NAOMI SACHS: Thank you, Mardelle. 

[APPLAUSE] 

And thank you all for coming and being here the day before break, you stalwart students. I'm just curious, how many of you are focused on health care? OK. And how many of you are on the hospitality side? OK. 

And what about, what have I missed? Anyone else? Sociology, physics? No? OK. So it's really either kind of either or, or both. 

And I'm so excited to be speaking for this class, because I think it's a really excellent idea to be having the two different sectors talk about how they intersect. And so I'm going to talk about how landscape can intersect with hospitality and with health care. 

And Brooke and I were having a conversation over breakfast about hospitality and how this is something that hotels and casinos and businesses have known for a long time. That it's good to have plants and it's good to have beautiful gardens. And that makes people feel good and probably makes them stay longer and spend more money. 

Health care, hmm, not so much. And in general, this whole thing with the patient experience, that's really-- health care has been very slow to catch on. And I'm sure you've been talking a lot about that in general. So it's an exciting time to be talking about landscapes and access to nature. 

This is what many people think of when they think about hospitals. And I'm going to probably use the term "hospitals" for health care and "hotels" for hospitality, even though, of course, hospitality covers a lot more than just hotels and spas. And there's all sorts of-- you can tell me all the different things that are incorporated in hospitality. And health care, hospitals, of course, there are senior living facilities and hospices and pediatric facilities and mental and behavioral health. That's all sort of "hospital" is like the coverall for me. It's just kind of what I default to. 

But hospital. This is an emergency department. I'm not going to name which hospital it is. But you know, they're kind of creepy places. And they're places that most of us don't want to go to. Can you think of a reason why someone might want to go to a hospital, little more happy occasion? Yeah. 

AUDIENCE: If they're gonna have a baby. 

NAOMI SACHS: Yes. If you're going to have a baby and you don't want to have it at home, that's a happy thing. It's still probably pretty nerve wracking and they've gotten better about it. But yeah, what else? Yeah? 

AUDIENCE: Possibly because you have a chronic disease and there is a procedure that is supposed to fix you. You could be excited to go to a hospital then. 

NAOMI SACHS: Right, right. If they're going to fix you if you've got a chronic disease or need knee replacement, for example, you know, you might be pretty excited actually at the possibility of feeling better afterwards, right. So there are some times when it's a happy occasion, but for the most part, people try to avoid hospitals. 

If you know anything about health care, you know that they're actually pretty dangerous places in terms of hospital acquired infections. And you know, even just going to the doctor's office, right. There's sick people there and you're worried about-- I mean, we have that here at Cornell too. Flu is going around. 

So that's how I got interested in this topic. I sort of, as Mardelle was saying, within our field, there's only so much that we can do. I knew I didn't want to be a doctor or a nurse or a social worker, but I wanted to try to make some sort of difference and still do landscape architecture and be creative. And so I heard about this thing called healing gardens. And I thought oh, well that could be a way to kind of merge these two passions. 

Because hospitals can look more like this. And they can be places of respite and have natural light and beautiful gardens outside and places where people can at least feel less stressed about whatever stressful situation is going on. And when I talk about people, I'm definitely talking about patients or residents if it's mental and behavioral health facility or a senior living facility. 

But also the visitors, the family members, the loved ones, and the staff. The staff are there often with 12 hour shifts, sometimes back to back. And they're there every single day. And so as you've probably discussed, making a place where staff are happy and comfortable and safe makes great business sense and good humane sense at the same time. 

So "healing gardens" is another catchall term. Restorative landscapes, landscapes for health, it's this idea that nature promotes human health and well-being. And there's been a lot of great research about stressed populations and that nature is good for everyone. But the more stressed someone tends to be, kind of the higher the return on investment, the more that nature and exposure to nature has a benefit for that person. 

So how many of you have heard of Roger Ulrich? OK, not too many. Oh, that's exciting. So I get to tell you about this groundbreaking research, which was way back probably before some of you were born, 1984. 

And it was the "View Through a Window" Study. Where this geography student-- right? Was he environmental psychology or geography? He was really interested in aesthetics and nature. 

And he decided to either study patients in hospitals or prison population, because those were the two most stressed types of groups that he could think of. And he found a natural experiment where he actually didn't do this experiment in real time. He looked at medical records of patients that had a room-- they were gallbladder patients recovering from surgery. Which at that time in 1984, you were there for up to a week or actually longer than a week. Here you know, now it would be like a day. 

