Draft - For Information Only
Dementia Friendly Hospitals
Supported by the Health Research Board
Workshop Report July 2017
You can keep up to date by referring to the website http://trinityhaus.tcd.ie/dementiafriendlyhospitals/ or by following us on Twitter @Trinity_Haus
From a Universal Design Approach
HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
Dementia Friendly Hospital Design: Stakeholder Workshop Date: 05-07-2017 Location: NDA, 25 Clyde Road, Dublin 4
1. Introduction This stakeholder engagement workshop was conducted as part of the dementia friendly hospital currently being undertaken by AMNCH and TrinityHaus, Trinity College Dublin. This research is being funded by the Health Research Board (HRB) as part of Applied Research Projects in Dementia 2015 programme in collaboration with The Atlantic Philanthropies (AP) and the Department of Health. This research is being conducted using mixed-methods research that involves a literature review, analysis of three case study Irish hospitals including AMNCH, Peamount and Naas, international case studies of dementia friendly hospitals, and a stakeholder engagement process. The workshop described in this current document was held as part of this engagement process to present key research findings to date and to elicit feedback from various stakeholders.
2. Workshop Aims and Objectives 2.1.
Overall Aim
The aim of this workshop was to present the outputs of the research to-date, elicit feedback from various stakeholders regarding their experiences of the built environment in the acute hospital setting, and solicit input on the development of the proposed Dementia Friendly Hospital from Universal Design Approach Guidelines.
Figure 1: Attendees carrying out workshop exercise.
2017 AMNCH TrinityHaus, Trinity College Dublin
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
2.2.
Specific Objectives and workshop agenda
• Introduce stakeholders to the project. • Introduce challenges for people with dementia in the acute hospital setting and outline the main design Issues. • Illustrate the benefits of Universal Design in the context of dementia friendly hospitals. • Present dementia friendly hospital design key findings. • Introduce Proposed Guidelines. • Conduct stakeholder exercise involving a typical inpatient ward to get feedback regarding the key the issues faced by people with dementia in the hospital environment and to provide the attendees with an opportunity to give input regarding the overall structure and format of the guidelines. • Facilitate an open discussion to capture any additional issues not covered in the presentations, handout or exercise.
3. Workshop Attendees 3.1.
Organisations represented at the Workshop
Approximately 50 invitations, targeting organizations representing key and relevant stakeholders at the local, national, and international level, in the area of dementia healthcare delivery, design, and policy, were circulated to, among others, participants from each of the research project case study hospitals, representatives from HSE Estates, and participants from hospitals engaged in the 20142017 the HSE and Genio Dementia Programme. A total of 20 participants from the following organizations took part in the workshop:
• • • • • • • • • • •
Tallaght Hospital, Dublin 24. Naas General Hospital, Kildare. Connolly Hospital, Dublin. Mercy Hospital, Cork. St Joseph’s Shankhill. The National Disability Authority’s Centre for Excellence in Universal Design. O’Connell Mahon Architects. HSE Estates. Hospice Friendly Hospitals Programme. Clinicians for Design (UK). Integrated Programme for Older People. (see appendix D for full list of attendees)
4. Workshop Exercise 4.1.
Aims and Objectives of Exercise
4.2.
Description of Exercise
The exercise was conducted to help attendees reflect on the typical issues that may arise for a person with dementia in the hospital setting in the context of their experiences, offer a chance to discuss these in a multi-disciplinary setting, and provide a specific exercise based on a realistic ward setting and patients to examine these issues and suggest design solutions.
•
Stakeholders were organised into four separate tables each with 4 or 5 individuals (mixed disciplines)
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
•
• •
•
Each group were given an A0 drawing containing a plan and photos of an existing hospital ward; for the purposes of this exercise, the ward was renamed as the hypothetical ‘Iveagh Ward’. This drawing also contained a specific persona to represent a patient that would be treated in this ward for a period of time (see Figure 2 below) All attendees were given an excerpt from the proposed guidelines and a feedback template that set out the main questions and provided space for comments and recommendations to be collated by the research team. The attendees were asked to work both individually and as a team to provide written feedback via the templates and drawings, and verbal via a rapporteur, on the following questions: A. What key difficulties would your persona or accompanying person experience in the Iveagh Ward? (Each group member to identify approx. 10 issues, and then the group to select top 10 issues across all input) B. Based on the key dementia friendly hospital design issues, suggest changes around the two following areas in the ward for your persona: 1) Improving orientation and navigation; 2) Redesign or reallocate one key space within the ward to improve conditions for your persona. (Each group member to identify 5, and then the group to select a top 5 from all input) The research team recorded verbal feedback in written form and collected completed feedback templates and drawings with notes and post-its for post workshop analysis.
