Research has shown that human wellbeing and health improves with the ability to spend time outdoors and to have access to green spaces and other forms of Nature (Gidlöf-Gunnarsson and Öhrström, 2007; Bush and Doyon, 2019; Jennings and Bamkole, 2019; de Bell et al., 2020). Our connection to Nature is strongly rooted in our evolutionary process and is an integral part of our regional identity. As humans, we engage with our environment and the natural world on both a physical and psychological level. The physical level refers to the direct interaction between humans and landscape, as a part of a complex, self-regulating system that includes biotic and abiotic elements that work together to maintain and perpetuate the conditions for life on Earth. The psychological level goes beyond what is tangible and delves into the underlying connection existent between humans and their environment (Born et al., 2001; Roös, 2021). This psychological connection is explored in the concept of “biophilia,” which was introduced by Fromm (1973) and later developed by Wilson (1984). The term biophilia refers to the innate attraction humans have toward nature and natural elements and is exemplified in the fields of architecture and urban planning by Kellert and Wilson (1995). The impact of biophilia can be traced to two different origins: first, being in the proximity of nature and visually interacting with natural elements (plants, animals, other people) and second, the response to biomimetic environments, which are designs that incorporate elements inspired by nature (Fromm, 1973; Wilson, 1984; Kellert and Wilson, 1995; Berto and Barbiero, 2017; Salingaros, 2019; Zhong et al., 2022). The mechanisms underlying these responses to the natural environment, as indicated by Philipp (2012), are similar to those of many other complementary and alternative medicine (CAM) therapies. External sensory stimuli releases natural opiates, such as endorphins and enkephalins, in specific regions of the brain. Thus, biophilic environmental stimuli can reduce depressive symptoms, speed up the healing process after stressful situations, and enhance cognitive function (Beute and de Kort, 2018; Gianfredi et al., 2021; Meuwese et al., 2021; Syrbe et al., 2021; Bressane et al., 2022; Szabo et al., 2022; Jin et al., 2023). These scientific insights bring a greater depth to our understanding of the strategies for incorporating biophilia in outdoor spaces design, including in urban design, cities presenting challenges in meeting environmental and societal wellbeing needs. The profound effects of biophilia demonstrate the importance of intentionally designing these spaces with a strong focus on nature, with strategies like integrating natural elements and processes, large variety of plants for a rich sensory experience and biodiversity, create habitats for wildlife, inclusion of water bodies that can add aesthetic value while providing calming sounds, generally use natural materials and mimick natural forms and patterns. A successful biophilic design encourages interaction with the natural world by integrating areas for gardening and sensory experiences, edible landscape, walking trails that incite and create curiosity, while learning about environmental systems, this leading to a stronger connection between man and nature, reinforcing the vital role of biophilia in communities, underscoring the potential for created green spaces to contribute to the environmental, physical and mental health (Soderlund and Newman, 2015; Lin et al., 2018; Xue et al., 2019; Totaforti, 2020; Russo and Andreucci, 2023). These principles find exceptional significance and their potential could be explored especially in spaces used by people that need recovery and care, in the context of healthcare facilities. Green spaces around the hospitals serve as prime locations for fulfilling the potential of biophilic design, forming a key aspect of the built environment, and also playing a significant role in the health and wellbeing of patients (Zhao et al., 2022). This importance transcends active engagement with nature; studies show that, sometimes, even a passive interaction, something as simple as a view of a natural scene from a hospital bed can have positive effects on patients that had surgical intervention, creating feelings of hope and strength that may contribute to a more efficient recovery process (Ulrich, 1986). The healing process consists not only in providing medical care, access to treatment, and medical procedures; but also in providing a healing environment for both physical and spiritual rehabilitation (Bratman et al., 2019; Fancourt et al., 2021), since “healing is a psychological and spiritual concept of health” (Özcan, 2006). The Optimal Healing Environment (OHE) framework suggests that the healing process has both inner and outer implications, and healing spaces that incorporate natural elements may be an important factor that still needs further research (Ananth, 2008).

