Dementia Friendly Hospital Design: Key Issues for Patients and Accompanying Persons in an Irish Acute Care Public Hospital

Abstract

Objectives:

Research was conducted to investigate the impact of the hospital environment on older people including patients with dementia and their accompanying persons (APs). The article presents key research findings in the case study hospital.

Background:

For many patients, the hospital is challenging due to the busy, unfamiliar, and stressful nature of the environment. For a person with dementia, the hospital experience can be exacerbated by cognitive impairment and behavioral or psychological symptoms and can therefore prove to be a frightening, distressing, and disorientating place.

Method:

The findings are based on a stakeholder engagement process where the research team spent approximately 150 hr observing within the hospital, administered 95 questionnaires to patients and/or APs, and conducted 12 structured interviews with patients and APs. A thematic analysis was employed to analyze and generate key themes emerging from the process.

Results:

Themes were grouped into overarching issues and design issues across spatial scales.

Conclusion:

This research confirms the negative impact of the acute hospital setting on older people with cognitive impairments including dementia and delirium. The multiple perspectives captured in this study, including most importantly people with dementia, ensure that stakeholder needs can be used to inform the design of the hospital environment. The research points to the value of understanding the lived experience of the person with dementia and APs. The voices of patients, particularly persons with dementia and their APs, are a crucial element in helping hospitals to fulfill their role as caregiving and healing facilities.

Keywords

dementia-friendly design thematic analysis case study acute care hospitals hospital architecture and design healthcare design evidence-based design

Background

Dementia is an umbrella term to describe a group of disorders caused by several diseases and conditions, with Alzheimer’s disease and vascular dementia being the most common (Cahill, O’Shea, & Pierce, 2012b). According to the Lancet Commissions on Dementia Prevention, Intervention, and Care (Livingston et al., 2017), there are approximately 47 million people currently living with dementia, with this number expected to triple by 2050; supporting the assertion that dementia is “the greatest global challenge for health and social care in the 21st century” (p. 1), the Commission acknowledges advances in knowledge around prevention and management, including the role of the pharmacological, psychological, social, and environmental interventions. Furthermore, specific to the built environment, the Commission points to the role of the environment regarding managing the symptoms of dementia, supporting carers, and its potential for improving cognition through environmental enrichment. Referring to Burns (2001), Fleming and Bennett (2014) outline some of the main symptoms of dementia including cognitive impairment (including amnesia, aphasia, apraxia, agnosia); Behavioral and Psychological Symptoms of Dementia (BPSD) (including depression, delusions, hallucinations); behaviors such as wandering, incessant walking or agitation, and dysfunction in activities of daily living, such as difficulties with shopping, driving or handling money, and in the later stages, more basic tasks such as dressing, eating, and bathing.

Dementia is an umbrella term to describe a group of disorders caused by several diseases and conditions, with Alzheimer’s disease and vascular dementia being the most common.

Given that increasing age is one of the strongest risk factors for dementia (Cahill, O’Shea, & Pierce, 2012a), it is also important to consider other age-related changes that a person with dementia may experience such as physical frailty, mobility difficulties leading to increased risks of falls, visual impairments, hearing loss, and circadian rhythm difficulties (Dementia Services Development Centre [DSDC], 2012). These impairments may be exacerbated in a person with dementia as they may fail to comprehend or compensate for these difficulties (Marshall, 2009).

With these impairments in mind, the hospital setting can prove challenging for many people due to an unfamiliar environment, stress, and possible sleep deprivation (Hanley, 2004). This may lead to poorer health outcomes, particularly for a person with dementia. When a person with dementia becomes hospitalized without the dementia having been diagnosed, their condition can worsen and may lead to additional problems such as injuries, malnutrition, and over or under medication, among others (Galvin et al., 2010).

…the hospital setting can prove challenging for many people due to an unfamiliar environment, stress, and possible sleep deprivation (Hanley, 2004). This may lead to poorer health outcomes, particularly for a person with dementia.

Unfortunately, many hospitals are not age or dementia attuned. Research by Barnes, Torrington, and Lindquist (2016) found that the acute care settings examined in their study did not adequately meet the needs of older patients, nor did the design reflect the importance attributed to the hospital-built environment by patients, family carers, or staff (Haywood, Barnes, Marsh, & Parker, 2018). Looking specifically at patients with dementia, Moyle, Olorenshaw, Wallis, and Borbasi (2008) argue that many hospitals are not designed to care for these patients, and this not only undermines their care (see Galvin et al., 2010) but also adds to the burden of care for the staff. According to these authors, negative factors in the typical hospital can include communication difficulties due to the busy hospital setting, multiple and competing stimuli, and inability to deal with wandering. They also speak about the important supporting role of family members and caregivers, a role which is often hard to maintain within the hospital setting (Li et al., 2003).

