By considering the experiences and perspectives of residents we can identify the design features of aged care facilities that meet their needs and facilitate them to live their lives positively, writes Dr Lee Chin.
Years working in aged care have given me the opportunity to observe residents living in many residential aged care settings. In some places, the social environment ensured the residents were happy, despite what I thought was poor design with confined spaces and lack of facilities. In contrast, I have seen purpose-built facilities with beautiful amenities where the residents seemed less happy.
As part of my PhD, I conducted research that aimed to identify the design features of aged care centres that supported residents to meet their needs and to live their lives positively. This qualitative research investigated how and why residents used the spaces, and how the buildings worked for the residents.
The study involved two aged care centres in metropolitan Sydney – one for profit and one not-for-profit. Staff, residents and families were informed of the study, reassuring them that the purpose was to observe the residents in the communal parts of the buildings and the outdoor areas and not staff practices.
I spent many hours over many months quietly observing the ways the buildings were used. What were the popular places? Where were the residents drawn? I looked at the places the residents chose to be, as opposed to the places the staff put them. I observed where there were spontaneous conversations, where there were smiles, and the places where there seemed to be equal power for residents and staff. I noted the differences between spaces – large and small; organised and free flowing; corridors and lounges. I sat and I watched. I answered residents’ questions and I participated in conversations if invited.
I live here, but I don’t live here
Early in the study, while sitting in a quiet lounge room, Norma* came in and sat down. She looked at me and asked, “Do you live here?” I smiled to myself, wondering if I looked like a resident. “No, I’m a visitor,” I replied. “Do you live here?” I asked. “Well darling,” she said, “it’s like this. I live here, but I don’t live here!” In this short conversation Norma had managed to summarise the purpose of my research. I wanted to see aged care facilities where the residents felt they were living their lives well. Later, when speaking with some staff they suggested I shouldn’t bother to speak with Norma, as she would not be able to offer me anything for the study.
My research also involved interviewing residents to discuss their favourite places and the areas they used in the facility. The interviews gave me a picture of life in the facility; they set the observations in context and helped me understand the residents’ reasons for using the spaces.
Transcribing the interviews was the most difficult task – I cried every time. The stories, the losses and the overwhelming sense of resignation moved me.
The dominant theme was a sense of loss. It pervaded every aspect of the interviews. The residents described a litany of losses in their lives – loved ones, friends, home, health, pets, gardens, treasures, personal and financial independence, mental capacity and, the greatest loss of all, a sense of personal value. Added to these were the feelings of resignation and lack of control. This sobering point should challenge us to consider the impact this can have upon the quality of life for our residents. Another resident, Dora, said:
“Well my time is not worth anything now.”
I saw many examples where a resident would fight to retain a sense of self and the ability to make choices, however insignificant they may seem to an outsider. These choices often related to how they used the building.
On several occasions staff made comments like “no one uses this space.” Later, I discovered that several residents used these areas at times they would have complete privacy. These residents often thought no one else used the spaces. Access to some of these areas was circuitous as confirmed by Hattie’s description of her favourite outdoor area:
“You go through the dining room out to the corridor, along the corridor, around the corner and you will see a door… it’s always locked. You have got to get someone to open it… I don’t tell anybody I am going out there ‘cause everybody will want to come and there’s only two chairs (she laughs). That’s my favourite spot…You need to see what goes on outside and you need to see things passing by and the trees and the outside. You need to see all these kind of things.”
Residents often used spaces because they were the only spaces that were available – not because they were adequate. I observed the residents would “make do” with a space. However, the residents were less likely to use inadequate spaces for sitting, socialising or personal hobbies – they chose to stay in their bedrooms or to forego the activity.
Buildings and the sense of loss
The major theme of the sense of loss raised several questions. Can buildings enable residents to mitigate their sense of loss? Are there design features that can assist residents to adapt and feel their losses less acutely? Can we create designs that offer meaningful choices for residents and meet personal needs for privacy? Can these choices contribute to assisting residents to retain a level of independence and to feel a sense of control?
My findings showed that a building design that supports the residents to be self-initiating and that offers real choices can enhance the residents’ experiences and the social environment. A building can create many opportunities for residents to be more self-directed in the ways they use the indoor and outdoor spaces. In turn, this contributes to the feeling of having influence over their lives and improving their quality of life.
For example, residents liked to have choices of spaces to sit – depending on the reason for sitting. Small sitting areas near bedrooms effectively expanded residents’ personal space.
Personal privacy was highly valued; residents found ways to have privacy in public spaces. Several residents described how they found privacy in spaces beyond their bedrooms. Ann spoke about an outdoor area: “It’s nice to get the fresh air and sunshine. I don’t want to make it too popular…I think I am the only one. So it’s my little spot.”
The desire for having a choice of spaces and activities was clearly expressed by Amy: “I never want to be part of that throng and sit in the [lounge] room and stare at the TV.”
Another highly valued feature were connections between indoors and outdoors – for example, direct views from inside to the gardens.
Further, my study highlighted that the importance of the secondary benefits of certain spaces, which can increase the overall benefit for residents.
For example, dining rooms were the social hubs – gathering before and after meals is a social tradition. Corridors were not just traffic areas, they were the neighbourhoods; everyone spoke to everyone in the corridors. Similarly, sitting spots on the way to the main areas encouraged conversations and assisted way finding.
Ultimately, I believe it is crucial to understand what our residents and potential residents want to do in the buildings and outdoor spaces. This will help us to create designs that enhance their lives. By using an intentional design approach, we can be deliberate in designing and building aged care facilities that respond to the physical, social and emotional needs of residents.
Dr Lee Chin is an aged care and community services consultant. She completed her PhD on the impact of the built environment on quality of life for residents in 2011. Feedback is welcome and can be emailed to email@example.com