Promoting Well-Being

Promoting well-being within a retirement community

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HEALTH DESIGN LAB AT EMILY CARR Jonathan Aitken - Director, Health Design Lab Guillermina Noël - Adjunct Researcher RESEARCH ASSISTANTS Kevan D’Agostino Farrah Olegario Nazareth Victoria Simansjah Simeng Wang MENNO PLACE TEAM MEMBERS Sharon Simpson - Project Lead Karen Baillie Hilde Wiebe Cyndy Gabriel Debbie Jamieson The Team of Clinical and Support Services in E1, Menno Home

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TABLE OF CONTENTS 0. PROJECT INTRODUCTION 4 1. BEST PRACTICES REVIEW 6

• Person Centred Care 8 • Living with Dementia 9 • Social and Physical Environment 9 • Positive Workplaces 11 • Summary 12 2. PRIMARY RESEARCH 14

• Interviews 16 • Co-Creation Sessions 18 • Summary 30 3. DATA ANALYSIS 32

• Aims and Methods 34 • Affinity Diagramming 34 • Matrix Approach 35 4. 10 DESIGN IDEAS FOR MENNO PLACE 36 5. RECOMMENDATIONS 59

• Future Research/Phase II 64 • Conclusion 65 6. REFERENCES & BIBLIOGRAPHY 66 7. APPENDIX 69

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PROJECT INTRODUCTION In September 2014, Menno Place, a residential care facility, and the Health Design Lab at Emily Carr University of Art & Design collaborated to study how to provide a healthy, comfortable and positive space for Menno Place’s residents, using low-cost and easily implementable solutions.

The Alzheimer Society of Canada estimates that there are about 750,000 people living with dementia in Canada. As the number of elderly people living longer increases, so does the number of people living with dementia. Consequently, there is a need for more and better-designed care facilities, and well-trained caregivers and personnel to address the needs of people living with dementia. Elderly people with dementia are particularly vulnerable to environmental surroundings, making them feel uncomfortable when they do not recognize a space. Physical and social environments can make people with dementia feel confused, agitated, and isolated. In contrast, environments that are more homelilke and put the person with dementia at the centre, seem to better respond to the residents’ needs. To address this research problem, the Health Design Lab team started reviewed best practices in dementia

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care. The review included peer-reviewed journals as well as leading dementia institutions’ websites including England’s Dementia Challenge and the Alzheimer Society of Canada. Our team also reviewed design case studies developed by the Helen Hamlyn Centre for Design.

The Health Design Lab team then applied then a human-centred and qualitative approach to study the problem. Our methodology allowed us to interact with users and engage with them in discussions, conversations, explorations, and activities that helped us to better understand their views, needs, and preferences regarding specific problems, objects and situations.

Our research process entailed the following: a) face-to-face interviews with six staff members who provide direct care to residents; b) a co-creation session with 15 family members; c) a co-creation session with 15 staff members from different areas; and d) a co-creation session with 7 community members.

From this user-centred and evidence-based design context our team explored ideas to improve the Menno Place care environment with a relatively small investment.

The Health Design Lab team designed 10 panels and presented 47 ideas to Menno

Place during a two-hour meeting. The ideas varied, including activities for residents, how to provide visual cues in the environment, how to personalize spaces, how to increase privacy, how to provide sensory stimulation, and how to make the environment look and be friendly to people with dementia and to the staff. The Menno Place selected team 10 ideas for further development.

The information collected helped the Health Design Lab team to: • understand how to make Menno Place look more like a home • ideate tools that could help reduce residents’ aggression while helping Menno Place look more like a home • explore ways to consider the families as experts

staff desires for shifts and their need for recognition, and economic limitations.

This publication describes the research process and the design ideas and recommendations emerging from it. While these ideas were specifically developed for Menno Place, we believe that the general principles can be applied to other dementia care facilities.

SPECIAL ACKNOWLEDGMENT We would like to profoundly thank everybody at Menno Place for their collaboration.

We would like to specially acknowledge the contributions of the family members, staff, stakeholders, and to Sharon Simpson for her continued support.

• consider ways to create community among Menno Place workers • create links between Menno Place and the community.

The project provided an excellent opportunity to explore a complex problem formed by a number of intertwined factors: health authority requirements; residents’ needs and desires; family expectations and needs;

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1 BEST PRACTICES REVIEW Person Centred Care 8 Living with Dementia 8 Social and Physical Environment 9 Positive Workplaces 11

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Residential care facilities all over the world are striving to make residents with dementia feel more at home. To achieve this, institutions apply person centred care, and create settings specially designed to better support and care for residents.

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The Health Design Lab team researched existing practices and methods for designing dementia facilities across Europe and North America. The Helen Hamlyn Centre of Design at the Royal College of Art in London, has done extensive research on residents’ living spaces and compiled it in their research archive “Design for Dementia.” In the 1990s, in the suburbs of Amsterdam, a pioneer idea was developed to foster independent living in a care facility for Holland’s most severe dementia patients. Hogewey provides residents with an “alternative reality.” Czorny Alzheimer Centre, a residential care facility in Surrey, British Columbia, emphasizes family involvement in patient care. Inspired by insights from these facilities’ practices, and environments, we refer to them in our own work. The Alzheimer Society of Canada promotes a person centred care philosophy.

This approach recognizes that “individuals have unique values, personal history and personality and that each person has an equal right to dignity, respect, and to participate fully in their environment” (p. 10). A person centred designed environment provides better support to residents and staff; fostering independence, and strengthening relational bonds.

Through this review our team identified

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four main themes: Person centred care, people living with dementia, social and physical environments, and positive workplaces. Each theme is discussed below.

PERSON CENTRED CARE Person centred dementia care refers to a facility’s culture being centred upon the values, attitudes, needs, and norms of people suffering from dementia (Koren, 2010).

It requires “breaking down departmental hierarchies, creating flexible job descriptions, and giving front-line workers more control over work environments” (Koren, 2010, p.2). It recognizes the importance of all staff members, regardless of their role within the hierarchy, in contributing to the quality of life and care of all individuals.

Some authors (Sugihara, Fujinami, Phaal, & Ikawa, 2015) refer to the term personhood to describe an approach in which caregivers pay special attention to the person with dementia and their needs rather that just focusing on the caregiver’s good intention.

In a person centred care approach, the caregiver closely observes the person with dementia, to identify what she/he wants, when, and why.

Empathizing with others is essential for understanding people’s concerns and

It is important to note that the behaviour of people with dementia is often pathologised as resulting from a disease, rather than understood as constituting a valid response to an inadequate social environment. (Boyle, 2008, p.304) emotions, particularly when working with vulnerable participants in a research context (Thieme et al., 2014).

LIVING WITH DEMENTIA According to the literature (Boyle, 2008), it is important to empower people with dementia by ensuring they have choice and control over their daily lives. A reduction in communication skills can cause frustration that may be exhibited as agitation. Agitation may be caused by conflicts between residents, or residents with staff because of the invasion of privacy. It appears to be beneficial to use groups to enrich conversations while doing other tasks such as baking and painting. These might enhance the lives of people with dementia (Perry, Galloway, Bottorff, & Nixon, 2005). However, it might be necessary to train partners about engaging conversational techniques.

Care and all resident related activities should be directed as much as possible by the resident. For example, residents would be offered choices and encouraged to make their own decisions about things personally affecting them, such as what to wear or when to go to bed (Koren, 2010, p.2).

Interpreting nonverbal behaviour in people with dementia is key. It is estimated that

nonverbal behaviour is used for more than half of the messages communicated and involves body movement, facial expression, physical appearance, intonation and speech rate (Hubbard, Cook, Tester, & Downs, 2002). Reducing falls and hip fractures is very important in caring for people with dementia. Activities that combine strategies such as exercise, balance training, staff education, and environmental adaptations are effective in reducing falls in people with dementia (Taylor, Delbaere, Close, & Lord, 2012).