The Irish National Dementia Strategy (Department of Health, 2014) states that up to 29% of patients over the age of 70 entering acute care public hospitals in Ireland may have dementia. The Irish National Audit of Dementia Care in Acute Hospitals 2014 (de Siun et al., 2014) found that 94% of hospitals had no dementia care pathway and that people with dementia often experience poor health outcomes, remain longer in hospital, and are at greater risk of mortality once admitted. Among numerous themes, the audit identifies the importance of the “physical ward environment” and reiterates the challenges presented by the hospital settings. It acknowledges that hospitals are designed primarily for surveillance, security, and infection control and therefore are incompatible with the needs of people with dementia. The audit presents issues concerning the physical environment including a lack of orientation cues, including clocks, calendars or personal possessions, inadequate wayfinding or signage, and a minimal use of dementia friendly color schemes or labeling.

Considering the sensitivity of a person with dementia to their environment, and the challenging nature of hospitals, it is not surprising that the Irish National Dementia Strategy or the Irish National Audit of Dementia Care in Acute Hospitals refers to the design of the built environment as a priority. However, while there is good research looking at specific areas within the hospital, including emergency departments (EDs; for instance, Birrer, Singh, & Kumar, 1999, Clevenger, Chu, Yang, & Hepburn, 2012, Cunningham & McWilliam, 2006) and inpatient wards (for instance, Andrews, 2013; Baille, Cox, & Merritt, 2012; Innes, Kelly, Scerri, & Abela, 2016; The King’s Fund, 2014; Waller, 2012), there is less that looks at people’s experiences of the physical hospital environment across the full spatial spectrum of the hospital, from campus location, down to internal spaces and building components. To address this, the current research used the case study hospital to examine issues relevant to dementia across a range of spatial scales, eliciting stakeholder feedback that presents a more integrated perception of the entire hospital.

Outline Description of Case Study Hospital

Tallaght University Hospital has a catchment population of approximately 450,000 people and sits on a 12-hectare campus located in medium density modern suburb of a large city. With a floor area in excess of 120,000 m², the hospital is spread over four floors, contains over 500 beds and approximately 3,000 staff, and provides child health, adult, psychiatric, and age-related healthcare on one site. The hospital campus is adjacent to the center of the suburb, well integrated in the community, and is well served by public transport.

Research Methodology

The findings presented are based on in-depth stakeholder engagement using questionnaires and structured interviews with patients and accompanying persons (APs). The study described herein met human subject protection approval. Considering that dementia mainly affects older people, often defined as people who are 65 years or older (Livingston et al., 2017), this research has largely focused on this older patient group. Given the general nature of acute hospitals and the need to cater to a diversity of patients, this research did not exclude older people without a diagnosis of dementia or mild cognitive impairment (MCI) as it was felt that their perspective was an important part of this study. Furthermore, due to the limited access to patient health information, and cases of undiagnosed dementia or MCI, it is difficult to confirm the exact percentage of patients surveyed who had these conditions. Notwithstanding this, 35% of patients in this research were identified having dementia, an MCI, or were attending a “Memory Clinic.” For the purposes of this research, an AP is used to describe a third party, typically a person such as a family member, close friend, or professional carer external to the hospital. A thematic analysis was conducted in line with Guest, MacQueen, and Namey (2012) to analyze and generate key themes emerging from the stakeholder feedback, and these themes in turn form the basis of key findings and discussion. The overall methodology is outlined in Figure 1, and briefly described below.

Figure 1.

Overview of Research Methodology

Identification of Main Hospital Areas

One of the primary aims of this research was to examine patient experience across the full hospital environment, that is, from the broad experience of approaching the campus, down to more immediate experiences within the building such as the use of furniture or thermal comfort. To enable this multiscale analysis, a spatial framework was employed that consisted of hierarchical spatial layers that start with the large scale of the hospital site and finish with small-scale components or directly experienced internal environmental conditions. This framework included site location, campus approach and entry, on-site circulation, building entry and internal circulation, main internal spaces, building components, and internal environment.

Due to time and resource limitations, as well as the size and complexity of the hospital, it was important to choose main areas, within the above spatial scales, that are frequented by older patients and people with dementia, as a focus for this research. To identify these areas, the research team consulted with patient-facing staff and management, examined architectural plans, conducted staff guided and independent hospital walk-throughs, and carried out on-site observation sessions. These exercises allowed the research team to select the key hospital areas for further examination, including the public areas, the age-related health outpatients clinic in the Outpatients Department (OPD). The geriatric medicine day hospital (DH) and ward, the acute medical assessment unit (AMAU) and the acute medical unit (AMU), the Emergency Department (ED), and representative inpatient wards. The final selection of these key areas was validated by a steering committee, comprising senior administrative and medical staff, patients, and people with dementia, with knowledge of and experience in the case study hospital.

