In light of recent events, care of residents living with dementia in nursing homes has been in the spotlight as people come to grips with the tragedies surrounding nursing homes around the globe. Greater attention is being paid to the designs of built environments and the role that it plays in helping us to remain healthy in the face of pandemics. The focus has not just been on physical design, but also on environments that are considerate of our social connections, mental health and overall well-being.
In Asia, residents living with dementia in nursing homes may not have primary caregivers, or their family caregivers may be unable to provide the high level of nursing care that they require. It comes as no surprise that I found pathogenic hospital-like designs as most common for nursing homes in East and Southeast Asia, as reported in a scoping review that I published in 2018. However, a hospital-like environment for long-term care can be distressing for residents, staff and families alike, with shared bathroom and toileting facilities, ward-like bedrooms, corridors that look the same, and multi-purpose communal halls providing the only space for residents’ daily meals and activities. During the global lockdown, visitors were restricted from nursing homes, leaving residents increasingly anxious, stress and depressed. A resident once mentioned that she felt her experience of loneliness while living in a nursing home was an irony. She had never lived with so many people all at once and yet never felt so alone.
These high-density and highly communal environments also contribute to the concerns of staff. In some facilities, staff must cover vast distances between floors and rooms. They have to navigate through narrow corridors and tight spaces on their daily shifts where social distancing is not possible with external staff or visitors. These environments can contribute to stressors, especially in places where personal protective equipment and testing may not be widely available or accessible. Open hospital-like or dormitory-style designs with communal areas provided little help in reducing transmission of the virus. With all the obstacles that the environment brings, it may be wise to stop and think about the systemic benefits that the built environment can bring on the physical, mental and cognitive health of residents living with dementia, staff, families and the public.
Designing for residents
A low-density self-contained environment allows the development of reliable social connections among residents and staff. This social connection can help residents to develop resilience against the feeling of loneliness and isolation. Smaller self-contained home or small clusters with a kitchen, living and garden spaces allow residents to live in a familiar home-like environment. Observations across the globe indicate that these home-like environments also enable quarantine procedures to be rolled out with ease without disruption to daily physical and social activities within the home. Activities can continue to be carried out much like a regular home in the community during lockdown. In the event of an infection, small self-sufficient homes allow for better control and prevention of transmission. The design has a positive impact on staffing models as each home can have a small number of regular staff assigned to providing care only to the residents in the home. Smaller staffing models promote a closer and more familiar relationship between residents and staff. With a good understanding of their residents, care staff may be able to pick up on changes in residents’ physical or mental status, enabling residents to attain the care that they need in early stages of their condition.
In high-density facilities containing communal living spaces and open bedrooms, imposing social distancing may be challenging. A recent study from South Korea looked at the seating arrangements in a call centre and transmission. It is clear that density and proximity is certainly implicated in the spread of coronavirus.
Without a supportive environment, facilities may risk utilising restraints such as a wheelchair, bedrails, soft restraints or chemical restraints to prevent cross-contamination and manage behavioural responsive. Nursing homes can be seen imposing restrictions or limiting access to communal dining and activities. It begs the question: what impact does this have on residents’ physical and mental health?
Designing for staff: Thinking lean and minimising staff footprints
Small self-contained spaces with smart designs enables essential spaces to be in close proximity to each other, proving vital for staff. In large communal nursing homes, staff amenities, stores and meeting rooms will have higher footfall. Not all homes are designed for efficiency, requiring staff to travel through expansive high-density areas, increasing their interaction with high touch surfaces and engagement with people facilitating the spread of infection. Good design that minimises staff footfall provides a safer environment for staff, reducing exposure and time spent on travel. A design that prioritises staff safety and works to support them will enable staff to feel secure, happier and more productive. These components are crucial as they lead to more positive between residents and fellow staff. With the right environment and a positive dementia care culture, staff retention during times of crisis can be maintained. During this time, reports have surfaced of nurses sleeping in hotels or nursing home staff choosing to stay at work to provide continuous care for their residents.
Designing for the family and community
The ability to provide for social connections is an issue raised by many caregivers across the globe. With many nursing homes in lockdown, homes with up-to-date technology allowed for video calls with family and converted face-to-face services into telehealth services. Though it may not be a quick fix for loneliness, residents and families can see each other through a different medium. The ability to see loved ones via video calls reduces feelings of anxiety and stress, especially for caregivers. The environment is also instrumental in the ability for the provision of telehealth. With adequate safe charging stations and the availability of wifi, residents and staff can utilise a range of technology to support them in their daily living, socialisation and maintenance of health.
Perhaps it is time to reassess the design of nursing homes for residents living with dementia. Going forward, I hope that we can open up this conversation to policymakers, developers, designers, care staff and of course, people living with dementia. We need to question what type of environment is best to deliver care in. Most importantly, we need to know what type of environment would a person wish to live in during the midst of a global pandemic.
Joanna is a PhD candidate with the University of Wollongong and a social media coordinator at the Wicking Dementia Research and Education Centre. Her research focuses on the development of a built environmental assessment tool for people living with dementia Singapore. Joanna has developed an environmental assessment tool for facilities providing high levels of care for people living with dementia in Singapore. Her research interest lies in the understanding of the influence of the built environment and how technology can reduce isolation and enhance social connectivity, education and engagement for people living with dementia and their families.