UH Mānoa MLA Capstone, Spring 2021 - Weber, Carol

THERAPEUTIC GARDEN DESIGN FOR VETERANS and THEIR HEALTHCARE PROVIDERS: Veterans Affairs Center for Aging, Honolulu, HI

by

Carol Diener Weber

THERAPEUTIC GARDEN DESIGN FOR VETERANS AND THEIR HEALTHCARE PROVIDERS: VA CENTER FOR AGING, HONOLULU, HI

A capstone design research project submitted in partial fulfillment of the Plan B requirements for the degree of MASTER OF LANDSCAPE ARCHITECTURE

May 2021

By Carol Diener Weber

Capstone committee: Judith Stilgenbauer, Chairperson Phoebe White Naomi Sachs

Keywords: Veterans, Therapeutic Gardens, Healing

ACKNOWLEDGMENTS MAHALO NUI LOA Judith Stilgenbauer Phoebe White Naomi Sachs Lyn Dubbs Kevin Weber This work is gratefully dedicated to all veterans

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CONTENTS ACKNOWLEDGMENTS LIST OF TABLES + FIGURES 1. INTRODUCTION + THESIS STATEMENT 2. BACKGROUND 3. PRECEDENTS + RESEARCH 4. SITE + SUBJECT 5. PROPOSAL 6. CONCLUSION 7. BIBLIOGRAPHY

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1. Introduction A. Unprecedented time This unusual time is unprecedented in the past century. During the ongoing 2020-21 COVID-19 pandemic, many of us have been cloistered indoors and find solace in escaping outside. The majority of us are working, attending school remotely and socially isolated. This odd routine is stressful. It is paramount that all have the opportunity to recharge with a refreshing break during the daily routine. However, first responders in healthcare settings are busy treating patients and the U.S. military continue their mission. They are among the groups of essential workers that cannot work remotely. These 24/7 career workers can easily suffer fatigue and stress in their demanding occupations. B. Unique qualifications I am a healthcare provider, a U.S. Navy veteran and in the process of becoming a landscape architect. I know how stressful it can be to deliver healthcare to a distressed patient. I personally found it energizing to have half an hour to myself to go outside for a run in the fresh air. Firsthand, I understand the life sacrifices which servicemembers undergo while serving in the military. It is difficult and basically impossible to explain the mental pressures of deployment. As a result of these experiences, I am very empathetic to patients, staff and family members regarding the burden of recovery/hospitalization, rehabilitation and the unique stressors as a healthcare provider. My interest continues to be strong in service to others and the community. What drew me to this capstone project was learning about therapeutic garden design in my coursework and the fact that I want to continue to make a positive difference, by contributing in a different way to veterans. Early in the research process, I spoke to a nurse at the Spark M. Matsunaga VA (U. S. Department of Veterans Affairs) Medical Center who was very excited about my topic. She explained that the VA has recently initiated a “Whole Health”1concept (Figure 1.1) and that a therapeutic garden would be welcomed. She further stated that the VA Center for Aging was in the most need of help in that regard. C. Site The VA Center for Aging is located within the 368 acreage of the Tripler Army Medical Center (TAMC) grounds in Honolulu, HI. This site is considered a component of the overall VA Pacific Islands Healthcare System (VAPIHCS) and thus affliated with the Spark M. Matsunaga VA Medical Center, which is located on the same campus. It has been operational since 1997. Additionally, important to note is that many of the VA staff are veterans themselves. This VA facility houses short and long-term rehabilitation veterans (considered a Community Living Center), hospice/memory care patients and, recently, a PRRP (post-traumatic stress disorder recovery rehabilitation program). The aim is to help each person regain their highest level of well-being prior to discharge. The building has 40 rooms and can expand to a 60 bed capacity. “Whole Health Study Shows the Success of Whole Health” https://www.va.gov/WHOLEHEALTH/features/Study_Shows the_Success_of_Whole_ Health.asp. June 8, 2020. Figure 1.1 Whole Health Initiative icon Accessed: January 15, 2021.

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D. Purpose In this timely capstone project, I intend to apply findings from precedents and literature review to the design of an outdoor therapeutic garden at the Veterans Affairs (VA) Center for Aging in Honolulu, Oʻahu, Hawaiʻi. The purpose is to aid in the healing rehabilitation of veteran patients and benefit their healthcare providers. The input of resident veterans, staff and healthcare providers will be considered in this design. Hawaiʻi is a unique tropical environment in which outdoor spaces can be utilized year-round. These optimal weather and growing conditions increase the opportunities to enjoy the lush outdoors. My goal is to create a restorative garden to contribute to residents’ and healthcare workers’ mental health and physical healing. I intend to incorporate native Hawaiian plants and those unique to the area. In addition, I will create a sense of place within the landscape to coincide with the island’s culture and history. The ultimate goal of this capstone project is to further the conversation so that therapeutic gardens may be integrated into larger policy initiatives and frameworks for overall healthcare of veterans. The legacy of landscape architecture has been to use design elements which can aid the healing process by increasing green space. 2. Background A. Green Space for Healing It is important that a landscape design be esthetically pleasing. However, it can also create a larger social impact by having a profound effect on physical and mental health, as well as the ecology of a site. One of the founders of the profession of landscape architecture, Frederick Law Olmsted, led a 19th-century campaign to provide public parks in the congested urban areas as a means of escape for the working lower class. The working class was exhausted after toiling very long hours with low wages and living in unsanitary conditions during the Industrial Revolution. By spending time in nature, people found that his landscapes created a sense of mental healing with the intention of lifting downtrodden spirits and providing equitable access. Years later we strive to continue the legacy of Olmsted, as landscape architects design therapeutic gardens as one way to provide healing for their users. B. Human Engagement with Nature There are many different thoughts and interpretations regarding what a therapeutic garden is. However, it is important to have a clear definition so as to have a common understanding, especially when there are many different users from multiple disciplines often involved: medical providers, patients with various needs and family members. According to the American Horticultural Therapy Association (AHTA), a therapeutic garden is “a plant dominated environment purposely designed to facilitate interaction with the healing elements of nature” (Hazen 2021).2 The association, in working with other groups, such as the American Society of Landscape Architects (ASLA), clarifies

https://www.ahta.org/assets/docs/therapeuticgardencharacteristics_ahtareprintpermission.pdf by Teresia Hazen, in Journal of Therapeutic Horticulture, volume 41, number 2, 2021.

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that a therapeutic garden must include scheduled activities, improved access and universal accessibility, have clearly delineated spaces, supply extensive plant interaction opportunities, provide safety and comfort and allow for a sense of familiarity. Numerous evidence-based studies associate fresh air and enjoyment of nature with human healing. Individuals will go for a walk, swim or bicycle to release tension and return recharged for the task at hand. It is well known that a landscape can be stimulating to one’s senses (sight, smell, sound, touch, and taste) and that the natural response is soothing. The following are the main theories which explain why humans engage with nature so positively. In 1973, “biophilia” was defined by Erich Fromm as the “passionate love of life and all that is alive” (as quoted in Marcus and Sachs 2014: 32).3 E.O. Wilson in 1993 stated the “biophilia theory” which describes “the innately emotional affiliation of human beings to other living organisms”.4 Humans have an innate ability to seek connections with life and nature. Wilson was a sociobiologist and studied the social behavior of all animals. ART or “Attention Restorative Theory” was described by Stephen and Rachel Kaplan. They developed this theory in the early 1990s when technology was rapidly advancing and people were spending less time outside. They found that directed, intense periods of concentration without any interruption or rest, could lead to mental fatigue. Kaplan and Kaplan detailed the following as important to restoration healing: a physical or psychological escape from routine activities, immersing oneself in a new or different environment yet not being uncomfortable, being involved without energy expended and be willing to appreciate the change on one’s own. To accommodate this in landscape design, the design must be organized or coherent, complex yet full of sensory mystery. It can be as simple as gazing at the ocean or staring out a window which gives the individual an opportunity to rest, relax, reflect and restore themselves.5 In 1999, Roger Ulrich developed the “Stress Reduction Theory” (SRT). It is based on numerous studies; many in hospital settings. The focus is on how natural environments can decrease physiological stress. He discovered that patients healed quicker, were happier with their healthcare providers and required less medication with window views of nature. His research concluded that being ill causes stress and that those caring for those who are sick are stressed. Ulrich found that in design, it is important to include elements which contribute to decreasing stress. These details emphasize that the user must have a sense of control with access to privacy, maintain close social support networks and that mild movement/exercise and natural distractions can help decrease stress levels. He found that even for someone inside a building; the view outside of greenscape (gardens, a park or trees) can alleviate tension.6 Marcus, Clare Cooper, and Naomi Sachs. Therapeutic Landscapes: An Evidence-Based Approach Gardens to Designing Healing Gardens and Restorative Outdoor Spaces, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, jhttp://ebookcentral.proquest.com/lib/uhm/detail. action?docID=1411617. Created from uhm on 2020-02-20 19:22:31. 4 Kellert, S., and E.O. Wilson.1993. The Biophilia Hypothesis. Washington, D.C: Island Press. 5 Kaplan, R., S. Kaplan and R.L. Ryan. 1998. With People in Mind. Washington, D.C: Island Press. 6 Ulrich, R.S. 1999. “Effects of Gardens on Health Outcomes: Theory and Research”. Pp.27-86 in Healing Gardens”: Therapeutic Benefits and Design Recommendations, edited by C. Cooper Marcus and M. Barnes. New York: John Wiley and Sons. 3

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Dr. Benjamin Rush, the father of American Psychiatry, was an advocate of the curative properties of a garden for those with mental illness. His 1812 book Medical Inquiries and Observations upon Diseases of the Mind revealed that those “digging in a garden” (as quoted in Detweiler et al. 2012:4)7 healed from their sickness versus those who did not do any gardening. It was after this, that hospitals began to consider landscaping with tree canopy and shaded walkways. Detweiler, et al. explained that there are many benefits from horticulture for elderly residents in rehabilitation.7 In his literature review, he summarized that gardening increases self esteem, improves attention and memory, creates relaxation, improves attention, social interaction and a sense of responsibility. He found it important to add design elements which are familiar to the elderly and reminiscent of their former home area. Paths should be designed so as not to have dead ends and to encourage exercise while easily leading back to the facility entrances. It is critical that the plants be edible or nontoxic and without pesticides since advanced dementia patients might ingest plants and soil. It was found that dementia patients with access to an outdoor area demonstrated agitation less often. There was found to be a decrease in the number of falls of dementia patients who use the garden. Overall, landscaped gardens have been found to improve the lives of elderly residents, by reducing chronic pain and decreasing medication use.7 More specific to the topic of this design research, there have been a number of small studies of veterans attending gardening activities with therapists 2009.8,9,10 These have demonstrated that gardening programs can help decrease stress levels, lower levels of depression, anxiety and hypervigilance by giving the veterans a sense of purpose, increased socialization and improved self-esteem. Gardening activities, as an adjunct to the therapy, helped these veterans transition into civilian life and develop tools to handle life situations.

Detweiler, Mark B et al. “What is the evidence to support the use of therapeutic gardens for the elderly?” Psychiatry Investigation vol 9, 2 (2012):100-10. doi: 10.4306/pi.2012.9.2.100.

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Kreski, Barbara. “Healing and Empowering Veterans in a Botanic Garden” Journal of Museum Education: Health and Wellness in Our Communities: The Impact of Museums, vol. 4, no. 2, Routledge, Apr. 2016, pp. 110-115, doi:10.1080/10598650.2016.1169734.

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Wise, Joanna. Digging for Victory: Horticultural Therapy with Veterans for Post-Traumatic Growth, Routledge, 2015. ProQuest Ebook Central. doi:10.4324/9780429473746. https://ebookcentral.proquest.com/lib/uhm/detail.action?docID=1978172

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Atkinson, Jacqueline. “An evaluation of the Gardening Leave project for ex-military personnel with PTSD and other combat related mental health problems.” Glasgow: the Pears Foundation (2009), pp.1-6.

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There is clinical evidence that horticultural programs and gardening for veterans can have positive effects. Studies have investigated the effects of plants and gardening activities on veterans. For example, one 2017 study looked at 15 student veterans and compared them to 15 in a control group. The authors found that after a six-week indoor plant care program, the former group of students were less depressed/stressed than those who did not have the opportunity to work in the greenhouse and indicated that they would continue to grow plants as a hobby. This is just one example of how stress and anxiety can be relieved by working with plants and that given an opportunity, it may become a hobby.11 Another pilot study involved 49 veterans in a Substance Abuse Residential Rehabilitation program, which compared a horticultural therapy group to a non-horticultural therapy. Decreased salivary cortisol levels (physiological indicators of stress) and decreased depression were noted in the horticultural therapy group.12 Another small study involved a horticultural therapy program with nine veterans at gardens on the agricultural campus at a large unnamed U.S. southeastern university.13 The program was entited “VEGGIE” or Veterans experiencing growth through garden intensive experiences. They found statistically significant results of lower depression and stress levels after completion of this 5-week program. A larger sample size and using a control group would increase validity of these results. Additional evidence of nature’s capacity for healing resulted from a very small study involving a cohort of eight veterans (six with PTSD) in a Danish military rehabilitation center.14 These veterans were involved in a 2-month nature-based therapy program in a forest therapy garden. Therapy sessions were for three hours three times each week. Veterans were interviewed during the process: initially, at 5 weeks, 10 weeks and one year. Gardening was available at a greenhouse, wooden cabin and cottage. Natureʻs calming effects were evident overtime which caused veterans to increase mindfulness. Initially veterans preferred solitude, refuge in sheltered areas but later sought out social interaction in the open. At one year, participants in the study stated that nature had

Kelley, Rosalie J., et al. “The Effects of Greenhouse Activities on Psychological Stress, Depression, and Anxiety Among University Students Who Served in the US Armed Forces.” Hortscience, vol. 52, no.12, Dec. 2017, pp. 1834–39. doi: 10.21273/HORTSCI12372-17.