Stakeholder Mapping: Identification and Selection of Patients and APs

Participants selected for this research fell into one of two stakeholder groups: patients and APs. Table 1 outlines the selection criteria for participants and the aims of data collection methods. Using this criteria, patients and APs were identified from within key hospital areas. With the assistance of the hospital staff, patients and APs were provided with information about the project and invited to take part through questionnaires or structured interviews. Table 2 provides an overall description of the sample of patients and APs. Table 3 provides information on the area of the hospital the stakeholders originated from and the data collection method(s) employed. 35% of the patients selected for this study were identified as having dementia, an MCI, or attending a “Memory Clinic.”

Table 1.

Stakeholder Selection Criteria.

Stakeholder Group	Selection Criteria
Patients and accompanying persons (APs)	Older persons who are an inpatient/outpatient/visitor to the hospital. Where a person selected to participate in a structured interview or fill out a questionnaire had received a diagnosis of dementia, participation was based on their own comfort level with respect to their diagnosis; guidance from hospital staff was sought to confirm suitability for study. AP is a family member/friend/carer/trusted figure, and who accompanies the older person with memory problems or dementia, in a carer capacity (no restriction on age, gender). Participant, whether this is a patient or an AP, is able to engage in interviews or complete a questionnaire. In the instance of the older person, they are able to do so alone, or in the company of their carer or staff member. Ability of participant (patient or an AP) to understand the questions and objectives of the research.

Stakeholder Group

Selection Criteria

Patients and accompanying persons (APs)

Older persons who are an inpatient/outpatient/visitor to the hospital.

Where a person selected to participate in a structured interview or fill out a questionnaire had received a diagnosis of dementia, participation was based on their own comfort level with respect to their diagnosis; guidance from hospital staff was sought to confirm suitability for study.

AP is a family member/friend/carer/trusted figure, and who accompanies the older person with memory problems or dementia, in a carer capacity (no restriction on age, gender).

Participant, whether this is a patient or an AP, is able to engage in interviews or complete a questionnaire. In the instance of the older person, they are able to do so alone, or in the company of their carer or staff member.

Ability of participant (patient or an AP) to understand the questions and objectives of the research.

Table 2.

Overview of Participants in Study: Patients, n = 99; SI (12), Q (87), and Accompanying Persons (APs), n = 24; SI (16), Q (8).

Patients (n = 99)			No. of Patients With Dementia and/or MCI
Age Category	No.	Gender (Male/Female)
20–44	3	0/3	Not known
45–64	5	3/2	Not known
65–74	26	13/13	8
75–84	45	15/30	20
85–94	19	8/11	7
95–104	1	1/0	0
APs (n = 24)
Age Category	No.	Gender (Male/Female)
20–44	5	2/3	n/a
45–64	7	1/6	n/a
65–74	6	2/4	n/a
75–84	6	3/3	n/a
85–94	n/a	n/a	n/a
95–104	n/a	n/a	n/a

Note. In the case of the structured interviews, all patients had an AP with them. As such, the research team conducted joint interviews (i.e., with patients and their APs). Furthermore, in some cases, the structured interviews could have as many as three participants (i.e., one patient and up to two APs). This explains the overall number of APs participating in the structured interviews (n = 16), being higher than the overall number of completed interviews (n = 12). With respect to the interviews, 4/12 interviews, the patient had two APs with them. Of the questionnaires returned, 87 were completed and returned by patients, and 8 were completed and returned by an AP. All patients who participated in the structured interviews (n = 12) were selected based on a previous diagnosis of dementia or mild cognitive impairments.

The table shows that 8% of patients were under the age of 65. It is unclear form the completed questionnaires returned by these individuals whether or not they had early-onset dementia or had been diagnosed with a mild cognitive impairment. With that in mind, and notwithstanding the fact that the research focuses on the perspectives of older persons (65 and over) and APs, the research team chose to include the perspectives of patients between the ages of 20 and 64, as the research team considered that the perspectives enriched the overall results and findings.

Table 3.

Stakeholder Groups, Hospital Areas, and Data Collection Method.

	Area of Hospital					Data Collection Method
Stakeholder Group	Outpatients Department	Day Hospital	Acute Medical Unit	Emergency Department	Inpatient Wards	Q (All Areas of Hospital)	SI (OPD only)
Patients (including persons with dementia, MCI, or attending memory clinic; %) and accompanying persons	n = 57	n = 17	n = 10	n = 0	n = 23	n = 95	n = 12

Note. All of the structured interviews took place in the OPD, while the questionnaires were distributed across all areas of the hospital (OPD, DH, AMU, ED, and IPW). For the purposes of this research, the definition of stakeholder is taken from ISO 21500—Guidance on project management, which defines a stakeholder as a person, group, or organization that has interests in, or can affect, be affected by, or perceive itself to be affected by, any aspect of the project. n = sample size; Q = questionnaire; SI = structured interview.

