Interiors Feature: Dignified design

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Long-term care furnishings are interiors are better suited for residents' aging bodies, senses and desire for privacy.

Imagine a facility where there are no medication carts or nurses' stations, every room has its own private European shower and other conveniences abound.
A pipe dream, right?
Not necessarily. Foulkeways at Gwynedd, a continuing care retirement community in Gwynedd, PA, underwent a complete overhaul of its 40 skilled nursing beds in 2001.
"We're the only skilled facility in the United States with walk-in closets," executive director Douglas A. Tweddale boasts.
Today, the unit has four clusters of 10 private rooms. Each room is equipped with its own shower, storage area and double-locked door for medications. Each cluster has its own dining room and country kitchen.
Tweddale's facility soon could be the norm. As more facilities are taking resident dignity, privacy and independence more seriously, they are designing accordingly.
They also are thinking more about what it means to be elderly, and factoring in adequate lighting and acoustics, as well as furniture that is built for aging bodies and floor patterns that are not disorienting.
The baby boomers have a lot to do with this new approach to design, says Martin Valins, director of senior care at EwingCole Architects. As notorious foes of the aging process, they also are communicating the importance of living life fully to the end, he added.
"The nursing home is probably the most misunderstood, unloved, overregulated component of the continuum of care," he says. "So the nursing home really has to reinvent itself. The nursing home is itself becoming a place of wellness, rehabilitation, recuperation."
'Sense-ible' planning
Designing for residents now means taking into account changes in eyesight, hearing, balance, range of movement and other challenges.
"I would say on the whole we are seeing more designs that reflect greater sensitivity to these kinds of issues," says Margaret Calkins, president of I.D.E.A.S. Inc., a research, education and consulting organization based in Kirtland, OH. It focuses on environments for frail and impaired older adults.
"The challenge for the field is there are a lot of facilities that are older, that have bad lighting and shiny floors, and all the furniture is already bought."
One persistent problem facing the long-term care industry is that 40- and 50-something designers are creating facilities for people in their 80s and 90s, according to Gregory J. Scott, a partner at Reese, Lower, Patrick & Scott Ltd. of Lancaster, PA.
"That kind of disparity in age is huge when it comes to being empathetic to what the issues are with aging," says Scott, who frequently lectures on the topic of better designing for the aging population to various industry professionals.
Designers make common mistakes when creating long-term care facilities, he says. These errors include everything from inadequate lighting in the hallways to disorienting carpet patterns to large dining rooms that create hearing problems.
"None of this is new," he says, but it is becoming more important to acknowledge such information "because of the impact a well-designed environment can have on quality of life, regardless of age."
Encouraging activity
Lighting is a significant aspect of design that affects functionality, experts say.
Calkins said better lighting has been linked to residents' ability to eat independently, improve conversation and increase caloric intake.
One of the challenges with lighting is maintaining quality along with quantity, Scott says.
"It's real tricky to do, because you don't want it to feel like an operating room," he says.
He suggests multiple sources of lights with dimming in the lobby, corridors and dining rooms.
Furniture also is important when considering residents' sense of independence, experts say.
Calkins thinks facilities should purchase furniture in different heights and sizes to allow for physical differences among residents.
"There is not much recognition of individual variances of people that should be recognized in the size of furniture," she says.
She suggests buying dining or room chairs with variances of two inches so a 16-inch chair could accommodate a shorter person and an 18-inch chair could serve a taller person.
"I'd like to see more progress being made," she says. "That would potentially enhance function and seat comfort."
It's important to accommodate people of varying heights so they can sit correctly – knees bent, 90 degrees knees to hips and 90 degrees hips to trunk – agrees Pam Erickson, national sales manager with Space Tables.
"That will help people have a healthful dining experience," Erickson says.
The look of furniture also has a psychological impact, says Tim Maloney, chairman of Fincastle Chair. He said his Strasburg, VA-based company attempts to create traditional-looking furniture with a positive association.
"We look back to Chippendale and bring in that sort of association to our designs," he says. He believes his furniture also evokes confidence in residents because of its sturdy and stable appearance.
"Our stuff is sort of massive and it just says, 'this is a dependable destination,'" he says.
The industry has made a lot of progress in creating furniture for dementia residents. The Invacare Continuing Care Group, of St. Louis, for example, has a furniture series featuring drawers with large rubberized, easy-to-grab handles.
Toileting and bathing are areas that can notably raise dignity questions. Toilets that are easy to get on and off of without assistance help to foster independence and improved quality of life. The same is true for bigger shower areas, in resident rooms.
"When someone has to be wheeled through a common area in a sheet, right there you have lost the feeling of dignity," says Sandra Hodge of JSA Architects of Portsmouth, NH.
Other features that can help residents feel independent are leaning rails in corridors, higher vanities in bathrooms and double-assist rails near toilets and in showers, as well as towel holders that are fastened securely to the wall.
A room of one's own
While special furniture and design features can improve residents' functionality, experts agree that quality of life also indirectly makes a difference.
"If we can create something that looks and feels like home, then people will be inspired to live a longer and more productive life," says James M. Warner, principal of JSA Architects.
The concept of the single bedroom is a hot topic in long-term care design and research today. It speaks to the underlying issues of privacy, dignity and independence that capture the meaning of home, Valins says.
"It's the single most important issue that will be the dividing line between the excellent and non-existent," Valins says.
He believes that new nursing home buildings without private rooms will be obsolete.
"Those new homes without private rooms will find themselves in a tough business situation if they don't make that investment," he says.
Studies have found that private rooms provide a wide array of psychosocial benefits, according to Calkins of I.D.E.A.S. These include privacy for conversations, a greater sense of control over lifestyle and environment, and not feeling like an "unwilling observer" to others.
Single rooms also have advantages in isolating people to cut the spread of infection. Moreover, they have shown success in reducing anxiety and aggression in people with Alzheimer's. (For more on private and shared rooms, see sidebar on preceding page.)
Another quality-of-life trend that helps instill a sense of dignity and confidence is the creation of smaller neighborhood modules.
"Certainly, having a place where you feel comfortable and feel at home, whether you call it home or not, is incredibly important to quality of life," Calkins says.
Working model
Tweddale of Foulkeways at Gwynedd has personally seen the benefits of single rooms and small units on residents' quality of life.
When his facility underwent a complete overhaul in 2001, the goal of the project was to remove the institutional feel of the building and create a more social model.
After the transformation, weight loss among residents decreased, staff turnover has been reduced to almost zero, and he gets calls nearly everyday from people who are interested in moving into the facility.
"No one wants to be in healthcare, but if they have to be in an environment, they like this one," Tweddale says.

