Keywords
dementia - environment design - nursing homes - health facility environment - surveys and questionnaires
Schlüsselwörter
Demenz - bauliche Umgebung - demenzsensible Gestaltungsprinzipien - stationäre Langzeitversorgung - Assessmentinstrument
Introduction
The built environment is a key component of dementia-specific care [1]. The term ‘built environment’ refers to
all human-made, planned and physical environments. This applies to both indoor and
outdoor areas where the existing natural environment has been altered [2]. In home-based care, an environment
adapted to a person’s needs can provide safety and help the person stay at home for
as long as possible [3]. However, even for
people with dementia living in nursing homes, an environment adapted to their needs
and preferences can help them remain independent, and thus contribute to a positive
quality of life [4].
In healthcare research, the built environment is an important contextual factor, for
example, when implementing interventions in a sustainable way [5] or for understanding the mechanisms
underlying the effectiveness of dementia-specific living concepts [6]. The effects of a dementia-sensitive
environment on the successful implementation of interventions have not yet been
systematically examined in German nursing home research. This is due to the
complexity of the construct and the lack of instruments tested in Germany. As a
result, the characteristics of the living concept, the group size in living units,
and the number of beds in nursing homes have previously been assessed to capture the
elements of the built environment [7].
The impact of environmental elements on dementia-specific care has been
internationally investigated for decades. This work resulted in the development of
guidelines for dementia-sensitive design of healthcare facilities [8]
[9] and assessment tools to evaluate the implementation of these design
principles [10].
Based on this knowledge, an existing tool (Environmental Audit Tool - High Care
(EAT-HC)) was adapted at the German Centre for Neurodegenerative Diseases, Site
Witten for Germany. As part of a multistage adaptation process, experts in research
and dementia care practice were involved in adapting the tool culturally sensitively
for use in German nursing homes [11].
The original tool was developed by an inter-professional team and has been shown to
have adequate validity and reliability when tested psychometrically [12]
[13]. The dimensions of the tool include ten dementia-sensitive key
design principles
[14], based on
the theory that the built environment can support a person’s declining ability to
perform activities of daily living [15].
These key design principles are based on questions regarding evidence-based
dementia-sensitive environmental elements related to different rooms
within a nursing home living unit.
Following adaptation of the EAT-HC to the German Environmental Audit Tool (G-EAT),
the instrument was tested for practicability, interrater reliability, and internal
consistency [16]. In this article, we
present the initial results of the development of a dementia-sensitive design for
nursing homes and discuss possible ways in which it can be applied. In doing so, we
addressed the following research questions:
To what extent are living units in German nursing homes designed according to
dementia-sensitive design principles?
-
Which spaces does the built environment of those living units include?
-
Which dementia-sensitive key design principles are fulfilled or not
fulfilled?
-
Which dementia-sensitive environmental elements are present in the
most or least living units?
Methodology
Study design
Qualitative and quantitative data were collected as part of a descriptive
cross-sectional study to test the feasibility and reliability of G-EAT. These
data were used for secondary data analysis in this study.
Recruitment and sampling
Data were collected from a convenience sample of nursing homes in North
Rhine-Westphalia. The reason for the regional limitation was that the underlying
conditions were regulated at the federal state level (e. g. HeimMindBauV NRW,
Wohn- und Teilhabegesetz NRW), which offers different possibilities for
the design and scale of the built environment. To recruit participants for the
study, 170 nursing homes within a 20 km radius of the research institute were
contacted in writing and then by telephone. To avoid clustering effects caused
by several living units in the same facility, one living unit was selected from
each participating nursing home.
Measurements
The built environment of the living units was assessed using the G-EAT. In the
version used here for non-secured living units, the instrument consists of 74
items [11], of which 72 items
(environmental elements) can be assigned to nine dimensions (key
design principles): Create a human scale; Reduce risks unobtrusively; Allow
people to see and be seen; Manage (positive/negative) levels of
stimulation; Support movement and engagement; Create a familiar place;
Links to the community. The dimension “environment as part of the
care concept” contains two additional questions, which are relevant for
the subsequent practice-oriented interpretation of the results. The psychometric
quality of the original instrument had already been tested and was determined
for the adapted German language instrument as part of the test study.