So some of the patients had a view of a brick wall and some had a view of just a few trees and some grass. Nothing elaborate, but still enough of a difference. And he looked at medical records to see how much pain medication the patients got, whether they were good patients, so how much they complained to the staff, and how soon they got out of the hospital. 

And lo and behold, found that those with the view of nature were indeed better patients. They complained less to the staff. They needed less pain medication. And most important, they got out of the hospital sooner. So do any of these have any effect on a business case on the bottom line for a health care organization? Do all of them? Yeah. 

And so this study was so important because first of all, it was the gold standard, right. Well yeah, I mean it was a randomized trial. So it was empirical research, it wasn't just qualitative of people saying, I really like gardens. They're really nice. Nature is nice. And it showed a positive return on investment for all of these different factors. So finally, the health care community, the medical community, and the design community said oh, maybe this is something that we should start paying attention to. 

And since then, we've had lots and lots and lots-- oops. Don't gesture too much. Lots and lots of great research about the benefits of nature in health care and also with lots of other populations, including the elderly and children and college students. And looking at biomarkers like salivary cortisol and heart rate and blood pressure and even MRIs and seeing what the brain is doing, and also self-reports like cognition and creativity. 

So with all of these different mental and physical markers, there are great examples of how nature and contact with nature both passive and active are beneficial for health and well-being. And when I say "passive" and "active," "active" I mean like gardening. Getting your hands dirty and working in the dirt and growing carrots or farming, that sort of thing. And "passive" would be just enjoying nature or taking a walk in the park. 

There's even some research that contact with nature, like even in a neighborhood green space, which is the research that Mardelle and I are doing, or just looking at pictures of nature, promotes altruism and promotes people being more connected with other people. So get a plant. Put it in your office or get a nature picture. 

And this, even with all of these decades of research, people still point back to the biophilia hypothesis. Which was first coined by Erich Fromm in I can't remember when. The 1950s, I think. But E.O. Wilson in his book Biophilia really took off. 

And it's this idea that we, as humans, are attracted to other life and living things. Which kind of makes sense, right? On a very intuitive level, we know that we need water to drink. And we need plants to eat and to give us shade. And we need air to survive. But also, there's often for people a spiritual connection in addition. 

And in terms of health care particularly, there are reasons why in surveys and interviews with people that the landscape and plants in particular are important in a health care setting. And one is that a garden is normal. It feels like life. And it's full of life if it's a real garden and not just one of those paved areas that look great in the glossy magazines, right. 

So it has life in it. It's life affirming. It shows the cycles of life. But it feels like real normal life rather than with all the beeping machines and the squeaking shoes on the floor, and you know, just antiseptic smells, and all of this alien stuff that we experience when we're inside of a health care facility. 

I was thinking about what in hotels, in hospitality, how many different areas that we have to experience pleasure. You know, there's the hotel room. There's also the restaurant and the spa and the pool and the gardens. There are a lot of places in a hotel where you can experience pleasure. What about in a hospital? Yeah. 

AUDIENCE: Potentially the gift shop. 

NAOMI SACHS: The gift shop, absolutely. 

AUDIENCE: Or if you're curious, you can probably just make your own pleasure by asking nurses about things. 

NAOMI SACHS: Yup. If you're curious. And some people. Yeah? 

AUDIENCE: I was going to mention like, if you're grabbing a coffee or something out front. But then you also have like nursing staff and other people in line with you. So it doesn't really bring you in, in that experience. 

NAOMI SACHS: Right, perhaps not as much of a sense of escape. But yeah, food. That's still, you know, coffee wakes you up. Some good food, maybe some cake that you wouldn't let yourself normally eat at home or pudding. Anything else? Sources of pleasure in the hospital? Yeah? 

AUDIENCE: When therapy dogs come in. 

NAOMI SACHS: Therapy dogs, right. So animal, that's wonderful. And there was actually the last time I was in the airport they had a therapy dog, probably to keep people from getting so mad in the airport. And gardens, right. 

So but in general in a hospital, many fewer sources of pleasure. And so the more that we can maximize those places where people can have relief from stress and pain, the better. 

Gardens and the landscape in health care in particular, just like in hospitality, they're really important sensory cues and clues. As soon as you drive into the parking lot or even before you drive over the property line, to be able to see trees and perhaps a beautiful building and know I'm going to be taken care of. This is a beautiful place. 

