MANCHESTER SCHOOL OF ARCHITECTURE MASTER OF ARCHITECTURE ( MArch )
DEMENTIA – A PLACE CALL HOME NAME : NURFATINAH BT. MOHD RASHIDEE STUDENT ID : 13156456 SUPERVISOR : DR. ALAN LEWIS 2014
TITLE PAGE………………………………………………………………………………………i TABLE OF CONTENT…………………………………………………………………………..ii ACKNOWLEDGEMENT………………………………………………………………………..iv LIST OF TABLES………………………………………………………………………………....v LIST OF PHOTOGRAPHS………………………………………………………………………v ABSTRACT……………………………………………………………………………………….vi DECLARATION ………………………………………………………………………………..vii
CHAPTER 1: THESIS INTENTION, CONTENTS, OVERVIEW 1.1 INTRODUCTION 1.1.1 Care Home…………………………………………………………………..1 1.1.2 Dementia…………………………………………………………………….3 1.1.3 DICE……………………………………………………………………...…4
1.2 AIM OF STUDY…………………………………………………………………..4 1.3 OBJECTIVE…………………………….………………………………………….5 1.4 THESIS OVERVIEW………………………..………………………………...…5 CHAPTER 2: LITERATURE REVIEW – THE MEANING OF HOME MEANING OF HOME……………………...……………………………………….6 2.1 FAMILIARITY……………………………………………………………………..8 2.2 SAFETY………………………………………….………………………………….9 2.3 CONTROL……………………………………………….……………………….11 2.4 IDENTITY………………………………………………………………………..13 2.5 COMFORT……………………………………………………………………….15 ii
CHAPTER 3 - DISCUSSION 3.1 FAMILIARITY……………………………………………………………………17 3.1.1 Institutional ambiance rather than normal domestic home………………….19 3.1.2 Does size matter?...........................................................................................19 3.1.3 Connection to nature……………………………………………………….20
3.2 SAFETY……………………….………………………………...…………………22 3.2.1 Contradiction of safety and well-being……………………………………...22 3.2.2 Falls………………………………………………………………………...23
3.3 CONTROL……………………………………………………………………….25 3.3.1Autonomy and Well-being…………………………………………………..25
3.4 IDENTITY………………………………………………………………………..28 3.4.1 Personalization……………………………………………………………...28 3.4.2 Gender……………………………………………………………………...31 3.4.3 Relationship with the staff…………………………………………………..32
3.5 COMFORT……………………………………………………………………….34 3.5.1 Over-heating ……………………………………………………………….34 3.5.2 Simple design solution……………………………………………………...35
CHAPTER 4 : CONCLUSION ………………………………………………………….38 REFERENCES
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ACKNOWLEDGEMENT I would like to thank first and foremost my supervisor Alan Lewis for constantly giving me guidance and support in making this dissertation possible. To Manchester University and Manchester Metropolitan University for the amazing facilities. To my husband who has given me endless encouragement. To my lecturers, my sponsorship – MARA, my family, friends who in one way another shared their ideas and support either morally, physically and financially. Above all, to the Great Almighty, the author of knowledge and wisdom, for giving me strength and countless love. Thank You.
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LIST OF TABLE TABLE 1……………………………………………………………………………………………………………………………39 Source: Peace, S. and Holland, C., “Homely residential care: a contradiction in terms?” Journal Social Policy, 30(3) 407)
LIST OF PHOTOGRAPH PHOTO 1…………………………………………………………………………………………………………………………..17 Source: Google image - http://lumenistics.com/wp-content/uploads/2012/10/eldercare-041.jpg PHOTO 2…………………………………………………………………………………………………………………………..17 Source: Google image - http://www.demenz-support.de/gradmannstiftung/bauprojekte/gradmannhaus_stuttgart_kaltental/wandelhalle/Bilder/ghaus_halle1.jpg PHOTO 3…………………………………………………………………………………………………………………………..18 Source: Google image - http://www.demenz-support.de/gradmannstiftung/bauprojekte/gradmannhaus_stuttgart_kaltental/wandelhalle/Bilder/ghaus_halle4.jpg PHOTO 4 …………………………………………………………………………………....................................................…….19 Source: Google image: http://www.lenhardtrodgers.net/wp-content/uploads/galleries/post-1740/full/spa.jpg PHOTO 5 ………………………………………………………………………………………………………………………….19 Source: Google image - http://www.springharborlife.org/wpcontent/uploads/2013/01/3rdFloorNursingStation.jpg PHOTO 6 ………………………………………………………………………………………………………………………….20 Source : HAPPI report PHOTO 7 ………………………………………………………………………………………………………………………….23 Source: Ann Sealy, The design of residential care and nursing homes for older people, Centre Accessible Environments 1998 PHOTO 8 ………………………………………………………………………………………………………………………….23 Source: Ann Sealy, The design of residential care and nursing homes for older people, Centre Accessible Environments 1998 PHOTO 9 ………………………………………………………………………………………………………………………….29 Source: Google image- http://www.pflege.de/uploads/nursing_homes/5051/large/haus-aja-textor-goethe_6561.jpg?1383680250 PHOTO 10 ………………………………………………………………….……………………...…………………………...…30 Source: Google image- http://www.lenhardtrodgers.net/wp-content/uploads/galleries/post-1740/full/bedroom.jpg PHOTO 11 ………………………………………………………………………….……………………………………………..30 Source: Google image- http://www.nationalcarehomeopenday.org.uk/sites/nchd/files/hulcott_bedroom.jpg PHOTO 12…………………………………………………………………………………………………………………………31 Source : Google image- http://buildipedia.com/aec-pros/design-news/twelve-things-every-designer-should-know-about-todays-seniorhousing?print=1&tmpl=component PHOTO 13 ………………………………………………………………………………………………………………………...36 Source: Alan Lewis, Extra Care Housing for People with Sight Loss: Lighting and Design
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ABSTRACT Older people living in residential and nursing care homes spend most of their time within the boundaries of the home, and may depend on the environment to compensate for their physical or cognitive frailties. There has been a robust literature on the meaning of home. Homeliness is a complex concept which is highly personal. However, there were five distinctive characters of a home that were continuously being repeated in the literature as being important to many individuals especially the older ages group relating to their home – familiarity, safety, control, identity and comfort. Some research has been proven that embedding these character in oneself has a positive impact on the health of an individual thus it is further explored in this paper. Health care environments are always closely related with being institutional therefore there has been a consensus that care home should be less like hospitals and more like home. This paper draws the literature on the meaning of home and design of care home for dementia to explore ways to create a setting that reflects home thus improves the occupant’s health and well-being.