SOCIAL AND PHYSICAL ENVIRONMENT A key issue in improving the residents’ environment is to better understand the way in which space impacts the quality of life of people with dementia and the quality of care provided (Timlin & Rysenbry, 2010). The design of a care home should help maintain the residents’ independence, help them to be active, improve working conditions, and foster family engagement and interactions. Best practices in the home care and dementia field advise the provision of environments that are less institutional and more homelike. Zeisel et al. (2003), highlights that although care units have to be designed to meet “safety requirements and construction standards

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that may seem rigid and imply institutional design responses, SCUs [special care units] should strive to model their interior environments after homelike settings to reduce aggressive [behaviours] and other symptoms” (p. 709). Similarly, Koren (2010) states that: Practices and structures should be designed to be less institutional and more homelike.

Small “households” of ten to fifteen residents would be the organizational unit.

Meals would be prepared on the units, and residents would have access to refrigerators for snacks. (p. 2)

It is also advised to minimize the length of corridors to reduce distances for staff and residents (Benbow, 2014).

According to the literature, there is a need for private environments in dementia care facilities. It appears that private spaces reduce aggression and agitation, and help to improve sleep patterns (Zeisel et al., 2003). Opportunities for personalisation also seem to be beneficial. Timlin and Rysenbry, (2010) state that “personalisation is an expression of self. The ability to personalise one’s immediate environment can have invaluable impact on the life of a resident. It can help provide fundamental cues to their identity” (p. 73).

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Experts also recommend walking paths with multi-sensory tools and activity areas.

These strategies improve residents’ moods and engage family members (Zeisel et al., 2003). Diversity in common living areas reduces residents’ social withdrawal (Zeisel et al., 2003). Spaces with controlled sensory input, specially designed for residents, appear to act as a strategy to reduce verbal aggression.

Regarding the social environment, good communication between the person with dementia, family members, and staff is a key component in terms of quality of life and meeting daily needs.

Relationships between residents, family members, staff, and the community should be close. For example, the same nurse aides would always care for a resident (a practice known as “consistent assignment”), because this appears to increase mutual familiarity and caring. (Koren, 2010, p. 2)

Good care facilities provide warm atmosphere and positive relationships among residents, their caregivers, and families. In this context, both social needs and safety are a priority (Alzheimer’s Society, 2007).

The Alzheimer’s Society (2007) states that “availability of activities and opportunities for occupation is a major determinant

of quality of life and affects mortality rates, depression, physical function and behavioural symptoms” (p. v). Activities also appear to be helpful in reducing agitated behaviours in dementia residents. Van der Ploeg, Eppingstall, Griffith, and O’Connor (2009) found that both Montessori activities and lavender oil therapy are effective for managing challenging behaviours in people with dementia.

POSITIVE WORKPLACES From the employee’s point of view, the key elements in a good working atmosphere are trust, pride, and joy (Great Place to Work Canada, 2015). Trusting relationships between employees and managers result in better relationships with colleagues, more respect, and an increase in job satisfaction.

Daily interactions based on trust maximize team performance and positively affect job results. According to person centred experts, daily tasks should be organized to reinforce and enable staff to better respond to residents’ needs and wants. Teamwork and training are essential in achieving this goal.

Management should enable collaborative and decentralized decision making. Flattening of the typical nursing home hierarchy and participatory management systems

would be encouraged. Aides would be given decision-making authority. These strategies appear to have positive effects on staff turnover and performance. (Koren, 2010, p. 2)

A team with strong skills and motivation, that is supported by management, will be better prepared to provide the best of care to people with dementia (Alzheimer’s Society, 2007).

Training should help staff understand what a difference they can make to residents’ quality of life by providing good quality person centred care. Staff need to be hopeful about what can be achieved with people with dementia and training should encourage positive attitudes to dementia when it is recognised or diagnosed. (Alzheimer’s Society, 2007, p. vii)

SUMMARY From the above it seems essential to place people with dementia at the centre of care decisions, paying special attention to their values, needs, attitudes, and norms. A good care facility is one that supports individuals with dementia’s freedom of choice and control over their lives while helping front-line workers focus on those residents’ needs.

Empathy and the appropriate dementia-care skills are the fundamental skills

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Review of articles The image shows some of the articles the Health Design Lab team reviewed.

Training should help staff understand what a difference they can make to residents’ quality of life by providing good quality person centred care. Staff need to be hopeful about what can be achieved with people with dementia and training should encourage positive attitudes to dementia when it is recognised or diagnosed. (Alzheimer’s Society, 2007, p. vii)

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required of staff. Providing private and more homelike spaces appears to be key for promoting quality of life and reduce agitation in people with dementia. Activities that meet the residents’ needs and preferences are effective strategies for reducing aggression. Finally, trusting relationships are essential for providing good quality dementia care.

The best practices review provided us with a more informed and solid background with which to begin approaching the problem.

This review guided our team in the creation of the questionnaire for the interviews with staff members, as well as the three co-creations sessions that we developed.

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2 PRIMARY RESEARCH Interviews 16 Co-Creation Sessions 18 Summary 30

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To better understand experiences of the residents, staff, and family members at Menno Place, and to identify positive and negative aspects of these experiences, the Health Design Lab applied a human-centred design approach to study the problem. This allows us to open a dialogue and interact personally with the stakeholders of the project. By approaching issues from the perspective of the people involved, it helps us to understand their views, needs, wants, intentions, perceptions, preferences, expectations, and frustrations regarding specific problems, objects, and situations. The results allow designers to gather insights and arrive at solutions that better respond to the current situation.

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The methodology used included interviews and co-creation sessions. The following sections present the methods used, the themes that emerged, and a brief summary of our findings.

INTERVIEWS

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Menno Place. Please see the Appendix at the end of this document to read the interview questionnaire.

Seven main themes emerged from the interviews. The themes are teamwork, home & interior, activities, pride, shift-problems, care, and aggression.

A key feature of interviews is that they provide the opportunity to focus on the individual. Interviews are useful for understanding participants’ perspectives within the context of their personal experiences.

By asking appropriate questions and listening carefully to the answers, the designer can gain a deep understanding of the problem studied, through the participants’ thoughts, feelings, needs, intentions, attitudes, views, and experiences. The designer is an active participant in managing the interview process in order to ensure that the required subjects are covered, and that the participants’ views are respected.

Teamwork was mentioned in questions relating to Menno’s working atmosphere, staff’s values, and improving staff performance. Teamwork refers to the importance of working in collaboration with other people, creating a happy working environment, and having shared goals. The staff consider teamwork as essential for providing the best possible care to residents. Trust is an essential element for working in teams. It seems that the level of teamwork varies across sections at Menno Place. A participant asserted, “each floor is specific, there are pros and cons on every floor.”

The team conducted a series of interviews at East One, a wing of Menno Place with full-time and part-time staff members.

Menno invited several participants to meet with research assistants in a private setting. The interviews were kept brief (40-50 minutes), with 24 questions, due to participants’ availability and their primary responsibility of assisting residents of

Home & interior refers to items and aspects of the interior space that can create a warmer, more inviting atmosphere with a less institutional and more homelike environment. Staff mentioned the need for more private and personalized spaces, and provided several suggestions to make Menno Place look more like a home, such as having warmer colours on the walls,

more windows, better lights (specifically avoiding fluorescent lighting), plants, family pictures, and cozier areas. The staff highlighted the importance of having bedrooms that do not look like hospital rooms, and avoiding having fake plants. The participants also suggested having units with small groups to better support the needs of the residents and having more park-like areas. Having a more homelike environment was associated with improving the residents’ experience.

Activities relates to things residents can do to reduce social isolation. Participants suggested tasks such as group games, classes, painting, poetry, gardening, storytelling, walking programs, quiet activities, dinner parties, baking clubs, men’s social clubs, and more trips. The staff related to activities as a way to enhance residents’ quality of life, and to help new residents to adapt to Menno. Interestingly, the staff did not consider providing activities as a way to reduce residents’ aggression.

Pride refers to receiving appreciation and love, providing genuine and selfless care, receiving gratitude and happiness, and having the honor of caring for people.

The staff seem to be proud of the work and the care they provide, and this aspect seems to be related to an increase in staff

job satisfaction. Participants suggested celebrating more of their work and achievements by having potlucks with co-workers, and displaying pictures and videos with co-workers, residents and families.

Shift problems refers to the rotating schedule of each employee (hour/days) within the organization to fulfill a set of tasks and provide full coverage. These 6-dayson/2-days-off shifts were associated with burnout due to prolonged hours of work, fatigue, and psychological stress. The inability of staff to influence decisions related to their job schedules causes frustration. One of the participants explained that to optimally support the needs of the residents, staff need to be at their best.

