by Jerald D. Peters Architect AAA AIBC MAA OAA SAA FRAIC LEED AP, Principal at ft3
Housing for seniors has experienced radical transformation in the recent past. Bachelor suites are disappearing in favour of more acceptable apartment accommodations. Grandmother taking over the spare bedroom is more commonly becoming the “granny flat”. We have moved from attempting to fix a crisis problem of housing seniors to an evolved longer term solution to quality of life for our seniors.
No doubt the population bulge that is the baby boomers moving into the seniors housing market is driving variety and options in our cities. No longer will our seniors, who comprise a significant percentage of the voting population, be relegated to bachelor suite ghettos, one bedroom lodges with inadequate living space and community functions or institutional nursing care where overmedicated elders stare blankly out the front door in a wheelchair parking lot. We know better and we are starting to do something about it.
Community Housing Versus Healthcare Models
For many years seniors, housing models were heavily influenced by healthcare efficiency. Nursing home “wings” were sized to match the maximum coverage capability of a single registered nurse. Residents were treated as patients with schedules to match treatment patterns, nursing protocol, and shift changes. The daily routine of the resident revolved around basic functions: getting up, meals, toileting, medication, and returning to bed. Residents were grouped according to care needs with dementia or Alzheimer’s patients clustered together or Special Care Units for behavioural challenges.
Today, trends indicate that issues of community building are becoming design drivers. In The Netherlands, residents are evaluated to determine the most appropriate social setting to be grouped together in a nursing home household. Households are comprised of compatible interests and culture including ethnicity and economic status in an effort to improve the success of relationship and community building.
For decades in Canada, churches and community groups have come together to develop nursing homes for their frail elderly based on a lifestyle of faith or common interests and charity. In recent years, the medical system has moved in, based on the bulk of operational funding from Provincial Healthcare budgets, and the origins of the faith based homes have become diluted and diminished. Nursing homes are increasingly based on end-of-life care and medical treatment supersedes faith, but should it?
The size of the household has an impact on quality of life. After decades of attempting variations in our nursing home environments, it is clear that size of home does have an impact on quality of life for our frail elderly. And why wouldn’t it? Does any one of us want to live in an institutional environment, with 20 resident bedrooms down a long corridor? In fact, we agreed on that two decades ago, but we have tried to redecorate facilities to more “home-like” environments, with more residential furnishings, fixtures and wall paper (without making the fundamental shift to an understanding of what a “household” should be), hanging on to medical efficiencies in our way of thinking.
But that is not quite true. Many before us have made this shift. Dr. Tooth in Australia in the early 1990s developed a model for Alzheimer’s residents that is still relevant today. Or Dr. Bill Thomas and the Green House movement. Or SAGE, the Eden Alternative, Chez Nous – the evolution continues to gain momentum. All of these models realized that reducing the size of the household and re-introducing the basic concepts of home, like flexibility in schedule, privacy and autonomy, freedom of choice and scale of surroundings more closely mimic the qualities of family and home. Making those fundamental shifts in thinking reduces the frustration of the resident – and consequently agitated behaviour is reduced.
There is not one perfect size for a household. Models of success range from six all the way to twenty. For higher needs like special care units with behavioural issues, the smaller size of six to eight residents is being adopted. Many households are in the range of ten to fifteen residents with designs to allow staffing to cover more than one household during the night.
Twenty residents seem to be the upper limit for success. More than anything, this is a carry-over of the medical model, pushing the household model to the limit in the name of staffing efficiency. However, a household at this size may not function well without the appropriate well behaved residents. Furthermore, the scale for family style environments is pushed to its extreme, perhaps beyond upper limits for home style dining rooms, kitchens, and living rooms.
Common sense, putting ourselves in the place of the resident and creativity will push the size of the household to an ideal range of six to fifteen, depending on the needs of the residents.
Care Matters – Changing the Workforce to Suit What is Needed
How we deliver care should suit the resident rather than the workflow of the staff. The Government of Saskatchewan and the Ministry of Health recognized this some time ago, adopting a “patient focused care” philosophy in 2009. This philosophy was overlaid on their approach to acute care and long-term care environments. Trending today is the phrase “patient experience”, emphasizing decision making through the eyes of the patient. Although the terminology should be updated to “resident” for long-term care environments, the concept and intent is on target.
Philosophically, in long-term care, the notions of flexible routines are becoming more common: getting up when you want to; eating a breakfast of your choosing; bathing at your preferred time; and so much more.
Furthermore, the concept of “relationship centred care” is emerging (http://salemhome.ca/). Changing the bed sheets is more than a task; it is an opportunity to engage with a resident in conversation. Preparing and serving meals is an opportunity to discuss ethnic backgrounds and familiar dishes and recipes, perhaps incorporating new menu items into future meals.
In this model, staff members enter into the home of the residents and have the mindset of respect and dignity, just as they would if they were walking into their own parents’ home, as part of the daily routines. Having a relationship with the resident allows for a better understanding of the resident’s needs – ultimately leading to improved familiarity and caregiving, less stress and medication and happier residents.
Medical models are built around specialization and forming a team of experts. In a residential long-term care facility the vast majority of daily care activities provided to residents by staff are non-medical. Specialist training for these activities is quite simply, over staffing. The vast majority of daily activities can and should be carried out by resident care attendants who are in relationship with the residents.
At Salem Home in Winkler, Manitoba, Canada residents are given a choice of entrées and side dishes from the “Susie Q” model of meal preparation. For many residents the meal times are significant events in the day and “choice” is a critical component of feeling dignity and a sense of control.
At de Hogeweyk in The Netherlands, residents live in five or six person households with like-minded roommates, shop at the “village” store, go out for meals at the pub or restaurant with family or take art classes. They don’t know that the products that they bought are returned to the store later or that the village with so many interesting opportunities for pleasurable daily activity is sheltered from the remainder of the city.
In Kerrobert, Saskatchewan, Canada, a small town of 1,001 residents, the long-term care facility is combined with the small acute care hospital and clinic. Medical and nursing staff, as well as support staff and administration are shared across disciplines. There are limitations to the specialty care that can be provided in a small town, but we are moving towards a model that focuses on the wellness of the individual rather than on their limitations – and quality of life is best provided where that resident wants to be, isn’t it?
Salutogenesis theory, a concept developed by Aaron Antonovsky, is a contrast to the pathogenic orientation of healthcare – suggesting that we focus on wellness factors instead of risk factors as a means promoting good health rather than curing disease (Alan Dilani, International Academy for Design and Health). The world leaders are adopting this approach and it makes sense for Seniors Housing and Nursing Care.
Written by Jerald D. Peters, Architect AAA AIBC MAA OAA SAA MRAIC LEED® AP. Principal at ft3
Jerald Peters brings more than 20 years of experience creating vibrant, functional spaces, and has provided leadership and technical expertise on an extensive array of projects in healthcare, institutional, housing, commercial, and religious environments.