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DECLARATION
I herewith declare that this thesis submitted for Master of Architecture of Manchester School of Arts has not been previously submitted for a master at another University and that it is my work
__________________________________ NURFATINAH BT. MOHD RASHIDEE STUDENT ID : 13156456
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CHAPTER 1: THESIS INTENTION, CONTENTS, OVERVIEW
1.1 INTRODUCTION 1.1.1 Care Home for the Dementia Care home or some people may call it residential care, provides care facilities for the aged group who are unable to look after themselves and with people with high levels of disabilities. According to RIBA silver linings report, the group of older is growing at a much faster rate than other age groups in the UK; evidence suggests that the number of people aged 60+ in the UK will increase by 43% between 2013 and 2035, and that in 2035, nearly a third of our people will be over the age of 60. Aging has become part of a wider, global phenomenon, not only in the UK. It is estimated that there will be 2 billion people aged over 60 worldwide by 2050, an increase of 250% on today’s figures. We can all now expect to live longer than any previous generation; since 1970, global life expectancy has risen by around 10 years for both men and women1. There is an expecting rise in the number of occupants at care home not only in the UK but also worldwide. With the increase in the number of people with dementia along with the associated with caring for these people at home, nursing homes will continue to play an important role in the provision of long-term care to older people2. Half a million older people in the UK live in communal care homes. These are vulnerable people that are physical frailty or have cognitive impairment, or both that can no longer live independently. With a policy of increasing support that enables people to remain in their own homes, in the community there has been corresponding increase in frailty in the care home population; it is estimated that 62% of care home residents have dementia3 and that all buildings designed for residential care are likely to serve people with dementia. Although only one person in 50 (2%) between the ages of 65 and 70 is affected by dementia, the proportion rises to one in five over the age of 80 (20%)4. Greater longevity in society as a whole means that number with people suffering from cognitive impairment will increase. 24.3 million people worldwide are estimated to have dementia today, and is forecast to reach 81.1 million in 2040. The figure is expected to double every 20 years. The rate of increase varies with location, with estimates of an increase of 100% in developed countries and 300% in India, China,South Asia and the Pacific5. With the increasing need for setting that provide 24-hour care for the frailest, it is challenging for carers and not always possible to deliver services that are expected from the community. In the UK the number of residential care places required to meet the need is estimated to increase from 459 000 in 2002 to 1130 000 in 2051. Low funding levels and increasing standards have put stress on the UK care home sector, and there have been widespread closures, particularly of small and medium sized homes. Although more independent settings for older people are of extra-care sheltered housing scheme being promoted by is government, specialist care homes for people with dementia are still being built. Demand for places exceeds 1
supply in some regions and these new care homes today tend to be corporately owned and large, providing 40–100 places. However, basic design, regulatory standard and efficiencies of scale have implications on the quality of life of occupants and other parties. Care home undoubtedly serves as double function settings; it serves as a home to the residents who live there, and a workplace for its other users of the building. In a well-designed home, the two objectives will not be in conflict, as both are crucial to the occupant’s health. Older people, particularly those with dementia, are likely to feel more at home in environments, which are familiar, thus creating a ‘homely’ environment, is essential in designing a care home for dementia. Evidence also suggests that there are care home settings with equally high level of well-being and home-like atmosphere. So what makes a care home feels like a home?
1. 2.
3. 4. 5.
RIBA, Silver Lining : The Active Third Age and the City, 2013 Assumpta Ryan, and Hugh McKenna, Familiarity as a key factor influencing rural family carer experience of the nursing home placement of an older relative: Quantitive Study (BMC Health Services Research 2013) 1. Judith Torrington,Evaluating quality of life in residential care buildings (Routledge,2007) 515 I bid Ferri, C., Prince, M., Brayne, C. et al.,Global, Prevalence of dementia: a Delphi consensus study (Lancet, 366(2005),2112.
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1.1.2 Dementia Dementia is a syndrome of a group of related symptoms, associated with an ongoing decline of the brain and its abilities1. Loss of memory is not the only deficit in dementia opposing to some popular belief. There are different kinds of symptoms in dementia2, including: (i) (ii) (iii)
impairment in activities of daily life, abnormal behavior loss of cognitive functions
Dementia is progressive, meaning that over several years the condition worsens and often results in high levels of dependency in the later stages3. However, dementia can only be delay but cannot cure the deterioration of brain cell. People with dementia have an altered sensitivity to environmental conditions, and some may become increasingly reactive to their environment4 thus can result to behavioural problems, which may burden the carers. Increased sensitivity seems to stem from the reduction of the individual’s ability to understand the implications of sensory experiences5. For example, there may be certain times of the day when individuals become disturbed and agitated. For example, ‘sundowning’ is a term used to describe disturbed behaviour in the evening. They would act aggressive when they start to experience anxiety and agitation. Some lose a sense of inhibition and may behave in ways that others find embarrassing or inappropriate. The changes brought about by dementia however, are not all negative for example, disinhibition can feed creativity and there are accounts of people becoming better dancers or artists as the disease progresses6. However, in practice, about 90% of people with dementia show behaviour problem7, which may be related to environmental stimuli. Apart from pharmacologic means, non-pharmacologic interventions can play an important role in managing the problem behaviour9.
1. 2. 3. 4. 5.
6. 7. 8.
The National Health Service, http://www.nhs.uk/Conditions/dementia guide/Pages/about-dementia.aspx Schmidt Luggen A., Cognition. In: Ebersole P, Hess P, Schmidt Luggen, 6th ed. (Toward healthy aging,2004) Better homes, http://www.bettercarehomes.org/ability/dementia/what-is-dementia.php Weaverdyck SE, “Assessment as a basis for intervention” Specialized dementia care units. Baltimore, MD, USA: The John Hopkins University Press; 1991. 23. Sloane PD, Mitchell CM, Weisman G, Zimmerman S, Foley KML, Lynn M, et al., “The Therapeutic Environment Screening Survey for Nursing Homes (TESSNH):an observational instrument for assessing the physical environment of institutional settings for persons with dementia.” Journals of Gerontology Series B: Psychological Sciences and Social Sciences (2002);57(2):S69–78. Judith Torington, Evaluating quality of life in residential building (Routledge; 2007)515 Ritchie K, Lovestone S., “The dementias” The Lancet 2002;360(9347):1759–66. Van Hoof J, Kort HSM, “Supportive living environments: a first concept of a dwelling designed for older adults with dementia” Dementia 2009;8(2) 293–316.
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1.1.3 DICE Design in Caring Environments (DICE) was a multidisciplinary project funded by the engineering and physical science research council (EPSRC) in the EQUAL programme involving the universities of Sheffield and Loughborough that seek relationship between quality of life of people with dementia and the design of care homes. The project was completed in 2003 and is a quantitative study carried out in 38 care homes in Sheffield and Rotterdam involving 452 residents. The methods: 1. 2. 3. 4.
Through observation ( dementia care mapping ) Interview and proxy information from the care-workers who knew their residents best Incorporating the CAPE Behaviour Rating Scale (a measure of dependency) The 20-item Pleasant Events Schedule-AD (a scale measuring frequency and enjoyment of pleasant activities) 5. Apparent Emotion Schedule (a scale producing two measures of outward signs of emotion). 6. Questionnaires were sent to 1066 nursing and care staff to assess their morale using relevant subscales of two measures: the Work and Life Attitudes Survey and the Nursing Stress Scale. The buildings were analysed using an evaluation tool designed for the project: the Sheffield Care Environment Assessment Matrix (SCEAM). Data from the building evaluation and the quality-of life observations were then collated in a multilevel analysis to identify aspects of the built environment that seemed to be associated with health outcomes.
1.2 AIM To understand the meaning of home especially to older people with dementia through literature studies in determining the value and meaningful character of home in order to make recommendation and implementation for future nursing home development.
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1.3 OBJECTIVE This study defines the importance of the environmental effect on one’s psychological health and behavior thus studies on the meaning of home to create the best ambiance for people with dementia in care home. The objectives are to : 1. 2. 3. 4.
Improve health and well-being Maintain identity Create a safe environment at care home without deteriorating quality of life Provide a homely surroundings with care that will enable them to live as independently as possible with privacy, dignity and with the opportunity to make their own choices. 5. Provide residents with an equal sense of control over their lives 6. Create the best ambiance for a workplace (staff), a homely place for residents and other users of the building.
1.4 THESIS OVERVIEW This chapter has given an introduction to what are care home, dementia and a brief explanation of the DICE tool. The aims and objective were also executed in this section. Chapter 2 provides a literature review on the meaning of home. There were five distinctive characters that have been repeatedly mentioned in the literature that seems to be important values to most individual especially to the older people regarding being at home. This chapter also explored other authors view on the five character and studies that have been conducted around the area. These theories and ideas are foundational to the thesis. Chapter 3 studies in depth on each character. It provides a brief discussion on the character, study on research that have previously being conducted around the topic and result that was obtained from it. This chapter also discusses and identify character that institutionalize the setting and recommends ways to make it feel more home thus improving the health and wellbeing of the occupant.