Data Collection

Using the spatial scale framework, both a questionnaire and a structured interview template were developed to understand how an older person, including a person with dementia, their families, or carers, experience the physical hospital environment. The questionnaire is included as Online Appendix A. The questionnaire, which employed a Likert-type scale approach, was developed and pretested by the research team in line with Sommer and Sommer (2002). At the end of each section of the questionnaire, there was also space for participants to provide additional comments or information to supplement the set questions in each section. In total, 225 questionnaires were distributed throughout the key hospital areas; of those, a total of 95 stakeholder questionnaires, completed by patients and/or APs in key areas of the case study hospital, were returned by post between May and November 2016. In addition, the research team conducted 12 structured interviews with patients and APs attending the age-related health clinic, which took place every Wednesday afternoon in the OPD of the case study hospital between April and May 2016. Participants for the structured interviews were selected by the age-related health clinical nurse manager overseeing the age-related health clinic in the OPD. The research team were provided with a consultation room (in the OPD) for interviews. Two research team members conducted the interviews with the selected patients and/or APs. A schedule of interviews is attached as Online Appendix B.

Thematic Analysis

Comments from the structured interviews and questionnaires were reviewed, analyzed, quantified (i.e., the number of times it arose—where a participant made multiple but similar comments, this was recorded as one comment) and compiled into short concise statements or codes. These codes were combined to generate themes and grouped according to the spatial framework described previously. The thematic analysis generated >140 codes, which were grouped into 33 separate themes. Some themes were generated from codes associated with a single comment, while others emerged from codes with up to 37 comments (see Table 4). Considering the high number of themes and for the sake of brevity in this article, the research team decided to prioritize and report on themes generated from 10 comments or more.

Table 4.

Group 2: Specific Spatial Scales.

		Frequency
		P/C
Themes relating to site location, approach, and entry	Location	1
	Issues relating to hospital arrival and departure	3
	Lack of direct access from public transport	10
Themes relating to on-site circulation	Site aesthetics	2
	Site layout and site design issues	12
	Traffic volume and parking generally	36
	Pressure on carers and APs due to parking challenges	16
	Problems with the car park building	26
	Campus lighting	1
	Campus signage	1
	Issues around outdoor seating	14
Themes relating to building entry and internal circulation	Problems with main entry doors	22
	Importance of a good reception area	11
	Wayfinding and orientation challenges within the hospital	37
Themes relating to main internal spaces	Issues related to hospital street	3
	Café and cafeteria	8
	Issues with toilets	13
	Lack of space	11
	Layout/configuration of spaces	1
	Lack of support for people with disabilities	1
	Interior design of space	11
Themes relating to building components	Issues with signage	22
	Wheelchair availability	13
	Issues with TV	6
	Issues with chairs	8
	Issues with the handwashing stations	3
Themes relating to internal environment	Challenges regarding the internal environment	13
	Noise levels are an issue	10
	Hospital smells	3
	Lighting issues	5

Note. Priority themes are given in green.

Key Findings and Discussion Based on Overarching Issues and Priority Themes

As discussed in the Method section, the hospital was examined in line with several key spatial scales. Across these scales, several key areas were identified that are most relevant to patients. Figure 2 presents stacked floor plans of the hospital to show the hospital across the six spatial scales, to identify the key focus areas, to illustrate the main horizontal and vertical circulation, and the relationships between the various focus areas. As shown, all patients enter through the main campus entrance and proceed along the main access road by car or foot to either the public car park or the main hospital entrance, the ED entrance, or the geriatric department entrance. Once inside the hospital, most of the horizontal circulation is along the hospital street, while vertical circulation is primarily via the central public stairs and lifts. Most of the outpatient, acute, or emergency facilities are located on the ground floor, while the general inpatient wards are located on the upper floors, Levels 2–4. The main issues emerging from the thematic analysis were organized according to the spatial scale framework. Figure 3 illustrates the findings according to the spatial scale, and these are discussed in detail in the following sections. Findings are grouped according to the following: (1) overarching issues (i.e., cutting across all spatial scales) and (2) themes by spatial scales.

Figure 2.

Stacked floor plan of case study hospital.

Figure 3.