Another participant thought that it might be beneficial if managers were to visit the units and observe the daily routines. The staff mentioned that to improve the residents’ experience, “management should be more attentive to the staff. Be on the floor.”

Care refers to providing a happy, enthusiastic, clean, and safe residential-care environment where meeting the needs of residents is central. The participants believe that they contribute to the Menno Place atmosphere because they care, listen, and connect with the elderly. When asked, “what do you value in your work,”

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participants answers included: “caring on a personal level,” “taking responsibility,” “to pay homage to,” “giving away what you have,” “caring for people,” “getting positive reactions,” “providing comfort, support and joy to residents,” and “working with the residents.” Caring appears to be associated with job satisfaction. Participants also mentioned that the burden of paperwork required by Fraser Health takes them away from caring for residents. Reducing the amount and complexity of paperwork might increase the quality and amount of care.

Aggression refers to the frustration, difficulties, and challenges that arise when dealing with aggressive residents. Staff mentioned that one of the challenges of their work is dealing with agitated and aggressive residents. One participant finds that noise, light, and pain are some of the causes of aggression. The “Chalet” is the area with more aggressive residents. It was suggested that having fewer residents in the “Chalet,” and more private areas, might contribute to reducing aggression.

Training was also mentioned during the interviews. Staff thought that everybody at Menno Place, regardless of their role and place in the staff hierarchy should receive training in dementia and aggression. The participants currently receive training, but

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suggested that it would be useful for that training to include examples not only of residents that have mild dementia, but also on those that have more severe cognitive impairments.

The interviews with staff provided very valuable information. They helped us to better understand the staff needs, and how to improve the residents’ experiences.

Some of the findings also appeared in the information collected during the co-creation with family members, particularly in areas related to the theme Home & Interior.

CO-CREATION SESSIONS Co-creation is the creative act of making, telling, and enacting, where designers provide activity kits to participants for them to interpret ambiguous questions and answer them; discuss problems; describe future experiences, concerns or opportunities; make “things;” and create prototypes.

Co-creating facilitates rapid understanding of complex social problems, exploring possible solutions, detecting mistakes in design ideas, and creating solutions tailored to people.

The lead researcher and three research assistants met several times to discuss the co-creation activities. They designed activ-

C0-creation toolkits for families Three packages were created for the family co-creation.

Each package was organized to facilitate quick introduction and performance of the activity.

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Family activity 1 & 2 The image above shows some of the items selected by family members to help Menno Place look more like home.

The image below shows the brochures created by the families to communicate Menno Place.

ity kits for family members, staff, and other stakeholders. To be better informed, the team had a two-hour session with a gerontologist about best practices surrounding dementia.

Family co-creation session The first co-creation session our team conducted was with family members of residents. The goal of this co-creation session was to identify items commonly found in living areas, bathroom, bedrooms, and kitchens, so that residents can feel like they are in a home setting. Fifteen family members participated in the co-creation. The participants were grouped into two tables, with two facilitators at each table. One facilitator assisted in the co-creation and the other took notes. The co-creation had three activity kits. The first two activities lasted for approximately 40 minutes each, and the last activity lasted approximately 15 minutes.

The activities started with an introduction about the difficulties Menno Place encounters in creating a homelike environment, while ensuring safety and good dementia care.

Family activity 1 The first activity kit included a tab-

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loid-sized page and pictures of items including tables, chairs, plants, floors, colours, mirrors, sinks, sofas, and bathroom cabinets. Participants selected pictures of the items most appropriate for meeting the needs of their loved ones in Menno Place.

The co-creation facilitators assisted the family members in cutting and taping the pictures.

First activity findings: In the first activity, the family members had difficulty transforming Menno into a more homelike and warmer space. One of the most difficult rooms to transform into a homier space was the bedroom; the beds require safety bars and a safety mat. Additionally, the bathrooms have to be adaptable for wheelchairs. The participants felt that there was not much that could be changed in these spaces. After some discussion, participants provided very valuable feedback despite the wide range of age-related disabilities among Menno Place residents. For common shared areas like the living room, family members suggested including chairs, armchairs, and sofas to support different body positions, and social situations. They also suggested a variety of tables, from coffee to dining tables to support different tasks and needs. They thought that plants, extra lighting, and cushions could help provide

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Family activity 3 The image above shows the tabloid page used to map the ideal residents’ daily activities.

Staff co-creation toolkits The image below shows the toolkits designed for the staff co-creation workshop.

a homier atmosphere. Family members selected wooden floors, noting that they could help reduce fractures after falls. For the bathroom, participants suggested light blue colours for the walls, clear light, tiles, and a full-length mirror that would allow women residents in wheelchairs to check their skirts. According to the participants, the kitchen is perhaps the area in Menno Place that looks least like home and most like an institution.

Family activity 2 The second activity kit included a letter-sized page, a large set of pictures, and directions for participants to create a Menno Place brochure. Key sentences and questions guided the participants in designing a tri-fold brochure. For example, for the cover of the brochure, the instructions included titling the brochure, selecting one or two pictures to illustrate Menno Place, and writing a brief sentence to introduce Menno Place. For the inside content, participants were directed to select suitable images to show Menno Place, and to describe Menno Place’s main attributes, such as safety and care, how Menno Place enriches the lives of the residents, and the quality of care provided. On the back page, the families described what is unique about Menno Place.

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Second activity findings: While in the first activity participants had difficulty in making Menno Place feel more like home, in this activity the main message they chose to convey was “Welcome Home.” This finding implies that even though Menno does not look much like home, it feels like home. Another message communicated in the brochures was “We care.” These two messages suggest that family members consider Menno Place a home for their loved ones, and that it provides a community of care. Family members described Menno as “unique,” “clean,” “more personal,” “semi-private,” “safe,” “a community of care,” and a place to “keep families together.”

Family activity 3 The third activity kit aimed to discover what participants consider ideal daytime activities for their loved ones. It included a tabloid-sized page divided into hours showing a daily cycle from the time someone gets up to the time they go to bed. The findings from the three co-creation sessions are outlined below.

Third activity findings: In the third activity, family members suggested more walks, music, a live opera subscription (Met Opera on Demand from the Metropolitan Opera House), and more trip-based activities such as museum visits. Interestingly, while best

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Awake (Start)

Narrate the ideal day/daily activities in the life of your love ones!

Go to Bed (End)

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Staff activity 1: Card sorting Some of the positive words selected and grouped by the staff members.

practices in dementia suggest that residents could perform some housekeeping activities such as folding laundry and setting tables, family members focused more on recreational activities.

Staff co-creation session The next co-creation session was conducted with staff, with the goal of identifying the work culture in Menno Place. In preparation, the Health Design Lab team read several case studies from Great Place to Work. There were approximately fifteen staff members from different departments and hierarchies participating in the co-creation. Following the same approach as the co-creation session with family members, the participants were grouped into two tables with two facilitators at each table.

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This co-creation session also consisted of three activities. The first one lasted for approximately 20 minutes; the second, 15 minutes; and the third, 20 minutes.

Staff activity 1 The first activity kit consisted of a set of 40 cards, each with a keyword and a brief context. For example, one keyword was “reputable,” and the sentence that provided context read: “working in an environment with a good reputation.” The keywords were pulled from case studies listed in Great Place to Work. The goal of this activity was to encourage discussion and identify the work philosophy and atmosphere at Menno. Participants selected and grouped the keywords into positive and negative aspects of work. Facilitators took note of the comments participants made

Staff activity 3: The day map The image shows one of the maps created by one of the staff groups.

during the discussion. Both groups were very engaged in the conversation.