Figure 2: Drawing showing ‘Iveagh Ward’ layout and one of the 4 personas
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
5. Workshop Key Findings 5.1.
Key Findings Methodology
Following the workshop the research team collated all feedback from the stakeholders and drew out key themes that captured both the issues or challenges that would be faced by a range of people with dementia on the Iveagh Ward, and the proposed solutions.
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These were organised according to the spatial framework of A) approach to ward; B) entry/exit and circulation; C) key spaces; D) Components; and E) Internal Environment (see Figure 3). The frequency with which various issues arose was also noted to illustrate the occurrence of these issues in the working lives of the stakeholders.
Figure 3: Key issues and solutions arising from the workshop (pink post-its capture the issues while yellow post-its are proposed solutions)
5.2.
Key Findings from Exercise
Table 1 A - Approach Issues Frq Lack of identity for ward 8 (thematics), especially at the entrance Lack of spatial hierarchy 1 (main street, and corridor very similar) Lack of signage on 1 approach B - Entry, Exit, Circulation Issues Excessive no. of doors 2 along main corridor possibly resulting in confusion Long and narrow corridors 4
Solutions See below for solutions identified at other spatial scales as they would also apply to approach (especially re signage and ward identity)
Solutions Conceal unimportant/potential hazards/exits if appropriate
Break up long-corridor by creating hubs (ie. seating)
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
Lack of orientation features/lighting
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See also – clutter, negatively impacting on circulation C - Key Spaces Issues Excessively clinical 4 setting/grim, lack of familiar facilities Lack of bathroom space 2 for shared room Distance to toilets is too 1 great for patients Need to be careful of 1 ceiling design and lighting because bed-bound patients will be looking up Lack of visual/spatial 2 orientation Poor visual access 4 (from/to staff and patients – sighting lines) Lack of contact/views to 1 outside/nature
Use of colour coding to define spaces (different themed rooms) + layers/hierarchy – CAUTION: need to balance colour coding so it doesn’t become distracting. Use of art at to key locations – entrance at ward, and at bed. Use landmarks for orientation and way-finding Divide circulation functions, ie. one for clinical uses, one for public (Note: this may be overall hospital-related). Signage – high contrast, large font; audit and remove unnecessary signage Consider signage hierarchy (emphasise user signage – public vs patients) Use thematically coloured furniture to identify key wards and spaces Use auditory cues Use lighting to emphasise important thresholds and key areas
Solutions Homely environment – while institution feeling may be appropriate in many parts of the hospital, certain spaces, such as a day room benefit from a homely and deinstitutionalized setting. Use TV/screens to display more personalized images/info
Provide contact with nature, including calming nature images Digital panels showing nature Provide external views to external No family room/sitting 11 In certain spaces, such as dayroom, break up with dividers room/quiet room/activity New day room – select existing staff room as family room; while it’s room removed from the main wards, it will encourage walking Retreat room from main activities – place it near nurses station for visibility and ease of access; make it part of circulation area (or wellintegrated) so it is easily accessed and becomes a social hub, but also, so that it doesn’t get swallowed up a storage. Nurses station – lack of 8 visibility (intimidating); glass partition too high, no counter Ward layout and location 1 of Nurses stations
Nurses station – remove partition, and provide good welcoming signage Provide reception counter
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
provides no welcome/reception at entrance Physical environment creates communication problems staff and patients Lack of potential to personalize bedsides Lack of staff presence (photo) but also lack of space/seating for staff
Nurses stations needs to be key landmark and welcoming/reception (Discussion point – should these be separate, ie. reception nearer to entrance and main nurses station, nearer to patients). 1
1 3
Lack of space in shared 4 ward (privacy issues, and space for activities, and space beside beds) Lack of end-of life facilities 1 and spaces D - Components Issues Lack of seating – including 5 breakout bays along corridor. Communal TVs in shared 1 wards is a problem Lack of signage, or poor 10 signage (too small) and poor contrast Lack of art 2 No handrails No clocks or other orientation cues (calendars) Clutter (walls and corridors)
7 2
Use of colour and other graphics/info to personalize/identify individual bed bays Decentralized nurses station – while this may help to some point re point above regarding welcome/reception, a central station should be maintained for peer-to-peer learning and creation of one good-sized working space. Need for multi-disciplinary rooms (for staff) Day rooms/family rooms need to take account of visitors of different ages (ie. children and teenagers – to encourage them to visit)
Solutions
Remove TVs Use of lighting to create directional guides/wayfinding Careful curation – need for curation of art and visual art/technology to ensure clutter free environment, suitability to patients (local, context) Install coloured/easy visible handrails Provide clocks and other orientation features
15 See above – note re audit of signs/remove from wall
E - Environment Issues Potential noise issues 1 Poor lighting – excessive 14 contrast and shadows; no controllable lighting Glare/reflection from floor 11 Lack of natural 1 light/excessive in some places
Consideration of technology early on in the design process (BUT – careful balance required so it is not used as a substitute for good care) Colour-coded crockery Solutions Use curved walls to attenuate noise Layering of lighting strategy Use lighting to emphasise thresholds, key areas Use smart lighting to improve day/night lighting, entrance Control glare – blinds, solar shading; no reflective materials.
