On December 12, 2001, the provincial government announced a restructuring of 
the province's health care system. The Fraser Valley Health Region was merged 
with two other Health Regions (Simon Fraser Health Region and South Fraser 
Health Region) to become the larger Fraser Health Authority. The impact this 

Project Timeline. 

1986 
1990 
1991 

1997: 

2000: 

2001, 
June: 

2001, 
Sept.: 

2002, 
Oct. : 
2004: 

Source: 

• Options explored for upgrade to local health services. 
• Construction of new facility recommended. 
• Marshall Road property purchased by Fraser Valley Regional 

Hospital District (FVRHD). Site previously used as provincial 
Veterinary laboratory (and chicken experimentation site). 

• Working drawings completed; Project placed on hold by provincial 
government. 

• B.C. Ministry of Health requests review of project; addition of 
Cancer Agency to acute care hospital plan. 

• Ministry advances funds (FVRHD agrees to 40% share capital 
costs). 

• Hazardous material removal and demolition contracts awarded, 
(private versus public). 

• Expected date of new working drawings. 
• Expected date of project completion at estimated cost of $240-

million. 

FVHR Project Home Page,2001. http://www.hsg.bc.ca/Projects/FVHC/ 

•47-

http://www.hsg.bc.ca/Projects/FVHC/


Accessible Landscape: Automobile Focused. 

Primary road access to Abbotsford is provided by the Trans-Canada Highway (#1) 
running west to Vancouver and east to Hope. Built in the 1960s, the highway allows 
for easy and rapid access to surrounding communities. Highway 11 provides the north-
south link to Mission (14 km) and the U.S. Border (3 km) at Sumas, Washington. Freight 
rail service is provided by CP Rail, CN, and Southern Railway of B.C. The local 
airport provides daily flights to national locales. 
Despite proximity to major highways, it is significant that 82% of the working 
population are employed either in or directly adjacent to the City of Abbotsford(City 
of Abbotsford, 2002). 

Proximity to the Trans-Canada Highway and easy access to surrounding regions will be 
significant in defining the hospital's catchment area and in allowing it to serve as a 
major trauma centre for highway related accidents. 

Bicycles 
cfe on the Bus 
Thanks to the following 
organizations which 
have provided bus-
mounted bike racks for 
the Central Fraser 
Valley Transit System: 
• Fraternal Order 

of Eagles 
• Seven Oaks Mall 
• University College of 

the Fraser Valley 
• Wenting Bicycles 

Despite accessibility to and through the area by major highways, 
transit service is limited. Hospital users will have high 
automobile dependence. This will impact on the amount and type of 
parking that will be required for the hospital design. Many 
suburban and rural areas are not serviced by buses, although there 
is a local increase in Park-and-Ride facilities as well as bus-
mounted bike racks. 

A local bus route (#5-North Poplar) currently passes by the 
hospital site, with hourly stops during business hours. An 
extension of hours and increased number of buses will be required 
for the hospital. 

Origins. 

Following word of the Fraser River Gold 
Rush, thousands of non-British citizens 
swept into the territory. In order to 
assert their claim on British Columbia, 
the British Government sent the Royal 
Engineers to survey the area in 1858 . 

Figure 6.1: Downtown 1907. 
Photo courtesy M.S.A. Museum. 

As reward for their services, the 
engineers were offered land at minimal 
prices. In 1891,Canadian Pacific Railway 
built a line from Mission to Sumas, 
Washington intersecting the only roadway 
through the valley, the Old Yale Road. A 
station setup at this point would become 
the Village of Abbotsford. It was 
incorporated in 1924 and became a city in 
1995 with the amalgamation of the 
districts of Abbotsford and Matsqui. 

Figure 6-2: Downtown 1930. 
Photo courtesy M.S.A. Museum. 

6.2 Analysis: 

Regional Context 

Figure 6-3: Relationships to Local 
Municipalities. 

The City of Abbotsford is located 
in the centre of the Fraser Valley 
of British Columbia, approximately 
7 0 km from downtown Vancouver to 
the west and Hope to the east. With 
a population of 119,818 (2001 
Canada Census), it is the fifth 
largest municipality in B.C. 

Abbotsford covers 359 square km 
(138 square miles), about 86% of 
which is part of the Agricultural 
Land Reserve and is some of the 
most productive farmland in 
Canada. 

The majority of residents live in 
the urban core, surrounded by 
farmlands and rural communities. 
Abbotsford is viewed as a true 
"city in the country" for this 
reason. 

"Abbotsford has continued to 
urbanize without sacrificing its 
rural roots."Abbotsford Chamber of 
Commerce, 2001. 

-48-



Above-Figure 6-4: 
Farms", Abbotsford. 
Below-Figure 6-5: 
Abbotsford. 

"Manzana Apple 

Winter Raspberry Canes, 

Edible Landscapes. 

The edible landscape is highly 
recognized and cherished in this region. 
The urban core of Abbotsford is 
approximately 32 km (20 miles) from the 
Pacific Ocean in White Rock and about the 
same distance to mountainous sites. The 
combination of sunshine and 
precipitation has resulted in an 
evergreen valley. Enjoying one of 
Canada's mildest climates, with a long 
frost-free season, mild winters and warm 
summers, Abbotsford has good, fertile 
soil conditions. 

These conditions have resulted in the 
area becoming the "berry capital" of 
B.C., with edible landscapes spread 
across the valley floor. 

In 1999, 12 million kilograms of raspberries, 90% of the total grown in B.C., came 
from Abbotsford and directly brought $21.4 million to the economy. In the same year, 
4 . 6 million kilograms of blueberries generated $9. 5 million. 

Scattered throughout the region are also producers of saskatoon berries, red 
currants, gooseberries and blackberries. Grass and corn are grown in large tracts, 
primarily to service the livestock (dairy cattle, equestrian) industry (City of 
Abbotsford, 2001). 

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Urban-Rural Harmony, 

Rural activities continue to be a 
significant part of the Abbotsford 
economy despite a growing diversity of 
businesses: food processing, aerospace, 
manufacturing, finance and retail. Farm 
receipts total more than $300 million 
annually (City of Abbotsford, 2001). 

Figure 6-6: Baling Hay in Abbotsford, 1941. 

Significant Views. 

Mountain views are an integral part of 
wayfinding and legibility in this valley 
landscape. Major peaks include Golden 
Ears, Mount Baker, and Sumas Mountain. A 
significant visual landmark is Mount 
Baker to the southeast, visible on clear 
days . 

Large expanses of farmland are situated 
within minutes from the urban core. 
These open spaces are generally closed to 
public use but exist as significant 
visual resources. 

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City of Abbotsford Population by Age Group -
1991 to 1996 

6 5 H 

11981 11936 • 1991 • 1996 

Figure 6-8: Population by Age 

Growing, Diverse Community. 

The 2001 census figures just 
released in March of 2002 indicate 
a 9.2% increase in population for 
Abbotsford since 1999. This is in 
contrast with 4.9% for the entire 
province. 

Despite a national trend towards 
aging communities, the census for 
Abbotsford revealed a minor drop in 
the percentage of population over 
65 and an increase in the under 19 
group. 

The implication for Abbotsford is 
that the City will have to continue 
providing services and facilities 
to service a family oriented 
community (City of Abbotsford Home 
Page, 2002) . 

Figure 6-9: Cultural Diversity 

Figure 6-7: Farm near Sumas Highway Exit. 

.. In 

O 

3 4-1 
O -H 

City of Abbotsford Ethnic 

Ukrainian 1 % j 
Irish 1% A 

Dutch 6% Mi 

German 8% [ 

Other 9% % ^ 

Indo-Canadian 

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Composition - 1996 

1 ^ ^ _ Multiple Origins 
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British 10% 

-49-



L o o k i n g N o r t h o v e r A b b o t s f o r d C i t y : R u r a l - U r b a n Harmony. 

T r a n s - C a n a d a Highway v i s i b l e i n f o r e g r o u n d r u n n i n g e a s t t o w e s t . ' 
The l a r g e g r e e n open s p a c e j u s t n o r t h of t h e Trans-Canada ( o u t l i n e d i n dashed l i n e ) i s t h e p l a n n e d h o s p i t a l s i t e . 
M i l l Lake, a s i g n i f i c a n t d e s t i n a t i o n s i t e for a c t i v e and p a s s i v e r e c r e a t i o n i s s i t u a t e d i n t h e middle ground. Dotted l i n e s w i t h arrows show p o t e n t i a l 
c o n n e c t i o n r o u t e s from t h e h o s p i t a l s i t e . 

Figure 6-10: Aerial View over Proposed Site, 2001. (Source: Fraser Valley Web Site, available at URL 
http://www.seethefraservalley.com/abbots/abbots.htm) 

R e g i o n a l C o n t e x t : Summary. 

S t r e n g t h s . 

1. Population "home-based": 
residents work and play close to 
home. 
2. Tradition of harmony between 
urban and rural interests. 
3. Diverse population in terms of 
culture, age, and socioeconomic 
status. 
4. Tradition of community 
involvement in local projects: 
examples are "Adopt-A-Street" and 
"Adopt-A-Park" . 

to 
to 

5. Proximity 
Highway and 
centres. 
6. Significant 
open space views 

Trans-Canada 
surrounding 

and spectacular 
Mt. Baker, Sumas 

Mountain, agricultural fields. 

Weaknesses. 

1. Significant rural areas in 
region with inadequate transit 
service: high automobile 
dependence. 

2. Sprawling layout of parks and 
recreation facilities in area: 
competition for users. 

3. Growing population: potential 
for urban-rural conflict and 
degradation of exiting open 
spaces. 

-50-

http://www.seethefraservalley.com/abbots/abbots.htm


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HOSPITAL S I T E 

MILL LAKE 
RECREATION 

H 
PRIMROSE AVE 
OPPORTUNITY 

Figure 6-11: Immediate Site Context, 2001/2 

Good Neighbors . 

Building height and mass 
will need to be minimized 
in order to fit in with the 
neighborhood character 
(maximum 4 storey). 
Consideration of the 
neighboring seniors' 
facilities in programming 
(visually and physically) 
will allow the hospital 
design to be more inclusive 
and serve the greater 
community. 

Trans-Canada 
Noise Barrier. 

Highway as 

The proximity of the Trans-
Canada Highway will be 
advantageous in terms of 
wayfinding to and from the 
hospital, as well as simply 
lives saved by quicker 
access to highway traumas. 
For on-site users of the 
hospital space, however, 
measures to decrease the 
noise effects of the 

highway will be necessary. Some degree of noise protection is currently in place due 
to an elevation in grade along the western edge and a constructed 2 metre berm along 
the eastern edge of the site. Noise calculations will be required during siting and 
design of the buildings and open space. 

Recreational Connections. 

A small park (Highland Park) is located across Gladwin to the west of the site. This 
area currently has children's play facilities. A more significant recreation site 
exists two blocks north of the site at Mill Lake. Mill Lake is a major local 
destination point for recreational activities that range from jogging and cycling to 
more passive bird watching. Just west of the lake is a large indoor and outdoor 
recreational site (Centennial Park) accessed from the hospital site down Gladwin 
Road. 

Accessible Views. 

Given the presence of the protective berm between the site and the highway, the 
potential for creating significant interior viewsheds is great. As well, the site is 
privy to significant off-site views that will be particularly vital to users of the 
higher hospital floors. Maintaining views to the rural, pastoral land south of the 
highway will be important. The value of this view as a restorative opportunity may 
well influence future zoning decisions. At present, this land is under ALR 
(Agricultural lad Reserve) and is protected. As mentioned previously, views to 
Mount Baker (directly southeast of site) are highly treasured by local residents. 
Currently, the elevation of the central knoll allows a good view to this landmark even 
without the benefit of building height. 

Figure 6-12: 
Highland Park to east of site. 

Figure 6-13: 
Menno Home and Hospital to north of site. 

Figure 6-14: 
Low-rise residential surrounds site. 

6.3 Analysis: 

Site Context. 

The proposed hospital site is 
situated in Abbotsford, British 
Columbia directly adjacent the 
Trans-Canada Highway on a 10.4 
hectare (25 acre) tract of land. It 
is surrounded by single family, 
low-rise residential and low-rise 
(maximum 4 storey) senior citizen 
care facilities. To the south are 
large expanses of rural farmland 
and to the north, the urban core of 
Abbotsford. Access to the site may 
be gained from either Clearbrook or 
MacCallum highway exits (5 minutes 
driving east and west from the 
site). 

Significant Factors to be 
Considered: 

6.3.1 Potential for Recreational 
Connections(Highland Park, 
Centennial Park, and Mill Lake, 
in particular). 
6.3.2 Proximity of Trans-Canada 
Highway and need for protection. 
6.3.3 Potential for Significant 
Viewsheds off-site (Mount Baker 
as most significant). 
6.3.4 The Senior Connection: 
Neighbors as Important Resources. 

Figure 6-15: 
Trans-Canada (#1) Highway to south of site. 

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Figure 6-16: Street Context 

- 5 1 -



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Figure 6-17: Visualization Sketch of Primrose Avenue amendments. Sidewalks, street trees, 
lighting, benches, decorative paving and signage are all possible interventions. The images 
to follow display existing conditions. 

Figure 6-18: Marshall Road looking east. 

Figure 6-19: Primrose Avenue looking north to 
Mill Lake viewing point. 

Consideration of Street Conditions. 

Access to and from the site (to Mill Lake 
Primrose connection or elsewhere) will 
require movement along the sloping 
Marshall Road that borders the North edge 
of the site (as pictured on top left) . This 
roadway will be the front door for the 
hospital site and considerations for 
street treatment will be necessary. 
Existing conditions are rural (mature 
Douglas Fir and unmanaged underbrush). 
There are existing 1.5 metre sidewalks 
that would require widening for dual 
wheelchair access. Managing the steep 
grade of this road will also be a 
consideration. Maintaining a rurally 
appropriate street edge while at the same 
time acknowledging the urban nature of a 
regional hospital will be required. 

Primrose Avenue (shown at bottom left) is the 
current main access from the site to Mill Lake. 
This flat route is two rural blocks along low-
rise residential housing. The street is poorly 
maintained at present and has no street trees or 
sidewalks. Users en route to the Mill Lake view 
point generally travel down the center of the 
road. 

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6.3.1 Context Focus 
Lake Access 

Mill 

Figure 6-20: Mill Lake Viewpoint. This 
constructed viewpoint at the end of Primrose 
Avenue overlooks the southern edge of Mill 
Lake and connects to a recreational trail that 
encircles the lake. 

Figure 6-21: Mill Lake Trail. Several 
opportunities to link this trail to hospital 
programs exist. For example, a staff running 
route that moves through the hospital and 
connects to Mill Lake could be used for after 
work stress reduction. Much of this trail is 
paved and/or gravel and is of a flat grade, 
facilitating wheelchair use. Issues of 
lighting would need to be addressed (safety 
and security) . 

Figure 6-22: Mill Lake. This is a significant 
local resource for both passive and active 
recreation. Local bird habitat include 
Mallard and Wood Ducks, Canada Geese, Hooded 
Mergansers, and Great Blue Heron. 

A viewpoint for Mill Lake has been 
constructed at the end of Primrose 
Avenue, a residential street on the 
eastern portion of the site. This 
route is well-used by residents of 
the seniors's facilities to access 
a trail that surrounds Mill Lake. A 
more sloping route to the lake is 
available down Gladwin (western 
portion of the site) . 
Opportunities: 
x Enhance Primrose Walkway 

(create a " W e l l n e s s 
Walkway") for community 
members and hospital users. 

x Create a loop connection 
through the hospital site 
that connects with the Mill 
lake walking and cycling 
trail. 

x Utilize Mill Lake as an off-
site yet a c c e s s i b l e 
restorative water feature 
for hospital site through 
connections. 

x Enhance habitat movement by 
creating a more cohesive 
green connection to open 
spaces through use of street 
trees. 

-52-



90 metres 

NOISE measured .3m 
above road surface 

HIGHWAYS 

Figure 6-23: Sound Protection assessment. 

SOUND BERM ENHANCEMENT 
'3 metre addition 
naturalistic, native tree planting of trees 

&? 3 m Mir t o o 
Ku>y «-i 

Figure 6-24: Sound Berm Construction. 

C u t a n d F i l l : R o u g h C a l c u l a t i o n s . 

Calculations are conceptual only to show 
potential for berm creation. 

• F i l l R e q u i r e d : 160m(L) X 22m(W) X 
3m (D) 

= 1 0 , 5 6 0 m3 (volume) 
• P o t e n t i a l f i l l from U n d e r g r o u n d 
P a r k i n g c o n s t r u c t i o n = 3 , 2 1 9 m3 

• P o t e n t i a l f i l l from S t o r m w a t e r 
P o n d / M a r s h C o n s t r u c t i o n ( r e q u i r e d 
b y C i t y of A b b o t s f o r d ) 

•= 170m X 30m X 8m = 4 0 , 8 0 0 m3 

**Resulting excess fill can be marketed to 
provide funds for project. 

Figure 6-25: Proposal for "Trans-Canada 
Green". 

Figure 6—26: Current south e a s t e r n berm (as 
viewed from Marshall Road) . 

Sound Buffering. 

The existing 2 metre high berm along the 
southeastern portion of the site has been 
examined for ability to provide sound 
protection for a high storey hospital 
building. This will be especially 
important for those patients who require 
long term hospital stays. Constant noise 
from daily rush hour traffic will be 
prohibitive to restoration. 

Calculations show that an increase of 2 
metres will provide noise protection to a 
height of 52 metres (approximately 11-13 
storeys), if the built form is set 90 
metres from highway. This enhanced berm 
should be planted with a mixture of dense 
mixed trees to enhance the sense of 
enclosure for the hospital open space. 
This is in keeping with the concept of 
volumetric space and creating archetypal 
spaces in which people feel most 
comfortable (Condon, 2001). 

A proposal is made to create a berm 
surface that can have future potential as 
a recreational trail, including 
equestrian use (minimum 3 metre shelf). 
A continuous green corridor currently 
runs along private and public property 
(industry and farms). Developing a 
suitable berm trail on the hospital site 
could facilitate future efforts to 
expand this link (see Figure 6-25) . 

Interim protection will require a high 
fence between the highway and the berm. 
The fence will be planted with fast 
growing shrubs and vines, thereby 
creating an important hedgerow link for 
habitat. 

6.3.2 Context Focus: 

Trans-Canada Highway 

Figure 6-27: View of Trans-Canada Highway 
along southern edge of site. 

This major commuter way presents 
visual, auditory, and physical 
barriers to the proposed hospital 
site. The proximity of the Trans-
Canada Highway will be 
advantageous in terms of 
wayfinding to and from the 
hospital, as well as simply lives 
saved by quicker access to highway 
traumas. 

For on-site users of the hospital 
space, measures to decrease the 
noise, if not the visual effects of 
the highway will be necessary. 
Existing protective conditions 
include a six-foot high chain link 
fence, a 2 metre berm and a lining 
of mature Douglas Fir trees. 

Noise analysis was done in order to 
determine optimal conditions for 
building siting, building height, 
and enhancement of berm (if 
required). This data is included 
here. 

Figure 6-28: Existing site berm as viewed 
from highway. 

-53-



P E R S O N 

Figure 6-29: General Viewshed Mapping to Mount Baker Visual Landmark. 

S a f e t y i n t h e 2 4 - h o u r e n v i r o n m e n t . 

Figure 6-30: Mount Baker-a regionally cherished 
(and well-photographed) visual landmark. 

6.3.4 Context Focus: Seniors 
as Neighbours 

The presence of two large senior's 
facilities (Mayfair and Menno) adjacent 
to the site present as a strong 
opportunity. Programming and 
development of access routes should 
include these users. The potential for 
senior's with cognitive disorders 
(Alzheimer's, dementia, etc.)using this 
site also heightens the demand for 
safety and security. Pathways will need 
to be clear with simple wayfinding and 
measures to protect against accidents 
will be required in the design. 

Special opportunities present in terms 
of cafes, restaurants (cafeteria) and 
meeting /greeting places. The use of 
open space for activities that can be 
shared by seniors's of all abilities 
will be important in the design. 