I can park in this parking lot in San Diego. It's really hot out, and there's lots of trees to shade my car. And then I'm going to get safely to the front of the building, which I can find my way to because there's great signage and the landscape is drawing me there anyway. And I know I'll be taken care of. 

So the first impression in health care is really important. And that's one of the ways, I think, that a lot of health organizations are starting to buy into this idea of landscape. If nothing else, it's a great way to make a first impression. 

Which is why-- I read some of your excellent questions. And I wish that we had time for me to answer all of them and for us to talk about them. But that's one reason why maintenance is so important, just like in a hotel. 

But you know, if you see a dead plant, which happened to me in a waiting room, you're like, is that the care that they're going to take for me? This plant died. What are they going to do with me or with my mom or my kid? 

So with the research on health care, there's been a lot of emphasis on stress. And part of that is that stress is much easier to measure than the opposite of stress. As I mentioned, there's heart rate and cortisol and self-reports of stress are pretty good, self-reports of happiness. And now we have MRIs, so that helps. But stress, in general, is easier to measure. 

It's also really bad for us, either primary, just stress in and of itself and the other physical problems that come from stress or that stress can exacerbate. And so there's a lot of research and a lot of money being thrown at how to reduce stress in all sorts of different environments, including at Cornell, where there's actually a Nature Rx program. I'm not sure, maybe some of you have gone to Cornell Health and have even been prescribed a nature prescription to go walk in the park or go sit by the water for a while. 

Some great research has been done more recently on stress and how it stimulates the immune system. So in health care especially, where a lot of people have depleted immune systems from stress and from being sick and having infections to have contact with nature, which is partly from the oils that are in some plants, you know, that are just kind of naturally given off by plants. You don't have to make tinctures out of them to get the benefits. And partly from that stress reduction, there's a stimulation of the immune system. And so as I mentioned, there is a benefit to patients and visitors and residents and also staff. 

So here you have two pictures. One is of a staff break room, kind of your traditional no windows. It's just stuck in a corner because it's just the staff, who cares. And then this is a staff garden at Legacy Health in Portland, Oregon, where staff can meet together, they can have lunch, and be outside for a breath of fresh air. 

And then as we've talked about a little bit already, the health care organization should also see these benefits to their own health, their own financial health. So yes, there's enhanced patient health and also satisfaction, right, the patient experience, the visitor experience. And there are some really good research about increase in satisfaction with waiting rooms and the entry and patient rooms. 

Enhanced safety. So there was, for example, one study that found that nurses who had a view of nature and some daylight were more attentive and had less stress than those who had no view at all. So you know, that comes down to medical errors and other areas where it's really important for staff safety. 

And then of course, marketing and PR. We care about the world. We care about the landscape. We care about you. 

Fundraising, gardens are actually really easy to fundraise for, because they're touchy-feely. If you're trying to raise money for an MRI machine or infection control, it's more difficult. But everyone wants to give money for a garden that's going to help people. The harder thing is fundraising for the maintenance and keeping that ongoing. And then yeah, so the triple bottom line is affected and is especially important for landscapes for health. 

And this is something that health care used to really implement a lot more. Florence Nightingale, in her research, thought and found that fresh air and daylight and beautiful colors were very important for the healing process for her patients. Cloister gardens, which were then turned into the cloisters were also health facilities, they were filled with medicinal plants. 

Of course, you know, they didn't have antibiotics. So you could look at it and say, well that's all they had was medicinal plants. But still, long after they are still using medicinal plants, they smell good, they taste good. And they have various ways of healing us. 

And then even for mental and behavioral health facilities, which were called asylums or insane asylums, whatever they were called, especially kind of at the turn of the last century, the late 1800s, early 1900s, patients gardening and doing exercise and going outdoors and having picnics and farming, that was a very important part of the treatment program. And then slowly, that has changed. This is a picture of a sanitarium where patients were wheeled outside for some sunlight for a certain amount of time every day. 

What we have-- and Brooke and I were also talking about this. The doctors being the ones who you pay attention to. And the doctor kind of-- everything is focused around the doctor and what he, probably back in those days, or she wants. 