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
Use thematically coloured furniture to identify key wards and spaces Use Auditory cues Conceal unimportant/potential hazards, exits, if appropriate Other Items raised Need for key stakeholders engagement to learn what works and ensure needs and preferences are included Leveraging synergies between various hospital improvement programmes (ie. hospice friendly) because everyone is chasing the same small budget Importance of UD as underpinning and linking approach – person-centred, but what person (need for inclusive approach) – while person centred care informs design (and design should support this) design needs to not be too specific and support a wide range of persons Need buy in from management, staff etc – change management process Provide individualized guide for patients using pictures, explain actions Provide staff training so they are supportive and knowledgeable about implementing changes.
5.3.
Discussion of Key Findings from Exercise
While the findings from this exercise reflect the specific conditions and physical layout of the ward presented in the drawings, it should be noted that this ward represents a typical ward found in many Irish hospitals built in the late 20th century. In this regard, it can be argued that the findings illustrate many of the key issues and challenges faced by people with dementia, accompanying persons, visitors and staff in hospital wards in Ireland.
Overall Issues and solutions
Lack of clear identity: One of the consistent concerns expressed at the workshop was the lack of identifying or distinctive features (colours, objects, art etc.) when approaching or within the ward. This results in anonymous and potentially disorienting spaces where it is hard to recognise one area of the hospital from another. Proposed mitigations included the use of colour coding, distinctive landmarks, and artwork to create unique and recognisable spaces. Inadequate orientation and wayfinding: As part of this identity issue is the inadequacy of orientation and wayfinding in the hospital street and within the confines of the ward. In this regard the use of colour, graphics, objects, art, furniture, and focused lighting and illumination at key thresholds and spaces were offered as potential solutions. Beyond spatial orientation, orientation to overall geographic location and to the time of day, month and season is also important. These aspects of orientation can be supported with clocks and calendars. In terms of wayfinding (i.e. getting from A to B), the same features recommended above, such as colour, graphics, etc., are important, however this is also where well designed signage is crucial. The participants pointed to the lack of signage, or poor quality of the signage in terms of small text and inadequate degrees of contrast. Clutter: Participants referred to clutter across a few spatial scales as a difficulty and suggested the removal of unnecessary features or objects, the concealment of non-patient access doors or other staff only items or spaces.
Internal circulation
While identity, orientation, and wayfinding obviously impact circulation, other issues also arose such as the excessive length and inadequate width of the main ward corridor.
