Health promoting outdoor environments for a nursing home - a program (in English)

VOLLSJร NURSING HOME Part II - Results of analysis and program proposal LK0262 Health promoting outdoor environments, 30th of April 2018

Natacha Bjurberg Kessidis, Louise Brisard, Florence Conteh Nordman, Galina Ekstrรถm, Anna Jรถnsson, Katriina Kipli & Fredrik Tigerschiรถld

TABLE OF CONTENT INTRODUCTION BACKGROUND

USER GROUP DESCRIPTION: A PROFILE INTO OLDER ADULTS

Age related changes in bodily functions Changes in brain and nervous system PUBLIC POLICY IN RELATION TO THE ELDERLY

WHO policy framework “Active Aging” - a global perspective Sweden’s national policy context for the elderly The role of the municipality RELEVANCE TO PROGRAM PROPOSAL

Four mechanisms linking nature to health Elderly’s green space preferences DESCRIPTION OF PROJECT SITE

Physical environment of Solkullen Surrounding environment Direct outdoor environment

AIM METHODS

FIRST POINT OF ENTRY: THE PARTICIPATORY DESIGN

Pilot study Observations Interviews SECOND POINT OF ENTRY: TOOLS FOR ANALYSIS

Four zones of contact with the outdoors Quality Evaluation Tool SWOT RESULTS OF ANALYSIS

RESULTS FROM FIRST POINT OF ENTRY: INTERVIEWS AND OBSERVATIONS

Theme #1 Everyday life activities Theme #2 Profile of groups in focus Theme #3 Physical Environment Theme #4 Existing Resources Theme #5 Incentives to use the outdoor environment Theme #6 Management

RESULTS FROM FOUR ZONES OF CONTACT WITH THE OUTDOORS

2 3 3 3 3 4 4 4 5 5 6 7 8 8 9 11 13 13 13 13 14 14 14 14 15 15 16 16 16 16 16 17 17 17 18

Zone 1: Inside the building Zone 2: The transition zone, where the indoors and outdoors meet Zone 3: Immediate surroundings Zone 4: The surroundings RESULTS FROM QUALITY EVALUATION TOOL

Most present qualities Least present qualities Conclusion from QET analysis RESULTS FROM SWOT ANALYSIS

Weaknesses Strengths Threats Opportunities Conclusion of SWOT PROGRAM PROPOSAL

PHYSICAL ENVIRONMENT

Structures Vegetation Suggested plants Equipment/tools SOCIAL RESOURCES

Encouragement Knowledge and network Enhanced use and increased activity Gardening Games and other social activities Social interactions Surrounding life Tradition and culture Physical activity Rest All year round Public administration input COMBINED EFFECT OF PHYSICAL AND SOCIAL ENHANCEMENTS

CONCLUSION LITERATURE Appendix 1 - QET matrix Appendix 2 - List of plant suggestions

18 19 19 20 21 21 24 24 25 27 27 27 28 29 30 30 31 31 32 31 32 34 36 34 36 34 36 37 40 37 40 37 40 37 41 38 42 38 42 39 43 39 43 40 44 40 44 41 45 41 45 41 45 42 46 42 46 43 47 46 50 47 51

INTRODUCTION

This report finalizes a group project carried out during the spring semester of 2018.

It constitutes a major part of the ‘Health promoting outdoor environments’ course held at the Swedish University of Agricultural Sciences (SLU) Alnarp campus, in which the overall aim has been to generate competence to understand, investigate and develop health promoting environments relating to different user groups’ specific needs as well as to people’s general needs. In order to reach this aim, the task of the group work was to create a program proposal for enhancement of an outdoor environment in a specific site based on thorough investigation both theoretically and on site.

This report begins with a background description composed by a literature study and initial observations of the particular site. In this section we describe the primary user group from a general perspective, the actual site and its context, relevant public policy in relation to social protection services received by the elderly as well as research suggestions for health benefits of contact with nature and outdoor environments.

Following the background, we present the aim of the project and in the methodology section, we describe how and why we chose the combination of analytical tools and qualitative research methods to investigate and evaluate the outdoor environments and the specific profiles and needs of the user group.

The projects site of focus was the outdoor environments of Solkullen nursing home, located in Vollsjö, Skåne. The core user group was the older adults residents living at Solkullen. The project also carried a conviction that enhancement of the outdoor environments that fit the needs and fulfillment of the residents could also benefit staff and visitors. Therefore these groups were also assigned attention. To keep an inclusive approach towards the people who are actually the ones affected by the program proposal, the project was inspired by and partly implementing the framework of participatory design throughout development process of the proposal.

To reinforce the actual program proposal, we present the results from the different methodologies applied along with the results of a SWOT-analysis, that summarizes the gathered findings. As a final conclusion we present the program proposal for enhancement of the outdoor environment at Solkullen nursing home.

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Unless stated otherwise in literature list, all figures in the document are produced and belongs to the authors.

BACKGROUND

Age related changes in bodily functions Normal aging inevitably brings changes to biological, physiological, psychological, behavioral and social processes (National Institute on Aging, 2016). Some changes may not affect abilities, like for instance graying hair, while other changes may cause decline in bodily and mental functions. Even though aging is a natural part of life and not to be considered a disease in itself, being of higher age is connected to an increased risk of developing a wide range of major chronic diseases (ibid). It is sometimes hard to make the distinction between functional loss due to normal aging processes and the onset of pathological changes from one or more diseases (Boss & Seegmiller, 1981).

The World Health Organization (WHO) summarizes the importance of healthy aging in their Global strategy and action plan on ageing and health in the following manner: “Longer lives are an incredibly valuable resource, both for each of us as individuals and for society more broadly. Older people participate in, and contribute to, society in many ways, including as mentors, caregivers, artists, consumers, innovators, entrepreneurs and members of the workforce. This social engagement may in turn reinforce the health and well-being of older people themselves. If people are experiencing these extra years in good health and live in a supportive environment, their ability to do the things they value will have few limits.”

(WHO, 2017, p.3)

Age-related loss of functions is caused by irreversible changes that occur in most bodily organs as a person ages (Boss & Seegmiller, 1981). As the changes take place at different times, at different pace, engaging different parts of the body amongst individuals, it can be concluded that normal aging is a very broad concept that brings a variety of levels of overall impact on the individual’s ability to be autonomous (Bell et al., 2001).

One of the major changes that is commonly seen in the aging groups, is decline in the cardiovascular system, for example due to decreased heart function, high blood pressure and thickening of the walls of arteries. Decrease in the functioning in respiratory system, often caused by lower gas exchange in the lungs, is another example of a major age-related change that may impair everyday life (Boss & Seegmiller, 1981).

USER GROUP DESCRIPTION: A PROFILE INTO OLDER ADULTS People over the age of 65 constitute the fastest growing population group in the industrialized world (Bell et al., 2001). This is also true for Sweden where this group of people has steadily increased in numbers over the last 150 years and there are yet no signs indicating that the trend will slow down. By the year of 2050 it is estimated that one fourth of the population of Sweden will be over 65 years of age (Folkhälsomyndigheten, 2013), and a million individuals among this group are predicted to be over the age of 80 (Statistiska Centralbyrån, 2015).

Commonly occurring issues in elderly adults are also loss of muscle mass and decreased bone density (Cooper Marcus & Sachs, 2014). Together with degenerative processes in joints, these age-related changes may very much affect a person’s ability to move (Boss & Seegmiller, 1981).

The group of people aged over 65 is however a greatly varied and heterogeneous group (Bell et al., 2001). The common feature they share is age, and the probability of suffering from some kind of age-related health issue, but other than that, this group might even be more diverse in needs and individual problems than any other population group. Some require practically no assistance in carrying on their everyday life, while others depend on extensive assistance to manage (ibid).

Changes in brain and nervous system Changes in the peripheral sensory structures, leading to impaired perceptual capacity, is another example of normal age-related function loss (Mather, 2016).

Some individuals might have problems with hearing, some with impaired vision 3

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while others might have problems with balance, spatial ability or coordination, constraining their ability to move around (Bell et al., 2001). When it comes to olfactory sense, i.e. smell, as much as two thirds of people above the age of 80 are reported to have impaired ability to smell. Also taste sensitivity tends to be affected with higher age (Mather, 2016).

To ensure that actions and or activities of this program proposal are sustainable, it was important that there be a component which looks at the implications of public policy process, specifically with regards to actions that adhere the intersectionality between nature, the outdoors environment and health. Additionally this has resonance as it applies to what directives in responsibilities and roles may be carried out by the relevant governance frameworks within Sweden ( from national to municipality). At the public policy level, the management of the Solkullen facility needs to be aware of the links to key research findings in the arena of health promoting outdoors environments and how it may apply to their own context. In this regard they will not only be informed but also empowered to continue upholding, sustaining and maintaining the proposed areas of the program. Additionally this provides insight into the existing political will, ideas and interest in creating health promoting outdoor areas in Sweden. Most importantly, an understanding of the current public policy climate holds additional relevance in that there can be a better clarity on where national priorities focus, all of which have undeniable implications on financial allocations towards the long-term maintenance of the proposed changes to the outdoor areas.

Furthermore, research suggests that the actual weight of the brain decreases with age as result of the breakdown and degeneration of myelin - a substance in the brain that facilitates transmission of neural impulses (Mather, 2016). Loss of myelin will cause neural signals to slow down and disrupt the timing of neural signals hitting neural circuits, which in practice will have negative impact on the sensory and cognitive functioning (ibid).

The distinction between normal and pathological changes in cognitive functions is sometimes hard to make (SBU, 2006). Dementia is the generic term for a series of conditions affecting the brain and causing primarily distorted thought processes and memory function. Different dementia disorders affect individuals in different ways depending on what area of the brain is engaged and also how severe the damage is. Therefore, various symptoms of dementia are possible, including for example: problems communicating, difficulties in orienting oneself, impaired practical skills, impaired ability to manage things that one used to manage, changes in personality, aggression, emotional numbness and lack of empathy (ibid).

WHO policy framework “Active Aging” - a global perspective WHO developed a policy framework called “Active Aging”, that includes three pillars of active aging: participation, health and security (Swedish National Institute for Public Health, 2004).The report stresses the importance of quality of life for the disabled and chronically ill elderly population groups. The report also proposes that programs be geared towards the elderly should ultimately be designed with the intention to prevent loneliness and isolation (Swedish National Public Health Institute, 2004).

Dementia is strongly correlated to age, approximately 1% of 65-year-olds and more than 50% of 90-year-olds have some kind of dementia disorder (SBU, 2006).

Following the primary symptoms, it is not seldom that the affected persons also suffer from anxiety, depression, suspiciousness and disillusions as reactions to their impaired mental functions (ibid).

Sweden’s national policy context for the elderly Sweden holds a stellar reputation internationally for its healthcare system, particularly the one that targets elderly care. However its ageing population is experiencing growing chronic conditions which require much more complex health services and is being tested for its ability to continuously deliver high-quality care (Organisation for Economic Co-operation and Development (OECD), 2013).

PUBLIC POLICY IN RELATION TO THE ELDERLY Healthy ageing as defined by the World Report on Ageing and Health is “the process of developing and maintaining the functional ability that enables wellbeing in older age” (WHO, 2015). Functional ability is further propagated in an individual’s physical, mental and psychosocial aptitude. Therefore this includes the environment in which he or she lives, this referring to the physical, social and policy environments and additionally the interaction between these (ibid).

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The Swedish health and long-term care systems are predominantly financed publicly and managed locally. The central government in Stockholm has the primarily but limited role to in guiding the implementation of key policies (OECD Reviews of Health Care Quality: Sweden 2013). The relevant Ministry charged with this at

RELEVANCE TO PROGRAM PROPOSAL

national level is the Swedish Ministry of Health and Social Affairs’ Division for Families and Social Services. Currently at this level, the policies targeting the elderly care are summarized as the following: » » » » » »

“A significant body of research, using a broad array methodologies and populations, and looking at a variety of health outcomes, confirms and sheds new light on what many people have known intuitively: that connection with nature is beneficial—even vital—for human health and well-being.”

(Marcus & Sachs, pg 14)

To create a national quality plan for elderly care To increase staffing levels in care services To strengthen knowledge and competence in elderly care To strengthen rights and support to people with dementia To work preventatively against fall injuries To support investment in housing for elderly people.

The objective of this section is to provide a “bridge” for the reader between the provided background context above and that of the following outdoor program proposal for the outdoor environment. It will seek to correlate the information now provided about the contextual knowledge/information about the elderly and their needs with a linguistic scope which will validate the relevance of sustainable outdoor health promoting environments.

The role of the municipality Aging in Sweden and services for the elderly has a long tradition of being managed locally by country’s 290 municipalities, 21 regions and county councils in the design and provision of health services for the elderly tailored to their specific geographical context (Davey et al 2013). These services include accommodation such as service flats, sheltered housing (supervised shared residential accommodation) and the nursing homes.

Research has increasingly suggested that older adults may benefit from contact with nature and the outdoors, in ways that are similar to other age groups, as evidenced by increased life satisfaction and reduced psychological and physiological stress (Rodiek, 2002). In an article published in 2008, titled “Outdoor Environments at Three Nursing Homes: Focus Group Interviews with Staff ”, Bengtsson and Carlsson investigated how outdoor environments at nursing homes for older persons was being experienced in order to gain knowledge which may have implications on design (Bengtsson & Carlsson, 2008).

This responsibly was transferred to the municipalities from the county councils based on reforms in the care for elderly, “Ädelreformen” in 1992. (Birgittaskolan Nursing School Student Handbook 2003) However there is overhead supervision of the municipalities carrying out these services by the National Board of Health and Welfare and the county administrative boards. More specifically, the National board of Health and Welfare engages in the national responsibility for coordination whilst the county administrative boards deal with ongoing supervision at regional level. Supervision is based on the rights of the individual and checks that the social welfare committees are operating in accordance with the law.

