Restorative Value of Outdoor Environments

“This is my world now; it's all that I have left. You see, I am old and I'm not as healthy as I used to be. I'm not necessarily happy with it, but I accept it. Occasionally, a member of my family will stop in to see me. He or she will bring me some flowers or a little present, maybe a pair of slippers, I have 8 pairs. We'll visit for a while and then they will return to the outside world and I'll be alone again.”

A son in his mother's nursing home room found this note and others after her death.

These words give us some insight into life in a long term care facility, from the inside and the perception of those who live in these facilities. Also, it reinforces the importance of planning and designing long term care facilities, both interior or outdoor space, as for most it will be their world.

Profile of Today’s Resident

The profile of residents residing in long term care facilities has dramatically changed. They are older, frailer, and less mobile with as high as 60% with some degree of cognitive impairment resulting in a more complex resident population.

This is why many provinces are redeveloping many of the facilities that were built in the 1960-70's that don't provide the therapeutic environments or meet the expectations of today's residents or recognize for most - its their world.

Impact of Environmental Design

This article attempts to demonstrate that sensitive, innovative design of both the interior and exterior of long term care facilities and the provision of visual access throughout help reinforce the reality of the world around our residents.

Living environments influence our quality of life including our health. If we are to have humane and normalized environments that support independence and emphasize dignity and personal choice, we must recognize that the way we design these settings does have a significant impact on health and well being.

To achieve these goals many long term care facilities have adapted the ten principles of the Eden Alternative. Edenizing surrenders the institutional point of view and adopts the human habitat mode that makes pets, plants and children the axis around which daily life in facilities turns.

To implement this philosophy facilities need to be designed with a lot of natural light so plants and trees will grow, animals can be accommodated and intergenerational programs such as child day care can be provided. These elements greatly enhance the feel of a facility and contribute to a living environment.

No matter how elegant and beautiful an environment, no matter how efficiently designed, no matter how safe - unless people can in some way participate in activities that affect their lives, the outcome is likely to be dissatisfaction and even illness. (Elizabeth C. Browley, Designing for Alzheimer Disease - Strategies for Creating Better Environments, 1997)

• as more residents spend most of their time in the "residential home area" distance and access become more important for resident participation.
• it is important to create a "homelike" environment; designers must inspect decisions regarding materials, finishes and surfaces from the standpoint of how these materials symbolically represent the residential imagery of the facility.

Considering for most residents it's their home where they sleep, eat, receive care and are entertained, we need to design so the things that are important at this stage of their lives can be presented in a positive way. Also, we need to understand the positive effect a well designed long term care facility can have on motivating staff, volunteers and acceptance by families and the community.

Much has been written about designing facilities for people with dementia, but it is important to recognize that many design features that benefit individuals with dementia benefit all residents.

Visual Access

Living in a more limited world, visual access is important in order to connect residents with the outside world and offer interesting choices for stimulating visual experiences. Designing for visual access reduces anxiety in both staff and residents, and assists residents in way finding. (Kristy Bennett, STRIDE June/September 2000)

In many of our existing facilities visual access is limited. Residents leave their room, walk up and down a corridor, only seeing outside space if a bedroom door is open or when moving to a lounge or other area of the home.

Bennett states, "The Australian experience has shown that the concepts of small, domestic, close to community, managing environmental stimulation, visual access, familiarity, planned wandering, privacy and community, security and safety and accessibility are particularly important in this regard".

These features enhance the resident's world and quality of life.

When we design living space around outdoor space, we open up the environment to give residents more light, sunshine and visual access in their world. Designs that provide visual access enhance the resident's world in the following ways:

• reinforces the real world by providing constant views to the world around them, e.g. seasons, plants, animals, other familiar points of interest.
• walking paths that provide visual access encourages mobility and make the journey a meaningful experience.
• living space designed around outdoor space allows residents to leave their rooms to view outdoor space and eliminates enclosed corridors and connects even the frailest residents with the outdoors.
• dining areas and lounges with interesting outdoor views enhance the experience and residents seem to stay longer.
• large bedroom windows or bay windows provide visual access for the very frail.
• corridors with small sitting alcoves or greenhouse windows offer greater visual access and natural daylight.
• town squares that exist in many facilities should feature views that connect residents with the normal life - cars, homes in the community, children playing and can convey a sense of generosity.
• familiar sites like a beauty parlour/barbershop, library, tuck shop, chapel help connect residents with there past life style.
• skylights provide natural lighting and sunshine in corridors, interior rooms, activity rooms, tub rooms and help connect residents with the outside world.

Many of the design features discussed are easier to incorporate in single storey facilities.

Brawley states, "Sunlight is a source of well being and provides residents with a sense of orientation, a subconscious reference to both the hour of the day and changing of the season."