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
Internal Spaces With regard to internal spaces the main issues that arose included an excessively clinical environment and poor visual access between staff and patients. However, the lack of a family or day room was deemed a major issue, as was the dearth of bathroom space and room generally within the shared 6-bed wards. The potential location of any family space would be problematic given current space constraints; nevertheless, it was suggested that a common space close to the nurses’ station, but also well integrated with the main circulation area, might be the best solution. However, it is also worth noting that a family room or common space in a location further from the main patient areas may provide a destination point and encourage walking. The nurses’ station was also highlighted as problematic. Participants were critical of the current design and layout suggesting that the nurses’ station was neither welcoming or patient-friendly. Concerns were raised that hospital wards typically have no obvious reception or information areas adjacent to the entrance, and that one must travel deep into the ward before finding the nearest thing in the form of a nurses’ station. There seemed to be consensus about the need to provide a welcoming space easily accessed by patients and visitors, however, the idea of a decentralised nurses’ station was debated due to a concern that decentralised stations undermine the peer-to-peer support and staff interaction provided by the larger centralised location. Components In terms of individual components, the absence of handrails along the main corridor was identified as a major disadvantage. Lack of seating and orientation devices was also highlighted, while the issue of excessive clutter was again commented on. As outlined previously, inadequate and poorly designed signage was deemed a problem. Environment Regarding the internal environmental comfort, poor lighting in the form of excessive contrast and inadequate illumination was highlighted. The other main issue focused on glare and excessive reflectance from floor surfaces. To ameliorate this a layered lighting strategy, solar control and the use of better artificial lighting control were suggested. General Issues In addition to issues relating to specific aspects or parts of the ward several broader and more contextual issues emerged. These included the need for greater stakeholder engagement, especially buy-in from management. Universal Design was identified as important to provide inclusive design catering to a wide range of patient, visitor and staff needs. Considering the many improvement issues that may be running at one time and budget constraints, it was argued that any overlaps between initiatives should be fully exploited to avoid replication or unnecessary competition for the same funding (e.g. between hospice friendly and dementia friendly design). The need to provide training to ensure that staff are supportive and knowledgeable about implementing changes was identified, while it was suggested that individualized guides for patients to explain the environment and point out key features might also help.
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
6. Conclusion and Next Steps This workshop provided an opportunity for a number of disciplines to come together to learn about the main research findings to date and to discuss the challenges and potential solutions regarding a real ward in an Irish hospital. Participants included medical, engineering, and architectural professionals, yet there was largely a consensus around the main issues and how to resolve them. It was acknowledged that budgets and existing building constraints are a challenge, however the recommendations put forward by the participants largely focussed on non-structural issues and in many cases involved de-cluttering and minor works such as painting, signage or the fitting of handrails. The provision of a family room or day area was one major change involving a greater level of reconfiguration, therefore this requires careful consideration as it is a leading concern. The findings from this report will feed into the overall project report that will be compose all key findings from the literature review, case studies, desk studies and stakeholder consultation. These key findings will be used to underpin the proposed Dementia Friendly Hospital from Universal Design Approach Guidelines.
You can keep up to date with this project by referring to the project website http://trinityhaus.tcd.ie/dementiafriendlyhospitals/ or by following us on Twitter @Trinity_Haus
2017 AMNCH TrinityHaus, Trinity College Dublin
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
Appendix A – Workshop Presentation
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Dementia Friendly Hospitals July 5 2017
Dementia Friendly Hospital Design from a Universal Design Approach
Agenda 9:00‐9:15 9:15‐9:30
Welcome and Introduction to Project Challenges for People with Dementia in the Acute Hospital Setting – Design Issues 10:15:‐10:30 The Benefits of Universal Design 9:30‐10:15 Dementia Friendly Hospital Design Key Findings 10:30‐10:45 ‐‐‐‐coffee break‐‐‐‐ 10:45‐11:00 Introduce Proposed Guidelines 11:00‐11:45 Stakeholder Exercise for input & feedback on Guidelines and Discussion 12:00‐12:50 Group Feedback 12:50‐13:00 Final Comments and Next Steps 13:00‐14:00 ‐‐‐‐lunch‐‐‐‐
AMCCH Prof Des O’Neill (PI) Dr. Sean Kennelly Prof. Gregory Swanwick Dr. Hillary Moss
TrinityHaus, TCD
Cathy McHale Claire Mooney Debra Fitzhenry Susan Lawson Gillian Harte Diana Burgui‐ Murua Eimear Dignan
Tom Grey Dimitra Xidous
CEUD Dr. Ger Craddock Neil Murphy RIAI
OCM & RIAI
ASI NCAH
Research Team
Sean Mahon Victoria Mannion
HSE Estates Paul de Freine RIAI
AMNCH COO
INWGPWD Seamus Cunningham
ASI Mary Hickey
National Dementia Office Anna de Siun
Introduction to Project: Key Objectives & Deliverables
Key Objectives • Literature review and best practice review • Desk‐based case studies to illustrate the key principles, approaches and features associated with dementia friendly design. • Detailed case studies of AMNCH, Peamount & Naas to engage directly with patients, family members & carers, staff & management. • Stakeholder workshop to discuss the main findings and proposed guidelines (patients and family, healthcare professionals, hospital management, building design professionals)
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• Findings and recommendations to underpin and prepare a ‘Dementia Friendly Hospital Design guidelines’ containing both stakeholder engagement and participatory design techniques, and a new preliminary ‘Irish Dementia Friendly Hospital Design Audit Tool’, adapted from the King’s Fund assessment tool but specifically tailored to the Irish context. • Disseminate key project related activities and outcomes across a range of social media platforms
Key Deliverables • Key Research Findings Report • Dementia Friendly Hospital Design Guidelines to include: • Advice around stakeholder engagement or participatory design processes. • Preliminary Irish Dementia Friendly Hospital Design Audit Tool • Dissemination materials and activities
Literature Review (200)
Methodology workshop
Key Design Issues (15)
Irish case studies through Onsite Analysis
Research methodology
Questionnaires Interviews
Exemplar Case Studies
Challenges for People with Dementia in the Acute Hospital Setting
Up to 29% of older patients entering hospitals may have dementia
"Hospitals should be dementia‐friendly from admission to discharge / death. This includes environmental aspects as well as clinical support”
Onsite Analysis
Hospitals are busy places and can be frightening & disorientating for people with dementia
Lack of dementia friendly design features
94% of hospitals have no dementia care pathway
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“
…at least one third of all persons with
dementia in the United States are hospitalized each year, and about one‐ fourth of all elderly hospital patients are persons with dementia.
