Home is Where the Heart Is: Designing Home-like Settings
The physical environment plays an important role in creating an atmosphere of home. Too seldom, however, are the deeper meanings of home fully incorporated into the design of dementia care settings. In this article, "home" is considered at three levels: as a psychological state, as an expression of self, and as a physical structure. Successful design must address all three levels, and must integrate the physical environment with operational and programmatic aspects of the setting.
Key Words: physical environment, design, meaning, expression of self, home
The information contained in this article was
supported by research funded by the National Institute on Aging
(grants AG15249-01 and AG12311).
"Mid pleasures and palaces though we may
Now, let's walk into a nursing home. If you've been in many nursing homes, you may have a composite picture of lots of different places. What are your first images like? Walk onto one of the units. Are there long hallways, and a single day room or shared social space? Think about the nursing station--is it a fortress behind which staff sit and passively monitor the residents? Or is it more like a concierge desk at a hotel? What is the lighting like? What does it smell like? How does it feel to be in this space? Again, pay attention to your emotions.
This exercise demonstrates the power of home. The images and feelings summoned by thinking about home were probably quite different than those evoked when thinking about the nursing home. Even the word home evokes positive, comfortable feelings. Thus, it is not surprising that many care facilities are trying to be less nursing home, and more nursing home--particularly for those individuals who will be long term residents in this setting.
"This is the true nature of home--it is the
place of Peace;
But these exercises also demonstrate that home is much more than a few simple decorating techniques. "Home" needs to be distinguished from "house." As Dovey3 put it, "Although a house is an object, a part of the environment, home is best conceived of as an emotionally based and meaningful relationship between dwellers and their dwelling places."
For the purposes of this article, there are three levels at which "home" needs to be considered: as a psychological state, as an expression of self, and as a physical structure. All three are important and intertwined, although the majority of this article will focus on the last level--physical structure.
Home as psychological state:
Ah, what is more blessed than to put cares away, when the mind lays by its burden, and tired with labor and far travel we have come to our own home and rest on the couch we longed for? This it is which is worth all these toils.
Home has been defined in many ways: a place of refuge or a secure place (Rainwater5), a place where one has control, a place of certainty and stability (Dovey6), a sacred place (Eliade7). Dovey8, who has conducted substantial research on home, suggests that "being at home is a mode of being whereby we are oriented within a spatial, temporal and sociocultural order that we understand."
"To be at home is to know where you are; it means to inhabit a secure center and to be oriented in space." (Dovey9)
Attempting to recreate this experience-this state of being home-for people with dementia can be challenging. Often when a resident says "I want to go home" they are not necessarily referring to the house they came from, but rather to a state of being that was comfortable, ordered, and fundamentally orienting. They want to return to a place that makes sense, where they can feel comfortable and not threatened by myriad things they cannot understand. This is the underlying principal behind both validation therapy10 and agenda behavior11--the importance of understanding the emotional state behind the overt actions. But, as will be seen below, the physical environment plays an important role in helping people feel either comfortable and at home or out of place and uncertain in a given setting.
Home as an expression of self:
When people change their environment to suit their tastes and to express their unique individuality, they are engaging in personalization. Even in places, such as rental apartment buildings where they may be strict rules governing personalization options (no holes in the walls, can not paint the apartment, etc.), most people still find subtle ways to express themselves or mark out their own territory. A small wreath of flowers on the front door, or a pot of flowers are simple examples of ways people personalize the entrance to their homes.
Personalization of homes in an overt statement of what is important to that person. Someone who loves cooking has a well-tended and obviously loved kitchen. For readers, the library will be embued with comfort and good lighting. Travelers may display photos and mementos of favored locations. The selection and placement of furniture can indicate whether conversations or the TV are more.