Bengtsson and Carlsson (2008) elaborate on two primary themes. The first theme looks to how residents can find comfort in the outdoors environment given and despite any special impressions particularly from the natural elements such as rain, heat etc. In the second theme, Bengtsson and Carlsson focus on the access to surrounding life, by utilizing the need of the residents to experience change and variety in the everyday situations.

Sjöbo municipality where the Solkullen nursing home is located currently has included the elderly population within its Green Structure Plan of 2016 and its Sustainable Development plan (currently being finalized). Within the Green structure plan, they state that ‘outdoor environments should be accessible to all citizens, which means that they should be designed for disabled and elderly people as well (Sjöbo Kommun Green Structure Plan, 2016, pg 20). In this respect there is political will and clear interest to ensure that the municipality is moving toward integrating healthcare and the outdoors environment.

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The authors further suggest an inspiring design, which promotes stimulation of senses and mind and provides positive impressions. The inspiring design also brings into play the concept of how outdoor space design can generate the restorative quality from “natural distraction,” giving users the opportunity to “distance oneself from negative situations, i.e., temporary escape, which is fundamental to the restorative resource control” (Bengtsson & Carlsson, pg 65). Additionally, the design gives possibilities to meet and to socialize in large as well as in small groups,

again supporting the evidence based research by Roger Ulrich who wrote that “control and access to privacy, social support, physical movement and exercise go further to strengthen identity and self-esteem by allowing the users to feel as though they are part of a meaningful context (Bengtsson & Carlsson, pg 51). Conclusively, Bengtsson and Carlsson do not present their research as a means to confuse or limit the options in design, but rather a “duality” of inspiring and comfortable design which goes towards exemplifying the basic needs and restrictions for users to be able to move around, be in and use the outdoor environment.

outdoor environment in connection to an nursing home may or may not promote physical activity. This connection motivates developing the outdoor environment toward qualities that promote physical activity.

The third mechanism, social cohesion, is mentioned by Ulrich (1999) as a significant healing aspect of health promoting gardens. In a literature review, Kawachi and Berkman state that “the association between social ties and mental health is securely established” (p. 465, 2001). Maas et al(2009) suggested that green space in the living environment is related to feeling less lonely and experiencing less shortage of social support. However, the authors did not find any correlation between green space and social support or contact with friends or neighbours (ibid). Van den Berg, Joye, and de Vries (2013) point out that the link between green space and social contact is unclear. Considering this, and that the link between social support and well-being is well established, it seems clear that working toward stimulating social support and contact in green spaces should reinforce the health promoting qualities of those spaces.

Four mechanisms linking nature to health Van den Berg, Joye, and de Vries (2013) discuss four main mechanisms linking nature to health benefits. These links are 1) improvement in air quality 2) stimulation of physical activity 3) facilitation of social cohesion and 4) restoration from or reduction in, stress and mental fatigue (ibid).

In a review of studies relating indoor air pollution and health, Jones (1999) mentions fifteen major indoor pollutants. These pollutants may rise to significantly higher concentrations in indoor environments than in outdoor environments (ibid). Spengler and Chen (2000) recommend using natural ventilation wherever and whenever possible, provided that the outdoor air quality would be acceptable as indoor air.

Natural ventilation works by diluting the contaminant concentration (ibid.), which suggests that being outdoors in an entirely naturally ventilated space would provide a higher degree of dilution of contaminants, thus providing salutogenic health promotion.

The fourth and strongest mechanism linking green spaces to health benefits, according to van den Berg, Joye, and de Vries (2013), is stress reduction. Psychological stress is a potential health risk (Schneiderman, Ironson, & Siegel, 2005; Socialstyrelsen, 2016; Ulrich, 1993) and is strongly linked to nationwide psychological illness in Sweden (Försäkringskassan, 2011, 2013; Grahn & Stigsdotter, 2003; Pálsdóttir, 2014; Socialstyrelsen, 2008). It seems reasonable to suggest that reducing stress may reduce these health risks.

Concerning the second mechanism, stimulation of physical activity, van den Berg, Joye, and de Vries (2013) highlight “consistent and growing evidence” of a positive relationship between greenery and physical activity for elderly. A study of 765 adults of age 66 and older found that replacing 30 minutes/day of sedentary time with light-intensity physical activity correlates with better physical health and wellbeing (Buman et al., 2010). Outdoor exercise can also help in decreasing the risk of falls and therefore bone fractures, as exposure to sunlight enhances the production of vitamin D, a crucial element in increasing bone density (Cooper Marcus & Sachs, 2014). Further, the study suggests a positive connection between light activity such as leisure walking and less stress, increased socialization and greater quality of life (ibid). Considering the connection between physical activity, health and nature for elderly there is clear indications of the importance of evaluating the way in which the

The relevance of psychological stress in a residential care facility may be questioned.

However, in a literature review of older people’s experiences in connection to being placed in a residential care facility Lee, Woo, & Mackenzie (2002) underline several different sources of suffering, including feelings off loss, insecurity, devalued sense of self, a loss of privacy and control over activities of daily living, powerlessness, sadness, depression, anger and betrayal. As a psychological stress response may occur when an individual interprets a situation as unexpected, novel, lacking in the sense of control or containing the threat of social evaluation (Lupien et al. 2007), it seems reasonable to expect some stress responses to occur in a typical residential care facility, given the different sources of suffering mentioned above. In the present study, however, interviews and observations are needed to validate the relevance of psychological stress in this specific context.

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In a study of 17 residents in a care facility, ranging from age 71 to 98 years, Rodiek (2002) subjected the residents to the same activities in both an outdoor horticultural environment and an indoor classroom environment. Before and after the experience, mood, anxiety and salivary cortisol of the subjects were assessed. Though the residents engaged in the same activities in both the indoor and outdoor environment, cortisol levels, i.e. stress levels, were significantly lower in the natural environment (ibid). This indicates that simply transporting an activity from an indoor environment to an outdoor environment may provide health benefits.

and suitable shades are important to them in institutional greenery. In parks, on the other hand, they are sensitive to safety, naturalness and aesthetics (Wen, Albert & Von Haaren, 2018).

Most of the existing studies about elderly people’s preferences for green spaces and their use have focused on urban areas and independently living elderly. According Wen, Albert & Von Haaren, more knowledge is needed about preferences of elderly people living in rural areas. Considering the knowledge gaps, and the dynamic relationship between activities and the relative importance levels of the preferences it is not possible to assume absolute preferences for all. On the contrary, elderly people in different contexts are sensitive to different landscape characteristics and therefore, the authors urge planners to learn the opinions of local elderly people.

In summary, all four mechanisms linking natural environments to health benefits, i.e. air quality, physical activity, social cohesion and stress reduction, as mentioned by van den Berg, Joye, and de Vries (2013), may be relevant to consider in the present project.

Elderly’s green space preferences According to a recent review by Wen, Albert & Von Haaren (2018), the current studies on elderly’s use of green spaces and their landscape preferences point out that despite diverse cultural backgrounds and purposes, some common preferences for nature-based recreation can be revealed among the elderly. These are classified as accessibility (proximity to park), infrastructure and facility, maintenance, and landscape features that are aesthetic, diverse, and comprehensible.

Furthermore, the elderly prefer gardening activities to develop the elderly’s creativity, identity, and participation, as well as inclusive parks or neighborhood open spaces where they can watch children playing, for instance (Kemperman & Timmermans, 2006; Sugiyama et al., 2008 in Wen, Albert & Von Haaren, 2018). Seeing children playing can for some, but not all, act as a motivator to visit the green space. However, the authors point out that there remains a lack of understanding in what comes to emotional ties between the elderly and nature, for example, memories and cultural heritage. Furthermore, only a few studies have focused on the needs of creativity, participation, and freedom.

According to Wen, Albert & Von Haaren, the way elderly people interact with nature, does interplay with landscape characteristics. Furthermore, the elderly often alter the order of their preferences when engaging in different activities. For example, elderly people are more sensitive to the connectivity, air quality, noise, and business settings in neighborhood greenery. Season changing landscape, open views, 7

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DESCRIPTION OF PROJECT SITE

The climate in the region presents a mean annual temperature of 7,5-8 degrees Celcius, and an annual mean precipitation of 750-825 mm (SMHI, 2018). The soil type at Vollsjö consist of till (Sveriges Geologiska Undersökning, 2018), a soil type typical for south of Sweden and excellent for farming. Vollsjö is situated in the Swedish cultivation zone of 1 (there are eight zones in the zone system) which means favorable growing conditions and a long growing period (Svensk Trädgård, 2018).

Solkullen nursing home is situated in Vollsjö in the municipality of Sjöbo, Skåne County. The vicinity consists of rural housing belonging to Vollsjö community, farmland, open fields, and other green areas (e.g. parks, rows of trees, lawns, forests, etc.).

East of Solkullen lies a public park and the buildings in the immediate surroundings are one story residential houses. The area south of the nursing home is regulated by a zoning plan granting use for residential purposes. The plan for this area includes family houses, row houses and apartments up to two stories (Sjöbo Kommun, 1999).

The farmlands south east of Vollsjö are a part of a national farmland conservation plan (Sjöbo Kommun, 2009).

Physical environment of Solkullen Solkullen elderly home consists of apartments in various sizes, two courtyards: an Solkullen nursing home consists of apartments in various sizes, two courtyards: an inner courtyard (304 sqm), and an open courtyard (317 sqm), as well as service facilities and offices. The total built area is approximately 2860 sqm. All the apartments are located at ground level. The main building, as revealed already in the name of the nursing home (Solkullen, in Swedish: sunny hill), is placed on a small hill and is following the terrain. At the lower (Northern) part are located the parking spots, the main entrance and the staff offices, as well as technical facilities, while at the higher (Southern) part are all the apartments for the elderly.

Figure 1. Overview of Vollsjö community and project site in white circle.

Figure 2. Solkullen. Plan.

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Surrounding environment The surrounding yard is designed strictly for function and logistics. There is a path just around the building constructed in a very simple manner (see figures 3-5). The two big open spaces, to the South and West, are covered with short grass and offer no physical objects, like paths, benches, or gardens, that could support the use of the available area. On the East side is located a big public park which is undeveloped.

It could be easily accessed if the conditions of the paths were adjusted to older and disabled people. The park has a big potential to enrich the life of the residence not only from the nursery home but also the neighborhood as it offers old trees, wetland and animal activities (see figures 6-8). Meeting different age groups for example old people and children is an existing possibility as the park is easily accessible both for the neighborhood and for the nursing home residents.

Figure 4. Pathway materials.

Figure 3. Pathway surrounding the building along the eastern facade.

Figure 5. Path surrounding the building along the western facade.

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Figure 6. The park like area in the east.

Figure 8 Animal activities.

Figure 7. Landscape view to the South.

Figure 9. Landscape view to the West.

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Figure 10. Patios at the West apartments.

Figure 11. Landscape view on South.

Direct outdoor environment The most of the apartments have their own private patio, which allows a direct contact with the outside environment if the physical ability or the wish is there (see figure 10). The apartments without patio provide a view, which is not adjusted to elderly as the landscape elements are too far away from the windows, considering the diminished vision of the viewers (see figures 9 and 11).

The two shared courtyards have a direct (through the apartments) and a indirect (through the corridors and the dining room) access. Both have a Southern position, see figure 12.

The Western courtyard is an open space, which can only be accessed from the inside of the building, from some of the northern apartments and through a corridor joining the apartments on the south side. The courtyard is surrounded by a one story structure, which helps letting in sunlight. There are two grass lawns and a stone path between them, a planting table, one tree and few bushes. The South side provides weather protection and some outdoor furniture. A small water cup for birds and a single lighting feature. The paths are lacking physical support like racks

Figure 12. The two courtyards.

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or pause benches and are completely blocked by furniture and bushes (see figures 13 -14).

The Eastern courtyard is designed as an open space (see figure 15) accessible from the surrounding land in the south. It is also in direct connection with the main dining hall, which has a large glass facade, allowing in all the available daylight and is providing a visual access to the outside environments, especially important for the residents during winter time. Just outside the dining hall there are furnitures for activities like socializing and gardening, as well as a space for grilling, which is a common activity in the warmer season, as revealed through a personal communication (February 6th, 2018). These activities happen on the hard ground cover, which is a minor part of the courtyard, while the major area is covered with low grass.

A larger part of the courtyard in South is not in use, mainly because of the openness towards the fields, which is not safe for use, especially for residents with various forms of dementia.

Figure 14. Western courtyard.

Figure 13. Western courtyard.

Figure 15. Eastern courtyard.

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AIM

In the Participatory Design, future users are involved in all phases of the design process (Bratteteig & Wagner, 2016). Authors Carpman and Grant (1993) identified five major benefits of this inclusive participation in the design process:

The aim of this study was to provide a program proposal for developing the current outdoor environment of the nursing home Solkullen toward health promoting qualities. The aim of the program is to enhance the use of the environment by includeing recommendations concerning the designed physical environment as well as social resources, that will meet the needs of the current and future users. The desired overall effect of this study is to increase the well-being of the residents at Solkullen.

1. Helping to clarify design objectives, 2. Lowering construction costs by avoiding errors, 3. Stimulating positive behavior and attitudes, 4. Creating a sense of community, and 5. Creating a marketing strategy.

According to Bratteteig & Wagner, the degree of participation varies according to the motivations for engaging users in the design process. These vary from pragmatic view, user participating in the process which enables easier implementation the design result to a political position according to which users have the right to have their say in the future design or use situation (ibid.).