“…often leave the hospital in worse shape than they arrived, having lost preadmission functional abilities.
National and international research confirms that an admission to an acute hospital can be distressing and disorientating for a person with dementia, and is often associated with a decline in their cognitive ability and levels of functioning around activities of daily living. (www.ucc.ie/en/inad/overview/)
Silverstein and Maslow 2006
The majority of wards did not have environmental cues to help the person with dementia orientate themselves; 56% of wards had no clocks visible, 93% of wards had no calendar visible, while 84% of wards had no personal objects visible. 74% of wards did not have signs to locate the toilets visible from the patient’s bed or door of their room. 43% of wards had no signs on their toilet doors while 33% of wards had no signs on their bathroom doors. 46% of wards had a day room or patients’ lounge (INAD 2014)
Designing for People with Dementia in the Acute Hospital Setting
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Buildings Universal Design Approach
All of us
Universal Design Approach
Person with Dementia Hospital
“
a process that enables & empowers a diverse population by improving human performance, health & wellness and social participation (Steinfeld and Maisel, 2012)
“Universal Design is the design and composition of an environment so that it can be accessed, understood and used to the greatest extent possible by all people, regardless of their age, size, ability or disability (NDA’s Centre for Excellence in Universal Design)
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“
1. Integrated into the a process that neighbourhood; enables & 2. Easy to approach, empowers a diverse enter and move population by about in; improving human 3. Easy to performance, health understand, safe to & wellness and use and manage; social participation 4. Flexible, cost effective and (Steinfeld and Maisel, 2012) adaptable over time
Dementia Friendly Hospital Design Key Findings A) Case Studies of 3 Irish Hospitals B) Literature Review - Key Dementia Friendly Design Issues - Design issues across all major spatial scales (overlap between UD&DFD)
C) Desk Studies
Peamount , Co Dublin
Case Studies Naas, Co Kildare Tallaght Dublin 22
• To examine how people interact with the hospital environment • To identify key issues specific to people with dementia and their carers in the context of the hospital environment • To assess how the built environment performs in the context of people with dementia, and to draw out key themes in relation to this
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B) Literature Review - Key Dementia Design Issues - Design Issues across all major spatial scales (overlap between UD & DFD)
Soften the institutional environment
Facilitate personalisation
Use familiar and recognisable design
Providing a people‐friendly environment
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Soften the institutional environment
Promote engagement with friends, family, staff & community
Facilitate personalisation
Use familiar and recognisable design
Promote participatory design approach
Patient & family friendly issues
Providing a people‐friendly environment
Provide a safe environment
Optimise positive sensory stimulation while minimising negative stimulation
Support diet, nutrition & hydration Support meaningful activities
Support patient safety and health
Support orientation & spatial cognition
Balance Sensory Stimulation
Contact with nature & access to outdoor spaces
Single rooms with space for belongings and for visitors.