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CHAPTER 2 – LITERATURE REVIEW: MEANING OF HOME We all have our own thought of what we correlate with ‘home’. Definition of home is highly individual and personal thus makes it a complex concept to pin down. Homeliness is being studied across many disciplines, from the psychological studies of personal and experiential aspect of home to sociological context sensitive focus on the experience and use of home. The idea of home for most people represents love, security and belonging and a place that are highly attached to some person especially to the elderly group. Furthermore, Lawton’s Environmental Docility Hypothesis examines disabling environments from the viewpoint of the person. This hypothesis states that the more a person is disabled the more they are encumbered by their immediate environmental situation. The phrase, ‘I want to go home’ is imperative for people with dementia and therefore deserves our close attention. For the purpose of this study, the meaning of home is only limited to the consideration of variation in the meanings of home for older age groups living in care home as a key factor. Since there is a robust literature on home and the meaning of home, however home in this study portray a building which one dwells. It’s an exploration of which nursing home can be design to reflect the qualities of a domestic home. Heidegger in his essay ‘building dwelling thinking’, first published in 1954, posses two questions: ‘what is it to dwell? and ‘how does building belong to dwelling?’1. Heidegger observes that building and dwelling are not the same: whilst dwellings are produced through building, not all buildings are dwellings. Thus, home is undeniably connected to a built form such as a house, but a house is not always a home2. Similarly, Alison Blunt and Robyn Dowling describe home is an idea and an imaginary that is imbued with feelings. In other words, home is a place/site, a set of feelings/ cultural meanings and the relations between the two3. This shows that home can be defined as a dwelling in which we live, or used to live, and the relations and social interaction within the dwelling, in which we find emotional attachment. Below are some quotes that strengthen the argument. “Home is constructed on the tension between two specific modalities: being home and not being home. Being home refers to the place where one lives within familiar, safe, protected boundaries; “not being home” is a matter of realizing that home was an illusion of coherence and safety based on the exclusion of specific histories of oppression and resistance, the repression of difference even within oneself” ( Mohanty 90).3
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“Our literal home is a “sacred,” mythic place, even for non-religious people. We all believe in a special space beyond our own doorsills that simply cannot be violated. This is my place, where I can close the door on chaos and find some kind of cosmos, peace, assurance of purpose. “This is mine; here I belong.” (unknown source)
However, throughout the search of the meaning of home and in literature studies associated with the elderly, words often repeated when describing ‘home’ are comfort, safety, familiarity, control and identity thus will be further explored in the following chapters as to see how important these element are in preserving the character of home in care home environment.
1. 2. 3. 4.
Heidegger, M., Building dwelling thinking, trans. Albert Hofstadter (Harper Colophon Books, New York, 1971), quoted in Alison Blunt & Robyn Dowling, Home (Routledge, 2006)3. Alison Blunt & Robyn Dowling, Home (Routledge, 2006)9. Ibid p.2 The meaning of Home – A Shelter SA project, http://sheltersa.wordpress.com/the-meaning-of-home/
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2.1 FAMILIARITY A significant proportion of our daily lives are routines actions, or at least actions which have a sense of the routine about them. Routine is associated with the predictability of daily life and the patterns of living that are regularly followed. The most salient characteristic of routine is familiarity. Familiarity is defined as “close acquaintance with or knowledge about something”1 and home is a place where are familiar with, where our normal daily life is performed. Familiarity of home provides an important context for care home. Shields & Norton suggest care home environment as: ‘It should look, feel, smell and function like a true home we are all familiar with in our own lives’2 The familiarity of home provides an important context for care. Arber and Ginn have related this to the home’s association with life roles, especially for older women, where to some house is like their work place. Occupants should be encouraged to engage more with domestic activities at care home. Familiar domestic tasks are ‘over-learned’ through decades of repetition and are, therefore, familiar, engaging and motivating3. It is also able to engage more people with dementia than craft or other leisure activities4. Rabig describe homelike deinstitutionalized models should have archetypal features of a private home, such as a kitchen, dining room, living room and laundry area. However, people with dementia living in a nursing home are at risk of reduced activity levels, increased passivity and overly dependent behavior5. This occurs because of the strict regulation enforced by the authority and anxiety of family’s occupants that resulted to limited activities one has in care home. Similarly, Torrington argued that there is a tension between Infection Control and Health and Safety on one side, and, person centered care and improved quality of life experiences on the other in care home. This leads to the question of safety, whether it improves or deteriorates the occupant’s quality of life.
1. 2. 3. 4.
5.
Ryan, A., and McKenna, H., Familiarity as a key factor influencing rural family carer experience of the nursing home placement of an older relative: Quantitive Study (BMC Health Services Research 2013) 6. Peace, S., and Holland, C., Homely residential care : a contradiction in terms?, (Journal Social Policy, 30(3)) 6 Brawley and Calkins, For Previous Home Makers (Alzheimer's Australia, 2004) 95 Mark Morgan Brown, Changes in Interactive Occupation and Social Engagement for People with Dementia (Surface Inclusive Design Research Centre, School of the Built Environment, University of Salford, Salford, U.K, 2013 )82 Mark Morgan Brown, Changes in Interactive Occupation and Social Engagement for People with Dementia (Surface Inclusive Design Research Centre, School of the Built Environment, University of Salford, Salford, U.K, 2013 )51
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2.2 SAFETY Safe is a word that is often repeated when describing a home. In fact one of the important element of home is that home provides shelter. A common definition of shelter means a place giving temporary protection from bad weather or danger. In a way, it describes as being in a protected place. Similarly, Alison Blunt and Robyn Dowling described home is a setting in which people feel secure and centred1. Likewise the feeling of safe is describe in a journal Meanings of home for older home owners2: “I think it's a feeling of security no one can budge when you're in your own home. You can do what you like, you can make it different, and it’s your asset.” (female, 80-89) For most people the home is more than shelter, it is part of the self (Sixsmith and Sixsmith, 1990; Altman and Low,1992; Gurney and Means, 1993). It is a place to which people can feelattached; ‘be themselves’; a place where safety and security is oftenreinforced by memories of the past and reminders of the present, perhaps represented in possessions (Low and Altman, 1992).From a psychological state, being at home means to be safe and secure, and in control of our actions and our environment. In the same way, Contemporary writers, Doyle, Fitchen and Howell have described the deeply ingrained sense that one should be safe from bodily and emotional invasion by outsider when in one’s home3. Rowles, a gerontologist who explored the spatial boundaries of the lives of older people, concluded that “home” was a “fulcrum for one’s orientation to the rest of the world”, a sacred, inviolable space4. In the study of ‘meaning of home in the stories of older women’, a feeling of safety, whether for themselves in their own surroundings or for other they loved, was essential. Many of the women remembered times when they were no longer able to care for loved ones at home because it was not safe5. Endy’s husband had Alzheimer’s disease and became confused, and Endy’s worried that he might wonder off, she talked about trying to make their home a safe place for him. I decided that I had to retire because he got so that he would leave the house sometimes…Some people suggested, “Why don’t you lock the door where he can’t get out?” but I couldn’t do that. You don’t know something might happen that he had to come out.
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When that feeling of safety was destroyed, the sense of comfort and belonging in one’s world was also destroyed6. Torrington emphasise the importance of designing buildings for confused as safe as possible, but they should also respect the freedom of the individual7. Many important considerations should be made when designing a home for the dementia. Person with dementia can easily get agitated, therefore it is vital to avoid unnecessary frustration and distressed to the demented person8. Being in a care facilities do make people feel like being in an institution, and some care home offer the same ambiance. Margeret suggested perhaps a sense of safety and control over one’s living space in an institution is associated with a sense of ‘at-homeness’ that can replace alienation9. “For a man’s house is his castle. One’s home is the safest refuge to everyone.” E. Coke
1. 2. 3. 4. 5. 6. 7. 8. 9.