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Detweiler, Mark, et al. “Horticultural Therapy: A Pilot Study on Modulating Cortisol Levels and Indices of Substance Craving, Posttraumatic Stress Disorder, Depression, and Quality of Life in Veterans.” Alternative Therapies in Health and Medicine, vol 21, no.4, Innovision Health Media, Inc., July 2015, pp. 36–41, http://search.proquest.com/doc.review/1696474522/ 12

Stowell, Derrick R, et al. “A Pilot Horticultural Therapy Program Serving Veterans with Mental Health Issues: Feasibility and Outcomes.” Complementary Therapies in Clinical Practice. Vol. 32, Elsevier Ltd, Aug. 2018, pp. 74–78. doi: 10.1016/j.ctcp.2018.05.007.

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Poulsen, Dorthe Varning, et al. “Everything just seems much more right in nature’: How veterans with post-traumatic stress disorder experience nature-based activities in a forest therapy garden”. Health Psychology Open, vol. 3, no. 1, SAGE Publications, Mar. 2016, pp. 1-14, doi: 10.1177/2055102916637090.

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become a significant part of their daily lives as a means of healing or if seeking a solution to an issue. This also was a very small study and would be more significant with a larger study population. At the VA Center for Aging, there is sparse vegetation and multiple opportunities available to introduce more diverse garden elements which provide opportunities for mental and physical healing through rehabilitation and direct engagement with nature. Among the staff and residents, there is an interest in gardening yet limited access for disabled patients. The intention is to incorporate gardening as one programmed activity at this site in order to achieve positive results similar to those summarized above. C. Population It is important to describe who is a U.S. veteran. The VA defines a “veteran” as a person who served in the active military, reserve and National Guard and was discharged or released under conditions other than dishonorable and may qualify for VA health care benefits. Veterans must have served for 24 continuous months unless they were discharged due to a disability early in the line of duty. A person without active duty time who was injured during training may still qualify as a veteran. There are eight priority group classifications which enables the VA to balance their resources with the demand for services.15 For successful landscape design, it is critical to know who the users of the landscape are and what their needs are. The population is aging and it is predicted that the number of those over 65 years of age will double by 2050 (to 17%). As people (veterans) age, it is imperative to consider that their mobility in the built environment changes. With aging, it is more difficult to orient oneself with diminished sensory, motor and cognitive skills. Landscape architects must design and build inclusively and for accessibility for all. It is essential to design to allow for a range of abilities so that people feel included, comfortable and able to participate. Many of the resident veterans at the VA Center for Aging are elderly, involved in short or long-term rehabilitation, and each in need of unique considerations. Rehabilitation can be lengthier as the veteran ages. (Bianchini, 2019)16. A portion of the general population has served in the military and some servicemembers suffer from post-traumatic stress disorder (PTSD). Depending on the conflict, it is estimated that 11-20% veterans suffer from PTSD. Mental illness affects national security by adversely impacting military readiness. PTSD-suffering personnel are unable to deploy. Their illness adversely affects work and family

U.S. Department of Veterans Affairs Office of Public and Intergovernmental Affairs “Federal Benefits for Veterans, Dependent and Survivors” Chapter 1 Health Care Benefits. Accessed March 17, 2021. https://www.va.gov/opa/publications/benefits_book/Chapter_1_Health_Care_Benefits.asp

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Bianchini, Jacquelyn, et al. “Aging”. THE DIRT, 20 Aug. 2019, Accessed March 16, 2021. https:// dirt.asla.org/category/aging/

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relationships.17 Mental illness may lead to alcohol and drug abuse. The victim may be more likely to lose workdays and/or be arrested. Personnel are often discharged from active-duty service prematurely. PTSD can be a main cause of suicide. Unfortunately, there is a social stigma associated with seeking treatment for mental health issues. Greater than 60% of veterans are aware of their symptoms yet do not seek treatment since they feel it could jeopardize their career. This lack of treatment can have detrimental effects on individuals and society as a whole.3 Medical intervention may consist of long-term medical interventions for veterans and family members suffering from psychological debilitating issues (e.g., PTSD). There is a large military presence in Hawaiʻi with 14 military installations located across the state. As of September 2020, there are 41,762 active-duty personnel and 9,593 National Guard/reservists on the Hawaiian Islands. 18 In addition, there are 60,000 family members associated with these military members.19 (Figure 1.2 on page 12) In the overall Pacific region, there are over 120,000 U.S. veterans. In the state of Hawaii, there are over 112,304 veterans; 10% of the state’s adults have served in the U.S. military (Housing Assistance Council, 2018).20 The greater number of veterans live on Oʻahu. In 2017, 8% of adult population veterans in the state lived on Oʻahu, 7% on Hawaiʻi island, 6% on Kauaʻi and less than 5% on other islands. Of these, 20% of these veterans have a service-connected disability (Figure 1.3 on page 13) D. VA healthcare system inundated Many VA hospitals are inundated with patients and cannot effectively care for the sheer number of them. DoD and VA (taxpayers) spend in excess of $3 billion dollars per year to treat PTSD. We are unsure of the specific treatment needed for healing of PTSD or other mental health illness. Not all treatment regimens are effective. The VA’s reputation over the past 2 decades has not been stellar and has been subject to bad press. It has been plagued with overworked employees, veterans with little mental healthcare access, long appointment waits, unnecessary deaths and overuse of opioid prescriptions. Recently, Congress required a change and demanded that the VA study a holistic approach to treatment of veterans. The Veterans Administration (VA) is now actively pursuing an initiative of “Whole Health” services.1 Refer to the illustration in Figure 1.4 on page 14 for a timeline of the Whole Health Initiative. Lehmann, Lauren P, et al. “Veterans in Substance Abuse Treatment Program Self-Initiate Box Gardening as a Stress Reducing Therapeutic Modality.” Complementary Therapies in Medicine, vol. 36, Elsevier Ltd, Feb. 2018, pp. 50–53, doi:10.1016/j.ctim.2017.10.013. 3 Ibid. 18 Number of Military and DoD Appropriated Fund (APF) Civilian Personnel Permanently Assigned by Duty Location and Service/Component Report_2009.xlsx. Accessed January 30, 2021 https://dwp. dmdc.osd.mil/dwp/api/download?fileName=DMDC_Website_Location_Report_2009.xls&groupName=milRegionCountry 19 “Duty in this Region, A Strategic Base in Paradise” Commander, Navy Installations Command. Accessed January 30, 2021. https://www.cnic.navy.mil/regions/cnrh/about/duty_in_this_region.html 20 The Housing Assistance Council “Veterans Data Central: Informing Strategies to Help Veterans”, 2018. Accessed January 30, 2021. http://veteransdata.info/states/215000/HAWAII.pdf 1 Ibid. 17

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A progess report demonstrates improvement in the lives of veterans who use Whole Health services. A three-year pilot study evaluated the effect of supplementation of the Whole Health approach to 18 VA flagship sites. The idea is that clinical care and complementary (holistic) care work together in a treatment plan. This method allows veterans to make use of all appropriate therapies and assist them in exploring what matters most in their health and well-being in order to live healthier lives. The report concludes that after three years, there has been success due to higher employee engagement and early indication of potential savings in pharmacy and outpatient care.21 Veterans with chronic pain who utilized this Whole Health concept had a threefold reduction in opioid use. The VA saw a 38% decrease in opioid use versus an 11% decrease among those without Whole Health use.21 Veterans using the Whole Health initiative reported being able to manage stress better and stated that the care they received was more “patient centered”. This medical management is more focused on empowerment of the patient, promotion of active partnership versus dependence on medical personnel. The focus is on non-drug therapy such as psychotherapy, mindfulness or meditation,any movement or exercise and/ or any manual use (acupuncture, massage, chiropractic). Healthcare providers involved with the Whole Health services reported lower burnout, more motivation, less turnover and were more likely to rate their facility as a “best place to work”. It is estimated that adopting this approach throughout all VA faciliites may take nearly one decade. The Whole Health concept creates more opportunity to design therapeutic gardens and landscapes for staff members and patients to enjoy. Outdoor opportunities are important to the theme of “whole health”. In other words, simply administering the physical or occupational therapy and the regimen of medication sometimes only cures part of the patientʻs issue. There is more to the overall problem and there is a need to address the whole health of patients with alternative, complementary methods. Landscape architects are an essential part of this movement for whole health. The illustration in Figure 1.5 on page 15 details how the Whole Health Initiative is a segway for Landscape Architecture. My intention is to contribute positively to the knowledge base of the landscape architecture profession and capitalize on the collaboration of healthcare partners to find methods in the design of outdoor spaces to improve overall health. Finally, it is imperative to be able to convince CEOs of hospitals and of those controlling the budgets of the need for therapeutic gardens to decrease stress, retain staff and improve patients’ healing. In this beautiful state of Hawaii, there can easily be more thoughtful designed therapeutic gardens.

Ibid. Bokhour, Barbara, et al. “Whole Health System of Care Evaluation- A Progress Report on Outcomes of the WHS Pilot at 18 Flagship Sites” 2020. Accessed 31 January 2021. https://www. va.gov/WHOLEHEALTH/docs/EPCCWholeHealthSystemofCareEvaluation-2020-02-18FINAL_508. pdf

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U. S. MILITARY PRESENCE IN WESTERN PACIFIC

SOUTH KOREA 25,374

JAPAN 35,598

HAWAIʻI PHILIPPINES 117

41,762 active-duty personnel 9,593 National Guard/reservists

GUAM 2,982

60,000 family members

SINGAPORE 122

14 military installations

DARWIN 200 (expected to grow to 2500)

TRIPLER ARMY MEDICAL CENTER* tertiary referral hospital

PINE GAP 129

* TAMC supports 264k local active duty, retired personnel, their families and veteran beneficiaries. Plus, referral of 171,000 military personnel, family members, veteran beneficiaries and forward deployed forces in > 40 countries throughout the Pacific region.

Figure 1.2 U.S. Military Presence in Western Pacific 12

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Service era of Hawaiʻi veterans:

VETERANS as % of adults on Hawaiʻi

(some serving in multiple eras)

5.5% WW II 8% 21% Korea Gulf War I

6%

28% Iraq & Afghanistan

8% > 5%

33% Vietnam

19% between conflicts

7% 20% have service connected disability HI veteran population = 112, 304 Hawaiʻi ranks #41 in U.S. in total veteran population VA Pacific Islands Health Care System responsible for >120,000 U.S. veterans in western Pacific

Figure 1.3 Veterans on Hawaiʻi

Spark M. Matsunaga VA Medical Center

The VA defines a “veteran” as a person who served in the active military, reserve and National Guard and was discharged or released under conditions other than dishonorable and may qualify for VA health care benefits. They must have served for 24 continuous months unless they were discharged due to a disability early in the line of duty. A person without active duty time who was injured during training may still qualify as a veteran.