First activity findings: In the first activity, staff grouped together the following words: responsibility, opportunity, active, and rewarding. The participants considered these words positive, and associated feeling responsible and rewarded, and having opportunities and an active role in their job, with personal growth and job satisfaction. Similarly, the staff grouped together accomplishment, individualism, freedom, and staff-oriented. They associated feeling accomplished, being self-reliant, having freedom, and having staff determine best work practices with team building and engagement at work. Caring and appreciation were grouped together. Caring for colleagues, and feeling that their colleagues

and residents appreciate their work was considered rewarding and related to staff fulfillment. Being inspired by the things they encounters at work, and feeling that they develop their skills and abilities at work, was associated with an energizing workforce and a place that promotes reputation. Having expertise at work was related to quality standards and as contributing to a good reputation. Making critical comments to encourage improvements was associated with progression, but staff emphasized that there is a need to be careful about the way that messages are communicated. Making critical comments was related to trust—when staff trust each other, they are more open to questioning and making critical comments. Specialization, having a particular skill or expertise

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at work, was considered by staff as related to providing quality of care, having and using evidence-based knowledge, and as enhancing the workplace by adding diversity. Teamwork was related to having good communication, a sense of belonging, and, as a result, benefiting residents. Staff also associated priority as a positive word; they considered safety to be their highest priority. Having sympathy for colleagues was associated with caring and building reputation. Staff mentioned that they preferred the word empathy instead of the word sympathy.

Staff activity 2 The second activity kit was a set of dialogue cards. The large cards contained pictures and speech bubbles. One bubble contained a sentence, while the other was left blank to be completed by participants. Participants had to discuss the picture and the sentence, and write down a response to each statement written on the card. The goal was to identify the attitudes of staff in certain situations. For example, a picture portraying a woman working in the kitchen says, “I care for the residents with dementia by…” with participants filling in the blank that follows.

Second activity findings: The main finding from the second activity was that staff are required to follow multiple protocols in

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order to care for residents. These protocols hinder the work atmosphere, and make it less dementia centred. Some staff members, particularly front-line workers, seem to be better trained for contact with dementia residents than others. Given the answers provided by the two groups, it was evident that one group was more empathetic than the other when interacting with residents.

This empathetic group highlighted the need to smile, be kind, and make time for the residents, regardless of their roles in the institution, while the other group highlighted the need to inquire and seek advice before reacting.

Staff activity 3 The last activity kit was a day map, narrating a day in the life of “Jen,” a fictitious character. The goal of this activity was to identify the emotions of staff working at Menno, and the positive and negative aspects of their work. Participants discussed the role of Jen at Menno, the work she performs daily, the feelings she gets through the day, and the positive and negative aspects of the work Jen performs.

Third activity findings: For the third activity, two main roles were selected for the Jen character: housekeeper and cook. The day map activity generated a positive and unexpected outcome. It created awareness

among staff members about the struggles they face daily.

One group made Jen a housekeeper. Jen feels frustrated sometimes during her tasks because of what she referred to as aggression from residents, but no details were provided concerning the aggression. Jen thinks that the job is physically demanding but finds ways to make it easier and she “makes it work for her.” Jen finds the size of the bins frustrating especially when they are too big and full. For Jen dealing with ten big garbage bags per day is demanding.

Jen is satisfied because eventually she was listened to.

Jen feels frustrated when receiving extra requests through the Housekeeping App because she cannot reply, and she feels locked into this communication system. Jen also noted that she feels bad when families are not satisfied.

The other group made Jen a dietary cook.

Jen enjoys personalizing her service, however, she finds it challenging to consider the likes, dislikes, and dietary restrictions of each resident. In addition, she also needs to ensure all supplies are sufficient. Jen noted the joy of serving the meal to residents because it is her chance to interact with them. Jen expressed being tired as the

week progresses due to the wide variety of things to remember. She feels pressured and concerned related to “caring.”

Two themes from the interviews also appeared in this co-creation workshop: the challenge of dealing with aggressive residents and the fatigue caused by the rotating schedule.

Stakeholders co-creation session The last co-creation session was conducted with a group of stakeholders that consisted of prominent political and religious figures from the Abbotsford community. The main goal of this co-creation was to understand the changes that stakeholders would make in order to provide a more homelike space for Menno Place’s residents. The second goal was to discover possible ways to engage Menno Place with the surrounding community. Seven people participated in two activities, each lasting 30 minutes.

Stakeholder activity 1 In the first activity, participants were instructed to look at a series of pictures of Menno Place, which included images of bathrooms, dining areas, hallways, bedrooms, and ornaments. The facilitators instructed participants to think about what they would change to make the areas more

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appropriate for people with dementia.

Following this step, they wrote their ideas on Post-its and placed them by the pictures.

This activity was very engaging and produced a lot of discussion.

First activity findings: Participants made many suggestions about physical details involving interior design and furnishings.

Stakeholders concluded that Menno Place needs to prioritize privacy and provide a culture of hospitality. They mentioned the need for better lighting and more windows to provide appealing stimulus. Warmer decorations were suggested to foster a family space within the rooms. A library and game areas were also suggested. Participants also recommended the use of warmer colours in furniture and walls, and adding family photos display areas.

Stakeholder activity 2 In the second activity, participants were encouraged to envision how they would promote, communicate, and engage Menno Place, with the public. Tabloid-sized pages were provided to participants for them to record their comments freely, with stakeholders instructed to write or

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draw different ways they would engage Menno Place with the community. This prompted a vivid discussion, with participants annotating their comments as the discussion continued. This activity sparked engagement and thoughtful dialogue that explored original ways to foster relationships between Menno Place and the wider community.

Second activity findings: Participants provided insightful suggestions during the second activity. The first suggestion was to avoid describing Menno Place as a nursing home. Participants suggested the idea of making a documentary series about the importance of seniors from the viewpoint of those affected. They also recommended organizing events, such as public speaker forums and monthly or quarterly teas, promoting youth to senior engagement, and connecting residents by taking them out into the community more or bringing the public into their lives more often. One idea they raised was to create a “campus of care�—a cooperative effort to keep couples together. They also suggested a transition support program, such as providing printed information and having a patient advocate

Activity 1: What would you change?

The image on the left shows the tool designed to prompt participants to explore what aspects of Menno Place they consider necessary to change.

Activity 2: Promoting Menno Place The image below shows one of the tabloid pages used during Activity 2 with the participants’ feedback.

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dedicated to giving helpful advice and assisting family and residents in their move from home to Menno smoothly. The term “residents” was considered not friendly, and therefore not appropriate. Another suggestion was to promote companionship among staff, residents, and across categories.

SUMMARY The value of consulting users is well known in design research. In this case, the co-creation provided very valuable information and insights.

The family co-creation showed that family members are experts about their loved ones. They are best situated to know what their loved ones like, dislike, and how to keep them comfortable. Family members were also aware of dementia care needs.

This suggests the need to consider and include family members as experts not only about their loved ones, but also about dementia care, generally.

The staff co-creation highlighted the need to adapt or combine existing protocols to focus on dementia centred care, and suggested that it might be beneficial for Menno Place if everyone, regardless of their role and place in the hierarchy, received training on best practices in dementia-friendly care.

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In Menno Place, there seems to be a lack of awareness among co-workers (managers, front-line workers, and those in charge of cleaning, cooking, and gardening) regarding each other’s daily routines. As it was mentioned in the staff interviews, it might be beneficial if managers visit the floor and partner with the employees in their daily routines. Finally, it appears that there is a need for more social communication among staff assigned to different floors.

The stakeholders’ co-creation provided new information. The participants in this particular co-creation provided insightful recommendations for changing conceptions of Menno Place from a nursing home to a community of care. As was also suggested in the staff interviews, stakeholders noted that it might be beneficial to bring the public into Menno Place more often. In addition, it was suggested that Menno Place offer a transition program with printed information and a “dementia care navigator” to comfort people with dementia and those who care for them. This might be a first step in moving towards a community of care.

Feedback Session The image below shows Menno Place team providing feedback to the HDLab team during a four-hour discussion meeting. On the right a picture of one of the posters with Post-its. Each Post-it was a vote for the idea.

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3 DATA ANALYSIS Aims and Methods 34 Affinity Diagramming 34 Matrix Approach 35

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Material collected through qualitative methods is invariably unstructured and unwieldy. A high proportion of it is text based, consisting of verbatim transcriptions of interviews or discussions, field notes or other written documents. (Ritchie & Spencer, 2002)

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AIMS AND METHODS The methods used to analyse data depend partly on the way the data was collected.

Our aim was to find out how to improve the Menno Place environment to better respond to residents and staff needs.

Therefore, the methods used to analyse the data had to facilitate our understanding of residents, family and staff needs; identify limitations and possibilities; and develop ideas and strategies for improvement.