METHODS In order to achieve the stated aim of the project there will be two points of entry within the selected methods. The first point of entry is the participatory design which will include incorporating the profiles and needs of the user groups through interviews and observations. The second point of entry for the methods is gaining an understanding of the different aspects of the outdoor environments and the qualities they present by utilizing two landscape analysis approaches, the Four zones of contact (4 Zones) and the Quality Evaluation Tool (QET). The methodological approach then concludes with the SWOT approach in order to culminate and analyze key findings.

FIRST POINT OF ENTRY: THE PARTICIPATORY DESIGN

In addition to the aforementioned listed benefits and motivations, it was beneficial for groups learning process to include methods that allowed familiarization of the user group and their specific needs. Therefore, qualitative research methods were used in combination with analytical tools from environmental psychology to inform our program design process.

In the study, the degree of participatory design, or user involvement, was limited by the time frame set for the project. Hence, interviews with staff and some residents was the lone degree to which the users were involved. The limited involvement of the staff and other stakeholders, and the fact that the stakeholders were only heard at one point in the process, limited the participatory aspect in the process. However, there is an opportunity to further involve the users after this project’s closing date since group members may continue to work with the program proposal even after the course. In this continuation, the staff may give feedback on the program proposal.

Pilot study

Figure 16. Map of chosen methods.

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As the very first step in the process, the manager of the nursing home of Solkullen was interviewed to map out the general needs and expectations, as well as the current situation at the nursing home. To initially familiarize the program proposal development team members with the site, a visit was made by a team member to document the site by taking photographs of the outdoor environment, and making initial observations. The findings from these initial channels of contact helped to define and develop the method used for analysis. To test the chosen methods, developed observation protocol and interview guide, another team member went to the site in advance to test them by doing some preliminary observations and conducting interviews.

they aim to reach the elaborated version of someone’s experience or opinion about something (Patel & Davidson, 2011).

Observations The main purpose for the observations was to gain an understanding of the residents’ needs in order to increase the use of the environment. Additionally, observations of the residents and their activities established an understanding of the primary user group (the residents). Through observations the program proposal development team members could thus ascertain the different levels of independence and abilities of the residents. Additionally, this also added and reinforced previously gained knowledge of older adults as annotated in the Background section of the proposal .

Observations provided an introduction into the subject, and as DeWalt and DeWalt put it, helped “develop a holistic understanding of the phenomena under study that is as objective and accurate as possible given the limitations of the method” (2002, p 92). Observations also informed on the primary user group, the staff, and gave some valuable insights into their working day.

With the observations and interviews the program proposal development team focused on establishing a clear image of the ongoing activities taking place within the indoor and outdoor areas. The interviews helped establish a further understanding of a) what is normally taking place outside (e.g. afternoon walk, a game of petanque); b) what potential activities could take place outside if a space suitable and provided (e.g. strolling, gardening); c) what normally takes place inside but that can also be relocated to the outside (e.g reading the newspaper, sitting, talking); d) what possible and non-existent activities could take place outside, but are now unavailable to the residents given that there is no environment currently to do such activities (i.e. activities specific to the location in question, e.g. painting a mural, planting a hedge, etc).

Interviews were conducted in a traditional manner, where interviewer and respondent were sitting down. Additionally, walking interviews, i.e. where respondent is being shadowed by the interviewer who is asking questions about the surroundings.

The interviews added to a better understanding of the project site through seasonal changes. The observations were conducted in the winter and early spring months hence not giving a view of potential activities, which could take place throughout the course of the year.

SECOND POINT OF ENTRY: TOOLS FOR ANALYSIS

Another purpose of the observations was to look at the physical environment, both inside and outside, to create an inventory of present features as well as looking into detail what different barriers or solutions that could hinder or encourage use of the outdoor environment. This included looking closer at thresholds, how easily doors would open, if individuals using a walker had trouble with . It also included looking at the green structures to deliberate on the different sensory stimulation qualities possible ( e.g. especially for warmer seasons) and additionally which activities could take place in the different areas.

Interviews To further deepen the understanding of the user groups’ needs and expectations, semi-structured interviews were held with both residents and the staff working at Solkullen. In qualitative research, semi-structured interviews are often used as

Two predefined landscape analytical tools, Four zones of contact with the outdoors and Quality Evaluation Tool (QET), were used to ascertain the current condition and structure of the outdoor environment.

Four zones of contact with the outdoors The selected tools for this program proposal aimed to achieve a broad and holistic view of both the indoor and outdoor environment of the project site. And to reach this broad and holistic view, the evidence-based model called Four zones of contact with the outdoors (Bengtsson, 2015) was applied as an analytical tool.

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The goal of the Four zones of contact model was to determine where the different zones were in relation to one another. More specifically the different zones of

contact (Bengtsson, 2015) can be listed as,

evaluated separately and all the different qualities were discussed in relevance for each area. As an example, seven qualities could be identified in one area. Simultaneously, the same area could be lacking twelve qualities. After concluding the evaluations for all the areas, we were able to see what qualities were most frequently identified; what qualities were present only in some places; and which qualities were lacking in the entire facility. This data is arranged in a raw data matrix (see appendix 1) .

Zone 1: The indoor environment, contact with the outdoors through windows Zone 2: The transition zone, where the indoors and outdoors meet Zone 3: The outdoor environment in direct contact with or close to buildings Zone 4: The surroundings The different zones of this program proposals’ selected project site were identified after the team spent several hours on location, both looking at the inside of the premises and walking around in the outdoor areas. The program proposal team had also conducted interviews with staff and residents before identifying the different zones.

This especially helped in identifying zone 2, as the aspect of use was interpreted as an influencing factor for the transition zone between indoors and outdoors.

SWOT SWOT is a strategic planning tool used to identify the Strengths, Weaknesses, Opportunities and Threats relating to a project (Hay and Castilla, 2006). The SWOT analysis was used to reach two objectives: to understand and to evaluate the data collected from the empirical study. By this method, different alternatives to improve the outdoor environment were highlighted.

Quality Evaluation Tool The Quality Evaluation Tool (Bengtsson & Grahn, 2014b) is meant to be used as a tool in evidence based design processes and offers a way to identify environmental qualities that can be useful in designing outdoor environments and healthcare settings (ibid). The tool contains dimensions from other theoretical models such as Perceived Sensory Dimensions (Grahn & Stigsdotter, 2010), which can be looked upon in more detail when applying the tool in a practical setting. Other concepts such as comfortable design, inspiring design and the gradient of challenge are meant to be used as parts of the QET when practising it (Bengtsson & Grahn, 2014b).

The SWOT tool consists of four parameters, two of which relate to internal attributes; strengths and weaknesses, and two to external factors; opportunities and threats (Hay and Castilla, 2006).

The program proposal team used the SWOT analysis as a way to bring the collected

The QET is divided into steps that are a part of the overall design process (appendix 1). The first step is to examine and evaluate the current outdoor environment in the project site using the 19 different environmental qualities that represent the QET. The second step is to evaluate the qualities’ importance to the user group in mind.

In this step the user group may be involved to add further weight to the process of evidence based design. In this step, it is important to find out what the users actually need. The final step in using the QET is to suggest measures from the data collected.

In order to ensure that the entire area was taken into account , the project site was divided into eight smaller areas (see fig 31 in Result section) that were identified after individuals members of the project proposal team walked around the vicinity.

The use of smaller entities enabled the program proposal team to better understand, evaluate and discuss the presence of the different qualities. Each smaller area was

Enhancers

Obstacles

Internal attributes

S​trengths

W​eaknesses

External attributes

O​pportunities

T​hreats

Figure 17. SWOT parameters adapted from Hay and Castilla (2006).

data together and analyse through four categories of the SWOT tool. The quadrants do not operate in isolation from each other but often there are connections between them and intricate linkages in the dynamics between them. Each of the four quadrant helped us formulate the recommendations which will be listed under the “Program proposal” heading.

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RESULTS OF ANALYSIS

Staff: Though the staff has a right for a break (30 min), due to the dynamic nature of the work, one can seldom plan the time for one’s brakes. A profile into the everyday activities of the staff revealed that the staff experience very little opportunities to walk and be outside with fellow staff members given the limited (30 mins) break.

In this section, summaries of the individual results from the different analyses, observations and interviews will be presented. Additionally, this section will introduce the results of the SWOT analysis, representing a structured summary of the collected data.

Theme #2 Profile of groups in focus Residents: It was observed that the residents were relatively mobile (e.g moving by themselves, in wheelchair or with the help of walkers) and several seemed keen and curious about the project. However it is important to note that whilst some residents could get around, most do need assistance to move about. Some residents additionally have impaired hearing and sight. Irrespective of this, there is a difference between residents at nursing home and residents of the service flats and their levels of varied independence to accessing the outdoor areas.

RESULTS FROM FIRST POINT OF ENTRY: INTERVIEWS AND OBSERVATIONS The results of the interview and observations were streamlined around six themes.

This was to ensure that all the information collected could be summarized into distinctive areas which would act as a guide and or compass in the eventual analysis of the key results of this particular methodology. The selected thematic areas are: 1) Everyday life activities 2) Profile of groups in focus 3) Physical Environment, 4) Existing Resources, 5) Incentives to use outdoor environment, and 6) Management.

There used to be a playground within the facility, which attracted children. The residents very much enjoyed and appreciated this interaction. The staff suggested that perhaps the program proposal should include an element that would enable interaction between residents and children.

Theme #1 Everyday life activities Residents: The residents’ primary activities range from engaging in conversation with one another, sitting alone, sleeping, walking in corridors and watching TV in their rooms.

The residents expressed a desire to have access to seasonal fresh fruit and herbs that could be grown in growing beds. It was observed, however, that whilst there were some growing beds in the outside area, they need to be modified and designed so that they are accessible for people getting around with the help of a wheelchair and walker. For the outdoor areas, it was observed (and confirmed by the staff) that there was a need for more comfortable garden chairs and tables within the courtyards (inner and outer). Currently there are plastic furnishings and very few places to rest. In addition, in the in both inner and outer courtyards, there is a crucial need to provide areas with improved protection from the seasonal elements (sun, rain and snow), which currently prevent some residents from going outside (no parasol in the summer). The staff also mentioned that some of the residents expressed a need for a place in the summertime where residents could “dip their feet” in water for heat relief.

Other activities that the staff mentioned as part of everyday life was the game of boule, singing, baking, card games, quiz, occasional parties, bingo and craft sessions.

According to management, the residents at times are taken to the nature for group excursions outside of the facility.

Main meeting points for the residents and in some cases staff as well, is the dining area, restaurant, and other common rooms. The most popular indoor spaces for residents seemed to be the areas that displayed a lot of natural light. One of these spaces was the dining area. Additionally these areas garnered a rather cozy and warm feel. Team members and staff noted that these were also indeed examples of activities which could occur in an outdoor area.

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Overarchingly, some residents suffer from feelings of loneliness. There are high rates of depression, especially amongst male residents. Most of the residents had been farmers at one point and some had engaged in extensive gardening. Most of the residents in the facility are originally from Vollsjö or nearby areas.

area. In addition, some stairs lack handrails. These outside areas also have poorly maintained paths. Additionally, some shrubs grow too close to the pathways, e.g. rhododendron and some ground is overgrown with weeds. There are currently residents who have apartments with patios, which look out to both inner and outer courtyards. Improving these areas can bring added benefits to their users. In the inner courtyard, there used to be a fountain but this was removed due to safety concerns and maintenance costs.

The facility is also currently in the midst of creating a specific area for residents who have been diagnosed with dementia.

Staff: The staff expressed that their primary need is to have a place to have their food, a place to relax with some peace and quiet. They would like a situation where they could be in a location without residents in order to fully relax. For this, the staff has two rooms made available for them, one bigger one where cooking is also possible and one smaller one, that is more quiet and is decorated so as to enable relaxation.

Currently, if staff members do go out for walks it is usually to accompany residents as support. There needs to be an area in the outdoors, where staff can also access and have privacy away from work. Just like the residents, they would like this area to have all-weather outdoors furniture (chairs and tables) that are not plastic ( for fika and social interactions).

Currently in the new and upcoming dementia wing of the facility, there is an outside (closed) winter garden like attachment with views of the outer courtyard. However, this area seemed unused, cold (no heating) but with great amounts of natural light and large windows to the outer courtyard.

Staff: Staff members have a lunch and ”relaxation” room in a basement like room with little to no access to natural light or natural elements. They also have another smaller relaxation room, which consist of a table, chairs, blue curtains, christmas lights and a CD player. This room is for relaxation and it is very quiet. The current physical environment is maintained by the staff. The proposed plan will also consider the staff to be taking care of the outdoor spaces and gardens. However, some staff expressed that whilst they did not mind this, there was sometimes simply not enough time to engage in gardening.

They additionally expressed some desire for some sensory stimuli such as running water (small fountain) and also seasonal fruits, berries, flowers and herbs ( for scents). As previously mentioned, having fruit trees and shrubs could be a way to invite children to do joint activities with the residents and also provide them (the staff) some psychological relief from the intensity of the job. The staff also expressed a desire for some climbing plants which could provide shade. These plants however need to be the type which require little to no weeding as they may be too busy to engage in maintenance. Currently, there is a significant amount of weeds and rosehips shrubs, having limited time to do weeding, a landscaping arrangement is needed to remedy this. The staff also expressed a desire for an area for barbecues and picnics which they could use with the residents, by and amongst themselves.

Theme #3 Physical Environment Residents: The team observed some barriers within the physical environment. The doorstep to the small inner courtyard is slightly elevated and not conducive for walkers and wheelchairs. In addition, there is a steep ramp into the “outdoor room”. There are heavy doors to the outdoors and once outdoors, there are differing elevations in the

Theme #4 Existing Resources Residents: There are currently some growing beds available in the courtyards. However, these are inaccessible for residents given the height and the residents’ inability to stand without support.

