Evidence-based facilities design in health care: a study of aged care facilities in Australia

Abstract

Many facilities for people with dementia have been built with little translation of the substantial body of evidence available to inform design. Knowledge translation has been described as a four-stage process: awareness, agreement, adoption and adherence. This paper identifies where knowledge translation fails in the design of aged care facilities for people with dementia. Ten aged care facilities were audited using the Environmental Audit Tool. Senior managers and architects involved in the facility design were then interviewed to ascertain their knowledge of evidence-based principles of dementia design, their agreement with the principles and the nature of the obstacles they had encountered in their implementation. All architects claimed at least partial awareness of the design principles. Five facility managers claimed full awareness. Those facilities designed with the input of managers who were fully aware of the principles were of significantly higher design quality. There was little agreement on the significance of other obstacles. Once aged care providers are aware of the principles, they appear to find ways to implement them. If the next generation of residential aged care facilities is to be suitable for people with dementia, the facility managers must be made aware of the available design principles, architects encouraged to be more active in sharing their knowledge and ways found to improve the exchange of knowledge between the parties.

Introduction

In 2009–2010 it was estimated that there were over 84,000 people with dementia in residential aged care facilities across Australia,¹ and the demand for these places is estimated to grow at 4% per annum between now and 2029.² This reflects a worldwide phenomenon; the number of people with dementia in the UK is currently estimated at 700,000 and will double within 30 years.³ The scale of the demand for residential facilities for people with dementia directs attention to the need for these facilities to be well designed.

There has been a substantial amount of empirical research into those aspects of the physical environment that can assist people with dementia by reducing confusion, agitation and depression while improving social interaction and engagement with the activities of everyday living.⁴ This research has been used to develop a set of principles that inform the design of residential aged care facilities for people with dementia.^4–7 The importance of the design in supporting quality of life for people with dementia has been recognized in guidelines published by the International Journal of Geriatric Psychiatry,⁸ the American Academy of Neurology,⁹ the American Geriatrics Society and American Association for Geriatric Psychiatry¹⁰ and the Australian Alzheimers Association.¹¹

While there are examples of good design to be found in Australia and elsewhere,¹² the results of an audit of 30 aged care facilities in Sydney, Australia showed that many have been designed in a way that does not reflect the application of the evidence-based principles.¹³ This gap between the actual design of facilities and the evidence base highlights a problem in the translation of dementia design knowledge into practice.

The steps involved in the process of translating knowledge into practice in health care have been analysed in several ways. The transtheoretical model,¹⁴ dealing with change at the level of the individual, suggests that health behaviour change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance and termination. Rogers,¹⁵ looking at the broader picture, conceptualized them as stages in the decision-innovation process and in their very influential paper Pathman et al. ¹⁶ provided a useful, four-stage framework for exploring the issues around knowledge translation on a large scale. He suggests that if knowledge is to be translated into practice, the potential knowledge users must first become aware of the existence of the evidence, for example by reading an article or a conference presentation. In the second stage, Pathman suggests that the user must evaluate the new knowledge and come to the conclusion that it is credible and they agree with it. In the third stage, the knowledge must be adopted into practice and in the fourth stage, adherence, the new application becomes business as usual, often as the result of the development of regulations to ensure compliance with accepted good practice.

The idea that knowledge translation in the area of the development of medical services is a simple linear process has, however, come under criticism. Newell et al. ¹⁷ have drawn attention to the role of ‘process knowledge’ as a facilitator in the transfer and application of ‘product knowledge’. This approach recognizes that the characteristics of the relationships within a project team will have a profound impact on the uptake of the available knowledge. McDonnel¹⁸ has investigated this in the area of client architect relationships and, while not using the language of knowledge transfer, has come to the similar conclusions. Analysing conversations between architects and building users, she describes the interchanges in a collaborative planning meeting and reports that ‘a priori designations of the roles of building user, client, designer … are also to some extent continually negotiated during conversation.’ McDonnel goes on to suggest that in the context of such negotiations, it is important not to ‘to overprivilege nor to under-rate expertise’ but rather acknowledge the expertise of others and their right to assert their expertise when the situation demands as ‘a practical way to get things done … a consensual act without implying power inequality.’

