As healthcare continues to be a polarizing national topic and obesity remains a growing epidemic, there is an increasing emphasis on employing preventive measures to attack the problem that is America’s collectively expanding waistline. And while obesity rates across the board are disconcerting, the most dismaying aspect is the increasing percentage of obese children, who are establishing a solid foundation for heart disease, diabetes, and a host of other maladies later on in life.

At the root of this pediatric healthcare problem is the lost connection between children and nature. For many reasons, children today fail to spend enough time outdoors in natural environments, which is an ideal setting for childhood development, social interaction, and recreation.

Fortunately, there are entities, like the Natural Learning Initiative (NLI), a research and design assistance program within North Carolina State University’s College of Design, that are making great strides to reverse the trend and bring nature back into children’s daily lives. NLI promotes the importance of the natural environment in the daily experience of all children through environmental design, action research, education, and  dissemination of information.

NLI has overseen a number of projects related to natural play, including 60 demonstration sites for its Preventing Obesity by Design (POD) program, as well as the development of an ongoing project launched in 2009, known as the Nature Play and Learning Area Guidelines project.

Robin Moore, a North Carolina State professor of landscape architecture and director of the Natural Learning Initiative, explains that while the majority of his team’s research has been focused on child development facilities like schools and daycare centers, there is great value, from a therapeutic perspective, in providing natural environments for children in the context of healthcare institutions.

“We talk about the child’s need for release from the stress of indoors, where medical procedures impinge on the child in highly structured environments,” Moore says, adding, “Walls confine the patient the whole time. Outside in the garden, conditions are reversed. The child gains a sense of freedom and stress is relieved.”

This contrast in experience between indoors and outside reflects what researchers Rachel and Stephen Kaplan have termed “directed attention” versus “voluntary attention.” For patients inside hospital rooms, the focus is on what’s being done to them; however, when outside, patients are free to let their minds and bodies wander.

“There’s a clear argument, supported by evidence, that we all should be spending more time outdoors, especially children,” Moore says. “But how? At NLI we say environments have to be compelling. Our design response focuses on natural diversity and the intrinsic interest that nature provides for a child, creating settings that offer something different every day. A hospital healing garden can become a type of special friend for a sick child and provide a positive relationship very different than that of a hospital ward. For the sick child meeting with a sibling or friend, nature provides a vehicle for close social contact. There’s always something new to observe and talk about.”


Appreciating the view
Kathy Harper, RN, MBA, EDAC, is the director of clinical planning at Parkland Hospital, a facility founded in 1894 that serves as Dallas County’s public hospital. She has a unique perspective from working for years on the clinical side of healthcare before moving to the institutional side, first with Children’s Medical Center of Dallas and now Parkland.

“When I was working in a clinical setting, land was there to be built on and not for anything else,” Harper says. “As long as the patient had a view of sunlight, it was great. That was pretty much the extent of it. Now, nature is an active part in the healing care of the patient; rather than just looking out the window, you go into nature.”

Harper says it was in the mid-1990s that she first encountered an outdoor healing garden at a hospital in Greenville, Texas, and knew it was something needed at other healthcare institutions. It was around this time—during which Harper’s interest in patient-centered design and care was cresting after studying Roger Ulrich’s research—that Children’s Medical Center of Dallas was focusing on the patient experience and recognizing the importance of patients being outside.

As a result, Children’s worked with a design team to transform a primarily concrete, one-plus-acre setting into a welcoming environment studded with playful elements. It included a children’s art wall carved from local limestone with tactile features; seating areas surrounded by cast-glass art panels; artistic dancing dragonflies; an outdoor café; and a babbling brook accented with an artist’s interpretation of fish swimming upstream.

 “The landscape begins to serve a purpose,” Harper says. “From what I’ve seen, patients and their families who can go outside, walk around, feel the sun, and enjoy the shade come back inside feeling much better. I’ve seen the benefits of it.”


Beyond the garden gate
In addition to providing usable outdoor space at healthcare institutions, opportunities exist to promote natural learning and outdoor recreation through partnerships with other public and private entities.

During her time with Children’s Medical Center,Harper was involved in the initial planning and development efforts for the hospital’s Plano, Texas, campus, Children’s Medical Center at Legacy. Prior to initial master planning efforts, the City of Plano Planning Department approached the Legacy team about a nature trail running through the city, which it planned to pass through this new property.

“We all worked together and came up with a method to keep some of the land wild and not make any improvements on it,” Harper says, “and it would tie into what the park and recreation system was trying to do with its trail system.”

Similarly, at Parkland, Harper and her colleagues have initiated discussions with the team behind the Trinity Strand Trail—a planned 7.8-mile, non-motorized hike-and-bike trail along the original Trinity River watercourse, adjacent to downtown Dallas—about partnership opportunities, with the hopes of making connections to the future trail segments.


Setting the stones in place
Of course, there are several key logistical issues that should be considered early on when designing a natural play environment. Of primary importance is the climate of the play area’s setting. In some parts of the country, an outdoor space could be used up to 250 days a year, while others may average closer to 60.

Moreover, even in milder climates with abundant sunshine, it’s essential to provide ample shade during summer months when temperatures can reach triple digits.

The design of outdoor spaces should also relate to the particular needs and age groups of users. For instance, with preschool children, natural areas like gardens provide sensory stimulation, which is a fundamental aspect of childhood brain development. For older children, oftentimes the social aspect is most imp
ortant. For children with special needs, particularly ADHD, research demonstrates the positive attention-focusing effects of a natural environment.

Thus, it’s important to design specific areas for the particular needs and age groups of all patients.

Another important consideration is the size of the outdoor space. While in most situations a healthcare institution has a finite amount of green space to work with, in some cases—when an institution is developing a new facility and breaking ground—the amount of available outdoor space can vary widely. It’s important to choose an appropriate size of outdoor space that corresponds with the size of the facilities and number of patients who will use it.

An expansive, multi-acre outdoor space can end up being largely inaccessible if patient rooms are not close enough for easy access. In addition, the larger the outdoor green space, the more extensive its maintenance needs will be.

The growing emphasis on preventive care as a means of stemming today’s pediatric health problems is encouraging. By educating children, families, and caregivers about the importance of nature play—and providing more opportunities for outdoor recreation in all settings, including healthcare facilities—we can help mitigate the problem and lessen the need for more patient beds. The key to getting there is through education and partnership.  

Brian Ott, ASLA, LEED AP, is Managing Principal, Austin, for TBG Partners. For more information, please visit