From the open courtyard there is a view of a large farm, which could bring about memories, certainly for people engaged in agricultural practices. Additionally, one can see and hear tractors and other farm machinery passing by. However, this area has varied elevation levels, few walking paths and no handrails.

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Theme #5 Incentives to use the outdoor environment Residents The staff informed the program proposal team that some residents experienced mental barriers towards using outdoor space in bad weather. Currently, there is

RESULTS FROM FOUR ZONES OF CONTACT WITH THE OUTDOORS

not enough infrastructure to protect users (especially residents) from inclement weather conditions, be it snow, rain, direct sunshine, wind or heat.

All four zones described by Bengtsson (2015) were identified in Solkullen, as illustrated in the figure 18.

Theme #6 Management Residents: The Solkullen facility had successfully applied for a grant to improve the outdoors environment of the facility. However, this grant comes with no assurance for additional resources to cover any maintenance costs and the long term upkeep of the green spaces and no further budget allocated after these funds run out. The Solkullen Management stated that though there was no budget included in the current running budget of the facility for this, the maintenance could be solved by the staff, who would take care of the maintenance. The management was asked about the possible role of the municipality in maintaining the proposed changes in the outdoor area, and they expressed that there was no current means to engaged in such assistance.

Zone 1

Inside the building

View of atrium, courtyard, residential areas, park like area or surrounding landscape

Zone 2

Transition zone

Private and common patios and conservatory

Zone 3

Immediate surroundings

Atrium with no view of zone 4, courtyard with possibility to view zone 4 and pathway around building

Zone 4

The wider neighborhood

Residential area, park like area, parking lots, close to surrounding agricultural landscape

Staff Currently the only maintenance conducted by the municipality is cutting the grass and trimming the shrubs in both courtyards. The staff expressed that it was not without effort that they got the municipality to come and perform the minimal maintenance tasks referred to above.

Figure 18. Map of four zones of contact with the outdoors at Solkullen.

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Zone 1: Inside the building Zone 1, representing the inside of the building, was found to have quite extensive possibilities to visual contact with the outdoor environment, however with different qualities in regard to the respective views. The area inside the building that was described as the common room, where meals were taken and most time of the days spent by residents, staff and visitors, had large windows facing a garden like area with possibility to view surrounding agricultural fields.

Figure 19. Common area with view over park-like area.

Zone 2: The transition zone, where the indoors and outdoors meet Zone 2, which is the transition zone between indoors and outdoors, could be identified as private terraces connected to individual apartments, but also as the common areas closely connected to the entrances where one could leave the building. The common areas identified as zone 2 were not per se elevated patios, but they were somehow a bit more sheltered in their proximity to the building, which enabled them to be looked upon as transition zones. In the facility was also a conservatory, which was not heated, and therefore more outdoor like even as it was situated inside. This was also considered to be a transition zone.

Figure 20. Private resident room with view of courtyard.

Figure 22. Common patio in closed courtyard.

Figure 21. Common room with view of less quality area.

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Figure 24.

Private patio.

Figure 23. Common transition area in front of main entrance.

Zone 3: Immediate surroundings Zone 3 was identified as 1) the inner courtyard with no view of the surrounding areas; 2) the open courtyard, that could be viewed from the main area inside the building; and also 3) the surrounding area, consisting of mainly grassfields, which were separated from the facility by the paved pathway around the building. The pathway was responsible for enabling people to use the outdoor surroundings, while the area beyond the pathway was only accessible for someone with very little impairment to move around. In front of the main area was also a parking lot designated for visitors to the nursing home. The apartments assigned to zone 3 had views out to the courtyard or fields.

Figure 25. Pathway enables the use of outdoor environment.

Figure 26. Some greenery between the parking and the facility.

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Figure 27. Inner courtyard.

Zone 4: The surroundings The wider neighborhood, i.e. the area just outside the paved pathway, was designated as zone 4. In the map ( figure 18) the zone 4 is constricted by the boundary of the building plot. However this zone is also meant to capture the surrounding areas that are visually connected. Zone 4 of Solkullen comprises residential areas, surrounding agricultural fields and also within the premises, a large park-like area.

The park-like area was described by the staff of Solkullen as not usable due to elevation changes in combination with overgrown and slippery pathways and other signs of decay, like broken benches.

Figure 30. View of surrounding farmlands from the border of the property.

Figure 28.

The park like area has differences in elevation.

RESULTS FROM QUALITY EVALUATION TOOL In order to examine the outdoor environment, eight smaller areas were identified within the study area for better understanding and easier evaluation of the present environmental qualities (areas I-VIII, see map, Figure 31). The following section illustrates the findings from the Quality Evaluation Tool (QET), which are also presented in the raw data matrix showing the different areas and the presence of the qualities (see appendix 1) and further elaborated on in a matrix infographic (see figure 32, p 23)

Figure 29.

Slippery pathway in parklike area.

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Figure 31.

Spatial map.: User’s areas identified on site

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Figure 32.

Matrix showing results of QET- analysis. See next page for further explanation.

Figure 32 on previous page displays the results from the QET analysis. On the top horizontal axis, the areas marked in Figure 31 are listed. On the left vertical axis, the 19 qualities from the QET are listed. Comfortable qualities are coded green, and inspiring qualities orange. The qualities and areas are sorted by frequency; the most common qualities of the comfortable and inspiring category respectively are placed at the top, and the areas with the highest number of total qualities are placed to the left. This results in a clustering of more common qualities and areas with higher numbers of total qualities toward the top left. Toward the bottom right, the least common qualities and areas with the least amount of total qualities are found. No judgement is made on whether or not more total qualities are better or worse, but it may be an indication of the area’s overall quality. The pie charts on the right are the sum of the number of areas that offer each quality respectively. The pie charts on the bottom are the sum of the number of qualities in each area respectively.

At the nursing home, there are elements that are memory-provoking in the different areas, e.g. the hammock and garden tools in Area V and the cherry tree in Area I. These recognizable elements create familiarity and can bring about old memories or the feel of home. Some but not all areas contain qualities that correspond to the environmental quality of joyful and meaningful activities. There are, for example, growing beds, a hammock, walking paths and planted flowers and shrubs.

At present time the areas provide a foundation for social interactions, but the activities corresponding to the users’ wishes is to be further investigated. For instance, Areas V and VI both have elements that give incentives for social opportunities, such as the growing beds, seating places, plants and vegetation, the view and animal life.

Least present qualities » Closeness and easy access » Safety and security » Different options in different weather » Contact with surrounding life » Culture and connection to past times » Symbolism/Reflection » Rich in species » Sensual pleasures of nature » Seasonal change in nature » Wild nature » Refuge

Most present qualities » Enclosure and entrance » Familiarity » Orientation & wayfinding » Joyful and meaningful activities » Social opportunities » Prospect » Space The outdoor environment at the nursing home is close at hand, and almost all the identified areas are visible from inside the building. The different areas have different protections, e.g. from wind and sun, and some have none. Some areas, e.g.

Areas IV, V and VI have trees, shrubs or walls that create an enclosed atmosphere and provide shelter from wind and also some level of visual privacy. The quality of enclosure might be present at some areas but the quality of entrance is less present since some areas lack the possibility for easy access.

One can easily appreciate that the outdoor environment that surrounds the nursing home of Solkullen in Vollsjö is close to the building where the elderly live. However the quality of easy access is less present since there are barriers present in the environment. Many areas are not fully accessible due to door thresholds, poorly maintained paths, lawns and slopes. Mental barriers could also be present, because there are distances that do not offer places to rest i.e. benches, along the way. It is important to have easy access in order for the residents to be able to move around easily without risking any physical injuries, e.g. falling or slipping.

The area which the nursing home is situated on is on top of a hill with good views on the surroundings and with not many hidden paths. Good views makes for easier orientation and wayfinding. Though the authors of this report found the comfortable quality of orientation and wayfinding to be present in many of the areas, people with different levels of physical abilities might find it more difficult to find their way.

The quality of safe and secure was found missing in several areas at the nursing home. Another quality that isn’t present at the nursing home today is the possibility to have different options in different kinds of weather. Being able to go outside just 25

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to sit or go for a short walk and at the same time have some kind of shelter is not possible at the nursing home today.

is hard to define because the need for refuge is highly individual. Therefore, this quality should be present if simply to offer the possibility to get away and be alone even if the need for it isn’t great.

The nursing home is situated in the outskirts of the town of Vollsjö, which gives the nursing home a fantastic view over the agricultural area and its vicinity but not much of other contact with surrounding life and the everyday life of the community.

However, there are residential houses in close connection to the nursing home.

Conclusion from QET analysis The QET analysis of the outdoor environment of the nursing home indicates a low presence of both comfortable and inspiring qualities. The overall result also show that the comfortable qualities are more present then the inspiring qualities on the whole. The most present qualities are enclosure and entrance, familiarity, orientation and wayfinding, prospect, space and serene. The qualities that were found least present at the nursing home, are different options in different kinds of weather and culture and connection. The quality of wild nature is the only quality that was not found present in any of the areas.

Culture and connection to past times, a quality not strongly represented at the nursing home, is an important quality that evokes the feeling of a place that is cozy and taken care of. This is a strong argument as to why maintenance is important and needs to be enhanced and maintained in the environment so that this important quality isn’t lost. Items, such as a barbecue set or a kitchen garden, that can help one feel that an area or place has a purpose and can bring back memories of the past , can evoke this quality.

There is potential to apply more qualities in the areas but an important question to highlight is if it is done on the cost of other qualities? Some present qualities can directly affect the presence of other qualities.

The quality symbolism/reflection is more present in the surrounding environments that are almost considered to be peripheral. An element that represent this quality could be the seasonal change of the farmlands. Furthermore, the qualities culture and connection to past times and symbolism/reflection aren’t strongly represented in the outdoor environment.

Another important question is whether or not the existing qualities are enough.

It is not only important to identify the qualities present but also to determine the strength of their presence. Just because a quality is present does not mean that it serves a good purpose. When enhancing the outdoor environment it can be beneficial to think about which qualities are worth keeping in a specific area and which are better valued in other areas. Determining the strength of the qualities requires further investigation and might be best evaluated by the user groups themselves.

Three closely related qualities that are not present in most of the areas are: rich in species, sensual pleasures of nature and seasonal change in nature. These qualities represent the possibility to experience seasonal change and the diversity in nature.

One quality that is missing altogether is the quality of wild nature. Areas where vegetation hasn’t been influenced by human hand are not found in the outdoor environment. However, the perception and experience of nature or more specifically, wild nature must be left for interpretation as there are several ways to interpret the degree of wildness. However, as Wild nature in many ways opposes other qualities, such as easy access that is crucial in the context of the nursing home, we deem wild nature to be a less crucial quality.

One aspect we must keep in mind is that when introducing wider range of qualities in a given area, we might lose the existing ones or they might be a contradiction when two qualities appear in the same space. For example, if the public park (area VI) develops to a more active and social area in the future, the quality refuge can decrease in value or disappear altogether. Similarly, if area VII adopts festive/social qualities, we lose the refuge quality if this area. In that case, we need to prioritise with the needs of the user group in mind and have a vision for the overall character of the different areas.

The quality of refuge is important but also a quality that isn’t present. It is important to have a place to take a break in or have a more private conversation where one can get a feeling of being secluded and have the possibility to recover. This quality

Furthermore, it might be useful to think about which areas will take least effort to further develop with a specific quality in mind. Which areas can most easily embody 26

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the feeling of refuge and meeting visitors in private? Which areas are already encouraging social interaction or are somehow tied to other areas that are prone to have lots of people passing by?

Considering the new dementia wing, connected with the open courtyard (area V), we need more/stronger comfortable qualities there to make the outdoor environment more suitable for residents, suffering from this disease. On the other hand, we need to focus on more/stronger inspiring qualities in the enclosed courtyard (area VI), because the residents connected to this area need more variation in experience and physical activity. While the latter is relatively achievable and desirable (considering the information we got from conversations with the residents and the staff), the mixing of all residents in the open courtyard may be challenging. If the most of the residents appreciate social interaction, the dementia suffering ones may be confused by unfamiliar faces and require clearer and simpler design in general. That is why this area must be designed more carefully.

Figure 34.

The results from the 4 Zones tool analysis overlapped with the eight areas used in the QET analysis.

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Figure 33.

The sum of each area’s number of different qualities from the QET analysis together with some of the results from the 4 Zones tool analysis. First, the areas were ordered by total number of different qualities from left to right, in falling order. Second, the results from the 4 Zones tool analysis were applied to the chart. By manner of coincidence, the same QET areas that proved to hold the highest number of qualities from the QET analysis were also the areas that were in closer to zone 1 in the 4 Zones tool. Thus, the results from the two analyses could be presented together in this chart.

RESULTS FROM SWOT ANALYSIS

by many family members who live further away in the cities, now and in the future.

Weaknesses Out of all the qualities included in the QET, naturalness or wild nature was found to be lacking in all studied areas in and around Solkullen.

As the green spaces now stands, it has little to no stimulating elements, both for stimulating sense or to stimulate wanting to go spend time outdoors.

There is no person assigned to be in charge of the maintenance of the outdoor environments (other than mowing lawns and basic maintenance) at the current time as no staff from the municipality has been assigned to this, which is most likely linked to budget allocations. This, on the other hand, has to do with the fact that municipalities are solely responsible for the upkeep of the entire facility. The current political and budgetary conditions makes it risky and unsustainable to plan modifications for the outdoor green spaces as their maintenance is not secured in planning. Although the staff currently says they will be able to manage the proposed changes on their own, it sets limitations to the type of garden design that can be realized. The outdoor environment should require little to no need for maintenance in order to keep it manageable due to the purely hobbyists gardening staff and the limited physical strength of the few volunteer residents. This limitation might sacrifice other aspects of the garden that might be crucial for making it attractive for the residents and having healing elements in it.