Inter-rater reliability, measured by inter-rater correlation coefficients,
varied between 0.662 and 0.869 at the subscale level. At the item level, 42% of
the items showed at least substantial agreement between two raters (Cohen’s
Kappa≥0.60) [16]. The G-EAT mainly
consists of dichotomous items, with 14 items offering categorical response
options. The structural characteristics of the living units were collected using
a context questionnaire that was applied in a previous study [17]. Definitions of the living units
were developed through site visits with staff and included the following
criteria: A) identification of rooms belonging to the living unit, B)
identification of shared spaces across living units, C) boundaries of the
living unit.
Data collection
Data collection took place between August and December 2019 and was conducted
with at least one staff member from the nursing home. First, a short training
session on the key design principles of dementia-sensitive design was held for
relevant staff members. This was followed by a tour of the facility and a joint
definition of a living unit. This was used to determine where residents could
spend time, regardless of whether they overlapped with the planned space or had
chosen alternative locations for certain activities (e. g. using corridors as a
place to spend time). The boundaries of the living unit refer to both those
within the facility and the outdoor areas belonging to the living unit, such as
a shared garden. One member of the research team then completed the G-EAT. To
answer the questions of the G-EAT, all shared spaces in the living unit were
explored. For ethical reasons, the answers to questions about the residents’
private rooms were based on information provided by the staff, as the
researchers did not enter private rooms without being invited to do so by the
residents.
Data analysis
Quantitative data analysis (G-EAT/context questionnaire) was performed
descriptively using SPSS 25 [18].
Because the reference values of the key design principles vary from
dimension to dimension, the percentage mean was calculated at this level, and
the weighted mean was used for the overall result of the G-EAT. A comparison of
the characteristics of the living units was carried out using qualitative
content analysis according to Mayring in MAXQDA 2022 [19]
[20].
Results
Contextual characteristics of included living units
This study included 42 living units in nursing homes in North Rhine-Westphalia.
The contextual characteristics are presented in [Tab. 1]. Most were run by nonprofit
organisations (73.8%) and located in cities (81.0%). Residents with and without
dementia lived together in most living units (integrative living concept)
(66.7%). Nursing homes were established in roughly equal proportions before
(47.6%) and after (52.4%) the introduction of the German long-term care
insurance system and the associated requirements for organisational change.
Group sizes varied between 9 and 40 residents.
Tab. 1 Contextual characteristics of the living
units.
|
Characteristics (N=42)
|
Sample
|
|
% (n)
|
|
Sponsorship
|
|
non-profit
|
73.8% (31)
|
|
profit
|
26.2% (11)
|
|
Size of the municipality in which the nursing home is
located
|
|
20.000–100.000 inhabitants
|
19.0% (8)
|
|
100.000–1,000.000 inhabitants
|
81,0% (34)
|
|
Living concept
|
|
integrative
|
66.7% (28)
|
|
segregative
|
34.3% (14)
|
|
Opening year of the facility
|
|
before 1994
|
47.6% (20)
|
|
before 1994
|
52.4% (22)
|
|
Group size
b
|
|
≤10 residents
|
2.4% (1)
|
|
11–16 residents
|
40.5% (17)
|
|
17–29 residents
|
45.2% (19)
|
|
≥30 residents
|
11.9% (5)
|
a Group classification based on the introduction of long-term
care insurance (SGB XI); year of opening, as the construction period may
extend over several years; bclassification using G-EAT
Included spaces of living units
Most living units provided only one multifunctional room for lunch or as a living
room (61.9%). In the four units, the staff defined corridors and intermediate
spaces as the main places where residents spend time. Thirteen living units had
their own outdoor spaces (six sheltered gardens and seven balconies). The
cafeteria (61.9%), party rooms (35.7%), and various group rooms were the primary
spaces used across all living units in the nursing home. The latter are either
multifunctional or have specific functions (e. g. corner shops, football rooms,
or bowling alleys). Of the living units, 71.4% are located on one floor, eight
are on the ground floor, and therefore have barrier-free access to outside
spaces without the need for a lift.