Key Findings

Group 1: Overarching Issues

Hospital environments are challenging for older people, including people with dementia

Patients are frequently transferred from one part of a hospital to another, depending on their needs and severity of their illness. Transfer of patients represents challenges, particularly for people with dementia due to changes in environment and staff, leading to disorientation and confusion. Due to constant movement, activity, and clinical nature of the hospital setting, patients and APs revealed a familiar aspect in relation to hospitals: They are busy and chaotic spaces that are especially difficult for an older person, including a person with dementia. Furthermore, sensory overload such as sound, lack of familiarity, disorientation, and difficulties in wayfinding due to the large-scale, complex, and often visually monotonous nature of the hospital contribute to the challenging nature of these environments, particularly for people with dementia.

The importance of AP support and the impact of the physical environment

Stakeholder feedback emphasizes the important role of APs to act as familiar and trusted carers within the hospital. APs in the case study hospital are relied upon by patients to successfully navigate the hospital environment; however, issues regarding poor signage and wayfinding within the case study hospital hinder AP ability in this regard. Furthermore, lack of space and facilities further exacerbate the AP’s ability to support the patient throughout the hospital journey. Specific issues have been identified across the spatial scales, and these are further discussed below (Group 2). It is worth noting the frustration expressed by many APs, particularly in relation to the challenges they experience regarding parking, the lack of adequate and safe drop-off zones in front of the hospital entrance, and, once inside the hospital, the lack of seating in waiting areas. A number of APs were forthright regarding the undue stress caused by the parking facilities in the case study hospital, with one individual noting that parking is “expensive and unpleasant”(SI-AP1), while another expressed their frustration regarding the parking facilities in the case study hospital as follows: “Parking (DISASTER!!!). IN EVERY HOSPITAL, WHEN CONTEMPLATING BUILDING NEW HOSPITAL, PLEASE BUILD CAR PARK FIRST!!!” (Q-AP2, stakeholder emphasis). Lastly, as reflected in Table 4, it has emerged from the stakeholder engagement that the AP, particularly a partner or sibling, may also be an older person with age-related impairments. Referring to the large size of campus of the case study hospital, one AP noted the challenge imposed by the distance between the car park facility and the main entrance: “I had a sore foot. I found it difficult to walk from parking” (Q-AP 3). Across the spatial scales, the research points to the case study hospital presenting several challenges on AP ability to fulfill their role as caregivers and provide support in relation to the full patient journey.

Patient perception of the built environment

The analysis of the data revealed that while patients and their APs rated certain built environment elements encountered during their visit to the hospital poorly, they went out of their way to share their opinions regarding the quality of care received and the efficiency and helpfulness of the staff in delivering that care. This would suggest that despite less than favorable ratings related to several built environment elements encountered during their hospital visit, patients and APs create a positive association with the hospital based on satisfaction related to quality of care received.

Group 2: Themes Specific to Spatial Scale

Site location, approach, and entry

Figure 4 presents respondent ratings regarding the location of the hospital, comfort and safety of adjacent areas and streets, and impressions relating to access to the hospital across various modes of transportation. Favorable ratings were recorded across all elements on questions related to this spatial scale; however, further analysis points to an issue with public transport, discussed below.

Figure 4.

Results: Site location, approach, and entry.

Priority theme 1: Lack of direct access from public transport

APs noted that with respect to the bus, it would be “better if there was a bus stop on the hospital campus” (SI-AP 4) as the location of the current bus stop is perceived as a “bit of a walk,” (SI-AP 4) especially for an older person, a person with dementia, or a person with mobility issues. Excessive distance from the light rail stop to the entrance of the hospital was also the reason cited for why patients and APs are not inclined to use the light rail as a means of getting to the hospital.

On-site circulation: Moving around the hospital grounds

Figure 5 focuses on respondents’ impressions with respect to the following: wayfinding on hospital grounds, degree of calm and safety on hospital grounds, including paths and external lighting, provision of outdoor seating and resting places, parking facilities, and convenience from car to main hospital entrance. Generally, the ratings for elements related to on-site circulation received a mixed response. Priority themes emerged and are discussed below.

Figure 5.

Results: Moving around hospital grounds.

Priority theme 2: Site layout and site design issues

Site layout and design appears to exacerbate the pressure placed on the AP to effectively navigate the hospital campus environment. According to feedback from both patients and APs, there is a need to incorporate more pedestrian crossings on campus, as well as improving the footpaths to accommodate the volume of pedestrian traffic (see Figure 6); however, regarding the pedestrian crossing located between the car park building and the hospital, the placement of the car park in such close proximity to the ED has contributed to an overall negative perception by both patients and APs of the hospital grounds with regard to them being safe and calm.

Figure 6.

Pedestrian path at the case study hospital.

