Creating Connection and culture Change through the physical facility environment in senior care housing options: Is it the place, program or the policy that makes a difference?

By: Stan Ingman, PhD; Kendall Brune, PhD, LNHA, Fellow; Jack Carmen, AIA

Rethinking the Role of Place – What Does it Mean to Have a Home?
The word “home” is a term that often associated with a place that is central to our lives may bring about images of a building, a room or at the very least features of a place. The term “Home Like” is tossed around in Long Term Care in marketing pieces that it has become meaningless.  The significance of the word “Home”, is significant and reaches beyond simple imagery. Homes are usually shared only with our families, relatives and close friends…seldom with strangers. Establish boundaries between our family and the outside world are established as we guard the privacy of the family and the nature of family activities. For the most part, all of this learned behavior is tossed out of the window when we move into a traditional nursing home or assisted living facility.  We didn’t have to wait until the first day of school to learn things like “when mom’s in the tub, don’t open to the bathroom door with company in the house.” We learned to respect the privacy of the people that we lived with by interacting with them, watching their behaviors, as well as relating these behaviors to different spaces in the home environment. It has been so long since we learned these early lessons, however, that there significance may now seem trivial. We respond intuitively, usually without much conscious thought about how the spaces relate to our activities, but familiar home designs provide at least four basic levels of privacy through designation of specific rooms as well as the location and type of access that is provided. Depending on, both, the behaviors and spaces (specific rooms), these levels can be identified as private, semi-private, semi-public and public. (Stan….you might have another way of saying this or describing privacy)_

The most private activities of the home are usually associated with sleeping, bathing/ grooming, and toileting. We do not typically expose these activities to guests and many times limit access even to other family members. The rooms labeled bedroom and bathroom even create an association with the nature of privacy that is connected with expected behaviors. Semi-private spaces are often associated with areas where we interact with members of the family in loosely structured ways. These spaces are still environments where “receiving guests” is not a formal activity and the nature of the space and it relationship to other spaces allow users to not feel “on-stage.” These areas may provide space for work that doesn’t invite guests, such as a laundry room or a home office. Semi-public spaces may be linked to activities including housekeeping, cooking, eating, and general forms of recreation such as watching TV or working on hobbies. Depending on individual situations or specific features of a space, these may represent rooms or even transitional spaces where a guest may be invited to participate actively or passively. Public domains usually include those actions and spaces that connect us to the broader community, such as picking up our mail, sitting on the front porch.

While every home is certainly slightly unique in its layout or exact assignment of spaces based on the needs of the family, there is usually always a public side of the house and a private side. The manner in which guests are greeted and included in activities of the house is also fairly consistent; there are rooms they feel welcome in, and rooms where they wouldn’t go without expressed permission. We rely of the physical features of space (e.g. walls and doors) to provide separation and protect more private areas from other, but the placement of rooms as well as the social norms of behavior cues these patterns. Without these patterns the privacy of the family and relationships between people would be violated. We see the evidence of these traditions in the multitude of homes that place rooms for social activities (public areas) closer to entrances and rooms for private activities away or separated from guest areas.

Changing the Culture of Privacy in Skilled Care Facilities
When we think about privacy in a nursing home, we are forced to focus on the procedures or rules that we follow in effort to maintain dignity. It is no wonder that we need these “rules” either. Designs of many nursing homes follow the traditional design standards of hospital corridors. Public hallways pass by the spaces that would be considered the most private in a residential home, the bedroom. The original design was not focused on the patterns of home life that would support the intuitive behaviors of privacy; therefore the experience of residential privacy often feels shallow. If the goal of a skilled care setting is to change from an institutional experience to a residential experience, then one way to begin may be to explore how residential privacy could be better supported. Simply adding familiar residential imagery may create a home-like setting, but the term home-like implies, “Pretend like this is your home.” Home means, “This is where you live.” To reach this point, we must focus on seemingly trivial details to capture the fundamental essence of what homes means to us all by understanding how the spaces of nursing homes could be formed and arranged to support attitudes and behaviors that are natural in a family setting.

By their nature, institutions are larger than our homes, bringing more people together than we would experience in our daily situations within our residential settings. The ability to “control access” to the individual and group, therefore, may become a seemingly impossible task as the access to the collective whole overrides the needs of the individual. If we use the context of privacy as it relates to the control of access, however, we can focus on the importance of creating the appropriate levels of personal relationships within a care setting. It means that the rooms in the facility as well as the patterns of movement between these rooms need to be scrutinized. In our home environments, we do not trot through the living room past guests visiting at our house in our bathing attire on our way to the shower, but in nursing home environments the arrangement of spaces often places private bathing rooms adjacent to public areas such as common hallways and nurses’ stations where visitors to the building come and go freely. Regulations certainly “mandate” standards for basic human dignity, but if the environments are not designed to respect the experiential nature of residential privacy then an essential feature of home is lost.