For a facility to be truly like home, it must accommodate these different patterns, by providing options to personalize their space in different ways. But it goes beyond simple personalization. People vary in how they show their priorities. Some may spend a great deal of time taking care of their home and garden--maintaining and renewing it--as if to convey loving respect. Others may make very few changes over the years, as if to suggest contentment and stability. Some people enjoy spending time in the kitchen, puttering around, planning the menu, preparing and cleaning up from meals, reading the paper, visiting with neighbors, and have kitchens that reflect the love and care it receives daily. Others, who view the kitchen as functional space to be used as little as possible, would much rather spend time elsewhere in the house-and these areas show the attention given to them. Regardless of the ways people choose to personalize their space, it is practically universal to want to identify a space as yours, in one way or another. And this need does not change simply because one has aged. For a facility to be truly like home, it must accommodate these different patterns, by providing options to engage in these familiar maintenance and domestic chores, without necessarily requiring residents to participate in these activities.
Expressing the self through personalization or patterns of daily activities is linked to the issue of control (which also impacts the psychological state, as mentioned above). In individual homes, people generally control what and where furniture and belongings are displayed. They also have control of when they engage in different activities. These options and decisions are more possible in individual homes than in group residential settings (nursing homes and assisted living settings) which have a broad range of subtle and not so subtle constraints. For example, it would not be considered appropriate behavior for a resident to tap a nap in the middle of the dining room during a meal, yet this could be done at home.
There is another aspect of control that is particularly important for this population. Due to cognitive deficits, it is recognized that it may not be appropriate for people with dementia to have complete control over what they do and where they go. Many facilities create secure or semi-secure units, so residents with dementia can not walk away and become lost. Often these units are on upper floors, making it even more difficult for people to leave the building inappropriately or unattended. While this goal of safety is laudable, its execution must be reconsidered. The ethics of locking people up, giving them virtually no access to outdoor space, needs to be examined. When these secure units are on upper floors of multi-level buildings, getting outside becomes a rare event. Staff are understandably busy with many caregiving tasks and the extra steps it requires just to get people outside may be more than they can manage. And this is considered acceptable. By contrast, in many states, prisoners--people who have committed crimes--are required to be allowed one hour in every 24 outside. It is the position of these authors that no secure unit should be considered acceptable unless it has direct, and at least partially unrestricted (during clement weather) access to a (secure) outdoor space. Research has demonstrated that there may be a correlation between some anxious behaviors (pacing, standing at doors, rattling the door handles) and having secured doors13. In this research, when the doors to the courtyard were unlocked, several residents would walk to the door and open it, then walk away. They didn't want to go outside, they wanted to know they could go outside.
While this is just one example of control, it highlights the challenges of creating a place that supports both the abilities and the disabilities of people with dementia. These are ethical challenges which caregivers face everyday, which need to be addressed more consciously. One way to address these issues is to give residents as much autonomy and control as possible over aspects of their lives that do not affect their ultimate safety
Home as Structure:
Beyond all the psychological and emotional levels of the meaning of home, there is also a very concrete, structural level that needs to be considered. In addition, it must be recognized and accepted that most long-term care facilities are not homes; they are larger, congregate residential settings with many unrelated people living together and sharing some amenities. Therefore, it is not realistic to assume that facilities will be able to actually recreate the complete expression of house or home. Nevertheless, the physical environment can be considered at several different levels: exterior elements, connection with neighborhood, scale, types of spaces, arrangement of spaces, and decor. Each of these topics will be considered separately.
Exterior Elements: The exterior of a building is the first impression we receive. A place that looks like a hospital or a hotel is unlikely to be considered a desirable housing choice. Obviously, it is easier to create a small, residential exterior appearance if the building is, actually, smaller (see Scale for more on this). But there are ways of breaking up the apparent mass of a building, through placement on the site, use of landscape features, and articulation of the exterior facade. Marsden15 using photographs of different building entrances and exterior elements (porches, building materials, roof articulations, landscaping, etc.) was able to demonstrate that people have distinct impressions of what make a place look more "home-like." Family members and elderly residents of retirement communities were asked to evaluate the photographs and showed remarkable agreement, although there were also some areas where they disagreed.