Specification of dementia-sensitive key design principles
With regard to the dementia-sensitive key design principles, it can be seen that
the dimension “Create a familiar place” is the most pronounced at 87.7%
(range 38–100%; SD±1.65) (see [Tab.
2]). The dimension “Allow people to see and be seen” has the
lowest level of expression (MW 37.3%, range 6–88%; SD 3.39). [Fig. 1] shows the different
characteristics of the dementia-sensitive key design principles.
Fig. 1 Box chart of the dementia sensitivity of living units at
the level of the dimensions (key design principles).
Tab. 2 Overview of dementia sensitivity of the
living environment at the dimension level (Key design
principles).
|
Key Design Principle (Dimension)
|
NItems
|
Max. Score
|
MW in % (score)
|
Range in % (score)
|
Standard deviation
|
|
Provide a human scale
|
2
|
4
|
54.8% (2.2)
|
0–75% (0–3)
|
±0.79
|
|
Reduce risks unobtrusively
|
13
|
16
|
60.4% (9.6)
|
38–88% (6–14)
|
±2.23
|
|
Allow people to see and be seen
|
10
|
16
|
37.3% (6.0)
|
6–88% (1–14)
|
±3.39
|
|
Manage levels of stimulation
|
25
|
30
|
65.8% (19.7)
|
40–83% (12–25)
|
±3.2
|
|
Support movement and engagement
|
9
|
9
|
77.4% (7.0)
|
33–100% (3–9)
|
±1.31
|
|
Create a familiar place
|
4
|
8
|
87.7% (7.0)
|
38–100% (3–8)
|
±1.09
|
|
Links to the community
|
9
|
13
|
83.4% (10.8)
|
54–100% (7–13)
|
±1.65
|
Specification of dementia-specific environmental elements
Individual items within a key design principle relate to various elements of a
living unit. Therefore, an analysis of the questions at the item level is
relevant to the interpretation of the results (see [Tab. 3] and [4]). The three environmental elements
that are fulfilled by most of the living units are “Bed/ensuite transfer is
easy” (100.0%), “Inside, ramps are wheelchair accessible” (97.6%)
and “Inside, floor surfaces are safe” (92.9%). The fewest living units
show the dementia-sensitive environmental elements “Doors are silent when
closing” (2.4%), “Inside, glare is avoided” (7.1%) and “Toilet
pan can be seen from bed” (14.3%).
Tab. 3 Fulfilment of dementia-sensitive
environmental design elements in living units (G-EAT dichotomous
items).
|
Dementia-sensitive environmental elements
|
Percentage of living units that fulfil the element (n)
a
|
|
Provide a human scale
|
|
|
Common areas are comfortable in scale
|
85.7% (36)
|
|
Reduce risks unobtrusively
|
|
|
Outside access is barrier-free
|
71.4% (30)
|
|
Outside, floor surfaces are safe
|
76.2% (32)
|
|
Outside, path surfaces are even
|
50.0% (21)
|
|
Outside, paths are obstacle-free
|
90.5% (38)
|
|
Outside, paths have appropriate width (1.8 m)
|
35.7% (15)
|
|
Outside, ramps are wheelchair accessible
|
78.6% (33)
|
|
Inside, floor surfaces are safe
|
92.9% (39)
|
|
Inside, contrast between floor surfaces is avoided
|
71.4% (30)
|
|
Inside, ramps are wheelchair accessible
