Writers: Jennifer Eveland and Serene Tng
What contributes to our sense of belonging as we age in a nursing home environment? Within a nursing home, how can we continue to maintain our independence and connection to the community?
A first interdisciplinary study of its kind is bringing together academics, professionals, policy makers and healthcare providers to delve deeper into how the design of the physical environment can improve the well-being of not only nursing home residents but also that of caregivers, staff and the larger community.
“With the design of nursing homes evolving over the years, the study is important given our ageing population, and nursing homes are increasingly becoming an integral part of our urban and social fabric. Good design can bring all these elements together,” says Associate Professor Fung John Chye from the Centre for Ageing Research in the Environment (CARE) at the National University of Singapore’s School of Design and Environment who is leading the study.
Led by NUS, in collaboration with URA, and other agencies and research partners, the study1 began in 2017 and seeks to recommend design principles and typologies for future nursing homes that can better support person-centric care models and are well integrated with the surrounding communities. It is expected to be completed in the first half of 2020.
Beyond the research on understanding the relationships between the built environment and the well-being of older adults, as well as the care model, evidence-based research findings and principles were also translated into design concepts by two architectural firms – FARM Architects in partnership with STUCK Design, and Silver Thomas Hanley International. The two firms were selected from six architectural firms2 shortlisted through NUS’s Request for Proposal based on conceptual designs produced by the firms.
The envisioned void deck as part of FARM's conceptual design. Image credit: FARM
In its conceptual design, Silver Thomas Hanley International (STHI) proposed for greenery to be integrated as part of the design for various floors and spaces to promote the residents’ sense of well-being. Image credit: STHI.
Key leads of the study and the design firms involved – Prof Fung, Natalie Pitt (Director, Silver Thomas Hanley), Tiah Nan Chyuan (Director, FARM Architects) and Yong Jieyu (Director, Stuck Design) – reflect on why innovation in the design of nursing homes matters.
What is the significance of the study?
John: This is probably the first interdisciplinary design-led study of its kind for nursing homes in Singapore. In looking at design, we considered many different dimensions – how design needs to integrate with the care aspect, the social aspect and how the community plays a crucial role. We also looked at leveraging technology to support some of the activities and functions of the nursing homes.
What is the person-centric care model?
John: Person-centric care is about delivering care that enables individuals to continue to maintain their sense of self and personhood in terms of autonomy, privacy and dignity. The foundation of the person-centric care model is based on the work of Professor Tom Kitwood from the University of Bradford who led the Bradford Dementia Group in the United Kingdom from 1992 to 1998.
He developed the care model as a response to the then prevailing model that was very much institutional-based and management-focused. Person-centric care is important to nursing home residents, in particular, persons with dementia as it enables them to maintain their sense of self.
Thus, another outcome of the study is also to propose and chart out what person-centric care entails for nursing homes in Singapore as there exists varied understanding and practices of the model here.
Natalie: An important part of the person-centric care model is to provide choice for the family, carers and residents, from how one personalises the space to the choice of one’s day-to-day activities.
Another key factor is the dignity of the resident. Particularly as they age or become unwell, it is important to maintain a sense of autonomy and well-being. Also important are elements like encouragement, establishing relationships and building communities among residents.
Person-centric care is unique to each resident, so it is about understanding the person and then allowing the space and the design to respond to those needs, and they might change through different phases of care. It is a journey and the building needs to respond in terms of adaptability and flexibility.
From a face plate, to a mobile unit, a drawer with lock and an individual lamp – FARM believes that being able to personalise one’s own private space in a nursing home can enhance the individual’s sense of belonging. Image credit: FARM.
At the heart of designing the nursing homes is enabling residents to maintain greater independence and a sense of self.
John: In our focus group sessions and workshops with healthcare operators of nursing homes, their residents and staff, as well as grassroots communities near nursing homes, having the ability to maintain one’s independence in a nursing home was cited as one of the most important aspects to consider. People perceive a loss of family and community connections when you go to a nursing home, and you become dependent on others as everything is taken care of by the institution.