Looking back in history, ever since the Middle Ages, the outdoor spaces of hospitals were designed in order to provide resting places where the ill could enjoy fresh air. As modern medicine advanced and the architectural design of hospitals became increasingly complex, the incorporation of outdoor healing spaces has been varied in use, new ideas and research directions began to develop, having as goals to explore the therapeutic opportunities of healing gardens or restorative landscapes, bringing together fields like architecture, landscape design and medicine, a blend that begins to reintroduce the ancient connections between healing and nature into the contemporary medical environment (Cooper Marcus and Barnes, 1995; van den Berg, 2005). Gardens, being humanity’s closest connection to the natural environment, have been and continue to be an important adjuvant in the process of stress rehabilitation being not just spaces for recovery but also for interaction and exploration. Furthermore, green spaces can be a statement to the power or adaptability and resilience, their natural cyclicity and transition trough seasons suggest the potential for renewal and growth after periods of dormancy, thus serving as a metaphor for patients on their healing journey, supporting the idea of hope and resilience during challenging times (Nordh et al., 2009; Adevi and Mårtensson, 2013). Current research has shown that gardens can offer sensorial places for autistic children, giving them opportunities to spend time outdoors in a calming environment, or designed to create invigorating landscapes for hyporeactive patients (Barakat et al., 2019; Ghazali et al., 2019). Other conditions, like depression and anxiety are experienced not only by mentally ill patients, but also in cases of convalescence, post-surgery recovery, COVID-19 measures of isolation or prolonged hospital stay. Being involved in outdoor gardening activities can have an ameliorative effect on people suffering from psychological distress by alleviating symptoms (Gerdes et al., 2022; Yang et al., 2022). During the COVID-19 pandemic, the use of green spaces and parks and participating in outdoor activities enhanced young people’s mental health and wellbeing, and was linked to lower the levels of emotional distress (Jackson et al., 2021; Larson et al., 2022). Designing areas surrounding hospitals as therapeutic gardens provides spaces for patients, institution staff, and family members to use and enjoy. It is proven that spending time in the garden walking, contemplating, or engaging in gardening activities could result in a decreased dosage of antipsychotics in dementia affected patients, in mood improvement and increased calmness (Rivasseau-Jonveaux et al., 2012; Whear et al., 2014). This pandemic underscored the critical role that well-designed and maintained therapeutic spaces can play in human health, and one way to ensure the effectiveness of these spaces is by conducting Post-occupancy evaluations.

Post- occupancy evaluation (POE) is a process by which the performance of a built environment is evaluated by users that express the satisfaction level concerning the space. This helps to determine how successful the design intent is and contributes to improving the design of therapeutic spaces (Moore, 1983; Preiser et al., 2015). Even though involving the end-user in the design process helps to create more suitable environments, post-occupancy evaluation is an important tool that offers valuable insight into the newly created space from the perspective of patients, family, and staff (Jiang et al., 2018; Lygum et al., 2019). It might provide information that may not have been considered even during the participatory design process (Buse et al., 2017). The physical environment, even though it has a major influence in a patient’s recovery, is not the only focus a design should have but also the social and interaction aspects, psychological or spiritual implications, thus the exploration and comprehension of the necessities that the final user has, are vital in developing an effective outcome (Abbas and Ghazali, 2011; Ghazali and Abbas, 2012a).

The presence of a garden is highly valued, and participating in garden activities can make nursing home residents feel a sense of familiarity and comfort (Eijkelenboom et al., 2017). Gardening activities or even spending time outdoors in a garden have beneficial implications in the patient’s state of mind, caring for the plants and enjoying the outcome from that process can have therapeutic effects (Piat et al., 2017). Horticulture therapy, along with other forms of conventional therapy can be an adjuvant factor and make a difference in the treatment of individuals suffering from mental disorders. Being involved in activities like fruit harvesting, planting, weeding, provides patients with a sense of purpose, and a valuable opportunity to spend time outdoors (Vujcic et al., 2017).

This paper provides a unique exploration of the opportunities offered by the green spaces around healthcare facilities, specifically, their development as sensory-therapeutic gardens. While similar research focuses on the physical characteristics of such spaces, the present study delves deeper into the importance of user feedback research for the improvement of design strategies for this type of garden. This research integrates findings from a selection of existing Post-occupancy studies conducted in healthcare facilities, underlining how user experiences can meaningfully inform the design process. The gathered information has led to the identification of a set of key principles which were subsequently applied in the design of a sensory-therapeutic garden in a healthcare setting in Cluj-Napoca, Romania. The study bridges the gap between theory and practice, demonstrating how insights from the field can be transformed into design decisions and its contribution lies the way the principles are applied, integrating user feedback, and situational context to enhance the functionality and relevance of therapeutic gardens. This approach can enhance the quality of user’s life while contributing to more sustainable, user-centered healthcare environments.

The research methodology for this study consists in three distinct stages. The first stage, was the consultation of various articles focusing on Post-occupancy evaluations of healthcare facilities, with the goal of identifying key principles in therapeutic landscape design. The second stage involved on site visits for data collection and the final stage, the application of these principles, informed by the literature and on site data, in the specific context of a sensory-therapeutic garden design in Cluj-Napoca, Romania.