Source: www.dataveteransdata.info 13

Figure 1.4 Timeline of VA Whole Health Initiative 14

Figure 1.5 VA Whole Health Initiative: A Segway for Landscape Architecture 15

Recent research has demonstrated that there is a positive correlation between therapeutic gardens, horticulture and restoration of mental and physical health as discussed (Atkinson, 2009, Detweiler, 2012, 2015. Wise, 2015, Poulsen, 2016, Kreski, 2016, Kelly et al. 2017, Stowell, 2018). Below, I will further discuss various design elements in nature-based therapy which have been found to be clinically effective for this unique population of veterans. These men and women have served our country and are in need of our support and the best rehabilitation to return them productively to the work force, their families and society. 3. Research A. Precedents The research focus of the subsequent precedent studies will be on those design elements that are beneficial in the design of a therapeutic garden for veterans as well as those in hospital settings/ hospice. While not all veterans at the Community Living Center may be suffering from PTSD, many of the design programs and elements are still applicable. The aim is to improve and activate the green space for all of the users at the project site: veterans, healthcare worker and visitors. The following precedents have particular design elements which will support and aid in the design of the therapeutic garden at my site. Warrior & Family Support Center (WFSC) Therapeutic Garden San Antonio, TX Designer: Quatrefoil, Inc. Portland, Oregon Principal (in charge): Brian E. Bainnson Year: 2008 Client: Wounded warriors and their families In 2015, The Warrior & Family Support Center Therapeutic Garden received an award as the “best therapeutic garden in the country” by the AHTA. Huffman served as project manager and general contractor. This project incorporates both passive and active therapeutic activities for small and large groups. Its scale is an expansive 20,000 sq ft garden (9 acres).3 The purpose is to extend the wounded warriors and their families time away from the hospital in a comfortable “living room”. There are many paths to explore different programs and encourage exercise. Plantings are very colorful, lots of greenery, with a rich variety in multilayers or tiers. The soothing sound of water features relaxes visitors and attracts wildlife. The design also provides areas of shade /canopy, an amphitheater, artificial turf and running track. The main design features include sequence, movement, balance, repetition and unity. The images on this page and the following page are from this precedent study.3 3

Ibid. 16

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Takeaways: • The lush vegetation is beautiful, provides privacy and solitude and a sense of immersion in nature, however, can be difficult for healthcare providers to visualize patients (safety and security concern). • Potted plants along stone columns help soften the building’s architecture. • There are many paths to explore and encourage exercise. However, this could be confusing to the elderly or memory care patient – perhaps too many paths and outdoor living rooms; needs to be more simplistic. • This was a collaborative design based on input of the patients’ medical needs and healthcare workers which is the intention of implementation in this design. • Many different textures of pavement help patient’s rehabilitation/gain equilibrium and stability in walking. Figure 3.1 Small rock waterfall • Good accessibility of raised planters at different heights with close proximity of planters for those who cannot walk far from building. • A pergola with a flowering vine gives the beautiful sense of entry into a special place. • Water features of fountain pots are visibly simple yet appealing, create easy access and are safe (no danger of patient falling in water). A small rock waterfall takes advantage of small space. (Figure 3.1) 3 • The compact exercise area is provided for those in rehabilitation. • Recognizes and creates spaces for both social and clinical needs of patients. • Many outdoor rooms include a children’s play area, fountain, raised beds for herbs and flowers, butterfly garden (bird bath, bird houses, benches), waterfall garden, serenity garden, rose garden and shade pavilions. VA Long Beach Healthcare System “Spreading the Seeds” 22 This is a VA Community Living Center (directly adjacent to the VA hospital) which features a patient garden with >50 raised garden beds, two greenhouses and a shade house, gazebo, rose garden and area designated for cacti and succulents. Veterans get outside, can dig and plant or just look and appreciate the results. (Figure 3.2) 22 Takeaways: • Once each week as a scheduled program, garden staff teach resident veterans to plant and care for plants. • Passive appreciation of the work and active participation in gardening are gained from raised garden beds.

Figure 3.2 Gardening at raised garden bed

Ibid. VA Long Beach Healthcare System “Spreading the Seeds” July 19, 2019. Accessed 02 March, 2021. https://www.longbeach.va.gov/LONGBEACH/features?2019_07_19_spreading_the_seeds_.asp

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The “Earth and Sky Garden” 23 Puget Sound VA Hospital, Seattle, WA Designer: Landscape Architecture students at UW Principal (in charge): Daniel Winterbottom Year: 2016 Client: Puget Sound VA hospital guests and patients The “Earth and Sky Garden” was designed and constructed in 2016 by 27 landscape architecture students at the University of Washington (UW). This project received the ASLA Student Community Service Award in 2017. The designers transformed a small concrete area at the Puget Sound VA hospital in Seattle into a healing garden. Its design includes spaces for meditation; many herbs, native plantings, a water fountain and long mahogany benches. The design idea was to reconnect visitors to the natural landscape – both earth and sky. Chairs incline so as to create a different experience and enlarge one’s view of this small space by looking to the sky. The design principles are contrast, learning, movement and tactile, visual and olfactory enhancement. This small outdoor space enhances one’s view from a large window inside. Fund raising volunteers collected $85k for the garden. The images on this page are from this precedent study. 23 Takeaways: • Space for meditation • Peaceful view from indoors yet private for those in garden • Accessibility by all emphasized by handrails, furniture and pathways • Vertical planting/wall creatively makes use of a compact space • Elements of hardscape are made from local sources • A maintenance manual created • Veteran input was received prior to the design

“Earth and Sky Garden: A Therapeutic Garden for the Puget Sound Veteran’s Affairs Hospital” Landscape Architecture Magazine, Accessed February 1, 2021. https://www.asla.org/2017/studentaward/297576.html

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The “Fisher House” Puget Sound VA Hospital 24 Seattle, WA Designer: Landscape Architecture students at UW Principal (in charge): Daniel Winterbottom Year: 2014 Client: Puget Sound VA hospital guests and patients This University of Washington project is located at Seattle VA Medical Center’s Fisher House. It was designed and built by UW landscape architecture students. These six outdoor rooms offer a familiar place, give a sense of connection, access to nature, well-being and belonging. These rooms can be for exercise, children’s play, contemplation, gardening, sensory stimulation and escape. Clear sight lines reinforce the sense of safety. This designed garden is screened from the parking lot and follows outside the building which utilizes otherwise unused space. A kitchen garden is full of herbs, vegetables and paved paths along with varying heights/ raised planters. A collaborative approach with heathcare providers was used in this design. In addition, focus groups were held which included the input of maintenance personnel, residents, staff and board members. This project received the ASLA Student Honor Award in 2014. The images on the following page were taken from this precedent study. 24 Takeaways: • These gardens offer a sense of familiarity and homeyness. • Rain garden attracts wildlife. It provides education for visitors regarding sustainability. • Six outdoor rooms allow for a variety of activities. • Semi-private elements with protection yet a view: bench swing with trellis, arbor and a curving seat wall and small pavilion. • Bench swing allows ADA access and creates a soothing motion.

“Creating Home, A Healing Garden for Veterans and their Families” Landscape Architecture Magazine. Accessed February 02, 2021. https://www.asla.org/2014studentawards/013.html

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Marianjoy Rehabilitation Hospital, Enabling Garden 25 Wheaton, Illinois Designer: Hitchcock Design Group with Stephen Rankin Associates (architect ) and Compass Engineering Client: Marianjoy Rehabilitation Hospital staff, guests and patients This hospital is situated on a 60-acre wooded campus with an open-air courtyard (enabling garden) for gathering, rehabilitation and relaxation. It accomodates both small and larger gatherings. In addition, the grounds include a rain garden, sensory garden, peace path and rose garden. The images on the following page were taken from this precedent study. 25 Takeaways: • Incorporation of many rehabilitation therapy aids: stairs, slopes, ramps and handrails. • The many different textures of surfaces allow for navigation practice. • Vertical and raised planters accommodate different needs universally. • The water feature is accessible to all and muffles noise in the courtyard. • The labrinyth is helpful for physical therapy, meditation or distraction.

“Hospital Courtyard Design”, 2021. Accessed: February 2, 2021. https://www.hitchcockdesigngroup.com/portfolio-item/marianjoy-rehabilitation hospital-enabling-garden/

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Banner Good Samaritan Medical Center Healing Garden26 Phoenix, AZ Designer: Orcutt/Winslow Architects, Floor & Ten Ecyk Landscape Architects Artist: Joan Baron Client: Healthcare providers, patients and guests of Banner Good Samaritan Medical Center In this project, an existing concrete courtyard was renovated to reflect the architecture of the nearby buildings. Terraced concrete garden walls mimic the building’s shape. Despite the extensive concrete, there are many areas available in this garden for seating, resting, gathering and seeking shade. The images on the following page were taken from this precedent study. Takeaways: • Curving water course provides a metaphor for the cycle of life (Cooper Marcus and Barnes 1995). • A beginning fountain pool symbolizes the ‘source’ or birth of life and an ending pool symbolizes the ‘return’ in a quiet contemplative form that provides many opportunities to experience the sound of water comfortably underneath a shaded network. • Many different types of colors and textures of plants (native) and stones are used to stimulate the senses and distract. • The use of colorful art and texture on the columns engages the user and creates a cheerful user experience. • The garden is visible from the patients’ rooms and the lobby.

“Banner Good Samaritan Medical Center Healing Garden” 2016. Accessed: February 2, 2021. http://floorassociates.com/wp-content/uploads/2016/08?Healing_Banner-Healing-Garden.pdf

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Banner Good Samaritan Medical Center Healing Garden

This project was a collaboration between Floor & Ten Eyck, The Orcutt/Winslow Partnership and Joan Baron, Artist. The challenge was to take an existing concrete courtyard (all over-structure) and turn it into a multi-sensory garden. Taking a cue from the adjacent curvilinear concrete hospital tower, sinuous concrete walls were created at seat height to add the dimension of human scale. These form the terraced garden that is visible from the patients’ rooms and the lobby of the hospital. The native, medicinal plants and the water feature that slip through the garden symbolize the different stages of life.

Client Banner Health Systems Location Phoenix, Arizona Design Team Orcutt/Winslow Partnership - 1998 Floor & Ten Eyck - 1998 Joan Baron, Artist - 1998 Floor Associates - 2005 renovation Size 20,000 Sq Ft Services Landscape Architecture Hardscape Design Water Feature Design Artist Design Coordination Budget $75,000 - 1998 $60,000 - 2005 Completion October 1996 November 2005 Renovation

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healing

4. Site and Subject A. Organizational hierarchy Worldwide, the USA has the most comprehensive organization of assistance for veterans when compared to any country. This goes back to 1636 when Plymouth pilgrims were battling the Pequot Indians and the colony passed a law to support the disabled soldiers. Veterans health administration (VHA) evolved from the first federal soldier’s facility established for Civil War veterans of the Union Army. On 03 March 1865, President Lincoln signed a law to establish a national institution specifically created for honorably discharged volunteer soldiers.27 The first National Home opened in Nov 1866 near Augusta, Maine only allowing those Union troops admittance. It was later renamed as the “National Home for Disabled Volunteer Soldiers” in 1873. This then became the template for future veteran’s hospitals. Refer to Figure 4.1 on page 28 for this timeline. By 1929, the federal system of national homes had grown to 11 installations across the USA and accepted American veterans of all American wars. Today the VHA operates one of the largest health care systems in the world. Nearly 60% of all residents obtain part of their medical training at VA hospitals.28 On the Moanalua ridge, Tripler Army Medical Center (TAMC) in Honolulu is the largest military hospital in the Asian Pacific rim. It is a tertiary care hospital. Patients are transferred here if there is a need for a higher level of specialty care. It serves local active duty and retired military along with residents scattered over half the earth (Japan, Guam, American Samoa and many Pacific Island nations) throughout nine U.S. jurisdictions and 40 other countries in the region. It is situated within the residential neighborhoods of Salt Lake and Moanalua on a 367-acre site. It began as Tripler Hospital on Fort Shafter on Oʻahu in 1907. In 1920, it was named after Dr. Charles Stuart Tripler, a Civil War physician. It needed a larger facility during World War II and a new building was commissioned to be built in its current location, designed in 1942 and completed in 1948 with additions in 1985.29 Its distinctive pink coral color painted building can be seen throughout Honolulu. The hospital was painted this color to emulate the Royal Hawaiian Hotel in Waikiki and is commonly known as the”Pink Lady”.

U.S. Department of Veterans Affairs. “A Brief History of the Veterans Health Administration”. 2015. Accessed February 10, 2021. https://www.va.gov/VISN5/about/history.asp 28 U.S. Department of Veterans Affairs. “History-VA History” 2021. Accessed February 10, 2021. https://www.va.gov/ about_va/vahistory.asp 29 Sallette, William, Tripler Army Medical Center. “Tripler; past and present” July 28, 2017. Accessed January 31,2021. https://www.tripler.armymedicalcenter.com.history/ 26 27