Priority theme 3: Traffic volume and parking generally

73% of respondents use the car as the main mode of transport to and from the hospital, of whom the highest proportion are those attending the age-related health outpatients’ clinic. It can be difficult to find parking during a busy day at the hospital. Insufficient disability parking was also a key concern.

Priority theme 4: Problems with car park building (see Figure 7)

The parking spaces in the car park are viewed as difficult to maneuver owing to their being too tight; furthermore, many patients and APs avoid parking on the upper floors due to the tight turning radii on the ramps between the levels and the concern that it is not easy for an older person with mobility issues to navigate through the car park environment when traveling down from an upper level. Lastly, one respondent noted the issue of accessibility in relation to the pedestrian crossing leading to and from the car park facilities: “zebra crossing from multi-storey [carpark] to hospital is poorly designed; when wheeling patient from hospital to car, there’s an edge on path onto crossing and it toppled patient from wheelchair”(Q-AP 5).

Figure 7.

Car park facilities, case study hospital.

Priority theme 5: Issues related to outdoor seating

Outdoor seating was rated poorly by respondents. While there was an acknowledgment that a place with some chairs to stop and regroup would be beneficial, particularly for patients with dementia, with regard to external seating, the “issue is smoking; nice to have seating but…doesn’t work” (Q-AP 6).

Priority theme 6: Pressure on APs due to parking challenges

In many cases, one AP is not sufficient. Having only one AP can mean that the patient must navigate a busy car park, and once that is accomplished, the person is then expected to successfully negotiate a significant distance from the car park building, including the pedestrian crossing, which has been highlighted as problematic due to its closer proximity to the ED than to the hospital main entrance. For an older person with mobility issues or a person with dementia wayfinding through a hospital campus, the size of the case study hospital can be a stressful experience; one respondent noted that it takes her father “20 mins to walk from the carpark to the main entrance as he needs to stop and look at things” (SI-AP 7). Some patients have a minimum of two AP join them for their hospital visit; this reduces the risk of a patient wandering off while their carer or family member is parking the car, and the stress and worry for the AP who is parking, knowing someone is with their family member or patient.

Building entry and internal circulation

Figure 8 outlines respondents’ impressions with respect to the following: hospital entrance, ease of use of hospital doors, orientation inside the hospital, and overall impressions of the hospital interior. Overall, impressions regarding building entry and circulating throughout the hospital were rated favorably. However, some issues arose, and these are discussed below.

Figure 8.

Results: Going in, finding way inside.

Priority theme 7: Problems with main entry doors

Key aspects leading respondents to give a less than favorable rating to the entrance doors include concerns with the weight and stiffness of the side doors and high levels of apprehension vis-à-vis the automatic rotating doors, leading most individuals to avoid them altogether, opting instead for the side doors (see Figure 9). One respondent stated that regarding accessibility neither door option is suitable; specifically, it is “impossible for wheelchairs if you have to use the side doors. Can’t hold them (the doors) and push the wheelchair, and yet, you can’t use the rotating door either. Very awkward” (Q-AP 8). The issue concerning the degree to which the automatic revolving door is both easily recognized and identifiable can be inferred from the following comment from an AP who stated that “Dad couldn’t find the door, but mum could” (SI-AP 9).

Figure 9.

Main entrance, case study hospital.

Priority theme 8: Importance of a good reception area

A good reception area will ideally provide patients and APs with a good starting point from which to navigate the internal hospital environment. A range of stakeholder views emerged regarding the reception area in the case study, with some viewing the reception as helpful and others foregoing it altogether.

Priority theme 9: Wayfinding and orientation challenges within the hospital

Patients and APs felt that the hospital is difficult to navigate due to having to move through too many corridors, especially on a first visit (i.e., scattered, big, and confusing). With respect to a first visit, there can be a higher demand on new patients to navigate the hospital environment (i.e., during a first visit, patients and their APs are sent for multiple tests, scheduled in different areas of the hospital, usually off the busy hospital street). Wayfinding difficulties are not restricted to patients attending the age-related health outpatients’ clinic. The location of certain tests and facilities (e.g., toilets) will lead to patient disorientation. Impressions regarding ease of orientation once inside were generally rated favorably; however, examination of the responses across interviews and questionnaires highlights that there are challenges associated with wayfinding and orientation. It is worth noting that patients and APs will ask someone for directions. In many cases, patients and APs will go straight to staff (i.e., will not use the signage) for assistance in navigating the hospital environment.

The uniformity of internal hospital spaces was identified as an issue that negatively impacts patient and AP ability to successfully navigate through the hospital environment. Findings highlight that consistent look of corridors (across all hospital levels), coupled with poor signage or signage that is ambiguous at best, contributes to an environment that patients find disorientating. One AP described being late for an appointment due to getting lost in the hospital as “unfair” (SI-AP 7).