People also tend to view the nursing home more as a medical facility and thus are less inclined to want to walk into a nursing home voluntarily unless they are visiting a family member or a relative or are volunteering at the home. We need to continually address these challenges in transforming the nursing home and changing our social perception and understanding of its role and place within our neighbourhoods and communities.
Jieyu: In maintaining the sense of self, a key aspect is the ability for the resident to still feel at home. In our design explorations, we thought about people’s perception of belonging and what it means to have a home. For example, the ability to host visitors contributes to the sense of belonging while in a nursing home, residents are typically assigned beds with minimal hosting spaces, which can feel like they are not in a place of their own. So we highlighted opportunities where we can blur the boundaries between a care facility and a home. Some of our design ideas were distilled from research by IKEA3 into what makes people feel at home from a mental and emotional point of view.
Tell us more about creating the home-like atmosphere.
John: Unlike a hospital ward where one may stay for a few days and move on, those in nursing homes tend to stay there much longer. Therefore, for nursing homes, creating a home-like atmosphere and environment becomes more important, which supports the person-centric care model. The newer nursing homes are increasingly designed based on person-centric care principles. One example is Ren Ci @ Ang Mo Kio. Its living space was designed to emulate a HDB flat as opposed to a dormitory type of design. This is one manifestation of person-centric care in design. There are many other aspects, for example, allowing personalisation for each resident, to enable them to make their bed space and immediate areas more personal to them.
Nan Chyuan: We asked how much private space do you need to feel at home? Then within that private space, what can be added? We identified 15 important elements that include the space around resident’s bed a threshold with a sliding door, a letterbox, table with drawers and a lamp that residents can turn on and off when they want. There is also a hosting table for entertaining. The furniture has concealed wheels and can be moved but are covered for a greater sense of permanence. A big part of the design is the ability to customise the space around their beds to retain individuality as much as possible.
The many elements of what makes a home. Image credit: FARM
Natalie: There are also the climatic aspects of design that need to be considered. In Singapore, aged-care buildings are typically naturally-ventilated, so a cross-flow of air improves comfort levels. Besides addressing heat and rain, access to daylight and views are also important design considerations.
Why is it important for nursing homes to integrate with their immediate neighbourhoods and how can their designs encourage community involvement?
John: If a nursing home is developed in isolation from its neighbourhood, the community is unlikely to interact with it. From an urban design perspective, the challenge is how to integrate the nursing home with the surrounding community so that we reduce the potential social stigmatisation of the nursing home.
For the two design concepts selected, the architects and designers explored how to make some amenities in the nursing homes accessible to the community. For example, if the nursing home has a daycare centre for the elderly that only operates during weekdays, then in the weekend, some of the spaces, such as the multi-purpose hall can be made available to the community to hold events and other activities.
Newer nursing home developments have adopted more open and fenceless design concepts. We should continue to evolve the design of future nursing homes to have greater porosity and accessibility, to encourage greater interactions between the nursing home residents and the community.
Natalie: Heritage is an important aspect to Singapore’s diverse history and cultures, so we engendered the kampong spirit, which is about highlighting communities and how they work together. We looked at how people inform the programming of the building. We integrated co-share spaces, from pop-up spaces to an amphitheatre, as part of the urban space for concerts or celebrations at key times of the year, plus a playground and gardens available to all. It is about integrating the nursing home environment within communities.
Nan Chyuan: We had an idea for a caregivers’ club – a space for neighbourhood caregivers. In Singapore, there are currently two gig-economy organisations providing in-home caregiver services, CaregiverAsia and Homage. Their caregivers travel island-wide. We can adapt from the Deliveroo model to link up caregivers located within the community with those who need it. This creates the idea of a community taking care of its own. This model could reduce booking fees, travel time for caregivers and booking times. Another idea is for an app that allows family and resident information to be tracked so different caregivers can read up and know how to engage individual residents about their personal interests.
Looking into the future, who are nursing homes for and how do you see its role and design evolving?