Way‐finding to support navigation
space and supports for physical movement
Good visibility and visual access
Support Orientation & Navigation
Space for retreat or conversely communal activities
space to support a person with dementia & accompanying person
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safety & security
Patient admission
care delivery
space a physica therapy
Appropriate & ethical use of technology
Proposed Guidelines
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Workshop Exercise
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A) Context – Iveagh Ward B) Personas C) What we need you to do D) Group feedback E) Final comments & next steps
Mary
Personas
Stephen
Catherine
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Michael
Group Feedback
Final Comments
Thank you more information contact Desmond.ONeill@amnch.ie tom.grey@tcd.ie xidousd@tcd.ie
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HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
Appendix B – Workshop Handouts (excerpt of guidelines & feedback document)
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2017 AMNCH TrinityHaus, Trinity College Dublin
Dementia Friendly Hospitals from a
Universal
Design Approach Supported by Estates
Funded by
Excerpt from Draft Guidelines - for Information only
Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
Dementia Friendly Hospitals from a Universal Design Approach Guidelines written and prepared by: Tom Grey and Dimitra Xidous, TrinityHaus Trinity College Dublin. Sean Mahon and Victoria Mannion, O’Connell Mahon Architects Des O’Neill, AMNCH and Trinity College Dublin Supported by: Paul de Freine HSE Estates Ger Craddock and Neil Murphy, the NDA’s Centre for Excellence in Universal Design Anna de Siun National Dementia Office …….others to be added as agreed………
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
Part A: Introduction, background and user guidance 1. Foreword. 2. Executive Summary. 3. Introduction (outline of research/guidelines background and relationship to other documents) 4. Challenges for people with dementia and accompanying persons in the acute hospital: implications for design of the built environment. 5. Benefits of the Universal Design approach. 6. Key dementia friendly hospital design issues 7. Levels of design and scales of intervention 8. Some typical Universal Design and dementia friendly design approaches in the hospital setting. 9. Guidance regarding design consultation/participation with people with dementia and family members or carers 10. How to use the guidelines at the various design levels
Part B: Design guidelines 11. Section 1: Site Location, Approach and Entry 12. Onsite Circulation 13. Building Entry and Internal Circulation 14. Key Internal and External Spaces 15. Building Components 16. Internal Environment
Part C: Useful Resources and Appendices 17. Links to relevant related guidance 18. Resources 19. Appendices
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
Introduction These guidelines provide detailed guidance in relation to dementia specific design issues and the Universal Design of acute hospitals in Ireland. For many patients, the hospital is challenging due to the busy, unfamiliar, and stressful nature of the environment. For a person with dementia the hospital experience can be exacerbated by cognitive impairment and behavioural or psychological symptoms, and can therefore prove to be a frightening, distressing, and disorientating place. In response to these issues research has been completed to investigate dementia friendly design for acute care public hospitals. This has examined how the physical hospital environment might provide a better experience for people with dementia, and how hospitals can be designed to enable family members and carers to provide support for the person with dementia throughout their visit to the hospital. This research underpins these guidelines to provide detailed guidance in relation to dementia specific design issues and the Universal Design of dementia friendly hospitals. It is hoped that this guidance will raise awareness about designing for dementia and highlight the benefits of adopting a Universal Design (UD) approach to ensure that hospitals support all people regardless of age, size ability or disability. In this context, these design guidelines can be used for the design of new build, extensions and the retrofit of existing hospitals to ensure that:
•
Hospitals are supportive, therapeutic and healing spaces for all people.
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Hospitals support families, visitors and staff as well as the person with dementia.
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Cost effective practical solutions will promote independence and address safety concerns.
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The well-being of the person with dementia and their families will be enhanced.
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
Designing for People with Dementia When designing environments that support people with dementia, it is important to understand the key symptoms so that the design responds to the needs and preferences of people with dementia, their family members, and carers. Dementia is an umbrella term to describe a group of disorders caused by several diseases and conditions, with Alzheimer’s disease and Vascular Dementia being the most common. When outlining the symptoms of dementia in terms of the built environment, the following broad classification is useful: •
Cognitive impairment: indicated by problems with memory (amnesia), speech or understanding of language (aphasia), a failure to carry out physical tasks despite having intact motor function (apraxia), and failure to recognise objects or people despite having knowledge of their characteristics (agnosia).
•
Behavioural and Psychological Symptoms (BPSD): the cognitive impairment may be accompanied by symptoms such as depression, delusions, hallucinations (visual and auditory) – and abnormal behaviours such as wandering, incessant walking or agitation.
•
Dysfunction in activities of daily living (ADL): In the early stages of dementia these can include more complex difficulties with shopping, driving or handling money. In the later stages more basic tasks are affected such as dressing, eating and bathing.