The uniformity of internal hospital spaces was identified as an issue that negatively impacts patient and AP ability to successfully navigate through the hospital environment.

Main internal spaces

Figure 10 highlights stakeholder perspectives regarding the main spaces in the hospital. Overall, the main spaces in the hospital were rated favorably by patients and their carers. Priority themes are discussed below.

Figure 10.

Results: Main spaces within hospital.

Priority theme 10: Issues with toilets

Despite the favorable rating captured in relation to toilets, 13 respondents highlighted problems, including not enough, too small, not accessible, being unclean, and odors. For wheelchair-accessible toilets, individuals must go to the OPD. The availability of wheelchair/hoist-friendly toilets needs to be addressed as the lack of these types of toilets is not ideal for patient comfort.

Priority theme 11: Lack of space (see Figure 11)

Respondents stated that the corridor leading to the age-related outpatient clinic is too narrow and that the space in the clinic itself is too small and tight for the volume of people. As previously noted, parking challenges translate into patients being accompanied to the hospital by at least two persons, and during a busy clinic, one appointment for one person could result in three people in the waiting area. Staff noted clinic ebb and flow impacts the capacity of the waiting room to cater to patients with respect to seating availability and wheelchair space.

Figure 11.

Cluttered space, case study hospital.

In relation to other key areas in the case study hospital, it is worth noting that owing to configuration and layout of the AMU, there is no space for pacing; this is an issue, particularly for persons with dementia, for whom space for pacing and walking is beneficial.

Priority theme 12: Interior design of space

The responses to interior design reflect a favorable view of the case study hospital among patients and APs. Specifically, patients and APs perceived the internal environment as bright, clean, and calm.

Building components

Figure 12 highlights stakeholder responses in relation to a variety of building components in the hospital environment. Challenges with regard to the signage and wheelchair availability are discussed below.

Figure 12.

Results: Building components.

Priority theme 13: Issues with signage

Findings show a less than favorable rating overall with regard to signage throughout the hospital. Eighteen respondents stressed that signage is problematic due to the number of signs (i.e., too few vs. too many), the size of the signs, as well as their positioning and visibility, and the use of hospital terminology. In addition, the signage that is used to identify each floor contains conflicting text regarding the number of that floor, that is, “first floor is level 2 and second floor is level 3” (Q-AP 10), and this leads to confusion regarding a person’s location within the hospital (see Figure 13). In addition, one respondent noted “ground floor is like a maze” (Q-AP 11).

Figure 13.

Conflicting signage, case study hospital.

Priority theme 14: Wheelchair availability

Patients and APs requiring a wheelchair when arriving at the hospital find it difficult to locate one. One respondent added that if wheelchairs were freely available, this would reduce the need for two carers down to one.

Internal environment

Figure 14 includes ratings on following internal hospital environment issues: comfort level with respect to heating, degree of fresh air and ventilation, lighting, noise, smells, and overall impressions on the degree to which the internal environment is calm and pleasant. Overall, respondents rated internal hospital environment favorably; however, despite the generally favorable ratings, the thematic analysis identified two issues, discussed below.

Figure 14.

Results: Internal environment.

Priority theme 15: Challenges regarding the internal environment

While the internal environment might be described as too hot for some, it may be too cold for others, and still, others may find it just right. Consideration should be given to how best to balance the internal environment in the context of infection control regulations.

Priority theme 16: Noise levels are an issue

Findings from the thematic analysis highlight that for some patients, particularly those in the AMU, noise is a concern, with one patient describing the environment as “not calm”; and another pointing with ‘people coming and going at all hours” (Q-P 1) when describing the negative impact of noise levels.

Limitations

This study has three main limitations. Firstly, not all areas of the hospital were covered due to time and resource limitations. Secondly, a nonvalidated questionnaire was used to gather stakeholder data. Finally, due to limited access to patient health information, and the potential cases of undiagnosed dementia or MCI, it is not possible to confirm the exact percentage of patients surveyed who had dementia or MCI.

Recommendations and Future Research

This article focuses specifically on the issues experienced by patients and APs in the acute hospital environment and does not provide solutions to address these issues. Considering that this research illustrates many design-related challenges for patients and APs, an obvious overall recommendation is that dementia friendly hospital design should be employed, and there are guidelines available in this regard (i.e., DSDC, 2012; Fleming & Bennett, 2014; Grey et al., 2018; Waller, Masterson, & Finn, 2013). However, stemming directly from this study, the following recommendations and future research are proposed:

Similar case studies should be conducted for a cross section of Irish hospitals including large, medium, and small facilities in rural, suburban, and urban settings.

Validate the questionnaire using an established questionnaire development process (for instance, Rattray & Jones, 2007).