|
97.6% (41)
|
|
Bed/ensuite transfer is easy
|
100.0% (42)
|
|
Allow people to see and be seen
|
|
|
Garden/outside area exit is seen from lounge/dining room
|
35.7% (15)
|
|
Dining room is seen from lounge room
|
81.0% (34)
|
|
Toilet is seen from lounge room
|
31.0% (13)
|
|
Toilet is seen from dining room
|
23.8% (10)
|
|
Lounge room is seen by staff
|
90.5% (38)
|
|
Dining room is seen by staff
|
85.7% (36)
|
|
Outside, resident area is seen by staff
|
38.1% (16)
|
|
Manage levels of stimulation
a
|
|
|
Doors to dangerous areas are invisible
|
66.7% (28)
|
|
Wardrobes are non-cluttered
|
21.4% (9)
|
|
Public address/paging/call system is unobtrusive
|
81.0% (34)
|
|
Doors are silent when closing
|
2.4% (1)
|
|
Visual clutter is absent
|
26.2% (11)
|
|
Inside, glare is avoided
|
7.1% (3)
|
|
Rooms are easily identifiable
|
90.5% (38)
|
|
Dining room is clearly recognisable
|
83.3% (35)
|
|
Lounge room is clearly recognisable
|
71.4% (30)
|
|
Corridors are clearly identifiable
|
57.1% (24)
|
|
Bedrooms are individually identified
|
73.8% (31)
|
|
Shared bathrooms/toilets are clearly identified
|
50.0% (21)
|
|
Toilet pan can be seen from bed
|
14.3% (6)
|
|
Toilet seats contrast with background
|
47.6% (20)
|
|
Inside, contrast aids visibility of surfaces/objects
|
88.1% (37)
|
|
Inside, olfactory cues are used
|
50.0% (21)
|
|
Inside, tactile cues are used
|
90.5% (38)
|
|
Inside, auditory cues are used
|
31.0% (13)
|
|
Outside, contrast aids visibility of surfaces/objects
|
92.9% (39)
|
|
Outside, materials/finishes are varied
|
95.2% (40)
|
|
Outside, olfactory cues are used
|
97.6% (41)
|
|
Outside, auditory cues are used
|
66.7% (28)
|
|
Outside view from dining/lounge is attractive
|
81.0% (34)
|
|
Support movement and engagement
|
|
|
In-/outside path clearly returns residents to starting
point
|
23.8% (10)
|
|
Outside, path passes participation opportunities
|
76.2% (32)
|
|
Outside, activity choices are available
|
64.3% (27)
|
|
Outside, seating is available
|
90.5% (38)
|
|
Outside, sunny and shady areas are available
|
85.7% (36)
|
|
Outside, passive activities are available
|
97.6% (41)
|
|
Outside, verandas and shaded seating are available
|
100.0% (42)
|
|
Inside, path passes participation opportunities
|
78.6% (33)
|
|
Inside, path passes conversation/rest areas
|
78.6% (33)
|
|
Links to the community
|
|
|
Dining room allows for dining alone
|
81.0% (34)
|
|
Lounge room includes private conversation areas
|
66.7% (28)
|
|
Outside, private conversation areas are available
|
100.0% (42)
|
|
Community interaction areas are accessible
|
97.6% (41)
|
|
Family/dining area is available in facility
|
100.0% (42)
|
|
Visitor break area is available
|
88.1% (37)
|
|
aN=42 living units
|
|
Tab. 4 Fulfilment of dementia-sensitive
environmental design elements in living units (G-EAT category
items).