Alison Blunt & Robyn Dowling, Home (Routledge, 2006)9. Ann Dupuis & David C. Thorns, “Meanings of home for older home owners,” Housing Studies, Vol. 11, No. 4, 1996,( 2014) Doyle, 1992; Fitchen, 1989; Howell, 1983, quoted in Margaret F. Moloney, Meaning of Home n the Stories of Older Women (SAGE 1997) 167 Rowles 1978,1987, quoted in Margaret F. Moloney, Meaning of Home n the Stories of Older Women (SAGE 1997) 167 Margaret F. Moloney, Meaning of home in the stories of older women (SAGE 1997) 171 Ibid Torington, J., Care Homes for Older People : A briefing and Design Guide ( E & FN Spon, 1996) 16 Ibid, p. 17 Margaret F. Moloney, Meaning of home in the stories of older women (SAGE 1997) 175
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2.3 CONTROL Many people who end up in nursing homes feel that they have lost control of their lives, and are often placed there against their wishes. Once in a residential home, they have little say on what they do, who they see and what they eat. Is this true? Choice, control and reassurance strongly inform the sense of being ‘at home’ and when satisfied, it allows extension of aspirations. Choice and control (also known as ‘autonomy’) is a key factor relating to the dignity of older people and is set within the context of human rights and equality1. Dictionary definitions of autonomy include: 'the power of self direction’ and 'the ability to make independent choices’2. Empowering older people in care homes to be involved in all decisions about their lifestyle and care is fundamental to their mental wellbeing3. Older people describe having control over their daily lives are important to them4. To them, having control over their daily life is about freedom to act, to be independent and mobile, as well as freedom to decide. For example, being given support to cook a meal will help the person to remain in control and be far more rewarding and meaningful than passively waiting for staff to cook the meal5. Similarly, Saunders claims that home is where people feel in control of their environment, free from surveillance, free to be themselves and at ease, in the deepest psychological sense, in a world that might at times be experienced as threatening and uncontrollable6. “I think [home] is a refuge.. home is a place where you should go and be on your own if you want to and you’ve got a place to hide.” “When you own a house you can close the door on the world when you go in because it doesn’t belong to anyone else but you.” In an interview for PSSRU Research Summary conducted with older people living in care homes and extra care housing, there was considerable agreement amongst respondents about what features are important in making a place feel like home. One of the features was having control of their own time 7: i. ii. iii. iv. v. vi.
Being in control of when friends/ relatives visit Being able to live in the home or scheme for as long as you want to Having control over how you spend your time Being able to come and go as you please Being able to arrange your room / flat to suit your own taste Being allowed to be alone if you want to.
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These features showed that a home is particularly important in preserving a sense of control. Similarly, when asked what characterized a homelike care home, Hauge and Heggen define home as a private space, over which one has control, which is the predominant space for personal relationship and has a strong symbolic meaning of each individual7. However there are care home now a day give autonomy to their residents for example through a semi conducted interviews with older people living in care homes (residential and nursing)or in the community, Boyle found that older people in residential care experienced the most control and people receiving domiciliary care the least. Nevertheless studies such as Boyle are difficult to find in the UK literature8. Many findings positively relate being in control for the elderly and well-being and whether care home does gives this sense of control to the residents. Thus this topic should be further explored.
1. 2. 3. 4. 5.
6. 7. 8.
social care institute for excellence, http://www.scie.org.uk/publications/guides/guide15/factors/choice/ NICE: National Institute and Care Excellence, http://publications.nice.org.uk/mental-wellbeing-of-olderpeople-in-care-homes-qs50, Lisa Callaghan and Ann-Marie Towers, Feeling in control: comparing older people's experiences in different care settings (Ageing and Society, 2014) pp 1 - 25 social care institute for excellence, http://www.scie.org.uk/publications/guides/guide15/factors/choice/ Deci & Ryan, 1987; Ryan et al.,1995, quoted in Virginia Grow Kasser and Richard M.Ryan, “The relation of Psychological Needs for Autonomy and Relatedness to Vitality, Well-Being, and mortality in a Nursing Home”, Journal of Applied Social Psychology Vol.29, no. 5, ( May 1999) 935–954 Saunders (1984,1986) quoted in Ann Dupuis and David C. Thorns, Home, Home Ownership and the Search for Ontological Security (Blackwell,1998) 38 Anne-Marie Towers, Control, well-being, and the meaning of home in care homes and extra care housing (PSSRU research summary 2006) Hauge, S. and Heggen, K, “The nursing home as a home: a field study of residents’ daily life in the common living rooms” Journal of Clinical Nursing, vol 17
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2.4 IDENTITY Home and dwelling are very important in most people's lives, and consequently, they are significant in influencing identity. Relph proclaims a very important theoretical concept surrounding the individual home, he said : “ without exception, the home is considered to be the ‘place’ of greatest personal significance in one’s life – ‘the central reference point of human existence”.1 There is for virtually everyone a deep association with and consciousness of the places where we were born and grew up, where we live now, or where we have had particularly moving experiences2. This connection seems to comprise a vital foundation which to study place identity. This shows that home definitely is secure base which identities are constructed. On the other hand, "Identity" can be described as the distinguishing character or personality of an individual3. People decorate their homes and workplaces according to their taste, so that their houses and gardens reflect and communicate who they are. Similarly, Lipsedge, lees-Maffei, Januarius, Olesen, and Araujo all concurs that the roles, routines, decoration and personal possessions used in the home contribute to a sense of identity and are used to express that sense of self to visitors to the public spaces of the home4. In another word, person’s sense of self is an expression of identity. However, Hayden claims that identity is intimately tied to memory which manifests itself in space5. Hume supports this claim and emphasized on the importance of memory as a source to discover and produce identity6. This is particularly important to the aging group especially people with dementia. The elderly reaffirm their identity and importance of role through the use of spatially based memories, intrinsically linking their lives to the identity and cultural value of ‘place’7. Daya and Hitchings agrees to this and stated ; identity is also both constituted and performed in place and places can be positive resources on which to draw in building selfidentity8. Gendered identities were also fashioned through the home where women tended strongly to fit the stereotypical gender of the housewife and mother while men looked after the structural side of things both within and outside the home such as carpentry9. This is to be further discussed in the following chapter.
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1. 2. 3. 4. 5. 6. 7. 8. 9.
LauraL.Lien, “Home as identity : Place – making and its implications in the built environment of older persons” Housing and society, 36(2)( 2009): 168 Ibid Hauge, Ashild Lappegard, Identity and place: a critical comparison of three identity theories(Architectural Science 2007) 1 Anne Fleming, Dr Pauline Banks, Dr Angela Kydd, Sally Stewart, A systematic review of the literature concerning design considerations of homeliness in care homes. 4 LauraL.Lien, “Home as identity : Place – making and its implications in the built environment of older persons” Housing and society, 36(2)( 2009): 168 Ziad b. Senan, “The house as an expression of identity: the case of the Palestinian house” FORUM vol. 2. (1993 ): 3 Rosie Daya and Russell Hitchings, “Only old ladies would do that: Age stigma and older people’s strategies for dealing with winter cold” Health Place 17(4) (2011):886 Ann Dupuis and David C. Thorns, Home, Home Ownership and the Search for Ontological Security (Blackwell 1998) 38. Peace, S. and Holland, C., “Homely residential care: a contradiction in terms?” Journal Social Policy, 30(3): 397
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2.5 COMFORT The general meaning of comfort is the state of ease or well being. Home should offer both physical and emotional comfort. It’s normal to want to enjoy the comforts of home, especially when aging challenges or serious illness means that we aren’t feeling our best. A number of widows commented on the comfort of having their own home gave them after their husband’s death. Home provided a refuge where they could go through the grief process in private, in whatever way they chose.
“ when my husband died, my home became absolutely everything to me. If I was up at the supermarket shopping and there might be some music from our old days of dancing and I’d scuttle home and as soon as I shut the front door I was secure and comfortable. In my circumstances I could have curled up and stayed inside forever; but I had to make myself get out. Particularly now since I’ve lost my husband, this is mine and I fell secure here.”1
This is an example of emotional comfort where they can just be in their comfortable zone and have their own space and privacy. So many factors influence comfort; privacy is one of it. Home is also characterised as a place of total privacy where one could do as one pleased without disturbance from the outside world. Many respondents commented on the sense of autonomy they had as home owners and the freedom they had to shut out the rest of the world. Frequently references were made to ‘being able to do what you wanted, when you wanted”, in your own home2. However, this character can fall under control section thus, will be discussed in the control chapter. Moreover, physical comfort is more important to be discussed in this chapter. Physical environment is very important determinant of psychosocial and health outcomes for older persons with Alzheimer’s disease and related dementias. Agitated behaviors, increased confusion, delusions, and other psychiatric disturbances are readily triggered by environmental stimuli. Temperature comfort is one of the factor influencing the physical environment. Thermal comfort is describe as the ‘the state of mind, which expresses satisfaction with thermal environment’3. People with dementia are known to have altered sensitivity to environmental conditions, and some may become increasingly reactive to their environment4. In practise, about 90% of people with dementia show problem behaviour, which may be related to environmental stimuli5. Thus, it is vital to discuss in the following chapters as there is a need to provide comfortable thermal environment to tackle behavioural problem of the demented people in care home.