Green spaces within the proximities of hospitals offer opportunities for patients to break a monotonous daily indoor routine and to spend time in nature. It is also beneficial for family members and visitors to interact with patients in a comfortable, relaxing environment and for the medical staff to have a peaceful place to retreat during a break. Using program elements like the present study suggests can help to redeem underutilized places in healthcare areas and help to transform them into healing environments (Cordoza et al., 2018; Weerasuriya et al., 2019). This paper adds to this body of knowledge by presenting an integrated approach toward designing sensory-therapeutic gardens. Drawing from a range of literature sources focusing on Post-occupancy Evaluations, rather than conducting a traditional literature review, to gather a set of key principles for therapeutic garden design. However, despite the design principles presented in this study, the design of sensory-therapeutic gardens remains a challenge due to the complexities of users’ needs and specific site conditions, underpinning the need for continuous refinement and adaptation of design principles based on site-specific evaluations (Jiang, 2014; Thaneshwari et al., 2018). Our research included a literature exploration of various articles focusing on Post-occupancy evaluations of healthcare facilities, gathering insights from a spectrum of healthcare contexts, further translating these principles into the specific context of a sensory-therapeutic garden design in Cluj-Napoca, Romania (Polat et al., 2019). Implementation of such initiatives and feedback from the users can bring improvements in the design process and thus lead to better understanding about the requirements of a therapeutic garden (Ivarsson and Grahn, 2010; Uwajeh et al., 2019). Post-occupancy research emphasizes the user’s needs, and highlights the positive and negative aspects of the newly created space. This then contributes to the constant improvement of the therapeutic garden design guidelines, aiding specialists in developing enhanced healing environments (Abbas and Ghazali, 2012; Sidenius et al., 2017).

Healing gardens with therapeutic properties are spaces that assist the recovery process and have both physical and spiritual implications (Hastuti, 2020; Hastuti and Lorica, 2020). Drawing from the user feedback and design key principles extracted from the literature exploration, the defining design features of therapeutic gardens encompass: (1) creating a well-organized space, (2) taking in account the facility’s profile when designing the space, (3) prioritizing softscape over hardscape, (4) supporting human-nature interaction, (5) ensure access and visibility, (6) provide plenty of seating and shaded areas, (7) include water features (8) design secluded areas for staff, (9) use vegetation and natural elements for multi-sensory stimulation, and (10) encourage biodiversity. This comprehensive set of principles provides a blueprint for the sensory-therapeutic garden design, that aligns with the previous findings (Vapaa, 2002; Asano, 2008; Pouya and Demirel, 2015). Furthermore, the design process presented in this study demonstrates how the principles derived from the literature exploration and user feedback were translated into a specific garden design, thus proving their applicability in real-world design scenarios.

The design features of the therapeutic garden should ideally meet the specialization of the hospital and the pathology of the users, as different types of patients have different needs. It is important to emphasize that not all pathologies have been extensively researched in terms of therapeutic gardens design, thus there still might be cases where in order for the user’s needs to be met, the specialists creating the garden need to rely on their professional experience and on a collaboration with the end user in developing the design (Eckerling, 1996). For example, garden design for cancer patients should have different properties than the one designed for children, mentally ill patients, or hospital staff in terms of colors, activities, fragrances, and accessibility; but they all should create a safe space with plenty of vegetation, provide shade, comfortable seating and facilitate independent movement (Fleming and Figueiredo, 2013; Paraskevopoulou and Kamperi, 2018). These are facts that are in concordance with the design proposal, having specific vegetation for lung pathology-related patients, providing medicinal plants and fresh fruits through the medicinal and edible plants area, that enhance the tactile sensory experience for patients with visual impairments.

By design, the aim of sensory-therapeutic gardens is to offer sensory experiences, with a recreational and/or educational outcome, actively engaging its visitors in exploration by stimulating all the senses: tactile, gustatory, olfactory, visual, auditory and movement (Hussein, 2010; Stepansky et al., 2022), the present proposal includes these features by integrating tactile, visual or auditive stimulating vegetation. Such gardens, besides a senses-themed design, should afford activities like fruit harvesting, exploration, interaction with the environment by using species with interesting foliage, incorporating water features, diversifying hardscape materials, stimulating curiosity, being accessible to all visitors, and to encourage social gathering (Hussein et al., 2016; Siu et al., 2020), a requirement sustained by the proposed occupational therapy area.