There are other dimensions identified by the QET analysis in certain places, while elsewhere lack of important dimensions from the point of view of comfort and/or inspiration was obvious. In some places, though some dimensions were present, the absence of other key dimensions rendered these places unattractive for use (see QET analysis).

The terrain is hilly, which might be too challenging for some elderly to move independently on. This may affect their motivations to go outside. In addition, there is a shortage of walking aids along the paths outside, e.g. benches to rest on or railings to hold on to. Furthermore, the paths can get slippery, when covered in leaves in the fall or during icy conditions. With no one to take care of these conditions, the outdoor environments becomes less safe. The form language of outdoor environment is at the moment dominated by straight lines and hard edges. The hardness of the surfaces is expressed by hard materials like concrete plates, bricks, glass and metal, which may not be perceived as pleasing. Furthermore, the contrast of the immediate surrounding against the fields and the park nearby is too abrupt, and thus, may be perceived as a boundary. Evident from the interviews, the area beyond the immediate surrounding is not used by the residents.

Furthermore, the changes that will be recommended by our plan, will not consider costs and whether or not they will fit the allocated funds that Solkullen has access to at the moment, as it is not included in the immediate scope of this work. Therefore, Solkullen will not have a clear view of what is possible for them to accomplish within the set budget. As part of the proposal, however, the role that funding plays will be presented, particularly in how the Solkullen facility can engage with the municipality.

Though the green spaces are immediately available outside the door, some of the doors may be too heavy for the frailest residents to open and close on their own. This limits their independence in moving in and out of the building. There is also a lack of sitting places made available in a variety of environments. There was a general lack of colorful plants as well as different levels of vegetation. Furthermore, there is a lack of ephemera or seasonal change in the present vegetation which means that there is little greenery to offer stimuli to the senses throughout the year.

The elevator that is used to bring up the residents in wheelchair was not working optimally. The surroundings outside do not include festive locations, which might be suitable for mood lifting meetings with family members with small children.

There are little attractions for children and youth to motivate them to visit the elderly. Furthermore, the facility is located rather remotely and can be hard to reach

The mood of the residents is crucial to overcome the stress moment in the process of going outdoors. An overcast sky seen from the window can decrease the will to go outside, even if the temperature is pleasant. It is hard to compensate for a lost life partner, or not be able to meet grandchildren who live far away, for not be able to feel the comfort of their own home and to meet neighbours and friends.

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Strengths A definite strength of Solkullen is that the facility is presently already promising and provides a good foundation to build on. The space to be used is big, and the views around the facility are pleasant. There is already greenery present at the facility that

can be used in the plans. The big windows in the facility bring a lot of natural light into the building and help to facilitate the transition from indoors to outdoors. The surrounding agricultural views are familiar to the residents, and might convey positive feelings. The facility is a one-storey building, with the exception of a limited second floor which house individuals who are only partly enjoying the services of the service flats. It is therefore a definite strength that no big investments need to be made in the building architecture to enable the enhanced use of the outdoor areas.

the hill means less cover from the weather elements (wind, rain, snow, sun). Therefore, the residents can experience all the elements directly when outside as well as indirectly, through the windows. Protection from the elements or lack thereof could discourage users from using the outdoors environment.

With the effects of climate change, the area could be affected by stronger elements, e.g. droughts and persisting heat. The area needs to be planned in a way that incorporates plants that can withstand extreme conditions, while at the same time demand minimal conditions. This may be challenging to be achieved in practice without interfering with other qualities like prospect and view from windows.

The space already facilitates different degrees of outdoor activities. There is a possibility to go out on one’s own, with minimum assistance, for a longer walk (around the building); or go out assisted to the close-by areas (courtyards closed and open) or, around the building, accompanied by a staff member. Furthermore, some residents have a terrace, that enables outdoor living in solitude and close to one’s room, if needed.

The zoning plan of the adjacent plot allows building two story buildings, which may block sunlight and threatens a valuable vista.

Due to the unknown future of the maintenance of the green spaces, the plan needs to focus on low maintenance needing vegetation. This, because it is not clear whether there will be enough funds from the municipality to have a dedicated employee working on the maintenance of the green spaces. Therefore, the green spaces have to be planned so that the staff will be able to manage them with very low effort.

However, low maintenance poses a risk of areas looking and feeling disordered and not taken care of. These possible occurrences might lead to the green spaces becoming unattractive and even creating negative impacts on health and well-being (cold, because of induces shade; heat stroke because of too much sun/warmth). The low level of maintenance may bring down the moods of the residents as no one takes care of their home environment On the other hand, the residents may be reminded of yet another job that needs to get done and feel a little inspired.

A lot of land is available to offer possibilities for planting activities like a landscape project would demand but also for hobby gardens for the residents to occupy themselves with, and to expand the area they use in their everyday. The south-facing orientation of the outdoor areas provides generous amount of sunlight for both humans and plants and the shape of the building is providing a good skeleton to support design for wind protection.

As we learnt from the interviews with the staff, the head of the facility is enthusiastic and committed to this project. Furthermore, some funding has already been secured. This enables the works to begin and can be considered one of the main strengths. Not only the head of the facility, but also the staff, seems keen to cooperate and look for ways to better use the outdoors spaces.

On a national scale, the importance of outdoor time ( friluftsliv) is well established.

This cultural value makes it so that justifying the enhancement of the outdoor spaces is not necessary. Furthermore, nature’s well-being potential has been recognized in this facility by the staff and residents who are enthusiastic about the changes to be made. Furthermore, we learnt from the interviews with the staff, that majority of the residents come from the area and are used to outdoor lifestyle having spent their life out of doors being engaged in gardening or farming activities.

Threats The location of Solkullen is on a hillock, which poses some limitations as to the gradient which might be challenging to elderly. Furthermore, the open location on

The facility will be extended with a dementia ward. This ward will be created in the east part of the building and a wall has already been built to separate these two wards from each other. As it might be chosen to keep the residents suffering from later stages of dementia from those who do not suffer from this illness, the staff might be faced with unplanned barriers to their uses of the current green spaces.

For example, if some of the outdoor spaces will be physically restricted from use for some residents, or if the use will be restricted temporarily, e.g. at certain hours of the day, this sets limitations to the uses of the outdoor spaces, which might in turn affect residents will to use the space in general.

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There is a risk that the outdoor space, after initial period of successful use due to a novelty effect, becomes less used due to lack of initiative from the staff who, for

reason or another, do no longer see the usefulness of the space, or do not have the time for maintaining it, or are discouraged because of the need to come up with activities for the elderly in the outdoor space in all weather. It can be, that the staff will have overestimated their capabilities in maintaining the outdoor spaces.

it applies to the aims of this program proposal. Possible solutions and avenues with regards to this will be addressed within the proposal part later in the text.

Opportunities Following a physical analysis of the outdoor environment, we conclude that the facility offers opportunities for enhancement with relatively little effort and with little demand of maintenance. There is an opportunity to easily and permanently increase the quality of most areas. For example, there is ample amount of space available, and existing greenery, which provides an opportunity for immediate use and immediate possibility to enjoy the green space. With relatively small changes (additional greenery, different textures and mobile elements), considerable changes can be seen. Though the area is big, the spaces to be enhanced are contained enough where enhancement is relatively easy and management as well. This suggest that increasing the usage will also be easier.

Although the staff at the moment seems enthusiastic about the prospect of using the outdoor space more, current staff members may be replaced with less enthusiastic individuals, which could cause a change in this.

Due to the fact that the staff already has a full workload, any changes in their routine – be it changes in staff set up or working hours – might affect them negatively.

The funds that are now available for the project, might turn out insufficient as the program plan (this document) is realized by a landscaping company. This because drafting a detailed budget with cost estimates is not in the scope of this project. In case the budget might be exceeded, it would be difficult to come up with additional funds, and the entire project’s quality might be jeopardized.

Some of the flats come with terraces, that could be harnessed for more use in the different seasons. They also enable enjoyment of the nearby nature, in solitude and not far from one’s room, if necessary.

Future sustainability is a major if not central threat to the long term viability of the proposed changes to the physical outdoors environment. The sustainability factor is based on three parameters: 1. Who will do the physical maintenance? The management has stated that they, the staff, will do the maintenance However, staff members expressed that whilst this was the case that they were sometimes too busy with resident care to engage in gardening let alone physical maintenance and upkeep of the outside area.

2. Funding and resources for maintenance do not exist within the current running and or future budget of the facility (confirmed by management) after the initial SEK 100k grant.

3. The role of the municipality in relation to this program proposal is unclear, given that the facility in itself is publicly funded. The municipality, apart from the grant of SEK 100K, is the only other available source of funding for the maintenance of the facility. However, this maintenance is limited in scope based on the observations and interviews. The municipalities mandates and budget are solely based on what national directives exist for the elderly care but are executed at the local level with local taxation. The current maintenance done by the municipality is part of the general infrastructure upkeep, the outdoors area does not have an independent significance in this respect, particularly as

The staff is positive about the possibilities the outside spaces offers to the residents and staff, and this positive attitude provides an opportunity for lasting change.

The municipality seems open, though not actively involved in the project. Harnessing this openness, perhaps an opportunity exists to discuss more support in maintaining the green spaces, e.g. in the form of a part-time employee to take care of the outdoor green spaces.

There is a trend of integrating different groups in the society to bring about social contact and increased quality of life. Following this trend, the Solkullen in Vollsjö could benefit from working with a group of e.g. schools and kindergartens who could visit the outdoor space of Solkullen and interact together with the residents around a mutually interesting theme. Furthermore, the help of volunteers, e.g. different civic organizations, scouts etc. as well as family members, could be explored and harnessed to help maintain the outdoor green spaces.

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By making the outdoor space attractive and opening it to the public, interaction with the elderly and the life outside could be increased. For example, the previously little used park area (ref to map) gives opportunity to meet the elderly with other age

groups from the surrounding area.

PROGRAM PROPOSAL

With the help of the program developed by the project proposal team, Vollsjö will be able to carry out specific and more targeted measures to enhance their outdoor environment in order to enhance the outdoor spaces and to improve the well-being of their residents and staff. By following the evidence based proposal, the use of these green spaces will more likely be increased.

In general and specific recommendations concerning the development of the In this thissection, section, general and specific recommendations concerning the developoutdoor environment as well as the use of the outdoor environment are presented.

The proposal ment of the outdoor environment as well as the use of the outdoor environment is divided into the main sections Physical Environment and Social Resources, divided into are presented. The proposal is divided into the main sections Physical environment subsections, are organized general toward solutions; a third and Social which resources, dividedfrom into more subsections, whichmore are detailed organized from and more section, called Combined Effect of the Physical and Social Enhancements is added to inform general toward more detailed solutions; and a third section, called Combined Effect how physical and social resources should be used together to ensure a positive outcome after of the Physical and social enhancements is added to inform how physical and social following this program. resources should be used together to ensure a positive outcome after following this program.

The proposal in this section result from the sum of the studies conducted in this project: the QET and the 4 Zones tool, as well as the general observations and interview findings, which The proposal ininto thisthe section from the sum of the studies conducted this were all included SWOTresult analysis described above.

An extraction of the maininSWOT project: the QET and the 4 Zones tool, as well as the general observations and interaspects was then made and put into a checklist to make sure every aspect has taken care of by view findings, weresolution. all included into the SWOT analysis described matching them which to a specific The SWOT aspects and the solution are putabove. into tables for easier reading.

Conclusion of SWOT Solkullen nursing home at Vollsjö has a high potential to become an exemplary facility with an excellent quality of the green space, actively used for the well-being of its residents. Physically and socially, the facility has wide range of potential and opportunities. The weaknesses, that mostly have to do with an underdeveloped physical environment, can be issued by simply filling the gaps.

Regarding public policies and regulations, on the other side, the concern is mainly connected to maintenance, which this program addresses with focus to low maintenance design. In general, the provided here proposal synchronize with the official documents and state for the well-being of the elderly people.

PROGRAM PROPOSAL PHYSICAL ENVIRONMENT

However, the biggest threat is that the future is still unclear. This makes planning for the best solution difficult. As it is now, the staff doesn’t know whether they should compromise with low maintenance solutions that brings up at least some enhancement and that will be able to sustain without much effort, or whether they can invest in long term solutions that, with time and continuous resources, will allow the place to become the best it can be.

SOCIAL RESOURCES

STRUCTURES

ENCOURAGEMENT

VEGETATION

KNOWLEDGE AND NETWORK

SUGGESTED PLANTS

ENHANCED USE AND INCREASED ACTIVITY

EQUIPMENT/TOOLS

GARDENING GAMES AND OTHER SOCIAL ACTIVITIES SOCIAL INTERACTIONS SURROUNDING LIFE TRADITION AND CULTURE PHYSICAL ACTIVITY REST ALL YEAR AROUND

PUBLIC ADMINISTRATION INPUT

COMBINED EFFECT OF THE PHYSICAL AND SOCIAL ENHANCEMENTS

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Figure 35.

Structure of developed program proposal.

PHYSICAL ENVIRONMENT Structures In this section we look at structures which support and enable different activities and also structures to support vegetation. A structure for activities can stimulate social gatherings, or physical activities, and also can make the access easier. Some examples are arranged in , a structural palette (see fig.37, p33) to inspire the new design in correspondence with the suggested list bellow.