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“ Try to discover [the] comfort zone. It’s probably not the same as yours. Consider the home’s temperature, lighting, and sounds[..]. Be extra sensitive in doing so – even the motion or [draught] form a ceiling fan can be annoying. Your [partner] may not know what is wrong, only feel uncomfortable. [The] only means of expression may be agitation or desperate efforts to escape the discomfort”. 6
1. 2. 3.
4. 5. 6.
Ann Dupuis and David C. Thorns, Home, Home Ownership and the Search for Ontological Security (Blackwell 1998) 38. Ibid J. van Hoof a,b,*, H.S.M. Kort a,c, J.L.M. Hensen b, M.S.H. Duijnstee a,d, P.G.S. Rutten b , , “Thermal comfort and the integrated design of homes for older people with dementia” Building and Environment 45 (2010): 358 Ibid Ibid Ibid p368
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CHAPTER 3 – DISCUSSION
3.1 FAMILIARITY Since people with dementia have memory difficulties and are unable to recognize new and unfamiliar things, therefore, environments should be as near as possible to what have been experienced before. Building needs to reflect domestic settings and cultural expectations. Space should be easily recognized. There is evidence that people with dementia are disturbed by ambiguity and tend to avoid spaces that look confusing1. For example, bathroom looks more like a dentist consulting room rather than a domestic bathroom. Way finding and orientation is also an important element to carefully consider when designing the architectural layout of a care home. Corridors should be straight forward, not misleading and does not portray the feeling of being in a long hospital corridor. Often this is a problem at nursing home where spaces are designed looking like institutional rather than the ambiance at home.
Photo 1: Corridor looking institutional: monotone, longitudinal and artificially lit
Photo 2: Corridor being lit with plenty of sunlight and changes in material makes the corridor looks more interesting
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Photo 3: Pocket of seating area in the corridor to encourage social interaction and to break the longitudinal corridor
3.1.1 Institutional ambiance rather than normal domestic home Care facilities are always associated with institutional sense. The idea of institutionalism most commonly associated with the works of Irving Goffman, encapsulated particular characteristics of institutions including homogeneity of daily living; lack of choice and personal autonomy; distance between the two worlds of paid workers and residents; and a secondary status by residents2. The white paper “Caring for People” said that community care should: “allow people to live as normal life as possible in their own homes or in a homely environment in the community”. Minimizing the institutional character to the extent possible is vital in creating the ‘home’ ambiance. Research found that adherence to occupational therapy recommendations was most likely if older person had positive perceptions about their ability to exert control over their own home environment3. For example, bath and toilet rails appear more acceptable than shower chairs, over toilet frames or commodes. This is because rails are perceived as looking ‘normal’ whereas other types of equipment can be perceived by the person as making them appear disabling. Another example is a large nursing station and med cart that figures prominently in the center of the unit portray the institutional character. Interestingly, the 18
federal regulations only require the facility to provide sufficient space and to enable staff to provide residents with needed services as required by standards and as identified in each resident's plan of care4. Is the design of a nursing station just a tradition that one follow? Moreover, a good relationship between the staff and residents would eliminate the institutional ambiance thus would make the occupants feel more emotionally supported.
Photo 4 : Assisted bathroom look more like a dentist consultation room
Photo 5: Nursing station
3.1.2 Does size matter? The size of care home has been severally questioned throughout the literature studies. Does the size of care home matter in terms of quality of life and the feeling of being at ‘home’? Is a small residential care home more likely to allow people to maintain their sense of self compared to large institution - or does size not matter if individuals have the flexibility of moving in out of groups? Willcocks et al. argued that: “in reality, the idea of providing a “homely” setting is a genteel facade behind which institutional patterns, not domestic ones, persist,’ if homeliness can be achieved anywhere within the residential care sector, it is these very small homes5. Similarly, Calkins in a review of the literature concerning long-term care design since 2002 supports finding of Parker, Barnes, McKee et al, (2004), regarding size of care homes from the viewpoint of activities of daily living (ADL) and quality of life (QoL) outcomes6. She agreed that the smaller units have better result for friendship, mobility and lower incidence of anxiety and depression. She also reports that there is a higher incidence of aggression but lower use of restraint in these units. Residents who were interviewed liked small home because it allowed them to live a secure, quiet life in a place where their need were met but 19
they did not have to engage with people more than they wanted to7. Evidence shows that the size of care home does matter. Smaller sized care home gave them comfort of being at home and improves their quality of life.
3.1.3 Connection to nature Older people tend to spend much more time indoors than any other age group thus leads to a massive reduction in external stimuli in their life.8 Not only should the occupant be safe to go out for example in the garden, the residents should also be able to communicate with the outside from inside by window or door. “I can see when it’s a strong wind, I can see those trees moving and there’s activity… I know everybody gets fed up with the wind but it’s a friend to me, seeing it move those trees.” Male, age 88 years9. Making connection to the outside is important to emphasize as some old people or care home tend to not have a good fenestration for example, the building depth is too extensive to allow good day lighting or some rooms even doesn’t have window.
Photo 6: Internal spaces should interact with the external environment
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Daylight often been integrated into the building as an architectural statement, yet the benefits of it is beyond architecture. Not only does it have positive effect on the occupants of the building, it is also seen of a way to answer the environmental related issues. The most important factor is the different spectrum of light that each source produces. Artificial light sources lack the blue portion of the colour spectrum which is the most important element needed for human10. Natural light, however provide full spectrum including the blue portion. This is the reason why natural light is the best source a human can get. Benefits of natural light not only provide energy efficiency, it also affects the occupants of a building through health and psychology aspects too. Some of the benefits are improving mood, enhance morale, lower fatigue, reduce eye strain and also engaging contact with outside living environment.
1. 2.
Toringgton, J,Upgrading building for older people (RIBA Enterprise, 2004)94 Peace, Sheila and Holland, Caroline Homely residential care: a contradiction in terms? Journal of Social Policy, 30(3) (2001): 394, 3. Michelle L Currin, Terry P Haines, Tracy A Comans and Kathy Heathcote, Staying safe at home. Home environmental audit recommendations and uptake in an older population at high risk of falling 4. Margaret P. Calkins, Creating Home in a Nursing Home: Fantasy or Reality?(President, IDEAS Inc, Board Chair, IDEAS Institute) 7, 5. Peace, Sheila and Holland, Caroline Homely residential care: a contradiction in terms? Journal of Social Policy, 30(3) (2001): 407 6. Fleming, A., Banks, P., Kydd A., Stewart, S., “A systematic review of the literature concerning design considerations of homeliness in care homes� Include Asia 2013: 6. 7. Peace, Sheila and Holland, Caroline Homely residential care: a contradiction in terms? Journal of Social Policy, 30(3) (2001): 404 8. Judith Torrington, Upgrading building for older people (RIBA Enterprise, 2004)94 9. Alan Lewis 10. L. Edwards and P. Torcellini, A literature Review of the Effects of Natural Light on Building Occupants (National Renewable Energy Laboratory)
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3.2 SAFETY Making home a safe place was also an important thread often repeated in the literature study of the meaning of home. In fact, Margeret Maloney suggested perhaps a sense of safety and control over one’s living space in an institution is associated with a sense of “ at-home-ness” that can replicate alienation1. Based on empirical research in care homes in which older people received care, their relatives and staff were asked what matters most to them in care homes, result showed that one of the sense that each group (older people, relatives and staff) needs was to fell secure2. Safety and health has always been an important aspect when designing a care home. Residential buildings are among the most regulated of all building types, with a statutory requirement to comply with National Minimum Standards3, and a raft of other standards regulating fire safety, food safety and hygiene, infection control, security of the premises and other users, and work place regulations to protect staff4.