Given that increasing age is one of the strongest risk factors for dementia, it is also important to consider other age-related changes that a person with dementia may experience such as: •
Physical frailty
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Mobility difficulties leading to increased risks of falls
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Visual impairments
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Hearing loss
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Circadian rhythm difficulties
These impairments may be exacerbated by dementia, as the person with dementia may fail to comprehend, or compensate for these difficulties
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
Benefits of Universal Design In Ireland, the Centre for Excellence in Universal Design at the National Disability Authority refers to Universal Design as:
“the design and composition of an environment so that it can be accessed, understood and used to the greatest extent possible by all people, regardless of age, size, ability or disability” We all have evolving needs based on different stages in our life cycles including varied health circumstances or age-related changes. A Universally Designed environment can adapt and change with us by factoring in at the outset key design features that enhance quality of life for everyone. The application of Universal Design thinking to the hospital environment recognises our differences and accommodates them through the integration at the outset of the design and construction stages of a Universally Designed hospital with the following:
• • •
Flexibility and ease of adaptability to meet peoples’ changing needs over time in a cost-effective way; Sustainable design to improve comfort and energy efficiency; and, Smart technologies to support independence and care delivery.
Universal Design is not about a ‘one-size-fits-all’ model – the UD environment enables the widest possible number of people to participate in society, and to live independently. A Universal Design Hospital works well for everyone and supports the delivery of care for a wide range of people. It is mainstream in aesthetics, not separate or distinct for those with special needs, and is designed according to 4 key Principles:
• • • •
1. Integrated into the neighbourhood; 2. Easy to approach, enter and move about in; 3. Easy to understand, safe to use and manage; 4. Flexible, cost effective and adaptable over time.
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
Key Design Issues Dementia-friendly hospital design supports dignity, independence, and wellbeing in a calm, supportive and inclusive environment that is accessible, usable and easily understood by people with dementia, accompanying persons, visitors and staff. Bearing in mind the four key Universal Design principles outlined earlier, the following Key Dementia Friendly Hospital Design Issues have emerged from the literature and stakeholder engagement.
A. Overall patient and family friendly issues 1. Promote engagement with friends and family, staff and community: As part of this approach, provide space and supports so that accompanying persons can remain with the person with dementia where appropriate. 2. Promote a participatory design approach: all key stakeholders contributing in a meaningful way to the design process to ensure their needs and preferences are incorporated into the building design
B. Provide a people-friendly environment 3. Soften the institutional environment: more human-scale, less clinical/functional in appearance. 4. Familiar design: recognisable design that is easily understood and intuitive to use. 5. Facilitate personalisation: provide opportunities to add personal belongings such as photos to reinforce identity and help with orientation.
C. Support patient safety and health 6. Provide a safe environment: unobtrusive safety measures that do not conflict with other issues such as privacy or the freedom to engage in physical activities. 7. Support diet, nutrition and hydration: calm, accessible and usable spaces, furniture and tableware, along with appropriate visual cues and other stimuli such as food smells to encourage appetite. 8. Support meaningful activities: including physical, social, and activities of daily living (ADLs)
D. Balance sensory stimulation 9. Optimise positive sensory stimulation (i.e. sunlight, music, artwork, images of nature etc.) while minimising negative stimulation (i.e. noise, glare etc.) as part of a calming and therapeutic approach. 10. Provide indoor and outdoor contact with nature, and also access to outdoor space to support active and passive therapeutic activities.
E. Support orientation and navigation 11. Support orientation to date, time, location, etc. and improve spatial cognition.
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Dementia Friendly Hospitals from a Universal Design Approach – excerpt from draft guidelines – 05-07-17
12. Provide good way-finding that supports navigation; this is linked to orientation but is largely about finding your way around or getting from one place to another. 13. Provide good visibility and visual access: Optimise lighting conditions and make sure important features (e.g. handrails), spaces (e.g. toilets), and people (e.g. staff) are clearly visible.
F. Provide adequate space to support the specific needs of a person with dementia 14. Bays or single rooms with space for personal belongings and adequate room for visitors. 15. Space for retreat in multi-bed wards (i.e. quiet sitting room for patients and family that can be used as respite from busy ward) and communal areas in single-bed wards to allow social interaction. 16. Provide space and supports for physical movement: including safe and stimulating walking or circulation routes.
