Demand for long-term care is expected to skyrocket with an aging population and the growing prevalence of conditions such as dementia. The most current statistics from The Alzheimer Society of Canada show 597,000 people are living with dementia. In 2030, this number is projected to rise to 955,900.

The quality of life awaiting future residents within the country’s institutional-like care facilities is facing scrutiny as researchers closely examine how these spaces are being reimagined for the better. While there is more focus on incorporating residentially-scaled elements, evidence is lacking as to which design features are most successful.

Michelle Porter, director of the Centre on Aging at the University of Manitoba, said there are dozens of long-term care facilities in the province designed around a very institutional model. “We are not going to be able to replace all of these spaces in the next couple of years with a different design, so being able to look at what could happen with a renovation is really important,” she said.

She was presenting her new co-authored paper, Renovations of a Long-Term Care Center for Residents with Advanced Dementia—Impact on Residents and Staff, during an online discussion hosted by the Canadian Centre for Healthcare Facilities.

The multi-method study analyzed pre- and post-renovation data over a five-year period, looking at residents with advanced dementia and staff at a special care centre in the Canadian Prairies.

By the end of the project, research showed that meeting residents’ needs was “partially successful,” while work conditions among staff improved.

A home-like renovation

Creating a home-like atmosphere was a key objective throughout the renovation, with a focus on reducing agitation, aggression and exit-seeking behaviours. Boosting biophilic and wayfinding elements, independence, physical and social activity, and the well-being and work conditions of staff, were other goals.

Designers and administrators also sought to upgrade furniture and finishes, and use the project as a learning lab for innovative technologies. Laura Funk, study co-author and professor of sociology at the University of Manitoba, described how using the LTC as a “testing ground” for unproven technologies was downplayed as the project progressed and could have been used more initially to attract funders.

To invoke a home-like feel, fifteen resident units were separated into smaller five-person “households.” The single large dining/recreation and lounge spaces per unit were replaced with three smaller lounge/dining spaces. Post renovation, overall noise levels were “significantly quieter” in the units, but flagged as “still louder” than what is fitting for a residential space.

Circadian lighting in the dining and lounge spaces, where residents spend ample amounts of time, mirrored outdoor conditions, with cooler bluish light at mid-day and warmer colour light in the mornings.

Resident rooms didn’t undergo major changes, although wayfinding was an important element that included personalizing room entrances, biophilic wall murals in the common areas, a more centralized nursing station, and camouflaged exits; for instance, a vinyl mural of a bookcase hides a doorway, which creates a safeguard.

Impacts on staff’s work conditions

A previous study in 2016 had flagged a knowledge gap related to the environmental effects LTC facilities have on staff, and so this issue became a notable strength of this current study according to several findings.

Staff members conveyed that the renovation improved their “enjoyment of time with residents.” Digital photographs outside of rooms was one added feature that provided moments for interaction. A newly installed staff communication system was another highlight of the project, garnering positive comments for saving time, the ability to call for help in an emergency and easier communication.

Of the physical environment, staff said it was slightly more positive post renovation. The aesthetic appearance and privacy levels of the primary work area, along with noise associated with conversations or patient vocalizations, figured into this perspective.

Job satisfaction and the stressfulness of work showed little change. The amount of personal care staff provided nearly doubled, possibly from new staff training models.

Most staff also felt there was ‘no impact’ on work safety, although 33.3 per cent conveyed this area as being more positive and 16.7 per cent reported it as negative or very negative.

After the dining room was separated, proper monitoring of choking hazards among all residents became a huge safety concern. Staff also reported that the smaller spaces kept some residents closer together during meals, which could have accelerated conflict. There were also fewer behaviours involving leisure, as space constraints may have figured into the ability to facilitate visits with family and friends. Another worker stated that the “nursing station looks like teller window at a bank and central location; can trigger responsive behaviors.”

Although the overall scores reflected a setting that wasn’t “significantly worse,” staff wished they would have been consulted more in the actual design of the spaces.

Impacts on the life of residents

Using a number of methods, the renovated space ultimately reflected both pros and cons within the living environment. Various items contributed to a home-like feel; notably photographs in display cabinets, windows with views, quiet spaces and customized doors were seen as positive additions.

Staff primarily described the new space as being a “better environment for residents,” with “homey-like decor and less stimulation overload,” and “more space for wandering and walking.” Other positives showed improved quality of life, along with mental stimulation, emotional well-being, interaction among family, staff and other residents, access to recreational opportunities, and lower elopement.

Other areas showed no “noticeable difference” compared to pre-renovation, mainly, residents’ autonomy and independence, engagement, their mobility, dining experience, and physical activity or safety. Aggressive behaviour remained unchanged, contrary to what designers had initially expected.

Through surveys, staff response was neutral in certain areas. Renovated dining areas were deemed challenging for group activities, but also quieter, without the need to use resident rooms. Fewer individuals in each dining area, with less clustering, meant fewer Protection for Persons in Care Office reports to complete; however, closer proximity among residents meant they had “nowhere to go to get away from each other, leading to negative interactions.”

Some staff felt the lay-out remained hospital-like. Others strongly expressed a lack of safety, stating the design was geared around higher functioning residents.

Evidence-based design strategies for the future

One idea that emerged throughout the project, with several staff suggesting so, is that “perhaps some of the evidence of best practices in design is not applicable to residents living with advanced dementia,” said Funk.

Although there were “confounding variables,” such as the lack of detailed feedback from residents, she suggested there is much to consider with both the research process and its conclusions.

For instance, she explained how differing perceptions can shape design elements. Workload and staffing concerns being a predominant factor led to designs that distract, separate, control or divert residents from risky situations.

There were also stigmatizing ideas, such as the belief that persons with advanced dementia don’t benefit as much from social engagement or group recreation as other residents.

While multiple methods of data gathering were used over time, from self-reported questionnaires and staff surveys to behaviour mapping, which measured space use and behavioural patterns in the physical environment, precise outcomes proved challenging to decipher due to an array of factors, such as a new staff training program.

“It really becomes challenging to say was it this design feature that led to this change or was it the fact they changed the staffing models,” said Porter. “There were some education workshops introduced during the time the renovations were occurring. . . it is hard to say anything was directly related to the actual physical environment.”

Going forward, the authors propose there is a greater role for researchers in evidence-based design. “More high-quality longitudinal studies are needed to determine whether renovations have intended outcomes for both residents and staff of dementia care units,” the study concluded.

The full study, Renovations of a Long-Term Care Center for Residents with Advanced Dementia—Impact on Residents and Staff, can be accessed here.

The research was recently presented during a seminar hosted by The Canadian Centre for Healthcare Facilities. CCHF is on mission is to improve healthcare environments for better care. For more information, contact [email protected] and visit www.cchf.net.