Facilities that have effectively created an experience of home have paid attention to the arrangement of spaces and the sequences of circulation between rooms that should have various levels of privacy. Cueing that we receive from features in the built environment can send a powerful message. A front door on a home implies that unless we are invited, we should request permission for entry. To barge into someone’s house unannounced and uninvited would typically be met with a negative reaction from the homeowner. Inside the home there are opportunities to signal behaviors though walls and doors as well. Another, unappreciated feature of residential homes are hallways. These spaces provide the signal to guests where not to “trespass” into more private areas of the house. In long-term care, hallways have often been identified as the “enemy,” and some designs have focused on eliminating them by circling resident bedrooms around the social areas. While a resident may be able to step right outside their door to get a seat at the dining table, they are also going to be in the center of every activity that takes place. Their ability to control access to themselves has been sacrificed for the sake of eliminating any significant circulation route. Access to other potential spaces of privacy, such as a bathing room, must also cross through a more public social areas, again reducing the ability of the resident to control information about their activities from others. It’s not an easy fix, however. The problem with institutional hallways is a factor of both length and public access. If planned strategically, however, corridors can be used as a buffer zone between the private and public spaces within the household unit and send a very clear signal about the nature of access to the spaces beyond. The potential to create a variety of privacy levels, therefore, can increase dramatically.

Scale — Large versus Small Spaces: What are the Impacts on Perception?
Another challenge that many facilities wrestle with is the size of space and deciding how to use it in the most effective way possible. Some skilled care facilities have one large room where a majority of the activities take place; including meals three times a day, crafts, television, worship services and other large group activities. Staff may be more open to adding “residential touches” to these rooms, but are often reluctant to switch out these spaces for several smaller ones because the multipurpose rooms has become a major component of the life of the nursing home. Staff will often say, “Oh, we can’t make that smaller, we’ll never be able to get everyone in here.” Or, “we have to have that large room, because at Christmas the children come and sing to the residents.” The big question is, “Do we design the spaces around one or two days of the year, or do we design for the other 363 days when a residential pattern of life would imply small groups that support family and meaningful one-on-one connections being made at a personal level?”

Gerontological research has taught us that residents who have a loss of vision or hearing will function better when information is closer to them. We bend down to make eye contact and to speak at a closer range so a resident can see, hear, and actually receive and respond to communication. A large room brings with in lots of auditory and visual stimulation, much of which can be difficult for older adults to accurately single out the information that is important to them. When there is so much going on and a resident doesn’t see very well or hear very well, then what is the quality of that information that 

they are receiving? It would seem that we assume that these functional needs disappear when the children’s choir comes at Christmas, or when a large group of the residents eat a meal in a big space at one time because no one is complaining much and the need for socialization is obviously important. Ideally, there would be a variety of spaces and rooms in the household would be sized for the families that live there. There would also be spaces outside of the house that accommodate residents and their families, staff, and other visitors. When we have a party in the house, it’s crowded, but it’s only for a short time and if the party is too big for the house, then we go to another location. Our homes are central to our lives, but we all like to “get out of the house.” Trips and activities where resident can go and participate in the larger community are a great way to experience life.

The Balance between Place & Policy
Any changes to the built environment will be less than effective, however, unless along with the changes to place, there are changes to policy. The balance between space standards and the program of care is so interrelated that if both aren’t considered together; neither will have as much potential as they would if they were planned in concert. The planned program of care can outline activities and types of experiences that you want your residents and staff to have, but the spaces to support these activities has to be put into place in order for the experience to be real. It means changing established patterns of schedules and procedures. If the staff are determined to get a large group of residents together to be social, and the space has been designed around a smaller scale household concept, the spaces will appear to fail. Likewise, if the program is focused on activities that would occur in the home, such as kitchen activities, but there isn’t an accessible kitchen designed for residents to use, then the program will appear to fail.

Experiencing different facilities that have made changes is a wonderful way to see the opportunities, but be careful to not assume that if you “just had that building” it would be easy. A design must be sensitive to the people who will live and work there, and the specific sense of community that creates an identity with the place. While there are features of other facilities that may show you what the potential is, resist the temptation to just ask for “one of those designs” thinking that it will save you time and money in the planning process. What you are likely to get is a building that you don’t know how to use effectively and the results may seem superficial, and even worse, unsatisfactory.

This is why it is important for part of the planning for culture change to involve others who are experts in design. Long-term care facilities are complicated creatures. There are construction standards and regulations that are put into place for the protection of occupants. It is possible to create the changes that you desire within the context of the codes and regulations, but you need professionals in order to do it. This involves design changes at all levels. Even the simple act of going to a residential furniture store for seating can have dangerous consequences. Make sure that you invest in prioritize the investment in your design team just as you prioritize the expertise you would put into place to care for your residents. The growth that staff go through to embrace a new way of thinking doesn’t happen overnight, therefore, it is important to remember that it will take some time to get your design team to reach the level of understanding that is necessary in order to them to propose the types of design changes that will match the plan for creating a new type of place. Most architects and designers are far removed from the daily life in skilled care. Even those firms that have been designing long-term care facilities for a long time, may not have a solid sense of what culture change means and let’s face it, it means different things to different long-term care providers. It can be helpful to involve a member of a design team in the early phases of the culture change evolution. In essence the phases of culture change are the development of a program of care and design. You are defining the activities that will take place in the home, and the environment should be supportive of those patterns of life.

Kaup, M. L. (2004). Exploring the impact of the built environment in culture change: Is it the place or the policy that makes a difference? Culture Change Now, 3, 7-8 & 30-31.

Leave a comment