One famous vocal Hawaiian veteran, Senator Spark M. Matsunaga, served as a member of the 100th Infantry Battalion during WW II. He was a member of the only infantry unit in the U.S. Army reserve in WW II (then mainly composed of second-generation Japanese). This unit was attached to the 442nd Regimental Combat team who saw heavy combat and Matsunaga was twice wounded in 1944. The 100th unit was unofficially nicknamed the “Purple Heart Battalion” and had a motto of “Go for Broke”. Mr. Matsunaga’s dreamed of having a health care facility available to veterans in the state of Hawaiʻi.31 In 1989, the VA began initial planning for this new medical center in HI. After his death, a bill was introduced in 1990 to designate the planned department of Veterans’ Affairs Medical Center in Hawaiʻi as the Spark M. Matsunaga Department of VA Medical Center. In 1992, in cooperation with the Department of Veterans Affairs, the U.S. Army agreed to have the VA Medical Center added onto the grounds at Tripler. The Spark M. Matsunaga Department of Veterans Affairs (VA) Medical Center on Oʻahu is located on the grounds of the TAMC. Historically, there was a 20-bed ward that opened in 1931 called “The Administration” to treat veterans at Tripler General Hospital (per TAMC historian, COL Mark Burnett telephone conversation on 19 Jan 21). The Spark M. Matsunaga Medical Center opened in 2000. Refer to FIgure 4.2 for the timeline of Tripler Army Medical Center and the Spark M. Matsunaga VA Medical Center. It is not a hospital, however, it does have an agreement with Tripler for hospital services. The VA Medical Center treats PTSD patients after their discharge from active duty on Oʻahu. According to a staff member at the Center for Aging who has worked at the facility since it admitted its first patients in October 1997, the local VA had only a small clinic in the federal building in downtown Honolulu and there were a few smaller clinics on neighboring islands. Two Hawaii senators, Spark M. Matsunaga and Daniel Inouye, both realized that there were many local veterans who needed services and that the population was growing. Their vision was to build both a longterm care facility (the Center for Aging) and the new clinic on Oahu to care for these veterans. The Community Living Center is a nursing home within the Center for Aging that is designed to resemble a home as closely as possible. The goal is to restore veterans to their highest level of well-being prior to being discharged home or an alternate facility. This 60-bed/ 40-room facility, was built in 1997 on the site of a former U.S. Army motor pool. See Figure 4.2 on page 29 for a depiction of the timeline of Tripler Army Medical Center and Spark M. Matsunaga VA Medical Center. The center treats a mixture of residents, some in transient rehabilitation and others in long-term rehabilitation. In addition, this center helps prevent a decline in health and provides comfort at the end of life (hospice). Here on Oʻahu, the VA has begun developing a new project which will accommodate a post-traumatic stress disorder recovery rehabilitation (PRRP) group. Residents are admitted based on service connection and need. If needed, they receive skilled nursing care for simple daily activities (bathing, getting dressed) and medical care. There are more than 100 Community Living Center locations throughout the United States. Mandatory eligibility is given to those veterans who need nursing home care for their service-related disabilities, veterans who are rated 70% service connected or more and veterans with total disability ratings based on individual “Spark Matsunaga” Densho Encyclopedia. Accessed January 31, 2021. https://encyclopedia. densho.org?Spark_Matsunaga/

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Figure 4.1 Timeline of veteran hospitals 28

Figure 4.2 Timeline of Tripler Army Medical Center & Spark M. Matsunaga VA Medical Center 29

unemployability. If space and resources are available, other veterans may be considered. Besides treatment in a hospital setting, the center provides extensive geriatric care through outpatient programs, including contract adult day care, homemaker health aide, home-based primary care and community nursing home placement. 32 The Center for Aging facility is affiliated with GRECC (Geriatric Research Education and Clinical Center). This concept was initiated in 1975 by Congress and its goal is to emphasize gerontology, the scientific study of the elderly, in hopes of improving the health care of veterans. It supports a multidisciplinary approach to research, clinical care and education. GRECC is located at 20 medical centers throughout the U.S. with each connected to a major research university. In this model, the aim is to gain knowledge regarding geriatric care by research, improve elderly veteran care by utilizing new methods and train VA staff and students regarding best practices. 33 B. Cultural history of Moanalua ahupuaʻa: This ahupuaʻa encompasses the Daniel K. Inouye International Airport, Salt Lake, Moanalua Gardens and the entire valley of Moanalua to the ridge of the Koʻolau range. The eastern border abuts Kalihi Valley to Kalihi Kai and the shore of Keʻehi lagoon. Moanalua means “two patches close to the road taken by travelers from ewa” or named for the area of flat land and sea reef. The travelers along the road found the taro leaves very large. This rich and fertile region had a very productive shoreline full of fishponds and upland forests which provided habitats for birds found only in Hawaiʻi. The Hawaiian hoary bat and rare Oʻahu creeper were last sighted here. The Chinese planted rice in the terraced lands and the Hawaiians planted wet taro. By the 1800s, this region was full of taro fields, sugar plantations and banana trees.34 Much of Oahuʻs history, as with other indigenous people years ago, was passed down through oral tradition. 500 years ago, Moanalua ahupuaʻa was the center for hula and chanting. Kamehameha conquered Oʻahu with battles in 1796. He was resting in Moanalua near a spring and heard chants which told of a infantʻs birth. He went to visit this baby (a descendent of King Kakuhihewa), laid down his sword and named the child: “Kapahikauaokameha”. This translates to “battlesword of Kamehameha”. This child was the grandfather of Nāmakahelu. Many stories regarding the ahupuaa’s history came from Nāmakahelu Kapahikikauakamehameha. She lived in the Kamanui valley (directly west of the project site). Upon King Kamehameha’s death in 1848, the valley was passed to his grandson King Kamehameha V, then to Princess “Community Living Centers” June, 2020. Accessed January 30, 2021 https://www.vagov/geriatrics/docs/community_living_center.pdf 32 U.S. Department of Veteran Affairs. “Geriatric Research Education and Clinical Center (GRECC)” December, 2020. Accessed January 30, 2021. https://www.va.gov/GRECC.Index.asp 33 Sterling, E.P and Catherine C. Summers. “Sites of Oahu”. Bernice P. Bishop Museum, 1978. Accessed February 01, 2021. https://edcs630m.files.wordpress.aom/2017/12/Sterling_ Summers_1978_sites-of-oahu.pdf 34 “Kamanui Valley, Moanalua Ahupuaʻa” Accessed February 03, 2021. https://moanaluagardensfoundation.org/wp-content/uploads/2014/05/Kamanaui-Valley.pdf 31

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Ruth Keelikolani in 1872 and with her death, to her cousin, Princess Bernice Pauhi Bishop. In 1883, the entire ahupuaʻa of Moanalua was willed by Bernice Bishop to her friend, Samuel Mills Damon. Damon moved to O’ahu in 1890. By the 20th century, the U.S. government was purchasing land, building military bases and sharing water with the plantation companies. Sugar was planted near the fish ponds due to the fertile soil. Damon died in 1924 and his trustees then began selling land to developers. Damon had maintained most of Moanalua as pasture land with some leased to banana, rice and sugar growers.35 Moanalua Valley contains Kamanui, the valley of the great power and Waolani, the valley of the spirits. There is a large rock which is considered sacred (akua) to Hawaiians. The rock is called Pohaku ka Luahine or “Old woman rock” and is found in the center of Moanalua valley. According to legend, many years ago, there was a heiau being consecrated and all sounds were forbidden (kapu) from man or animal or the offender’s life was threatened. A baby cried and its grandmother quickly ran with it into the Kamananui valley for safety. She fled to this boulder and waited as soldiers searched for them. They were not located and it was the rock’s spirit or mana which saved them.36 It is the largest free-standing petroglyph boulder at 11'x 8' x 6' with birdmen and human carvings in various sizes up to 22". The boulder has a 22" x 27" kōane board containing 90 holes. Kōnane is similar to checkers; played with lava rock and coral pieces. This rock of petroglyphs is included in the National Historic Register of Historic Places. Its period of significance is 1749-1500 in the areas of prehistoric, religion and art significance.36 The Moanalua Gardens Foundation, a non-profit organization, worked endlessly with others to preserve the land and historic significance of this ahupuaʻa. They directly helped thwart the planned construction of the H-3 freeway in the 1970s which was supposed to pass within 100 ft of this rock.37 It is unknown as to how the TAMC site was utilized by native Hawaiians. Perhaps sweet potatoes or bananas were grown due to the plentiful rainfall. Just before Tripler was built in 1944, pineapple plantations were at the location. The area south of TAMC is now Moanalua Gardens Park and had traditionally been used for wet taro agriculture. Two large taro plantations existed southwest of the Moanalua stream. Historically, six large fishponds, famous for crabs and mullets, were situated on flat inland areas and along the shore of the ahupuaʻa. The dryness and topography of the TAMC site were not favorable for taro farming.39 Refer to Figure 4.3 on page 32 for an illustration of the Moanalua ahupuaʻa cultural attributes. “Ka Makani Hoʻeo Moanalua The Hoʻeo, whistling wind of Moanalua” Accessed February 03, 2021. https://www.ksbe.edu/assets/site/special_section/regions/ewa/Halau_o_Puuloa_Moanalua.pdf 36 National Historic Register of Historic Places. National Register Digital Assets. Accessed February 05, 2021. https://npgallery.nps.gov/NRHP/AssetDetail/cb19760-d688-465d-9a94-dc95593863ca/ 37 http://www.hawaii.edu/ohelo/courtdecisions/StopH3-76.htm 39 “Environmental Assessment for a FY94 Forensic Toxicology Drug Testing Laboratory” Tripler Army Medical Center, Oahu, Hawaii. Department of the Army. October,1991. Accessed January 31, 2021. http://oeqc2.doh.hawaii.gov/EA_EIS_Archive/1991-11-08-OA-FEA- Tripler_Medical-Center.pdf 35

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Figure 4.3 Cultural Attributes of the Moanalua ahupuaʻa 32

C. Existing conditions Much of the following information of existing conditions was gathered from ArcGIS and from an environmental study performed at Tripler by the Department of Army, Pacific Ocean Division, Corps of Engineers (1991).30 The state of Hawaiʻi is located in the central Pacific, 2400 miles west of San Francisco, 2780 miles southwest of Anchorage and 5293 miles west of Manila, Phillipines. Oʻahu is the third largest island in the Hawaiian island chain and home to nearly one million people. The city of Honolulu, the state capital and largest city is located here. Oʻahu is 597 square miles in area. Refer to Figure 4.4 on page 35. The project site is located on the south side of the island of Oʻahu. Oʻahu was created by two volcanoes and the remnants seen are the Koʻolau range to the east and the Waianae range to the west. Many land divisions or boundaries used by ancient Hawaiians are still used in Hawaiʻi today. The whole island or “mokupini” is Oʻahu and the site is situated in a section, the “moku” of Kona. A moku is a large land division which divides portions of the island. Each moku is composed of a smaller land unit, the “ahupuaʻa” of Moanalua. A ahupuaʻa is a division of land which includes the top of the mountain and extends to the ocean. Each land division had resources which provided for sustainability of its occupants. It is composed of a lowland agricultural area and a highland forested region. Today, this ahupuaʻa is composed of 65% conservation land and 35% urban use. Refer to Figure 4.5 on page 36 for the project site location. The project is situated at the lower portion of the Moanalua ridge. This ridge extends perpendicular to the Koʻolau mountain range. The compound sits on grades ranging from 5% to12% with elevations of 200 to 700 feet. The ridge has a slope of 8% to 12% yet slopes greater than 150% can be located on the sides of deep ravines which drain the area. The majority of the soil (70%) at the site is composed of the manana series. This type of soil is formed from eroded and weathered volcanic matter. In profile, its composition is an 8" layer of dark reddish brown silty clay loam over 42” of silty clay soil. 30% of the soil is “rock land” which is exposed basalt. This soil is acidic, has a moderate run-off potential and medium erosion potential. The surface layer’s water capacity is 1.2"/ ft and 1.3"/ft in the subsoil layer. Vegetation root penetration is approximately 15-30" 39 The watershed area of Moanalua ahupuaʻa is 10.5 square miles and its maximum elevation is 2812’. There are three streams within this ahupuaʻa: Kalou, Manaiki and Moanalua. Moanalua stream is a perennial stream, 24.5 miles in length, located northwest of this site, receives the majority of the run-off from TAMC and feeds ultimately into the ocean at Keʻehi Lagoon. Manaiki stream is southeast of the other streams. Both Moanalua and Manaiki streams have cut deep valleys on either side of the Tripler Army Medical Center compound. TAMC is not located within a flood zone. However, any change to the TAMC grounds can directly effect those areas below it which are adjacent to the Moanalua stream. 39

Ibid. 33

The City and County zoning of TAMC is designated as Federal. The state land use is considered urban. City and county do not regulate federal property land use. Nearly 40% of the grounds are undeveloped and predominanted by the ubiquitous Leucaena leucocephala (koa haole). Other companion plants include Syzgium cumini (Java Plum), Lantana camara (common lantana) and Acacia farnesiana (sweet acacia) which grow in dense thickets around the site. The landscaped areas have an assortment of vegetation: Eucalyptus, Norfolk pines, palms, monkeypod, Royal poinciana, Waipahu fig, African Tulip, Purple allamanda, Bougainvillea, wedelia and Bermuda grass. Years ago, the Koʻolau mountains were covered with ohia and koa forests. Very few remnant native trees remain. This project site, the VA Center for Aging, is located on the Tripler Army Medical Center (TAMC) base which is about 4 miles west of Honolulu and 3 miles east of Pearl Harbor. The entire campus occupies 367 acres. TAMC is connected to central and eastern Honolulu, Joint Base Pearl Harbor, the Daniel K. Inouye International Airport and west Oʻahu by Interstate H-1 freeway, the Moanalua Freeway (Interstate Highway 72) and Puuloa Road. Jarrett White Road originates at the Puuola Road interchange of Moanalua Freeway. Refer to Figure 4.6 on page 37 for vehicular circulation to the project site. All traffic access to TAMC is by Jarrett White Road, a four-lane road which transitions into three lanes at the TAMC entrance. After passing through the sentry guarded main gate, the road runs uphill in a counterclockwise one way loop with various turn offs to parking lots. Two main roads (Jarrett White and Krukowski) form a continuous loop and these roads connect to most of the destination areas. A third road, Patterson, bisects the loop near the midpoint. These roads handle traffic efficiently. The grounds are not pedestrian friendly in that the only sidewalks are adjacent to the buildings. There are no bike lanes on this base. In addition, there are many areas of impervious surfaces: asphalt roads,large asphalt paved parking lots throughout the campus and one parking garage. There is very little tree canopy at the parking lots. Despite the large parking lot size, parking on the installation can be quite limited and difficult at times. The Tripler trolley helps transport staff personnel and patients back and forth from the parking areas to the hospital and the Spark M. Matsunaga Medical Center. A public transit bus does enter the base with various stops. One public bus stop is located near the parking lot of the VA Center for Aging, with a walkway ramp, within 80 feet of the main entrance. Refer to Figure 4.7 on page 38 for the Tripler Army Medical Center base circulation. It is important to note that the land of this compound is owned by the Department of Defense. Tripler Army Medical Center is considered part of the Department of Defense whereas the VA buildings are owned by the Veterans Affairs. Refer to Figure 4.8 on page 39 for this diagram. Figure 4.9 on page 40 explains in more detail the relationship between Tripler Army Medical Center, Spark M. Matsunaga VA Medical Center and the VA Center for Aging.