This is Mount Sinai Medical Center. At least on this face, no windows at all, and there are a few. But with the rise of medicine and HVAC where you couldn't control the environment or you didn't want to have anything from outside so that you could control the indoor environment, and keeping germs outside and inside, unfortunately, we have this pathogenic approach to medicine and health care. Where you were only addressing what was broken and the disease, and not necessarily thinking about what was good for people's overall health. And so pathogenic design is the same thing. It's really just what does this facility need in order to get people well and get them out as soon as possible and where the doctors can be the most efficient. 

And now we're starting to look at salutogenic design, so the opposite of pathogenic designs. "Salus" coming from "health." And "genesis" coming from "origin." So salutogenic is-- and this is your cocktail party word of the day-- design for health. 

And you can see that in hospitals. You can see that at Cornell with for example, buildings that have stairs front and center so that you're encouraged to take the stairs rather than find the elevator and take that. Or walk up the hill rather than taking the bus or driving. So there are a lot of ways to encourage people to be healthier. And one of those is by providing gardens and access to nature and light and fresh air. 

And so health care has come along pretty well. But again, back to that idea of pleasure. Now I'm not sure whether it's appropriate even for a health care facility to be talking about pleasure, but if we're already talking about the patient experience, the family experience, the community experience, well, why not talk about those places in a hospital where people could potentially experience pleasure? Where they could find beauty, where they could experience awe and a sense of inspiration. 

And if you hear stories from people who've wandered around in hospital gardens, you hear that. You know, just gazing upon a flower or looking at the fish in the koi pond, or feeling the sun on my face after waiting in the waiting room for five hours while my husband gets dialysis. It's really powerful. And again, when someone is in that stressful environment, it's even more powerful than just if it's always around you and just going outside is not quite as important a thing. 

Paradise, you know, what do we think of when we think of paradise? It's a lot easier to go to a hotel in Florida and think about paradise or Hawaii than it is to think about paradise except for perhaps the hereafter, with hospitals. 

And fun, right. When I think of hospitals, I don't think about fun. But why not? Why can't I take my well-child to a garden and a playground in a hospital while my sick child is getting chemotherapy? Or while my husband is getting a treatment? Or while we're both waiting for our appointment and we have a little buzzer on us so that we can wait outside and play in the garden and on the turtles while this other stressful stuff is happening. 

Or as a staff member, maybe I want to take a walk at the end of the day or the beginning of the day to get some fresh air, to move around, recalibrate, walk with a friend or by myself. Or just lie on a bench and chill for five minutes or 10 minutes. Put my feet up and forget about what's going on in the stressful OR or PT room or wherever else. 

This is a garden that was initiated by a physical therapist. This is the PT room that looks out over this beautiful garden. So PT is very painful and stressful for people. And so if they can have this garden and think in a day I'm going to get so much better that I'm going to be able to go out there and walk on the path, that's pretty powerful. 

Chemotherapy, why not be able to look out on a beautiful view of nature and have the people who are helping me with my chemo also be able to do that all day long rather than sitting in a windowless room and just thinking about, oh my god, what's going on with my life. 

So some of you may have seen this article. It was from a few years ago. "Is this a hospital or a hotel?" And we are in this age, which I think is a positive thing, where health care facilities are trying to be more hospitality oriented. 

And there was actually this whole article about it. And you'll see on the second paragraph, "in the $63 million community hospitals, patients all enjoy private rooms with couches, flat screen TVs, and views in nature." Yay! I was so happy when I saw that. That's an example of a great hospitality-like facility. 

And then they have this quiz that you can take. Is it a hotel or is it a hospital? I think this one's a hospital. And I actually took it clicking hospital every time, because I thought maybe they're just tricking and they're saying no actually, they're all hospitals. But some were hotels and some were hospitals. 

But there are key differences. And so that's where the strange bedfellows comes in. We can't just treat hospitals like hospitality, like hotels. There are some key differences. What might some of those be? Yeah? 

AUDIENCE: The degree to which you can move around the space. 

NAOMI SACHS: Right. The degree to which you can move around in this space. So yeah, if you're really sick or you just had surgery and you've got your hospital gown with your butt hanging out the back, because they still haven't figured out some good fashion sense around that, that's one limitation. What else? Yes? 

AUDIENCE: The amount of stuff you need store-- I guess it's a different type of stuff that you need to store in hospital versus a hotel. 

NAOMI SACHS: Yeah right, storage. Whether it's storage for the patient and also of course, all the medical supplies they have to think about. Yeah? 

