design in Dementia care
The concept of group living in the nursing home setting is recognized as being a supportive and positive arrangement for residents with dementia, as well as a
beneficial environment for care staff. There are, however, a number of considerations in establishing a group living concept, with the main one involving the design features of the environment itself. This article looks at the advantages – and disadvantages – of group living as it relates to the ‘Small House’, with its two sub-sets: the Neighbourhood or Household Model, and the Independent Small House Model.
The physical environment sets a limit to what can be achieved
in the care of people with dementia
An important principle in the physical design of nursing home facilities was highlighted by Richard Fleming, a psychologist and director of the Dementia Services Development Centre at the University of Wollongong in New South Wales, Australia: “In the long term, the physical environment sets a limit to what can be achieved in the care of people with dementia – particularly those who are mobile. A good environment can, almost by itself, reduce confusion and agitation, improve wayfinding and encourage social interaction.
“On the other hand, a poor environment increases confusion and problem be-haviours and will eventually reduce staff to a state of helplessness, in which they feel that nothing can be done” (Fleming and Purandare, 2010; Fleming, 2009).
Small scale clusters
In an article entitled “Ten new and emerging trends in residential group living environments,” it was pointed out that one of the most significant North American developments was the movement from large scale nursing homes to small scale clusters of about ten residents each. It was noted that these individual clusters are often combined into group clusters of between 5 and 7 units and connected to a larger system of service provision. Nursing homes in Northern Europe have had this model for years based on clusters of 6 to 8 residents (Regnier and Denton, 2009). Typically, residents’ rooms are grouped around the kitchen, dining, living and activity areas.
Dr. Margaret Calkins, Ph.D., looked at the ten most significant changes in senior living design over the past decade and concluded that the Small-House and Household model was one of the major highlights (Calkins, 2011).
She found that virtually every study that examined resident/staff outcomes pertaining to the size of resident groupings concluded that the outcomes were more positive with smaller groupings. Outcomes included less disruptive behaviours, greater socialization, less use of psychoactive medications, and greater resident, family and staff satisfaction. She went on to discuss the particular efforts being made to deal with codes and regulations that hamper Small-House and Household development.
Small and homelike
In the Fleming-Purandare article, their review of the current research literature found that residents should:
• be able to see the features that are most important to them from the location(s) where they spend most of their time
• have unobtrusive security measures;
• have a variety of amenity spaces;
• have a single bed room; and
• be able to enjoy a minimum of un-helpful stimulation while experiencing maximum beneficial stimulation such as high levels of illumination (Fleming and Purandare, 2010).
The authors further maintained that “it is desirable that the facility be small, have a homelike appearance, provide opportunities for engagement with the ordinary activities of daily living, and have accessible outdoor space.”
Gaius Nelson, a U.S. architect describes the evolution of nursing homes from the “institutional to the small house model,” (Nelson, 2009). Nelson, a pioneer in the movement toward the Small House model, was instrumental in the development of the Creekview Household model in Oshkosh, Wisconsin. He based the size of his Household on the observation that “in any group we tend to see one-third of residents who participate in all offered activities, one-third who almost never participate, and one-third who may or may not join in.” He concluded that a Household of between 8 and 12 would provide the optimum formation for a social group of between three and eight residents.
Small scale ‘dementia homes’
Caroline Cantley and colleague re-viewed several British nursing homes in her book “Put Yourself in my Place,” (2002). She found that there is broad agreement that it is desirable for dementia care Homes to be small scale – in the range of six to around 14 residents. She points out that as the size of the unit increases, there is a move away from having a “family feel” in the Home. Despite this, however, she indicates that financial viability is driving the size of Homes upward in number of residents cared for.
Staffing models and costs are also impacted by the size of the house. The Multilevel Design Guidelines British Columbia 1994 recommended, for example, that “the Care Unit (House) should have the smallest number of beds that is operationally feasible with available staffing.”
Recently a Health Authority in B.C. moved from recommending 18 as the maximum number of residents, to Houses of 25, with 20 the preferred for dementia units (Fraser Health, 2007). These larger Houses can compromise the quality of care, with longer corridors and larger groups of residents to manage.
Mitigating the negatives
There are physical designs, however, that can mitigate some of the negatives associated with larger Houses. An L or Chevron shape or an H shape, for example, can provide sub-divisions within the larger House, i.e., two wings or smaller Households which could each have 5 to 12 resident bedrooms with adjacent lounge and dining area. Alternatively, the combined census of 10 to 24 could dine together for staffing efficiency. The combined wings would share utility and other support areas.