Porches and porticos were viewed more favorably than long driveways with porte-cocheres by both residents and family members. The scale of porte-cocheres as well as wide driveways with signage indicating clearance heights suggested the entrance could accommodate a truck or an ambulance, which evoked more images of institutional building types such as hospitals, hotels and funeral homes15. Residents did favor certain covered walkways at the entrance to provide protection from the weather even if it included an unfamiliar housing cue such as a canopy. In contrast, family members viewed familiar housing cues (porches and porticos) as more important than sheltered covering. With respect to exterior elements, residents and family members felt that attention to maintenance and small details such as picnic benches and seating at the entrance and decorative features were positive. Natural building materials such as wood and to some degree brick were viewed as more home-like than synthetic materials such as stucco. In addition, residents tended to view one-story buildings more favorable than two or three story ones, whereas building height was not particularly salient in the family members' perceptions15.
Connection with neighborhood: People live in varied settings: dense urban neighborhoods filled with many apartment buildings and houses very close together; suburban lots of identical size with similar set backs and overall design; rural communities with varied houses on multi-acre lots, and many other options in between. While a discussion of setting at this scale may not seem relevant to the overall goal of this article on long-term care settings, it actually is quite relevant. As facilities move away from an institutional model and toward something that is more reflective of home, what that home is, and how it is related to its neighbors must be considered at a fundamental level. Consider these two options. In one scenario, the old "nursing unit"--a cluster of bedrooms with shared bathing and social spaces--is reconceptualized as a "household" and the shared spaces become the living room and dining room, and the bedrooms remain the bedrooms. In another scenario, the bedroom is considered the apartment, and the shared spaces become more like neighborhood spaces--the corner deli or cafe, the library or lobby or game room of the apartment building. This latter scenario may actually be more appropriate for facilities with existing bedrooms arranged along a double loaded corridor. It is critical for facilities to decide which approach they are taking, as it fundamentally alters how different spaces are handled. It is, however, a complicated decision which has many implications, and therefore will be addressed in several of the subsequent sections.
Scale: One key feature that makes a place feel institutional is the scale of the spaces. Large-scale spaces, or rooms that hold over 25 people, are not common in residential environments. Most living rooms comfortably hold 5 to 10 people, and are rarely more than 300 square feet. And few people have a dining room that will easily seat more than 10 people. Most residential ceilings are from eight to ten feet high (with the exception of recently popular cathedral ceilings). In contrast, many long term care facilities have large shared spaces (which some refer to as living rooms, others as day rooms) that are two stories in height, and which have large expanses of glass. Dining rooms may easily accommodate 30, 40, even 60 people. While many of these differences reflect the fact that long-term care facilities are designed to provide service to a large number of people, if the goal or intent is to create a setting that feels like home, it is imperative to break-down the scale of the spaces. This can be challenging--particularly so in existing facilities. But there are things that can be done to help.
The first level at which this must be considered is the scale of what has traditionally been referred to as the "unit." Based primarily on notions of staff efficiency, most traditional nursing units have housed between 40 and 70 residents, often in rooms shared with one, two or three other people. Increasingly facilities are creating pods or clusters of 12 to 24 residents. Usually, several pods are grouped together to allow for increased staff efficiencies (sharing some support spaces, and reducing the number of staff at night), but keeping them sufficiently separated that residents feel they are living with a small group of others (anywhere from 6 to 16). . It is easier to break-down the scale of the unit when doing new construction, than when renovating an existing facility. Yet there are often ways to adjust the scale of existing buildings as well.
Obviously, this alternative of breaking up the units into households is not possible, or easily feasible, in existing facilities. Other alternatives must be considered. In facilities with existing long hallways, the layout may suggest it is more appropriate to consider the "unit" the neighborhood, and treat all bedrooms like resident apartments in an apartment building. The shared social spaces would then be treated either like community spaces (e.g. the dining room would be like a restaurant that seats 20 or more). The down side to this approach is that in many apartment buildings, this hallway space remains anonymous, public, and "unowned."
The alternative approach would be to consider the unit more like a home, with the bedrooms simply reflecting a person's bedroom in a larger home. In this case, a top priority is to minimize the length of the corridors, since houses rarely have hallways that are more than 15-25 feet long. Long hallways not only appear institutional, they require a great deal of energy for older people to walk down, and it can be hard to orient oneself if identical sets of doorways line both walls. Several techniques can be used to break up the appearance of long hallways. First, consider treating different sections of the hallway differently. The ideal solution would be to have multiple small living rooms or parlors along the length of the hallway, so people do not have to travel so far to get to activities.