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Figure 4.4 The location of Hawaiʻi 35

Figure 4.5 Project site location 36

Figure 4.6 Vehicular circulation to project site 37

Figure 4.7 38

Figure 4.8 39

Figure 4.9 40

Northeast tradewinds at 14-17 mph prevail throughout the year. The winds may shift to the southwest (kona) during the winter months of November through March. It is rare to see a completely cloudless day at this project site. The steady tradewinds which pass over the Koʻolau mountains create orographic precipitation. The median average annual rainfall is 39.5”; the wettest months are November - January while June - August are the driest. The average temperature is 75° F. The coldest month is usually February at an average of 71° F and warmest of 79.5° F in August. There is no significant air pollution associated with this site. Refer to Figure 4.10 on page 43. Site inventory: The VA Center for Aging is located at the site of the former motor pool (bldg 113) for Tripler Army Medical Center. The facility is at the northwestern side of the base and built upon a small flat plateau situated at 260’ above sea level. Its area occupies 260,100 square feet. The surrounding landscape of the facility has a perimeter fence and is partitioned into three separate areas. The south and eastern portions of the foundation were created by cutting into the existing hillside while the north and western borders slope steeply down toward Moanalua valley. Krukowski Road borders the site to the east. North and west of this facility’s fence is a densely forested ravine composed of predominantly the ubiquitous Leucaena leucocephala (koa haole). To the south of the site, is a large retention wall and stairs leading down to a parking lot to the Corps of Engineers’ building. An asphalt paved parking lot is located at the eastern aspect and southern portion of the project site. There are 34 parking spaces available at the front of building near the main entrance. In addition, there are 8 parking spaces located near the side entrance plus 16 spaces under a solar panel roof on the southern portion of the parking lot. Krukowski Road borders the site to the east. The building is a one story building built in the “Neo-Mediterrean style”. This type of architecture mixes Italian, Greek, Spanish and Moroccan architecture with North American ideas. This building has coral colored painted stucco walls with a low pitched, sloping hip roof with red barrel roof tiles. The overhanging roofs provide shade and shelter to many benches. The building is divided into three sections. The first wing (Wing A) holds clinical and administrative offices. The second wing (Wing B) holds patients in need of rehabilitation and those in the PRRP program. Wing B is composed of double rooms, each sharing a restroom with another two-bedroom suite. The third wing (Wing C) is for hospice and memory care patients. Wing C is composed of single rooms each with their own restrooms. The entire facility is enclosed by a 8’ fence which separates the wings into three outdoor areas. Refer to Figure 4.11 on page 44 for the plan diagram of this facility. Exterior lighting is permanently placed at ground level along the sidewalks and also mounted on the vertical fence posts. To supplement illumination, there are additional ground lighting fixtures along some areas of the sidewalk path in the landscape north of the Community Living Center (Wing B). Existing circulation at the VA Center for Aging is composed of a main entrance for staff and visitors at the front parking lot. There is a side entrance (near the dining room portico) which is for staff and after-hour visitors. Each wing has its own exit door into the exterior. Doors remain 41

unlocked at all times and easily managed with handicapped door access push buttons. The majority of pedestrian traffic is through the areas of the administration spaces, the dining room and Community Living Center. A large fence encircles the facility and also separates the wings into separate outdoor zones. Due to this fence enclosure configuration, one cannot access the grounds without entering the facility. Refer to Figure 4.12 on page 45 for the existing circulation diagram. The Admin and Clinical spaces house a multi-purpose room, the rehabilitation medical services and the home based primary care unit. At this time, the PRRP patients are using the multipurpose room and the yard north of this area which is fenced off from the remainder of the facility to provide privacy and avoid interaction between the Center for Aging patients and staff. The PRRP patients are housed in the southern portion of wing B, separated from the elderly population by an interior wall in the passageway, and exit for outdoor activities in the southeast courtyard. This separation is due to the different physical and cognitive needs of these patient populations. There are nurseʻs stations for Wings B and C located at the center of each wing. The dining room is located near the side entrance and has a small portico with a view out to a small courtyard with a large specimen tree. Refer to Figure 4.13 on page 46 for the existing programming at the site. Figures 4.13 through 4.17 on pages 47-50 are photographs of the existing site. The existing vegetation is comprised of very little tree canopy, sparse shrubbery and groundcover. Trees include Ptychosperma macarthurii (Macarthur Palm), Delonix regia (Royal Poinciana), Ficus microcarpa (Chinese Banyan), Acacia koa (koa), Cycas revoluta (Sago palm), Guaiacum officinale (Lignum vitae), Plumeria rubra and Dypsis lutescens (Areca palm). Shrubs include: Alpinia purpurata (red ginger), Codiaeum variegatum (croton), Cordyline fruticosa (red and green ti), Crinum asiaticum (spider lily), Strelitzia nicolai (Bird of paradise), Allamanda blanchetii (purple allamanda) and Hibiscus rosa-sinensis (Chinese hibiscus). Groundcover includes only a few areas of Microsorum scolopendria (lauaʻe) and mainly grass. The planting pattern consists mainly of plumeria trees with groupings of ti, red ginger and many spider lily plants. There are two resident gardens which are composed of roses (5 different types), vegetables include okra, long and lima beans, eggplant and chili peppers. One area (in the corner) has succulents: aloe. The resident garden has croton, torch ginger, papaya, gardenia, bird of paradise and spider ginger. In addition, the resident garden includes the following herbs: three types of basil, lemongrass, green onions, rosemary, passion fruit, dragonfruit, lime, lemon and Hawaiian orange and papaya trees. Also, poinsettia, jade plants, hibiscus, shell ginger and torch ginger. The entire site is surrounded by a steep drop off of forest filled mainly with Leucaena leucocephala. Refer to Figure 4.18 diagram on page 51 for details of existing vegetation. Figure 4.19 on page 52 depicts the sparse groundcover. The existing hardscape is composed of concrete porticos, walking paths and patios. There are also two asphalt parking lots and three outdoor gazebos on the property. The large sloping roof is 86,663 sq ft in area. The entire site is 191,365 sq ft. Of this, the majority (77% or approximately 149,821.6 sq ft) of the site is composed of impermeable material. Refer to Figure 4.20 diagram on page 53 for site’s existing hardscape. Existing sections were made at six locations. The sections reveal the sparse vegetation and rather flat topography of the site surrounded by the steep drop-off at the northern aspect of the project site. Refer to Figures 4.21-4.23 on pages 54-56 for additional details.

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Figure 4.10 43

Figure 4.11 44

Figure 4.12 45

Figure 4.13 46

Figure 4.14 47

Figure 4.15 48

Figure 4.16 49

Figure 4.17 50

Figure 4.18 51

Figure 4.19 52

Figure 4.20 53

Figure 4.21 54

Figure 4.22 55

Figure 4.23 56

Site Analysis: Strengths of this site include the views at its elevation to the south and west and the staff mention that the sunsets can be beautiful. This should be emphasized in the design. Views provide a sense of orientation, are therapeutic, an important part of healing to decrease stress by relaxation and positive natural distraction. The building’s large overhanging roof and gazebos provide canopy and shelter from the elements. Shade is especially important for human comfort, to reduce glare for those taking medications (PTSD and elderly), those with poor vision and for resting (elderly and memory care). Refuge is important for the PTSD patient in order to feel secure and safe in the landscape. The existing fencing is restrictive yet partitions the facility into its separate populations’ needs and permits four separate spaces for design to accomodate these different patient healing needs. This obtrusive fence can be softened with plantings of shrubs or vines. The fence creates a boundary and a sense of security for those who may wander (memory care) or are in need of this psychological comfort (PTSD patients). The fence also provides safety due to the adjacent steep drop-off and slope. Base Facilities will mow the grass and provide minimal pruning occasionally. Volunteers normally help with landscape maintenance. Maintenance is critical to the long-term success of a therapeutic garden. The property has many very large, overgrown giant crinum lily plants (Crinum asiaticum), of which, some are growing too close to the sidewalks. These can be a safety hazard especially for those navigating with walkers or wheelchairs. The dining room has a plain view of a concrete wall in a courtyard of overgrown vegetation with a large specimen tree. This tree is in need of celebration by design. The large unesthetic wall could be improved upon by softening with plantings. It is important for healing to emphasize green views from the interior looking outside. Evidence has shown that patients heal quicker, take less medication and are happier if they face vegetation versus a wall. Views are therapeutic, an important part of healing to decrease stress by relaxation and positive natural distraction. This room is also used as a multipurpose room for programming throughout the day (after dining room hours) so an improved view is important for healthcare personnel, visitors and the residents. The facility is concerned about the environment, sustainablity and energy efficiency. This is evidenced by the large solar-paneled roof which supplies an electric power station for the facility’s eight government vehicles parked underneath. There is much underutilized open space which can be used for new planting design and programming. The site contains few trees, shrubs and groundcover. This minimal landscape creates little litter, few obstacles for tripping and needs little maintenance. However, from an ecological view, there is little biofiltration of stormwater run-off which is important to diminish due to its location on the ridgeline in the ahupuaʻa. Also, this lack of vegetation creates lack of interest, 57

sensory stimulation, privacy and natural shade. More vegetation could create more prospect and refuge which is especially important to those healing from PTSD. The landscape is very similar throughout the facility; sparse and similiar plantings, boring with little differentiation. The lack of orientation or differentiation of exterior landscape could create depression due to redundancy and lack of views, cause wayfinding issues for visitors and especially, the elderly, affecting mainly those in memory care. Vegetation is important for wildlife and wildlife is an important positive distraction for the elderly in memory care and for the PTSD patients. Biodiversity promotes resilience. The inground permanent lighting provides insufficient illumination as evidenced by its supplementation with additional ground lighting in a few areas near the Community Living Center. Good lighting is especially important to the safety of the elderly who suffer from poor vision. The large amount of impermeable pavement creates a heat island effect and increases stormwater runoff on this site. This could easily be alleviated by incorporating permeable pavement. The facility has a very large overhanging roof which could be utilized better. Some areas of the facility are without water (Wing C) and rather than placing more costly irrigation, it would be appropriate to collect rainwater from the expansive roof to supplement landscaping water needs. Rainwater harvesting can capture the roof runoff, producing 4582 gallons of water which can be utilized in areas where there is no irrigation of vegetation. This creates a considerable financial savings for the taxpayers/government in the water bill at this facility. Biofiltration of stormwater and pools of standing water can be handled more ecologically by using rain gardens versus the existing inlet grates in the grass for speedy drainage in the landscape. The concrete pathways are separated into specific wings. In order to provide improved connectivity, I would design one connected circumferential perimeter path at the facility. This would give staff personnel an option to incorporate some refreshing exercise into their day and also invigorate visitors. The path could be extended into the koa haole forested area, similar to a nature walk area, as topography allows. Strengths and weaknesses of the site are summarized by Figures 4.24 and 4.25 on pages 59-60. The site analysis is found in Figure 4.26 on page 61.