G. Appropriate use of technology 17. Appropriate use of technology for care delivery, safety or therapy (i.e. sensory stimulation)
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Iveagh Ward Upgrade Exercise Name: ______________________________ Table: _______________________________ A. What key difficulties would your persona or accompanying person experience in the Iveagh Ward? Each group member to identify approx. 10 issues:
(NB: Group to select top 10 issues across all input; use post-its and affix top 10 issues to drawing)
Page 1 – see overleaf
B. Based on the key dementia friendly hospital design issues, suggest changes around the two following areas in the ward for your persona: 1. Improving orientation and navigation
(NB: Each group member to identify 5, and the group to select a top 5 from all input; use postits and affix to drawing) 2. Redesign or reallocate one key space within the ward to improve conditions for your persona
(NB: each member to contribute up to 5 ideas; group feedback on top 2 ideas; use post-its and affix to drawing).
3. Any other issues or suggestions
Page 2
HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
Appendix C – Workshop Attendees
Dementia Friendly Hospital Design from a Universal Design Approach Workshop Date and Time: July 5th 9:00-13:00 Location: NDA, 25 Clyde Road, Dublin 4 Name Organization Research Team Prof. Des O’Neill AMNCH/TCD (PI on HRB project) Tom Grey TrinityHaus (TCD) Dimitra Xidous TrintiyHays (TCD) Dementia Friendly Hospitals – Steering Committee Sean Kennelly AMNCH (Geriatrician) Greg Swanwick AMNCH (Psychiatric Ward) Eimear Diggan AMNCH (Dietitian) Susan Lawson AMNCH Cathy McHale AMNCH (CNM, Age-related Health) Diana Burgui Murua AMNCH (Social Services) Gillian Harte AMNCH Claire Mooney AMNCH (Falls Clinic) Deborah Fitzhenry AMNCH (CNM, Age-related Health) Ger Craddock CEUD Neil Murphy CEUD Sean Mahon O’Connell Mahon Architects Victoria Mannion O’Connell Machon Architects Mary Hickey Alzheimer’s Society of Ireland Seamus Cunningham Working Group on Dementia Anna deSiun National Dementia Office Paul De Freine HSE Estates Case Study Hospitals Aine Coe Naas General Hospital Joan Elliot Naas General Hospital Oleg Shrolik Naas Hospital Mary Doyle Peamount Carmel Ryan Peamount Other Organizations Mary Lovegrove Hospice Foundation Mary Lynch Hospice Foundation Alice Anderson Development Officer (Hospice Friendly Hospitals Programme) Ronan Rose Roberts Architect Eve Edelstein Clinicians for Design Elizabeth van den Brink Clinicians for Design Eibhlis Cahalane (Services Lead - Assistive Technology libraries project for Older People) Eibhlis.Cahalane@hse.ie
2017 AMNCH TrinityHaus, Trinity College Dublin
Attending
Table
Y Y Y
1
N
N Y
2
Y
3
N Y Y
2
Y Y
4 4
N (away) Y
1
Y N
1
13
HRB Applied Research Projects in Dementia 2015 – Stakeholder Workshop Findings
Mary McGuire Lead for Acute hospitals Genio project mary.mcguire@genio.ie Anne O’Hea OT in Cork aohea@muh.ie Joan Mannion - Community nurse with psychiatry of later life Joanm.Mannion@hse.ie and has been rolling out the 4 hour acute hospital programme to all staff in the 3 acute hospitals in the Midlands for the past 2 years. Caroline Clifford caroline.clifford@hse.ie Siobhan Grant – St. Joseph’s Shankhill Siobhan.Grant@sjog.ie Norma Sheehan Director of Nursing, St Joseph’s Shankhill Colette Ryan – Carebright (Dementia Village Bruff Limerick) cryan@carebright.ie Cairin Conway – Manager, Understand Together cairin.conway@hse.ie Des Mulligan Integrated Programme for Older People PJ Harnett Integrated Programme for Older People Damien Clarke Engineering Advisor (M&E) - HSE Estates Derek Dockrell Project Manager, HSE DNE. Susan O’Reilly Dementia Nurse Specialist – Connolly Hospital Eimear Short Senior Medical Social Worker - Connolly Hospital
N (away)
Niamh Ganley Karl Dalton George Jefferies Matthew Gibb
Occupational Therapist, Connolly Hospital Connolly Hospital Connolly Hospital St James Hospital
2017 AMNCH TrinityHaus, Trinity College Dublin
Y
2
Y
3
Y N (away) Y Y Y Y
2
Y y y N
2 4 3
1 4 3 1
14