3.2.1 Contradiction of safety and well being Although Imogen Blood relates security makes a positive environment5 thus improve one’s well-being, surprisingly, in the DICE study, findings showed that the overall well-being scored the lowest in large home (13%) with the highest safety regulation. However, small homes scored the highest in well-being (38%) following with medium homes (33%) 6. This result shows that the higher the security levels in a care home, the lower level of well being of the occupant. The association between high standards of safety, compliance with regulatory standards and a poorer quality of life found in the DICE study highlights a dilemma that increasingly is being recognized as a policy issue. Judith Torrington design for safety causes problems when it entails restriction of activity for example locked doors with keypad codes that prevent residents from ‘wandering’ off the premises, or restricted access to kitchens7. Confronting people with a locked door causes frustration and irritation especially to people with dementia. These examples of highly security door are rarely something you find at a normal home, rather it is found in commercial buildings. Relatively, activities that do take place in the home such as gardening, cleaning, dusting and cooking are eliminated from care home settings, generally for health and safety reasons8. Contradictory to The Wagner report, it emphasized the importance of allowing people in residential care to take risks and to have a degree of autonomy9. The negative association between safety and health and enjoyment of activities is probably due to physical restrictions. Similarly, Netuveli agrees that limitation of physical activities is associated with poor quality of life10. Giving good support for people with cognitive frailty and by giving residents control of their environment, the activity levels are likely to be increased11. Thus, reinforcing the hypothesis that activity is important for a good quality of life and therefore should not be eliminated from care home settings.
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3.2.2 Falls Fall all are a major hazard to the old people and often happen at home. One study found that 64% of falls occurred in the bedroom with 18.7% happening in the passageways. The rooms with the most recorded falls were the bedroom 21.4%, the kitchen 19.1%, the lounge and dining area 27.4%. Two other studies had similar findings with most hazards being found in the bathroom (59%) and with most rooms in any community-dwelling older person’s home having at least two potential hazards12. Architecture and interior design plays an important role to reduce a likelihood of fall. Even a small change of level contributes to this factor of falling. Good choice of material and simple measures such as keeping rooms free of general clutter on the floors, removing loose rugs or frayed carpets and having good lighting can help reduce falls. Many falls happen on steps and stairs. Fitting a second handrail on the stairs, putting up grab rails by steps and clearly marking edges of steps or any changes of floor level are just some measures worth taking sooner rather than later13. As for bathroom, recommendation such as grab rails and a toilet seat riser can help with being unsteady when going from sitting to standing. Furthermore, the use of level access shower is suggested safer compared to the use of bath14. However, installing the right equipment in care home should be chosen wisely to avoid the care home looking institutional. The setting should look ‘normal’ not perceived by the person as making them appear disable.
Photo 7 : Marking edges of steps
Photo 8 : avoid obstruction on the floor for example rug to avoid risk of falling
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The fear of litigation and pressure from relatives obligate the care providers to be extremely cautious in dealing with the safety regulation to minimize risk in these settings. However, as mentioned, this had impact on well-being and pleasurable activities thus restrict the resident’s freedom in the place so call ‘home’. Torrington suggests that the potential for safety and security considerations to have an impact on well-being needs to be openly debated with care staff and relatives, who by culture and inclination tend to be protective15. An exploration of the ways in which nurses can make institution a home with regard to enhancing safety, enabling caring relationships, and providing residents with their own space without creating a sense of having invaded them should be further explored16. The setting should support residents’ participation in activities they normally enjoy. The challenge is to full fill the regulation without damaging the quality of life.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
Margaret F. Moloney, The Meanings of Home in the Stories of Older Women, western journal of nursing research Tom Owen and Julienne Meyer, with Michelle Cornell, Penny Dudman, Zara Ferreira, Sally Hamilton, John Moore and Jane Wallis, My home life : promoting quality of life in care home, 12 Judith Torington, Evaluating quality of life in residential building (Routledge; 2007)524 Judith Torington, Evaluating quality of life in residential building (Routledge; 2007) 520 Tom Owen and Julienne Meyer, with Michelle Cornell, Penny Dudman, Zara Ferreira, Sally Hamilton, John Moore and Jane Wallis, My home life : promoting quality of life in care home, 12 Judith Torington, Evaluating quality of life in residential building (Routledge; 2007)52 Ibid Judith Torington, Evaluating quality of life in residential building (Routledge; 2007)521 Peace, Sheila and Holland, Caroline Homely residential care: a contradiction in terms? Journal of Social Policy, 30(3) (2001): 408. Alison Orrell, KevinMcKee, JudithTorrington, SarahBarnes, RobinDarton, Ann Netten, AlanLewis, The relationship between building design and residents’ quality of life in extra care housing schemes.53 Judith Torington, Evaluating quality of life in residential building (Routledge; 2007)524 Margaret F. Moloney, Meaning of home in the stories of older women (SAGE 1997) 175 Ccare Repair England, Live with the dementia : making your home a better place to live with dementia.6 Ibid Judith Torington, Evaluating quality of life in residential building (Routledge; 2007)525 Margaret F. Moloney, Meaning of home in the stories of older women (SAGE 1997)
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3.3 CONTROL Domestic homes are imbued with their own cultural and personal meanings, which has become a familiar and meaningful part of their life experience. It has an understanding of ‘ways of doing things’ there, and usually, some control over how things are done. In contrast, people receiving care in other contexts, may find that ‘ways of doing things’ there do not always suit their own customary routines or preferences and their routines may be regulated by others1. For older people, moving from his or her own home to care home can trigger the feeling of loss control of their surroundings, thus the decline in autonomy and concerns about the future. Control over daily life is defined as having the option to do what they want, when they want to, for example, having meals, going to bed and getting up and going out whenever you want to2. Choice and control also known as autonomy refers not to independence but rather volition. When one is independent, action is characterized by a sense of freedom and ability to choose3.
3.2.1 Autonomy and well-being Autonomy appears to be central to people’s well-being and may be salient for elderly people in institutional settings4. Studies in nursing homes have tended to support view that autonomy is just as critical to the institutionalized elderly as it is to people in other contexts and phases of development. Larger and Rodin reported that nursing-home residents who were encouraged to take responsibility and make decisions for themselves were more alert, active and happy than were residents who were treated in a sympathetic manner and told the staff desired to care for them and make them happy5. A follow-up study showed that improvements in health and decreases in mortality rate were evident in the group that was afforded greater personal autonomy after 18 months, while the comparison group mainly accounted for changes in ratings of mood, awareness, sociability, attitude, and physical activity6. Not only should they have control over their personal space, beyond that, people can also make decision within the household. They can light fire, re-heat yesterday’s dinner, redecorate a room or dig up the garden7. Residents, staff and relatives, must appreciate the fine balance between rights and risks that will continually have to be negotiated in places that centre on the resident. There is care home that takes away the residents autonomy to ensure the resident’s health and safety, however, there is evidence that doing everything possible to eliminate the risk can act against quality of life8. Here’s an example of there are care home that allows residents to participate with domestic activities though some strict regulation does not allow it.
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“ I had great battles with the inspecting officer, who said they should not be allowed in the kitchen because of contamination. Although our staff has been on the food hygiene course, residents obviously haven’t. I said that it was a small home, and if they wanted to go in and take their relatives in to make a coffee or to do baking under supervision… my residents weren’t going to be stopped from doing that. He’s not happy with it but he allowed it. They go once week wash their hands, wear an apron, fasten their hair back or wear a hat, so they are supervised under basic hygiene rules by members of staff.” Small home proprietors9.
Recent study of the expectations and experiences of older people moving into residential care suggests that the expectation that residential care is associated with a total loss of control and autonomy can be overly pessimistic. Surprisingly, older people who had recently moved into residential care told researchers that they had more control over their daily lives than they expected, their quality of life had improved, their health needs were better met and they were socialising as much or more than they used to10. However, small homes are nevertheless in danger of replicating the controlling environment of those larger residential settings where authentic autonomy may be lost11. In conclusion, an emphasize on resident who has high autonomy support from both staff and friend/family would be associated with greater emotional health and personal autonomy, as reflected in one’s independent self-regulation regarding daily event, would also predict well-being. Thus, it is vital for the resident to have the choices and control over their environment, just like having control of their own home.
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1.