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Figure 4.24 59

Figure 4.25 60

Figure 4.26 61

D. Population at Center for Aging: Veterans range in age from 56 to 101. The average age is 80-85 years of age. Normally, veterans enter at about age 65. The B wing is composed of long term rehabilitation residents now during the pandemic. Normally, there are short-term rehabilitation and respite patients but they are not accomodated at this time during the COVID-19 pandemic. Of these long term residents approximately 60% are over age 60. The other patients vary in age. Patients are originally from all over the country. About 10 have family here on Oʻahu. Some veterans have no family here. The majority are Vietnam war veterans, with the remainder being Korean war veterans, some non-war era and a few WW II veterans. There are multiple patients with amputated limbs or body parts, recovering from strokes, suffering dementia, Parkinson’s disease and effects of Agent Orange. There are no female patients at this time. If they arrive, they are placed in private rooms in Wing C. The facility has 45 beds but can expand to a maximum capacity to 60 beds. At this time, there are about 30 occupied beds in Wing B and 15 beds in Wing C. Many patients are in and out of this facility frequently due to quick recovery and rehabilitation after 2-3 months. Some remain longer. Care is very individually patient centered case by case. One patient has been a resident for over 15 years. The facility does re-evaluate each patient every three months and depending on the complexity of the condition, will extend them there for more rehabilitation treatment. The team which treats the patients consist of one social worker, one psychologist and one physician. In addition, there is a rehabilitation department composed of speech, occupational, physical and recreational therapists and social workers. Sometimes, healthcare students are involved in rotations there as well. Refer to Figure 4.27 on page 64 for a diagram depicting the different staff members and their roles. The VA recently introduced a group of about 30 PRRP (Post Traumatic Recovery Rehabilitation Program) patients who will work with mini-teams emphasizing mental health. These patients are composed of younger people, and a few Vietnam war veterans. Their rehabilitation program is 18 months long. Refer to figure 4.28 on page 65 for a diagram describing the patient population. Healthcare provider staff and resident input: According to the recreational therapist on site, existing programming is composed of two types: individual and group. Individualized programming consists of, yet are not limited to outdoor strolls, music-based interventions, reminiscing, arts/crafts, talk story, poetry and journaling. Group programming consist of, yet are not limited to current events, indoor bowling, horseshoes, bingo, sing-along, music appreciation, drumming, ukulele, arts and crafts, card games, special events and outings, entertainment and special meals. There is no dedicated recreation room. The dining room hosts the majority of group activities. Recreation therapy is highly encouraged but not mandatory. Some veterans prefer to pursue their own independent leisure lifestyle. They enjoy surfing the web, reading, listening to music, socializing with select peers and/or watching TV. They have a monthly calendar of various scheduled events and activities. Depending on their acuity and activity tolerance, hospice veterans interact with all. 62

The nursing staff normally eat their meals on the patio, in the kitchen area or office. Some may go to their car on their breaks to listen to music and relax. The staff explained that there had been a landscape plan for a Japanese garden years ago near the hospice wing C and a koi pond was built. This pond was not constructed well, leaked and was quickly removed due to the danger of flooding. There are many faucets and plenty of garden hoses for Wing B whereas Wing C has none and suffers from lack of water. Wing B receives so much rain plus irrigation that there are puddles and sometimes flooding on the sidewalk at the fenceline. A patio (near the B wing) is used for parties (families gather) and has water spigots available for watering the garden by hoses. Staff would like to see aromatic (yet insect repelling) and a variety of colorful plants planted, such as lavender or gardenia. They explained that the patients like fruit, flowers, herbs, vegetables (as a kitchen garden) since they are easy to care for and pick. Many residents need adaptive gardening equipment due to missing digits or other appendages. The staff stated that the largest need is for a therapeutic garden is for hospice wing (Wing C). Facility maintenance mows the grass and prunes the branches of the trees and shrubs periodically. Maintenance is mainly by volunteers every other Sunday which has not been possible within the past few months due to the pandemic. According to a 21-year staff member, the enclosing 8 feet high fence has not ever been commented on in any negative way by any resident, staff or visitor. One long-term rehabilitation veteran/resident explained that he is a member of the resident council, supervises the garden in two areas and has begun gardening for his own well-being/therapy. He shared with me the details of which plants he was growing in the gardens (detailed in the existing vegetation description). The veteran/resident explained that he would like to see the other residents get involved and interested in gardening. Patients feel rewarded by planting seeds in a pot and watching them grow: “I did it!” He wants to have staff push patients on gurnees so that they can be close to plantings to touch, smell and get involved (need raised planters). He would like to see a butterfly garden (did have a crown flower shrub in the past). The resident mentioned that the challenge is access since many are in wheelchairs. The area needs raised garden beds to allow access for the gardeners. The garden needs better organization. Another concern is exterior lighting – it is dim, especially on the lanai at night. There are many creatures: ants, flies, centipedes, frogs and feral cats. 5.

Proposal - Evidence Based Design for “Center for Aging”

In order to design a therapeutic garden for the Center for Aging, it is essential to be familiar with the stakeholders; the patient population, their healthcare providers’ needs and desires and the visitors’ experience. The aim is to facilitate what needs to be done to rehabilitate, assist the patient’s recovery and mitigate stress for all. Depending on the type of rehabilitation, as well as the various cognitive and physical abilities, the design may differ. These environmentally based interventions are complementary medicine and are very helpful in improving quality of life when there is no completely effective treatment for patients’ suffering. Plants which are blooming or producing berries remind all that life is cyclical and provide reassurance of hope. Even shadows of leaves can attract attention. Plants create a multisensory stimulation to all experiences.

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Figure 4.27 64

Figure 4.28 65

A. Designing for the users There are general design guidelines which are important to consider for healthcare facilities. According to Marcus and Sachs, these include: safety, privacy, inclusive accessibility, comfort, a source of positive distraction, passive and active engagement with nature for different users, esthetics, maintenance and sustainability.3 Furthermore, the garden should be a contrast to the indoor milieu and have doors which are easily accessible and unlocked to the exterior. The design should incorporate esthetic lighting, provide sufficient shade, have enclosure for safety, emphasize a view, be legible from the main door, provide covered seating, have a transition from interior to exterior landscape, have a sense of place context, and provide spaces for different experiences and social support. Vegetation should give adequate privacy for both parties – those inside looking out and those outside in the garden should enjoy areas of semi-privacy. The following specific guidelines are important considerations for each population group at the Center for Aging. Many guidelines do overlap into other groups’ needs. Refer to Figure 5.1 on page 67 which illustrates the various design drivers influencing the design decisions. Figure 5.2 on page 68 is a matrix to help organize the various different user needs to appropriately match the needed design elements to enable healing. This matrix listed those existing site elements. PRRP (Post Traumatic Recovery Rehabilitation Program) patients These PTSD patients in Wing B may be taking medications which increase glare and UV light sensitivity. It is important to give PTSD patients prospect and refuge and work to regain their trust. Colors should be muted – white, purples, greens, pastel colors and blues are less stressful and calming than bright vibrant colors, as reds and yellows. They must have a sense of control, be comfortable and feel safe. The design must be clear not ambiguous, no blind turns or overgrown shrubs, to decrease any perceptual or sensory distortion and must be defensible. Plantings must not obscure any views. Asmun, in her thesis, discusses the “EMR theory”.40 This theory is eye movement, desensitization and reprocessing. Understory planting can promote left and right eye movements with use of red and blue visual cues. This helps ground the user to make him aware of his surroundings. She also states the importance of archetypes and meditative and horticultural therapies. 37 The locations of meditative therapy can provide distant views for personal reflection. The sound of water gives stress relief. View of archetypal landscapes lends feelings of safety and control. It is important to provide space for individual reflection as well as space for small or large groups nearby. Artwork created by veterans can connect them to the space and give a sense of ownership and belonging. Familiar materials provide for reconnection to oneself, nature and others around the area. Strolling garden landscapes help invoke a sense of mystery for the user as they move through space and come upon hidden views.

Ibid. Asmun, Sarah, et al. “Healing invisible wounds: Landscapes for wounded warriors suffering from posttraumatic stress disorder (ptsd)” ProQuest Dissertations Publishing, 1 Jan 2013. Accessed January 15, 2021. http://search.proquest.com/docview/1464789945/.

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Spaces must be available for self-care activities and to create a level of coping skills which increases independence and recovery.41 Clear wayfinding signs are critical to avoid any confusion, create sense of safety and diminish sensory or perceptual distortion. Secluded areas help decrease over stimulation which increases patient’s calmness. Spaces needs to be seen in their entirety, without uncertain hidden turns or obtrusive plantings, in order for the veteran to be comfortable. Wagenfeld emphasizes veteran engagement in activities that they want and need to do so as to develop their self-identity, sense of purpose and reestablish their social connections. She emphasizes the importance of the landscape architect in their understanding of the physical and cultural effects of a designed spaces. In the outdoor spaces, the veteran must feel safe and in control, easily accessible, protected from the elements and enjoy privacy and allow for choices. Stimuli must be introduced gradually in steps which can be designed to accommodate in the outdoor landscape. It is important to not create attention fatigue in a veteran suffering PTSD who is already filled with hyper-arousal. Nature with its positive distractions, as a bird feeder or water feature, help relieve the veteran’s intrusive memories. An outdoor physical obstacle course can help treat those chronic stressors and rebuild self-confidence. Any meaningful activity which has a purpose is beneficial to a veteran’s self of well-being and healing. Examples include gardening, music practice or service dog training. Security and privacy is paramount yet veterans must be visible to staff at all times. Marcus emphasizes the need for spaces within the landscape for reflection, a smoking area to de-stress, and spaces to accommodate family members.3 Physical activity/walking can decrease depression. Plant labels may help stimulate interest and conversation. Fragrant plants stimulate senses and textured plants are tempting to touch. The garden should be raised up to the height of a gardener in a wheelchair or walker. Planting bed heights can vary from 1-4 feet tall to accomodate flexibility of users. Marcus recommends considering a vertical wall garden which is suitable for seated work. Roll under beds are options for a wheelchair user. Sit side beds are easy to create. Containers in various sizes and heights help create accessiblity. It is necessary to create an adjacent worktop for garden tools and refreshments. Avoid objects which could cause harm to oneself or others.3 Rehabilitation patients The design must incorporate curvilinear paths without sharp corners and with good traction, having <2% slope, at least 7 feet wide with a passing node of 25 feet to best accommodate those in wheelchairs or walkers. In addition, the control joints of the paving should be <1/8” without any rounded or beveled edges and there should be curbs or raised edges along the path to prevent washout from the planted areas. One must consider adequate space and benches which allow access for wheelchairs. Different routes of various lengths, varied surface materials and grade Wagenfeld, Amy, et al. “Collaborative design: Outdoor Environments for Veterans with PTSD.” Facilities, vol. 31, no. 9/10, Emerald Group Publishing Limited, July 2013, pp. 391-406, doi: 10.1108/02632771311324954. 3 Ibid. 41

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Figure 5.1 68

Figure 5.2 69

changes may be helpful to the recovery based on the healthcare provider’s input. Benches with arms and backs provide grip and comfort for seating. Wood is the best choice since other materials can retain heat or cold, with the latter not typically being an issue in a tropical climate such at this site. Wood also does not create glare and is sturdy; yet can be light enough to move. Seating must be at < 25’ spacing to allow for rest and provide the opportunity for prospect and refuge. Tables are important for lunch, games and paperwork.3 Potted plants and raised garden beds of different heights can create increased accessibility to those with limited reach or with limited visibility. Occupational and physical therapists utilize different heights for patient therapy with an emphasis on patient stretching and increasing their range of motion. Speech therapists are able to work with patients by vocal identification of plants, reading labels or recalling memories. In addition, fruits and flowers may be used in crafts and cooking. Programming, for example, as gardening for a little as ½ hour, has been found to be effective for veterans in decreasing their stress and depression.13 Memory Care Residents As patients age, their eyes lose the ability to dilate and contract. The transitions from dark to light can be uncomfortable. Filtered, fine textured canopies or high shade help ease these transitions. Elderly with cataracts cannot see cooler colors well and these appear to fade to grey. Brighter yellows and oranges retain their vividness so these contrasting vibrant colors should be utilized in gardens. According to the Alzheimerʻs Association, 60% of dementia patients wander. In a therapeutic garden, a circular or figure 8 path with a single entrance and exit creates a more directed activity for walking versus wandering and decreases confusion for these patients. It is important to have areas of rest. Lush plantings and tree canopy provide a serene environment.42 These patients need a clear line of sight to decrease confusion and orientation, whereas, PTSD suffering patients also desire a clear line of sight to have a sense of control of their environment which helps decrease their hyper-arousal symptoms. It is imperative to consider how patients will use the space. Alzheimer’s patients better utilize gardens in the morning. Studies have revealed that natural light is important to these patients and that they tend to be less agitated after exposure to morning sunlight. 3 Thus, designers must consider planting details and shadows created in the garden. Long shadows (sundowning) in the afternoon may increase agitation and be frightening to these patients. 3 However, shade is important since these patients may not be able to recognize if they are seated in an area that is too hot or too

Ibid. Ibid. 42 “Professional Practice. Universal Design: Gardens”. American Society of Landscape Architects, 2021. Accessed 03 February 2021. https://www.asla.org/universalgardens.aspx 3 Ibid. 3

