What is your Building Saying?
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- serve.

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 above.

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?


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