Conduct further research into the needs and preferences of APs in the hospital setting.

Conclusion

This research illustrates many negative issues for older patients and people with dementia within acute hospitals and therefore resonates with similar existing studies in this area (e.g., Barnes, Torrington, & Lindquist, 2016; de Siun et al., 2014; Haywood et al., 2018; Moyle, Olorenshaw, Wallis, & Borbasi, 2008). Hospitals are busy, complex, unfamiliar, and often inhospitable environments. These negative attributes are exacerbated by frequent patient transfer within the hospital, which can lead to additional disorientation and add stress.

While many issues were identified throughout the hospital, key difficulties include parking, spatial disorientation, problems with wayfinding, particularly around signage, and a general lack of space within wards for socialization, activities, walking, and exercise.

Stakeholder feedback emphasizes the important role of APs to act as familiar and trusted carers within the hospital; however, findings point to a lack of support for APs, and this in turn has an impact on their ability to successfully navigate the hospital environment and potentially remain by the patient’s side throughout their hospital journey.

An important feature of this research is the examination of the hospital environment across a range of spatial scales. Taking a holistic approach with respect to examining the built environment of the case study hospital, the research reveals challenges across all scales, from a lack of direct access to certain public transport stops at the macro scale, down to issues around signage at the micro scale. For a hospital to support people with dementia, the built environment must be accessible and usable at all scales. For instance, well-designed internal signage is of little use to a person if they are prevented from reaching the building through external barriers such as inaccessible public transport or an unusable entrance door.

The research points to the value of understanding the lived experience of an older person, including the person with dementia and their AP. It is important to note that no two people with dementia will have the same experience with regard to their illness, nor will they have the same perspective in relation to the hospital environment. Similarly, APs may also be older persons, with age-related impairments that impact on their ability to remain at the side of the person with dementia throughout their hospital journey. In this regard, this research highlights that the voices of patients, particularly persons with dementia and their APs, are a crucial element in helping hospitals to fulfill their role as caregiving and healing facilities.

Implications for Practice

For various reasons, the hospital is a challenging place for older patients and people with dementia; however, these challenges can be alleviated by careful design. It is therefore incumbent on hospital designers to ensure that the environment addresses the needs of older patients and people with dementia.

Due to the high levels of supervision and care, when a patient with dementia visits the ED or outpatients department, they are often accompanied by two people. This increased number of visitors should be factored into space and seating calculations. In addition, for a person with dementia, the hospital experience is heavily influenced by the level of support they get from these APs; therefore, it is important that sufficient space and supports are provided for APs so they can remain with the patient for as much of the hospital journey as possible.

Due to cognitive impairments and loss of agency, there are practical difficulties associated with participatory design and people with dementia. Consequently, it is important that designers liaise with APs, including family members, friends, and carers, and healthcare professionals, and utilize specific approaches and tools to elicit feedback from people with dementia in an appropriate and sensitive manner.

For many patients, the hospital is challenging due to the busy, unfamiliar, and stressful nature of the environment (Hanley, 2004; Ulrich et al., 2008). For a person with dementia, these challenges can be exacerbated by cognitive impairment and behavioral and psychological symptoms of dementia and can therefore prove to be a frightening, distressing, and disorientating place (Galvin et al., 2010; Moyle et al., 2008). The physical environment of the hospital is a major part of this experience, and if not appropriately designed, can contribute to the stress and cognitive load experienced by a patient with dementia (de Siun et al., 2014; DSDC, 2012; Parker, Fadayevatan, & Lee, 2006; Waller et al., 2013). To investigate these issues, this case study looks at a large Irish acute-care public hospital (Grey et al., 2017) and reports on the findings from a stakeholder engagement process that was conducted within the hospital to ascertain views of patients and APs about how the built environment caters to the needs of people with dementia. This article presents key findings that emerged from a thematic analysis of stakeholder feedback and suggests implications for design practice.

Supplemental Material

Supplemental Material, Appendices_A_and_B - Dementia Friendly Hospital Design: Key Issues for Patients and Accompanying Persons in an Irish Acute Care Public Hospital

Supplemental Material, Appendices_A_and_B for Dementia Friendly Hospital Design: Key Issues for Patients and Accompanying Persons in an Irish Acute Care Public Hospital by Dimitra Xidous, Tom Grey, S. P. Kennelly, Cathy McHale and Desmond O’Neill in HERD: Health Environments Research & Design Journal

Footnotes

Acknowledgments

The authors would like to thank the Meath Foundation for funding a research project looking at the design of dementia friendly hospitals. This paper has emerged as a supporting document within this research.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Meath Foundation (Grant No. 204477.13649).

Supplemental Material

Supplemental material for this article is available online.

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