This will be an important issue not only as a result of staff working all hours, but also due 
to the potential for high use by seniors with potential for cognitive impairment. Safety 
will be maximized with lighting and easy way finding from buildings to parking lots, main 
streets (bus connections) and evening garden/restreat spaces. Principles of Crime 
Prevention through Environmental Design (CPTED) will be followed whenever possible (see 
Appendix II) . Examples will include: 

• Visible plantings/details/furniture that require a minimum of upkeep; 
• Spaces intended for use by the public versus those restricted to hospital 

patients/staff clearly identified with real or symbolic boundaries; 
• Entrances and exits clearly marked with sidewalks and lighting; 
• Safety features used in areas of potential danger to persons with impaired cognitive 

abilities (e.g. around water bodies, roadways); 
• Visual access around and through buildings maximized to discourage intruders and 

improve wayfinding; 
• Landscaping in sensitive areas (high use after dusk) adheres to "groundcover-canopy 

strategy" with shrubs below eye level. Eye level is considered from a wheelchair 
position. 

6.3.3 Context Focus: 
Accessible Regional Views 

For many users of the hospital, 
confinement to the building will be 
an issue (staff, patients, and 
visitors). Given the presence of 
the protective berm between the 
site and the highway, the potential 
for creating interior restorative 
viewsheds is great. The presence 
of surrounding viewing potentials 
is particularly important for 
users of upper hospital floors. 

Views to the rural, pastoral land 
across the highway to the south 
will be important. Maintaining 
the integrity of this view may 
influence future zoning decisions. 
At present, this land is under ALR 
(Agricultural lad Reserve) and is 
marginally protected. As 
mentioned previously, views to 
Mount Baker (directly southeast of 
site) are highly treasured by local 
residents. The existing elevation 
of the central portion of the site 
enables a good view to this 
landmark even without the benefit 
of building height. 

The map pictured on this page shows 
the southeast location of Mount 
Baker in relation to the site. 
Given the flat river valley land in 
between the site and this landmark, 
extensive viewshed mapping was not 
required, however, orientation of 
views will be a major consideration 
in the design. 

These measures to promote safety and security (both real and existential) will 
advantageous not only to surrounding seniors but to staff, patients and families as well. 

be 
Mount Baker presents as a picturesque 
landmark even in the presence of foreground 
industry (in this case, one of several car 
junkyards in the area). 

-54-



Figure 6-31: 
Ortho Map of 10. 4 hectare proposed hospital site, 2001-prior to building demolition 
(courtesy of City of Abbotsford) . 

6.4 
On-Site Conditions 

6.4.1 Methodology. 

Given the restrictions on access to 
the site (high perimeter fencing, 
demolition activity in progress), 
analysis was challenging and 
assumptions had to be made. 
Methods used included: 

• Use of aerial photography 
(supplied by City of 
Abbotsford as well as 
private sources) , 

• Use of contour information 
obtained from City of 
Abbotsford, 

• Use of data gathered by 
initial site analysis and 
planning team, Resource 
Planning Group (located at 
FVRH Project Home Page), 

• Limited ground-truthing, 
using photography from all 
available viewpoints, 

• Few ventures onto the site 
after hours, 

• Discussions with local 
r e s i d e n t s r e g a r d i n g 
conditions of soil, water 
drainage and general 
conditions, 

• Research 
conditions 
area, 

• Personal knowledge of the 
area and its conditions. 

The site was observed over the span 
of several months: October through 
March. This enabled a fuller 
interpretation of denseness of 
vegetation through the seasons as 
well as a cursory evaluation of the 
effect of the British Columbia 
rainy season on the site landscape. 

A generalized analysis of on-site 
conditions is presented here as 
well as a summary of opportunities 
based on the restorative design 
literature. 

into regional 
affecting this 

0 50 100 

GRAPHIC SCALE (metres) 

•55-



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» • • - ' ' 

2- La/»e 

Figure 6-32: 
ANALYSIS MAP- Summary of site conditions, 2001. [ft ••'.'. ' 

I I GRAPHIC SCAJ GRAPHIC SCALE (metres) 

Significant Viewsheds 
• Exterior: Mt. Baker is visible to southeast 

from upper knoll; rural agricultural fields 
are visible across the highway to the south. 

• Interior: a current potential exists for 
interior woodland views in the Douglas Fir 
knoll and open pastoral views behind the 
highway berm. 

Topography. 
• Two flat plateaus surround a man-made treed 

knoll in centre of site: peak of knoll at 72 
metre above seal level, lowland at 55 metre 
above sea level. This suggests a 
significant challenge for grading the site 
to accommodate univeral accessibility. 

Vegetation 
• Primarily Douglas Fir, second growth (60-70 

metres in height) is 
identified at edges of 
property and at apex of treed 
k n o l l . D e c i d u o u s 
cottonwood, alder, scrub, 
decaying/damaged coniferous 
trees and unmanaged Rubus 
d i s c o l o r ( H i m a l a y a n 
blackberry) are on slopes of the knoll. 
Views and access into the knoll highly 
limited by scrub and Rubus discolor. Small 
pockets of abandoned, cultivated orchard 
species noted on northeastern and 
southwestern portions of site (e.g. 
Hazelnut) . 

Conifer Woodland 
Douglas Fir, some 
Cedar/Hemlock 

Deciduous/Mixed 
(alder/cott onwood/ 
Cedar) and scrub 

various exotic 
conifers, varied heights 

Poplar X3 planted 

\ Old field area 
{Phazelnut) 

I Visible Rubus discolor 

<5% s l o p e s 

5-10% s l o p e 

0-25% s l o p e s 

>25% s l o p e s 

6 . 4 . 2 
S u m m a r y 
C o n d i t i o n s 

o f O n - S i t e 

Figure 6-33: ANALYSIS MAP- Vegetation Analysis, 2001-2002. Figure 6-34: ANALYSIS MAP- Topography Analysis, 2001. 

Soils. 
• This area is characterized by 

sandy, loamy soil that is 
generally well draining. 

Water/Drainage 
No significant water bodies are 
noted on the site. Current 
drainage is either subsurface 
or directed into ditches at edge 
of Trans-Canada Hwy (along 
south end of site). 

Wildlife 
• H a b i t a t f o r s m a l l 

mammals(evidence of voles) and 
raptors is noted in the open 
pastures. No significant bird 
or animal life was noted in the 
largely coniferous knoll. No 
obvious signs of larger habitat 
(deer, coyote)were seen 
although these animals have 
been spotted in nearby open 
spaces and are prevented access 
to the site by current 
protective fencing. 

Human Trace 
• Traces from old roads and 

chicken barns are evident due to 
very recent demolition. There 
are no remaining built forms. 

Elements (climate, wind) 
• Significant winds in this area 

are from southeast in winter. 
Noise 

Noise from highway is audible 
throughout the site and is 
greater at peak travel times and 
on rainy days. 

-56-



Connect to Recreation Connect t o Recreation 

"All existing mature 
Douglas Fir stands 
present as strong 
cues to regional 
identity. This 
includes the central 
knoll as well as 
perimeter stands. 

Figure 6-35: ANALYSIS MAP- Summary of Restorative Opportunities 

On-Site Conditions : 
Restorative Opportunities . 

This graphic overlay explores the 
opportunities and constraints of 
the existing site conditions 
relative to the principles 
outlined in Chapter IV. An attempt 
is made to identify areas that may 
be enhanced and/or protected in 
order to achieve a landscape that 
is archetypal, compatible, living, 
and accessible. A 'Critical Area 
Map' follows on page XX that 
highlights very specific elements 
that will help direct the site 
layout and the eventual design and 
programming of the hospital. 

In the following chapter, the final 
scheme is analyzed from all the 
various viewpoints, using these 
analysis maps to guide decisions 
for protection and/or enhancement 
of landscape areas. Both 
functional and restorative 
'requirements' were used to guide 
this final design. 

1. Opportunities & Constraints: 
Archetypal Landscape. 

Two primary areas are identified as 
potentials for an open pastoral 
experience, the upper west corner 
and the south to south-east portion 
of the site. Currently very flat 
areas, these will also serve as 
prime locations for constructing 
the built form. Given that 
enhancement (an increase in height 
and planting mass) is required 
along the southern berm, the 
southern pasture may prove to be 
the most appropriate place to 
protect and enhance the wide-open 
feel of a pasture. 

In contrast, the southwestern 
corner of the site is situated on 
an elevated plateau and does not 
require a berm. Subsequently, 
this area may prove the sunniest 
space for gardening activities to 
occur. 

-57-



The central treed knoll is considered worthy of protection for several reasons 
already discussed (habitat enhancement, areas for prospect-refuge, 
regionalism, aesthetics, and wayfinding). A challenge will be to salvage this 
site without allowing the built form (hospital buildings and parking lots) to 
demolish these mature, highly recognizable trees. 

Figure 6-36: Central treed knoll on proposed hospital site, November 2001. 

A small park to the west of the site also offers views to an open space 
preferred by humans and may be included in the open space program, particularly 
for viewing opportunities if buildings and windows are oriented in that 
direction. 

The grade change along the site may facilitate the construction of a water body 
(lake and/or marsh) in which users will find comfort. The importance of water 
in the restorative landscape has been discussed in previous chapters. 

2. Opportunities & Constraints: Compatible Landscape. 

Protecting and enhancing current views to regional landmarks (ALR land, 
surrounding peaks) will enhance the sense of belonging. Ensuring that these 
views are kept open and not made inaccessible by inappropriate built program 
placement will be important. 

Another issue to be considered is the creation of a welcoming, legible front 
entrance. The currently well-used corner of Gladwin and Marshall (with an 
existing bus stop)presents as an opportunity. Use of this corner as the main 
entrance would allow the large space on the eastern portion of the site to be 
developed for open space programs accessible not only by the hospital but also 

-58-



Douglas Fir that currently border the site are retained, it will be important 
to ensure a maintenance plan that ensures the balance between mystery and 
legibility are not disrupted. Currently, these stands do not exist as 
impenetrable barriers. 

3. Opportunities & Constraints: Living Landscape. 

A review of current habitat types and potential habitat types will enable the 
designer to attract birds and small mammals in a natural manner. By enhancing 
and protecting those areas already suitable for different types of birds and 
mammals, the site will have a higher likelihood of filling with life and signs 
of life. The rough overlay shown here in Figure 6-35 identifies existing 
landscape types that may be protected (open pasture, treed knoll, old fields, 
etc.). This does not rule out, however, the active design and creation of new 
habitat areas that will more aggressively attract birds and animals. In 
particular, bringing water features (large and small) onto this site will be 
advantageous to a large number of species. The proposed final plan for the 
design will attempt to protect and/or create as many 'natural habitats' as 
possible. 

For example, retention of the inner forest knoll will provide habitat for 
raptors (feeding) and, if supplemented with appropriate edge plantings and a 
tiered understory structure will enhance the interior bird and wildlife 
population. Another example may be the retention of existing open pasture as a 
means of introducing domesticated animals onto the site, for permanent or 
temporal use (sheep, cows, horses, etc.) . 

-59-



This issue of habitats for biodiversity will be explored further in the 
following chapter. 

The other element of the living landscape is humans working, playing and 
exploring in the physical open space. Sunny southern exposures lead to 
opportunities for community and/or hospital-based gardens, walkways and other 
outdoor programs. As identified, the sloping, southern portion of the site 
presents as a viable place for these activities to occur. A danger will be the 
construction of a large built program that may block sunlight. 

Living Landscape Focus: Potential for Rural-Edible Landscaping. 

As discussed in previous chapters, patients (and staff and visitors) will feel 
more comfortable (and encounter less stress) if surrounded by regionally 
familiar programs or plantings. An edible landscape on the hospital site will 
not only give evidence of life (the living landscape) but will also be a 
familiar and regional site, easily understood by local residents. The sunny, 
southern exposure of much of the site and the good groundwater drainage would 
indicate a potential to grow and harvest regional crops such as raspberries, 
blueberries, strawberries, corn, grass for hay, etc. Creating an edible 
landscape on the site will have the added benefit of providing important 
habitat for certain types of birds and wildlife. 

Introducing community gardens or orchards onto the site will also increase the 
possibilities for community interaction on the hospital grounds. 

On a purely aesthetic level, edible landscapes (in particular blueberry and 
raspberry fields) create all-season interest and provide an appealing local 
alternative to mass plantings of exotic shrubs. 

Living Landscape Focus: Potential for Greenway Connections. 

Habitat loss and fragmentation are the most serious threats facing populations 
of birds across North America and around the world (Audubon Society, 2001) . For 
several years, residents of the Fraser Valley have participated in what is 

-60-



Figure 6-39: Red-tailed hawk. 

Figure 6-40: Townsend warbler. 

Figure 6-41: Stellar jay. 

participated in what is becoming the 
large "business" of "back-yard" care 
of small birds. A multitude of 
specialty stores in the area offers 
seed, feeders and apparatus. 

Each December 29 the Central Valley 
Naturalists co-ordinate the 
'Audubon Christmas Bird Count' for 
the Abbotsford/Mission area. This 
is in participation with birding 
groups across Canada, the United 
States, Central and South America, 
the Caribbean, and several Pacific 
islands where North American 
breeding birds spend their winters. 

Of the 93 bird species counted in 
this region last year, it is 
important to note that 38 were 
observed in gardens, including rare 
sightings of Townsend's warblers. 
This indicates a high degree of 
participation by local residents 
(Abbotsford-Mission Times Online, 
2001) . 

"North America 's Birds are in 
trouble. Through stressing action by 
people at the local, grassroots 
level, ordinary citizens are given 
an opportunity to protect globally 
important places and help save the 
birds that use them from decline and 
extinction (Audubon Society, 
2001)." 

The enclosed nature of the site 
(sandwiched between highway and 
urban core) inhibits the potential 
to join hospital open space with 
surrounding terrain-based habitat 
corridors. 

One potential and vital greenway 
connection, however, is the now-
existing continuous green that 
follows the length of the Trans-
Canada Highway. This includes not 
only the center meridian but also the 
edges. This exists as a potential 
resource for both habitat 
enhancement and recreational 
purposes. 

-61-



Figure 6-42: Views from the Highway: Potential Private-Public Green Corridor. 

4. Opportunities & Constraints: Accessible Landscape. 

Graded relatively flat on either side of the treed knoll, a Marshall Street 
entrance to the hospital site will be easily accessible by a range of users. A 
unique challenge will be creating an accessible open space in the protected 
berm area that deals with a 10-metre+ drop from apex to base. Paths that allow 
neighbors of all physical abilities (those with impaired mobility to those 
seeking a recreation challenge) to access and enjoy the site programs will 
require a creative approach to both grading and pathway design. 

A legible, strong entrance will be required for persons arriving under great 
stress. Ambulance arrivals will require a separate entrance that is not 
closed off to the public but that will be a secondary route at best. Gladwin 
Road presents as a possibility for this access. Fire and other emergency 
vehicles will require a 3-metre minimum clearance around all built structures 
as well as access into the open space program areas. This may limit the choice 
of materials, as these pathways should be fully accessible during all seasons. 

Satisfying the functional aspect of accessibility will need to be balanced 
with restorative requirements for a welcoming entrance and a promise of 
discovery beyond (a sense of mystery). This may require a separate entrance 
for recreation and community members that does not interfere with the urgent 
functional arrivals related to hospital programs. 

-62-



Respond to existing topography and utilize to create open space and sense of enclosure: 

• Use central elevated knoll (prospect position) to create viewing opportunities to surrounding peaks and farmland; 
• Use flat pastures and low plateaus to create accessible open space program areas, large water feature (s) and a sense of 

the open savannah for viewers; 
• Enhance existing berm to heighten sense of enclosure and to protect from highway noise; 
• Grade site in a manner that enables a wide range of users to move throughout the site easily. 

Maintain as many existing mature trees and/or landscape units as possible: 

• Retain as much of mature, second-growth Douglas Fir in central knoll as possible and create programs that will allow the 
trees to be used as a physical as well as visual resource (trails, areas of refuge); 

• Retain mature, second-growth Douglas Fir along east border of site in order to maintain sense of mystery that currently 
exists between hospital site and neighboring senior's facility; 

• Retain as many ornamental and native mature trees within site, and intersperse with newly developed plantings and 
programs; 

• Retain areas of old field/old orchard, recognizing their importance to local habitat (e.g. in particular, old field in 
southeast corner of site, and old hazelnut orchard in northeast corner); 

• Recognize that some trees will need to be removed to make room for built structures (parking lots, roads, buildings). 
Priority will be placed on retaining mature Douglas Fir in central knoll and along site perimeters. 

Decrease visual and auditory impact of Trans-Canada Highway: 

• Increase height of existing berm according to sound calculations and need for enclosure; 
• Recognize this as a major opportunity to create a restorative enclosure landscape form, by enhancing landform with 

vegetation; 
• Design this area of the berm as a useable trail to act as a 'precedent' for future connections along the Trans-Canada 

Highway. 

Facilitate views to significant regional landmarks: 

• Promote southeast views to Mt. Baker via building orientation/orientation of roof gardens and terraces. Hospital 
buildings should be oriented primarily southeast to take advantage of sunny exposure as well as Mt. Baker views; 

• Orientation of built structure should enable southern views to agricultural fields and regionally familiar activities 
(gardens/crops, etc.); 

• Placement of open space programs should be done in consideration of views from hospital building. In particular, those 
hospital units that feature long-term stay or required bed rest should have enabled views to south and southeast 
features and landmarks. 

Connect with neighbors and neighboring amenities in program and design development: 

• Hospital building mass and height should be designed in consideration of the size of neighboring seniors' facilities 
(stepping of hospital buildings may be appropriate). As well, large open space should be located and designed to serve 
the hospital as well as these neighboring facilities; 

M Connections to Mill Lake recreation site to the north should be considered in new road and entrance development, perhaps 
by creating a loop through the hospital that extends to connect with the Mill Lake loop; 

• The design and programming should take advantage of the relatively isolated nature of the site (minimal to no 
restaurants, shops or coffee shops) in order to draw community members onto site. 

Maximize potential for 'living landscape' in a sustainable manner. This will require: 

• Enhancement and creation of preferred habitat landscapes for birds and mammals; 
• Involvement of the local community in open space programming and management (proposal will be included in program 

development); 
• Inclusion of maintenance requirements in design proposal; 
• Development of water body on site according to stormwater collection requirements of proposed building. 

6.5 Site-Specific Design 
Objectives 

1. Existing topography will be 
used to create open spaces and a 
sense of enclosure. 

2. A strong effort will be made 
to retain mature trees and 
landscape units. 

3. The visual and auditory 
impact of the Trans-Canada 
Highway will be reduced. 

4. Views to significant 
regional landmarks will be 
promoted. 

5. Neighbors and neighboring 
amenities will be considered in all 
design moves. 

6. A sustainable approach 
design will guide the process . 

t o 

Notes. 

Final grading will be shown on 
master plan of completed 
design. 
Retained trees will be marked on 
final plan. A biodiversity 
overlay will identify both 
retained and created areas for 
habitat. 
The enhanced berm will be 
constructed according to 
calculations shown. 
A general description of 
hospital program placement will 
be detailed in the next chapter. 
Program placement will be done 
according to both functional 
and restorative requirements. 
Sensitivity to neighbors will 
be illustrated in drawings that 
propose general building 
appearance and staggering of 
building heights. Large-scale 
cross-sections of the proposed 
built structure will be 
presented. 
Calculations for the pond and 
marsh to retain stormwater have 
been done using a rough estimate 
of changes to runoff. 

- 6 3 -



CHAPTER VII 

A Vision for Restorative Hospital Design: 
The Valley Health Centre (VHC) 

7.1 Site Narratives 

The intention of this project was to give an image and sense of the 
restorative hospital landscape. Experiential qualities of the design were 
a strong motivator for design decisions. The goal was to create a place 
that would be living, breathing, familiar, and accessible and would offer 
an appropriate blend of legibility and mystery. Considerations of the 
diverse intended users (hospital in- patients, out patients, visitors, 
staff members and community interests) led to the development of a design 
for a place that while globally restorative, offers unique opportunities 
along a continuum of needs and abilities. 

7 . 1 . 1 The P a t i e n t ' s E x p e r i e n c e 
"Our arrival to the hospital was easy to understand...everyone 
arrives at the same central place off Marshall Road. My 
sister dropped me off and then continued on to the underground 
parking. I was automatically drawn towards the hospital's 
front glassed-in atrium. I could see reception inside but 
there were also views to a little forest tucked in behind the 
hospital building... My 2-bed room faced out over an almost 
farm-like area where I could see sheep grazing, kids picking 
fruit, and gardeners tying back raspberry canes. Mt. Baker 
loomed over the whole scene. Feeling pretty good today before 
my surgery I thought I'd go down and walk along the paths I 
could see winding in and out. I grabbed a drink and a 
magazine from the Community Cafe and headed out along the 
Orchard Walk..." 