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sunny. Tinted concrete helps reduce glare. Using fixed and mobile seating can help create sun/ shade choices. In addition, these patients must have a sense of control in their environment, feel independence and a sense of exploration by going out into the garden independently. For patient safety, the staff must be able to supervise with a visible view of the patient from inside the building. For the patient’s protection, the building should surround the garden and if not, an enclosing fence should be 8 feet high.3 The boundary or edges may be disguised with vegetation but must not be climbable. The idea is to create a feeling of security and eliminate wayfinding confusion for the patient yet not feel trapped or enclosed. If the view is of a nearby street or parking lot, the resident may be more likely to elope due to temptation or focused attention being outside the garden versus inside. It is important to offer stimulation for conversation in the gardens since they are usually the preferred area for residents to visit with families. Features which bring back memories such as a flagpole, water feature, windchimes, pergola, gazebo, garden shed or barbeque grill, may also act as reference points to help orient patients to the path. Seating must be available to allow patient resting at close intervals. Pathways must be a figure eight or loop to aid in orientation and decrease confusion. These paths must be clear of obstacles to prevent patient falls or tripping. Movement and exercise in the elderly have been shown to delay dementia’s onset. It is important to provide a destination point or goal to encourage movement into the garden, such as a pergola or gazebo, with rest opportunities along the way. 3 Lighting must be usable and make the garden attractive at night. The plant palette must be thoughtfully considered for a memory garden. The designer must consider the most vulnerable patient when choosing the limitations of plant selection and carefully heed the medical Hippocratic oath of “Do no harm”. The plants chosen for the memory garden must not be toxic since patients often revert to infancy and place all items in their mouths. Include those plants which are not harmful to touch (e.g. avoid thorny roses), plants which were popular in youth or culturally valuable, and those which are multisensory. It is crucial to avoid the nuisance vegetation which cause irritating pollen production, litter and hard seedpods. Hospice residents The emphasis is on palliative treatment and quality of life care for hospice care patients. Hospice gardens are similar to memory care gardens in that it is important to keep the landscape familiar and not stressful, create the opportunity to get away from indoors, provide reassurance and meditation, consider views from the horizontal patient perspective, position the patient close to hear the soothing nature sounds and lastly, maintain the garden similarly to one of a residential garden. The sense of smell is the last sense remaining before death so it is crucial to plant fragrant flowers and foliage in the therapeutic garden. Ideal plants selected must be nontoxic, easily pickable, composed of different textures and must liven the garden with sounds

3

Ibid. 71

and movement in the breeze. The recommendations by Marcus are that these be long-lasting perennials planted with ornamental grasses.3 Views of the vegetation must be of different scales; those close to a window as well as that of a far-off view. Colors must be pleasingly bright to distract and uplift, calming yet cheerful. Plant palette for the therapeutic garden According to Marni Barne’s chapter “Planting and Maintaining Therapeutic Gardens” in Marcus and Sach’s textbook, plants are engaging and multisensory, they can offer rest and shelter with their canopies, provoke conversation and help enhance or recall memories.3 The majority of these colorful plants in therapeutic landscapes must have direct sun for a minimum of ½ day. In the design plant palette, there are six groups to consider: trees, shrubs, perennials, herbs and grasses, annuals, groundcover and vines.3 Of course, the right plant or tree in the right place is most successful! Trees symbolize longevity and preserving existing trees provide a sense of stability. Dense canopies create cozy or secluded sensations while filtered shade offers screening or protection. Shrubs provide interest, screening, privacy and buffer. Perennials, ornamental grasses and herbs can provide contrast and drama to the landscape. Groundcovers and vines are “resting places for the eye”, grow quickly and frequently need little maintenance. Plants allow exploration by enticing people into the garden, help the user pause and look, slow down their pace and relax, while the placement near different elements can change views and create smaller spaces generally. Those most interesting plants should be positioned near the entrances to attract people outside. It is also critical to consider future issues such as overgrowth of plants causing safety problems, blocking window views or tree roots upheaving pavement. Also, the designer must include plants that allow the eye to move upwards and consider those which attract attention. Smaller scale plantings may work to provide a feeling of comfort and familiarity versus a large swath which looks more foreign, unnatural and forced. Plants and trees create microclimates and different sense of place for their users. Other sensory indulgences include flowers, berries and leaves which are edible. The garden’s fragrances can be appealing and a welcome contrast to the interior space’s odors. The leaves rustling in the landscape can be pleasant to hear. Some plant leaves are smoother and feel cooler to the touch. Plants can also be incorporated into many activities or programming such as garden activities of Bingo cards (with plant pictures), quotations, labeling of plants, educational talks on ethnobotany, culinary uses, scavenger hunts, or naming plants of certain colors found in the garden. A maintenance manual is imperative to better explain the purpose and value of the outdoor spaces to facility personnel. Plants must be pruned, maintained and kept healthy, especially when many different people are involved and may not come routinely. A healthy garden reflects favorably upon its healing patients and staff. An uncared-for garden creates confusion, unsafe conditions and depression for residents and staff due to its poor esthetics and overgrowth. Otherwise, plants may become unintentionally overgrown and replaced with other plants and decorations which may create 3

Ibid. 72

a garden which no longer has the intended therapeutic and peaceful effects. B. Design proposal for a Therapeutic Garden The client expressed that the largest need is for a therapeutic garden in the Hospice/Memory care area (Wing C). I created a broad stroke design for the entire site with thoughts that more design could occur in future phases. This design will incorporate a number of different garden zones with the goals of stimulating the senses with a variety of plants, create areas of passive and active engagement. The design will produce distraction, relaxation and provide environmental education. This proposal will include a butterfly garden, lei garden, native plant garden, rain garden and sensory garden. Active engagement through programs include a forest walk, raised planter gardening and social gathering. More seating and areas of rest are essential for the frail elderly and this will be provided by lightweight, stable moveable furniture < 25 feet apart. Generally, the garden must not have dense canopy or be too jungly in appearance for veterans. Borrowed views will be utilized. A “borrowed view” includes any visual element beyond the site which is then incorporated into the landscape. These elements help expand the user’s view and makes the garden feel larger. To the north and west of Wing C, is a forest of haole koa and to the east, are the grounds behind Wing B. Hawaiʻi is a special place in a unique location with an indigenous culture. My intent is to use sustainable materials, native plantings and design elements in such a way as to create a sense of place at this site that reflects its uniqueness and encourages healing. Refer to Figure 5.3 on page 74. Planting Design The site is currently composed of grass with very few shrubs. This area does not have supplemental irrigation, so the goal is to create a landscape which does not require costly inground irrigation. The proposed interventions are designed to use little to no supplemental irrigation. All plants need water and the plan is to supplement natural rainfall by capturing the roof runoff. This will conserve water thus creating little maintenance and saving costs which are critical for this facility. Beyond this, water conservation practice affects the whole island positively and unfortunately is not the norm of landscapes in Hawaiʻi. Locals and tourists expect to see lush vegetation for the “tropical plants” which depend heavily on consistent irrigation. Xeriscape gardening is simply defined as using water efficiently versus strictly drought tolerant landscaping. The idea is to create regions or plant communities according to the surrounding environmental conditions and the plants’ water needs. Important points to consider are heat, moisture, shade, sun and wind. The landscape architect is aware that grass needs the most watering. In this garden design, the designer will utilize more mulch and use ground cover for those plants with little water needs. To conserve water, the designer will group plants with similar water requirements together and add organic soil to better absorb water (decrease runoff). Watering as needed saves water and also positively affects pest control and pruning maintenance. However, it is imperative that new plants receive water initially to establish their roots.43 Mulch helps promote retention of water, slows down evaporation and controls weeds. In addition, this design will use native plants which are also drought tolerant. Native plants are those that arrived by birds, wind or ocean and survived on the islands naturally without the aid of humans. There are over 317 endangered and threatened species in Hawaii, and of these, 273 are plants. Nearly 90% of the plants seen on Oahu are not native. By planting native Brooks, L. and Diane Moses. “Waterwise Gardening with Xeriscape”. Accessed March 20, 2021. https://www.ctahr.hawaii.edu/ehmg/news/V4-Xeriscaping.pdf

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Figure 5.3 74

plants, the designer is creating a habitat for wildlife, especially for Hawaii’s native birds and insects.44 What is critically important is to establish a Hawaiian sense of place by increasing native and Polynesian-introduced plantings. The hope is to increase the public’s understanding and appreciation for Hawaiian culture and history. 90% of the native flora here on the Hawaiian islands are found only here and nowhere else.44 Low irrigation landscaping in Hawaiʻi may include several of these native Hawaiian plants: kokʻio keʻokeʻo (Hibiscus waimeae), alaheʻe (Psydrax odorata), kokiʻo ʻula (Hibiscus clayi), kupukupu fern (Nephrolepsis cordifolia “Duffi”), kuluʻi (Nototrichium sandwicensis),ʻaʻaliʻi (Dodonea viscosa), pohinahina (Vitex rotundifolia), loulu fan palm (Pritchardia sp.), ʻIlima (Sida fallax), a’e (Sapindus saponaria), naupaka (Scaevola taccada) and ʻūlei (Osteomeles anthyllidifolia). These plants will be strongly considered in the design of the Center for Aging landscape. Many will serve multiple purposes in the sensory garden and lei garden. A sensory garden should appeal to all senses: touch, hearing, sight, taste and hearing. Plants must be colorful and inviting, stimulate conversation and be non-toxic. Unfortunately, many of the native Hawaiian plants are not bright in color. In addition to appealing to the senses, it is important to carefully select plants which are not invasive and to study each plantʻs HWRA (Hawaiʻi Weed Risk Assessment). Low-water use plants for a sensory garden are those which need watering 1-2 x per week. These plants include Anigozanthos x ʻAmber Velvet’ or orange Kangaroo Paw, Lavandula stoechas ‘OttoQuest’ or Spanish lavender, Penstemon eatonii or Firecracker penstemon, Phlomis fruticosa ‘compact form’ Jerusalem sage, Rosmarinus officinalis ‘Prostratus’ dwarf rosemary, Stachys Byzantina Lamb’s Ear and Thymus X Citriodorus ‘Aureus’ Lemon Thyme.45 Other plants include Sedum morganianum (burro’s tail), Sempervivum tectorum (Hen and Chick plants), Beaucarnea recurvata (ponytail palm), the panda plant (Kalanchoe tomentosa) and rabbitʻs foot (Davilla fejeensis). Other textured and colorful plants to possibly include are: Graptophyllum pictum (Caricature plant), Acalypha wilkesiana (Copperleaf), Gardenia taitensis (Tiare), Calathea makoyana (Peacock plant), Ophiopogon japonicus (Mondo grass), Nephrolepsis exaltata (Kupukupu), Codiaeum variagatum ‘Ram’s Horn’, Bambus vulgaris ‘Vittata’ (variegated bamboo) and Cyrtostachys renda (red sealing wax palm), Coccoloba uvifera (sea grape), Malvaviscus penduliflorus (Turk’s cap), Holmskioldia sanguinea (Chinese hat plant), Psydrax odorata (alaheʻe), Petrea volubilis (Sandpaper vine), Sadleria cyatheoides (Amaumau fern), Persea americana (avocado), Passiflora laurifolia (Perfumed passionflower), Metrosideros polymorpha (Oʻhiʻa lehua), Callistemon citrinus (red bottle brush) or Callistemon viminalis (weeping bottle brush), Celosia (Cock’s comb) and Gomphrena globosa (Globe Amaranth). In the planting design of a therapeutic garden, it is important to utilize colors which can be calming and peaceful. Cool colors such as blue, purple, violet, pale pastels and white create a feeling of calmness and restoration. Warm colors as red, orange, and yellow can draw attention, highlight, distract and uplift spirits. Complimentary colors provide contrast which is easier for those with vision difficulties to appreciate. “Why native plants?” University of Hawaii, 2009. Accessed March 20, 2021. http://nativeplants. hawaii.edu/general/Why 45 City of Riverside Public Utilities “Sensory Garden”. Accessed March 20, 2021 http://riverside publicutilities.com/goeske/garden-sensory.asp 44

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The staff and residents are concerned about unwelcome insects. One design objective is to attract beneficial insects. Examples include the two native butterflies in Hawaii: the Kamehameha butterfly and Blackburn’s butterfly. These will create a positive distraction for the staff and residents plus help naturally pollinate. Another aim is to lure native crickets and spiders to devour garden pests and thus decrease the need for pesticides. Those native plants which attract butterflies and caterpillers will be considered for the Memory Care butterfly garden: Dodonea viscosa (ʻAʻaliʻ i), many native Hibiscus (Hibiscus brackenridgei, Hibiscus arnottianus, Hibiscus waimea, and Hibiscus kokio), and Bidens torta (Ko ʻokoʻ olau). Certain native plants are attractive to caterpillars to include Pipturus albidus (Māmaki) and Gnaphalium sandwicensium (ʻEna ʻena).46 Other butterfly attracting plants include the Caloptropis gigantea or the crown flower. At the Center for Aging, the residents are requesting raised planters for gardening. Some plants which appeal to the sense of touch, taste and smell include herbs such as: mint, lemongrass, lavender, rosemary, sage, parsley, thai basil, dill, cilantro and fennel. Other herbs and vegetables to consider are chamomile, chives, catnip, lemon balm, swiss chard, kale, small tomatoes, and lettuce. Growing plants for a lei garden will encourage staff and residents to pick, smell flowers and string leis. A few of the native plants to include are Sida fallax (llima), kupukupu (sword fern), Dodonea viscosa (ʻaʻaliʻi) good for wind, Fagraea berterorana (pua keni keni) and Artemisia mauiensis (Hinahina). This ahupuaʻa is considered a historic center for hula and chanting. Lei making classes at this site will help revive this cultural tradition. The soothing and calming scents, colors and textures of the lei flowers create a healing atmosphere for all. It will be rewarding and uplifting for residents to see the flowers grown in their own backyard utilized! Leis are very popular to this day and traditionally worn by hula dancers. Native Hawaiians brought the tradition of lei making and wearing leis to these islands from Polynesia. Hardscape Exterior walkways at the Center for Aging must be easily navigable, level, have adequate lighting, be clear, dry and safe. Memory care patients are less confused if the pathways are in loops of a figure 8. A single exit and entrance help orient the patients. Directed activity, as movement and exercise, has been found to delay dementia in the elderly. The existing paths at the Center for Aging are in good shape and replacement is a high cost on a limited government budget and not necessary at this time. However, after carefully studying the landscape and the building entrances, I had other design thoughts. It is important to consider alternatives to present options to the client and to explore opportunities so as not to miss options for design. The path variants explored in this study were not considered a significant improvement. This would negate sustainable practice and would not be a climate positive design to consider new paths due to the disruptive noise of the construction equipment (adverse effects on wildlife in the forested area and residents). The alternatives to the existing main paths also appeared too similar to what was already present and would create little gain or cost benefit to the client. The distance achieved by creating the newly selected path was measured to be very similar to the distance of the existing path.