|
Dementia-sensitive environmental element
|
Percentage of living units that fulfil the element (n)
|
|
Reduce risks unobtrusively
|
|
|
no
|
yes
|
yes, unobtrusively
|
|
|
Access to kitchen can be restricted
|
69.1% (29)
|
21.4% (9)
|
9.5% (4)
|
|
|
Resident kitchen has safe appliances
|
50.0% (21)
|
21.4% (9)
|
28.6% (12)
|
|
|
Resident kitchen has master switch
|
64.3% (27)
|
7.1% (3)
|
28.6% (12)
|
|
|
Allow people to see and be seen
|
|
|
|
|
|
0–25%
|
26–50%
|
51–75%
|
76–100%
|
|
Lounge room is visible from bedrooms
|
57.1% (24)
|
11.9% (5)
|
9.5% (4)
|
21.4% (9)
|
|
Bedrooms are visible from lounge room
|
64.3% (27)
|
31.0% (13)
|
2.4% (1)
|
2.4% (1)
|
|
Dining room is visible from bedrooms
|
64.3% (27)
|
14.3% (6)
|
7.1% (3)
|
14.3% (6)
|
|
Manage levels of stimulation
|
|
|
|
|
|
Pathway is defined from bedroom to dining room
|
52.4% (22)
|
19.0% (8)
|
11.9% (5)
|
16.7% (7)
|
|
Window view from bed is attractive
|
2.4% (1)
|
9.5% (4)
|
16.7% (7)
|
71.4% (30)
|
|
Create a familiar place
|
many
|
a few
|
none
|
|
|
Proportion of lounge furniture that is familiar
|
71.4% (30)
|
28.6% (12)
|
0% (0)
|
|
|
Proportion of bedroom furniture that is familiar
|
69.0% (29)
|
28.6% (12)
|
2.4% (1)
|
|
|
Bedrooms have residents’ own decorations/photos
|
95.2% (40)
|
4.8% (2)
|
0% (0)
|
|
|
Bedrooms have residents’ own furniture
|
66.7% (28)
|
33.3% (14)
|
0% (0)
|
|
|
Links to the community
|
|
|
|
|
|
0
|
1
|
2 or more
|
|
|
Inside, small group areas are available
|
0% (0)
|
9.5% (4)
|
90.5% (38)
|
|
|
no
|
1
|
2
|
3 or more
|
|
Inside, private conversation areas are available
|
0% (0)
|
11.9% (5)
|
31.0% (13)
|
57.1% (24)
|
|
1
|
2 or 3
|
4 or more
|
|
|
Inside, variety of different areas are available
|
14.3% (6)
|
57.1% (24)
|
28.6% (12)
|
|
The least pronounced key design principle, “Allow people to see and be
seen”, shows that in more than 50% of the living units, less than 25% of
the residents can use direct visual axes between different rooms. The
environmental elements covered by the “Create a familiar place” dimension
show that unfamiliar furniture is used in only one case. To answer these
questions, furniture and objects that do not appear familiar but must be present
for functional and/or occupational safety reasons (e. g. height-adjustable care
bed) were defined in advance.
Discussion
We illustrate that living units are heterogeneous in terms of equipment and spatial
arrangements. Environmental elements aimed at creating familiarity are present in
almost all living units, while the possibility of visual axes between rooms and the
avoidance of negative acoustic and visual stimuli is limited.
General conditions for the realisation of dementia-sensitive environmental
design
General conditions for the realisation of dementia-sensitive environmental
design
A comparison of the degree of fulfilment of the individual questions with existing
regulations that influence the construction of nursing homes in Germany shows that
some environmental elements that are fulfilled by the majority of living units are
also laid down in legally binding regulations such as DIN 18040–1 “Barrier-free
construction”
[21]. Another
condition to bear in mind is that missing visual axes can only be corrected with
great effort and the involvement of architects, whereas environmental elements that
promote positive acoustic, olfactory, or tactile stimuli can be implemented by a
multi-professional team in the facility as part of the design of the living
environment.
Challenges in capturing the dementia sensitivity of the built environment
Challenges in capturing the dementia sensitivity of the built environment
The challenge of capturing the complexity of the built environment using a systematic
assessment tool was also evident in this preliminary exploration. On the one hand,
the question arises as to whether and, if so, which references can be used as a
basis for the questions to be assessed categorically, for example, when determining
the number of familiar pieces of furniture in shared rooms. In contrast, some of the
content perspective questions showed a need for a more in-depth exploration of the
underlying environmental elements, for example, identifying the sources of stimuli
provided indoors or outdoors. To address this, additional items were added to the
tested version of the G-EAT as well as free text boxes [16].
In addition, the joint tour of the nursing home with the staff of the participating
facilities made it clear that the results were linked to the goals of the respective
nursing home as well as the organisational culture and social environment (e. g.
opening up the facility to the neighbourhood) and needed to be discussed in this
context. On the one hand, this is in line with the intention of the creators of the
original instrument to initiate reflection within the team [14]. On the contrary, this is consistent
with the findings of colleagues in the Netherlands on the interrelationship between
built, social, and organisational aspects of the environment in residential
long-term care [22].