7.1.2 The Staff Member's Experience 

"Since I usually arrive late at night and walk from the 
parking lot, I appreciate the well-lit pathway. It feels very 
safe. I can see the Emergency Entrance from my car. Last 
night I nearly exploded after some patient threw a tray at me. 
I almost felt like starting smoking again. Instead I escaped 
outside to our private garden and tried to pretend I was 
somewhere else. It actually made me feel better.... " 

7 . 1 . 3 The P u b l i c E x p e r i e n c e 

I moved into Menno Home a year ago when my arthritis got 
really bad and I couldn't get around without my wheelchair. 
Before they put up the new Valley Health Centre, there wasn't 
anywhere around for me to go on my own. I feel much more 
independent now. I try to leave Menno Home once or twice a 
week and wheel myself down the hospital's back lane to take 
lunch in their cafe. Even in bad weather, I can sit inside the 
cafeteria and enjoy the garden view and the view to the marsh. 
It's also great to be able to just sit and people watch (or 
birdwatch...or squirrel watch) . Those of us who meet here, 

- 64 



particularly on sunny days, move the tables around so we can 
watch the people passing by and challenge younger people to 
games of chess. 
They have a group of volunteers here that help take care of 
the gardens, bring in pets, talk to patients. Last week I 
helped man the booth selling apples..." 

7.2 Introduction of Design and Program. 

A program and design has been put forth in this project for the proposed 
site in Abbotsford, B.C., as discussed in Chapter VI. An effort has been 
made to combine the functional with the restorative in order to create a 
hospital landscape that is welcoming to all members of the community, 
regardless of individual health or well-being. 

This hospital landscape has been designed differently from typical modern 
health care facilities. It is not like the typical urban hospital that 
thousands of people pass by daily on foot but dare not enter. It is not 
like the typical rural hospital that hundreds pass by daily in car without 
realizing its existence. This hospital site stands as a 25-acre (10.4-
hectare) landscape designed to welcome the Fraser Valley community onto 
its grounds, regardless of ability, age or health status. It is a place 
where healing through technology and healing through nature occur 
simultaneously. It is a place where the environment works with rather 
than against the caregivers to reduce stress, cure illness, and promote 
well-being of patients. It is a place that recognizes that these 
caregivers are themselves facing crisis proportions of work-related stress 
and offers them refuge and retreat. The Valley Health Centre (VHC) 
strives to stand as a precedent for restorative design and a new vision 
for the future of health care design. 

This project required telescoping between a variety of scales. The many 
facets of hospital design required a process that was at times loose and 
sketchy and yet at other times overly concerned with data, grading and 
calculations. The vision, or conceptual site plan, is presented and then 
explained through several analysis maps (key views, circulation, open 
space, biodiversity, etc.). Program elements are described with both text 
and with images. 

The following page features an image of the final master plan. Through 
mapping, analysis, and written text, this design will be scrutinized and 
critiqued for its ability to adhere to the principles set out in this 
project. A combination of traditional, functional reference points are 
combined with more unique, restorative focused means of measurement. Two 
larger pullout versions of the master plan, with graphic scales, are 
included at the end of this chapter, showing proposed schemes for grading 
and vegetation retention. 

Certain design elements referenced in this chapter may appear in the 
chapter to follow. 

- 65 -



MU3«V3$M 

I'1 
f 

< 

UllJM 

^ rr i 

o 

,:-iJ' n / 

v0*. G, '
; • 

, I 

° uti - .! 

Figure 7-1: Master Plan for FVHC (Fraser Valley Health Centre). (Refer to 
Figures 7-21 and 7-22 for grading and vegetation schemes). 

- 66 -



Reiteration of Project Goals: Holistic Restorative Characteristics. 

Every landscape within the site is considered part of the whole. As an 
entity, this site design aims to incorporate the four following 
restorative characteristics: 

1. Archetypal Landscape. 

The landscape plan makes use of archetypal forms that are inherently 
familiar and comfortable: the open meadow, the protected clearing, and the 
prospect lookout (roof top gardens, berm lookouts). Significantly, a very 
large open space area hugged by a constructed, treed berm along the Trans-
Canada Highway creates a strong sense of enclosure. Existing large open 
areas of pasture have been retained for their therapeutic value (human 
preference) as well as their value to certain types of habitat. 

2. Compatible Landscape. 

The landscape plan offers a range of choices for degrees of legibility 
with some areas very functional and legible (areas of high stress-e.g. 
Emergency entrance, main Entrance) and others offering more mystery and 
intrigue (areas for play or retreat-e.g. open shared space, private 
gardens). Throughout the landscape are clear indications of regional 
belonging: views to Mount Baker, views to mature Douglas Fir trees, views 
to local raspberry farms. The landscape is designed to promote a sense of 
security and control with lighting of sensitive areas, choices for 
movement (refer to Circulation diagrams that follow). Redundancy is an 
important feature of the pathways created on this site for two primary 
reasons: to give users a sense of control over their actions and to reduce 
the risk of entering into unsafe situations. 

3. Life-supporting Landscape. 

The living landscape proposed in this design features food, water, birds, 
animals, and farming. Biological diversity is facilitated through the 
creation of a wetland marsh, as well as plant choices and plant 
arrangements (linear connections, vertical stratification, and habitat 
attracting plants). A unique mode of analysis used to determine layout 
for both open space and built form paid attention to current or potential 
habitat values. Open space was evaluated for its worth as a life-giving 
force before, rather than after the "creation" of the design. 

Attention to landscaping should extend off-site and up Primrose Avenue two 
rural blocks to connect to the rich and diverse Mill Lake. This 
intervention has been described previously in chapter VI. This now quiet 
route is currently accessible to patients in wheelchairs from neighboring 
senior's facilities. With the construction of a large hospital traffic 
will increase. For this reason, a street retrofit (with canopy street 
trees, wide sidewalk and rest stops) is proposed. 

4. Accessible Landscape. 

Movement into and through the landscape has been designed in an equitable 
manner so that all users, regardless of ability, feel welcomed. Patients 
in wheelchairs will have access throughout the living landscape (forest, 
marsh, and orchard) during all seasons along simple asphalt pathways 
graded to no more than 8%. In areas where a more natural appearance is 

- 67 -



preferred, yet there is still a strong need for firm support under the 
weight of traffic (e.g. emergency vehicle routes and turnarounds), grass 
crete planted with Sweet Woodruff or Thyme has been suggested. Rest stops 
along major paths will be no farther apart than 200 metres (Mooney, 1999, 
p. 4) . Visual access will be a strong consideration: from the 
streets/highways (Gladwin, Marshall and the Trans-Canada), from the 
neighbours (Menno Home and Hospital, Mayfair Senior's Home, and several 
nearby single family homes), and from inside the buildings (windows sited 
.7 metre from floor to enable views from beds). 

Significant changes in grade on the site combined with a strong desire to 
maintain site-specificity and avoid the "blank slate approach" to design 
created an interesting, and oftentimes, frustrating exercise in grading. 
The resulting design, however, accomplishes the goals of accessibility and 
also creates interesting areas of peaks, lookouts, ravines and marshes. 

The practical, functional side of hospital design reared its ugly head 
early on in the design process. By dealing with these issues head on, 
however, it has been possible to envision simple possibilities that are 
surprising in their simplicity and their ability to combine function with 
therapeutic benefit. For example, the design required a minimum 3 to 4-
metre clearance around all building edges with a 13-metre turning radius 
for emergency vehicles. This challenge presented an opportunity to create 
instant, accessible outdoor spaces for pushing patients in wheelchairs and 
beds outside for fresh air. 

7 . 3 Design Process 

Having developed the goals for design and the program for the site, the 
challenge was to translate philosophy and vision into a workable solution. 
Early design exploration focused purely on the conceptual. Rough sketches 
were used to make sense of a large site and a complicated program. The 

most effective approach 
discovered for this project 
was to move back and forth 
between the qualitative (pure 
imagination, instincts, and 
preferences) and a developed 
set of quantitative 
measures/mappings by which to 
rate the progress of the 
design. These measures will 
be discussed here (in text and 
graphic) in an effort to prove 
the validity of the final 
design. The design process 
was most successful when 
guided by the following 
tenets: 

1. Sustainable Practices as a 
Mandatory Component of Design. 
Accept the fundamentals of 

Figure 7-2: Example of one of multiple sustainable growth and 
rough conceptual design sketches. development and allow them to 

help guide the design: 

- 68 -



• Identify an open space typology that respects both humans and 
habitat through promotion of biodiversity, 

• Take advantage of local bylaws that demand stormwater detention on-
site to create a beneficial water body. 

Measure: Biodiversity Mapping. 

2. Site Layout: General considerations are strongly affected by site 
analysis. 

Maintain respect for findings of site analysis and aim to keep valuable 
resources (site-specificity): 

• Understand negative 
impacts on the site and find 
solutions that can be 
restorative as well as 
functional. For example, 
building a sound berm that 
blocks out noise from the 
highway has the added 
benefit of creating an area 
with a strong sense of 
comforting enclosure, 

• Achieve a balance 
between the newly created 
and the preserved. For 
example, transitions between 
retained portions of the 
central treed knoll and 
other open spaces should be 
done in a harmonious manner 
(use native plants, balance 
open and closed areas, 
enable views into the treed 
knoll), 

Understand through local research what measures will be most 
effective in this region (physically, socially, economically, and 
culturally). For example, while an open space program that features 
edible landscaping might not 'fit' into a more urban area, it does 
coincide with local traditions and preferences, 
Develop a sense of pride for regional landmarks and develop a site 
plan which maintains key views to regional landmarks. 

Figure 7-3: Example of one of multiple rough 
conceptual design sketches. 

Measure: General 
Delineation. 

Layout Considerations Mapping and Built Program 

3. Visual access to the landscape of high importance to all users of site. 
Assess current key views to be protected and vision future views: 

• Consider important indoor-outdoor visual relationships. 
Measure: Key View Mapping. 

4. Circulation requires a combination of legibility and mystery. 
Understand and accept the importance of a foolproof circulation pattern 
that will not heighten stress levels: 

- 69 -



• Treat perceived obstacles as challenges to find new solutions 
(clustered parking enhances safety and reduces cost of security, 
emergency access creates accessible surfaces for bed-patients). 

Measure: Circulation Mapping. 

5. Community Participation Integral to Project Survival. 
Explore the potential for inclusion of community members in the 
design/program and its ultimate survival: 

• Identify what roles they can and cannot play. 

• Delineate areas within the design that will be particular to one or 
more user groups. 

Measure: open Space Organization and Management. 

7 . 4 Sustainable Practices: Required Component of Design 

Sustainability is commonly referred to as living one's life in a manner in 
which the world will be protected for future generations (Earth Summit, 
1992). In 1987, the World Commission on Environment and Development 
developed a definition of sustainability that was included in its 
findings, which became known as the Brundtland Report (Bruntland, 1987). 

"Development that meets the needs of the present without compromising the 
ability of future generations to meet their own needs". 

• The World Commission on Environment and Development, Brundtland 
Commission, 1987. 

At the Earth Summit in Rio de Janeiro, 1992, this definition was affirmed 
and elaborated upon. "Human beings are at the centre of concerns for 
sustainable development. They are entitled to a healthy and productive 
life in harmony with nature" (Earth Summit, 1992) . 

For architecture and landscape architecture, this means "design that 
delivers buildings and communities with lower environmental impacts while 
enhancing health, productivity, community, and quality of life" 
(Callenbach, 1993). 

Sustainability is not limited to impacts on the natural environment, but 
on individuals and the community at large as well. A common concept often 
referred to in sustainable design is the 'Green Triangle of Environment, 
Economy and Equity'. Social sustainability, environmental sustainability, 
and economic sustainability necessarily go hand in hand. "Any time you do 
something beneficial for one of them, you will almost inevitably do 
something beneficial for the other two" (Callenbach, 1993). 

While the focus of this thesis project is to attempt to influence the 
health and well-being of those individuals in current contact with the 
hospital environment, it would be delinquent to proceed without concern 
for future resources. Steps taken in the design process have been with 
consideration of economic, social, and environmental sustainability. As 
discussed previously, a hospital landscape that is designed with the users 
in mind will affect the long-term health (economic and social) of users 
ranging from patients to staff to community members. Economic benefits 
have been hypothesized as deriving from a reduction in stress amongst 
staff and therefore a reduction in absenteeism, and higher productivity. 
Stress reduction in the patient and family poulations should be reflected 

- 70 -



in better response to treatment, shorter hospital stays, and less demands 
on caregivers (Ulrich, 1984). 

Certain measures have been taken to heighten the "ecological 
sustainability" of this proposed design. In particular, efforts were 
focused in the area of habitat protection and enhancement. This will take 
form in three primary ways: 

1. Analysis of landscape units within proposed site plan that may provide 
(now or in the future) benefit to birds, small mammals, insects, 
amphibians and other beneficial native creatures; 

2. Collection of water run-off on-site in order to prevent further 
degradation of streams entering the fragile Fraser River system and its 
fluctuating salmon population; 

3. Development of a program by which community members can actively 
participate in the land stewardship, thereby increasing awareness, 
volunteerism, and a sense of civic duty towards protection of regional 
landscapes. It is hoped that any program initiative will involve local 
schoolchildren to help further the awareness and education of youth. 

While the above are stated as measures to promote sustainable and 
responsible protection of regional resources, each intervention will have 
the double effect of being restorative and therapeutic by nature. As 
discussed previously, exposure to nature has strong healing effects that 
are enhanced with any degree of participation. Hospital patients, staff 
and visitors receive restorative benefits through the act of simply 
viewing a stream, pond or marsh. The opportunity to actively monitor and 
count rises in bird, fish or mammal populations will only enhance this 
effect by increasing level of interaction with nature (Lewis, 1996) . 

7.4.1 Biological Diversity Enhancement. 

Refer to Figure 7-5: Biodiversity Analysis. 

Efforts to promote biological diversity (biodiversity) and prevent and/or 
slow down the continuing extinction of species offer significant 
restorative benefits by enhancing the "living" nature of the landscape 
(Kellert and Wilson, 1993) . This task, however, is also considered by 
many experts to be perhaps the most significant ecological emergency by 
modern man from a purely ecological standpoint. E.O. Wilson describes our 
"mass extinction of species" as being the "most destructive global 
environmental change of all time" (Wilson, 1999) . 

An effort has been made to not simply attract animals and birds to this 
proposed hospital site but rather to enhance or in some cases, simply 
protect, habitat that is already vital to the survival of local species. 
Unfortunately, the choppy nature of suburban development has left few 
terrestrial resources that can be relied upon to create linear 
connections. Disconnected from its natural surroundings by the Trans-
Canada Highway to the south and urban Abbotsford to the north, a concerted 
effort on site is required to enhance biodiversity. 

Habitat (or ecosystem) may be generally referred to as a particular 
environment that allows a particular species to live and thrive (Harding, 
1994). Man's disturbance of the landscape has disrupted the natural 

- 71 -



progression of habitats for mammals, birds, insects and amphibians. 
Efforts to bring life onto a landscape will have the double benefit of 
producing restorative benefits for humans, and creating or returning 
habitat for creatures, promoting regional biodiversity. 

The site was analyzed for potential or present ecosystems. Any identified 
spaces will be enhanced or protected, and in some cases, recreated. 
Planting styles and plant choices are dependent on their ability to 
attract living creatures. For example, whenever possible, vertical 
stratification, linear connections and an edible palette has been used. 
Plants (trees, shrubs, and groundcovers) that offer forage, nesting, 
movement, or lookout opportunities are maximized. Interventions or 
enhancements will range from colourful, sunny gardens designed to attract 
hummingbirds and butterflies to hedgerows created with a variety of native 
species that will be used for bird and small mammal movement and nesting. 
Red-listed species (considered high risk for extinction) will be 
recognized as needing high priority measures. For example, several hawks 
and owls are at risk in British Columbia (Harding and McCullum, 1994). 
Construction of hawk and owl friendly landscape typologies will be 

considered. An open pasture 
edged by tall "lookout" trees 
(existing conifers) will provide 
forage space. An ephemeral 
mowing system versus regular 
lawn clipping will enhance 
forage potential. Allowing 
existing and "new" old fields to 
evolve naturally will also 
contribute. The site will also 
be managed to prevent further 
disruption to natural 
conditions. Invasive exotic 
plantings will be avoided. 
Despite the aesthetic and 
possible visual restorative 
benefits of exotic wild flowers, 
these plants disrupt and take 
the place of native flora (and, 
subsequently, disrupt the local 
habitat). Specific small-scale 
interventions to enhance 
existence of certain species may 
also be introduced (e.g. wood 
duck nesting boxes). 

In the previous chapter on site analysis, several open spaces were 
identified as potentially restorative, either for their abilities to 
create archetypal experiences or their abilities to promote a landscape 
alive with birds, mammals and/or community members (e.g. gardening). 
Figure 6-35 outlined a basic preliminary assessment of the site in terms 
of restorative potential. The design proposed here makes use of several 
of those potentials, and makes a point of including new areas of habitat 
to enhance regional biodiversity. The following diagram is an assessment 
of the final proposed design in terms of its ability to enhance and 
protect habitat biodiversity on the hospital site. This is merely the 
first of several 'analyses' by which designs were evaluated. 

- 72 -



"Bio4 WftfSl^ - BifipHJia •* Refer -f-o fc^ for descriptions 

CX2> 

CE> 
CS) 
cx> 
' S > 
•'••'?} 

."€> 

d b 
,xx> 

- " • 

Fru'i4 O r e h a r q 

Gjar4en CE<fc t W 

T o n d - Harsh 

Taiturt 

Woo4lan<l 

Conifer slant) 

tfi«4 t r e e sfanq 

CM FieM 

t i n i w t Tlan+i'ncjS 

He.iotrov(5 

Figure 7-5: Biodiversity Analysis of Proposed 

Site Plan. Several significant open space types of 

high habitat value are identified as currently 

existing and/or possible to create with a minimum of 

effort. Designing for the protection of habitat 

results in a diversity of spaces also restorative to 

humans. The preferred open pasture provides 

sustenance for raptors and owls. Orchards and 

gardens for human cultivation attract small animals 

and birds. Sunny areas planted with bright reds and 

yellows attract hummingbirds. Old fields (abandoned 

orchards) are not only valuable due to their 

increasingly unique nature, but they also give strong 

ties to regional childhood experiences. The 10 

identified habitat types in this proposed scheme 

offer a great mix of biodiversity, offering both 

social and ecological (and, if gardens prove 

fruitful, perhaps economical) sustainability. 

73 



7.4.2 Stormwater Collection. 

Refer to Figure 7-7: Concept Plan Constructed Wetland on following page. 

As well as promoting biodiversity and providing restorative benefits, a 
marshland will serve to collect on-site stormwater runoff. Enhancing the 
current low topography site and creating a marshland has multiple benefits 
for humans and for the environment. Wetlands in developed areas provide 
wildlife habitat, store and improve the quality of stormwater runoff, and 
prevent degradation of streams and loss of fish habitat farther down the 
system. The wetland should be as large as possible, in order to maximize: 
• bird species that will be attracted, 

• runoff storage and treatment capacity, and 
• restorative wetland edge available. 

It is possible, and is often the practice, to construct detention ponds 
that collect stormwater but do not attract birds and wildlife. A study by 
the National Institute for Urban Wildlife, however, showed that urban 
residents vastly preferred ponds or marshes designed purposefully to 
attract habitat (Link, 1999). 

Detention Pond Design Considerations and Calculations. 

For assessment of predevelopment stormwater calculations, the 10.4-hectare 
(25-acre) site was considered to be approximately twice as much area in 
flat pasture with well-drained soil as hilly woodland, also with well-
drained soil. For post-development calculations, hard roofs and/or paving 
were estimated to take up 400m2, with reductions in both hilly woodland 
and flat pasture. In actual fact, this number may be reduced by the 
addition of green roofs and roof gardens. 

Within the built environment, practices that minimize stormwater runoff 
will be used encouraged. These are: 

=> Outdoor parking lots designed with swales for water collection, 
=> Turf roofs used to decrease runoff, 

=> Roof runoff directed into planting beds or to larger marshland or 
accessible rain barrels to create "rain gardens" with multiple 
benefits. 

Detention pond sizing was calculated for a 10-year storm, as the desired 
effect would be to have standing water in as much of the area as often as 
possible. The conceptual plan of the constructed wetland to follow gives 
an indication of the water feature design intention: 

Depth of pond will vary from areas of emergent wetland and actual "island" 
to areas of standing water (lined pool). A fountain and waterfall 
extending from the plaza into the wetland will feature a circulating pump 
system for water. The 'stages' of the water feature will be: 

• A lined pond will be created closest to the hospital and its programs 
and will be accessible by a level path, 

• An unlined pond with gradations in depth will extend out into the open 
space landscape, and will also be accessible to the largest number of 
users (grade less than 6% and year-round materials for pathways), 

74 



• F a r t h e s t from t h e h o s p i t a l and a t t h e l o w e s t p o i n t w i l l be a s h a l l o w 
marshland c o n s t r u c t i o n t h a t w i l l s e r v e p r i m a r i l y f o r b i r d / a m p h i b i a n 
h a b i t a t enhancement. V i s u a l a c c e s s w i l l be made a v a i l a b l e from a 
simply d e s i g n e d l o o k o u t p o i n t b u t p h y s i c a l a c c e s s w i l l be l i m i t e d t o 
v o l u n t e e r s . 