To analyse the co-creation sessions, we used affinity diagramming as a method; to analyse the interviews we used a matrix. The following paragraphs describe each method in detail.

AFFINITY DIAGRAMMING This method helps designers organize and handle data. Our team captured attitudes, behaviours, issues, concerns, and needs from notes and pictures. These observations were then noted on a Post-it that reference the original transcript, sometimes as keywords or as brief sentences. The Post-its were posted on a wall or on a white board. These notes were then grouped based on affinity; in other words, notes that shared similar key ideas or that were recurrent were clustered together to form

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themes. Arriving at themes is time consuming and requires rigorous interpretation.

Post-it notes are particularly useful during the refinement period, as they can be moved and regrouped to better represent the meaning of the theme. Once the clustering and refinement stages were completed, the data was interpreted to define concepts, create categories, find associations, seek explanations, and develop new ideas based on people’s answers and reactions.

Each theme was then labeled. For example, the following keywords were grouped under the theme living and dining interior “paint,” “warm colours,” “arm chairs and sofas,” “cushions,” “homey,” “plants,” “homey lights,” “picture frames,” “family photos,” “warmer decoration,” “inviting and warm,” “more windows,” and “comfort.”

Living and dining interior represents items and aspects that can help making Menno look more homelike and less clinical. These key words emerged from the two co-creation sessions held with family members and with stakeholders. This theme not only provided an explanation, but also insights, which helped our team to arrive at design principles and recommendations.

MATRIX APPROACH To analyze data from the interviews our team created a matrix. The first step in creating a matrix is familiarization. Before sorting data, designers need to become familiar with the information. This requires listening to or reading the transcripts several times. During the familiarization stage, key sentences or words are identified. In this way, researchers begin to summarize and synthesize data to arrive at themes or categories. Frequently, the questions asked provide a framework to start sorting the themes.

look of Menno?” Some of the key words answering this question included “paint and carpets,” “soft chairs, pictures, paint,” “homey,” “plants and personal items,” and “secure pictures frames.” The category was labeled Home & Interior.

An advantage of this method is that, since the matrix shows the question and the participant, it enables researchers to quickly and easily access the original material. It also facilitates comparison, and it makes the analyses accessible to other team members.

The matrix is a double-entry chart. The question being asked is written at the top of the chart. On the left, each row represents a participant. Key sentences are placed inside the cells. Post-its are then used to label the themes emerging from the answers. For example, one of our questions was: “What would you add or change to improve the

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4 10 DESIGN IDEAS FOR MENNO PLACE

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Introduction From a user-centred and evidence-based design context our team explored ideas to improve the Menno Place care environment with a relatively small investment.

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Our team invited staff from Menno Place for a collective brainstorming session. We presented 47 ideas to them, ranging from simple design implementations to technical design products. The ideas focused on how to provide visual cues in the environment, how to personalize spaces, how to increase privacy, how to provide sensory stimulation, how to make the environment look and be friendly to people with dementia and staff, and create activities for residents.

The panels of concepts were presented by the Health Design Lab team. After all the concepts of a panel were presented, Menno Place staff engaged in a discussion about their thoughts, opinions, ideas, and the suitability of each concept for Menno Place.

After an intensive four-hour discussion session, together with Menno Place staff, our team narrowed the list of concepts to the top ten design recommendations.

The concepts and sketches have been divided and presented according to the spaces and contexts they were designed for, which include:

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• Bedroom • Bathroom • Dining Areas • Hallways • Activities • Decoration • General Solutions • Community—Staff Engagement • Montessori Activities

47 Ideas Four of the posters designed to present forty seven ideas to Menno Place team.

HALLWAYS

MONTESSORI ACTIVITIES

Residents spend lots of time going through hallways.

Decoration in hallways can be used to facilitate orientation and to provide visual stimulation

We propose some activities based on the Montessori approach. The Montessori method is being used with dementia showing very positive results: increased length of participation, and reduce agitation.

Recommendation 1

Recommendation 2

Blackboard For the hallways we propose to add a blackboard area where to write the current week day. It could also be used to wish Happy Birthday to some of the residents. While helping residents to remember what day it is, this text areas can add some entertainment to the hallways.

Origami deco We propose Origami areas to make the hallways more cheerful. The origami can be made by residents and families.

Recommendation 1

Recommendation 2

Fig 1.5 Locks and Latches A locks and latches board can help the residents keep their hands busy and work their motor skills. This activity is a good way to help reduce anxiety in the residents.

Color matching Using paint sample cards and wooden clothespins a matching activity can be created helping the residents be connected.

Recommendation 3

Recommendation 4

Color doors and frames People with dementia need visual contrast. Doors and door frames can be color painted to facilitate recognizing them. Alternatively we proposed to color paint the area surrounding the door.

This area can be used to personalize the entrance to each room.

Wood hungers Wood hungers can be placed in the corridors. They can be used for decoration, or to hang personal items and pictures around the doors of the residents room.

This will help identifying them.

Recommendation 3 Nuts activity Nuts sorting and nut counting can be a very entertaining activity. This activity helps promote motor and mathematical skills while engaging the senses and helping the residents reconnect with the world surrounding them.

These are recommendations our team came up with to cater towards resident’s bedroom spaces.

Recommendation 2

Recommendation 5

Placemat activity Setting a table is a daily activity.

This placemat activity can help the residents stay active, feel useful, and connect with their memories. The placemat if in color can make the table more joyful.

Sensory wall This wood panel can be used to provide privacy in a large area, while presenting a sensory, tactile experience for residents to touch and enjoy.

DINING ROOM

BEDROOM Recommendation 1

Recommendation 4

These are recommendations our team came up with to cater towards resident’s dining areas.

Recommendation 1

Recommendation 3

Night lights provide residents safety when getting out of bed during the night.

Recommendation 4 Sensory tools can help residents feel at ease, and provide mental breaks and stimulation.

SmartCells compress and absorb pressure and impact energy from standing, weight-shifting, walking or the impact of a fall. Only½ inch thick, yet reduce impact forces more than 2 times better than mats that are more than twice as thick.

Some movable dividers can be taken apart and assembled when needed.

They can also hold plants to give liveliness to parts of rooms.

Interchangeable clothes pins make it inexpensive and allow for families to easily customize bedrooms with photographs of past and present.

Recommendation 5

Dividing walls can help provide much needed privacy. They also can be tailored to give more storage space and filter light in and out.

Recommendation 6

Recommendation 3

Recommendation 4

Home Bed Assist Rail with folding bed board which provides the assistance needed to get in and out of bed. It supports up to 250 pounds and may be used on any side of the bed The tri-fold bed board makes it easy to carry and store away.

Having cushioned interchangeable floor mats provide an inexpensive and safe way to prevent injury from falling.

Eatwell and products like it, are tableware sets for people with cognitive impairments, such as Alzheimer’s. The colors and design of this tableware set help people with Alzheimer’s eat more effectively and with less confusion.

Recommendation 7

Ode is a new product to help older adults living with dementia and Alzheimer’s. Releasing authentic food fragrances into living spaces before mealtimes, ode promotes appetite and helps in situations of weight loss. With different fragrances at breakfast, lunch and dinner, ode creates a sensory connection with mealtimes.

Recommendation 8 Mobiles can help engage and soothe residents when feeling anxious overwhelmed or having trouble sleeping

Recommendation 5

Recommendation 6 Handmade decor can help bring personality to any room. For examples, these letters that were written can be displayed in certain areas around the dining area, helping promote feelings of positivity for staff, families and residents.

By providing a sturdy and comfortable chair, residents can relax in private space.

Better lighting can help reduce anxiety, bring brightness to areas, and help residents and staff feel and see better.

Directional lighting can help place light where needed.

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1

Personalizing the bedroom: Photos on string Through our research, we identified the need to personalize environments, and the benefits that personal spaces provide residents, such as reduced anxiety and aggression.

Photos on string is an interchangeable photo system. The basic elements consist of a piece of string or twine set horizontally and affixed at both ends to a wall, large wooden clothespins, and personal pictures.

For safety reasons, and to prevent the disassembling of the display system, the string needs to be threaded through the spring coils of the clothespins.

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The pictures can be selected by the person with dementia and their family, or they can be photos that were recently taken at Menno Place.