Nelson (2009) points out that inter-connected multiple Households have greater flexibility in either adding staff as needs increase, or reducing staff levels during the night time. This is particularly important where residents with behaviour or mental health issues are cared for. Adjustments in staffing levels are more difficult in separate detached houses where staffing can never be reduced to less than one staff member per Household.
Hilde Verbeek recently published her thesis for Maastricht University titled “Redesigning Dementia Care,” which is an evaluation of small-scale, homelike care environments (2011).
She designed and executed a twelve month study in the Netherlands com-paring dementia residents of twenty-eight small-scale living facilities with an average of six to eight beds, with twenty-one traditional nursing home wards of at least twenty residents each. Residents were matched for cognitive and functional status and stage of dementia.
She found significantly fewer physical restraints and psychotropic drug use in the small-scale living facilities compared with regular wards. In addition, residents in small-scale living facilities were significantly more soc-ially engaged, and displayed more physically non-aggressive behaviour, such as wandering, than residents in regular wards.
Verbeek also found significantly lower levels of burnout symptoms for nursing staff working in most typical small-scale living facilities. Family members and staff mainly reported positive experiences with the small-scale living arrangement. Families were especially appreciative of the personal attention staff could provide their loved ones.
Department of Veterans Affairs (USA) Design Guide
In June 2011 the US Department of Veterans Affairs brought out its much awaited Design Guide for Community Living Centres (formerly called Nursing Homes). The authors describe their new Design Guide as a “paradigm shift” transforming the driver of care in nursing homes from a medical model to “resident centered care” based on the Small House model of 10 to 12 residents. They see the Small Houses grouped into neighbourhoods of not more than twelve homes, with a community centre hub for social activities and support services. http://www.cfm.va.gov/til/dGuide/dgCLC.pdf
A major consideration in Smaller Houses or Linked Households is that of the financial impact.
Jenkins and colleagues discuss this in their recent article, “Financial Implications of the Green House Model” (Jenkins et al., 2011). It was found that the operations of the Small House model are comparable in cost to traditional nursing home operations. For example, care staff generally multi-task; the increase in staff needed to cover smaller units is offset by a commensurate decrease in housekeeping, dietary, laundry, activity and administrative staff.
Verbeek in her study found that small-scale living facilities were reported to be more vulnerable to shortages in staff. She adds that the size of these small facilities, which average seven residents per House in the Netherlands, could hamper their financial feasibility. To overcome this she points out that some explorative studies suggest that a clustering of units or slightly larger groups (e.g., 10 to 12 residents) could improve the facilities financial feasibility. She calls for more cost-analyses and cost-effectiveness studies. Anecdotal information and experience suggests that linked households and grouped houses offer the best economies of scale for operations as opposed to independently located Small-Houses.
Rethinking amenity space
One impact of smaller, self-contained wings or Households is the need for a larger allocation of amenity space. Houses need to be self-contained in terms of amenity space, i.e., lounge, activity, and dining areas. Allocation per resident for these areas averages around 2.5 square metres [27 sq. ft.] for lounge/activity, and 3 square metres [32 sq. ft.] for dining. In addition, there is usually an allocation for multipurpose space.
Recent post-occupancy reviews indicate that, with the increasing complexity of residents in care, it really is necessary to rethink the allocation of amenity spaces. It is becoming especially difficult for complex care residents to actively participate in more traditional programs such as a Country Kitchen or entertainment activities and larger gatherings outside the residents’ House. As attractive as it is to provide programming outside the residents’ House, it is becoming less practical, and extremely staff intensive. Portering complex care residents to out-of-house amenities not only takes a lot of staff time, but stretches staff resources left to manage residents remaining in the Houses.
Facilities are reporting that complex care residents are increasingly using in-house spaces for entertainment and group activities. Moreover, there is not a great deal of mixing of resident groups for these larger types of activities; i.e., frail but stable elderly residents do not really appreciate being grouped with dementia residents for social activities.
In order to sub-divide the Large House population of 25 to 30 into more manageable Social Wings or Smaller Households, it really requires an increase in the in-house allocation of social space. Something in the range of 3 to 4 square metres [32 to 43 sq. ft.] per resident will allow sub-groups to have their own lounge and activity areas. This can be achieved by transferring some multi-purpose space to within the House. This would still leave some multi-purpose space for those residents who can participate in out-of-house activities; this could be a family and visitor meeting area such as a café or multi-purpose meeting room and chapel. This additional in-house amenity space can be offset with a reduction in corridor area, both in width and length. There is some movement towards corridor-free designs, though this has licensing/regulatory barriers.
One factor to consider in reducing the area requirements for corridors is to reduce the use of handrails which effect the usable width of corridors.
In British Columbia they have been building some complex care facilities without handrails. The thinking is that residents who use mobility aids do not need hand rails. Indeed, much damage is done to walls when residents in wheelchairs use handrails inappropriately to propel themselves along.
