Following on the heels of Fresh Air on My Face (Gilliard and Marshall 2012), Marshall and Gilliard have presented the care sector with yet another challenge concerning the natural world – and rightly so. Quite simply, ‘the aim of this book is to get people with dementia outside in contact with nature more often, by making outside areas and outside experiences more familiar to them’ (p. 25). The diversity of viewpoints they have invited into this collection to articulate the ways this can be done is to be applauded. Each of the 12 contributors is given a chapter, which collectively represent perspectives from Norway, Scotland, England, Japan, Africa, Canada, Australia and Britain more generally. The place settings explored are various and include the care or nursing home landscape, the visited landscape and countryside, a retirement community, South African homesteads, the hospital, coast, farm, moors, hills and islands.
The editors feel that ‘this is a very new approach to outside areas, where there is very little literature or guidance’ (p. 143). However, the design of cultural landscapes is well-established for landscape architects who regularly address the natural and familiar – if it is specified in the design brief. Because this dimension of person-centred care is hard to achieve, these solutions are offered:
1. Change our language from ‘gardens' to ‘outside’ or ‘outdoor spaces'.
2. Know about the backgrounds of people using the spaces.
3. Be aware of diversity.
4. Build this awareness into the core thinking of any establishment or design.
5. Provide culturally appropriate outside spaces and objects through spatial design.
6. Provide for staff what is meaningful for them also.
This powerful little book strongly advocates for better care quality, not just to provide activity and spaces that are culturally appropriate, but because our engagement with nature is therapeutic – physically, emotionally and spiritually. Reading perhaps between the lines, this message is however loud and clear. In Sidsel Bjørneby's chapter, ‘How Norwegian People with Dementia Experience Nature’, we learn that, ‘(t)raditionally, nature represents what people in Norway value … most old persons in cities have spent their childhood and youth in rural districts, where life was close to and dependent on nature’ (p. 79). The photos and memories of life on the coast and the farm are exquisite. In the rural and island Scottish communities, Gillean Maclean tells us it is ‘literally a matter of life and death to those who have lived their lives in a rural environment that they have access to fresh air and stimulating and familiar views, sounds and smells' (p. 94). In the North East of England, Karen Franks and Kate Andrews discovered in their urbanised setting that the participants sought out ways to connect with the natural world throughout their lives. ‘They used nature as a way to bring balance to their lives and their emotional state’ (p. 123). Joan Domicelj relates people with dementia to the migrants she studied, how they ‘leave behind the physical settings and communities that underpinned their cultural identities and enter new environments that may be hard to adjust to. Their experiences can, perhaps, act as useful metaphors for those felt by people with dementia who are being cared for in unfamiliar places' (pp. 136–7).
We also learn about individuals who are part of ‘a closely knit landscape’ from Margaret-Anne Tibbs in ‘Some Southern African Understandings of Nature’:
The bush in which they live is so essential to who they are that [it] is almost impossible for them to imagine life away from it. As people age, the need to return to the particular landscape which contains their homestead becomes hard to resist. For people with dementia this need to be enfolded by the landscape may become essential to their wellbeing. (p. 65)
A powerful voice on the therapeutic value of nature for people with dementia is Beth Britton's. In the retrospective of her father, ‘A Family's Perspective on Nature and Dementia: Using the Great Outdoors to Help the Inner Person’, she says, ‘by failing to appreciate the need to remain connected with the world around them, those caring for people with dementia are contributing to the mental decline associated with this disease’ (p. 31). This is fact, plain and simple.
This book could also have been titled …Spiritually Appropriate Outside Spaces. It contains riveting messages about the interconnection of spirit, dementia and place. Wendy Hulko's chapter, ‘Digging Up the Roots: Nature and Dementia for First Nation Elders', draws from interview data from Secwepemc People, one of three Aboriginal groups in Canada. This group ‘views dementia as a relatively new phenomenon brought on largely by colonization and the resulting destruction in their traditional lifestyles' (p. 96). And since, ‘the health of the environment is seen to be directly tied to the health of the people … nature has a role to play in the prevention of memory loss in later life and the care of persons with dementia’ (p. 96). Hulko references the causes of dementia as largely social and environmental (diet, chemicals, medication, pollution, trauma, drugs and alcohol, etc.) as opposed to biological. This research insists that ‘nature can and should be drawn upon in caring for Elders experiencing memory loss and/or diagnosed with dementia … whether it be food that is drawn from the surrounding land or water, holding storytelling sessions with youth outdoors, or in combination with activities such as digging up the roots or growing tomatoes' (p. 102).
An outstanding chapter by Judith Jones highlights the relevance of the spiritual and meaningful aspects of nature in ‘A Sense of Place: An Anthroposophic Approach’. Simeon Care in Aberdeen is an outstanding Camphill community home which draws together nature, spirit, anthroposophy and Christianity into the love and nurture of older people.
In Simeon we recognise that one positive way of alleviating stress is by maintaining what is natural and familiar … The simplest things can bring the most joy – opportunities to peel vegetables, to look out at the changing weather and go for walks in the garden. These are opportunities life gives us to restore the familiar, to share experience and to allow the healing and harmonising spirit in nature to work. (p. 118)
This book is appropriate for care service providers to prompt reflection on the care home experience and suggest improvement. It needs to be read by design professionals working in the care sector who don't often meet or get to know people with dementia. Occupational and horticultural therapists could also gain some valuable insight and activity ideas. As well as calling for understanding and action in both environment and care quality improvements, this book contains insight into the greater spiritual question. Nature is not just a healthy diversion from the hi-tech world but a winding path into our core beliefs about the meaning of life across all cultures. How central this is to the experience of growing older.