The string and the wood clothespins make the system inexpensive, and allow for families and staff to easily personalize bedrooms with photographs of the past and present.

Future research is necessary to arrive at optimal personalization strategies (see page 61).

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2

Providing visual cues: Coloured doors & door frames People with dementia might suffer from visual impairments that cause them to become disoriented, and which can eventually reduce independence. Visual cues can have a major impact on people with dementia, providing a sense of well-being and autonomy.

People with dementia need visual contrast; deliberate use of colours can help significantly. Painted coloured areas around doors, along with coloured doors, can facilitate the easy recognition of bedrooms and

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main environments within Menno Place.

The door and the surrounding area should have different, contrasting colours.

In addition, painted coloured areas around each door helps to personalize the entrance to each room, and reinforce a sense of personal space.

Further research is necessary to better understand how to use colour in the environment to enhance residents’ abilities (see page 62).

Bathroom

Dining

Bedroom

Hallway

Chalet

Option 1

Chalet

Option 2

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3

Multi-sensory hallway: Origami and sentences on the wall Our research indicates the need to minimize the length of hallways in dementia environments, and to provide walking paths with multi-sensory tools. Our team proposed the creation of sensory areas in the hallways by displaying origami. Origami on the walls can make the hallways more cheerful, and provide landmarks and sensory stimulation. The origami would have to be placed at a height where residents can touch them, providing an opportunity for visual and tactile stimulation.

In addition, the origami can be made by residents, families, and staff. Participating in craft activities can help maintain existing skills, provide joy, and boost confidence among people with dementia. Our research suggests that keeping people with dementia occupied with activities they can perform may improve their quality of life, reduce agitation, and provide a better atmosphere for those around them.

The origami can be mounted on the walls using double adhesive tape. It can also be used to decorate common areas such as dining and living rooms.

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Other areas of the hallways could display positive sentences, providing pleasant moments to everybody at Menno Place.

This hope-fostering strategy could assist people with dementia to maintain their quality of life.

Five sentences were selected in collaboration with the Menno Place team to display in their hallways.

1. Cast all your anxiety on Him because he cares for you. 1 Peter 5:7 2. I can do everything through Him who gives me strength. Philippians 4:13 3. Let us always meet each other with a smile, for the smile is the beginning of love. Mother Teresa 4. Therefore we do not lose heart. Even though our outward man is perishing, yet the inward man is being renewed day-by-day. 2 Corinthians 4:16 5. Be so happy that, when other people look at you, they become happy too.

Future work should look at the way landmarks facilitate residents’ orientation (see page 62).

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Origami Flower Easy folding instructions

1

Start with a square sheet of paper, first crease the paper horizontally

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You should now have 4 folded triangles.

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Your sheet of paper should now look like this.

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Select the back and front triangles and fold them backwards until there points meet.

12

Flip the paper so you’re viewing it from the bottom

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Your sheet of paper should now look like this.

13

Use your fingers to open the triangle sections to resemble pedals of a flower.

9

Rotate your folded paper until it lines up with the diagram below.

14

Repeat step 13 till you fully open each triangle into a wide pedal shape.

then unfold it and crease it vertically and unfold.

2

3

4

5

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Crease the sheet of paper diagonally by bringing the top left and bottom right corners together, make a crease, unfold then bring the top right and bottom left corners together. Crease and unfold.

You should be left with a square sheet of paper with horizontal, vertical and two diagonal creases.

Bring the top left and bottom left corners together to create a folded triangle, repeat on the right side, and press two triangles together.

Fold pressed triangle in half.

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Take the bottom point of the triangle and fold it upward until all four triangle points meet.

15

Arrange your pedals that form your finished flower.

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4

Hallway memory enhancer: Today is…

As mentioned above, providing walkways with multi-sensory tools helps improve residents’ moods. A chalkboard wall can encourage residents to keep track of the day and communicate key events such as residents’ birthdays and events.

The sentence “Today is…” can be printed on white vinyl and mounted on the board.

A person in charge of the board can, in col-

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laboration with residents, write the day or event with chalk every day.

This idea can also contribute some stimulus to Menno Place hallways.

5

Stimulating the senses: Wooden peg tactile wall Spaces with controlled sensory input can help reducing verbal aggression. In addition, provision of activities and opportunities for occupation seem to influence residents’ quality of life.

This wooden panel can provide some privacy in a large area, while presenting a sensory, tactile experience for residents to touch and enjoy. This idea might be particularly suitable for the Chalet.

Our team proposed a wooden peg tactile wall. The wall would be approximately 1.5 x 1.5m, and have large wood pegs that can be pushed through the wall. The pegs would have a rounded end to facilitate pushing.

To visualize this idea we showed an illustration based on a product designed by “ooo my design.” There is a need to study how this wall should be designed for dementia residents (see page 62).

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6

Stimulating the senses: Montessori sensory cushions Spaces with input specially designed for people with dementia are known to be a successful strategy for reducing verbal aggression. Additionally, it appears that availability of activities is a determinant of quality of life. Regarding the physical environment, it seems that providing a homelike atmosphere reduces aggressive behaviours.

To provide a homelike environment, family members at the co-creation session suggested adding cushions. Our team proposed creating special decorative cushions that include Montessori features, thereby serving two functions. Montessori activities have been found to be effective for treating challenging behaviours in individuals with dementia. These Montessori sensory cushions would have a comfort pocket; residents can embrace the cushion putting one hand inside the pocket, or just sit with their hands on it, helping them to feel at ease. The cushions would also have pom-poms and zippers to provide distraction and entertainment. These additions can help to keep the residents’ hands busy, thus making them feel more comfortable.

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The cushions can be made by volunteers.

Colours should match those of the environment. It is advisable to avoid combining different patterns to reduce the amount of visual stimulation from patterns.

These sensory cushions could be placed in bedrooms, living rooms and dining areas.

They should be washed daily.

Further work is required to arrive at the optimal features the cushion should have (see page 62).

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7

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Montessori activities: Matching colours Activities can help relieve symptoms of anxiety and sadness. Montessori activities in particular, have been found effective for reducing challenging behaviours in dementia residents. Reducing agitation and aggressive behaviours can benefit the residents, family members and staff.

ments required for this activity include paint sample cards and painted wooden clothespins. The wooden clothespins are painted to match the colours on the sample card. Other objects, such as plastic cups or small buckets are good alternatives to add on to the activity.

Finding activities to engage residents can be a challenge. Activities should be selected based on the levels of impairment and residents’ preferences. Our team proposed a colour matching activity. It can be played individually and helps provide motor and visual stimulation to the brain. The ele-

Montessori activities rely on people with dementia’s remaining strengths and abilities. In the case of this activity, it is important for the colours to have a substantial difference among them. Otherwise, the residents might not be able to perform the activities due to possible visual deficits.

This could cause frustration and other negative feelings.

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8

Being active: Weaving figures As has been previously noted, activities can have beneficial effects on individuals with dementia. Among the many activities proposed by staff were those related to arts and crafts. The staff consider activities as a way to enhance the residents quality of life. Our team proposed string art as an activity.

Instructions for string art: To produce string art, it is first necessary to select an image. It can be a simple shape, such as a heart or a number, or a figure such a bird or deer profile. It can even be a letter or a word – perhaps a resident’s name.

Print a silhouette of the image.

You will also need wood and nails, or a foam board and pins. Place the silhouette on the wood or foam board, and trace the outline

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with pins. You can also cut the silhouette out and tape it to the wood. Place the pins or nails into the board following the pattern.

Decide how closely you want to space the pins.

Select one or more thread colours. Now you can start the activity with the residents.

Each person determines a starting point and ties a knot around that pin, and starts weaving. There is no right or wrong way to weave around the pins.

The length of the activity depends on the complexity of the shape, and on the level of engagement and energy of the participants.

The work produced can be displayed on the walls of the hallways as decoration, or in bedrooms. The art can be touched offering visual and tactile stimulation to residents.

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9

Connecting peers: Pair-up cards Person centred dementia care requires a positive working atmosphere based on trust and favourable relationships. Teamwork and training are essential for achieving person centred care. These elements, combined with others, seem to result in job satisfaction and reduce staff turnover.

To foster connections between co-workers at Menno Place, our team proposes Pair-up cards. These cards create bonds between staff members from different departments who have a common interest: their skills and abilities. By pairing up to learn a new skill, staff are given the opportunity to spend time with other people who are responsible in a different field at Menno Place.

