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For many patients, the hospital is a challenging setting due to the busy, unfamiliar and stressful nature of the environment. For a person with dementia, the hospital experience can be exacerbated by cognitive impairment and behavioural or psychological symptoms and can therefore prove to be a frightening, distressing and disorientating place.
In response to these issues, research1 was completed to investigate dementia-friendly design for acute care public hospitals. Based on a detailed literature and best practice review, national and international case studies, and an in-depth stakeholder engagement process, the research team2 examined how the physical hospital environment might provide a better experience for people with dementia, and how hospitals can be designed to enable family members and carers to provide support for the person with dementia throughout their visit to the hospital.
Following this research, a set of guidelines focusing on Dementia-Friendly Hospitals from a Universal Design Approach were developed to provide detailed guidance in relation to dementia-specific design issues and the universal design of dementia-friendly hospitals.
Figure 1: Impact of the hospital on a person living with dementia
Bringing together dementia-friendly design and universal design
Considering the physical, sensory and cognitive impairments associated with dementia, and the various needs of accompanying persons, visitors and staff in a typical hospital, it is important to adopt a design approach that is not dementia-specific, but rather one that is inclusive and takes account of the complexity of hospitals and the diversity of its users.
Universal design represents such an approach. It is defined as “the design and composition of an environment so that it can be accessed, understood and used to the greatest extent possible by all people, regardless of age, size, ability or disability”. It recognises that we all have evolving needs based on different stages in our life cycles, including varied health circumstances or age-related changes. A universally-designed environment can respond to our needs by factoring in at the outset key design features that enhance quality of life for everyone. Furthermore, universal design promotes a higher and more inclusive baseline from which specialised care, personalisation or adaptation for specific needs can take place.
In this context, the stress placed on many people with dementia by the built environment can be alleviated through a universal design approach. The hospital environment can also provide a prosthetic or enabling environment in relation to disabilities or functional impairments, particularly for patients who may be at their most vulnerable due to illness while in hospital. In addition, it is possible to go beyond these and start considering how the built environment can be designed to play a more active and positive role in providing supportive, healthful and therapeutic places and spaces for people with dementia.
In this regard, universally-designed dementia-friendly hospitals:
Are accessible, understandable and easy to use for all occupants.
Recognise the cognitive, behavioural and psychological, physical and sensory difficulties that a person with dementia may experience as a patient or visitor to the hospital.
Reduce hospital-related environmental stress.
Provide a prosthetic or enabling environment to account for dementia-related disability.
Create a healthful and therapeutic setting to promote healing.
Recognise that dementia-friendly design not only supports people with dementia, but also supports accompanying persons, visitors and staff in their caring roles.
The research team and other attendees at the launch of the guidelines
Understanding the key design issues across all major spatial scales
Drawing on a wide range of literature and international best practice, the research team developed a set of 18 key design issues that should be considered as part of any retrofit or new-build project. These issues are broken into themes that include engagement and participation, where issues such as engagement with families and friends or support for accompanying persons are promoted. Providing a people-centred environment focuses on softening the institutional environment and facilitating familiarity and personalisation. Patient safety, health and wellbeing not only looks at some of the key safety issues, but also addresses critical aspects of the care, such as the support of meaningful physical and social activities. Balancing sensory stimulation involves issues around positive sensory stimulation or contact with nature, while supporting orientation and navigation reinforces the orientation to date, time and location, or issues around good visual access and way-finding. Adequate space to support the needs of a person with dementia refers to the need for both communal space and retreat space, while also ensuring the provision of supportive conditions for patient mobilisation and activities. Finally, appropriate use of technology highlights the importance of technology for care delivery, safety and therapy, yet cautions against obtrusive or inappropriate measures that undermine dignity or might cause distress.
These key issues are applicable across the full spatial spectrum of the hospital, from approaching and entering the hospital site or campus, to individual rooms, right down to smaller building components and technology within the hospital. In this regard, the research systematically investigated the key spatial scales with a number of case study Irish hospitals and used the results to structure and inform the guidelines.
Building on these spatial scales, the guidelines firstly examine the ‘hospital as a whole’ and following on from this, break the hospital into distinct sections, including: Site location, approach and entry; campus design and site circulation; building approach, entry and internal circulation; key internal and external spaces; building components; technology; and finally, internal environment.
This holistic approach to the hospital is a unique aspect of these guidelines. Furthermore, setting out how the 18 key design issues can be considered at each spatial scale helps create an environment that supports people with dementia on a day-to-day basis as they travel to, move around, and leave the hospital.
Figure 2: Key design issues across the all spaces within the hospital
The research conducted as part of these guidelines confirmed the negative impact of the acute hospital setting on many patients with dementia. However, it also illustrated the positivity and expertise that exists in a typical hospital around the needs of people with dementia, and demonstrates a genuine willingness to improve the physical environment in this regard.
These guidelines provide many evidence-based design features that can support dementia-friendly and universally-designed environments in hospitals. The guidelines will support a wide and diverse range of patients, visitors and staff of all ages, sizes, abilities and disabilities, while also helping hospitals to fulfil their role as care-giving and healing facilities.
1. These guidelines were completed as part of a research project funded by the Health Research Board (HRB) Applied Research Projects in Dementia 2015 programme, administered by the HRB in collaboration with The Atlantic Philanthropies (AP) and the Department of Health (DoH). The research team would like to thank the HRB for funding this research and for providing much support throughout the process.
2. The Principal Investigator for this research is Prof Desmond O’Neill (Trinity College Dublin (TCD) and Tallaght Hospital) and the research and guidelines were completed by TrinityHaus, TCD and Tallaght University Hospital, Dublin, in collaboration with the Centre for Excellence in Universal Design, Health Services Executive (HSE) Estates, Alzheimer Society of Ireland, Irish Dementia Working Group, O’Connell Mahon Architects, the National Dementia Office, the Dementia Services Information and Development Centre, St James’s Hospital, Dublin, Mercy University Hospital Cork, and Connolly Hospital, Dublin.
A select number of key literature references can be provided if required.
Figure 3: Three-dimensional drawing of Tallaght University Hospital showing major spatial scales and key patient areas and occupant movement within the hospital