This study applies Pathman's model of knowledge translation to the exploration of obstacles that frustrate the application of the existing knowledge on good design for people with dementia. It also calls on the insights of Newell and McDonnel to help explain the lack of knowledge transfer that occurred in some teams, even when the knowledge was available, when there was a failure to achieve ‘a practical way to get things done’.

Methods

Recruitment

This Australian study involved five facilities in the State of Tasmania and five in the State of NSW. In Tasmania, a convenience sample of facilities that had been either built or renovated within the last five years was accessed. The NSW sample was selected to ensure that the facilities had been built within the last two years. They were identified by randomizing a comprehensive list of aged care facilities in the greater Sydney area, using the Microsoft Excel randomization function and telephoning facilities in order. The question ‘have you completed the construction of any new wings, units, facilities in the last 2 years?’ was asked of the most senior person available. If the answer was affirmative the question ‘were any of the units specifically designed for people with dementia?’ was asked. When both questions were answered in the affirmative, the study was described and the respondent asked if they would participate. If this question was answered in the affirmative the consent process was initiated.

Calls were made to 269 NSW facilities. Contact could not be made with 12, 244 did not meet criteria and 13 facilities (4.8%) met the criteria. Of these 13 facilities: three declined to take part in the study immediately, two showed interest in the study but took too long deciding whether or not to participate, three took information about the study via phone or email but did not return any further emails, and five completed the consent process.

Data collection and analysis

The study involved undertaking an audit of each facility using the Environmental Audit Tool (EAT).¹³ This tool provides information on the degree to which the 10 design principles described in Table 1 have been applied. The audits were carried out by two auditors with extensive experience in the use of the EAT. The data gathered were used in the production of a report that highlighted the gaps between the design of the facility and the optimum design as defined by the principles underpinning the EAT. This report was provided to the aged care facility representatives who had been involved in the design process and to the architects. The aged care facility managers and the architects were then interviewed by the first author by telephone, separately, using a semistructured interview designed to guide the respondent through a discussion of their awareness, acceptance and adoption of the principles of design that underpinned the audit. Particular attention was given to the exploration of the reasons for the gap between the ideal, as defined by a perfect score on the EAT and the actual environment.

Table 1

Principles to guide the design of environments for people with dementia

1. Safety and security	The confusion that accompanies dementia determines the need for a variety of safety features to be built into the environment. They include a secure perimeter, hot water control and safety switches in the kitchen. As obtrusive attention to safety and security increases anxiety and agitation, unobtrusive measures are to be preferred
2. Small	The larger a facility the more confusing it is likely to be for residents. High-quality care is easier to provide in small groups
3. Simple with good ‘visual access’	Confusion may be reduced by caring for the confused person in a simple environment. The simplest environment is one in which the resident can see everywhere that she wants to go to from wherever she is. This principle limits the inclusion of corridors in the design and results in the staff being able to see the residents almost all of the time. This reduces anxiety in both staff and residents
4. Reduced unwanted stimulation	The person with dementia experiences difficulties in coping with a large amount of stimulation. The unit must be designed to reduce the impact of stimulation that is unnecessary for the well-being of the resident, e.g. entry and exit doors used for deliveries, staff movements, etc. should not be visible to the residents. Noise must also be mimimized
5. Highlighting of important stimuli	Stimuli that are important to the residents should be highlighted. These include toilet doors, exit to safe outside area, aids to recognition on bedroom doors
6. Provision for wandering	Wandering is sometimes a feature of the behaviour of the person with dementia. The design should allow it to take place safely but not encourage it. The wandering path should provide an opportunity for the person to go outside and take them past areas of interest in the expectation that they will provide the person with an alternative to repetitive wandering
7. Familiarity	The person with dementia recalls the distant past more easily than the recent past. It follows then that their experience of recent furniture designs and decors must be less congruent with their present mental state than their experience of decors that they enjoyed in their younger days. To ensure that their experience of their surroundings is in keeping with their mental state, the decor should be such that it would have been familiar to the residents in their early adulthood
8. Privacy and community	People with dementia require a range of opportunities for social interaction. Spaces are needed for sitting quietly alone, with one or two intimate friends and in larger groups
9. Links to the community	The chances that the residents will continue to be part of their social network after admission should be maximized by providing for their care in small units in their community. These units should provide amenities that encourage visitors so that links with families and friends are not broken
10. Domestic	The environment should be as homelike as possible, recognizing that the primary problem is often dementia, not an acute illness. In the absence of a treatment for dementia, the goal of care is to maintain the persons abilities for as long as possible. This requires that they have opportunities, facilities and encouragement to use their abilities. So, all of the facilities found in an ordinary house need to be provided, these include a kitchen, laundry, bathroom, etc.

