Do Newer Buildings Equal Better Dementia Care?

1. Do Newer Buildings Equal Better Dementia Care? James Struthers Trent University May 14 2014

2. Do Newer Buildings Equal Better Dementia Care? • Presentation summarizes my conclusions from week- long site visits in the dementia units of two long term care facilities in Ontario, Canada which our team studied in December 2012 and May 2013. • Both of these “secure units” shared many features. • Both were non-profits operating within the same provincial jurisdiction (identical regulations and per capita funding). • Same number of residents (30-34) who shared a comparable spectrum of dementia and wandering behaviour. • Same staffing to resident ratio. • Many similar interior characteristics (L-corridor design patterns; extensive and very visible use of alarms). • The most obvious key difference was the age of each facility.

3. St. Jude’s (first opened 1866. Maternity ward converted to nursing home, 1980)

4. Harmony Centre (opened 2005)

5. Initial impressions of St. Jude’s, (field observations by team members) • “The floors are small, the residence old and rather shabby”. • “I think I’d probably want it rebuilt.” • “St. Jude’s looks like a hospital, right? So environmentally, it’s not friendly.” • “It needs a paint job...The place is old.” • “Few personal effects. Not home like. Felt sterile and sparse.” • “Rooms are crowded. It must be difficult to do the cleaning.” • “Bathrooms are dark and institutional looking.” • “Main lounge is very tired. • “The big dining room is not homely in any sense of the word...It is simply a dining room in an institution.” • “It’s difficult to imagine a less homely starting point.”

6. Initial impressions of Harmony Centre (from field observations by team members) • “Rooms are spacious and bright, all individualized and personalized.” • “There is a newer model hospital bed (with side rails). The closet is quite spacious. There is also a bathroom, again new looking, with safety features (rail).” • “Dining room windows gives limited view of beautiful courtyard. Natural light...Pendant overhead lights. Fresh carnations...between dining room and nursing station.” • “It was a pleasant and warm feeling with colours like sage green and cream with wood trim throughout. Hallways were mostly free of clutter. Pieces of furniture were colour co-ordinated and new looking.”

7. Early Impressions Can Be Deceptive • First observations reflected superiority of new, “purpose-built” facility to old converted hospital unit. • End of our week-long site visits revealed more nuance. St. Jude’s provided better dementia care than we first thought. Harmony Centre, despite its newness, didn’t live up to expectations. • Each facility had particular strengths and weaknesses re: quality of care. • Key question: why didn’t the 2005 facility provide overwhelmingly better dementia care than a building dating from 1866?

8. Staff interviews raised some questions • “It’s an old building... A lot of people because the look of the place is not the best... look at other places, very, very new...and it’s like heaven, you know. ‘Oh my god, it’s beautiful to live here,’ but at the same time do they better care? Not necessarily.” -Interview with nurse, St. Jude’s. • “We have to create... an atmosphere where it’s okay to sit there and talk or read or do something [with them] instead of just parking them all at the desk and then there you are at the desk and you’re doing your thing because it’s really important and meanwhile they’re all staring out the window and they don’t have anything to occupy them.” -Interview with nurse, Harmony Centre.

9. Four Key Comparisons Between St. Jude’s and Harmony Centre • Location • Convergence • Strategic vs. Dysfunctional Use of Space • History

10. Location • “I know a lot of people take walks and a great location we’re at in the summertime anyways. Being downtown they can go to the market and do different things. We have museums or whatever.” -Interview with Director of Care, St. Jude’s • “The nursing home is near a highway and within walking distance from some supermarkets. But there are no sidewalks and to walk along the highway seems to be risky. “ - Team member field note, Harmony Centre

11. Convergence “St. Jude’s is unique in that the union group is a part of the hospital bargaining group so the staff are part of the hospital and they receive the same wages as you would be if you were working in complex continuing care... There can be mobilization of resources ...Say our night RN doesn’t show up. Our scheduling resource can backfill from someone on the hospital side and mobilize them to the residence.” -Interview with CEO, St. Jude’s

12. Strategic Use of Space, St. Jude’s • “At the end of the corridor there was a bus bench beside an actual bus schedule and route map. The walls were decorated with photographs of trams and buses from the 1930s and 1930s. A woman was sitting on the bus bench as though she was actually waiting for the bus.” • “Dining room for mobile residents ...contained a china cabinet, real dining table and dining chairs...Overall a much warmer space.” • “The rooftop garden is clearly an important facility for some of the residents, at least in the summer.” • “View from the 6th floor of St. Jude’s was wonderful...A great view of [the city].” -Team members field notes, St. Jude’s

13. Dysfunctional Use of Space, Harmony Centre “People like to walk, right? But the way that the nursing station is set up they’re blind to it. They can’t see where people are walking...They try to aggregate people so that the few staff that are here can keep an eye on them.” - Interview, family member. “The staff have everybody lined up and I hate that too. So the residents are all lined up in rows in chairs instead of in nice... conversation groups... I find it a challenge in terms of making it a nice, warm and inviting space for the residents and their families to come and sit and meet and talk and engage.” –Interview, CEO, Harmony Centre.

14. Floor Plan, Secure Unit, Harmony Centre

15. History Matters, St. Jude’s “Philosophically the building almost reflects somebody’s life that kind of took off. It’s transitioned, you know, from being a sort of young hospital to an aging facility...[for] long-term care, a different kind of a mission but still very appropriate.” -Interview with Director of Care, St. Jude’s “[We] discussed a photo on the wall of volunteers at St. Jude’s. A majority...were men....It turns out that the male volunteers are heavily involved in Catholic lay organizations in the area...We also observed a framed “In Memoriam” poster on the wall with the names ...of all the residents who had died on the unit from 1992 to 2012.” -Team member’s field note, St. Jude’s

16. History Doesn’t Matter, Harmony Centre “On arrival Harmony Centre looked very different than St. Jude’s: suburban, busy highway, commuter feel as opposed to the very urban and very old buildings of [the other facility]. It doesn’t feel like it is part of a community, unlike St. Jude’s.” -Team member field note, Harmony Centre. “There was nothing on the walls linking the nursing home to the city of Toronto, [the surrounding suburban community], or even to Canada. The decoration consisted of paintings of flowers, gardens, cafés and tranquil landscapes. It was typical “nursing home art”. -Team member field note, Harmony Centre.

17. Conclusion • This comparison doesn’t discount the many improvements represented by the new design of the Harmony Centre: larger private rooms; individual bathrooms; wider hallways; better lighting; staff rooms; better food cooked on site; softer colours; a ground floor garden; all of which are obvious on a first visit. • However, it does highlight a lack of imagination in thinking about interior designs which will enhance dementia care, especially re: sight lines and the size and location of the nursing station. That the building is newer, is unquestionable. Whether it provides better dementia care, is debatable.