Predevelopment 

Q=CIA 1=1.2 (10 year storm 24h) A: 25 acres 

Post development 

H i l l y woodland C=.25 X 300m2 
Flat p a s t u r e C=.10 X 700m2 

Cave= (300 X 2.5} (700 X 1.0) 
1000 

So, 0= 0.15 X 1.2 X 25 

C= Roofs/paving C=.90 X 400m2 
Hilly woodland C=.25 X 140m2 
Flat pasture C=.10 X 460m2 

Cave= (400 X .90)+(140 X .30) + =(460 X .10) 
1000 

= .75 = -5 
4.5ft3/a I So, Q» 0.15 X 1.2 X 25 = 4.5ft3/s 

Detention Pond Sizing 

TIME 

min/sec 
5 (300) 
10 (600) 
20 (1200) 
30 (1800) 
40 (2400) 

60 (3600) 
120 (7200) 

Post Development 
INFLOW 

ft3/s 
21.5 
21 
13.75 
10 
8.75 

6.25 
4.35 

cvmu ft3 
8250 
12600 
16500 
18000 
21000 

22500 
31400 

Pre Development 
OUTFLOW 

m3/s 
4.5 
4.5 
4.5 
4.5 
4.5 

4 .5 

4.5 

cumu ft3 
1350 
2700 
5400 
8100 
10800 

16200 
32400 

NET 
STORAGE 
ft3 
6900 
9900 
11100 
9900 
1-200 

6300 

-10 0 0 

Maximum Storage Volume Required^ 
Comrersion= 3219 m3) 

Depth Calculation: 

11100 ft3 for 10 year-24 hour storm (Metric 

3219 m3 = 3500 m2 in plan 
at .9m (average) 

Figure 7-6 (above): 
Stormwater Detention 
Calculations 

Figure 7-7 (right): 
Conceptual Plan of 
Constructed Wetland 

Constructed Pond and Wetland 

Community 
considered 
project. 

These issues will be discussed later in this chapter 
and proposal for Community Stewardship Involvement. 

Involvement, Stewardship and Educational Programs are 
integral aspects of the ensured sustainability of any 

in a discussion 

- 75 -



7.5 Hospital Program: Site Layout 

Refer to Figures 7-8 through 7-13 (Site Layout General Considerations and 
Program Placements) on following pages. 

At the time of this proposed design, the defined hospital program 
included: 

1. A Regional Acute Care Hospital of 350 beds was planned. A wide 
variety of programs were anticipated including Emergency, Maternity, 
Oncology, Medical-Surgical, Intensive Care, and Geriatrics. A large 
Mental Health/Psychiatry program was planned. 

2. A Cancer Clinic (outpatient treatment and diagnostics, including 
radiation therapy) was planned. 

3. A Wellness Centre was planned. The program for the wellness centre 
is defined for this project as: 

• outpatient teaching, programs and follow-up, 
• staff recreation facilities, 
• teaching facilities for community and staff (including 

auditorium), 
• administration and staff services (payroll, human resources, 

etc.) will also be maintained in this structure. 

The total area required for the built program is 62,000 square metres 
(Source: FVHR Project Home Page, 2001). 

In order to design for specific users, an attempt to program hospital 
functions and locate important destinations has been made and is outlined 
in the footprint concepts that follow in Figures 7-5, 7-6, and 7-7. It 
would be expected that rather than placing programs and facilities in 
isolation, this task would best be done in consultation with the various 
staff members and experts in the individual fields. 

A pavilion-style of construction combined with a central tower was chosen 
to maximize views to surrounding open space and regional landmarks. This 
style (long, linear buildings) also allows for a higher degree of natural 
sunlight for all patient (and staff/visitor rooms) as well as an increase 
in legibility. Many current architects, critical of the dinosaur nature 
of modern hospitals are returning to this 18th-19th century style of 
construction (Pearson, 1995). In this proposal, however, rather than 
looking out over a private hospital courtyard, views are directed to open 
space, shared with the local community. 

7.5.1 General Recommendations for Siting of Programs and Building Layout. 

Many of the decisions made were drawn from both the earlier discussions on 
specific user needs and on the results of the site analysis. For example, 
patients suffering from high stress illness (cardiac care, intensive care, 
psychiatry, etc.) were given priority for views to positive distraction. 
Patients entering the hospital for short stay, diagnostics, and tests that 
create a high index of fear were given priority access to outdoor plaza, 
cafeteria, and accessible walkways. A strong effort was made to group 
patients together rather than segregate. It is with purpose that the 
hospital has one main cafeteria rather than several small satellites. 
Placement of the primary open space was also made in consideration of 

76 



senior neighbours as well as recreationalists. Certain populations, by-
virtue of their illness were located more towards the inner shady core 
that surrounds the retained Douglas fir Knoll (for example, cancer 
treatment). All patients, however, have access to both sunny and shady 
areas within the hospital environs. A strong effort was made to retain 
and enhance site resources whenever possible and to use disadvantages as 
benefits. 

Figure 7-8: Site Layout Considerations (simplified for graphic purposes). 

• The bulk of inpatient rooms are oriented to southwest or southeast open 
space with some rooms facing the more intimate inner forest core: 
patients will be afforded a choice of views. 

• Siting and layout of built structures responds to open space programs 
with creation of large and small enclosures. 

• Sharing of open space, of entrances, and of parking will work to 
integrate rather than segregate. 

• The southeastern low point (behind constructed berm necessary for noise 
protection) creates a perfect potential for shared open space. The new 
design of the open space creates a form of 'cloister' situated between 
highway, new hospital, and neighboring senior's facilities. 

• Walkways through the hospital are direct, leading from elevator to 
elevator, with the cafeteria as midpoint. Walkways will be lined with 
windows on both sides to enable outdoor views. The initial entry will 
feature views direct to nature beyond. 

- 77 -



• Staggered heights of buildings facilitate views and enhance human 
scale. By concentrating the height of buildings towards the centre of 
the complex, the hospital will also blend in more appropriately with 
the surrounding small-scale houses/complexes. 

• Strong indoor-outdoor relationships are created to improve views to 
nature and promote fascination. These include: atria with greenery, 
skylights, roof gardens, water fountains, indoor aquariums. 

• Building orientation takes advantage of views to Mount Baker, views to 
open space, views to nature, and views south to agricultural fields. 

• Roof gardens are accessible when possible. 

• Configuration of buildings in this manner allows for the retention of a 
large portion of the central knoll of Douglas Fir. Several other 
important or potentially important identified habitat areas are also 
protected-refer to Biodiversity Mapping, Figure 7-5) . 

• Choices for sun or shade are made possible via building orientation. 
• Windows will be set no higher than .75 metre off floor to facilitate 

views from beds. 
• Use of the hospital tower promotes opportunities for walking indoors. 

• Primary street access is from Marshall at Gladwin, the current site of 
a transit stop. Gladwin Road becomes a side access for parking as well 
as a main entrance for emergency vehicles. 

• An evident street face is defined, and shared open space is defined. 
Parking has been clustered to enhance safety and security for staff as 
well as to improve wayfinding by visitors/patients. Lighting of 
significant pathways will be vital for this 24-hour environment. 

Figure 7-9: Example of Lighting: Image of Kaiser Permanente Medical Complex in 
Fontana, Ca. Nighttime building illumination from top down scatters light 
towards and onto walkways, giving a sense of connection and security. Lighting 
would continue in this manner along paths by illumination of lane trees. Day 
and evening lighting effects can also be achieved through appropriate 
placement of trees in relation to sun angles. 

- 78 -



Marshall Road 

"O 
o 
o 
c 

SDDDD 
( h P a r k i n s 

DDDD 

Wellness 
Centre 

& Library 

3-storey 
( 1 2 + 

m e t r e s ) 

: : 2 "i 
i : 

Cancer Clinic 

4-storey (16+ 
m e t r e s ) 

Below Ground 

5-storey 
2 0 + metres) 

B e l o i v G r o u n d S e r v i c 

I e v e l s o f P a r k i n 

DDtLQUD 
( i n c l u d e s D i s a b l e d ) 

(diukry).-

em Wing: Paji^nt Kcoms{upper floors) & 
Service^acilities (lower floors) 

5-storey {20+ m e t r e s ) 
Below Ground S e r v i c e s : 

elivery, S t o r e s , e t c . 

BACK LANE 
DISASTER PARKING 

(est. 100 cars) 

DDDDDDD DDDDDDD 
DDTODD DLOTDD 
DDDDDDD DDDDDDD 

Central Tower (Nursing Units) 
" R o o f top garden** 

10-storey (40+ m e t r e s ) 
Below Ground S e r v i c e s : 

2 levels of Parking 

. . . 

T h i r d F l o o r 

C a n c e r Clinic 
C o u n s e l l i n g 

and t r e a t m e n t 

S u p p o r t S t a f f 
O u t p a t i e n t 

r S e c u r e S t a f f A r e a s : M e d i c a l R e c o r d s P h a r m a c y K f l 
CCU/1CU 

r s i n g U n i t s 

Fifth Floor 

9 S I 
G e r i a t r i c s - P e d i a t r i c s 

a n d 
s h a r e d g a r d e n 

F o u r t h F l o o r 

C a n c e r C l i n i c 
C o u n s e l l i n g 

a n d t r e a t m e n t N u r s i n g U n i t s 
B i • ( P s y c h i a t r y : 

O f f i c e s : T r a d i t i o n a l v i e w s a n d b a l c o n y ) 
a n d a l t e r n a t i v e 

P a l l i a t i v e Care 
( b a l c o n y g a r d e n ) V f l 

Nursing U n i t s 

S i x t h F l o o r 

N u r s i n g U n i t s 

Figure 7-10: Built Program Basics. Figure 7-12: Program Proposals, Floors 3 to 6. 

Ground minus 2 

Ground Floor 
Wellness C e n t r e : 
a u d i t o r i u m , 
library, 
c l a s s r o o m s 

C a n c e r Clinic 
R e c e p t i o n 

= 
p i t a I R e c e p t i o n 

tttng A r e a 

D i a g n o s t i c s 
Cafeteria 

C o n n e c t i o n t o 
o u t d o o r 

o p e n s p a c e 

P u r c h a s i n g , 
E l e c t r i c a l , 
S e r v i c e s 

Ground minus 1 
S t o r a g e 
E l e c t r i c a l 

R a d i a t i o n 
Rooms 

D e l i v e r y / S t o r e s 
A u t o p s y 

P a r k i n g (300 c a r s ) 

I S Second Floor 
R e c r e a t i o n 
F a c i l i t i e s C a n c e r CHnlc 

•

C o u n s e l l i n g 
• o u t d o o r b a l c o n y S t o r e s , 

P h y s i c a l P l a n t 

O f f i c e s , S u p p o r t • OR'CCR S t e p d o w n C a r d i a c 
and T e l e m e t r y 

Seventh Floor 

Nursing U n i t s 

Ninth Floor 

Nursing Units 

Eighth Floor 

Nursing Units 

Tenth Floor 

Staff Resources and Private Garden 
(staff and/or special occasions 

Figure 7-11: Program Proposals, Floors G-2 to 2, Figure 7-13: Program Proposals, Floors 7 to 10. 

7.5.2 Proposed Hospital Programs. 

An exploration into program 
placement that "fits" with the 
design is shown in these diagrams. 
Programs were situated according 
to an assessment of needs for sun 
or shade, views to nature versus 
views to activity, proximity to 
outdoors, as well as potentials to 
group users together for social 
support and/or efficiency in 
shared open space. 

1. Efforts are made to minimize 
mass of building. The building is 
staggered, with a central tower 
"hidden" amongst the Douglas Fir 
woodlot. 
2. Parking (both under and above 
ground) is offered in this still 
largely rural area. Until transit 
catches up, patients, visitors and 
staff will be highly dependent on 
the automobile. Parking is 
clustered for safety purposes with 
600 below ground stalls, 200 above 
ground stalls, and flexible above 
ground temporary parking (main 
entrance street and back lane*) . 

In the case of a Disaster Response, 
however, this lane could be opened 
up to handle 100+ extra cars. 

3. Patient wings are located 
primarily to the south and south 
east of the building in order to 
facilitate views to landmarks as 
well as the open space program. 
Offices, generally located in the 
central entrance core of the 
hospital do not have the same views 
of open space but they are privy to 
sunlight and views of the shared 
entrance area. 
4. Placement/programs of specific 
patient populations follows the 
discussion in Chapter IV. For 
example, diagnostic patients have 
easy access to outdoor gardens, 
walking routes, and the Cafe. 
5. Clustering of buildings and 
programs maximizes open space and 
allows for retention of existing 
resources, views, and vegetation. 

-79-



7.6 Key Views. 

Given the strong evidence of the restorative benefits that result from 
visual access to nature, consideration of key views was considered of high 
importance. Key Views are identified as those subject to one or more of 
the following elements: 

1. High Frequency. For example, views outside the windows of ICU/CCU 
patient rooms are very important as these patients may be confined 
to bedrest for days, weeks or longer. Attention not only to the 
scenic beauty and the restorative quality of the view is important, 
but also consideration of seasonal and temporal changes to spark 
fascination in the viewers. The most pastoral of views will become 
a source of sensory deprivation without some signs of life, 
evolution and change. 

2. High Number of Viewers. For example, if the cafeteria is to become 
a welcoming place for staff, visitors, patients and community 
members alike, then this view will require enough interest to appeal 
to a wide range of users. Hallways, entrances, and waiting areas 
may be used by very large numbers of persons and yet are often 
overlooked as viewing opportunities. 

3. High Expectations. A rooftop garden that offers views to Mount 
Baker and southern agricultural fields should be oriented in such a 
way as to enable a full and complete vista. Vegetation growing 
along the enhanced berm (southeastern corner) may need to be pruned 
and maintained to preserve the integrity of this view. 

Criteria for evaluation of key views has been adapted from the Procedures 
and Standards for Visual Landscape Inventory used by the British Columbia 
Ministry of Forests (B.C. Ministry of Forests, 1997). 

There are some areas (e.g. primary entrance, cafeteria with view to open 
space) that will be affected by all three parameters and are therefore 
vital for maintenance and attention. 

As discussed in the previous chapter on site analysis, exterior views are 
vital to this region (views to mountains and agricultural fields). These 
views are enhanced through the construction of the central tower as well 
as a proposal for several rooftop gardens that allow individuals to ascend 
to key viewing points. Interior site views will also be important in both 
the enclosed marshland and the Douglas Fir woodlot. 

Views into the site have also been considered. For example, small areas 
of orchard trees will be visible from both Marshall road and the Trans-
Canada Highway, giving motorists a visible cue to the site. The site 
should present a welcoming presence in order to encourage community use. 
This may range from the functional placement of a popular coffee shop near 
the entrance to an unobstructed view along a winding bicycle/walking path. 

It is also noted on the Key View Map that visual access through the built 
form has been highlighted in some areas. Most importantly, the entrance 
offers a view not only into the reception lobby but directly through to 
the woodlot behind, enhancing the sense of access, comfort and enclosure 
without blocking the entrance of sunlight. Glass atria and glass-covered 
walkways are envisioned throughout the site providing easy visual access 
to nature: trees, water, open space, and habitat. 

- 80 -



The primary key view facilitated/promoted by this design are as follows: 

KEY VIEWS: high frenuency, high duration, high number of viewers, ano/pr high expectations, 
' Refer to Key for view specifics. 

Figure 7-14: Key Views (interior and exterior) Influencing Site Design. 

View 
1. 

2. 

3. 
4. 

5. 
6. 
7. 

8. 
9. 
10. 

11. 

12. 
13. 

14. 

15. 

16. 

Description 
Welcoming street face with hints of landscape beyond: visible 
orchard, sunny entrances. 
Sky roof over community auditorium leading to health library and 
outdoor reading room. 
Legible view to emergency. Clear visual access for ambulances. 
View from ER to orchard filled berm: sense of protective 
enclosure, view of living landscape. 
View from highway to hospital orchard: visual cue. 
From upper tower and roof garden, view to landmark Mt. Baker. 
From Cafe and patient rooms (N.B. CCU/ICU), view to interior 
landscape: design for biophilia. 
View from Mayfair Home to open space and Cafe: welcoming. 
Welcoming views from Marshall Road (to open space and Cafe). 
View from Marshall Road (and Menno Home) to front yard orchard: 
visual cue, invitation. 
View from Psychiatry (N.B. lounge, locked rooms) to woodlot and 
old orchard. 
View from Tower (all floors) to interior woodlot. 
View from Diagnostics Indoor waiting area to outdoor waiting 
area and woodlot trail access. 
View along hospital corridor to interior woodlot and waiting 
areas. 
View from main entrance/reception (hospital and cancer clinic) 
to woodlot garden area. 
Interior views of native coniferous "forest": 60-70 year-old 
Douglas Fir trees, some Alder/Cottonwood/Maple. 

- 81 -



7.7 Site Circulation. 

7.7.1 Requirements. 

Main Street: A legible main street entrance with easy physical and visual 
access to main entrances and parking. Entrances to the 3 main programs 
will be shared to avoid stigmatizing one group. On-street parking will be 
available as well as a drop-off and turn-around. 

Emergency Street: An easy access route will be available for ambulances. 
This should be a secondary access point only for public and staff. Street 
parking will be disallowed to decrease potential conflict between cars and 
emergency vehicles. 

Fire and Emergency Lanes: Emergency access is planned throughout the site 
open space and around all built forms. A 3-metre perimeter around the 
building is graded and paved, with grass-crete installed where necessary 
to provide access for fire vehicles. 

Experiential Roads and Paths: The delights of a back country road are 
provided for in the open space program with a curvilinear path that 
features a water crossing. Vehicular access is limited and road parking 
is available only for community volunteers. Walking, jogging, cycling, 
roller blading, and equestrian passage will be encouraged along this 
pathway. A variety of pathways, some simple, circular and direct and 
others more circuitous give users a variety of options and a sense of 
control. 

Secondary Recreation Connections: As discussed briefly in chapter VI (Site 
Analysis), it is considered vital to include in the site circulation 
connections to off-site amenities. A "Wellness Walkway" route along 
Primrose Avenue would require little more than simple street restoration 
to enhance this flat access to the Mill Lake viewpoint. This route then 
connects to a more challenging path that traverses Mill Lake and returns 
to the site via the steeper Gladwin Road. This presents a recreational 
opportunity for staff as well as community members. The aforementioned 
"Trans-Canada Green" (running along highway edge) should also be 
considered during berm construction. 

7.7.2 Vehicular Circulation. 

Legibility is high on the list of priorities for circulation in the 
hospital environment. From emergency vehicles to anxious patients and 
families, to staff members late for work, the priority is to get to the 
hospital as quickly as possible. Primary access for all users is simple 
and direct, although there is provision for a more pastoral back lane 
drive. The two major entrances are clearly evident (Main and Emergency) 
as are entrances to parking (above and below ground). Provisions have 
also been made for visitors to park briefly on the main Entrance Street 
while waiting for relatives or friends. 

- 82 -



j a a j a a a g i -*<~ i ^ - . i > u l w , f i l«rdl 

i 100 WA! N ACCESS * p**,^ ia.-* 
Section - tlevstion 

ggs=^»- ^3£ka ' 

:^RytMf, L L J Z J 8a i2Jjoe LZaiZaJ PhRWNd 

i l O O t . R . ACCESS * *o pi'K.r,^ on si-rte* 

IT^V 
QftCriftgiL 0?EM PASTURE 

1 100 BACK LANE. PR&Fli. restricted icesss/bti+s.n. 

Figure 7-15: Typical Street and Lane Profiles for 
Restorative Facility. 

Main Street 
Access (view 
south into 
site off 
Marshall 
Road): urban 
typology, 
shared 
entrance. 

Emergency 
Vehicle 
Primary Access 
(view east 
into site off 
Gladwin Road): 
limited 
access. 

Back Lane 
Access: rural 
typology, 
restricted for 
recreational 
and open space 
s tewardship 
programs. 