Other visual stimulations that can enhance a resident's view of their world:

• use of pictures, murals that depict familiar landmarks or interesting scenes and plate racks in bedrooms or sitting areas that cannot be reached by the cognitively impaired.
• display counters along corridors add to the décor and provide interesting visual experiences. Display cabinets outside bedroom with personal artifacts or large display cabinets at the entrance to living space prompt residents to stop and look and helps with way finding.
• furnishings, antiques, artifacts from the past, fireplace create an interesting visual experience.
• interior gardens and water fountains bring what is normally outside inside for year round visual enjoyment.
• fish tanks create a calming visual experience.
• horticulture as a therapy, is becoming well recognized as a treatment modality in many health care settings. (Mitchell L. Hewson, Using Horticulture Therapy to Improve Quality of Life for People with Alzheimer Disease, 2001)

Therapeutic Parks

Therapeutic parks, interior courtyards, outdoor porches and the grounds around facilities can provide interesting, stimulating views. These areas should be accessible, secure and integrate with their environment on a sensory level. Entrances into and out of outside areas should be well defined.

Familiar environments will help a resident feel that they are in control and connected with their life long experiences by being exposed to things that are familiar, whether they be recognizable building elements, décor, familiar articles or outdoor scenes.

Designs of outdoor space must vary according to available space, microclimate and existing natural features, or perhaps present themes that are relevant to certain cultures or the geography of the area. A key guiding principle relevant to the design of outdoor space is the provision of an outdoor environment with the potential for numerous casual and organized events, which can complement on-going indoor activities. (Mary Jane Lovering, The American Journal of Alzherimers Care and Related Disorders/ Research, May/June 1990)

Endless wandering paths with safe walking surfaces of different textures with special attention to width and grade for wheelchairs. The layout should provide a stimulating visual experience.

• create "backyard setting" with raised flower gardens, herb gardens, rock gardens, vegetable gardens and trees.
• attractive, familiar backyard types of fencing attractively landscaped but providing unobtrusive security.
• colourful shelters, awnings and umbrellas make a visual statement in outdoor space.
• friendly, attractive, comfortable furnishings provide rest stations and the opportunity for privacy and socializing.
• create an attractive habitat with bird feeders, bird baths and aviaries to attract other types of residents - birds, squirrels and cats. (residents often state the most difficult things to leave were their pets.)
• to encourage and expand use of these areas, it is important to provide a barbecue pit, a sound system, lighting.
• Themes in outdoor space can offer familiar, interesting visual experiences.

These suggestions are not exhaustive and when developing outdoor space there is an opportunity to be innovative and creative and provide visual experiences that expand the residents’ world. As we care for an increased number of frail residents, the opportunity to enjoy outdoor space should be an important component of their care plan.

Design Example

For a floor plan demonstrating the application of the design features discussed, see the example in the print issue of STRIDE. The Regional Municipality of Niagara operates Douglas H. Rapelje Lodge, Welland, Ontario. Montgomery and Sisam, Architects and Chapman Murray Associates, Joint Venture Architects.

• consists of four 30 bed resident houses and a central building organized to create a range of courtyards.
• each house has endless wandering paths with an interesting configuration that provides visual access to an interior safe, secure courtyard.
• along the wandering paths are small rest areas with a view to the outdoors.
• each house has an activity room that views both the interior courtyard and a large therapeutic park located between two of the houses.
• each house has a dining room with spacious views of the surrounding area.
• wandering paths from the houses to the Town Square pass large spacious windows that overlook the therapeutic parks that have been designed with interesting themes.
• the Town Square has skylights and expansive window spaces that overlook the entrance so that the residents can see visitors coming and going, cars passing by and family housing. Also, the skylights provide natural light and sunshine.
• separation of "resident personal space" and "public space".

The design provides a warm, open and bright environment that provides continual contact with the outside world. Also, the natural lighting supports the concept of a living environment with plants, trees and interior gardens that residents enjoy year round.

Capital Funding

Architects and planning teams striving to create innovative designs are often hampered because of the limitations imposed by present capital funding.

It often results in traditional designs and prevents the use of technology that would enhance mobility, safety and independence for residents and assist staff with care needs.

As provinces such as Ontario construct 20,000 new beds and redevelop 16,000 existing beds, designs need to be evaluated, to identify best design practices and assure information is shared that will result in ongoing improvement of environments we create for the frail elderly.

Planning Team

Innovative, sensitive design of long term care facilities just doesn't happen. It takes creative, committed people who understand how the designs will function for users and set goals that generate solutions.

Selecting the right architect, and team members, will greatly influence design outcome.

"The expertise of innovative design professionals, armed with a practical knowledge of Alzheimer's disease, results of latest research, the ability to ask questions that identify problem areas and design skills to develop better solutions give rise to hope and real expectations for better care environments." (Browley)

There is a need to develop a philosophy that creates living environments.

Conclusion

It is important as we design long term care facilities that we acknowledge today's residents are different and for many we are creating their world.

We need to open our minds, be innovative and creative so the design outcome offers a therapeutic environment for the frail elderly.

Visual access and relationships and linkages between indoors and outdoors should be pursued wherever opportunities exist.

We need to walk a day in their world and design better worlds for today's residents.

After all "THIS IS MY WORLD NOW".