A second technique to break-down the apparent length of the hallways is to distinguish doorways from each other. For example, essential doorways, such as the entrance to a bathroom can look distinct, either with color, or with a three-dimensional canopy over the entrance. If this canopy can be seen from down the hall, it can also act as an orientation cue. Resident bedroom doors can also be decorated, as they sometimes are in apartment buildings. Although this is a great technique which supports orientation16 it must be recognized that display cases and signs at bedrooms are not typically found in people's homes. You must decide whether your priority lies with supporting orientation, or recreating a place that feels like home. There are other alternatives besides the display case: consider encouraging each resident to bring a favorite piece of art from home to hang outside their bedroom entrance. While it might not be the location where these pieces hung in their former homes, and it can make the hallway quite busy with lots of different styles, it is more common to have art on hallway walls than to have display cabinets or curio cupboards. Research suggests these types of personalized cues can have a positive impact on helping people find their own rooms16.
Hallways are not the only large spaces in many facilities. Many of the shared social spaces were designed for 30-50 residents to congregate in--clearly not a residential scale. It is probably best--especially for people with dementia who are easily overwhelmed in large and busy spaces--to have several smaller rooms for 10-12 people. This can be hard to achieve in existing facilities. If a space is primarily used for dining, for example, permanent or semi-permanent barriers can be constructed. These could be attractive half walls, with planters or lattice work above. It may be helpful to look at the ways local restaurants create smaller feeling spaces without completely dividing an area. The same is true for activity rooms. As an alternative, especially for facilities that are short on storage space, cabinets on locking castors can be useful, as they can either be moved against the wall if larger space is needed for a special event or holiday dinner, or pulled out to subdivide a larger area. This is a great solution for facilities with large dayrooms, in which residents often sit in chairs arranged around the perimeter of the room. Using cabinets or other dividers sub-divides the space allowing for several smaller groupings of furniture.
Types of Spaces: Related to the issue of scale, it is also important to define the types of spaces. If the basic grouping of residents is considered a "house" (and residents' rooms are bedrooms), then the shared spaces for this group of 6-16 should reflect the spaces typically found in their homes in the community: kitchen, living room, dining room, and sometimes library/den or family room. In the future, it will be more common to also have an office. If the basic group of residents rooms is considered a "neighborhood," then the residents' apartments should contain these basic living spaces (kitchen, dining and living rooms in addition to bedroom and bathroom). The shared spaces should then reflect more public, communal spaces, like a local restaurant, the village green, an art gallery, the public library, and/or a senior center. Some facilities (particularly those with larger numbers of residents) have found that local, well-known restaurants are interested in opening a small cafe/lunch counter right in the facility. Others are including a pub or cocktail lounge, recognizing that many people are used to having a drink before dinner. A nursing home in Oregon not only has the only restaurant in town, but the local bank and beauty shop also operate out of the facility. This is a wonderful way to break-down the separation often found between long-term care facilities and the communities they are located in; it entices local residents to come into the building.
It is also important to consider what rooms are called. At the simplest level, having a living room or family room is more familiar than having a day room or an activity room (which sound more institutional or like a senior center). Language is also important at the larger scale of the unit. Many facilities are moving away from the term "unit" to calling these groupings of residents clusters or pods. However, one could question how residential these terms are. As one administrator17 put it, "Whales and peas live in pods, and grapes come in clusters. People live in households..". Language affects our thinking at a fundamental level, and should be considered carefully. This may be why some facilities are giving their units names, such as "Hill House" or "Beacon Place."
Arrangement of Spaces: When you walk in the front door of your house, or your neighbor's house, almost any house or apartment, what do you come to first? It may be a foyer, or a hallway, or the living room, but it's almost never the bedroom18. Yet, when you enter most long term care units, what is the first space you encounter? A hallway with bedrooms. This may be difficult to change in existing facilities, but certainly any facility that is being designed and newly constructed, that wants to create an atmosphere of home, should consider the relative arrangement of spaces. Houses and apartments, at least in most Western cultures, have a general organization of shared, semi-public spaces at the front of the house (living room and often dining room), followed by the kitchen (which also often has a back door), and some transitional element (hallway or stairs) before you reach the more private area with the bedroom(s). There are exceptions: some bungalows and apartments have bedrooms that open directly onto the living room or dining room, although in many cases people have modified these rooms to be a TV room or an office.