Primary access to the VHC is from Marshall Road (runs east to west). All 
new arrivals to the hospital are dropped off or arrive at the Main 
Entrance off Marshall. Connections to all three major programs (Regional 
Hospital, Cancer clinic, Wellness Centre) can be made from this central 
location, thus promoting a sense of legibility and community. Aboveground 
parking is grouped on the western edge of site, within a short walking 

- 83 -



distance of the hospital. This area will have special attention to 
lighting and security present at change of shift for staff security. 

Secondary access is via Gladwin Road (no exit road running north to south 
along western site edge). This secondary route will be used primarily for 
ambulance arrivals and for staff (close to parking). 
permitted on this street and street trees are kept to a 
clear visual access in 

Parking is not 
minimum to enable 

As discussed, 
vehicles have 
all building 

to open space, 
is used in 
soft ground 

create a more 
natural appearance to these 
functional areas. 

emergencies. 
emergency 
access to 
fronts and 
Grasscrete 
potentially 
areas to 

awjiggacjigg 

mmSoowmt MM—MOB 

CROSS-SECTION 

Be 
a- vr TMCK OAAUCJWTt 

Figure 7-16: Grass Crete Section. 
Source: www.progressiveconcrete.com 

Delivery trucks have access via the "back lane" road. This is a 6-metre 
wide asphalt road with a gravel edge. This back road and "back door" 
delivery area will be visible to users on site. This is considered within 
character of this mixed urban/rural region. 

Main Access Marshall Road 

Building Front 
Fire Access 

To U76 Parking 

o o o o o a O / Back Lane 

Auto Circulation 
Major C'rcJa-tion 

!•» Minor Circula+«»n 
o e m a H & s t i ' i c + e d (Open ^pace. f-nKjrd/n) 
o o o o E m c r c j c / i c y A c c e s s Only-

Figure 7-17: Circulation for Automobiles: Emphasis on Legibility. 

- 84 -

http://www.progressiveconcrete.com


7.7.3 Self-powered (universal design). 

— - ftskafirt btpksis 

Figure 7-18: Circulation: Self-Powered: Emphasis on Options. 

Cyclists, pedestrians and wheelchairs access the hospital via the new 
Entrance Street or back lane depending on their destination. Arrivals to 
the hospital, Wellness Centre, or Cancer Clinic all share the main 
entrance node. The back lane leads to the "Community Cafe" (cafeteria, 
coffee shop, limited retail) as well as to open space programs (marsh, 
pasture, gardening, orchards). Several accessible walking paths are 
available on the VHC (Valley Health Centre) property, passing through the 
woodlot, the orchards, the gardens, and around the pond/marsh. All these 
paths/roads are graded at less than 8% slope with frequent rest stops. 
Distance between rest stops is dependent on anticipated use. In high use 
areas, rest stops occur every 200 metres, and in low use areas are 500 
metres apart. The majority of paths are designed for year-round use 
(asphalt, grasscrete or crushed gravel). 

7.7.4 Equestrian. 

Local residents passing through on horseback can use the back lane and 
pasture and would exit on Gladwin. The previously discussed 'Trans-
Canada-Green' corridor link along the highway will be a future resource 
for equestrian interests (refer to Section 6.3.2, Figure 6-25). 

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7 . 8 Open Space Organization 

This analysis attempts to bring together restorative design on the land 
with^ the realities of practical management. The hospital design was 
examined and evaluated according to which areas necessarily fall under the 
jurisdiction of hospital management (primarily for maintenance and 
security) and which areas could become part of a "Co-Management Process" 
or collaborative effort with local community groups. 

• • 

Open Space Organization. 

Hospital Managed: 

1 

visitor emphasis 

patient emphasis 

• M staff emphasis 

Co-Managed (public-private): 

5 

Figure 7-19: Open Space Organization and Management 
(explanation on following page). 

The community emphasis of the open space program 
is made evident by the large area mapped as 
falling under "Co-Managed" jurisdiction. Also 
identified within the hospital jurisdiction were 
areas with particular potential for meeting the 
needs of specific user groups. As noted on the 
diagram above, certain areas were chosen to 
highlight specific interventions for patients, 
visitors, staff or the community at large. 

It should be stated that although certain areas 
are being highlighted as special or unique for one population of users, it 
is expected that all users of the spaces will receive therapeutic benefit. 
For example, a highly restful and peaceful garden with flowing water and 
sounds of birds may provide great satisfaction to patients recovering from 
acute coronary incidents. This same garden, however, would also provide 
great benefit to that patient's family members and caregivers. 

- 86 



7.8.1 Explanation of Open Space Organization. 

Management/ 
Stewardship 

1. Hospital 
Managed 

2. Hospital 
Managed 

3. Hospital 
Managed 

4 . Hospital 
Managed 

5. Co-Managed 
(Public-
Private) 

Primary 
Users 

All Users 

Patients 

Visitors 

Staff 

All Users, 
including 
community 
members 

Implications 

Security and maintenance done by hospital 
staff, with costs and workload kept to a 
minimum. Private fundraising may be 
required for construction of special gardens 
or spaces. 
Garden and landscape programs may become 
components of medical therapy 
(physiotherapy, occupational therapy, pet 
therapy, follow-up programs post 
cardiovascular and/or cerebrovascular 
accidents, spinal cord or brain injury, 
psychiatric in/outpatient programs). The 
majority of these programs would require 
supervision by qualified medical staff. 

The larger open landscape is presented as an 
opportunity for co-management with a 
community group. This would involve a 
combined effort between management from the 
regional group and from the hospital, with 
decisions mutually agreed upon in regards to 
planting and programs. Although the open 
space should remain open and available to 
all users, it does not preclude the 
possibility of contracting out local farmers 
to harvest crops, berries or raise limited 
livestock on the property. All of these 
activities would enhance the restorative 
benefit of the open space. 

1. Open Space for All Users-Hospital Managed: These include the more 
"urban" areas of the site (entrances, library garden, outdoor 
plaza/cafe) and those areas in such proximity to the hospital as to 
require special concern for security (e.g. the Douglas fir woodlot). 
Maintenance will be the responsibility of the hospital. 

2. Open Space with Emphasis on Patient Needs-Hospital Managed: Although 
all patient groups have been considered in the design of this 
landscape, it was only possible to select a very few for illustration 
of specific interventions. Highlighted for further exploration were two 
diverse groups with varying needs. A garden was designed to meet the 
needs of patients and families faced with cancer treatment. The 
psychiatric population was explored in terms of open space needs. As 
well, some general interventions to benefit all patients were proposed, 
for instance increasing the accessibility of outdoors to hospital 
patients. These interventions are illustrated and discussed in the 
following chapter. 

3. Open Space with Emphasis on the Needs of Visitors/Outpatients-Hospital 
Managed: Highlighted for further exploration is the internal strip of 
"potential" visitor space that is visually accessible from the entrance 
and corridors. 

- 87 -



4. Open Space with Emphasis on Staff Needs-Hospital Managed: It is 
anticipated that a variety of spaces will be required for staff: for 
meals, quick retreats and social/educational/recreational gatherings. 
Considered vital are issues of security, brief retreats/refuge away 
from patients and areas to congregate. Examples of consideration of 
staff needs are highlighted in the design in the following prototypical 
responses: 

• Clustering of parking and well-lit primary passage from parking 
to hospital (CPTED principles), 

• Cafeteria space/coffee shared with community, 
• Mount Baker Roof Garden atop patient care tower intended for 

staff retreat (informal and formal gatherings), 
• Private garden refuge outside emergency for ER staff, support 

staff and EHS attendants, 
• Easy and safe access to Wellness Centre for recreation/education. 

Chosen for further exploration in this project are the two private 
staff refuges. 

5. Open Space with Emphasis on Community Needs: The primary user groups 
will be those members of the community concerned with stewardship of 
the land and those interested in recreation. Ideally, a program that 
combines both objectives will develop over time. 

• Public Recreation Opportunities on site include: 
Dogwalking, jogging, strolling, picnicking, bird and animal watching, pick 
up sporting games, passive activities-reading, sunning, and people 
watching. The primary use area will be the open pasture and marshland 
with connection to the Community Cafe. Washrooms will be shared with 
landscape volunteer facilities. Educational opportunities will also be 
available at the Outpatient/Wellness Centre, situated in the core of the 
main Shared Entrance. 

• Public Landscape Stewardship Opportunities: 
Responsibilities and requirements are outlined below. 

7.9 Proposal for Community Landscape Stewardship. 

The southeastern "skirt" of the design exists as an edible, living 
landscape that will require stewardship and management. In the public 
health care system, such expenditures are difficult to justify without 
significant community involvement. A proposal has been made to develop a 
co-management system of stewardship of this hospital open space. 

A volunteer community group-the "VHC Healing Gardeners Society" is 
proposed to take on the shared management of this landscape unit with the 
hospital. The optimal condition would be to develop this society along 
with the public process set up to formulate goals and objectives for 
hospital design. Local interest groups that may be approached to form the 
Healing Gardeners include: 

• Central Fraser Valley Naturalist Society and other groups concerned 
with habitat, 

• Local 4-H programs/farming clubs, 
• Local berry farmers (able to offer equipment on loan and expertise), 

- 88 -



• Local school groups (Trinity Western University, highschools, 
elementary schools), 

• Local horticultural/plant appreciation societies and community 
gardening groups, 

• Local professionals/technicians (foresters, landscape architects, 
engineers, carpenters, etc.) 

• Senior's Peer Counseling of B.C., Friends of Schizophrenia and other 
community based programs of support. 

7.9.1 Infrastructure Required: 

The community will require a staging centre situated amidst the healing 
landscape agriculture. This centre should include: 
• Tool shed/Tractor Shed/Garden Shed, 
• Booth for seasonal produce marketing, 

• Accessible Road for Tractor (share hospital delivery lane), 

• Place for coffee-food-snacks, 

• Place for visiting/learning/sharing, 
• Washrooms and access to clean water, 

• Barn/shed/shelter for visiting pasture animals, 
• Area for public interaction with visiting animals, 

• Potential for gardens/orchards to be used for rehabilitation purposes 
(e.g. accessible surfaces). 

7.9.2 Responsibilities of Volunteer Group: 

The Healing Stewardship Society will take on an active role in managing, 
maintaining and preserving the restorative open space and will meet, as 

- 89 -



required, with hospital management, security, horticultural therapists, 
health care providers and patients and families. The involvement and 
visible presence of the group will in itself provide benefits as 
preference for rural farmscapes has been shown to increase with the 
evidence of active stewardship (Sheppard, 2001). Specific 
responsibilities are discussed below. 

Sub-Area 

Urban 
Woodlot 

Habitat 
Orchards 
/Berries 
/Gardens 

Open 
Pasture 

Lowland/ 
Wetland 

All open 
space 

Responsibilities 

Monitoring of trail paths and trail rest stops will be 
required to ensure freedom from graffiti, and hazards (fallen 
branches, etc.) . It will be important to monitor the 
continuing health of trees and watch for potential blow-down. 
This is not expected to be a great concern as the retained 
trees are sheltered from significant wind by large buildings. 
Shade loving bulbs and native herbaceous plants are visioned 
along forest edges of paths and volunteers will be responsible 
for the maintenance of this woodland edge. 
Trees in the orchards will be chosen with public input 
(examples may be hazelnut, heritage apple or crabapple) . 
Organic production, avoiding the use of pesticides will be 
recommended. At harvest times, the Healing Garden Group may 
market produce from a booth situated near garden shed 
(accessible to hospital patients and staff). Extra produce 
may be sold to local markets to raise funds. 
Ensuring good maintenance and safety will be important. Local 
farms will be solicited to bring in farm animals on a temporal 
basis to "mow" the open space. Community members with 
attachment to rural property/4-H clubs, etc. will be 
encouraged to organize these domesticated grazing animal 
outings. Locally available are horses, ponies, sheep, goats, 
llamas and dairy cattle. Minimal fencing combined with 
hedgerows will contain the animals. Monitoring and 
maintenance of the hedgerows will be required. 

The intention for this area is to allow it to flourish in a 
naturalistic manner. Responsibilities will therefore include 
monitoring the balance between functionality and mystery. 
Plantings may require pruning in order to enable safe views 
and safe passage. The volunteers may take on monitoring of 
habitat (counting/identification). 
The monitoring and elimination of exotic invasive plants will 
be the society's responsibility for all open space areas. A 
particular focus will be on the highly disruptive Rubus 
discolor (Himalayan Blackberry) . This invasive shrub, 
although it does have some value as bird/small mammal habitat, 
is particularly aggressive in the Fraser Valley conditions. 
Site analysis revealed a significant amount present in the 
lower reaches of the Douglas Fir woodlot. 

7.9.3 The Community Viewshed 

Views within the site are strongly addressed in this design. Perhaps 
equally as vital are the views into the site as experienced by passersby. 
Drawing in the community involves more than programming and designing a 
welcoming inner sanctum. The community must first be drawn onto and into 
the site. 

- 90 -



• First Order of Community Access= Visual Access 
• Second Order of Community Access= Physical Access 

Drawing in the community requires a welcoming street face that hints to 
landscape experiences beyond. The main entrance and the back lane 
entrance have both been designed to accomplish this goal. The main 
entrance speaks strongly of function, legibility and access to programs. 
This approach is uncomplicated, with visible parking (underground and 
aboveground) and a shared, accessible entrance. In times of high stress, 
patients and visitors need this simplicity: all answers, no questions. 

The back lane, in contrast, appeals strongly to biophilic needs for nature 
and features a stronger sense of mystery. The lane winds and slopes past 
the "back door" (delivery) , passes along an open field and across a body 
of water. Passage through an orchard greets the user at either end of this 
rural lane. For highway users, a glimpse into the southern "back yard" 
orchard provides a sense of place. Those approaching west along Marshall 
are greeted by an open door that pulls them into the shared main entrance. 

Figure 7-21: Primary community arrival to all hospital programs (view south from 
Marshall road). Easy wayfinding yet references of natural resources beyond. 

The following section highlights two specific and important interventions 
made on the site: grading (Figure 7-22) and vegetation retention (Figure 
7-23). These actions are illustrated using the master plan. 

- 91 -



Menno Home and H o s p i t a l 

•Canada H i g ^ T ( 

F i g u r e 7 - 2 2 M a s t e r P l a n w i t h P r o p o s e d C h a n g e s t o G r a d i n g . 

7 . 1 0 M a s t e r P l a n : S p e c i f i c s . 

7 . 1 0 . 1 S i t e G r a d i n g . 

KEY: 

Solid line refers to 
proposed grade changes . 

Dashed line refers to 
existing grade changes . 

**Altered grades all meet up 
with existing grades at edge of 
property line, with the exception of 
the enhanced herm. It is assumed 
that sound protection would also be 
built for May fair Home & Hospital. 

A decision was made following site 
analysis to let current 
topographical conditions guide the 
design for the new hospital and 
landscape. The low point was 
identified and chosen as an 
appropriate locale for water 
location. The elevated knoll, 
considered a regional landmark, 
was chosen for retention and 
enhancement. Ensuring the 
survival of this mature, second-
growth stand of Douglas fir trees 
presented a particular challenge 
for siting and grading. 

The final design features two 
significant open spaces: the 
central treed area ("hugged" by 
built form) and the large southern 
open area. Bordered on all sides 
by hospital facilities and/or 
constructed berm, this open space 
becomes a large cloistered and 
sheltered "garden". 

As becomes more evident in cross-
sections (in next chapter), there 
is a major drop from the hospital 
floor elevation to the 
southeastern portion of the site. 
This drop enabled the creation of a 
restorative waterfall and water 
body at the base of the Cafe 
(cafeteria). Despite this drop of 
nearly 15 metres from the knoll 
apex to the low point, it was 
possible to grade paths <8% and 
achieve universal accessibility. 

-92-



Menno Home & Hospital 

R±*h»*Y (eZ^^ 

Figure 7-23 
Master Plan 
with Details 
of Retained 
Vegetation. 

A s i t e -
s p e c i f i c 
approach was 
u s e d and 
efforts were 
made to begin 
with available 
r e s o u r c e s , 
enhance where 
possible and 
protect where 
required. 

Efforts were 
made to bring 
new design 
together with 
e x i s t i n g 
features in a 
h a r m o n i o u s 
manner that 
would promote 
restoration. 

7. In order to maintain views to meeting Baker, this corner will require maintenance to keep vegetation at suitable height. 
8. Berm enhancement will require removal of current vegetation. As much as possible, these trees will be replaced after raising the berm. 
9. Little ^pockets' of existing native trees within the orchard plantings may develop into private, special landmarks. 
10. The southwest portion of the berm does not need to be raised, but vegetation should be enhanced (noise protection/sense of enclosure) . 
11. The highway berm currently has a good balance of open and closed areas and should be monitored to ensure views to southern farms are not 
blocked. 
12. Adjacent homes and parks feature several mature native and exotic trees that should be protected to maintain a respectful transition 
between the large hospital and its humble surroundings. 

7.10 Master Plan: Specifics. 

7.10.2 Vegetation Retention. 

KEY: 
Areas/trees marked 
with an X and colored 
green (medium grey in 
B&W copies) indicate 
retention of existing 
vegetation. 

A prime objective that followed 
site analysis was the retention of 
as many mature trees on site as 
possible. This is for several 
reasons, such as: 
* Respect for history and evolution 
of site, 
* Economic benefits (dollars saved 
by reducing need to buy mature 
trees, reduced cost of tree 
removal), 
* Immediate restorative benefits 
derived from having mature trees 
already on-site in view of hospital 
users. 

NOTES. 
1. The majority of healthy trees in 
the central knoll are retained. 
This space becomes a vital 
restorative resource for users. 
2. Remnants of an old hazelnut 
orchard are retained amidst an old 
field that has both important 
habitat and restorative value. 
3. Mature Douglas Fir trees 
currently line the northern side of 
Marshall Road and are retained. 
These trees help to reduce the 
height and mass of proposed 
buildings. 
4. A stand of Douglas Fir at 
proposed new "Back Door" entrance 
creates a landmark and enhances 
wayfinding. 
5. Currently a sparsely vegetated 
area, this open space becomes prime 
location for open pasture, as well 
as stormwater retention (water 
flows to southeastern corner of 
site). 
6. Existing tall stand of Douglas 
Fir frames view of Mayfair 
residents into open space. 

-93-



Summary. 

The task of satisfying both restorative and functional requirements, while 
attempting to adhere to a strong landscape ethic that respects the humble 
origins of a place and tries to build upon rather than build over is a 
challenging procedure. 

From a functional point of view, this design, as it progressed, was 
constantly cross-checked with needs of emergency vehicles, stressed 
emergency arrivals, and harried staff members. Legible circulation and a 
simple building configuration were required for all main entrances and 
major nodes of activity. Sustainable practices were employed where 
possible, and, in fact, the desire to enhance biodiversity played a 
significant role in determining what open space was most valuable for 
retention. Site analysis and consideration of varied user needs played 

strongly in determination of open space 
and built layout, configuration, and 
programming. Programs inside and 
outside the hospital rely strongly on 
one another. For example, if it were 
not possible to place the 
Intensive/Cardiac Care Units on the 
southern tower with views to the open 
space, then a new viewshed will be 
required. 

The configuration of the buildings and 
the open space, in this broad plan, 
while satisfying several other stated 
objectives, allows for the retention of 
a large portion of the central Douglas 
Fir knoll. Several other important or 
potentially important habitat areas are 
also protected (old fields, large open 
pasture, healthy hedgerow of mature 
Douglas fir on the eastern border) . 
Neighbors (both single-family homes and 
senior's facilities) have been 
considered as evidenced by the gradated 
height of the hospital and the 
facilitated access points. 

By proposing a management plan that 
seeks to involve the community in the 
construction and maintenance of the 
open space programs, (and, ideally, 
with fundraising for smaller gardens) 
should enhance the feasibility of many 
of these proposed programs. Designed 
with, in essence, a large public park 
and an accessible outdoor/indoor 
cafeteria, the "complex is a place for 
both the sick and the healthy. It can 
be an integral part of everyday life, 
not just an emergency destination" 
(Pearson, 1995). 

'S.* T- -3+, s 

Figure 7-24: Rough worksheets used 
on-site and in studio helped form 
the design process. 

- 94 



8 . 1 U r b a n E n t r a n c e : Shared H o s p i t a l Open Space. 

j=3>s 

Figure 8-1: Axon "cutaway" 
view of main entrance atrium. 
Immediate views to inner 
woodlot and to visitor 
seating areas. 