Facility managers were identified in all cases, but in one case the architect could not be identified, and in another the architect repeatedly cancelled the interview and could not be interviewed before the end of the project. All interviews were audiotaped and transcribed.

The semistructured interview questions were developed to guide the interview through the stages of knowledge transfer described above. The development of the questions relating to difficulties with the adoption of the knowledge, i.e. the application of design principles to dementia facilities was informed by a discussion with the participants in a workshop at a dementia conference attended by a broad cross section of managers, researchers and direct care staff.¹⁹ These included the potential impact on the application of the design principles of regulations, costs, family preferences and corporate policies. Their relevance to the design of facilities for people with dementia was checked by searching the literature from 2000. Keywords used for the search were: Australia, long-term care, nursing homes, standards, regulations, costs, family, policies and administration in the CINAHL, Medline and Art & Architecture databases. The review identified four papers of relevance to factors that may have an influence on environmental design. These provided support for the inclusion of standards²⁰ and family preferences.^21–24 The remaining topics were included in the interview on the basis of the views of the cross-section of aged care service providers involved in the conference workshop. The interview was completed with open ended questions to elicit any other factors that the architects and managers considered relevant.

The thematic analysis of the data was conducted by the first author in keeping with the process described by Braun and Clarke.²⁵ All of the transcripts were read to ensure a complete familiarization with the data, a ‘theoretical’ thematic analysis²⁵ was conducted to ascertain the ideas embedded in the answers to the specific questions contained in the interview protocol, and an inductive analysis was conducted of the spontaneous comments and answers given to general questions, e.g. ‘can you think of anything else?’. Responses were manually coded and then assigned to potential themes. When all of the responses had been coded and collated, their relevance to the themes was checked and the themes modified if required.

The themes generated and the responses used to identify them were then scrutinized by the other two authors. This resulted in the clarification of the themes and the support for them.

Ethics approval was obtained from the Ethics Committees of the University of Tasmania and the University of Wollongong.

Results

Six facilities were specifically designed for people with dementia, three were refurbished to accommodate people with dementia and one was a generalist facility that admitted people with dementia. The EAT total scores ranged from 57.4 to 79.9, with a mean of 67.9 and a standard deviation of 8.34.

The professional backgrounds of the managers and the architects are described in Table 2.

Table 2

Experience and views of aged care facility representatives and architects

Years of dementia experience and professional background of facility managers	Conscious awareness of principles	Agreement with principles	Years in practice and specialization of architect	Conscious awareness of principles	Agreement with principles	Environmental Audit Tool score	Tension between manager and architect	Site restrictions
25 years registered nurse (RN) – psych and general	Yes	Yes	30 years, specialist in dementia design	Partial	Partial	78.3		Yes
8 years insurance, finance and local government	No		30+ years, specialist in dementia design	Yes	Yes	62.8	Yes
14 years RN with Masters in Health Service Management	No		40 years not a dementia design specialist	Yes	Yes	58.5		Yes
13 years Accounting and business management	No		Not available			59.6
12 years Business management	No		30+ years, specialist in dementia design	Yes	Yes	70.8	Yes
25 years RN	Yes	Yes	10 years, specialist in dementia design	Yes	Yes	69.4	Yes	Yes
25 years RN and registered geriatric nurse	Yes	Yes	Not available			79.9	Yes
25 years Hospital and aged care management	Yes	Yes	35 years, specialist in dementia design	Yes	Yes	66.1		Yes
15 years RN	Yes	Yes	20 years, specialist in dementia design	Yes	Yes	76.1
20 years RN with masters in business administration	Partial	Partial	19 years, specialist in dementia design	Yes	Yes	57.4	Yes	Yes

Five of the aged care facility managers clearly described an awareness of the principles contained in the report provided to them. One claimed to ‘have read them in the past’ and four responded that they were not aware of the principles of design. All of the managers who were aware of the principles stated that they agreed with them.