AUDIENCE: Staying in a room at a hospital where you don't have a choice of which hospital you go to, and therefore the room, right. In terms of going to a hotel, you can usually pick your chain scale and choose a price. 

NAOMI SACHS: Yeah, yeah. Or even, I've gone to hotels and one room looks out over a roof with asphalt. And I've said, can you put me on the other side where there's a view of the lake. Yeah, no problem. It's the same price point. 

So yeah. Mostly people who go to hospitals, they don't choose to be here unless they're having a baby or having surgery that they elected. But a lot of times people, they don't choose to be there. They may not have a choice of the hospital, although that's getting a little better, and they're stripped of a lot of choices once they get there. So what are you going to have for food? Although that's getting better. What are you going to eat? What's your schedule like? How many doctors are going to poke and prod you throughout the day? So the more opportunities that we can give for choice and control the better. 

So yeah, it's still a hospital. And so the goals are still first and foremost to help people heal, to help people be healthy, be the most well that they can be. Or be in the least amount of pain that they can be, to keep people safe and to make people comfortable. 

And of course, with hospitality this is all really important too. You want to have people feel safe. You want to have people feel very comfortable and have them come back again and again. You know, cleaning is still really important. There are lots of sick people who go through hotels too. But in health care, of course as I mentioned, like the immune system is so depleted, that having that cleanliness is critical. 

And so designers and organizations that are thinking about health care really have to take this sort of Hippocratic designer's oath of to do no harm. And here, you know, this lovely path you might have at some sort of Canyon Ranch spa, but that would not work in a hospital setting. A poisonous plant might be fine somewhere in a hotel, probably not good in a behavioral health facility or a pediatric hospital. And water features, we'll talk about those in a second. 

So this is a garden for a burn center in Portland, Oregon. And it was created using evidence-based design. So the color of the paving so that it's not a glare in people's eyes. A lot of shade, these are burn patients who are recovering. There's a water feature to give people that cooling sense of water. There are different surfaces. So this was designed with physical therapists, occupational therapists, horticultural therapists to really get the most out of the garden as a therapeutic space in addition to a space that people can just go and hang out after a stressful day. 

This again is that pediatric facility. And there is space, there's paving wide enough for wheelchairs. And the cracks in the grout are small enough that even an IV pole can run across without it tipping over. So evidence-based design is really, really important with health care. 

Another thing that's really important is buy in. And unfortunately, the CEO of this hospital left and the new one who came in didn't think that gardens were really that important, and this garden has gone downhill a lot, unfortunately, since then. I haven't seen pictures lately, but that's what I've heard. 

So back to this picture. What's another issue that we might have to worry about in health care facilities? Yeah? 

AUDIENCE: So like you said, hospitals tend to be somewhat unclean places, where that term you used where, hospital gained infections-- 

NAOMI SACHS: Right, Hospital-Acquired Infections, HAIs. 

AUDIENCE: So the thing about hotels that it can oftentimes facilitate a social atmosphere such as in the lobby or in bar. 

NAOMI SACHS: Hmm. 

AUDIENCE: In a hospital, the HVAC systems need to by able to adequately do air circulation. 

NAOMI SACHS: Yep. 

AUDIENCE: You need to clean off all the materials. So there's limitations in how open these spaces can be. 

NAOMI SACHS: That's true. How open they can be. And also, it's just really important to keep them clean, and including water. 

So I was actually surprised that this is a hospital with an indoor water feature. There are lots of examples of those, but infection control people, as soon as you mention a water feature, especially indoors, they go oh, oh, no. And then you have to do a lot of convincing. And the most important thing is maintenance. So keeping-- you know, designing something so it can be kept clean and then testing it and keeping it clean. 

Does anyone know what these two images have in common? Aside from they're both sort of vertical. OK, so this is let's see, the Bellevue-Stratford Hotel, which in 1976 was the home to the American Legion Conference in Philadelphia in 1976. 

Over 100 people got sick. 29 people died. And a year later they realized, they figured out that it was this new bacterium that was a waterborne bacterium that had infected people and caused a very severe kind of pneumonia, which is now known as Legionnaires' disease after that conference. So there's your health care-hospitality connection. 

But that's a really big deal. In everywhere, including hotels, and it's really important, but especially in places like hospitals where people's immune systems are-- where they're immunocompromised, that's another good cocktail party word. And you really have to be careful that any sort of water feature is safe. And people love water. So that's like people always ask for a water feature. And that is a wonderful place for people to gather around. 