The elimination of handrails could be a considerable cost saving. Nelson, in his article (2009), states that “within a Household, the need for and desirability of handrails is significantly reduced, if not eliminated.”
A case can be made for more home-like, narrower corridors, i.e., 1830 mm (6 feet), rather than the traditional 2400 mm (8 feet) of nursing homes.
The Ontario Long Term Care Home Design Manual (Ontario Ministry of Health, 2009) calls for a minimum corridor width of 1820 mm (6 feet). Building Codes have traditionally required that corridors be 2400 mm (8 feet) as it may be necessary to move a resident in a bed in emergencies. However, the new National Building Code of Canada (NBC, 2010) contains a new occupancy classification for care facilities, and requirements that are commensurate with the anticipated use conditions of a variety of facilities that provide care, but do not perform invasive medical treatment.
One of the results of a changed classification for some care facilities is that “corridors shall be at least 1650 mm wide” (5.4 feet). In addition, dead-ends up to 6 metres (20 feet) long are permitted by the 2010, National Building Code.
The Multilevel Design Guidelines, British Columbia 1994, point out that a 1830 mm corridor width [6 feet] with rest areas or lay-bys at the resident room doors is adequate to move beds in and out of the resident rooms and is also adequate for two wheelchairs and for people with moderate to severe cognitive dysfunctions to pass each other. The main advantage to the wider 2440 mm corridor [8 feet] is the accommodation of cleaning and storage carts which frequently clutter corridors. This could better be met with built-in alcoves, or adequate equipment and supply storage, or both.
The Design Guidelines for Queensland Residential Care Facilities (1999) call for “discrete bays to provide for trolleys and equipment.” A 6-foot-wide corridor with alcoves and inset doorways could work quite satisfactorily and save considerable space. Nelson recommends the elimination of the requirement for eight foot corridors in nursing homes, and going with six feet instead (2009).
Excessive corridor distance
An interesting analysis of the effect of excessive corridor distance is provided by Celine Pinet in an article entitled “Distance and the Use of Social Space by Nursing Home Residents.”
Pinet (1999) studied the behaviours of 960 residents in five nursing homes and concluded that there was a significant negative relationship between distance and the probability that a resident would use a social space. A space 6 metres [20 feet] away would be used five times as often as a space 30 metres [100 feet] away. A double-loaded corridor with 15 resident rooms can easily be over 40 metres in length (130 feet). Pinet concludes by suggesting that it would be advantageous for spaces used for informal socializing be located closer to the residents’ bedrooms.
Victor Regnier in his book, “Design for Assisted Living” (2002), also sup-ports shorter corridors. He indicates that there should be a bench or a chair every 10 to 12 metres [35 to 40 feet], and that corridors, without an offset, should be no longer than 10 to 12 metres.
“The single point perspective of a 30 metre-long [100 foot] corridor can be overwhelming…. Asymmetrical corridor plans are more interesting than an orthogonal square and often aid orientation” (Ibid., 2002). And this brings us to the issue of the physical layout of the House.
The Small House layout – floor plan design
Key elements to review for efficiency and effectiveness, or functionality, are the overall layout of Homes in terms of grouping of core services and amenities, location of bathing rooms, corridor length, and privacy zones. The functionality and co-location of components (i.e., amenities, etc.) is critical in reducing distances travelled, and facilitating wayfinding; probably the least successful in achieving this is a rectangle of rooms around a large courtyard.
Small Houses have the advantage of minimal corridors or short straight corridors linking resident rooms to core amenities. In Larger Houses, layouts that work best utilize wing designs such as A, Y, V, T, X, H or L shapes with short corridors and amenities grouped together. A courtyard can work if shared by two U shaped Houses so that travel distances are minimized.
Gesine Marquardt in ”Wayfinding for people with Dementia: A Review of the Role of Architectural Design” provides an excellent summary of research on this issue.
In particular, Marquardt evaluates straight corridor, L-shaped, and square designs.
She found that a fundamental problem for dementia residents was the declining ability to visualize in one’s “mind’s eye”a map or a path way to a destination : “most participants were incapable of developing an overall plan to solve a wayfinding task”: not only can they not see around corners, they can’t visualize what’s around the corner. She details results from studies such as Passini and her own that found a short corridor design is best, with easy line of sight to destinations like amenities; and next, an L shaped design with only one change in direction. Preferably the amenities are located in the angle of the L with resident rooms along the arms, again making for a straight line of sight. Square shapes with multiple changes in direction are difficult for dementia residents to navigate because of numerous shifts in direction. Long, undifferentiated double-loaded corridors interfered the most with residents’ wayfinding abilities.