(Single) room with a view
It may pay, literally, to invest in private rooms, studies show.
Here are some reasons why:
- People prefer privacy (for conversations, for a sense lifestyle control, and for not feeling like an "unwilling observer" to others).
- Residents with dementia, anxiety and aggression often fare better in private rooms.
- Roommates can cause emotional distress.
- There is a reduced risk of nosocomial infections.
- It is easier to market private rooms.
- Staff spend less time managing roommate issues.
- Staff-resident communications improve.
- It could cost less than $2 a day more to build a private room (based on a construction cost analysis of 189 private and shared bedroom plans; assume mortgage of 7% interest for 30 years).
Source: Margaret Calkins, I.D.E.A.S. Institute. Information is based on an analysis of several studies.

Design disasters
Some mistakes to avoid – and ways to fix them – for your next renovation

Problem: Kitchen cabinets that are so high residents can't reach them
Solution: Install cabinets 15 inches above countertops.

Problem: Toilet seats that are too low to the ground
Solution: Install toilet seats 17 inches above the ground.

Problem: Hard-to-reach bathroom faucets and cabinets
Solution: Keep the faucet to the side of the sink. Install a medicine cabinet to the side of a vanity mirror. Install removable vanity doors below sink.

Problem: Noisy dining room
Solution: Install acoustical wall panels to absorb sound. Another idea is to build a coffered ceiling with a sheet vinyl floor.

Problem: Uneven lighting or lighting of the wrong intensity in the lobby
Solution: Install multiple sources of lights with dimming effect. Lights should be moderately bright (30 FC) and ambient.

Problem: Stairs whose color blends into the landing
Solution: Create a contrast in colors between the edge of the steps and the landing.

Source: Gregory Scott, partner, Reese, Lower, Patrick & Scott, Ltd., Lancaster, PA, 2006