Carroll and Rendell provide both garden designers and skilled nursing facility administrators and managers with a clear understanding of what supports and perpetuates an actively enjoyed garden. Through numerous firsthand observations and survey findings they introduce the seemingly invisible yet critically important care culture. Further analysis by Carroll and Rendell provide us with a Care Culture Map and the Care Culture Spectrum as tools that need to be shared and discussed by designers and their clients before any design is initiated.

Understanding the social character of the care culture setting into which a new design will be placed or an existing design is to be refurbished allows designer and client to identify where along the 9-stage care culture spectrum it is located, where in terms of active use they want it to be located, and most importantly how to move it to the identified goal.

The Care Culture Map is not a map like that found in an atlas or driving app. It is referred to as a “map” in that you can readily see where you are along the nine-stage, Care-culture spectrum, see where you want your care facility to be, and the steps the administrators of the care setting will need to take to move their care setting to the next stage. The care culture stages or phases move in nine increments from “task-oriented care practices” or the poorest care culture setting, to “person-centered care, to “relationship- centered care” or the best, most supportive care culture of garden use and enjoyment.

While your first impression of the map may be that it is bit daunting, Carroll and Rendell take us step-by-step through its make-up and use. Once you understand how to read it it really is an elegant production. Carroll and Rendell’s down-to-earth language allows you to easily see how to get from where you find yourself in the care spectrum to where you want your care culture to be and how to get there. “The care culture was after all, the key factor in determining whether a garden around a care setting was actively used or not, and to what degree” (6). I recommend having at least one, if not more, copies of the Care Culture Handbook, the Designer Handbook, and the Care Culture Map on hand to share with potential clients.

Having been both a registered landscape architect and associate professor in Canadian and American universities for 40 years, I readily agree with and wholeheartedly support Carroll and Rendell’s thinking regarding their research. As they noted, “As practical people, we decided against publishing our findings in an academic paper and instead created a unique, and visual arrangement of our findings in the form of a map” (2016,5).and for that decision, I am grateful.

As a registered landscape architect, I have devoted my efforts to understanding what environmental designers can bring to the lives of people living with dementia and their care partners. Even so, initially, my training prevented me from seeing the factors bearing on what supports and perpetuates successful actively enjoyed garden experiences. Fortunately, I discovered Carroll and Rendell’s efforts to answer a simple question, “Why Don’t We Go Into the Garden?” It is a poignant two-sided question that their research, research in which they never expected to become immersed, brought them. One side of the question comes from those wishing to go outside and enjoy the benefits of sunshine and the aromas, colors, and textures of various plants. The other aspect of the question becomes more apparent when we ask, “What is Preventing Us from Enjoying the Garden?”

While their research findings are exclusive to the social-management culture of care facilities, much of their findings, the nature and importance of recognizing the care culture, can be transferred to the design and installation of public memory gardens. I wish I was still teaching so I could direct the needed research into what makes for successful public care culture settings.

On behalf of the millions of people living with dementia and the millions of care partners and memory care administrators and staff, I am so grateful for Carroll and Rendell’s practical, down-to-earth research and publications of a little considered approach to successful dementia memory garden designs. Unique to their evidence-based findings is the clarity with which they highlight and simplify the reasons for care-facility gardens failure verses those likely to succeed as vital places of emotional and physical enjoyment. The critical reason is not the quality of the design but the social culture controlling the arena in which a design exists, is set to be refurbished, or into which it will be located. The critical reason is the care culture.

Carroll and Rendell’s firsthand observations and interviews derived from 17 care settings, 600 diary records, and 874 firsthand observations spanning 20 site visits to seven care facilities gave rise to the 3’ x 4’ Care Culture Map.

Visually intimidating at first, the Care Culture Map, in plain, easy to follow language provides 9 progressive care culture settings between Task-oriented Care Practices, Person-centered Care, and Relationship-centered Care. This Care-culture Spectrum enables the designer, in consultation with the culture setting managers to readily identify where their culture setting is situated along the spectrum, what care setting they would like to adopt, and, most importantly, how to get there or what Carroll and Rendell call the Culture-change Journey.

As a poignant, practical, yet critical look at why some memory garden designs succeed and some fail Carroll and Rendell’s garden design program guide vitally strengthens the chances of a highly successful garden design for three reasons. First, in not producing an academic review of their resreach they made their findings readily accessible to and understandable by a broad audience of designers, non-designers, community decision makers, and care facility administrators, managers, and staff. Second, their research may send small tremors through the garden design industry with their eye-opening finding that the quality of a garden design has little to do with the successful use of a garden. The primary influence on a garden’s success or failure resides with the care culture in which it is located.

“While we observed the care practices that were being deployed so deftly and sensitively by the member staff who accompanied the resident [so playfully into a dandelion patch]…we realized that the garden in this care setting for people living with dementia did not need to be pretty or have a variety of features or objects in it in order to be actively used (2016, 4).

[Given that observation] we could see that we needed to re-visit our assumptions that the answer to our original question lay in the design of the garden. We could see that it had something to do with the care culture of the homes, a phenomenon altogether more subtle and harder to capture. Al our subsequent visits to care settings, and our analysis of the information recorded by staff, focused on the practices, processes, and attitudes inside as much as outside the care setting” (2016,4).

And third, in that it provides skilled care facility administrators, especially those caring for people living with dementia and their care partners, with a practical guide, or what Carroll and Rendell call a Care Culture Map, that enables facility administrators and staff to see where they are along a nine-stage care culture spectrum.

Thank you Debbie Carroll and Mark Rendell for pulling the curtain of familiarity back to allow us to see the context, the major factors influencing what is typically considered the success or failure of gardens designed for people living with dementia and their carers and families and friends.

“The evidence from our research also identified that increasing engagement with the current outside space has little to do with needing more time, more money, or more staff.

Rather, it is all about the value placed by the care setting as a whole on the outdoor space to aid in the care and support of individual residents. Some of the most actively used gardens in our research were those that had the least money spent on them and the fewest features.”

As an Eco Gerontologist passionate about optimizing the therapeutic use of outdoor spaces, I highly recommend the Care Culture Handbook and Map. These tools are easy to understand and are perfect for engaging your care team to value outdoor engagement as a form of care. The Care Culture Map is a fantastic diagnostic tool to assess where your community stands and to discover simple ways to elevate your care to the highest level: ‘Relationship-Centered Care’.

Fully Valuing ‘daily’ outdoor engagement as a form of care is key to maximizing the therapeutic benefits of outdoor spaces. Thank You so much Debbie and Mark!!!