One of the architects expressed only partial awareness of and partial agreement with the principles, the remainder described themselves as being aware of the principles and agreeing with them.

The mean EAT scores of the facilities where the manager was aware of the principles was 73.96, significantly higher (t-test, sig. 0.01) than the mean EAT score of 61.82 for those facilities where the manager described themselves as unaware or only partially aware of the principles. Analysis of the differences between the EAT subscale scores revealed that the difference in the overall quality of the environment, as represented by the total EAT score, was brought about by higher mean scores in eight out of the 10 EAT subscales in those facilities where the managers were fully aware of the principles (Table 3).

Table 3

Comparison between environments planned by managers with and without knowledge of design principles

EAT sub scales	Mean EAT score in facilities where managers were fully aware of principles	Mean EAT score in facilities where managers were not fully aware of principles	Significance of difference (t-test, 2 tailed)
Safety	73.02	73.52	NS
Size	63.82	26.66	0.08
Visual access	59.36	37.26	0.07
Stimulus reduction	85.28	45	0.003
Stimulus enhancement	85.02	71.14	NS
Planned wandering	82.78	80.02	NS
Familiarity	74.86	78.32	NS
Privacy and community	78.66	65	NS
Links to community	78.68	100	NS
Domestic	51.68	41.28	NS
Total score	73.96	61.82	0.01

EAT, Environmental Audit Tool; NS, non-significant

The analysis of the response to the specific questions concerning the application of the principles, stage three in Pathman's model, is summarized below.

Regulations as an impediment to applying the principles

Two managers identified regulations as being an obstacle to the implementation of the principles. The responses of the others suggested that while regulations have to be considered, there was always room for negotiation:

you'd have to argue with people. I know the [CEO]… has done that at [facility X] …, they've got rid of the hand rails in their new designs, and still got accreditation. (Manager 7)

Regulations were of more concern to the architects with four reporting that contending with regulations restricted the application of the principles, particularly with respect to making facilities seem more home like:

… most of our challenges in our office are basically dealing with authorities. It depends on how the standards are written. Sometimes they are ridiculous requirement. (Arch. 2)

Cost as an impediment to applying the principles

Cost was identified as a major obstacle to the application of the principles by three managers. Capital and operating costs were differentiated. One manager reported that their dementia specific facility was built in the knowledge that residents would have to pay more than the usual amount for a bond and that the residents would make additional payments under the extra service provisions for funding residential aged care. However, others argued strongly that good design was not an additional cost in terms of capital outlay and that it led to a reduction in operating costs:

…there's no falls, the people exercise, they're happier. So cost per person and the [decrease in] staff [turnover], there's no turnover here… [means] it actually works better on costs.

There was no consensus on the theme of cost from the point of view of the managers.

Three architects were of the opinion that the application of the principles resulted in greater capital costs because the separation of resident spaces from service spaces and the lower number of residents in individual units resulting in a larger overall building. However, the other architects did not support this view:

[The application of] those principles doesn't really jump out as putting a rather large burden on a budget … building that we produced there would've been … a little dearer than the other residential units that we provided, but not unreasonably and certainly it did not worry the client. (Arch. 3)

Family member views impede the application of the principles

There was little evidence for the existence of consensus on the importance of the views of family members in determining the nature of the design of facilities. Two managers expressed the view that relatives choose the residential facility not the resident and one of them was particularly concerned that the choice is made on the basis of their preference for a hotel like environment:

Yeah of course they [family members] choose and when relatives come, even though mum has a diagnosis of dementia, they don't want her to have a bed in [facility] because it looks different. It doesn't look as hotel like as the rest of the building… (Manager 5)

The architects were divided on the importance of this issue.