Peace, Sheila and Holland, Caroline Homely residential care: a contradiction in terms? Journal of Social Policy, 30(3) (2001): 1 2. Ann-Marie Towers, Control, Well-Being and the Meaning of Home in Care Homes and Extra Care Housing,PSSRU Research Summary, July 2006. 3. langer and rodin 1976, adapted from Virginia grow Kasser and Richard M. Ryan, The relation of psychological needs for autonomy and relatedness to vitality, well-being, and mortality in a nursing home. 937 4. Ibid 5. Ibid 6. Ibid 7. langer and rodin 1976, adapted from Virginia grow Kasser and Richard M. Ryan, The relation of psychological needs for autonomy and relatedness to vitality, well-being, and mortality in a nursing home. 937 8. Peace, Sheila and Holland, Caroline Homely residential care: a contradiction in terms? Journal of Social Policy, 30(3) (2001): 397 9. Ibid p401 10. Lisa Callaghan and Ann-Marie Towers, Feeling in control: comparing older people's experiences in different care settings (Ageing and Society, 2014) 3 11. Peace, Sheila and Holland, Caroline Homely residential care: a contradiction in terms? Journal of Social Policy, 30(3) (2001): 408
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3.4 IDENTITY Home and dwelling are very imperative in most people's lives, and consequently, they are significant in influencing identity1. Personal significance attaches to a home. For some old people, this is deeply important, and their sense of place attachment is very high2. Place attachment defines as a bond that occurs between individuals and their significant environments3. It is the feeling that is developed towards places that are highly familiar to an individual, for example, where we belong, like, home. Place attachment is stronger for settings that evoke personal memories, and this type of place attachment is thought to contribute to a stable sense of self4. The National Development Team for Inclusion and the Centre for Policy on Ageing argue that older people need to be able to have their views and experiences taken into account on an ongoing basis to allow them to have real choice and control in key decisions that are made, which affect them at both an individual and collective basis5. They produce a framework on what older people need to have ‘choice and control’ over the key ‘domains’ that they say are important to them. These domains include their personal identity, relationships with others, meaningful daily life, home and personal surroundings, transport and mobility, support and care, income and finances6. Furthermore, Manzo’s highlights how place attachment not only stems from the physical house, but also the surrounding environment thus helps define how the house becomes a home and cultivates a sense of emotional attachment for an individual7. In older age, familiar places such as a home are invested with emotional and symbolic meaning and help to maintain a positive affirmation of self. Maintaining and developing older people’s personal identity promotes dignity and has a positive impact on their sense of identity and mental wellbeing. When a strong attachment and sense of place is present with regard to the home, it improves health and well being and potentially even life lengthening8.
3.4.1 Personalization Personalization and the feel of identity make the domestic nature of home. Homes and workplaces are personalized by decoration so that their houses and spaces reflect who they are. Because nursing care continues to be an essential function, the design of new or adapted environments should be given particular consideration if they are to avoid the institutional characteristics. Personalization is one way of doing so. Personalization is significant to the older people living in care home. It means looking at the resident’s choice, not just their needs8. Traditional care home facilities or some care home today often prohibit or severely limit residents from bringing in items from home. Personalizing their spaces would both give comfort and tell others something about the unique experiences and lifestyle of each resident.
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Photo 9 : Not only the private space should be personalized, however, public area for example, the living room should be decorated like a domestic living room at home.
Bedroom has always epitomized private and personal space, it should allow for flexibility of arrangement, not only to meet particular needs and preferences but also to enable residents to be offered the option of bringing some of their own furniture and thing they are attached to. Adaptability of the resident’s own furniture suggests that a built-in –furniture should be avoided wherever possible. Storage however is necessary to provide. Residents may bring their own bedspreads, duvet covers and soft furnishing to make it feel in their own bedroom. Personalization of their own private area is important as their personal possessions are their only tangible links with the past; therefore for people with dementia, it may be the only objects they recognize as familiar. Other examples are family photographs or a favorite old armchair. Wall space should be well designed to allow personalization for example, a border that acts as a shelf for them to decorate it photo frames. By personalizing, they can identify their own private space and sustain their self-respect. Therefore, room size should be adequate for the flexibility of the arrangements. Another benefit of personalization is that if all rooms are standard with similar furniture and decoration, the confused resident might open the wrong door may not realize their mistake.
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Photo 10: Standard design room with similar furniture and decoration might confuse the residents
Photo 11 : Personalized room makes the bedroom feel more at home
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3.4.2 Gender The meanings of home vary across social division such as gender, class and race. Leith introduces the opinion that ‘to some degree, multiplicity in meaning of the concept of home appears to be related to societal differences between the genders, be they real or perceived’9. This opinion stems from women fulfilling approved societal roles within the home, such as housewife, homemaker and mother. These roles may have given women a degree of control over the home, and for a strong identity10. Men though, may have traditionally spent more time out of the domestic home, hence a stronger need to feel connected to the outdoor than women11. Outdoor activities for example, gardening, can enhance their well-being. Unfortunately, activities that usually do take place at their domestic home such as gardening, cleaning, dusting and cooking are mostly being eliminated from care home settings, generally for health and safety reasons. However, by giving good support for people with cognitive frailty and by giving residents control of their environment for example, by provision of kitchenettes and laundries for residents and their relatives to use individually gives an outlet to the desire to engage in domestic task. Nagy conducted post – occupancy evaluations of kitchen in residential homes for people with Alzheimer disease and the evaluation demonstrated a slowing progression of the disease by providing domestic features for individual use and personalization12. This integral component, should be reinforces to the residential environment thus should be implemented in the care home setting.
Photo 12: Open plan design encourages the occupants to engage with domestic task
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3.4.3 Relationship of staff and residents Building trusting relationship with between staff and residents are important to allow residents feel safe in talking about their memories and what quality life means to them. Staff should be taught to recognize the importance of the residents personal objects and use them in order to get the residents more quickly and in greater depth. Resident’s views on what is important to their quality of life should be given attention. The staff needs to regularly review what is important for people throughout their journey of care. For example: Bill had been a dairy farmer, always getting up at 4am to round up his cattle. He became distressed and frustrated if he could not start his day as he always had. To reassure him, Bill’s working trousers would be waiting for him when he awoke ld give him a glass of milk and talk about the cows by name. Then, Bill would settle happily in his arm chair and await his cooked breakfast around 6am after ‘milking’13. Listening to the resident’s need may improve their psychological mood and their well-being. Determining how identities are shaped and perpetuated within home setting can influence a better home design for individuals as they age. Housing preferences of the aging population often point to the ideal of “aging in place,” the concept that allows individuals to maintain their habits, routines, memories, and daily activities makes the focus of “home as identity” a feasible, warranted, and necessary to be implemented in care home14.
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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Relph, 1976 ,adapted from Hauge, Ashild Lappegard, “Identity and place: a critical comparison of three identity theories” Architectural Science Review, March 1(2007) 1 Judith Torrington,Upgrading building for older people (RIBA Enterprise, 2004)68. Leila Scannell, Robert Gifford, “Defining place attachment: A tripartite organizing framework” Journal of Environmental Psychology 30 (2010) 1 Twigger-Ross & Uzzell, 1996, adapted in L. Scannel, R. Gofford, Defining place attachment : A tripartite organizing framework, Journal of environmental Psychology 30(2010), 2 ‘Voice, choice and control’ in care homes. Page 18 Ibid Manzo 2003, adapted in Laura L. Lien, Home as Identity : Place-making and its implications in the built environment of older person Rosie Daya and Russell Hitchings, “Only old ladies would do that: Age stigma and older people’s strategies for dealing with winter cold” Health Place 17(4) (2011):886 Fleming, A., Banks, P., Kydd A., Stewart, S., A systematic review of the literature concerning design considerations of homeliness in care homes. (include Asia 2013)3. I bid I bid Nagy, J. W (2002) Kitchens that help residents re-establish home. Alzheimers Care Quarterly, vol 3, no 1 Making your home a better place to live with dementia. Hauge, Ashild Lappegard Identity and place: a critical comparison of three identity theories (Architectural Science Review, March 1, 2007 )
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3.5 COMFORT The thermal condition can be described as the characteristics of the condition that affect the heat exchange between the human body and the environment1. Thermal comfort however, is described as ‘a state of mind, which expresses satisfaction with the thermal environment2. Since people with dementia respond on a sensory level, rather than on intellectual level, and given some of the cognitive and behavioural problems, extra attention should be paid to the indoor environment in relation to comfort and behaviour3. It is, however, important to stress that cognitive impairment is not caused by environmental design, but problem behaviours may be exacerbated by inappropriate environments. The desired quality of building services for older adults with dementia, and their implementation in daily life is likely to be different from that of other healthy groups. Therefore, there is a need to provide them with comfortable thermal condition to avoid discomfort thus may lead to behavioral problems. There are a number of reasons why older people receive thermal comfort differently from other age groups. In principle, as the body age, basal metabolism and circadian rhyhmicity declines thus the ability to regulate body temperature tends to decrease leading to lower body temperatures. In addition, average older adults have lower activity level than a younger person which is the main reason that they need higher ambient temperature5. According to Schellen, older adults prefer higher ambient temperatures where mild thermal challenges can cause significant physiological responses6. For instance, an increased systolic blood pressure levels is a result of cold temperature exposures. Older adults, should, therefore, be protected from even mild thermal disturbances.
