By: Margaret Calkins, PhD
Most people like knowing what to expect,
and having their expectations met. This is part of the reason why
chain or franchise restaurants are so popular. If you go into a
McDonald's, you know what it is going to look like, smell like,
and what the food will be like. And if that's not your style, maybe
you prefer Olive Garden or Morton's Steak House, or any of the myriad
other chain restaurants that range from fast food to elegant cuisine.
In each of the eateries mentioned above, the food, the ambiance,
and the service are all very different. We know what to expect,
as do the restaurants. You would not be welcomed into a Morton's
Steak House wearing cut off shorts and a tank top. They, and the
other diners, expect a more elegant level of dress.
And let's face it, we all like to be comfortable and fit in. Have
you ever been to a party where you misjudged what the appropriate
attire was, and were either overdressed or too casual? How did you
feel? Most people are uncomfortable in this situation, even embarrassed.
Some will say they felt foolish because they didn't fit in. It you're
lucky, it was a party with friends and you all had a good laugh
and then tried to put it behind you.
So, what does this have to do with the built environment of dementia
care settings? It's simple. People try to "read" the environment
for cues as to how they should act and what they should do. They
also read it for cues as to how they should expect to be treated.
You don't get valet parking at a fast food joint-it's strictly self-
Imagine walking into a new doctor's office-someone you've never
seen before. What if, when you opened the door, there was an oriental
rug on the floor, nice art on the walls, comfortable wing back chairs,
a fresh pot of coffee brewing for you, and a receptionist clearly
in view of the entrance, waiting to check you in. Alternatively,
what if the room had dull and chipped linoleum floor, chairs that
looked like they were 30 years old and about to fall apart, nothing
to read, poor lighting, and a frosted glass window that separated
you from the receptionist, so he or she didn't even know you had
arrived. Although these are both waiting areas, they send very different
messages about what to expect. So the question I ask you, is what
is your environment saying to the people who use it?
Take a critical look-don't do this simply from memory while sitting
at your desk. Get out there and really look at it to see if you
can read what it is saying to you-and to your residents and family
members. Start out in the parking lot with the exterior of the building.
If you were driving up for the first time-maybe considering a move
here for yourself or a family member-what impression does the building
give you? Does it look like a multi-story institution, or maybe
a hospital? Is there a place (or are there enough places) near the
entrance for visitors to park, or are the choice spots reserved
for the administrator and doctors? What does this tell you about
who the facility values and wants to please? Does the landscaping
look like it belongs in front of an office building, or in front
of a home? Many houses have a front porch that invites you to stop
and pass the time of day with a friend. What is the image your facility
projects-and what image does it want to project?
Now walk inside the front door. Look around. What cues is the environment
giving you about what to expect in this place? If you immediately
come to a nurses' station, then it's probably telling you that this
is a place where medical care is given utmost importance. Look at
it. Does it suggest you are providing that latest and newest technologies,
or are you reflecting a 30 year old "institutional" approach
to care. As a potential resident or family member, how does this
make you feel? Or maybe your entrance opens onto a multi-storied
lobby space that looks more like an elegant hotel. Then you might
expect to find a concierge, someone who is there to answer your
questions, and help you get comfortably settled. Maybe it looks
more like an office with a receptionist-very business-like and efficient.
Or maybe your entrance feels like you're walking into someone's
front hall and living room. Regardless of which of these (or myriad
other) images the entry suggests, it is important to know what your
environment is saying, because this shapes people's perceptions
of your organization. They are going to expect a different level
of customer service if it looks like a posh resort than they might
expect if it looks like the second example of the waiting room described
The outside and front are particularly important because they help
to form the first impressions of your potential future customers.
Newcomers to a setting spend much more time and effort "reading"
the environment because it is new and unfamiliar. When the staff
patterns of interaction don't match the image the physical environment
has set up for them, people will be less comfortable because their
expectations are not being met. It's also important for there to
be a match between these front areas and the rest of the building.
So what about the individual care areas? They are now being referred
to by a variety of names-unit, pod, cluster, area, house/household,
and neighborhood, among others. Does your environment support and
reflect what you call your care areas? Let's use "household"
as an example, because it's an increasingly popular way to refer
to these areas. In most people's experiences, a household is more
than simply a collection of bedrooms with an associated staff work
space. A household suggests a style of interpersonal relationships-more
casual and like family-which are based on patterns of close-knit
living activities. People in a household, at least in the community,
typically eat together and, with the exception of an occasional
guest, not with a lot of other people. There are also typical activities,
such as bathing, that occur in the household, whereas other activities,
such as going to the beauty shop for a cut, style or perm, that
are done outside of the home. In general, people in a household
tend to spend more time doing domestic chores related to food, cleaning,
home maintenance and yard and garden care. And many houses are more
cluttered, filled with the artifacts of rich and varied life experiences.
Look at your care areas/unit/households carefully. Does your setting
convey any of these images? And if it does, and this is the image
you are trying to convey, then does it also function like a household?
Are residents free to sleep in if they choose to? Are you set up
(operationally and physically) to offer breakfast to both early
and late risers? If someone has a life-long habit of drinking a
cup of coffee first thing in the morning, maybe even before getting
washed up and dressed, can you accommodate this continuity of familiar
routine? These are the details that help make a place that "looks"
like home also "feel" like home.
If you provide one (a physical environment that begins to look like
a household) without the other (support for continued familiar patterns
of daily routine and activity), then it's likely that people-residents,
family and staff-will not be completely comfortable in this setting.
And we know that when people with dementia are not comfortable,
they are more likely to act out in ways that are stressful for them
and more difficult for staff to manage.
The message here is not that every place should try to feel like
home. But that you need to be aware that your building is talking
to your residents and families. Do you know what it's saying? And
is it saying what you want it to say?