The cards consist of customized and fillable text boxes where staff can enter their

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name, date of birth, department or area they are in, skills they have, and skills they would like to learn more about. For example, a staff member might have advanced skills in knitting, but want to learn more about how to work with spreadsheets and word documents. Through word of mouth and exchanging cards, staff will find a co-worker with complementary skillsets. They can meet up during or outside of office hours to learn and teach together, getting the opportunity to know one another better outside of their work environments. Each worker can print as many cards as they would like, given the flexibility of the card format our team has provided. These cards can be placed statically in staff workstations or can be carried by staff, like a business card.

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10

Dealing with disruptive behaviours: Walking stick/table Another item suggested by family members to help Menno Place look more like home was coffee tables.

However, disruptive actions, such as restlessness and pushing things around, are common in individuals with dementia.

Moving things like small furniture items can be disturbing for other residents, and stressful for caregivers. While these behaviours can be seen as impulsive or inappropriate, it is important to understand them as a means of communicating emotions like frustration and loneliness.

As an alternative to coffee tables, our team proposed walking sticks with wheels.

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These sticks have a small surface attached to them, and can function both as a balancing stick and as a coffee table. The surface can also be replaced with a container to serve as a basket for residents to carry their preferred objects around with them.

These objects can be dolls, books, or other personal items. Designed with a sleek aesthetic, the walking sticks can provide residents with a reason for moving things around.

To visualize this idea we showed an illustration based on a product designed by “Lanzavecchia + Wai.� There is a need to study how to design this product for dementia residents (see page 62).

5 RECOMMENDATIONS Future Research/Phase II 64 Conclusion 65

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To avoid redundancy, the recommendations below are presented without rationales, since those rationales have been previously discussed above, in the Best practices and Primary research sections.

The following paragraphs outline recommendations and suggestions made by participants in our study.

Making Menno Place more like home

1 Bedrooms should be for one person only, and should be considered as a private space for residents: a private area in which to sleep, bathe, groom, rest, and receive friends and families.

A hallmark of “home” is privacy. In a residential care facility, the bedroom is a private living space.

2

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areas. They also help to create a visual space that communicates the resident’s identity.

However, allowing each new resident to redecorate the bedroom entirely is not possible, nor sustainable.

3 Include photo frames, plants (avoid fake plants), and cushions to help to provide a more homelike atmosphere.

Plants provide oxygen and filter toxins from the air, benefitting both residents and staff. For safety reasons, plants should not be poisonous. They should be placed at a level out of residents’ reach.

4 Avoid using fluorescent lights; they do not provide a homelike atmosphere.

Use lights that will create a warmer atmosphere and that can be adapted to different needs and situations.

Assign areas of the bedroom to residents for personalization. Bedrooms should allow for customization while keeping the identity of Menno Place.

5

A characteristic of “home” is personalization. Personal items provide a sense of belonging. They help to communicate boundaries between private and common

It is important to also consider what the person with dementia sees through windows. Residents need visual stimulation and beauty.

Consider ways to provide more natural light, such as skylights.

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9

Provide a warmer and cozier atmosphere by painting the walls with light, warm colours.

Provide visual variation among rooms (bedrooms, bathrooms, common areas). Create rooms with clear and diverse identities.

It is important to provide contrast between the furniture and walls. Colours should harmonize with each other, but they should not be too similar in colour or tone.

7 Rearrange furniture, thinking about the needs of staff and people with dementia.

The arrangement of spaces should be free of physical and visual obstacles, so that residents can move independently. Provide space for people that want to be alone, for couples, and for residents and family members. Consider also the need to easily adapt spaces for group activities. Take into account that the layouts should mimic home, not a waiting room.

8 Create a library that residents can access.

The librarian should receive training in dementia care. Also create a games room that residents can access when they feel like it. Recreational therapists with appropriate dementia care should be in the room to suggest activities according to residents’ preferences and to guide them.

10 Explore warmer and safer material for flooring.

Wooden floors were suggested as an option to provide a more homelike environment, to reduce falls, and to reduce fractures.

11 Avoid long corridors and dead-ends.

Provide landmarks in the hallways to facilitate wayfinding.

12 Design units for small groups of people, and more homelike kitchens.

If reducing the size of the kitchen is not possible, apply strategies such as an open kitchen, to incorporate it more into the residents’ daily lives. Allow food aromas to enter other areas, where they can be sensed by residents.

13 Consider dividing large dining areas with moveable or temporary walls.

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The temporary dividing walls should be safe, provide a degree of privacy, and facilitate ongoing staff monitoring.

14 Provide opportunities for activities that are not just recreational; housekeeping is a part of daily life.

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Allow residents with dementia to perform certain daily tasks such as folding the laundry, setting a table, and washing vegetables.

This will provide residents with a sense of purpose, and foster relationships between residents and staff.

Foster teamwork and trusting relationships.

Ensure they participate in decision-making.

This helps them to provide the best possible care to residents.

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Avoid staff stress and burnout, which negatively affects the residents’ experiences and overall staff job satisfaction.

Reduce institutional areas in hallways and avoid leaving housekeeping carts in them.

Care for the staff.

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This will help Menno Place to provide a more homelike environment.

This will increase the quantity and quality of care and social interactions between staff and residents.

Fostering a community of care

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16

Connect Menno Place leaders with residents and staff.

Train all personnel in dementia care.

The training should vary, depending on staff roles and responsibility. Training should be supported, recognized, and celebrated. Consider experts, peers, and family members as options for training. Family

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members have knowledge and experience in dementia and are experts on their loved ones. This will also foster better relationships and partnerships between families and staff. Ensure training is implemented.

Create a system of leaders doing rounds, so that managers can be on the facility floor frequently. The rounding should not be used or perceived as an evaluation, but rather as a way to understand and provide support to staff.

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24

Evaluate how to improve work procedures such as completing Fraser Health paperwork.

Create design tools that will help staff working in the kitchen to personalize services, while reducing working memory and applying adequate memory aid strategies.

This will allow staff more time to care for residents.

21

Reducing the staff working memory load will help them to provide better care to residents.

Help new residents and their families transition from home to Menno Place.

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Create written and visual material to help residents and families navigate this process.

Consider providing a person, such as care navigator, to help for the first month of this transition period.

22 Develop strategies to become leaders in dementia best practices.

Organize events with leaders and experts in the field. Create a library to provide educational resources for family members, staff and residents with milder dementia.

23 Use communication technology with employees that allows for possibility of dialogue or requests for clarification.

Produce documentaries with residents with dementia discussing their experience of living with this condition.

Publish them on the website as open access.

26 Create programs, partnerships and activities to promote youth-to-senior engagement.

This will help foster connections between Menno Place and the community.

27 Change the understanding and communication of Menno Place from that of a nursing home to a dementia care community.

This will help improve the public perception of the institution and its quality of care.

This will help reduce staff’s frustration.

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FUTURE RESEARCH/PHASE II Several areas for future research and development have been identified throughout this project. The Health Design Lab team would like to propose a second phase to apply novel findings to simple and implementable design outcomes.

Phase II of this collaboration could include developing prototypes, evaluating them with users, implementing them and evaluating the implementation to ensure success.

The areas that our team would like to continue studying are: 1. Personalization. What kinds of strategies can be designed to allow residents to personalize their bedrooms, while helping Menno Place maintain their identity? We would like to work in close collaboration with Menno staff and observe the residents’ use of bedrooms to arrive at solutions that will facilitate customization, while maintaining Menno Place’s visual language.

2. Providing visual cues. How can we enhance the Menno Place environment using light and colour? We would like to further explore how the use of colour, contrast, and light can enhance the environment, so that residents will feel confident when moving around and will easily identify the different facilities.

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3. Multi-sensory hallway. In what way and to what extent are landmarks facilitating wayfinding? There is a need to observe whether landmarks in the hallways help residents to orient themselves at Menno Place, or if there is a need to increase them, or place them in different areas.

4. Wooden pegs tactile wall. How can we apply physical and cognitive ergonomic factors to arrive at an optimal wooden pegs tactile wall? There is a need to create a prototype and observe how residents interact with the wall so that this object responds to Menno Place and the residents’ needs.