So I've been to many, many health care facilities. And I always take pictures of the fountains. And this is both at Yale New Haven Hospital and the Smilow Cancer Hospital. So you know, there are great examples. And it's just a matter of being careful and maintenance. But this is something to think about and where it's a little bit different with hospitality than with health care. 

So if you want information about the research behind all of this and biophilia and some of these issues that I talked about, design guidelines, that's in the books that I wrote with Clare Cooper-Marcus, who's one of my mentors. And I think there are some copies in the library. 

Some of you have asked, we won't get to get to all the questions, but there are chapters in the book on different types of facilities. So cancer care, pediatric, dementia care facilities, frail elderly, general acute care hospitals. And we talk about there's a chapter on the business case as well. So that might be useful for people. 

And then this is the URL for the therapeutic landscapes network. It's healinglandscapes.org. And I encourage you, as Mardelle said, even if you just need to look at some pretty pictures and take a little breather, you can do that. 

And I think that's it. So and there's my email. Feel free to email me and ask me questions. Or we can meet and have a cup of coffee or tea maybe outside in the garden one of these days. Thanks very much. 

[APPLAUSE] 

AUDIENCE: OK, I'm going to throw out a couple questions first of all for you if you're ready. So this first one is from [INAUDIBLE]. Is that correct? 

AUDIENCE: Nay. 

AUDIENCE: Nay, thank you very much. So in "Landscapes for Health" you discuss the importance of creating a landscape that sustain and nurture people and the environment, but is it cost effective. In your opinion, how would you design a landscape to produce sustainability while keeping a positive [INAUDIBLE]? 

NAOMI SACHS: That's a really good question. So is it cost effective is always the big question, right. I mean, hospitals are businesses. Even if they're nonprofits, they're still businesses. They still have to watch the bottom line. And that's why so often the garden doesn't end up happening. Because it's seen as icing on the cake. You know, it's nice. 

And of course, of course, we're going to have one. And then as the budget starts getting whittled away, it gets value engineered out. Or we get some paving and one pot and one stone slab that's supposed to be the bench and that's it. So that's why the research is so important. Because that can really start to help you make the business case. 

And that's why we need you, too. Because many of you have minds for business. I don't. So that's why I'm in academe doing what I do. By connecting and putting a dollar value on things like social support and exercise and beauty and awe and experience, that's how we're going to be able to make things more cost effective or at least the reason for the cost and sustainability. 

I wrote a paper, it was on the intersection of sustainable and therapeutic landscapes, so sort of similar looking at the pros and cons and how they support each other and where they might diverge. But a lot of times, hospitals will start with-- there was one hospital in Warwick, Rhode Island where they were first tasked with making their facility more sustainable because they didn't have any-- they needed storm water credits. And so they needed to create rain gardens and other areas to catch the runoff. And someone said, well, why don't we also make healing gardens. And they did. 

And they created these beautiful outdoor spaces that also collected the rain water and rooftop gardens. So they were completely mutually supportive. And then they created their whole mission and branding around this idea of caring for the patient, caring for the community, caring for the Earth. 

AUDIENCE: So you touched on this briefly, but the question is about-- this is from Elizabeth, whatever. 

NAOMI SACHS: Elizabeth. 

AUDIENCE: Yes. So how does landscape design vary across specialized clients, schools, hospital facilities, [INAUDIBLE]? 

NAOMI SACHS: Yeah. There are general principles that would be for any population. And then when you start to look at specific populations like pediatric, you know, things need to be scaled to a different scale. Children love to climb on everything and put everything in their mouths. 

And if there's a water feature they are going to play with it and in it, unless you design it really carefully so they can't reach it. And they explore. And it's a great opportunity to enable children to explore with other children or with their parents or by themselves. And to really have what we call positive distraction in a stressful environment. 

And then for frail elderly, helping people feel safe and comfortable, providing more benches so that you know, if there's a long pathway, someone who's inside might not even go out if they see that there's not a bench until way over there, and I just want to go and sit. You know, here's the entrance. 

I want to be able to first of all get out the door, but the door is too heavy. It closes too fast. It smacks me on the butt when I try to get out. I'm worried. I can't get my walker over the threshold. This is all based on research of feedback from people. So even being able to get out the building is critical. 