Supportive structure is recommended in order to create spaces to satisfy the elderly needs outdoors.

Some suggested structural elements are: » Water features, preferably with moving water - a habitat for water plants and aspect wild animals; providing calmingSolutions atmosphere. The placement of water SWOT features should be in connection to paths or sitting areas. Some examples of ⇓⇓Lacking naturalness or wild nature Water features, preferably with moving suitable water features include: water - a habitat for water plants and wild ⇓⇓Too little key comfort and/or inspira› (shallow) pond; animals; providing calming atmosphere. tion qualities to makeofuse of other existing › collector rainwater; The placement of water features should qualities › small fountain; be in connection to paths or sitting areas. ⇓⇓Lack of› stimuli stream;in different seasons Some examples of suitable water features include: › outdoor foot bath; ⇓⇓Lack of sensory stimuli › bird bath.

• (shallow) pond; » Wooden structures: privacy screens, festive elements (e.g. gazebo) and • collector of rainwater; shadow providing pergolas - which allow climbing vegetation; wind protection • small fountain; » Planting solutions to bring the vegetation on a reachable level to stimulate the sense of touch - support for climbing vegetation, planting tables, planting • stream; pots on sitting level • outdoor foot bath; » Transition zones - more shared transition areas; • bird bath. » Comfortable (ergonomic) outdoor furniture » Use the building body - supporting structures for hanging plant pots and creating transition zones in general (see appendix 2) » Inspiring outdoor lighting - using/enjoying the outdoors after sunset » Infrastructure - walkable paths to encourage physical activities and new experiences, and supporting physical and mental difficulties › When planning paths, some things to consider in order to accommodate users behavior & needs: • Texture and material;

• Flatness of path; Solutions • Hardness of ground material; ⇓⇓Too• little physical aid like and Wooden structures: Sound of walking onrails path; benches • Needs for maintenance of materials • used on path; privacy screens, ⇓⇓Too• little sitting choices Gradient of path level; • festive elements (e.g. gazebo) and • Shape of pathplants (smooth corners); ⇓⇓Too little colourful andlines lack and of rounded shadow providing pergolas - which allow • Wayfinding (e.g prospect and landmarks); variation in plant’s heights climbing vegetation; • Resting areas along the way; ⇓⇓Hinders for visiting friends and fami• wind protection • Railing; lies (troubled elevator, lack of outdoor aid for walking, gardening, Practicality of maintenance in terms• ofsupporting rain and snowfall; areas•for meeting visitors, lack of children etc.: railings • Target spaces (paths, which lead to special rooms: old trees, solitude, friendly environments) theme gardens); ⇓⇓Open landscape (no natural cover from • anti-slipping solutions and materials. the weather) » Texture and material; ✓✓A› lot of landoftopath; use for a landscape proFlatness ject› and activities Hardness of afterwards ground material; › Sound of walking on path; ✓✓Room for outdoor activities - path › Needs for maintenance of materials used on path; around the building, courtyards, patios › Gradient of path level; › Shape of path (smooth lines and rounded corners); ⇓⇓Too little colourful andand lacklandmarks); of Planting solutions to bring the vegetation › Wayfinding (e.g plants prospect variation in plant’s heights on a reachable level to stimulate the sense › Resting areas along the way; of touch - support for climbing vegetation, › Railing; ⇓⇓Nobody assigned to outdoor mainteplanting tables, planting pots on sitting › Practicalityrequirement of maintenance in terms of rain and snowfall; nance-currently, for easy level maintained › Target gardens spaces (paths, which lead to special rooms: old trees, solitude, Transition zones - more shared and wind theme gardens); ✓✓Apartmentson the ground floor › anti-slipping solutions and materials. protected transition areas; ✓✓Room for outdoor activities - path • chairs with armrests Comfortable (ergonomic) outdoor furniaround the building, courtyards, patios ture.

• tables of different sizes ✓✓A lot of land to use forsizes; a landscape pro• pots in different ject› and activities afterwards Shaded and partly shaded sitting areas; › Protectionbad from rainand andstress wind;of ⇓⇓Overcoming mood going out (changing environmental condi› Railing; tions) is hardof sitting area (smooth lines and rounded corners): › Shape › Maintenance level of materials used; › Practicality of maintenance in terms of rain and snowfall; › Social choices: sitting in a group, or privately; » Outdoor visitors areas, children friendly;

SWOT aspect

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SWOT aspect

Solutions

⇓⇓Overcoming bad mood and stress of going out (changing environmental conditions) is hard

Use the building body

⇓⇓Extreme weather conditions: dry and warm in summer, very wet/lot of snow in winter. ⇓⇓Lack of visual softness in the lines and edges ⇓⇓Has the staff overestimated their capacity to use the outdoors on everyday basis?

SWOT aspect -continuing-

• supporting structures for hanging plant pots and • creating transition zones in general, both for humans and plants (see fig.37ex: 19,20,21) / also, easy for the staff to incorporate the use in the daily routines.

⇓⇓Too many obstacles in the terrain ⇓⇓Lack of sitting choices ⇓⇓Lack of visual softness in the lines and edges ⇓⇓Too little physical aid like rails and benches ⇓⇓Hinders for visiting friends and families (troubled elevator, lack of outdoor areas for meeting visitors, lack of children friendly environments) ⇓⇓Straight lines and hard edges ⇓⇓Nobody assigned to outdoor maintenance-currently, requirement for easy maintained gardens ⇓⇓Challenging terrain ⇓⇓The program proposal focused on low maintenance ⇓⇓Mixing regular residents with dementia patients

✓✓Apartments- on the ground floor

⇓⇓Too little key comfort and/or inspiration qualities to make use of other existing qualities

-continuing-

⇓⇓Mixing regular residents with dementia • Resting areas along the way; patients • Railing; • Practicality of maintenance in terms of • A lot of land to use for a landscape rain and snowfall; project and activities afterwards • Target spaces (paths, which lead to • Existing greenery, old trees and good special rooms: old trees, solitude, theme amount of space gardens); • Anti-slipping solutions and materials.

✓✓Good and big building

⇓⇓Lack of sensory stimuli

Solutions

Inspiring outdoor lighting - using/enjoying the outdoors after sunset

⇓⇓Lack of stimuli in different seasons Infrastructure - walkable paths to encourage physical activities and new experiences, and supporting physical and mental difficulties. When planning paths, ⇓⇓Too many obstacles in the terrain some things to consider in order to ac⇓⇓Risk for slipping due to lack of outdoor commodate users behavior & needs: maintenance • Texture and material; • Flatness of path; ⇓⇓Lack of visual softness in the lines and • Hardness of ground material; edges • Sound of walking on path; ⇓⇓Lack of stimuli in different seasons • Needs for maintenance of materials used on path; ⇓⇓Hinders for visiting friends and fami• Gradient of path level; lies (troubled elevator, lack of outdoor areas for meeting visitors, lack of children • Shape of path (smooth lines and rounded corners); friendly environments) • Wayfinding (e.g prospect and land⇓⇓Lack of sensory stimuli marks); ⇓⇓Too little key comfort and/or inspiration qualities to make use of other existing qualities

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Sitting areas to offer an opportunity to be outdoors without any particular activity.

When planning sitting areas, some things to consider are: • Texture and material; • Flatness of sitting area; • Slopes to and from sitting area; • Hardness of ground material; • Sounds in the area; • Wayfinding to and from sitting area; • Immediate surroundings (vegetation and structures); • View from sitting area; • Sturdy but movable furniture, such as: • chairs with armrests • tables of different sizes • pots in different sizes; • Shaded and partly shaded sitting areas; • Protection from rain and wind; • Railing; • Shape of sitting area (smooth lines and rounded corners): • Maintenance level of materials used; • Practicality of maintenance in terms of rain and snowfall; • Social choices: sitting in a group, or privately;

SWOT aspect

outdoor qualities than any other indoor area like beautiful views, fresh air, sounds from surrounding life, possibilities for physical activities and physical access to outdoor features. This is recommended to inspire further exploration of the outdoors, or to at least bring some of the outdoor benefits if going outside is not an option at a given moment. To minimize the stress from changing environmental conditions, the transition spaces should be also designed to help the climatization of the body: average temperature and amount of light/humidity/wind between indoors and outdoors; and also to help the mental adjustment: less energy demand then outdoor vistas, for example - no need to change shoes and clothing (maybe just using poncho or blanket), no need for other person’s assistance, near to toilet, ability to reach stuff if needed.

Solutions

⇓⇓Hinders for visiting friends and famiOutdoor visitors areas, children friendly lies (troubled elevator, lack of outdoor areas for meeting visitors, lack of children friendly environments) ⇓⇓Too little key comfort and/or inspiration qualities to make use of other existing qualities

Vertical gardens (less maintenance demanding);

⇓⇓Risk for slipping due to lack of outdoor maintenance ⇓⇓Lack of visual softness in the lines and edges ⇓⇓Overcoming bad mood and stress of going out (changing environmental conditions) is hard ⇓⇓Straight lines and hard edges

Soft shapes in the landscape: curvy lines, vegetation instead of, or used in combination with structural elements and harmony in colours would gradually make the shifting between the elderly home and the surrounding nature.

This approach would also contribute to visually pleasing and calming outdoor areas.

With the establishment of the new dementia wing, we need to understand that dementia patients are not prisoners, therefore they are not to feel spatially restricted! The physical environment is there to provide familiarity and easy wayfinding through recognizable symbols and landmarks. “Getting escape” issues should be solved with other, primarily organizational/ technological methods. If there is an absolutely need for fences, they should be discreet and not looking very much like such and do not block landscape views. Possible solution is, for example, a big scale trellis with some delicate climbing vegetation.

In order to comprehend as many areas as possible within the given budget, the design solutions must be both inexpensive and creative. As the area is big, it is possible to find some completely free materials like fallen tree branches, which can be used for different garden sculptures

The risk of slipping due to lack of outdoor maintenance may be addressed to a limited degree with good design. However, to truly cope with this issue, increased outdoor maintenance resources (such as employees or funds) may be needed.

The doors that connect the main indoor areas to the main outdoor areas should be easy for everyone to open. However, the doors should not be light enough for draft to open them. Reachable buttons for opening doors may be helpful for eliminating barriers between indoor and outdoor environments, while maintaining a desirable indoor climate.

In general, transition areas should be able to provide more desirable

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Figure 36.

Inspirational picture of discreet fence.

1. Low cost anti-slip solution 2. Comfortable furniture 3. Discrete fence 4. Exercise on wheelchair 5. Familiarity 6. Rain of flowers 7. Green tunnel 8. Inspiring lighting outdoors 9. Aid along a path 10. Pause beside a path 11. Privacy screens 12. Refuge 13. Musical feature 14. Stepable plants 15. Reachable plants 16. Reachable water feature 17. Social space for people with different levels of disability 18. The view from inside the building 19. Soften the hard edges!

20. Use the building!

21. Transition zones 22. Simple activity/familiarity/ wind 23. Experiencing wild nature: suitable path 24. Pergola 25. Social space under the shadow 26. Accident protection near water feature 27. Amusing water play 28. Bird bath 29. Raised planting bed 30. Pleasure of the walk

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Figure 37.

Pallet of examples of supporting structures.

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› Humidity (note: vegetation may affect humidity The vegetation should bedense chosen in concideration with: levels and insect

Vegetation Plants can be useful providing aesthetic and other pleasures in the green spaces of the nursing home. Well chosen plants and carefully designed plantings may be used to provoke memories and provide sensory stimuli for the user group. Furthermore, with a diversity of plants, seasonal change can be guaranteed and the green space can offer visual stimuli throughout the year.

populations) › visual access to the surroundings (agricultural fields, streets, etc.)

SWOT ›aspect visual interest from windows andSolutions terraces ⇓⇓Big windows, agricultural be chosen so › easy familiar maintenance whereviews possiblePrecipitation: (dwarf treesplants in theshould courtyards, perenthat they hinder evapotranspiration and nials, self-sustaining plants) ✓✓Apartments- on the ground floor

offer shade during hottest seasons. However, the plan needs to also consider days of heavy snowfall or rainy days so that the A list of plants, often traditional and fragrant, that may be used in the outdoor enviview from the windows is not blocked. ⇓ronment ⇓Lack of to sensory enrichstimuli the biodiversity and sensory stimuli aspects, have been suggested ✓ ✓Personal patios to enjoy nearby nature in Suggested plants solitude

Some general things to consider when choosing plants are: » Plants should be chosen so that they hinder evapotranspiration and offer shade during hottest seasons. However, the plan needs to also consider days of heavy snowfall or rainy days so that the view from the windows is not blocked. » Plants should be placed to stimulate contact between the user and the plant » Plants should offer more than visual stimuli » Avoid invasive plants that contribute to deterioration of biodiversity » Plants should be chosen with consideration to › seasonal change › memory provoking, traditional characteristics › material for crafting › textures and fragrances › visual attraction values › providing food and spices › providing something to take indoors › insect attraction › air quality improvement properties › horticultural values (i.e.: Could the residents take cuttings or seeds to cultivate the plant?) › structural properties (i.e.: Does the plant create a pillar, wall or roof that may be used as a structure in the environment?) › management level » Plants should be placed with consideration to: › connectedness to paths and sitting areas › height and accessibility to user › visual contact with indoor and outdoor areas › site conditions and plant site preferences (temperature, moisture, light, wind etc) › distances to other greenery › Heat island effects, and trapping of air with pollutants into one space

a list, seeassigned Appendix 2. The suggested ⇓in⇓Nobody to outdoor mainte- plants may be used to provoke memories and provide sensoryrequirement stimuli for the user group. This list of suggestions aims to provide nance-currently, for easy some inspiration maintained gardensand should not be used in absence of professional advice. The list is not complete, and additional plants must be considered when planning the final

⇓⇓Open landscape (no natural cover from design of the project area. As the plant suggestions concern mostly herbaceous the weather)

plants, professional help is recommended when choosing larger plant material, such as trees and large bushes. Note that an increased number of plants and plant ⇓species ⇓Lack ofmay stimuli in different within nature: plants should contribute to aseasons higher level ofInteraction maintenance the outdoor environstimulate contact between the user and the To increase the desired effect ⇓ment. ⇓Overcoming bad mood and stress of of the vegetation, it is considered as a good plant practice prace key plant speciescondiin connection with sitting areas going outto (changing environmental tions) is hard

Equipment/tools In order to stimulate spontaneous gardening, placing a few easily accessible ⇓⇓Overcoming bad mood and stress of Perception: plants should offer more than gardening tools at various locations aroundvisual the garden going out (changing environmental condistimulimay be a simple but helpful measure.