Opportunities for assessing context in implementation studies
Opportunities for assessing context in implementation studies
The abundance of some items in the G-EAT that are associated with regulations for the
construction of nursing homes in Germany and the practical benefits of a
comprehensive assessment of dementia-sensitive environmental elements seem to
contradict each other. Nevertheless, the systematic assessment of the built
environment based on evidence-based principles offers an opportunity to look more
closely at the construct of the ‘built environment’ in the future. In addition,
implementation studies, e. g. through the recording of contextual characteristics as
part of process evaluations, should take greater account of the factors of “the aim
of the environment for the care concept” and the heterogeneity of the spaces in the
living unit. Frameworks used in implementation research, such as the Consolidated
Framework for Implementation Research (CFIR), already capture certain
environment-related characteristics and can serve as an example of how to include
the environmental context factor in implementation studies [23]. In addition, capturing the context of
quality improvement projects in health and long-term care settings could also help
focus on the sustainable implementation of the intervention by considering
environmental characteristics [24].
Limitations and strengths
Limitations and strengths
The results presented here have some systematic limitations. This is a secondary data
analysis of data from a convenience sample of living units limited to the federal
state of North Rhine-Westphalia, in which smaller cities/towns could not be
included, although facilities belonging to a medium-sized or large city were also
located in more rural areas. It should also be noted that the interrater reliability
of the G-EAT was first tested with this survey, and then further questions that were
not included in this initial exploration were added [16]. The restriction of obtaining balanced
information on all the spaces belonging to the living unit also limits the
significance of the results. For example, the occasional collection of questions
regarding residents’ private rooms poses an ethical challenge to data collection,
which must be addressed in future projects.
However, it should be emphasised that the systematic recording and evaluation of the
definitions of living units in this study enabled the heterogeneity of settings to
be made visible. This contributes to the discourse on the possibilities of
interpreting and comparing the types of living units and their effects as locations
for implementing interventions.
Conclusions
The G-EAT can be used to initiate a systematic review of the built environment as a
key element of dementia-specific care. The results of the fulfilment of
dementia-sensitive key design principles and elements can support multiprofessional
care teams in prioritising various refurbishment or redesign activities. To
implement dementia-sensitive changes during the day-to-day care of residents,
scientifically supported implementation of the G-EAT as an initial assessment tool
and redesign process support in nursing homes is required.
Conclusion and outlook for further use of the G-EAT
Conclusion and outlook for further use of the G-EAT
As described above, the results of this exploration should serve as a basis for a
Germany-wide systematic assessment of the dementia sensitivity of living units in
nursing homes. In addition, the G-EAT should already be used in practice, but also
in health research projects, for example, for a more in-depth description of the
contextual factor “built environment”. In addition to systematic recording using an
assessment tool, it is necessary to focus on the residents’ direct perspectives. A
qualitative interview study of residents with dementia is currently being conducted
to determine how this can be accomplished.
Ethical considerations
The entire study was conducted with the approval of the Ethics Committee of the
German Society of Nursing Science (application number: 18–005). This article does
not include studies on humans or animals.
Data availability statement
Data availability statement
The data collected and/or analyzed in this study are available on request from the
corresponding author. The German Environmental Audit Tool was translated and tested
by the German Centre for Neurodegenerative Diseases based on the Australian
Environmental Audit Tool. Written permission was granted by the developers for
authorised use and further development of the original tool.
This article is part of the DNVF supplement “Health Care Research and
Implementation”.
Authors contribution
Study design: AF, BH; Recruitment and data collection AF, KS; data analysis: AF; data
interpretation: AF, KS, HV, RP, BH; manuscript writing: AF; manuscript review: KS,
HV, RP, BH. The corresponding author ensures that all authors have read and approved
the final manuscript and meet the ICMJE criteria for authorship.
„This article is part of the DNVF supplement “Health Care Research and
Implementation”
