Assisted Living: Needs, Practices, and Policies in Residential Care for the Elderly

8. The Physical Environment

8 The Physical Environment Philip D. Sloane, M.D., M.P.H., Sheryl Zimmerman, Ph.D., and Joan F. Walsh, Ph.D. There is little doubt that the physical environment affects the comfort and well-being of residents, staff, and visitors in residential care/assisted living (RC/AL) facilities. The environment’s contribution to quality of life is pervasive and extensive. It provides the all-important first impression by which visitors and potential residents often judge a facility. It can aid or hinder staff as they carry out everyday duties such as bed changing, toileting , bathing, and monitoring residents who wander. It can help make family visits pleasant or difficult, depending on its ability to provide privacy and enable activities that residents can share with their loved ones. It can give residents opportunities to feel that they are in a good place; it can provide them with meaningful experiences; it can provide them with comfort , safety, and a sense of home—or it can do none of these things. Virtually all residents of long-term-care facilities have physical, mental , or cognitive disabilities, and a major function of the physical environment is to help them live as effectively and independently as possible. Residents with dementia are especially challenging, for many of them need to be led to activities, directed to the toilet, and prevented from having experiences that will frighten or confuse them. Given the variety of health problems and disabilities in the population they serve (see chapter 7 for a discussion of resident needs), RC/AL facilities must have environments that are flexible and serve multiple purposes. The overall goal of physical environments for older persons should be the enhancement of the quality of life. To achieve this goal, environments must address a variety of dimensions, each of which is believed to contribute to quality of life. We approach the physical environment of RC/AL settings by considering seven key dimensions, using a modification of the model proposed by Lawton and associates (1997): • Safety and security • Resident orientation • Stimulation without stress • Privacy and personal control • Facilitation of social interaction • Continuity with the residents’ past • Cleanliness and maintenance We discuss these seven key dimensions primarily as they apply to RC/AL facilities. Data are provided from the Collaborative Studies of Long-Term Care (CS-LTC), a research study funded by the National Institutes of Health and jointly conducted by scientists from the University of North Carolina at Chapel Hill, the University of Maryland at Baltimore , and the University of Maryland at Baltimore County. The CSLTC studied a stratified random sample of 193 RC/AL facilities and 40 nursing homes in Florida, Maryland, New Jersey, and North Carolina, each of which received a data-collection site visit by one or more of the study’s data-collection teams. Within the study’s sample of RC/AL facilities , three strata were studied: facilities with fewer than sixteen beds; facilities with sixteen or more beds constructed since 1987 and containing one or more features associated with new, purpose-built models (termed new-model facilities); and other facilities with sixteen or more beds (termed traditional facilities). Details of the CS-LTC methods are provided in chapter 6. This chapter discusses the rationale for each environmental dimension and some strategies that can be used to maximize the goals for each dimension . Data from the CS-LTC on measurable aspects of those goals are presented, by stratum. Also, illustrative data from the CS-LTC are presented as they describe components of “Eden Alternative,” a subject of considerable attention in the long-term-care industry. The chapter concludes with a summary of the findings of the CS-LTC and their implications for practice and future research. Systematic Observation of the Physical Structure of Residential Care/Assisted Living Settings: The Therapeutic Environment Screening Survey for Residential Care The majority of the data presented in this chapter were gathered by direct observation using the Therapeutic Environment Screening Survey for Residential Care (TESS-RC). The TESS-RC is an instrument designed 174 P. D. Sloane, S. Zimmerman, and J. F. Walsh to be completed in a 30- to 45-minute systematic walk through an RC/AL facility. It systematically gathers information on an entire facility or on a unit within a facility. In the CS-LTC, TESS-RC observations were conducted by trained research staff, most of whom had extensive field experience in long-term...