5. Montessori sensory cushions. In what way and to what extent are the sensory features of the cushion providing necessary comfort and stimulation? There is a need to observe use of the cushions by residents, and evaluate their impact and effectiveness.

6. Walking stick/table. What are the right features and dimensions for the stick to ensure safety and maximum usability and stability? There is a need to further study this tool, to be able to create a prototype according to the residents’ needs and to evaluate its effectiveness.

7. Providing privacy in dining areas. What kind of characteristics and materials should these moveable walls or room dividers

have, so that they are safe, provide a degree of privacy, and facilitate ongoing staff monitoring? There is a need to further study this design problem so that it will comply with all the requirements mentioned.

8. Transition program. What is the information needed for residents and their families when transitioning from home to Menno Place? There is a need to understand the information needs of the users to design a “transition� tool that will be relevant to them and fulfill their expectations.

9. Facilitating the cook’s job. What are the information processing difficulties that the kitchen staff confront daily, and what causes them? There is a need to study the working situation of the cook in order to identify the information processing difficulties that she faces, when they happen, what causes them, and then to create tools that will help her overcome them.

CONCLUSION We hope that this project report is the first step in providing a better understanding of how to make Menno Place look more homelike, how to create a better atmosphere for both residents and staff, and how to develop stronger links between Menno Place and the larger community.

The project certainly provides a foundation for future work, and it is our hope that we will continue collaborating to help Menno Place achieve its goals: to bring the quality of dementia care to its best.

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6 REFERENCES & BIBLIOGRAPHY

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Alzheimer’s Society. (2007). Home from home: A report highlighting opportunities for improving standards of dementia care in care homes. Retrieved from http://alzheimers.org. uk/site/scripts/download_info.php?fileID=270 Alzheimer’s Society. (2011). Guidelines for Care: Person-centred care of people with dementia living in care homes. Retrieved from http://www.alzheimer.ca/~/media/Files/national/Culture-change/culture_change_framework_e.pdf Barnes, S., & Design in Caring Environments Study Group. (2002). The design of caring environments and the quality of life of older people. Ageing and Society, 22(6). 775-789.

Benbow. B. (2014). Best practice design guidelines: Nursing home complex care and dementia.

Retrieved from http://wabenbow.com/wp-content/uploads/2010/03/Benbow-Best-Practice-Design-Guideline-November-2014-compressed.pdf Bright, K., & Egger, V. (2008). Using visual contrast for effective, inclusive, environments.

Information Design Journal, 16(3), 178-189.

Boyle, G. (2008). Autonomy in long-term care: a need, a right or a luxury? Disability & Society, 23(4), 299-310.

Campbell-Dollaghan, K. (2014). An Amazing Village Designed Just For People With Dementia. Retrieved from http://gizmodo.com/inside-an-amazing-village-designed-justfor-people-with-1526062373 Canadian Healthcare Association. (2009). New Directions for Facility-Based Long Term Care. Retrieved from http://www.healthcarecan.ca/wp-content/uploads/2012/11/CHA_ LTC_9-22-09_eng.pdf De Geest, G. (2007). The Living Dementia Case-Study Approach: Caregivers Discover What Works and What Doesn’t. Vancouver, Canada: Trafford Publishing.

Dementia Challenge. (n.d.). Retrieved April 10, 2015, from http://www.engage.dh.gov.uk/ dementiachallenge/ Diaz Moore, K. (2004). Interpreting the “hidden program”of a place: An example from dementia day care. Journal of Aging Studies, 18, 297-320.

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Gillespie, R. J., Harrison, L., & Mullan, J. (2015). Medication management concerns of ethnic minority family caregivers of people living with dementia. Dementia, 15(4), 47-62.

Hubbard, G., Cook, A., Tester, S., & Downs, M. (2002). Beyond words: Older people with dementia using and interpreting nonverbal behavior. Journal of Aging Studies, 16, 155-167.

Koren, M. J. (2010). Person-Centered care for nursing home residents: The culture-change movement. Health Affairs, 29(2), 1-6.

Perry, J., Galloway, S., Bottorff, J. L., & Nixon, S. (2005). Nurse-patient communication in dementia improving the odds. Journal of gerontological nursing, 31(4), 43-52.

Ritchie, J., & Spencer, L. (2002). Qualitative Data Analysis for Applied Policy Research. In A. M. Huberman & M. B. Miles (Eds.), The Qualitative Research Companion (305-329). Thousand Oaks: Sage.

Shields, S. (2006). In Pursuit of the Sunbeam: A Practical Guide to Transformation from Institution to Household. Kansas, KC: Action Pact Press.

Skrajner. M., Malone, M., Camp, C., McGowan, A., & Gorzelle, G. (2007). Montessori-Based Dementia Programming. Alzheimer’s Care Quarterly, 8(1), 53-64.

Sugihara, T., Fujinami, T., Phaal, R., & Ikawa, Y. (2015). A technology roadmap of assistive technologies for dementia care in Japan. Dementia, 14(1), 80-103.

Taylor, M. E., Delbaere, K, Close, J. C. T., & Lord, S. R. (2012). Managing falls in older patients with cognitive impairment. Aging Health, 8(6), 573-588.

Thieme, A., Vines, J., Wallace, J,. Clarke, R., Slovak, P., ... Grimes, A. (2014). Enabling empathy in health and care: Design Methods and challenges. Retrieved from http://di.ncl.ac.uk/ empathy/files/2013/11/Empathy_Workshop_CHI2014__Ext_Abstracts_preprint.pdf Timlin, G., & Rysenbry, N. (2010). Design for Dementia: Improving dining and bedroom environments in care homes. Helen Hamlyn Centre, Royal College of Art. Retrieved from http:// www.rca.ac.uk/documents/392/DESIGN_FOR_DEMENTIA__w.pdf.

Timlin, G., Ying, J., & Johansson, L. (2010). Better care homes. Retrieved from http://www. bettercarehomes.org Van der Ploeg, E., Eppingstall, B., Griffith, J., O’Connor, D. (2009). Design of two studies on non-pharmacological interventions to reduce agitated behaviours in persons with dementia. Alzheimer’s & Dementia, 5(5), e10-e17.

Zeisel, J., Silverstein, N. M., Hyde, J., Levkoff, S., Powell Lawton, M., & Holmes, W. (2003).

Environmental correlates to behavioral health outcomes in alzheimer’s special care units.

The Gerontologist, 43(5), 697-711.

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7 APPENDIX

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Menno Place | Staff Questionnaire Menno Place and ECUAD are working together to study ways to improve Menno Place’s residents experience. This provides Menno Place with an opportunity to consult with their own resident population as well as the public, to boost public perception, and to create a meaningful dialogue on what a healthy, positive residential care environment might look like.

Part of this project involves the collection of opinions and advice from people working at Menno Place. To this end we ask you please to respond to the following questions.

Gender: Please indicate your gender 1. Male/Female Age: Please indicate your age • 25-34 years old • 35-44 • 45-54 • 55-64 • 65-74 1. How long have you been working at Menno Place?

2. Can you describe what does Menno Place means to you?

3. Could you briefly describe your job at Menno Place?

4. Do you receive recognition for your work?

5. Do you find your work rewarding?

6. Could you describe the Menno Place working atmosphere?

7. Why do you think that you fit this atmosphere?

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8. What do you value in your work?

9. What could be done to help you improve your job performance?

10. Do you celebrate your work? If yes, how?

11. Would you like to receive training about interacting with dementia people?

12. Would you recommend Menno Place to a friend that is looking for a job? Why? 13. From your personal perspective, what changes in the organization would help you better support the needs of the residents?

14. Taking a broader perspective, what changes in management or procedures could improve the residents experience of the place?

15. How easy you think it is for a new resident to adapt to Menno Place?

16. What changes in the interior would improve Menno Place for its users?

17. What would you add or change to improve the look of the place? !

18. What activities could be organized to improve the residents experience?

19. What activities could be organized to connect Menno Place more with the community?

20. How would you define a healthy and positive residential care environment?

21. What does it mean to care for a person with dementia?

22. Do you think residents feel at home at Menno Place? Why? 23. What do you think is quality of life for a resident with dementia?

24. Do you have any other comment to add that would help improve the residents experience in the place?

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