She concluded that “the layout of the circulation system significantly affected the residents’ orientation and was identified as the most influential environmental factor on a resident’s wayfinding abilities.”
Floor layouts with multiple shifts in direction can be mitigated with reference points or spatial anchors such as landmarks, signs, pictograms, memory boxes, etc.; and by spatial proximity of amenities such as the dining, living, activity rooms.
Marquardt also explores Outdoor Wayfinding. She found that outdoor space is more used if it is easily accessed: i.e. from the dining/living room area: i.e. good visual access.
To function well the Homes need to be laid out in a way that organizes day-time amenity areas in an efficient way for staff and residents, provides a privacy zone for bedrooms and bathing, and keeps corridors short for the frail elderly, for wayfinding and for staff.
‘Hierarchy of space’
Nelson in his article (2009) discusses a “hierarchy of Space” where movement is from a public zone, to a semi-public, to a semi-private, to a private zone. The idea is to achieve short corridors with functional grouping of spaces. In particular, it is important in Larger Houses to achieve some physical sub-grouping within the House so that 7 to 12 residents can meet in more intimate social spaces.
Small house models
Small house layouts can be grouped into two sub-sets:
(1) Neighbourhood or Household Models, i.e., the Adard Model and Nelson’s Creekview with linked groups; and
(2) Independent Small House Model of which the trademarked ‘Green House’ concept is the most predominant.
On another page on this site: Floor plan Layouts for dementia units in Nursing Homes several graphic examples of these two sub-sets of Small House designs are presented, along with brief commentaries on each design .
Both the Small-House models and the Neighbourhood/Household models are emerging across Canada and are proving to be operationally feasible, particularly if linked or grouped together. More research is needed to compare capital and operating costs of these models with more traditional nursing homes.
• Cantley, C. and Wilson, R., Put Yourself in my place, 2002. See: <http://www.jrf.org.uk/sites/files/jrf/1861348118.pdf>.
• Calkins, M., Ten Senior Living Design Innovations, LTC; 60(3); March, 2011.
• Cutler, L., and Kane, R., “Transforming Nursing Homes, Implications,” 2009. See:<www.allhealth.orgbriefingmaterials/GreenHouseDesign-919.pdf>.
• Fleming, R., Environmental design and modification for people with dementia. From a workshop on environmental design for people with dementia; University of Wollongong, NSW, Australia; 2009.
• Fleming, R. and Purandare, N., Long-term care for people with dementia: environmental design guidelines, International Psychogeriatrics; 22; special issue #7; p.S53-S57; May 18, 2010.
• Jenkins, R., et al., Financial implications of ‘The Green House Model,’ Seniors Housing & Care Journal; 19(1); 2011. See: <http://thegreenhouseproject.org/wp-content/uploads/2011/09/NIC_2011_SHCJ_GreenHouseArticle.pdf>.
Marquardt, Gesine, Wayfinding for People with Dementia: A Review of the Role of Architectural Design, Health Environmental Research & Design Journal, vol.4, No.2, Winder 2011.
• NBC – National Building Code of Canada 2010; “New residential care classification created in building and fire codes,” National Research Council of Canada, Ottawa. See:<www.nrc-cnrc.gc.ca/eng/ibp/irc/ci/v15no2/2.html>.
• Nelson, G., “Household Models for Nurs-ing Home Environments,” a paper written for the Pioneer Network, 2009. See: >http://www.pioneernetwork.net/Data/Documents/NelsonHousehold-ResidentialPaper.pdf>.
• The Multilevel Design Guidelines British Columbia, 1994. Available at: <http://wabenbow.com/?page_id=122>.
• Ontario Ministry of Health, “Long Term Care Home Design Manual, 2009.” See: <www.health.gov.on.ca/english/providers/program/ltc_redev/renewalstrategy/pdf/home_design_manual.pdf>.
• Pinet, C., Distance and the use of social space by nursing home residents, Journal of Interior Design; 25(1); May, 1999.
• Design Guidelines for Queensland Residential Care Facilities. Queensland (Australia) Health, 1999. See: <www.health.qld.gov.au/cwamb/agedguide/13037.pdf>.
• Regnier, V., Design for Assisted Living: Guidelines for Housing the Physically and Mentally Frail; John Wiley, New York; 2002.
• Regnier, V. and Denton, A., Ten new and emerging trends in residential group living environments, NeuroRehabilitation; vol. 25; p.169-188; 2009.
• Verbeek, H., Redesigning Dementia Care: An evaluation of small-scale, homelike care environments; 2011; thesis, Maastricht University, The Netherlands.
• Fraser Health: Residential Complex Care Building Requirements; Fraser Health Authority, B.C.; 2007.