Corporate policies override design principles

Corporate policies, for example, the centralized preparation of meals, were seen by only two managers as over-riding the application of principles. One manager reported that his application of the principles had been so successful that it had changed corporate policies. The architects were more likely to see corporate policies as an obstacle but again, there was no consensus on this issue. For example, one architect highlighted the influence of corporate policies on food preparation:

Well, I mean obviously they [the aged care facility] want to operate how they want to operate the food preparation… [yet] in your report you sort of say residents don't have access to the kitchen area. Well, that was intentional [on the part of the organization]… (Arch. 4)

However, overall there was no evidence of strong, consistent themes describing obstacles to the application of the design principles emerging from the specific questions raised during the interviews.

Analysis of the managers' spontaneous comments and responses to general questions, such as ‘can you think of anything else?’ identified a number of themes. The strongest was site restrictions followed by weakly supported themes of industrial relations, practicality, lack of clear identification of people with dementia as being the target group, conflict with the operational model and lack of understanding of the principles by the architects. One manager summarized her dissatisfaction with what she saw as a common approach to the planning process:

you just can't say we've got four houses, and just put a lock on the door of that fourth house for [residents with] dementia, and basically the floor plan is exactly the same. (Manager 7)

The architects also nominated site restrictions, but their main concerns were clashes between the ideals implied by the design principles and the practical operational issues. One architects response to a question on his awareness of the design principles ‘yes, as principals but sometimes principles can't be put into practice.’ (Architect 8) was made understandable by the description of the brief given to him ‘The overall brief, if you like, the brief of the board of directors was to get as many beds as you can in this site as cheaply as possible’ (Manager 10).

Architects were also concerned with inconsistencies in the client team leading to conflicting instructions and an unclear original brief:

where they [managers] have competing views or views that are very sort of dogmatic, that you may not agree with. … that's where it's harder because you really don't have any room to move. You can sort of have the argument [to try to convince them], but that's not to say you're going to win. (Arch. 4)

In five cases these types of difficulties caused some tension between the architects and the clients.

Discussion

Table 2 shows that the managers who took part in this study had considerable experience in services for people with dementia. Five of them were fully aware of the principle and five were not. They had commissioned architects who, with one exception, claimed to be fully aware of the principle that were presented to them. The exception was an architect who claimed partial awareness. Notwithstanding the architect's claims regarding their awareness of the principles, there was a significant difference in the quality of environments that resulted from the involvement of a manager who was aware of the principles in the planning as compared with environments that were refurbished when the manager reported little knowledge of the principles. The mean EAT score of the five facilities designed with the input of a manager who was aware of the principles, 73.96, was significantly higher (t-test, P = 0.01) than the mean score of the facilities whose design was influenced by managers who were not fully aware of the design principles, 61.82.

Table 3 shows that this difference is largely attributable to the better facilities having fewer beds, good visual access and, most significantly, improved reduction of unhelpful stimulation. These characteristics are important, having been shown to be associated with better outcomes for the residents.^26–29

There is practically no literature to assist us to understand the nature of the obstacles to ensure that the next generation of residential aged care facilities is suitable for people with dementia. This study highlights the difference that having a manager who is aware of having a basic set of design principles makes to the quality of the environment. As all of the managers who were aware of the principles agreed with them the problems associated with putting the knowledge into practice cannot be described as occurring in Pathman's second stage of knowledge translation, i.e. establishing agreement.

The managers did see a number of obstacles in the adoption stage but no consensus emerged from the analysis. The weak themes explaining the lack of application of the principles comprised operating and capital costs, and the restrictions imposed by the site. Only a small minority of managers saw regulations, pressure from relatives, corporate policies, industrial relations issues, mismatches between the design and the operational model as impeding the application of the principles.

A minority of the architects identified site restrictions, regulations, operating costs and difficulties in coming to an agreement with the client on the brief as the major obstacles. The significance of the difficulties in establishing a clear brief and restrictions in the sites were assessed by comparing the means EAT scores of those facilities where there were no problems to those where problems were present. There were no significant differences in the t-test results, suggesting that these difficulties did not have as great an impact on the quality of the environment as the level of the managers awareness.

