We’ve all heard the statistics surrounding the aging boomers: A near doubling of the number of people over 65 is expected by 2050.
While evidence-based design is often focused on acute care environments, there’s a growing body of research for long-term care, as well. The Rothschild Foundation, recognized for its support of improvements in this segment of healthcare, recently provided funding to The Center for Health Design (CHD) to conduct a systematic literature review to identify how residential care environments can enable health and well-being.
Looking at papers published since 2000, CHD’s Anjali Joseph and colleagues assessed the following: (1) resident health and quality of life, (2) resident safety, and (3) staff health and organizational outcomes.
A systematic review takes a very focused approach in determining what to review, and following the search, the authors reviewed 68 research studies to develop three models that link design strategies (e.g., medication safety zones) to environmental conditions (e.g., reduced distractions) and outcomes that can be measured following occupancy (e.g., medication errors).
As we age, limitations in physical function become increasingly common and are a significant factor in our ability to perform daily activities. We balance daily demands (environmental stress) with our personal competence, resulting in a person-environment fit (good or bad). The authors reviewed a number of papers that surround overall environmental quality that support this fit. These papers look at a range of environmental categories such as lighting, noise, cleanliness, homelike atmosphere, and privacy.
This evaluation of categories that make up the overall environment is linked to numerous outcomes, among them:
- Self-reported health
- Ability to conduct daily living activities
- Mobility and physical activity
- Agitation
- Aggressive behavior
- Medication use
- Stress
- Mood
- Social engagement
- Elopement behavior and wandering
- Cognition and disorientation
- Sleep disorders
- Family perceived satisfaction
- Job satisfaction affecting staff turnover and retention.
Although the review doesn’t focus on the use of specific tools, the authors reference two that have been used to evaluate overall environmental quality, including the Therapeutic Environment Screening Survey for Nursing Homes and Residential Care facilities (TESS-NH/RC), which was initially developed in 1990 by the Program on Aging, Disability and Long-Term Care at the University of North Carolina at Chapel Hill, and the Professional Environment Assessment Protocol (PEAP), initially developed by Norris-Baker (Center for Aging, Kansas State University) and colleagues in 1999.
Both focus on the evaluation of physical aspects of long-term care settings for residents with dementia.
As practical methods for evaluation, the TESS tool has been more widely used than the PEAP. While not included in the review, the Environmental Audit Tool (EAT), was created and subsequently validated in 2012, and also serves to assess the quality of environments for people with dementia. It’s purportedly easier to use and less time-consuming to complete than the TESS tool.
While the availability of tools to evaluate dementia-specific variables is readily available, the authors identify that there are fewer studies to understand the impact of the facility design on cognitively “intact” residents. They also note the limitations of some of the current research that include mixed results and small sample sizes.
Importantly, they highlight the lack of focus on staff outcomes in long-term care settings and a dearth of research in the area of resident safety and adverse events.
Clearly, we can do more to advance our understanding of these environments, but how? The authors provide guidance and suggest that to build the body of knowledge, future research should consider:
- Infections in residential and long-term care
- Medication errors
- Lighting to improve sleep, circadian rhythms, or balance and gait
- Aging-in-place supports
- Wayfinding for an aging, non-dementia population
- Room occupancy (private versus shared)
- Staff work stress and job performance.
The manuscript is currently in the peer-review process. Additional detail will be available in a journal following the finalization of an expert evaluation of the research methods, procedures, and quality.