±••260 Axonimetric : Bui 14 Form Facili+ates Views to /Nature 
Olam EMrance ^ Hospital Fbt-ts-fl 

Description. 
A welcoming urban street face at Gladwin and Marshall is proposed. An entrance street (2 
lanes for passage, 1 for parking) becomes a defined volume of space that also acts as a 
waiting area, staff break area, and public visit area. All three hospital programs are 
accessed from this area. The orientation of buildings will enable sunny experiences. 
Glass atriums at building fronts allow visual access to gardens and landscapes beyond. 
Restorative Benefits. 
Stress for new arrivals is reduced by the easy wayfinding provided with a single, shared 
entrance for all users. Stress is also reduced by providing easy physical and visual access 
into the hospital and through to the woodlot open space behind. A wide band of planting in 
front of the Wellness Centre will feature a bermed grassy seating area with canopy trees. 
In summer, users may choose to lay under the trees. In winter, they will use the covered 
benches set 200 metres apart in this high use area. The entire area is graded for 
accessibility without the use of ramps or stairs. As this space sits adjacent to the 
Wellness Centre, evening and weekend use will be expected (courses, lectures, workshops, 
indoor recreation). A sense of security is provided through good upkeep, good lighting and 
wayfinding, and clear visual paths (refer to CPTED Appendix II) . 
Users. 
This is the primary entrance for all new arrivals to all hospital programs (patients, 
staff, and the public) . 

key 

Figure 8-2: Location of shared entrance. 

Maintenance. 
The design includes pavers, planters, 
benches, lighting, and simple planting 
schemes. The goal will be to achieve low 
maintenance requirements through 
simplicity in design and patterns and site 
fixtures. 
Special Features. 
Entrance to the main hospital features 
arrival at an indoor "living landscape". 
Inner offices and clinics will face onto 
this indoor cloister garden. Easy visual 
and physical connections are made to 
pavilion-style hallways and to central 
woodlot area. 

Figure 8-3: Detail of shared entrance street 
plan. On-street parking and easy access to 
underground parking as well as turnaround will 
reduce stress of arrivals. 

CHAPTER VIII 
The Restorative Vision: 
Details and Specialized 

Spaces 

Design and program discussion to 
this point has focused primarily on 
large-scale interventions and the 
choices behind them. The overall 
site layout has been described 
(through text and visuals) as one 
that is holistically restorative 
to the widest range of users. The 
Valley Health Centre, as proposed, 
is welcoming to the community and 
offers a variety of spaces, large 
and small, for staff, patients, and 
visitors to seek stress reducing 
activities. This chapter will 
deal primarily with the close-up 
look at several of those spaces, 
with descriptions and original 
drawings that aim to illustrate how 
the application of restorative 
design principles can create a 
landscape that promotes wellness 
and reduces stress. 

Individual spaces for users with 
unique needs will be explored in 
more detail. It is expected, 
however, that many more of these 
unique spaces would be required. 
The spaces provided here are 
designed to act as precedents for 
future spaces, and as motivators 
for the imagination. The absence 
of strong research into the design 
needs and requirements of special 
populations requires the designer 
to simply learn as much about that 
group as possible, envision 
oneself in his/her place and 
imagine what you would 
require...or what you would wish 
for. 

The spaces are outlined as they 
were presented in the preceding 
section, according to intended 
users and intended management of 
the space. Each space is described 
briefly, followed by a summary of 
restorative benefits, the intended 
users, and special maintenance 
needs, if any. 

-95-



M « H ~-^m—..—~ - • in i • * - . ! • • . . . 
TJ 0 

D j [j g Q n D a 
aj O D D 0 
a Q DJJ.JL0 
rs a o o o o G o 

[fa i 

1_—_*— — . — — ^ - j p 

8 . 2 C o m m u n i t y C a f e : 
S h a r e d H o s p i t a l Open S p a c e 

»,iiWAti> ^ - w ^ ^ f l j p - ^ - * 

i : b c o SecfiOA-Elavalion : view Ntst of enhanced term ^nd dortf+rucied mars n . 
Figure 8-4: View (west) towards Community Cafe and open space program. Stewardship society staging Centre and Marsh Lookout are visible. Cafe 
hidden behind simple concrete bridge traversing water body. 

Restorative Benefits. 
Social support is stressed in this design and 
program. Also facilitated are: physical and 
visual access to nature (including proximity to 
moving water), accessibility to wide number of 
people, and enclosure in the living landscape. 
Users. 
All Users: Patients, Staff, and Public. Pet 
Therapy will be encouraged in outdoor plaza. 
Maintenance. 
Maintenance should be minimal and will be the 
responsibility of hospital staff. The design is 
kept simple to orient views outward. Movable 
seating will require maintenance (left out rain 
and shine), as will the water feature and simple 
planters. The area is purposely designed open 
and flexible. This will enable the space to be 
configured for use by various groups for parties, 
rehabilitation or teaching sessions, or just 
simply for sitting and visiting. 
Special Features. 
The cafe is designed to draw in members of the 
community and is therefore easily accessed by 
hospital users as well as by the public (via the 
back lane) . Views to the enclosed open space will 
be a primary feature. 

Figure 8-5: Location Cafe. 

Description. 

This is a sunny, accessible open 
plaza at the southern base of the 
patient tower. It connects to a 
ground floor cafeteria, as well as 
a modified "food court". Private 
enterprise will be encouraged 
(snack shop, coffee shop, etc.) The 
Cafe will be an open plaza that 
encourages eating, meeting, 
t a l k i n g , a n d 
people/habitat/animal watching. 
The plaza itself features a large 
water feature at a height of 1 
metre, suitable for resting beside 
and touching the water. At the 
foot of the cafe is a 2-metre 
waterfall that drops into the 
constructed pond and then 
gradually moves down into the more 
natural marshland in the 
southeastern corner. Paths on 
either side of the waterfall are 
graded at <8% to allow wheelchair 
access. Handrails will also be 
required. The plaza has views to 
the marshland (and footbridge 
that passes over water to lookout 
shelter)and to the hospital 
volunteer garden shed. Paths lead 
out from the plaza to the marsh, 
orchards and raspberry fields. 
Although there are open views to 
the water and pasture, the area 
will have a protective sense of 
enclosure created by the tower, 
berm, and trees. 

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Urban Woodlot: Description. 

A significant amount of the mature, second 
growth Douglas Fir at the centre of the site 
has been retained and is hugged by the built 
form. The main hospital buildings wrap 
around the woodlot edge, thereby 
maximizing views to the trees for all users 
of the hospital. Trails are graded within 
the woodlot to allow universal use with 
frequent small nodes supplied with seating 
and water features (fountains for dogs, 
humans and birds) . 

Restorative Benefits. 
The forest has multiple benefits: 
promotion of biodiversity, experiential, 
and recreational. This area will provide 
lookout habitat for raptors overlooking 
the adjacent pasture as well as nesting and 
forage for a variety of species. The trees 
give a strong sense of regional identity. 
At the heart of this "urban woodlot" is a 
small clearing and rustic shelter that 
serves as an "away" place (meditation, 
refuge, grieving, small ceremonies). This 
forest clearing is intended for no more 
than 12 people in order to retain the strong 
sense of shelter and enclosure. 

Users. 
All users will benefit from views to the 
forest and edge experiences. Public, 
outpatient programs, visitors, and certain 
patients (e.g. psychiatric) will make use 
of internal trails. Staff may use internal 
trails as a means of arrival/exit from 
site. Nurses leaving after day shift 
(catching bus on Marshall) may choose to 
leave in groups via the forest as a way to 
discard the day's stress (security 
issues) . 

Maintenance. 
Maintenance and monitoring of trails will 
be the responsibility of the proposed 
volunteer group. Simple forest trails 
will be made accessible year round using 
packed gravel. Edge plantings of shrubs 
may require pruning to keep open ground 
plane views into the forest. 
Security measures will include: 

• emergency call boxes be placed along 
trails, 

• lighting of one major path, 
• security personnel present during 

shift change/peak use. 

Space within a Space: 
The Forest Cloister. 

Description. 
The inner edge between the 
building and the woodlot 
will be a shady site with 
significant exposure to 
nature. A 3 metre wide strip 
serves functionally as fire 
access and has the added 
benefit of providing spaces 
for visitors (and others) to 
wait. The main hospital 
entrance and corridor link 
provides visual cues to the 
presence of these gardens. 
Access to woodlot trails is 
apparent at each node. 

Restorative Benefits. 
The experience provided in 
these spaces will be 
complete immersion in nature. The built form protectively at one's back, views and 
thoughts are oriented into the woodlot. Edge planting will be primarily native (no 
exotic invasives) with punctuations of color and fragrance: Choisya, Philadelphus, 
Rhododenron. Forest edge bulb plantings will mark changes in season. A woodland 
garden planting strategy for the forest edge (a variety of canopy heights) and a 
liberal use of Acer circinatum will help provide bird habitat, thereby introducing 
restorative sights and sounds. 

Figure 8-6 (above): 
Multi-faith congregation centre in 
centre of woodlot. Accessed by 
following one of several looped trails, 
this rustic space with little more than 
benches and a minimal overhead will be 
available to all persons or groups of 
persons in need of respite. Programs 
may be promoted/developed in 
association with Pastoral Care. 

8 . 3 Urban Woodlot: Shared 
Hospital Open Space 

Figure 8-7 (left & right) : 
Collages of native plants. A native 
palette will be encouraged in the forest 
and on the forest edge to enhance 
biodiversity and promote education 
about local, native plantings. 
Occasional fragrant or unique exotics 
may be introduced for special 
places/occasions. Invasive exotics 
will be kept in check. 

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Figure 8-8 : Location Woodlot. 

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potential for walking route thai corrects to nearby recreation 

potenti^oT^^^ 

Figure 8-9: Location Paths. 

rOUteConne^o7alol^^ 
: . ; ; - — ' " , • " - - • • • - - _ . . . _ _ 

Way i 

An effort was made to maximize access to all parts of the site, leaving 
only the lower reaches of the marsh off-limits for birds to flourish 
unimpeded. 

The paths are made of a variety of textures to give interest yet 
accessibility: recycled asphalt or crushed gravel or grasscrete. Areas 
of grasscrete are planted with appropriate groundcovers (sweet 
woodruff in shady forest areas, turf in sunny areas) . All paths lead out 
from the hospital core. The diversity of materials/surfaces can also be 
utilized in hospital programs aimed at rehabilitation. For example, 
patients recovering from strokes (with impaired mobility and possible 
dependence on wheelchairs or devices) must learn to handle a variety of 
surfaces. 

Restorative Benefits. 
All paths offer strong connections to nature. Balance of understanding 
to mystery alters from trail to trail, allowing patients to choose 
level of security or complexity. All paths can be left behind if 
patients prefer to wander in the orchard, pasture or forest. 

It should be noted that an emphasis was placed on paths that are linear 
and formal, yet natural. Orchards, rows of raspberries, community 
garden plots, and other such paths offer a sense of order within the 
chaos experienced by patients and visitors of hospitals. Choices are 
present yet uncomplicated. Wayfinding is facilitated. A variety of 
rest stops should be built every 200-400 m and made of natural, familiar 
content and material. Simple wood benches are planned. 

Users. 
Public, staff, and all patients can use these loops. Psychiatric patients in particular were in mind with this design. Along these trails, 
public art may be featured but should only be of a natural content, keeping stress and misinterpretation to a minimum (Ulrich, 1992) . 

Looping and redundancy of trails is featured not only for safety measures but to allow staff members to mark off certain loops as appropriate 
distances to walk/run during break times. 

Maintenance. 
Path upkeep should be enough to maintain accessibility yet allow natural weathering. Raking 
gravel, replenishing gravel or groundcovers, clearing snow, and raking leaves will be among the 
tasks taken on by the volunteer group. Any major upkeep requirements (e.g. repairing broken 
pavers or clearing hazardous trees) will fall to the hospital. In selected areas, path side 
plantings will need pruning to maintain clear visual access for safety purposes. All paths will 
feature automatic dusk lighting on 2-hour timers. Engineering will have the potential to turn on 
lighting at any hour, however, in case of emergency. Emergency call boxes will be placed at 
locations along the paths. Gates may be required to close off paths after nightfall. Maintenance 
by hospital staff of these features will be required. 

Focus : Designing for Function Creates Restorative Opportunities . 

Several areas that required vehicular access utilized materials that would also provide more 
natural settings for walking. For example, a special opportunity for a pathway arose in the design 
for fire access to the north building face. This grasscrete turnaround also serves as a walking 
loop for psychiatric patients. 

The need to provide 3-metre access around the buildings for fire access also provided 
opportunities to enable outdoor access by all patients (wheelchairs, bed-patients) as well as 
frequent visitor and staff nodes. These areas will be highlighted later in this chapter. Figure 8-10: Grass crete. Functional with 

a more natural appearance. 

8 . 4 Accessible Walking 
Loops : Co-Managed Open Space 
(also Staff/Visitor/Patient Open 
Space). 

Description. 

These (and many more) pathways have 
been designed for maximum 
accessibility, control, options 
and experiences. Users are given 3 
distinct road types on the site. 
These are primarily the functional 
routes. These varied paths act as 
the restorative routes for 
walking, jogging, cycling, or 
simply viewing. By utilizing the 
regional aesthetic and propensity 
for growing fruit, some 
interesting walks through rows of 
trees and canes were created. A 
looping system was created within 
the woodlot to increase 
defensibility. 

The formal lines of orchards and 
gardens are very comforting to trek 
through during times of stress. 
Straight lines are less stressful 
and give a sense of order to the 
chaos that often accompanies 
hospitalization. 

1*0 Accessible Raspberry Canes 
•year-round p^t-hs 
•even q n a d e s 
•plan4s <l.Sm haiqUt 

Figure 8-11: Accessible Raspberry 
Walks : Unconventional, ''regional' 
pathways. 

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Examples of Designed Accessible Walking Loops 

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Conceptual SKe+ck • Harsh Uta\k 

Figure 8-12 : Conceptual Walkway past Marsh. 

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Figure 8-13: Conceptual Walkway, rows 
of Raspberry Canes & Community Gardens. 

Conceptual SKetch ; Orchard Wa! fc 

Figure 8-14: Conceptual Walkway down Orchard 
Rows. 

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Figure 8-15 : Woodlot T r a i l s and Rest Stops . 

8.4.1. 
Research Findings Supporting 
Walking Programs for Mental and 
Physical Health: 

An Overview: 

1. Women and Cognitive Function. 
In this 2001 study, 5,925 women 
(age 65 and older) were tested for 
cognitive function at 8 year 
intervals. Researchers found that 
for every mile walked per week 
there was a 13 percent less chance 
of cognitive decline (Yaffe, 
2001) . 

"Women who walk regularly 
are less likely to 
experience the memory loss 
and other declines in mental 
function that can come with 
aging. This is an important 
intervention that all of us 
can do and it could have huge 
implications in preventing 
cognitive decline" (Yaffee, 
2001). 

2 . Prevention of Diabetes. 
This 1997 trial showed an 
impressive reduction in the 
development of diabetes following 
regular physical activity. 
Moderate-intensity physical 
activity (walking to jogging) was 
found to be associated with a one-
third to two-thirds lower 
incidence of NIDDM (non-insulin 
dependent diabetes) over 4 to 14 
years in persons at high risk for 
the disease (e.g. family history). 
It was concluded that public health 
programs aimed at increasing 
opportunities for physical 
activity before illness would be a 
beneficial investment for 
communities (Clark, 1997). 

3. Treatment of Depressive Mental 
Illness. 
An NIH (National Institute of 
Health) supported study at Duke 
University in 1999 made headlines 
when it was discovered that 
patients who took brisk 30-minute 

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walks or jogs three times a week recovered from major depression almost as well as those on anti-depressant medication (60% vs. 64%) . 
Perhaps even more significant, when the original patients were tested again 6 months later, only 8% of the exercise group (who continued 
their exercise) had a return of symptoms. The drug group had a relapse rate of 38% (Blumenthal, 1999) . 

4 . Exercise as a Singular Treatment for Mental Illness . 
The National Institute of Mental Health recognizes exercise as a valid treatment for anxiety and depression. Early clinical trial evidence 
also suggests that regular exercise may be useful as a singular treatment for some anxiety disorders, for individuals suffering from body 
image disturbance, and for the reduction of problem behavior of developmentally disabled persons, as well as an adjunct in the treatment 
programs for schizophrenia, conversion disorder, and alcohol dependence (Wattles, 2001). 

Facilitating Walking/Exercise 
Programs : Summary Remarks . 

Shoulder 
strap 

Electrode 

Monitor 

Figure 8-16: Holter Monitor: The patient wears a 
small monitor with electrodes attached to the 
chest. This allows continuous monitoring of 
cardiac activity at rest and during physical 
activity. 

5. Walking Programs for Heart Health. 
The Healthy Heart Program at St. Paul's Hospital in Vancouver, British Columbia is 
renowned for its work in both the prevention and treatment of all manners of heart disease. 
A significant aspect of their patient program is the initiation of an exercise program 
suitable for each individual, beginning with simple treadmill walks and progressing from 
there. Since physical inactivity is the most prevalent modifiable risk factor for heart 
disease, increasing physical activity or "active living" is a major goal for participants 
in the Healthy Heart Program (Healthy Heart Program, 2002) . 

"Physical inactivity Lack of physical activity is a risk factor for coronary heart 
disease. Regular aerobic exercise plays a significant role in preventing heart and 
blood vessel disease. Even modest levels of low-intensity physical activity are 
beneficial if done regularly and long term. Exercise can help control blood 
cholesterol, diabetes and obesity as well as help to lower blood pressure "(Healthy 
Heart Program, 2002) . 

6. Reduce Risk of Cancer Development. 
Women who are active reduce their risk of cancer by 30% vs . sedentary counterparts . This is 
similar to the Lean women who exercise reduced their risk of breast cancer incidence by 43% 
compared to sedentary counterparts. This study supports the work done by University of 
southern California and University of Norway that states that physical activity can 
reduce breast cancer incidence from 25-60% in the groups of women studied. 

"Participation in recreational physical activity in any period of life, rather than 
during a specific period, appears to be relevant, implying that women who start with 
recreational physical activity at later ages may still benefit from their efforts 
(Verloop et al, 2000) . 

7 . Relieve Symptoms of Arthritis. 
The recommended and often standard treatment for forms of rheumatoid arthritis include 
such harsh medications as Methotrexate, an antimetabolite often used in the treatment of 
cancer (e.g. chemotherapy). It has been shown to be successful, but not without harsh side 
effects. 

As a personal and entirely anecdotal endorsement of walking/jogging/running, my own battle with a rare form of hereditary arthritis began 
before I had my 30th birthday. The rheumatologist gave me several options, including the above drug therapy. Frightened by the prospect of 
receiving "chemotherapy", I chose one of his other "alternative" options: vigorous exercise. By taking up running (marathon running) and 
attempting to decrease stress in my life, I have managed to ward off the worst of the illness. I occasionally have opportunity to speak with 
others with similar genetic conditions: men and women, many younger than I, often disabled and unable to work/study/play or enjoy life. I 
am a strong advocate of regular and vigorous exercise (the actual amount dictated by the body's pain response). Perhaps the most 
significant barrier, according to patients, is the lack of facilities where they can begin a program (walking, swimming, etc.) and feel 
comfortable about the pace at which they must begin. 

A strong recommendation by the Mayo clinic for all forms of arthritis, but in particular inflammatory and rheumatoid forms is to "...exercise 
to strengthen muscles around joints, increase your range of motion and increase your overall fitness" (Mayo Clinic, 2002) . 

8. Exercise as a Cost-Efficient Treatment. 
Perhaps most significant in a public health care system, the treatment of mental health with exercise and activity has been shown to be far 
more cost-effective than the standard drug therapy treatment (Greist, 1979) . 

The Valley Health Centre has great 
potential to create activity 
options for all members of the 
community. Beginning (and 
maintaining) physical exercise to 
prevent and control illness is not 
as simple as just 'going out for a 
w a l k ' . G u i d a n c e b y 
rheumatologists, cardiologists, 
physiotherapists and other health 
care professionals (dependent on 
illness being treated) is needed. 

Taking steps to prevent the 
development and/or progression of 
illnesses will not only prove cost 
efficient in the long term but will 
go far in improving the general 
health, well-being, and happiness 
of the community at large. 

-100-



Figure 8-17 (above) : Photoshop Visualization. 
Moving along accessible raspberry cane paths (grass crete surface in 
selected pathways; height restriction on raspberry canes). 
Figure 8-18 (below): Photoshop Visualization. 
Moving along pathways through 'Old Fields'/'Old Orchards' (some 
present on site, others to be designed). Surfaces will be year-round: 
range of materials, (e.g. asphalt, coarse gravel, concrete in areas 
near buildings). 