John: Who the nursing homes are for in the future is a key question our research tries to answer. Nursing homes, even the current ones, will have to support three major age groups. The Pioneer Generation who are the predominant current users of nursing homes, the young-old i.e. the Merdeka Generation who may in five to ten years’ time consider using a nursing home, and the future old or the Millennial Generation who may need to use the nursing home in 30 years’ time.
The new nursing homes that are developed now have to have sufficient flexibility and adaptability to respond to the changing needs as it will be difficult to retrofit and modify the infrastructure later on. The nursing home designs must have a certain degree of flexibility. For instance, one of the ideas now is to design for flexibility in bed configurations to cater to changing demands in the future.
In the future, nursing homes will continue to play an important role but this role will have to evolve and transform. I hope that in 20 to 30 years’ time, each community can have some kind of nursing or care hub within the HDB neighbourhood to look after the elderly in its midst. This can offer more options and less people will need to rely on the traditional nursing homes. We can continue to have the institutions but transform them into homes for elderly requiring higher level of care and then at the same time develop community-based care. We already have homecare services but some individuals may find it costlier and may prefer accessing services in the community care hub instead.
Nursing homes in the future could also evolve to becoming not just an institution for long-term care but can have community activities and commercial functions that the community can access and use. Nursing home residents will benefit because of the potential for incidental encounters and social interactions.
Natalie: Technology integration is a big thing, from residents’ access to technology to how the building can accommodate new technology or at least be future-proofed for it. The future of nursing homes should consider what families and carers need as well. For example, there can be kitchen facilities and barbecue pits to allow a family to cook and share a meal together.
Nan Chyuan: While we strive for an eventual "age in place" solution in the near future, there will still be a need for nursing homes. From our research, it is important to encourage positive engagement with the residents in their immediate living environment. Changing little habits can encourage active participation and eventual ownership. There is strong correlation between having a sense of ownership and one’s mental well-being.
In Singapore, our climate does not change much throughout the year, so our sense of time may be highly repetitive and flat. So we thought about the flowering cycles of plants or even harvesting of fruits and vegetables. We set different gardens on each floor, so that when each blooms or is ready to harvest, residents are encouraged to go see it or actively take care of the plants.
FARM envisioned the creation of different types of gardens on various floors based on the harvesting and flowering cycles throughout the year as a way of encouraging residents to stay active and engaged. Image credit: FARM.
We also recognised that some elderly come with skills and could become go-to people for residents who need repairs or other help. There was a proposal to introduce internal currency that can be spent within the community to buy fruits or other items. The idea is to create a city in a city, and it is really how each of these ideas are trying to answer the bigger questions of the project.
This study and other efforts are part of an ongoing learning journey in shaping the evolving design of nursing homes and the larger physical environment. It is a journey that is both personal and collective. It is about understanding what each of us need to age well and how well-designed places and spaces can help build up stronger communities able to support one other.
The conceptual designs from the study were presented at URA’s exhibition, “Designing our Age-Friendly City”, together with other design solutions that contribute to the age-friendly neighbourhood, from 17 October 2019 to 4 January 2020. The exhibition is the eighth instalment of URA’s Urban Lab series that presents ideas and urban solutions for a liveable and sustainable Singapore.
1 Other government, research and industry partners of the “Designing Future-Ready and Sustainable Nursing Homes for Person-Centric Care Models in Communities” study are the Agency for Integrated Care (AIC), Ministry of Health (MOH), MOH Holdings, Building and Construction Authority, Geriatric Education & Research Institute, National University Hospital, DUKE-NUS Centre for Ageing Research and Education, Ren Ci @ Ang Mo Kio, National University Health Systems and CoNex Systems. This research is supported by the Singapore Ministry of National Development (MND) and the National Research Foundation (NRF), Prime Minister’s Office under the Land and Liveability National Innovation Challenge (L2NIC) Research Programme Award No. L2NICTDF1-2017-5. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the interviewees, and do not reflect the views of MND and NRF, as well as URA, other agencies and research partners involved in the study.
2 The four other design firms are HKS Asia Pacific & AWP, DP Architects, Lekker Architects and Formwerkz Architects.
3 IKEA’s annual Life at Home study is a comprehensive global survey into the factors that make people from various cultures feel a sense of home.