And then once you're out, I just want a seat right here outside so I can breathe some fresh air, watch the world going by. Maybe if I'm feeling really good and it's a nice day I can go to this bench. And then I'll get the sun. Oh, OK. And I'll be able to talk to someone. 

So that's really important in environments where people are frail, afraid of going outside, or not sure on their feet. And there's lots of other examples of that. I don't know if I covered that enough. 

AUDIENCE: That's good. [INAUDIBLE]. 

NAOMI SACHS: Yes? 

AUDIENCE: Could you speak a little to how hospitals can be creative with small spaces? Just because [INAUDIBLE] 

NAOMI SACHS: Yeah. 

AUDIENCE: That folks in a supply [? chain company ?] who are struggling just to get space [INAUDIBLE]. If you're going to take this route, you know, [INAUDIBLE] how do you do that? Because if it's a small space, hey, it looks nice to me, but you're still going to be taking [INAUDIBLE]. 

NAOMI SACHS: Right, that's a great question. And actually Mardelle and I are working a little bit on a project in DC at Unity Health, which is a huge community health facility. And they have I think 25 facilities, small facilities in DC. And they're getting a grant from an organization where they're going to get some sort of nature space in two of their facilities. But one of them, there's no outdoor space except maybe the rooftop, although it would be quite expensive. And then you got to worry about how to get people there and how to make sure they don't jump off or fall off. 

And so we've been talking a lot about even indoors how to create this biophilic design. How to create experiences and exposure with nature and do it safely, but where people still get that sense of connection. And that can be done, and just like I mentioned about pictures, you know, just looking at pictures. 

And oh, one of you also asked a great question about technology and the intersection of technology and where I see that going. So technology is actually-- I have my pet peeves about people like being on their cell phones as they walk around a garden not really experiencing it. And I worry about technology taking over. And having VR, we don't need to go to the garden because we can just experience it here in my head. 

But if to use like the Care Channel, which is you should look it up. It's TV on a monitor, but they show moving nature images and sound and people can control the channels and the sound. So having videos, pictures, indoor plants. 

AUDIENCE: At Dell Children's Hospital, they have a wall that has butterflies projected on it. So as child, you can go up to it and try to catch a butterfly. 

NAOMI SACHS: Yeah. 

AUDIENCE: There was someplace else. So there are ways to integrate these things. 

NAOMI SACHS: So we're going to be looking into some of that. And then for facilities that don't have a lot of space, there are ways to do murals or to do a little pocket. You know, I've seen gardens that are this big that still are lush and beautiful. 

And when I did my dissertation, the survey for both patients and visitors and staff had about 15 different options to choose from why do you go to the garden and what do you do when you get there. And number one for both patients and visitors and staff was to get fresh air. And you know, we think about fresh air like also sort of metaphorically. Oh, I just needed a breath of fresh air. Or that person is a breath of fresh air. But just something that is life affirming and a mini escape from the health care facility. 

You had another question. 

AUDIENCE: Oh, he stole my question. 

NAOMI SACHS: Oh, OK. Great. Yeah? 

AUDIENCE: What do you with someone that's-- this is a very sort of specific question-- but people who are in quarantine or [INAUDIBLE] so they really can't be exposed to other people, can't leave their room for X number of days. What have you seen are some of the best practices for creating pleasure in that environment where they can't really go anywhere else [INAUDIBLE]? 

NAOMI SACHS: Yeah, that's a great question. And there are people who-- or in behavioral health facilities who aren't allowed to leave their room or their unit. And so there, of course, virtual nature is really important, whether it's the Care Channel or some other images. 

Having a view is important. So you know, and this is where your landscape architect is your friend. Because a lot of times landscape architects are brought in at the very end to shrub it up, you know, to put some parsley around the meat loaf. And that doesn't help when you've sited the building facing away from the beautiful mountain view or the stream. 

And so if you can work with the landscape architect and site the building so that especially people who are confined to their beds can easily, from their bed, preferably without having to turn and get a neck crick because the window is over there, look out the window and see all that beautiful life, either a borrowed view of the mountains or a garden that they can look at and perhaps anticipate I'm going to be able to go there pretty soon. That's a good question. 

AUDIENCE: Great. 

NAOMI SACHS: All right, so we got lots of questions that we didn't answer. Feel free to email me and I'll try to get to them. 

AUDIENCE: So great. Thank you, everybody. And thank Naomi again. 

NAOMI SACHS: Thank you. 

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