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Figure 8-20 (pictured below) : 
Photoshop Visualization. Hand-
rendered image of Community 
Stewardship Staging Centre (shown as 
simple rendering in figure 7-19). 

In this image, life has been brought 
into the Centre through the addition of 
site-specific photography, animals, 
signage, people, and possible 
programs. For instance, depending on 
the choice of trees to be planted in 
the orchards, heritage apples or other 
fruits may be marketed to hospital 
staff, visitors, and patients and the 
community at large. The Centre is 
designed to have a welcoming, 
accessible feel that caters to all 
persons, regardless of ability or 
health stages. 

Free-roaming rescue animals may become 
a part of the open space program 
(important restorative and altruism 
benefits) . 

-101-



Figure 8-21: Location Primary Psychiatry Programs/Designs. 

; n ^ ~ ^ b . .-
Outdoor "P*ro Turnaround/ 

WalMng Pwlmatw / Walking Loop" 

Prospect-Refuge 

i <0>: 
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Figure 8-22: Outdoor Psychiatry Connections - paths (A) and node: 
(B) . Arrows to Open Space Programs/Potential Programs. 

Garden •/,• 
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Design/Program Objectives (for Inpatient-Psychiatry Unit) : 

1. Access to open space programs and walking programs is facilitated and 
controlled by staff according to patient restrictions. In particular, 
access to the nearby woodlot, Old Field and new orchard will become a 
component of patient treatment. As patients are given higher levels of 
independence, access to these areas should increase. Although the unit is 
on the fourth floor, elevator access will provide easy wayfinding to exits 
and entrances with necessary signage to direct patients to programs. It is 
expected that patients will likely be introduced to the various programs as 
a component of their treatment plan. It should also be noted that attention 
to security should be high, with target hardening where applicable. 

2. Access to the cafe (a place to take coffee, smoke, people-watch, or 
socialize) is also facilitated by elevator routes. A controlled elevator 
from the fourth to the first floor will offer a direct route to the cafe. 
This will be an important place for social support. 

3. A walking circle/area is designed within visual access of caregivers. The 
Fire Access 'turnaround' doubles as a walking circle, and a grasscrete 
surface permits use year round while maintaining a natural feel. As well, a 
portion of the nearby 'Old Field' bordering the Woodlot will be fenced off 
(preferably with hedgerows) to give a safe "inner sanctum" for patients to 
wander in nature. The size and extent of this area would require further 
analysis. 

4. Exterior views to nature are promoted, in particular from: 

a. The shared "day room" (lounge), and 

b. Locked rooms, where patients admitted against their will under the 
Provincial Mental Health Act are kept for a limited time if deemed necessary 
for staff or patient safety. Patients in these situations are often 
suicidal and/or homicidal and strong efforts to reduce stress are needed. 
Routinely, this extends only to painting walls in muted colors. This plan 
proposes opening up views (through safe, unbreakable glass) to the forest 
and pasture beyond. 

5. A visible smoking nook is built (visible to caregivers and patients on 
ward) into the design. A high percentage of psychiatric patients are 
smokers and stress may be reduced if they can visualize a place where this 
activity is permitted. These nooks are designed in a very similar manner to 
those illustrated later on as 'Visitor Open Space' . 

6. Access to prospect-refuge is facilitated by proximity to the Woodlot and 
to private areas in the Old Field. The topography of this portion of the 
hospital allows patients to sit on a hillside and view activity on Marshall 
Road below. Access into the Woodlot will be determined according to patient 
restrictions. 

A unique, and likely popular location will be the area overlooking the 
hospital delivery bay. The inner Fire lane provides quick and easy access to 
the upper balcony overlooking this 'Back Door'. Despite the seemingly 
unaesthetic appeal of "Delivery Areas" , these are traditionally well used by 
both hospital staff and patients as refuges for escape. 

8 . 5 Psychiatric Population: 
Challenge for Programming and 
Design 

This new hospital serving the 
Fraser Valley of British Columbia 
is expected to care for a large 
number of patients suffering from 
a variety of mental illnesses. 
Special attention is required in 
both design and programming. This 
project attempts to point out the 
urgency of including this often 
forgotten group in early stages of 
design. 

Drawing from conversations with 
other health care professionals, 
as well as the designer's own 
personal experience with this 
patient population, these main 
objectives for design have been 
delineated: 

1. Access to open space programs , 
2. Access to the cafe, 
3. A walking circle/area, 
4 . Exterior views to nature, 
5. A visible smoking nook, 
6. Access to prospect-refuge. 

Outdoor Programs 

Fourth Floor 

Cancer Clinic 
Counselling 

and treatment 

Offices: Traditional 
and alternative 

Nursing Units * > 
(Psychiatry: 
views and balcony) 

elevator 
Palliative Care 

(balcony garden) 

Nursing Units 

Indoor & Outdoor Cafe 

Outdoor Programs 

Figure 8 - 2 3 : Focus on P s y c h i a t r y 
Placement i n B u i l t Program ( e l e v a t o r 
a c c e s s t o programs) . 

- 1 0 2 -



Anecdote (a call for a defined walking route) . . . 

Working on a secured psychiatric facility in an urban core, I was assignee 
the task of accompanying a large man (300 lbs of muscle developed through 
fits of rage) on a supervised walk pass. Patients who had showr. 
improvement were given these passes. I knew little of his history...we all 
knew little. He had been very closed mouthed since admission. As we set ofi 
down a back alley, I tried in vain to find a route that would be 
interesting, yet defensible for me. This became more of a concern as his 
xlife story' began to unfold with multiple arrests for violent crimes. As 
we walked down alleys lined with 6-foot high fences I could see him becoming 
vuch more relaxed and more free with his "tales". My own stress levels were, 
however, soaring. 
We returned without incident. The psychiatrist was thrilled with this 
new discovery of "Walk & Talk". The first thing I did? I got in the car anc 
vapped out a safe, secure walking route that would reduce his stress yet 
keep mine under control. That "secure" walking route became the standarc 
for all walk passes. 

The Need f o r F l e x i b i l i t y . 

A l t h o u g h t h e r e i s a d e f i n e d " P s y c h i a t r i c U n i t ' , p a t i e n t s s u f f e r i n g 
from m e n t a l i l l n e s s a r e f o u n d t h r o u g h o u t t h e h o s p i t a l . Women w i t h 
p o s t - p a r t u m d e p r e s s i o n a r e f o u n d i n t h e o b s t e t r i c s u n i t s . 
A n o r e x i c s a r e t r e a t e d on m e d i c a l f l o o r s f o r g a s t r i c t u b e - f e e d i n g 
a n d i n CCU/ICU f o r l i f e - t h r e a t e n i n g e l e c t r o l y t e i m b a l a n c e s . 
P e r s o n s w i t h m e n t a l i l l n e s s a r e o f t e n v i c t i m s o f a s s a u l t a n d 
r e q u i r e s u r g i c a l t r e a t m e n t . N o n - c o m p l i a n c e w i t h m e d i c a t i o n s , 
p o v e r t y , p o o r n u t r i t i o n , a n d a h i g h p r e v a l e n c e of s u b s t a n c e a b u s e 
l e a v e s many o p e n t o a h o s t of m e d i c a l c o m p l i c a t i o n s . L i k e t h e 
c a r e g i v e r , t h e d e s i g n e r m u s t b e p r e p a r e d f o r e v e r y e v e n t u a l i t y . 
D e s i g n s a n d p r o g r a m s t h r o u g h o u t t h e h o s p i t a l m u s t b e f l e x i b l e a n d 
a c c o m m o d a t i n g . 

Fire access and 
WalKJncj Uop 

Da.y Room 
Close Obs. 
Locked Security r_ 

consider open atria/sky roofs to maximize sunlight 

1-ZbO Psychiatry Sitinq M a i 

Figure 8-26: Detail Plan of Psychiatric Siting (indoor-outdoor 
relationship evident). 

Figure 8-25: "Back Door Privacy". An option to retreat to area above 
loading dock for solace and some degree of Prospect-Refuge. 

Research Highlight: Schizophrenia £ Smoking Behaviour. 

Patients with schizophrenia have an extremely high prevalence of 
smoking; a 1986 US study found 88% of these patients were smokers 
compared with only 33% in the general population (Hughes, et al, 
1986). The increase in dopamine release induced by smoking has been 
hypothesized as being helpful in alleviating some of the positive 
schizophrenic symptoms (delusions, hallucinations, paranoia 
etc.). Therefore, schizophrenics may smoke in an attempt to self 
medicate (Hughes, et al, 1986). 

Smoking also interacts with neuroleptic treatment (common drug 
treatment for schizophrenics, includes the drugs Haloperidol anc 
Chlorpromazine). Neuroleptic plasma levels are reduced causing 
higher doses to be prescribed and subsequently, leading to higher 
incidence of side effects (Goff, et al, 1992). 

One study actually showed that patients smoke more when treated with 
the neuroleptic Haloperidol than during a medication-free stat 
(McEvoy, et al, 1995) . 

The argument could be made that until medical science discovers a 
more effective treatment for the disease, smoking may be an 
unfortunate but inevitable side effect. For some this may seen 
contrary to design a health care facility that enables smoking. For 
this designer, it is merely an attempt to design for all user needs, 

The Dilemma of Designing for 
Smoking. 

This project may receive criticism 
for actively designing spaces for 
people, and in particular 
patients, to smoke cigarettes. 
Medical science has not yet 
adequately developed a fool-proof 
cure for this addictive habit, and 
it is the objective of this project 
to provide for, and design for the 
needs of the clients. 
Patients suffering from mental 
illness are at particular risk for 
this form of substance abuse. 
While provincial rules dictate no 
smoking indoors, the design does 
feature several areas suitable for 
smoking. A very brief overview of 
medical research that supports 
this design move is offered here. 

-103-



U n i q u e . D e s i g n I m p l / c a f i o n s : 

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Figure 8-27: Section-Elevation of Cancer Clinic Woodlot Garden (view north) . It should be noted that the design of a shady woodland garden for the Cancer 
Clinic does not imply that only sedate and sorrowful programs will occur here. Celebrations and gatherings can take place in the forest clearing. During 
the day, hikers or cyclists may pass through the rest area and visit. Pet therapy should be strongly encouraged, to the point of having a resident pet. 

8 . 6 : C a n c e r C l i n i c W o o d l o t 
G a r d e n : P a t i e n t Open S p a c e 

Description. 
This garden utilizes the power of 
the shady treed landscape. It is 
built primarily for the patient 
(and loved ones) . A roof deck 
emerges from the second floor of 
the building and offers an 
accessible route to an elevated 
position on the centre knoll. The 
garden area is in fact a small 
clearing in the woods that offers a 
water feature and simple site 
furniture. 

Restorative Benefits. 
Users of this private garden space 
have the potential for: 
• sensitivity to ultraviolet 

rays, 
• impaired skin integrity, 
• heightened feelings of 

helplessness/hopelessness, 
and a 

• strong sense of loss of 
control. 

Offering these patients (and the 
staff who care for them) a space 
enclosed by the healing power of 
nature is vital. This is a shady 
garden protected from wind. Rain 
protection is given with an 
overhead structure on which vines 
are trained. Waterproof, fabric 
chairs will be comfortable to 
sensitive skin.. Situated on the 
edge of the Urban Woodlot, this 

Figure 8-28: Location of Cancer Clinic 
Garden Design. 

r 

, 

-104-



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Figure 8-29: D e t a i l - G e n e r a l P l a n t i n g Scheme f o r Cancer 
Woodlot Garden. Immediate views a r e a v a i l a b l e t o i n n e r 
woodlot and t o v i s i t o r s e a t i n g a r e a s . 

g a r d e n w i l l a l s o o f f e r s t h e c h o i c e 
of " e s c a p i n g " , t h e r e b y r e g a i n i n g 
some c o n t r o l . 

A d d i t i o n a l l y : 
• P l a n t s w i t h p l e a s i n g f r a g r a n c e s 
and t e x t u r e s w i l l b e u s e d ; 
• E m p h a s i s on g r e e n / b l u e / w h i t e i n 
c o l o r p a l e t t e ( s o o t h i n g a n d 
p e a c e f u l c o l o r s ) ; 
• A w o o d l a n d g a r d e n a p p r o a c h w i l l 
be u s e d t o e n h a n c e b i r d / h a b i t a t 
a t t r a c t i o n ; 
• P e a c e f u l s o u n d s w i l l b e 
i n c o r p o r a t e d t h r o u g h a s m a l l w a t e r 
f o u n t a i n . 

U s e r s . 
Unique: Cancer Clinic patients, 
visitors and staff. Encouragement 
of pet therapy will require special 
features for visiting pets (e.g. 
drinking fountains) . 

Maintenance. 
This space will require a higher 
level of maintenance by hospital 
gardeners due to the small size and 
need for finer attention to detail. 
Deck and bridge maintenance will be 
required, particularly in winter 
seasons. The deck and bridge will 
be of concrete construction with 
wood and cast iron details. 

•105-



elevator bank, it will be available for long or short breaks. The design will 
be minimal so as not to distract from the surroundings. A permanent podium 
may be constructed to allow the space to be used for awards and ceremonies 
(private or public). 

Restorative Benefits 
Stress reduction is offered through contact with nature and escape (from work 
and from patients). Significantly these gardens are places where staff are 
not accountable to the public and can momentarily let down their defenses. 
A sense of control is imparted to users. More so in the rooftop garden, a 
strong sense of away is made available to the user. 

Users 
E.R. Refuge: Emergency staff, night shift staff and 
ambulance/police/security personnel will be the primary users. Patients are 
not given visual or physical access to this space. 
Mt. Baker Retreat: This area is restricted to staff except for special 
occasions. A wide array of staff will be expected to use this garden. 

Maintenance 
Hospital gardener maintenance will be required although staff may take on 
these relatively small gardens as their own project (as long as the space and 
budget for plants and materials is provided) . 

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Figure 8-30 (above) : Detail Plan of Mt Baker Staff Retreat. 

Figure 8-31 (left): Plan of Emergency Entrance (with interior 
connections). 

Figure 8-32 (below) : Location of Proposed Staff Refuges. 

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8.7 S t a f f Refuges: 
Open Space 

Staff 

Two gardens are featured here. It 
is expected, however, that several 
more would be included in the final 
plan. 

Description 

a. Emergency Room Staff Refuge 
This a small but vital garden space 
created within a nook of the built 
form outside Emergency. Enclosed 
by plantings, it will be a means of 
quick and brief immersion in 
nature for stress reduction and 
retreat and refuge. The proximity 
of the garden to the E.R. allows 
this space to be used frequently 
for brief periods of time 
throughout the shift. The garden 
provides a view of Emergency 
Health Service (e.g. paramedics) 
arrivals. This visual access will 
be particularly important on night 
shifts. 

This garden space will likely be 
shared by a range of 
professionals, as the ER is often 
the gathering point for several 
public professions. A card-
controlled access from the outside 
keeps the place safe from non-
intended users. The inner 
entrance leads directly into the 
staff lounge. 

b. Mount Baker Visual Retreat 
Situated atop the 10-storey tower, 
and facing south, this space 
focuses on the views outwards. 
Views to regional landmarks are 
maximized from this point (Mt. 
Baker and southern rural lands). 
As well, a significant view of the 
open space program is facilitated, 
and the height is low enough to 
prevent complete removal from the 
sense of enclosure. Perhaps in 
reaction to the lack of attention 
staff have been given in modern 
design of hospitals, this group of 
users have been afforded this 
choice garden spot for refuge. 
Easily accessed by a central 

•106-

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proximity to ambulance bays, allowing users to monitor incoming patients. 

Human Scale Interventions. 

The illustration at left 
highlights more than just the 
design and location of the E.R. 
Staff Refuge. It is recommended 
that the built form should feature 
fenestration and indentations as 
detailed here. Dropping down the 
occasional portion of roof top not 
only creates an instant roof garden 
(physical and/or visual access) 
but also helps to decrease the 
apparent mass of building size. 

Multiple large windows, set low to 
facilitate views from beds also 
help break up the size and scale of 
the structure. 

Creating a more human-scale and 
friendly appearance to the built 
structure will benefit all users, 
from immediate hospital personnel 
to community members passing by. 
For the staff member taking a brief 
retreat outdoors, the building 
will act as their backdrop from 
which they observe nature. A 
sympathetic built form will 
enhance the degree of stress 
reduction. For members of the 
public, viewing the hospital as an 
impressive, yet humanistic 
structure will increase chances of 
them coming on to 
the property to 
use the cafe or 
participate in 
volunteer or 
social support 
programs. 

This attempt to 
humanize the 
buildings will be 
e s p e c i a l l y 
important on this 
site, given the 
existence of 
single family 
homes and low-
rise senior's 
f a c i l i t i e s 
nearby. 

-107-

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8.8 Accessible Building 

Perimeter: Visitor Open Space & 
Patient Open Space 

Description 
As has been described previously, 
the built form is surrounded by a 
minimum 3-metre wide pathway, 
accessible to emergency vehicles 
as well as individuals on foot, in 
wheelchair, or in hospital beds. 
Small indentations are placed 
along this pathway to demarcate 
special areas for rest by users. 
In most cases, these indentations 
correspond with entrances, sliding 
glass doors or large windows. As 
the visitor arrives at the front 
atrium, he or she is instantly cued 
as to the presence of a waiting 
area (s) within the hospital, 
nestled below the mature Douglas 
Fir. The designs for these spaces 
are all meant to be simple, with 
subdued planting, water features 
where possible and simple yet 
comfortable benches. A bench is 
always strategically placed 
opposite the entrance to the 
"waiting nook" to give evidence of 
human sign and increase comfort 
level. 

Restorative Benefits. 
Legibility, proximity to nature, 
accessibility, and the presence of 
an enclosed, hugging 'archetypal' 
space are all present in this 
design element. 

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- 1 0 8 -

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Figure 8-36 : Outdoors Accessibility Achieved for All Users . 

Anecdotal support of design. 

yAs the night progressed, it was not the fact that his wife of fifty years had 
suffered a massive stroke that frustrated and angered him. It was not even 
the fact that she would clearly die that night that upset him. Reconciled 
with the imminent passing of his beloved wife, it was the frustration that she 
would most assuredly die in this emergency room, in this windowless corner, 
in this artificial and sterile environment, that he could not suffer any 
longer. She had lived all her life "outside": wife of a farmer, avid 
gardener, caretaker of numerous rescued animals. How could she pass away 
without one last breath of fresh air, one last passing bird song, or one last 
feel of the breeze through the native maple trees? 

Despite the fact that we were in a small emergency in a rural area, pushing 
that bed outside, over the curb, and next to the non-descript staff 'garden' 
was a challenge that required the full participation of several nurses and 
security guards. Nevertheless, that 40 minutes of manpower was the best 
nursing care plan we could have devised for the man who was about to lose his 
wife. She did pass away, in a corner or the emergency, later that afternoon, 
but for him to have spent just 30 minutes at dawn watching the sunrise as she 
slept beside him in her hospital bed was enough to calm him and leave him with 
good memories of her final moments. 

Why should it be so difficult to take patients outside, everyone in the 
department wondered?' 

Emergency Vehicle 
Access 

Shady Garden 
Experience 

Users. 
All users will find these spaces 
beneficial. The highest use, 
however, will be by visitors, 
patients awaiting diagnostic tests 
(laboratory and ultrasound 
departments are also located on 
ground floor) and patients. In 
particular, this provides an easy 
means by which caregivers can push 
beds outdoors for restorative 
purposes as well as for emergency 
evacuation purposes . 

Maintenance. 
Upkeep will be done by hospital 
employees with assistance from 
volunteers if desired. Upkeep 
should be low-cost as the primary 
goal is to keep planting schemes 
and design features simple, 
native, and low in labor. Plants 
that grow well in shady 
environments will need to be 
employed. Surfaces will need to be 
kept clear of debris in order to 
ensure easy movement of hospital 
beds, wheelchairs, and emergency 
vehicles. 

:f. 

9 >y* 

Figure 8-37: 
Sample Visitor Nook-Adobe Photoshop Visualization. 

Site Furniture. 
Benches, artwork, water features, 
and other site furniture and 
amenities will all be of a simple 
and easy to maintain nature. 
Abstract art will be avoided to 
reduce stress (Ulrich, 1992). 
These small nooks on the inner core 
of the hospital may be a potential 
site for local artisans to be 
involved in creating regionally-
themed benches (refer to Figure 4-
3: Abbotsford Bench Art Program) . 

•109-



Figure 8-38 : Axonimetric of entire site showing depth of enclosure and open space. 