The lack of the presence of any consensus, between the managers and architects, on significant obstacles to the adoption of the principles once they are known, suggests that there are no common impediments to the application of the design principles. The impediment that has the greatest impact occurs in the first stage of Pathman's model, awareness, and is particularly relevant to managers. Once the managers are aware of the principles, they tend to agree with them and find ways to implement them – and produce higher quality facilities.

The presence of a very high scoring facility in which the manager was fully aware of the principles while the architect only described himself as partially aware, further supports the conclusion that the managers awareness of the design principles is a key to their application. This is corroborated by the negative example, illustrated above, where the manager, who was not fully aware of the principles, briefed an architect who claimed awareness, to put as many cheap beds on the site as possible. The result was a poor quality environment.

It is unreasonable to place all of the responsibility for the application of evidence-based design principles on the aged care managers. The lack of influence of architects, who claimed awareness of the principles, must raise questions about the willingness of architects to take on an active role as educator and professional guide. The data suggest that on at least three projects there was the opportunity for the architects to raise the awareness of the managers. If they tried they were not successful and followed the directions of inadequately informed managers.

However, the data suggest that the fundamental problem lies not with either the managers or the architects but with their combined failure to establish an effective project team. Newell et al. ¹⁷ have highlighted the vital role that the exchange of knowledge within the project team plays in achieving best practice outcomes. Successful project teams are characterized by a willingness to interact, debate and go through a process of sense making in which the members try on the perspectives of the others involved in the process. The presence of tension between architects and managers in 50% of the projects described here may well be an indication of the difficulty of establishing a successful team and the resultant problems in realizing ‘a practical way to get things done’. The architects concerns about the quality and consistency of the brief are noteworthy and suggest the lack of a common understanding of the knowledge base, or principles, that can be used as a foundation for the exchange of ideas that is necessary to achieve a common, well informed, view of the project.

The lack of impact of the expertise of the architects may be explained in McDonnell's terms. It appears that either the architects have over-privileged the expertise of the building users or the building users have under-rated the expertise of the architects. In either case the result is an inability to make use of knowledge that is available to the team.

The relatively poor outcomes in the five homes where the managers were not fully aware of the principles of design may therefore be explained in two ways. The first is a failure in Pathman's first stage of knowledge transfer, the existing evidence-based information had not been brought to the attention of the managers, they were simply not aware of it. Secondly, the tensions between the architects and the clients described in three of these homes are probably an indication of the failure to establish a cohesive team characterized by mutual respect and the ability to hear other points of view, negating the availability of the knowledge from the architects.

An alternative explanation, in some cases, is that producing positive outcomes for the residents by applying evidence-based principles is not a priority. The availability of the knowledge to bring this about is irrelevant when the brief does not include them.

In Australia the need to provide assistance to facility managers and the architects has been recognized and a national programme aimed at making information available to them during the planning process has commenced through the activities of the five Dementia Training Study Centres established by the Australian Government. This project involves a day long meeting between the managers, architects and a consultant who provides a systematic explanation of the principles of design, an audit of the existing facility and assists with starting a planning process based on a common understanding of the principles.

The capital cost of providing one residential aged care place in Australia is estimated at $200,000–$240,000, $109,000 of which is provided by the Commonwealth Government.²⁴ While the number of places that will be provided in the coming years will be determined by the interplay of the many factors, such as the speed of development of community services and the changes in funding mechanisms now being considered,²⁹ it has been estimated that in Australia, 9000 new beds per year for the next 20 years will be required for people with dementia.² The lack of awareness of well-established design principles must be recognized as a major obstacle to meet their needs and obtaining the best outcome from the capital expenditure. It is essential that the knowledge that is available on how to design for people with dementia be provided to both the managers and the architects, and that attention be given to facilitating discussions between them.

The study is limited by the small size of the sample and the possibility that the experiences of those that chose not to be audited may be different from those that did. It is further limited by reliance on the self report of the managers and architects in relation to their awareness of the design principles. Future research should involve larger sample sizes and an objective measure of awareness of the design principles.

Competing interests: The study was carried out while the first author was employed as the Director of HammondCare's Dementia Services Development Centre. None of the authors have a conflict of interest.

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