Overall, however, the structure of a typical house should be used as the template for organizing the structure of a care setting that is trying to create the feeling of home. The first level of decision making has to do with the scale of the whole project. The design and management team needs to decide whether multiple households are connected together, or whether each household will essentially be free-standing. Both models can work. In the former case, the end result is a larger building, which is harder to make look residential from the outside (see Exterior Appearance, above), but may be viewed as more efficient. In the latter case, the end result is something more like a neighborhood of small houses. Indeed, several projects have been developed which look more like a residential neighborhood of similar homes than a long term care facility.
The next decision is whether the "front door" to the household connects to the rest of the building (assuming there are several households being grouped together) or whether it leads outdoors. Connecting the front door to the outdoors is a more residential sequence, and works especially well if the households are separate buildings. When households are combined into a larger building, it is still possible to have the "front door" open to the outside (e.g. courtyard), and have a "back door" that connects to the rest of the building. In some facilities (e.g. The Wealshire in Lincolnshire, IL), this back door opens into the kitchen area--just as it does in many houses. In The Meadows, in Hammond, Australia, there are three households that are connected by a service corridor used only by staff. This corridor leads to the kitchen pantry area and laundry room. The advantage of this arrangement is that there is never an "institutional" cart visible to the residents in the building.
In existing buildings, it is clearly not possible to completely restructure the space. Therefore, the facility must decide how much of a priority creating spaces that feel homelike are, and what the options are. Existing spaces that are comprised of long hallways with bedrooms on either side (commonly referred to as "double loaded" corridors) may be more ideally suited to the apartment style approach described above, rather than a household approach. In the apartment approach, each resident's room is considered their apartment, and the shared common spaces are either more like what you would find in an apartment building (community rooms, maybe a restaurant), or what you would find in the community (ice cream parlor, deli or lunch counter, community center, etc.). Unfortunately, this model may not be as supportive of the needs of people with dementia who are moderately to severely impaired.
The alternative is to make the best of what you have. First, try to define households in as small a group of bedrooms and associated shared spaces as makes sense given your particular plan. If possible, avoid having units that must serve as passage ways to other units, because then you are doubling the amount of traffic going through the "front" unit, which--again--is not homelike. If it is not easy to create a living room and dining room at the main entrance to the household, consider this entrance to the rest of the facility as the back door, and create a front door off the main living and dining rooms which leads to a secure courtyard. This means residents can have largely unrestricted access to a secure outdoor space--an important aspect of control discussed above. This arrangement--having living and dining rooms at the center of the unit--may be especially effective if you are trying to keep residents away from the less secure exits of the unit.
Another important area to consider is the staff space. In the traditional, institutional setting, a large, highly visible nursing station was required. In many areas, codes may still require that there be a place where staff can be easily located, and where they can easily monitor residents. However, advances in technology are making it less important to have a person simply sitting behind a desk monitoring the call bell system. This is particularly true in an area for people with dementia who may not know how to properly use a call bell system. Call bells that are tied directly to staff pagers allow staff to respond faster to residents who need their assistance. Other systems rely on motion control sensors, and do not require the person with dementia to know how to pull the cord when needing or wanting assistance. With all these changes, facilities are finding new ways to support staff needs, without the large, institutional feature of the traditional nurse's station. Some facilities have simply updated the nurse's station, making it look more like a concierge desk (which would be more appropriate in a resort model, "Defining Place-based Models of Care: Conceptualizing Care Settings as Home, Resort or Hospital" in this issue). Others are creating small, residential scaled desks, either in out of the way corners or as part of a kitchen area. Many people have a small desk area in their kitchen, so this can feel familiar. However, these small desks may not be sufficient to meet the paper work requirements of many regulatory agencies. Many facilities find it useful to have a separate, enclosed work area for staff to do paper work and charting. These spaces are often not visible to the unit, so staff are not expected to both be doing paper work and supervising residents, and thus can do the paper work more efficiently, and then get back to spending time with the residents. This has the added benefit of eliminating the nurse's station as the activity focal point of the unit, which leads to residents sitting around the station all day long.