Figure 8-39: Location Open Space 
Programs. 

facilitate this. The siting of 
design of significant, memorable 
features that create landmarks, 
small or large will enhance this 
understanding. A significant tree, 
a bridge, a garden shelter are 
easily identified and recalled. At 
the opposite end of the spectrum, 
seasonal bulb plantings in the 
meadow beyond, or a unique display 
of natural stone art at water's 
edge may only be noticed after 
successive visits, yet give an 
equally strong sense of 
understanding (Kaplan, Kaplan and 
Ryan, 1998). 

Users 
All users: Patients, Staff, and 
Public. 

Maintenance 
M a i n t e n a n c e w i l l be t h e focus of t h e 
p r e v i o u s l y d i s c u s s e d H e a l i n g 
G a r d e n e r s ' S o c i e t y . 

8.9 The Open Space-
"Pasture, Pond and 
P r o d u c t i o n " : Co-Managed Open 
Space 

Description. 
At the core of this open space is 
the pond or marsh (dependent on 
season and rainfall) . Designed 
with an accessible path it provides 
benefit to human, aquatic, aerial 
and terrestrial habitat. Pasture 
land and edible landscapes buffer 
the water from its built 
environment. The open space 
landscape, while skirting the 
hospital's southeastern edge, in 
fact creates a very positive, 
volumetric space between Mayfair 
Hospital, the new hospital, and the 
Highway Berm (Condon, 1988). The 
tall Douglas Fir trees edging the 
property contribute to the human 
scale of the space, by furthering 
the sense of enclosure. Small 
pockets of space along the meadow 
edge become even more human scale 
when the open space recesses under 
tree canopies . 

Restorative Benefits. 

Visual and physical access to a 
living landscape will appeal to the 
biophilic nature in all users. 
Creating an actual working 
landscape that requires human 
stewardship for functioning 
appeals to the universal need to 
nurture. Providing opportunities 
for nurturing is identified as an 
important means of battling the 
helplessness and hopelessness 
experienced by hospital patients 
(Beck & Katcher, 1984) . 

Movement into and through the open 
space should be filled with choices 
and options for varying degrees of 
interaction with nature. 
Opportunities for movement that 
features high understanding and 
legibility will facilitate a 
strong sense of personal security 
(Kaplan, Kaplan and Ryan, 1998). 
The accessible paths will 
facilitate this. The siting of 

-110-



CHAPTER IX 

Final Recommendations for Future Inquiry or Design 

9.1 Recommendations for Proposal 

• Public presentation at University of British Columbia: April 30, 2002 
* Presentation to City of Abbotsford Staff: 31 May, 2002 

Some of the following recommendations or follow-up ideas developed late in 
the design process and time simply did not permit further research/drawing 
or exploration. Other issues were raised during the public presentation 
at the University of British Columbia or at an informal presentation given 
to City of Abbotsford staff. 

1. Traffic Calming measures along Main Street Entrance into hospital may 
be required/explored. 

2. Development of street guidelines specific to Marshall Road would 
require further inquiry into rurally appropriate street treatment. 
This front Marshall Road may also be considered for inclusion in 
hospital programming, as it becomes part of a "loop" around and through 
the hospital. Issues to consider would include: 

• The profile of Marshall and Gladwin, which may require widening 
of the sidewalks to allow for passage of two wheelchairs; 

• The appropriateness of Marshall for wheelchairs/disabled due to 
its steep grade; 

• Whether the Marshall road street treatment would include 
retention and enhancement of current Douglas Fir on both sides. 
Keep mystery to a minimum by eliminating mid-size shrubs except 
at apex of knoll. Appropriate understory may be planted under 
these large "street trees"; 

• The possibility of creating a running loop for staff that uses 
back lane and travels along Marshall (one large loop). 

3. Consider the use of hazelnut trees 
in orchards. These trees grow very 
well in this climate and the 
hardness of the outer shell 
virtually eliminates the chance of a 
child allergic to nuts cracking open 
and ingesting one. The outer shells 
are not allergens. 

4. Consider the use of Heritage apple 
trees in orchards. There are local 
growers in the Abbotsford area 
working with highly disease 
resistant, heritage trees and may be 
interested in 'donating' trees for the hospital orchards. Maintenance, 
research, and follow-up care would likely involve these interest 

- Ill -



groups. Also, non-fruiting but flowering trees may be considered for 
orchards (if known to attract large numbers of birds). 

5. Guidelines for communities may be explored and developed, that ask or 
answer the following question: To what extent does a local community 
have influence on a large regional, provincially funded hospital? 

6. The University of British Columbia or other local schools may have 
large scale agricultural programs that require land that would be 
interested in joining the co-management of the open space, and donating 
product and time. 

7. A defined running track with 24 hour lighting that runs through and 
around the site would be useful not only for community members but also 
for staff. Many larger regional hospitals now feature 24-hour gyms 
with treadmills where nightshift workers will spend their 45-minute 
'breaks'. While it is expected the Wellness Centre will include access 
to treadmills, an outdoor track with an appropriate surface would be a 
particular treat in this mild climate. The possibility then exists to 
create a yearly fundraising "Run for the Hospital" that would cross 
through the hospital and around Mill Lake. The distances of these 
running routes have not been explored. 

8. A proposal has been made for a 
rooftop garden that is shared by 
both geriatric/rehabilitation and 
paediatric populations. Another 
unique feature would be a defined 
and designed play area for children 
(patients, visitors, and community) 
within the open space area. The 
long flat lawn south of the 
hospital and just east of the 
cafeteria would be an appropriate 
place for this design. 

9. In the proposed plan, grassy Figure 9-1: A designed, supervised 
treed swales are in all parking play area for children; in plain 
lots. These plantings may require v i e w of hospital. 
enhancement in the shared parking 
lots to the southwest, in 
consideration of views from the western side of the hospital and tower. 

10. In this proposal, the community has been considered strongly as a 
component of the design and the program. More specific design plans, 
however, would require a much more involved effort to identify very 
specific community groups and their needs. For example, identification 
of preferred types of recreation (rollerblading, equestrian, cycling, 
etc.) . Given that this region is home to a very high and growing 
number of horse breeders and owners, the desire to place a small riding 
ring on the site may be expressed by the community as a means of 
increasing involvement as well as a restorative vision for hospital 
patients. Full determination of open space programs would need 
community input and decision-making. 

- 112 -



11. Recycling and discard 
of waste is an issue to be 
explored within the hospital 
site: for compostables, 
paper, plastic, and 
biohazards. Hospitals are 
well known to be highly 
wasteful. This can be blamed 
on the high risk of biohazard 
but it is also well known 
amongst hospital workers that 
little effort/budget is put 
into efforts at recycling. 

12. Alternate energy use 
may be explored on site: 
solar, wind, water. 
Windmills were not explored 

based on cursory data that these are harmful to bird populations. This 
would require further investigation. 

13. Emergency Health Services (EHS) access from 

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Figure 9-2: EHS access onto Gladwin from Trans-
Canada Highway. This close proximity would have a 
significant impact on morbidity/mortality of 
highway trauma victims. 

Trans-Canada Highway 
onto Gladwin and 
into the hospital 
would be effective 
in decreasing 
ambulance transit 
times for major 
traumas. Such an 
access point would 
make this hospital a 
primary provider of 
highway accident 
care. Measures would 
need to be taken to 
ensure this does not 
become a "short-cut" 
for highway access 
by the general 
public. One 

possible solution 
may be a 
electronic 
accessible 
ambulances 

controlled 
gate 

only by 

14. Security 
issues related to 
welcoming the 
community onto the 
landscape have been 
mentioned briefly 
here. A more 
thorough delineation 
of security measures 
would be required. 
For example, while 

- 113 -



several walkways have been designed for use by all individuals, certain 
areas may require fencing or (preferably) hedgerowing. An example 
would be a boundary created in the north Old Field space for use by 
psychiatric patients. Water features, although designed to be shallow 
would require safety measures (regional fencing, etc.) in high use 
areas. 

15. The open space area becomes in all essence a significant public 
park. Programming for special celebrations (cultural, regional, etc.) 
should be done during the design phase, beginning with the planning of 
a significant ribbon-cutting ceremony. Special events could be 
celebrated here: e.g. annual Strawberry/Raspberry/Blueberry festivals. 
The open space could be leased out to groups for one-day events (e.g. 
club picnics, obedience dog trials, etc.). 

16. A final image/map/overlay that would be created (given more time) 
would be a "Community Integration Overlay". This overlay would detail 
several possible community activities. These might include: 

• Drivers passing by, 
• Pedestrians walking by, 
• Recreationalists cycling or jogging through, 
• Visitors stopping at cafe for a cold drink or a latte, 
• Children playing in defined open space near cafe, 
• Seniors walking in open space, 
• Celebrations going on in open space, 
• Staff members taking lunch under an orchard tree, 
• Community members gardening or pruning orchard trees, 
• Community members arriving at Wellness Centre for talks on 

health promotion, disease prevention, 
• Schoolchildren taking inventory of bird habitat in marshland. 

17. A very few examples of roof gardens, private gardens, and water 
features have been chosen to illustrate in this project. As a major 
emphasis was on creating an entire restorative landscape for the site, 
time did not permit the design or even the locating of all unique 
spaces. It is assumed that the landscape should become filled 
(incrementally) over time with a variety of unique spaces that feature 
comfortable seating, access to water, views to nature, and the 
potential for interaction with other humans or with habitat. For 
example, pathways in the Douglas Fir Woodlot feature a variety of rest 
stops that could become the focus of a local design competition to 
create benches and water features. 

18. In terms of the very important water feature, the plan has laid out 
a main waterfall at the base of the southern cafe, a lined pool and two 
marshlands (one only accessible by humans, the other for habitat and 
maintenance stewards only). Several smaller, accessible water features 
should become a standard part of all small places. This is detailed in 
some of the unique features (e.g. Cancer Clinic Garden) detailed. 

19. The plan of the built form also features several "indentations' that 
create visitor/patient spaces. While it is not detailed, the entire 
perimeter of the ground floor should be fitted with movable overhead 
shelters to enable patients to easily make their way out side in 
chairs, by foot, or even if pushed in bed. 

- 114 -



Figure 9-3 (this page): Examples of varied water features. Preferred for 
greater restorative benefits are any features with moving, splashing, spraying 
water due to the effect of negative ions (Parsons, 2000). 

115 



9.2 Follow-up Research Encouraged. 

As has been mentioned, several assumptions were made during this project. 
Given the author's experience in the field of health care, these 
assumptions were possible. For the designer not equipped with twenty 
years experience beside health care providers, dealing with death and 
illness, and facing on a regular basis the stress from all users of a 
hospital environment, these assumptions would be impossible. 
Unfortunately, the research done for this project revealed very little in 
the way of evidence-based testing of preferences (in particular, of staff 
and visitors) . Research was rare in terms of specific needs for all 
groups in terms of needs or wants in the way of amenities, activities, 
programs, garden styles. 

The natural, woodland garden style was utilized in several of the 
interventions done for this project. This was done as a result of 
regional and local site analysis, site conditions, and known local 
preferences. It was also done as a means of attracting habitat in order 
to enhance the 'living' aspect of the landscape. This planting style, 
however, was entirely possible because of the location of the proposed 
site. Would this style of garden be as restorative in a region known for 
its arid conditions and sparse growing conditions? Would the cost of 
irrigation be worth the benefits, or in this case would regional 
preferences win out? Research across cultures and across regions would be 
helpful. 

Figure 9-4: Image of 'Mountain Stream' BEDSCAPES ™. Developed with the 
assistance of Dr. Roger Ulrich, these "scenic curtains" are designed to 
envelop the patient in a stress-reducing atmosphere within the confines of 
the hospital. 

- 116 -



Specific testing of needs of staff members in the hospital setting would 
also be extremely helpful. As a Certified Emergency Nurse, the author has 
enough access to those staff members to be able to do impromptu 
questioning of preferences and needs but no document was found in the 
research to quantify any of these anecdotal findings. 

In terms of patients, specific populations are rarely referred to in the 
literature. Patients are generally spoken of as a single entity 
experiencing a single form of stress. Researchers of stress and its 
detrimental effects, however, would surely differentiate between the short 
bursts of anxiety experienced pre-diagnositics versus the long-term weight 
of dealing with a terminal diagnosis. The needs for unique spaces, for 
views, for facilities, for choices, and for comfort will differ greatly 
across the wellness-illness continuum. Specific research for designers in 
this area would be helpful. 

Figure 9-5: Beth Israel Cardiac 
Catheterization Study, 1999. 
Patients awaiting cardiac catheter 
procedures (angioplasties, 
angiograms, stent implantations, 
etc.) are routinely brought into 
the diagnostic room several minutes 
prior to the actual test for 
preparations, last minute 
screening, research trials, etc. 
Strong sedatives/analgesics are 
generally used to keep the patient 
awake but calm (Diazepam, Fentanyl, 
Versed). This randomized trial 
showed a dramatic reduction in 
stress with exposure to the 
"natural scenes" combined with 
"natural sounds". 

One has to query the results of a 
study, however, when the first 
investigator listed is also 
associated with the product. This 
would be an intriguing study to 
conduct at random cardiac units 
across North America. 

Questions arise as to "How much nature is enough?" Roger Ulrich has shown 
benefits in patients who are exposed simply to curtains imprinted with 
natural imagery. A Cardiac Catheterization study done in 1999 at Beth 
Israel, NYC, showed dramatic stress reduction in patients exposed to 
natural scenes with natural sounds while awaiting catherization (Horowitz 
and Ulrich, 1999). 

However, Ulrich does agree with Lewis (1996) that, as participation 
increases so too do the benefits. Is a small, green roof top garden 
sufficient to give the restorative benefits required? And, if so, for what 
segment of the patient, visitor, staff population is this enough? 

Or is it necessary or even desirable to provide all users with access to 
large open spaces in which to wander or wheel or gaze? 

- 117 -



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http://92
http://0.html


Appendix I: Principles of Universal Design 

In order to achieve accessibility of built forms and open spaces, the 
following guidelines should be applied to design and programming. 

1. Aim for Equitable Use: 

• Design is useful and marketable to people with diverse abilities. 

• Provide the same means of use for all users: identical whenever 
possible/equivalent when not. 

• Avoid segregating or stigmatizing any users. 

• Provisions for privacy, security, and safety should be equally 
available to all users. 

• Make the design appealing to all users. 

2. Aim for Flexibility in Use: 

• Design accommodates a wide range of individual preferences and 
abilities. 

• Provide choice and options for use. 
• Facilitate the user's accuracy and precision. 
• Provide adaptability to the user's pace. 

3. Aim for Legibility of Essential Information: 
• Use of the design is easy to understand, regardless of user's 

experience, knowledge, cultural background, language skills, or 
concentration level but not condescending. 

• Eliminate unnecessary complexity. 
• Simple signage and wayfinding. 
• Accommodate a wide range of literacy and language skills. 
• Arrange information consistent with its importance (hierarchy of 

information). 

4. Aim for Awareness of diverse interpretations: 

• Use different modes (pictorial, verbal, tactile) for redundant 
presentation of essential information. 

• Provide adequate contrast between essential information and its 
surroundings. 

• Provide compatibility with a variety of techniques or devices 
used by people with sensory limitations (eg. Signage for sight-
impaired) . 

5. Aim for Tolerance for Error: 

• Design should minimize hazards and the adverse consequences of 
accidental or unintended actions. 

• Arrange elements to minimize hazards and errors: Frequently used 
elements easily accessible and visible. 

• Provide choices and options to prevent users entering into 
situations beyond their abilities. 

• Provide warnings of hazards and errors. 

6. Aim for Low Physical Effort Always an Option: 

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• Design can be used efficiently and comfortably and with a minimum 
of fatigue, yet opportunities for challenge are available. 

• Allow user to maintain a neutral body position. 

• Use reasonable operating forces. 

• Minimize repetitive actions. 

• Minimize sustained physical effort. 

7. Size and Space for Approach and Use: 

• Appropriate size and space is provided for approach, reach, 
manipulation, and use regardless of user's body size, posture, or 
mobility. 

• Provide a clear line of sight to important elements for any 
seated /standing user. 

• Make reach to all components comfortable for any seated/standing 
user. 

• Accommodate variations in hand and grip size. 
• Provide adequate space for the use of assistance devices or 

personal assistance. 

Modifed from: 

Center for Universal Design. 1997, The Principles of Universal Design, 
developed for North Carolina State University (Online), Available: 
http://www.design.ncsu.edu:8120/cud/univ design/princ overview.htm (2001, 
November). 

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http://www.design.ncsu.edu:8120/cud/univ


Appendix II: Principles of CPTED 
(Crime Prevention through Environmental Design) 

CPTED ((Crime Prevention through Environmental Design) contends that by 
designing the physical environment in a manner that positively influences 
human behaviour, it is possible to create a climate of safety in a 
community. Perhaps as significant as the reduction in crime, is the 
heightened feeling of security sensed by the legitimate users of the 
space. As a 24-hour facility, the hospital requires a design strategy 
that, without abandoning aesthetics, allows for safe passage by staff and 
visitors to and from cars/buses/buildings/programs at every hour of the 
night. The principles of CPTED contend that, while there are occasions in 
which locked gates and fences become necessary, much can be done to 
heighten safety and security through manipulation of the external 
environment and its components. 

CPTED was developed in the 1960's for use by architects, city planners, 
landscape architects, interior designers, and law enforcement personnel. 

The principles of CPTED hinge on the following five key strategies: 
Territoriality, Natural Surveillance, Activity Support, Access 
Control/Target Hardening, and Image/Maintenance. 

1. Territoriality. 

People protect territory that they feel is their own and have a certain 
respect for the territory of others. 

Ownership is expressed through good upkeep, and care and attention to 
environment: fences, artwork, paving, signage, planting, and gateways. 
Applying a hierarchy of space identifies ownership by delineating private 
space from public space through real or symbolic boundaries. 

2. Natural Surveillance. 

Criminals don't want to be seen. 

Visual access around buildings, along pathways and in outdoor spaces is 
maximized to discourage intruders. Elements to be considered: 

• Building orientation (to face open space), 

• Windows (placement, height), 
• Entrances & exits (indoor-outdoor relationships), 
• Parking lots (isolation versus clustering) , 

• Walkways (lighting, designated, redundancy of loops), 
• Landscape planting (open versus closed, pruning of shrubs to 

maintain visibility), 
• Fences and walls (permeability, escape routes), 
• Signage (to discourage and/or encourage use as required). 

Landscaping in sensitive areas adheres to the "groundcover-canopy" 
strategy. In the hospital environment, eye level must be considered from a 
wheelchair position. 

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The addition of programs, activities, or persons in plain view further 
discourages unwanted behaviour (for example, parking lot attendants and 
reception clerks). Lighting of sensitive areas will further enhance 
natural surveillance. 

3. Activity support. 

Encouraging positive activity in public spaces helps discourage crime. 
This has the added benefit of providing restorative benefits if patients 
are in visual access of these activities (Ulrich 1992). 

Programs designed to bring community members together for legitimate 
activities increases natural surveillance as well as feelings of 
ownership, thus preventing crime. Providing amenities that support 
community events furthers this strategy. 

4. Natural Access control/Target Hardening. 

Interventions may be required to enforce restrictions on use/access. 

Natural Access control is aimed at preventing users from entering into 
unsafe situations through the use of sidewalks, paving, lighting, signage 
and/or landscaping to clearly guide the public to and from entrances and 
exits. The use of fences, signage and/or or landscaping to prevent and/or 
discourage public access to or from dark and/or unmonitored areas may also 
be required. Target hardening, necessary in higher risk areas, uses 
physical barriers, security devices and tamper-resistant materials to 
restrict entrance. It is expected that areas of a health care facility 
will require this more definite form of crime prevention in addition to 
the more general environmental manipulations. In particular, placement of 
emergency call boxes and security personnel posted at parking 
lots/walkways for shift changes. 

5. Image/Maintenance Considerations. 

A maintained place is a watched place. 

Ensuring that a building or open space is clean, well maintained, and 
graffiti-free facilitates the CPTED principles of natural surveillance, 
natural access control and territorial reinforcement. 

Recommended CPTED References: 

National Crime Prevention Council. 2002 (Online), Available: 
http://www.ncpc.org/2add4dc.htm (2002, January). 

CPTED Home Page. 2001 (Online), Available: http://www.opted.com.au/ 
(2001, December). 

Royal Canadian Mounted Police. 2002, 'Creating Safer Communities 
Website' (Online), Available: http://www.rcmp-ccaps.com/cpted.htm 
(2002, January). 

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http://www.ncpc.org/2add4dc.htm
http://www.opted.com.au/
http://www.rcmp-ccaps.com/cpted.htm