3.5.1 Overheating Comfort is another point that relates closely to home. To feel comfortable, they need to be able to control their own environment. Enabling old people to change their environment condition to their own needs and at their comfort level makes a big difference to their quality of life. This is an important factor to consider in the design process and when building is being refitted as the occupants who will be occupying the care homes are especially of people with high frailty and have restrictions on physical movement. Living in cold homes is associated with a number of physical and mental health illnesses and is believed to contribute to the approximate 2,700 excess winter deaths that occur in England and Wales each year, which is more than the number killed in traffic accidents7. Anxiety from family, community with given the possible detrimental effects to health of living in a cold dwelling, it is unsurprising that housing providers seem focused on the need to keep the older occupants of their extra-care housing schemes warm.
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Though it is substantial to provide the old people high ambient temperature, however, in practice, with central heating schemes it is possible that the home gets overheated especially during the summer. “I think it is a thirteen point five duvet... but more often than not I just put it over the end of the bed because it is, it is too warm.” Female occupant, aged 64 years; energy efficient scheme
3.5.2 Simple design solution In cases mentioned above, for example overheating, occupants should have opportunity’s to control the indoor climate and building service. They should be able to control their own temperature to their comfort level either by the help of technology or passive solution such as opening window. However, the importance of temperature control for people with dementia at home is stressed by Gitlin Marshall8 mentions the potential of technology, for example can reduce irritability when people with dementia are hot, by controlling temperature. With advance technology, nowadays, control mechanisms are intelligently designed and are widely available in the market. However, the installed systems available at care homes are hopelessly inadequate for old people as the interface are too small, too fiddly, too stiff, require strength to operate, are too difficult to see properly and they are frequent at the wrong place. If these matters are left as it is, the result will be inaccessibility and a waste. Mrs. B4 is in her 50s, and cares for her father (aged 80), who is diagnosed with probable Alzheimer’s disease: ‘‘He always turns up the heating very high. And he always says: ‘It is so hot in here’. [The thermostat] is much too small. He turns [the button] but then he cannot see [the display] exactly. He thinks he turns the right way, but he turns it to [its limits]. He simply does not see the little letters, the temperature. So all that needs to be a bit larger, or something like it.’’9 Simple design solution can probably solve little matter as problem mentioned before. Fittings for the dementia home should be improvised and be made especially for their purpose. Correspondingly, Steinfeld suggests that thermostat controls should only function within the optimal thermal comfort range10.A good implementation of such technologies is crucial to not only protect people, but also to provide comfort and to maintain well-being of older people with dementia. Technology should create an environment that is comfortable to the person with dementia, their family and staff.
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Photo 13: Thermostat installed at care home unsuitable for the occupants because the display is too small. It had to be marked by the user at care home. There is a need to custom- design fittings and equipment for the old people for their suitability.
The search for new comprehensive comfort model that include a person with cognitive limitation should not be ceased thus all every party should all try to understand the implications of dementia on daily functioning in relation to the indoor climate and related building systems in order to create a more comfortable and enabling indoor environment for persons with dementia in the future.
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1.
Joost van Hoof, Mitja Mazej,Jan L.M. Hensen, “Thermal comfort: research and practice”, Frontiers in Bioscience 15(2) 765-788
2. 3.
Ibid
4. 5. 6.
Ibid
7.
John Hills, Fuel poverty : the problem and its measurement, http://sticerd.lse.ac.uk/dps/case/cr/CASEreport69.pdf
8.
J. van Hoof, H.S.M. Kort, and J.L.M. Hensen, Thermal comfort and HVAC design for people with dementia, IFA’s 9th Global Conference on Ageing, Montréal, Canada (2008)
Joost van Hoof, Helianthe S.M. Kort, Mia S.H. Duijnstee, Antonius M.C. Schoutens, Jan L.M. Hensen and Simon H.A. Begemann, “The indoor environment in relation to people with dementia”, proceeding of the 11th International Conferences on Indoor Air Quality and Climate.
Ibid REHVA, Federation of European Heating, Ventilation and Air Conditioning Assosiations, http://www.rehva.eu/publications-and-resources/hvac-journal/2013/032013/indoor-environmental-criteriafor-older-adults-ageing-means-business-full-lenght-version/?L=0%27
9. Ibid 10.Ibid
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CHAPTER 4 – CONCLUSION
A literature review of the meaning of home has demonstrated the complexity of defining home, and the subsequent difficulty of creating a homely environment in care homes. However, there were five outstanding features of a home that was regarded as highly important in preserving the domesticity of home. Historical evidence of early workhouse and asylums, and onwards, caring and accommodation were not the only goals of institutions; they also sought to separate those seen as ‘unfit’ from the public gaze and most of all public integration. However, the lifestyle of people within an institution who were old or mentally ill began to be explored in the 1950’s onwards with revelation about the effects of “institutionalism”. Irving Goffmann work was commonly associated with this concept, encapsulated particular characteristics of institutions including homogeneity of daily living; lack of choice and personal autonomy; distance between the two world of paid workers and resident; and the acceptance of a secondary status residents1. The question is have we now moved away from these worlds or is it still ingrained behind those doors? Environmental stimuli have shown given a positive effect on one’s health and well-being thus it is important that the setting that are provided in a nursing home today should encourage better environmental settings. Clearly, design of the building can have an impact on the occupants, for example, small nursing home resulted to a more positive result on health and wellbeing of the occupants compared to a larger scale nursing home. However, emotion is also highly influential in whether or not an older person feels at home in a residential home. More positive emotions towards the residential home can be supported by giving them autonomy of their daily lives by engaging them with meaningful domestic activities, encourage a positive relationship with those around them; residents, staff and their family and treat them with dignity and respect. Building up their positive emotions would truly give their life meaning and makes life worth living. Table 12 below shows the balance between attributes of the domestic and the institutional character. The institutional characters in the table should be replaced with the domestic characters to create a more homeliness care home.
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Table 1 : Balance attributes between domestic and institutional Domesticity
institutionalisation
Privacy
surveillance
Informality
regulation
Risk
security
Normalisation
Specialization
Personal
professional
So what makes these places so different from the traditional nursing home? What does it take to make the residents happy? Well, it is actually the simple things, in fact the things that very much the same that people who do not live in nursing home wants. It is a set of values that focus on quality of life at least as much as quality of care that they want. The requests are not impossible to obtain. So why, then is it so difficult to provide this? Unfortunately, new facilities are being built every day, with very little knowledge of how the built environment impacts residents, families, visitors and staff. There are numbers of facilities across the country trying to improvise their nursing home becoming more of a home-like environment and some have been very successful at doing so. Most of the ‘home-like’ care home result to a positive impact on their occupants. Therefore, evidence has shown that it is achievable to provide high quality care for the occupants of the care home. Through good design and psychological skill, it is possible to create a place where one can feel ‘at home’ and possibly even call it home. “There’s no place like home. There’s no place like home. There’s no place like home.” - Dorothy, in The Wizard of Oz
1. Sheila Peace and Caroline Holland , Homely residential care: a contradiction in terms? (Journal of Social Policy, 30(3)) 395 2. Sheila Peace and Caroline Holland , Homely residential care: a contradiction in terms? (Journal of Social Policy, 30(3)) 407
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