Since the abilities of the potential spontaneous gardeners may vary, tions) is hard providing different types of tools is important. Some examples of gardening tools ⇓⇓Lack of stimuli in different seasons that may be useful are: hose/watering system, secateurs, hoes, rakes (small and large), brooms, shovels and spades (small and large), wheelbarrows and compost ⇓areas. ⇓LackFurthermore, of stimuli in different seasons Biodiversity: avoid invasive gardening has many potential benefits, such as: plants that contribute to deterioration of biodiversity ⇓⇓Lack or wild nature » ofItnaturalness is a physical activity with complete freedom in what physical level is ⇓⇓Lack of colourful plants and variation in desired. plant’s» heights It provides visible results after completion, which may cause feelings of ⇓⇓thesatisfaction program proposal focused on low and ownership. maintenance » It may be done as a social activity or individually. ✓✓Existing treespoint and good » It greenery, serves as old a focal for bystanders to look at. amount of space

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Another simple measure that may enable more outside activity, is ensuring that every resident has access to proper clothing that may be used in all types of weather.

⇓⇓Lack of stimuli in different seasons

Seasonal change concidered choices

✓✓Big windows, familiar agricultural views

Memory provoking, traditional characteristics

⇓⇓Mixing regular residents with dementia patients ✓✓The staff is cooperative and positive to changes

Material for crafting

⇓⇓Lack of sensory stimuli

Textures and fragrances

✓✓Personal patios to enjoy nearby nature in solitude

• Visual attraction values • Providing food and spices • Providing something to take indoors • Insect/animal attraction • Air quality improvement properties • Horticultural values (i.e.: Could the residents take cuttings or seeds to cultivate the plant?)

• Structural properties (i.e.: Does the plant create a pillar, wall or roof that may be used as a structure in the environment?)

• Management level

⇓⇓Overcoming bad mood and stress of going out (changing environmental conditions) is hard ⇓⇓Lack of sensory stimuli ⇓⇓Lack of sitting choices

⇓⇓Too little key comfort and/or inspiration qualities to make use of other existing qualities

Connectedness to paths and sitting areas

⇓⇓Lack of sensory stimuli ⇓⇓Too little colourful plants and lack of variation in plant’s heights

Height and accessibility to user

⇓⇓Overcoming bad mood and stress of going out (changing environmental conditions) is hard

Visual contact through indoor and outdoor areas

⇓⇓Nobody assigned to outdoor maintenance-currently, requirement for easy maintained gardens

Site conditions and plant preferences (temperature, moisture, light, wind etc) 37

⇓⇓Lacking of key comfort and/or inspiration qualities to make use of other existing qualities

Distances to other greenery

⇓⇓Lacking of key comfort and/or inspiration qualities to make use of other existing qualities

Heat island effects, and trapping of air with pollutants into one space

⇓⇓Lacking of key comfort and/or inspiration qualities to make use of other existing qualities

Humidity (note: dense vegetation may affect humidity levels and insect populations)

✓✓Big windows, familiar agricultural views

Visual access to the surroundings (agricultural fields, streets, etc.)

✓✓Personal patios to enjoy nearby nature in solitude ✓✓Big windows, familiar agricultural views

Visual interest from windows and terraces

⇓⇓Nobody assigned to outdoor maintenance-currently, requirement for easy maintained gardens

Еasy maintenance where possible (dwarf trees in the courtyards, perennials, selfsustaining plants)

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1. Balkan anemone 2. Aubrietia 3. Crocus 4. Double daisy 5. Cowslip 6. Hyacinth 7. Christmas rose 8. Kaiser’s crown 9. Orpine 10. Strawberry 11. Primula 12. Cherry tree 13. Grape hyacinth 14. Scilla 15. Pilewort 16. Tulip 17. Coltsfoot 18. Heath violet 19. Snowdrop and 20. Winter aconite 21. Wood anemone 22. Yellow-star-of-Bethlehem 23. Glory-of-the-snow 24. Snake’s head fritillary 25. Forget-me-not 26. Bukhara iris 27. Iris Harmony 28. Lily of the valley 29. Plum tree 30. Daffodil

Figure 38.

Pallet of spring vegetation.

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1. Ornamental onion 2. Apple Aroma 3. Conference pear 4. Daylily 5. Cherry tree 6. Butterfly-bush 7. Honey perfume rose 8. Orpine 9. Lambs-ear 10. Levender 11. Bleeding heart 12. Miscanthus sinnesis 13. Carrots 14. Adria bellflower 15. Oceania hybrid tea rose 16. Peony 17. Plum 18. Rhubarb 19. Woodland strawberry 20. Lilac 21. Poppy 22. Red/Blackcurrant 23. Viola tricolour 24. Brunnera “Jack Frost�

25. Japanese maple 26. Himalayan birch 27. Silver birch 28. Ceanthus tree 29. Colorado blue spruce 30. Linden

Figure 39.

Sense awakening pallet.

The encouragement recommendations shouldthe be focused on developing them should also be kept in mind when planning outdoor environment.

Our social resources: recommendation is to plan for a variety of activities and places to try to catch

SOCIAL RESOURCES

different needs and wishes.

Enhancing the outdoor environment is the first step in enabling outside stay. This can be done by first transforming the physical environment. The following step is to create incentives for the use of the outdoor environment. This step requires both physical resources as a foundation and later the social resources as further incentives, as a layer for active use.

SWOT aspect

✓✓Growing interestresponsible for participationin- Help fromindoors other residents, staff, famHaving a person for activities not only but outdoors as well, is volving volunteers and different organizaily, third parties (e.g. volunteers) essential for optimizing outside stay. Organized activities not only createfora social tions. gardening, foot bath, observing social context but also encourages people to participate.

Bringing activities traditionally interaction, games, performances (music, done inside to the outside environment in an organized way, may stimulate the theater). wish to participate, e.g moving the card game club or boule game outside. Bringing organized outdoor activities on the schedule might also facilitate staff resources, ⇓⇓No room for extra routines Plan the program in a way that helps the meaning that if outdoor activities are tostaff, be on the daily or weekly schedule it by offering the residents and staff becomes a part of everyday routines and may feel cumbersome or be subject alikenot a pleasant outdoor environment thatto stress for both staff and residents. Using the outdoor environment should also be a not only invites it to be used, but also enapart of the care that is being provided at thebles nursing home, similar to medicinal care easy use. and regular care. External human resources, e.g. garden therapists or recreation counselors might also be beneficial betterupunderstanding of how to use the ✓✓Opportunity for interaction of differ-for a Open some parts of the Solkullen’s outdoor environment.

This would also mean more professional knowledge ent age groups if the quality of the nearby outdoor space to enable interaction. about public park is lifted the disciplines, e.g.up. garden therapy, that may be applied at the nursing home.

Encouragement It is important to understand that enhancing the outdoor environment will not by itself enable further use of it. There are still challenges with people’s motivation, mood and wishes to actually use the outdoor environment. Both social and visual encouragement are important key factors that may help facilitate outside stay.

Depending on the abilities of the user, different activities can be quite demanding.

Our recommendation is therefore to ease the transition from indoors to outdoors by taking the activity further step by step. This means that it is good to continue the daily routines, for example, drinking tea in the morning in Zone 1 by an open window, and later continue that activity in Zone 2.

The outside stay is not only meant to benefit the residents but the other user groups as well. Spending time outside on your work time, taking walks or engaging in an activity will both create added values to your work day but also release any need to spend time outside on your leisure time after work.

Many of the activities or the suggested enhancements can be enjoyed independently by the residents (e.g. walking, quiet contemplating, watching birds, some gardening).

However, it should be also considered, that many of the recommended activities will only come to life if the elderly will receive help from other residents, staff, family members or third parties, such as volunteers (e.g. some gardening, dipping feet in water). It should furthermore be considered that different levels of participation should be allowed and planned for. For example, while others have a need for direct socializing, some others might be quite happy with only observing interactions or, e.g. children playing. Therefore, the area should cater for activities that simultaneously can be done alone or with help.

Help from third parties nearby the nursing home might also help facilitate and allocate activities at the nursing home. Inviting preschool students to the nursing home’s, e.g. to help planting strawberries in the garden during the summer or making bird food to hang in the trees in the winter, are ways to interact with the surrounding community and bringing some more life into the nursing home. Having other people groups at the nursing home would be a nice variation and could also release some pressure from the staff to do activities.

Knowledge and network It is necessary for all user groups to be informed about the outdoor environment´s benefits for health and well-being. Information could be provided along with social encouragement through informative talks or guest lectures.

There should also be an underlying plan for changes in residents at the nursing home. Newcomers might be more or less physically active and features directed to

Solutions

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Enhanced use and increased activity The following section will provide recommendations on social resources that can increase the frequency of outside stay. Social situations tend to develop by themselves when opportunities as well with social platforms are present. The recommendations also try to mirror activities and social setups that can be done throughout the year and on different times of the day. Since the quality of joyful and mean-

SWOT aspect

Solutions

⇓⇓Overcoming bad mood and stress of going out (changing environmental conditions) is hard

Informative talks with the residents and guest lecturers

⇓⇓Having the right kind of human resources - the current staff who demonstrate a very positive outlook to the enhancement of the outdoor environment are not permanent fixtures at the Solkullen nursing home

Creating facility guidelines to be streamlined into the daily care of the residents that ensures use of the outdoors area and or that residents be encouraged to use it by their caregivers( nurses and nurse aids)

✓✓Current staff has positive attitude towards the outdoor use

As part of recruitment ensuring that applicants know that the outdoors environment is also part of the caregiving process alongside clinical and medical care After recruitment and during orientation again reinforcing the importance of using the outdoors area This should also be done during in-house service training.

Involving family members to be a part of the organizational culture.

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⇓⇓Has the staff overestimated their capacity to use the outdoors on everyday basis?

Having a person responsible for activities outside. Organized schedule for activities outdoors.

✓✓The population in general is used with the outdoor life.

Inviting pre-schools and schools to participate in planting activities.

ingful activities and culture and connection was lacking in many of the area, a great emphasis should be put on developing foundations for these qualities.

Gardening Gardening is an activity that can be done both by oneself and with others. It enables the user to use all their sensory modalities when engaging with different kinds of plants. Being able to pick up soil and strain it between one’s fingers and smell or eat freshly picked berries are activities that can be joyful for many. Garden areas also work as a social meeting point in the outdoor environment and may relate and also connect the users to previous life. Raised garden beds are practical since they allow the user to both interact and come closer to the plantings. Being part of something that is important like taking part in growing plants to be able to surround oneself with nature makes for a higher quality of being. To be able to take part of this it is important that enough and good equipment, such as gloves and general garden tools, to feel the motivation and urge to be outside and engage in the plantings.

Figure 40.

Exchanging practical knowledge.

Figure 41.

Gardening with raised beds.

Games and other social activities Bringing activities that are traditionally done inside to the outdoors, is a convenient way to increase outside stay. Playing a game of chess, card or boule can be done in different kinds of weather and does not demand ideal weather conditions. Outdoor games provide exercise for both body and mind. Organized games and activities is a good way to connect with each other and they may stimulate cohesion. Increasing the availability and ease of access to such games, is important to stimulate usage.

Details such as keeping the games visible and not stored away but also providing a variety of ways to sit, e.g. under a parasol, roof, tree crown or under the sun, are different ways for achieving this.

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Figure 42.

Playing chess.

Figure 43.

Playing boule.

Surrounding life Contact with surrounding life is an important part of feeling connection and perhaps also a pull factor towards a will to be outdoors. Contact with animals, for example birds and dogs, and other humans is a vital part for having contact with one’s surroundings. It doesn’t even necessarily have to mean direct contact; just seeing or hearing other life can be a calm activity that at the same time gives the possibility for contemplation and bonding with what is all around. Feeding birds, hearing kids play or interact with a dog owner walking its dog are activities that can be engaged in solitude as well as in company with a close mate and also with benefit throughout the whole year. To be able to enjoy the surrounding life one must feel comfortable and safe in doing so. Furthermore it must be possible to sit down and rest and when seated be able to enjoy the surroundings.

Social interactions Places to sit and talk, play games, have a fika or barbecue in the outdoors is perfect for social interactions and to get together. A place for a barbeque area or maybe a hammock could be an good way for meeting both family and friends; as well as enjoying the weather over a cup of coffee. When planning these areas, striving for variety between different choices may be a significant success factor. Having different choices for these interactions in the outdoor environment is important.

Equally important for these social areas is that they are inviting and accessible. It must be a consideration what and how the different areas are placed and designed.

Outside furniture need to be built of robust material and have both back and arm support. Different ground materials also needs to be considered to make them accessible for wheelchairs.

Figure 44.

Having “fika”.

Figure 45.

Playing a game of cards.

Figure 46.

Feeding birds.

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Figure 47.