“Hawaii Backyard Conservation – Ideas for every homeowner”. PRC_HawaiiBackyardConservation.pdf. USDA publication.

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The design decision was to leave the paths within the property as they are and “add on” another phase or possibility for an optional trail leading into the koa haole forest (as the topography allows) with gate openings for access. This potential forest trail would provide a sense of immersion in nature, a different scenic view and sense of escape for staff, residents, patients and visitors. However, the proposed new path might present an issue for staff due to lack of visibility of lone residents walking in the forested area, so the gates would have to be unlocked and locked at appropriate times. Moving the fence would be ideal to accomodate this path, however expensive, and may not be ideal for patient safety and visibility to staff. Removal of the vegetation around this forest path to provide visibility of the path would defeat the purpose of engaging nature and remove the privacy which it would afford the user. Refer to Figure 5.4 on page 79 for diagrams of alternative studies. Refer to Figures 5.5- 5.6 on pages 80-81 for proposed designs for active and passive engagement. Additional seating (within 25 feet intervals) will afford patrons more opportunity for rest and enjoyment of the surroundings as seen on Figure 5.7 on page 82. Figure 5.8 on page 83 is the new circulation. The large parking lot is asphalt and the paths are concrete at the facility. These impervious surfaces are in good shape and serviceable yet comprise 70% of the site’s total surface. The design recommendation is for permeable materials as a sustainable replacement and tree plantings in the parking lot if possible. This is very important generally and especially here since the site location’s stormwater run-off contributes to streams which flow into the polluted Keʻehi lagoon and ultimately into the ocean. Furniture can be ecologically designed for this site using sustainably harvested wood. Unfortunately, in Hawaiʻi, the majority of timber is imported. There is little locally produced lumber and what there is available is mainly utilized in craftswork. There are little sustainable lumber resources available. Many architectural firms and construction companies state that the high cost of Hawaiian wood is the main reason for importing other wood, as well as the local wood being non-sustainable and limited in availability.44 Acacia Koa has been a recent focus with a reforestation initiative on the island of Hawaiʻi to plant these trees with the hope to have a sustainable source in the future. It is not an endangered tree but was heavily harvested and mismanaged over the years.45 The Waiākea Timber Management Area (WTMA) is composed of non-native hardwood trees for the intent of harvesting commercially. These trees include Queensland maple (Flindersia brayleyana), Tropical ash (Fraxinus uhdei), Australian toon (Toona ciliate) and Eucalyptus saligna and grandis. It was created in order to provide a consistent supply of lumber as a forest industry in Hawaiʻi.46 Thus far, very little harvesting has occurred. Two recent student doctoral theses at the University of Hawaiʻi at Mānoa School of Architecture researched sustainable building material harvested from Moluccan albizia (Falcataria moluccana) and another from coconut (Cocos nucifera) wood. Monkeypod is considered invasive on Hawaiʻi, however, Joseph Valenti, was innovatively successful at repurposing this wood for building. He used CNC (computer numerically controlled) routing and structural engineering to Valenti, Joseph. “Rescaling urbanism: fostering low-tech, digitally fabricated and transient structures through innovation in local renewable material.” 2016. URI: http://hdl/handle. net/10125/45570. 45 Lovell, Blaze. “Saving Hawaiiʻs Koa Industry- And The Environment”. December 30, 2020. Accessed April 09, 2021. https://www.civilbeat.org/2020/12/saving-hawaiis-koa-industry-and-theenvironment/. 46 “Waiākea Timber Management Area”. 2021. Accessed March, 28, 2021. https://dlnr/hawaii.gov/ forestry/frs/timber-management-areas/waiakeatma/. 44

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accomplish this goal.46 Another Doctor of Architecture student, William Keanu, successfully designed and produced coconut lumber by utilizing coconut wood with Lignoloc®.47 Lignoloc® by Beck are nails composed of beech wood and composite resin. Their tensile strength is similar to aluminum nails and can be placed easily with a pneumatic drill. These nails form a strong bond with the lumber with no predrilling necessary. This technique is superior to using nails in the humid Hawaiiian climate in which nails quickly rust. Historically, coconut wood was used by native Hawaiians for housing and for boat building. Coconut is a Polynesian introduced canoe plant. I will use coconut wood and Lignoloc® to build the outdoor elements for the Center for Aging in order to create sustainability, using local native material and increasing the longevity of the outdoor furniture. Refer to Figure 5.9 on page 84. The design opportunities include module and mobile seating for social support in groups, small conversations or solitude. A table designed to seat six makes a comfortable space for group conversation. In addition, this design includes multiple raised garden planters for wheelchair and walker access with smaller tables to hold gardening tools or refreshments. The goal is to provide comfort and universal accessibility. In addition, a coco lumber swing is designed to provide relaxation for staff members and visitors. In this design, a coconut fiber rope will attach the coco lumber swing. Coconut fiber (coir) has the greatest toughness of all natural fibers. It is very elastic, durable, and resistant to rotting.48 These qualities are critical for the lasting endurance of materials in the outdoor environment. Refer to Figures 5.10- 5.17 on pages 85-92. Another design opportunity is regarding the window views and privacy. Many of the residents’ window blinds appeared closed during a recent visit. The staff stated that the veterans appreciate their privacy, do not complain about the views outside and it is variable as to how often the blinds are closed. Some close the blinds when the sunlight is too bright. The design of screening for the windows is a complex design issue since the windows are tinted green yet one can see into the windows as clear as one can see looking out. The ideal solution, although costly, would be to replace the windows with one way glass windows (transparent on one side and reflective on the other). Unique to this ahupuaʻa, in the cultural history of this site, is its large rock with petroglyphs and a hand carved kōnane checkerboard. I intend to incorporate the Polynesian game of kōnane by placing a lava rock gameboard slab onto a tabletop at the Center for Aging. This game is similar to checkers, played with lava rock and coral pieces on a carved rock. This will create a recreational opportunity for all to enjoy and spark conversation regarding this historical game and its relationship to place. Refer to Figure 5.17 on page 92. Lava rock is also a familiar local material and will be incorporated into the base of the pergolas and swings. Refer to FIgures 5.16 and 5.18 on pages 91 and 93. A pergola creates a sense of entering a new space. Keanu, William K. “Coconut lumber: An assessment of old and new approaches and methods of using coconut wood”. 2020. URI: https://hdl.handle.net/10125/68935. 48 Ahmad, Waqas, et al. “Effect of Coconut Fiber Length and Content on Properties of High Strength Concrete” February 28, 2020. Accessed April 12, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7084858/ 49 Golenda, Garbrielle. “7 Modern Takes on the Traditional Thatched Roof” Accessed April 7, 2021. https://architizer.com/blog/inspiration/collections/thatch-looks-good-7-terrific-instances-of-thecraft-building-method/ 47

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Figure 5.4 79

Figure 5.5 80

Figure 5.6 81

Figure 5.7 82

Figure 5.8 83

Figure 5.9

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Figure 5.11 86

Figure 5.12

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Figure 5.15 90

Figure 5.16 91

Figure 5.17 92

Figure 5.18 93

Pandanus tectorius (hala) is a native tree to Hawaiʻi. Its dried leaves (lauhala) are exceptionally strong and were used by ancient Hawaiians for plaiting or weaving various utilitarian articles: mats, roofs, sails, bedding, clothing, pillows, baskets, hats and other handicrafts. My design will incorporate this into the table tops and back rests. Refer to Figure 5.19 on page 96. Recently, contemporary thatching has been used by architects as a reinterpretation of roofing worldwide.49 Thatching using local renewable resources by skilled craftsmen creates a more environmentally conscious roof and, in many cases, can last longer than a traditional roof. In this design, I will incorporate a hale with a natural thatched roof of lauhala. Hale translates to house, shelter or home in Hawaiian. Thatched roofs of lauhala in Hawaii have been known to last as long as 50 years. The lava rock walls support coconut wood posts and rafters. This design uses local materials and is sited strategically using the open end style: “Hale Halawai”.50 The hale is a form of indigenous architecture constructed with few walls in order to maximize natural breezes. It incorporates overhanging roofs to offer protection from the rain and sun. Native Hawaiians constructed hales with careful thought regarding their surroundings. The location of this hale is dictated by its relationship to the northeastern tradewinds and the sun path of the site. One roof surface is slanted facing the northeast so as to deflect tradewinds, provide protection from the the sun and thus create shade and cooler temperatures for the occupants. The hale will be located at the northeastern portion of the site (farthest away from the building) in order to provide an area of healing solitude for quiet reflection and a sense of “being away”. Refer to Figures 5.20 - 5.22 on pages 97-99. My proposed planting scheme is lively. Its goal is to engage all people by fully indulging their senses and thus, augmenting healing. Refer to Figures 5.23- 5.26 on pages 100-104. My illustrative plan includes a forest walk, raised planter area, trellis with swings and three different gardens. It is important to offer variety to this group. Refer to Figure 5.27 on page 105. The forest walk would include some plantings as an understory in order to create biodiversity, enrich the soil, provide biofiltration and slow down stormwater runoff. Refer to Figures 5.28-5.29 on pages 106-107. The new sections are full of vegetation (Figure 5.30 on page 108). I am envisioning places for people to enjoy the outdoors of Hawaii; to enable these folks to see, smell, touch as much as they can from a close vicinity or afar and to engage the people in healing activities as strolling and gardening or just resting in the cool shade of the hale. See perspectives in Figures 5.31-5.33 on pages 109-111. The landscape itself is in need of healing. There is a large roof surface with plenty of rainwater to provide for rainwater harvesting. Wing C has no irrigation and this will inexpensively provide water. The harvesting potential is large and not to mention, help heal the environment by slowing runoff velocity. Wing C has a slight depression with inlet grates which will be filled with plants as a bioretention area. Refer to Figures 5.34 -5.45 on pages 111-112.

https://www.honolulu.gov/rep/site/ocs/roh/ROHChapter16a12.pdf Accessed April 6, 2021.

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VI. Conclusion The intention of this capstone project was to contribute, through landscape design, to the healing rehabilitation of veteran patients and their healthcare providers at the Center for Aging in Honolulu, Hawaii. This study involved input from residents and staff regarding the design of a therapeutic garden. It has explored the complex needs of the population at the Center for Aging and the opportunities at this specific site in Hawaiʻi. Did I accomplish the goal of meeting the needs of this population? The matrix on page 113 summarizes the many design elements which I have incorporated to aid the physical, mental and spiritual healing of patients, staff and visitors at the Center for Aging. The locale-and-site specific design elements create a sense of place and familiarity which is essential to healing. Sustainable efforts are evident in the use of locally sourced materials and those design elements which can be used in multiple configurations. Many of these configurations of outdoor furniture can be used to furnish other areas on campus. It is imperative to heal the environment by slowing down stormwater runoff which has been accomplished in this design by the incorporation of permeable pavement, abundant groundcover and the use of rainwater harvesting. Rainwater harvesting creates opportunity for watering those plants which have no additional manmade irrigation and decreases cost to the client. By incorporating more diverse plantings and native plants, this will enrich the soil and create more wildlife diversity. This can have a much larger impact on the ahupuaʻa if this is carried out throughout the entire Tripler Army Medical Center campus. Ideally, under different circumstances, it would have been more convenient to meet face-to-face with staff members regarding design thoughts. However, the COVID-19 pandemic created some obstacles to communication which were resolved by email and telephone conversations. To conclude, the Veterans Affairs Whole Health Initiative is searching for alternative methods to augment medicine which is a definite segway for more therapeutic gardens to be integrated into larger policies and frameworks for overall healthcare of veterans. I have demonstrated this clearly in my design proposal. Many design details are interpreted and unique to this area yet the general concepts can be incorporated into any VA medical center throughout the United States using the healing goals of the VA Whole Health initiative. It is my hope that this project will stimulate the conversation around the creation of additional therapeutic gardens to aid the healing of the veteran population as well as the staff who work so diligently everyday to offer their services. There are many opportunities available calling for landscape architects to complement medical practice through therapeutic garden design.

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PROPOSED DESIGN

EXISTING

Figure 5.31 108

PROPOSED DESIGN

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Figure 5.32 109

EXISTING

PROPOSED DESIGN “FOREST WALK”

Figure 5.33 110

Figure 5.34 111

Figure 5.35 112

Figure 5.36 113

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