Other support services also need to be considered. Housekeeping carts, clean and (particularly soiled) linen carts and large food carts are almost always institutional in style and usage. If possible, design a kitchen for the unit that has a separate entrance, so food can come onto the unit and trash can leave the unit without crossing other spaces. Be sure there is a place where the food cart can be placed so it is accessible, but not out in the open and visible to all residents. Consider ways of storing a clean set of sheets in a cabinet (secured, if necessary) in the resident's room. Enclosed laundry hampers in each room that are emptied regularly may be able to be substituted for large soiled carts kept in the hallways all morning. Look around for other signs of the old institution, and be creative about ways to eliminate these non-residential features.
Decor: Finally, the overall decor of the household will also have an impact on how it is perceived by residents and family alike. There seem to be two current trends in décor: hospitality style or quaint "Americana." As was mentioned above, it's important to know your residents. Were they likely to have decorator-designed interiors with matching fabrics and coordinating prints? Did they fill every corner of their house with collectables, bows and dolls? Or were they likely to have collected pieces over a lifetime of living, an eclectic array of styles and colors and patterns? Knowing what is familiar to the people who will be living there is critical if you want to be like home. If possible, go (and get your interior designer to go) out to visit the homes of prospective residents and see how they decorated their houses.
In most homes, different rooms serve different purposes, and are designed to look very different. Seldom does a person have the same chair in the dining room as in their bedroom and their living room. Institutions, on the other hand, are marked by a uniformity of both furniture and design. All wall treatment is the same, or so coordinated that it's hard to tell one space from the next. When a well designed chair is found, it is used everywhere: in the bedroom, in the dining room, in the activity room. But this approach to interior design will not make a place feel like home. Making rooms feel very different--light and airy versus warm, rich earth tones--also gives residents a sense that the spaces available to them are different. If there are three of four different shared spaces, but they all look and feel alike, and are about the same size, what does it matter if you are in one versus another? When the rooms vary not only in size, but in overall decor, they add to the feeling of choice.
Few facilities take sufficient advantage of letting residents bring in their own possessions. We recognize that some licensures restrict the amount or type of furniture residents are allowed to bring, and some existing building designs are so restrictive there is almost no opportunity for personal furniture. Nevertheless, personal possessions--as described above--are incredibly important for helping to define who we are. Look at a residential-style hotel, one of the newer suites with a living room and a small kitchen in addition to the bedroom and bathroom. It seems to have all the components of a small apartment--yet would you ever mistake it for home? Probably not. It's the lack of personal possessions--furniture, art, pictures of your family--all those little things that help make a place feel like home. It's not surprising many residents feel they are living in a hotel. The furniture was already there when they moved in, and it looks like the furniture in the room next door. It's not arranged the way they would have it arranged at home. Rather than a plaid bedspread, they would prefer the flowered quilt that their grandmother made. As for all the knickknacks and memorabilia they've picked up on their travels around the country, there's no mantel place to display them on.
The first step to giving a feeling of home is to provide as little furniture as possible. Encourage people to bring their own furniture, and only supply what they are unwilling or unable to bring. Second, be sure there are places to display items, ideally places that are somewhat out of the way or are secured. Many facilities are adding plate shelves 5 1/2 to 7 feet up the wall--still visible without being too accessible. Others are providing display space behind glass.
Finally, consider what furniture and display items residents can provide in the shared living spaces. People don't just live in their bedrooms at home; they have living rooms and dining rooms full of important items. If you want residents to feel at home, encourage them to bring some items for decorating these public rooms. The decor may be somewhat eclectic, but it can also promote the sense that this is their space. Some facilities have had great success letting residents bring in their favorite chair for the living room, while others have found this caused problems when someone other than the "owner" sat in it. This may need to be tried out on an individual basis. And there will be problems with some chairs and fire regulations (which vary from state to state). It is sometimes possible to have cushions treated sufficiently to make them flame retardant and suitable for bringing into the facility.