Enjoying company.

Physical activity Physical activity is important to stimulate both body and mind. Creating specific areas for exercise, such as an outdoor gym, are good introduced elements that can encourage the use of the outdoor environment. Providing examples for exercises to perform or having organized walking circles are good ways to turn recreation into a social activity. Walking is an example of an activity that can be performed all year round, anytime during the day and in different kinds of weather. Walking requires accessible walking paths with the potential to sit down and rest, with different stimuli along the way and with soft edges that pleases the eye and makes one curious as to what is right around the bend.

Tradition and culture Traditional activities that may provoke old memories are important features in the everyday life. This can appeal to one’s previous life and also act as natural conversation topics. Hanging the laundry outside is a good way to bring the summer inside and doing some garden chores may bring back positive memories. Some traditional plants may also provoke memories, such as “myskmadra� (Galium odoratum).

Myskmadra is traditionally picked as a bouquet to bring to the church, hang in the closet for its scent or as a material for binding wreaths.

Figure 50.

Enjoying the outdoor gym.

Figure 48.

Laundry outside.

Figure 49.

Pruning roses.

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Figure 51.

Walking together.

All year round There are activities that can be performed throughout the entire year. The current weather condition is of importance to what extent and how often and how long these activities can be done in the outdoor environment. More or less physical or grueling activities can be done outside depending on the outdoor location. One can sit comfortably and knit, read a book, solve crosswords, watch birds or enjoy seasonal decorations, e.g.christmas lights, easter feathers or halloween pumpkins.

Other more physical activities include swinging a swing and walking.

Rest Some activities that typically are performed indoors can easily be moved outdoors when the weather allows it. Resting, enjoying the sun or the shade, reading and bathing in fresh air in a comfy chair are good opportunities to use the outdoor environment without much physical activity. Spiritual activities such as meditation, watching the stars under the night sky and praying are also examples of activities that work very well and can be done outdoors.

Figure 52.

Resting on a bench.

Figure 54.

Knitting.

Figure 53.

Reading a book.

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Public administration input To further explore how it is possible to utilize opportunities and resources incorporated already in the legislation, a member of the team contacted the Municipality of Sjöbo City. The municipality seemed open and responsive with regards to the program proposal and has expressed interest in studying this document. They also expressed an appreciation of the process and the challenge of the funding, while, at the same time, they raised the fact that the elderly population is included within the municipality’s Green Structure Plan from 2016 and its currently finalized Sustainable Development plan(Personal Communication with Venus Krantz, Miljöstrateg

Stadsbyggnadsförvaltningen Sjöbo Kommun, April 16th 2018). Within the Green Structure Plan, the municipality administration stated that “outdoor environments should be accessible to all citizens, which means that they should be designed for disabled and elderly people as well” (Sjöbo kommuns Grönstruktur-och naturvårdsprogram, 2016, p. 20).

CONCLUSION This program proposal has described the group project carried out during the spring semester of 2018 as partial fulfillment of the course ‘Health promoting outdoor environments’ course held at the Swedish University of Agricultural Sciences (SLU) Alnarp campus.

The municipality administration has also expressed an interest that the program proposal for the Solkullen nursing home could be, possibly, used as an example/ template for other nursing homes in the municipality(Personal Communication with Venus Krantz, Miljöstrateg Stadsbyggnadsförvaltningen Sjöbo Kommun, April 16th 2018). There maybe an opportunity to utilize the green spaces at Solkullen nursing home as part of the roll out / implementation activities in the Green Structure and Sustainable Development plans. Based on this official ground it is recommended that the management of the Solkullen nursing home engage with the municipality to see which parts of the program proposal could be scaled up or reinforced as a part of activities within the Green Structure and Sustainable Development Plans

In this program proposal we have described the theoretical background to motivate the need and benefits to health from having an attractive outdoor space and a program to enhance the use of such spaces for the elderly. Furthermore, we have described the methods we used to collect information and analyze the current state of the environment at the Vollsjö nursing home. We have brought together all our data into a SWOT analysis that has highlighted the Strengths, Weaknesses, Opportunities and Threats we have identified at the Solkullen nursing home in Vollsjö.

Finally, we have drafted proposal lists pertaining to the enhancement of the physical space but also the social resources of the facility in order to enhance the use of the green spaces to promote wellbeing of the residents and staff of the nursing home.

The program may serve as a support for the nursing home administration in evaluating the needs for changes.

COMBINED EFFECT OF PHYSICAL AND SOCIAL ENHANCEMENTS Every social encouragement must be supported by the physical environment and vise versa: the provided physical environment should get the attention, a reminder from the staff that outside there is something which waits to be used.

In the SWOT analysis it was acknowledged as an opportunity that if this program is followed, the outdoor qualities will most likely increase in significance. This possible outcome will bring numerous benefits, not only for the elderly, living in Solkullen: the positive effect will extend over other groups of people and stakeholders as well.

If the outdoor qualities for the Solkullens residents increase, the following benefits are expected to follow: 1) increased physical and mental health of the residents, 2) increased physical and mental health of the staff, 3) increased professional motivation of the staff, 4) increased amount of visitors at the nursing home, 5) positive attitudes towards the nursing home from people from the surrounding area, 6) easier to find staff when needed, due to the positive attitude, 7) increase of positive attitude towards elderly people in general.

Including therapists/inspirers (either within the organization, or scheduled for regular visits) who work with the outdoors intentionally can be useful. Another way to enhance the usage of the outdoor environment is to compose a plan, based on the landscape design, which explains the purpose of the key elements and how they are supposed to be used. This plan can be then included in the staff instruction documentation to ensure the knowledge remains even in the future, after the project is completed.

As mentioned before, the physical environment is the very first step, and the second one lies upon creating of a social context that is useful for the user groups. A good outdoor environment is only as good as it is used, meaning that the usability of the outdoor environment is an important function.

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Statistiska Centralbyrån. 2015. Sveriges framtida befolkning 2015–2060: Tre miljoner fler bor i Sverige år 2060. (2018-02-01) https://www.scb.se/sv_/Hittastatistik/Statistik-efter-amne/Befolkning/Befolkningsframskrivningar/Befolkningsframskrivningar/14498/14505/Behallare-for-Press/389899/

Figure 1: Lantmäteriet Figure 40: http://sbcwilmington.com/senior-outdoor-activities-for-stronger-mental-health/ Figure 41: http://www.pcnursinghome.net/activities.html Figure 42: https://m.znaj.ua/ru/science/opredelen-vozrastnoj-barer-dlya-cheloveka Figure 43: https://sverigesradio.se/sida/artikel.aspx?programid=114&artikel=4625364 Figure 44: https://www.gettyimages.com/detail/photo/group-of-elderly-people-sitting-at-garden-table-and-royalty-free-image/491800578 Figure 45: http://peoria-233.comfortkeepers.com/home/blog?article=173&date=2017-01-04&title=social-interaction--in-home-caregiver-peoria Figure 46: http://www.palmlakecare.com.au/our-stories/the-importance-of-hobbies-for-seniors Figure 47: https://medical-alert-systems.bestreviews.net/pets-miraculous-medicine-seniors/ Figure 48: http://colorelle.se/2011/june/ett-ar-i-huset.html Figure 49: https://www.rawpixel.com/ Figure 50: https://www.vlt.se/allmant/90-aringar-besoker-garna-utegymmet Figure 51: https://www.lacasadiriposo.it/n/un_giardino_zen_per_gli_anziani_in_ casa_di_riposo/295 Figure 52: http://nationalpost.com/news/canada/elderly-couples-can-hear-theirpartners-voice-more-clearly-than-a-strangers-study-finds Figure 53: https://www.freepik.com/free-photo/close-up-of-elderly-woman-reading-a-novel_952357.htm Figure 54: https://www.istockphoto.com/se/fotografier/elderly-woman-sticking-tongue-out-concentration-funny-face?sort=mostpopular&mediatype=photography&phrase=elderly%20woman%20sticking%20tongue%20out%20concentration%20funny%20face

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(2018-02-01) http://tradgard.org/svensk_tradgard/zonkarta/index.html Sveriges Geologiska Undersökning. 2018. Kartgenerator. (2018-02-06) http://maps2.sgu.se/kartgenerator/maporder_sv.html Ulrich, R. S. (1993). Biophilia, Biophobia, and Natural Landscapes. In The biophilia hypothesis (pp. 73–137). Washington, D.C.: Island Press.

Ulrich, R. S. (1999). Effects of gardens on health outcomes theory and research. In C. Cooper Marcus & M. Barnes (Eds.), Healing Gardens: Therapeutic Benefits and Design Recommendations (pp. 27–86). John Wiley & Sons. Retrieved from http:// www.google.com.hk/books?hl=zh-TW&lr=&id=YRY1WejQok8C&pgis=1 Ulrich, R. (2001). Effects of healthcare environmental design on medical outcomes.

In A. Dilani (Ed.), Design & Health: The Therapeutic Benefits of Design. Stockholm: Svensk byggtjänst. van den Berg, A. E., Joye, Y., & de Vries, S. (2013). Health benefits of nature. In L. Steg, A. E. van den Berg, & J. I. M. de Groot (Eds.), Environmental psychology: an introduction (pp. 47–56). British Psychological Society and John Wiley & Sons, Ltd. Wang, S., Ang, H. M., & Tade, M. O. (2007). Volatile organic compounds in indoor environment and photocatalytic oxidation: State of the art. Environment International, 33(5), 694–705.

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Sustainable Cities and Society. Elsevier Ltd 49

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Appendix 1 - QET matrix

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Appendix 2 - List of plant suggestions Note: This list of suggestions aims to provide some inspiration and should not be used in absence of professional advice.

Scientific Name

Common Name

Motivation

Alchemilla mollis

Jättedaggkåpa

Summer blossom, interesting effect on leaves

Allium schoenoprasum

Gräslök

Food, traditional

Anemone blanda

Balkansippa

Spring blossom

Anemone nemorosa

Vitsippa

Spring blossom

Aster amellus

Brittsommaraster

Late summer blossom, traditional

Aubrieta x cultorum

Aubrietia

Spring blossom, ground cover

Buddleja davidii

Fjärilsbuske

Late summer blossom, traditional

Campanula portenschlagiana

Murklocka

Clematis x hybrida ‘Jackmanii’

Lamprocapnos spectabilis

Löjtnantshjärta

Early summer blossom, traditional

Lavandula angustifolia 'Hidcote'

Lavendel

Summer blossom, traditional, fragrant

Leucojum vernum

Snöklocka

Spring blossom, traditional

Malus domestica ‘Aroma’

Äpple ‘Aroma’

Food, traditional

Matteuccia struthiopteris

Strutbräken

Summer greenery, traditional

Miscanthus sinensis 'Silberfeder'

Glansmiscanthus

Tall grass

Muscari botryoides

Pärlhyacint

Spring blossom

Paeonia suffruticosa

Buskpion

Summer blossom, fragrant

Summer blossom

Papaver orientale ‘Brilliant’

Trädgårdsjättevallmo

Summer blossom, traditional

Jackmanklematis

Summer blossom, climber

Pinus mugo 'Gnom'

Bergtall

Crocus vernus

Vårkrokus

Spring blossom, traditional

Bushy pine, connects to forest

by Vombsjön

Daucus carota ssp. sativus 'Jaune du Doubs'

Morot

Food, traditional

Pinus sylvestris

Tall

Connects to forest by Vombsjön

Polygonatum x hybridum

Jätterams

Summer blossom, traditional

Doronicum magnificum

Vårkrage

Late spring blossom, traditional

Primula veris

Gullviva

Summer blossom, traditional

Eranthis hyemalis

Vintergäck

Early spring blossom, traditional

Primula vulgaris

Jordviva

Spring blossom

Fragaria vesca

Smultron

Food, traditional

Kejsarkrona

Spring greenery, late spring blossom

Prunus avium ‘Allmän Gulröd Bigarrå’

Sötkörsbär

Fritillaria imperialis

Late spring blossom, food, traditional

Prunus cerasifera

Körsbärsplommon

Spring blossom, volume

Gagea lutea

Vårlök

Spring blossom

Prunus domestica

Plommon

Spring blossom, food, traditional

Galanthus nivalis

Snödroppe

Early spring blossom, traditional

Lungört

Spring blossom

Galium odoratum

Myskmadra

Early summer blossom, traditional, fragrant, ground cover, spice

Pulmonaria saccharata ‘Mrs. Moon’ Pyrus communis ‘Alexander Lukas’

Päron ‘Alexander Lukas’

Gives fruit at a young age

Helleborus niger

Julros

Early spring blossom

Rheum rhabarbarum

Rabarber

Food, traditional

Hemerocallis ‘Moment of truth’

Daglilja

Summer blossom

Ribes nigrum

Svarta vinbär

Food, traditional

Hosta fortunei ‘Francee’

Blomsterfunkia

Ground cover

Ribes rubrum

Röda vinbär

Food, traditional

Hyacinthus orientalis

Hyacint

Spring blossom, traditional

Scilla forbesii

Vårstjärna

Spring blossom

Kärleksört

Spring greenery, late summer blossom

Scilla siberica

Rysk blåstjärna

Spring blossom

Stachys byzantina

Lammöron

Tactile

Hylotelephium telephium

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Syringa vulgaris

Syren

Summer blossom, traditional, fragrant

Tulipa purissima

Tulpan ‘Purissima’ Tulpan darwinhybrid

Late spring blossom, traditional

Tussilago farfara

Hästhov

Spring blossom, traditional

Vinca minor

Vintergröna

Spring blossom, ground cover

Viola odorata

Luktviol

Spring blossom

Viola tricolor ssp. tricolor

Styvmorsviol

Spring blossom, traditional

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