A very important part of a successful therapeutic design would be the patient’s, family members and medical staff involvement and/or opinion in the design process from the beginning, since they will be the final users of the space, and maybe have different expectations, needs or ideas for the garden (Heath, 2004; Senes et al., 2012). This was an aspect that in this study was not considered. Also, staff members are directly involved in the patient’s recovery and are as equally important when making design choices about their working environment. Research indicates a significant gap in finding what medical staff needs in order to provide quality services while preserving their own health (Huisman et al., 2012; Smidl et al., 2017), so in the present design proposal it was considered necessary to integrate a secluded area for the medical staff. Besides recommendations from scientific literature or user feedback, another factor that might influence the outcome of a therapeutic garden design is the site’s location and surroundings. Aspects like the terrain topography (slopes, flat terrain, or mixed), climate (influences the vegetation palette that can be used in the design), vicinities (can bring the necessity to create sound barriers being located near a noisy area, or some sights might need to be highlighted or, conversely, hidden) can have major implications in the decision making process regarding the zoning, functions and aesthetics of the garden (Salamy, 1995; Shahrad, 2012). In the present study, the fragmented space led to the partitioning of the functional zoning of the space.

While POE method can provide valuable information on designing healing spaces, more modern evaluation methods can be used, that offer more objective, time efficient and standardized approaches. For instance, in individuals with dementia, the positive impact that the garden exposure had on the mood and reduced medication was reflected in the lower levels of cortisol and blood pressure, offering a more accurate evaluation of the therapeutic effects (Pedrinolla et al., 2019; Murroni et al., 2021). Electroencephalogram technology is a non-invasive approach that allows the measurement of mood indicators, and in the context of evaluating individuals participating in gardening-related activities, revealed that, in addition to experiencing relaxation, participants also felt a sense of interest and engagement in the activity (Du et al., 2022). Other methods, like wearable sensors can be used to measure physiological responses to outdoor environments, a method that, combined with the use of virtual reality can reveal the potential impact of a proposed design even before it was built (Skulimowski and Badurowicz, 2017; Zhang et al., 2021). Eye tracking technology can reveal insights on what elements of the garden capture visitors’ attention and for how long, allowing designers to understand what elements are most engaging and appealing, or aspects that may be less successful in capturing interest, and even more, it can help uncover any discrepancies between what the subjects verbally report as their preferences and what their gaze patterns disclose (Amati et al., 2018; Junker and Nollen, 2018).

The evolution of technology and new findings in medicine provide hospitals with equipment that improves the quality of the medical services. However, studies have shown that often this is not enough, and the quality of the environment around the patient has a major impact on the recovery process and length of hospital stay. There has been a preference for the design of old hospitals as compared to the new ones, and there is a correlation between the time spent in the hospital and the user’s satisfaction level concerning the surrounding environment. This shows that over time, designers have lost something of essential value in conceiving healing environments (Ghazali and Abbas, 2012b).

Since ancient times man has felt a deep connection with nature and natural environment, always seeking to integrate it in the healing process, and green spaces around hospitals can provide a great opportunity to create sensory-therapeutic gardens. This study has shed light on the importance of these types of spaces showcasing their potential to facilitate interaction not only between people, but also to encourage a human-nature connection, to provide access to all visitors, and to create a recreational space also for staff and family members. Not only does this enrich the aesthetic of a place with great variety in color and texture given by the materials and vegetation used, but also can invite for further investigation, to bring curiosity into the visitor’s mind. They can create opportunities for outdoor activities like gardening or sensory exploration of nature, by using intriguing and captivating elements in the design but they can serve also as contemplative spaces where one can just spend time outdoor observing nature in silence. Since there are not any precise guidelines for how sensory-therapeutic garden should look like, the design often reflects the landscape designer’s perspective and intuition, but post-occupancy studies often reveal new perspectives, bringing constant improvements. Through an exploration of scientific literature focusing on Post-occupancy evaluations, we have identified key features of healing landscapes that contribute to the effectiveness of these spaces. This paper offers an innovative perspective by translating these general principles into a specific design context, filling a gap in existing guidelines, bringing practical aspects for future sensory-therapeutic garden design, combining literature-derived principles with user feedback and site-specific condition, demonstrating the flexibility and adaptability of these features. However, it is crucial to acknowledge that further research is needed in order to continually refine and improve de design of healing spaces by integrating emerging technologies, enabling more evidence-based design practices.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

MD and AS: conceptualization, resources, project administration, and funding acquisition. MD, AD, and PS: methodology and software. PS, MB, RB, and AS: validation. DD, PS, and MB: formal analysis. MD, D-MM, and DD: investigation. MD and DD: writing–original draft preparation. PS, RB, and AS: writing–review and editing. MD, D-MM, and PS: visualization. MB, RB, and AS: supervision. All authors have read and agreed to the published version of the manuscript.