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Life-Span Design of Residential Environments for an Aging Population

The Quest for Privacy in the Design of Living
Environments for the Aging

Barbara L. Geddis, A.I.A.
Partner
Perkins, Geddis, Eastman, Architects and Planners

Universal design principles are being sought, I contribute only an exceedingly short list. I have devoted much of my 17-year career as an architect and planner to creating compassionate and exemplary settings for the aging population. Along the way, I have learned and unlearned many current standards, complied with and critiqued various codes, and accumulated a few biases. The state of the art in design for older people mandates an eclectic approach; an openness to what is happening in other fields of research and design; and a commitment to changing preconceived notions, current standards, and, ultimately, the codes themselves.

One interesting trend in retirement housing is the increasingly popular residential unit with a double master bedroom that is two equally generous separate bedrooms with private baths. The market data seem to suggest that a wide variety of retired persons enjoy this unit: happily married couples who nonetheless want their own domain; other relatives who are roommates (e.g., sisters, sister and brother, mother and daughters); or simply friends who wish to share a unit for economic and/or social reasons and still maintain personal territory. In essence, such an arrangement offers the freedom to choose privacy or community, solitude or friendship. It has been common in college dormitory housing trends for some time. Even hotel design has added the "parlor suite" concept: a private sleeping area and a front entertainment or work space.

Universal means "applying to all"; for my purposes here, this means all settings for the aging and/or all aging persons, whether in a house, home, unit, or institution. The strong, simultaneous trends noted above should alert the design and research professions that such a concept can be widely applied across the continuum of settings for older persons. However, the one fundamental principle privacy-has received little serious attention, particularly in more confined settings.

This paper describes the often thwarted quest for privacy in heavily regulated designed settings for the aging and offers some avenues for future exploration.

The Basic Premises

Specialized housing and caring settings for older persons often defy and intrude upon privacy, inhibit independence, discourage self-reliance, restrict freedom, and offer few opportunities for contemplation, voluntary solitude, or intimacy, for that matter. All these values make direct physical demands on program and architectural design, and all in turn can be directly enhanced by different design.

At the heart of this issue are a few premises about our values:

• The physical manifestation and extent of privacy in our culture and in our homes reflect status.
• The achievement of independence and self-reliance reflects success.
• The accomplishment of peace and freedom from anxiety offers opportunity for contemplation.
• The ability to enjoy solitude is a gift and a buffer against loneliness.
• The recent judicial recognition of rights to privacy reflects some acknowledgment of a fundamental right.

 

How then can these values be incorporated into housing for older people? What are the obstacles to be overcome? And what are the precedents for reminding us that, after all, the common unit of privacy is the place where people live, whether it be a house, an apartment, a simple bedroom, or, as poet Robert Browning put it, "privacy, an obscure nook just for me"?.

In evaluating the practice of designing the long-term care setting for the decades ahead, it is useful to review the status of private spaces throughout history, note the ruling criteria today, and suggest enlightened criteria for tomorrow.

Historical Background

To begin with, it is important to review the historical evolution of privacy in house design over the centuries. Even in A.D. 100, Vitruvius, the Roman architect and engineer, made the following distinction:

Private rooms are those into which nobody has the right to enter without an invitation, such as bedrooms, dining rooms, bathrooms. . . . The common are those which any of the people have a perfect right to enter, even with out an invitation, that is entrance courts, etc.

But the concept was lost for centuries as the bustling, all-purpose rooms of the Middle Ages evolved. Only later, as belief in the values of individualism and domesticity began to develop toward the end of the eighteenth century and especially at the beginning of the nineteenth century did the notion of privacy reawaken. In households of the nobility, privacy was recognized in sleeping, eating, religious, and social rituals. The large, all-purpose rooms linked by interconnecting doors gave way to small, single-purpose rooms, especially in Northern Europe. In addition, as the population became better educated and reading became more valued, places in the house to enjoy more introspective activities evolved.

By the end of the late nineteenth century, with the Victorians' penchant for privacy, the separation of spaces became extreme. Family and servants lived on separate floor levels and had separate staircases; children were separated from parents; and an odd assortment of function rooms appeared: foyers, parlors, nannies' rooms, ballrooms, breakfast nooks, libraries, etc. Every aspect of domestic and social existence was compartmentalized. In effect, an implied morality and class separation guided the layout of house design, with clear delineations of public and private domain.

Although the perception of public vs. private space varies significantly from culture to culture, the threshold where private space ends and public space begins must still be acknowledged in design (see Figure 2). One of the inherited burdens in designing living environments for the aging population today is the lack of these clear ground rules of residential design of the past. Instead, the architectural antecedents for both the modem long-term care center and the congregate housing complex derive from three strongly intertwined building types: hospitals, prisons, and hotels, all of which have little to do with residential households. Supervision was their overriding goal, and only in the twentieth century have these buildings evolved to provide for any semblance of privacy.

It is interesting to note that the basic shape of the floor plans of many modem nursing homes-a center point from which one can view all corridors derives directly from the hospital and radial plans of the seventeenth and eighteenth centuries. Today, the nurses' station is at this center. Historically, altars and chapels were at the center, and later, given the high mortality rate, central domes for ventilation and removing used air were constructed. Innovation in design of future settings for older people requires a reconsideration of that center of the universe: at the center should be the person who has to make a home there.

If you live in fear that your own senses may fail, you may not want absolute privacy. But privacy as defined herein does not mean aloneness or isolation or withdrawal. It simply means everyone's right to have whatever level of visual, acoustic, and psychological separation we all occasionally require. And the old saying that good fences can make good neighbors might well apply.

The quest for privacy may mean questioning published space standards enforced by the state's departments of health, social services, or housing. It may mean redefining the physical limits of care and custody. Ultimately, it will also include observing and talking with the residents about their concerns.

We have spent days, months, and years discussing, planning, designing, and building with the idea that an individual's right to privacy is a fundamental one.

As such, it is not to be relinquished at the entrance to a nursing home just because health and/or safety issues have emerged. What follows are some of the most common reservations various sponsors hold about the cost of redesigning to support the quest for privacy, and our answers to these concerns:

• Why bother? Most people will not appreciate it anyway. If assurance of physical privacy makes a measurable difference in quality of life for even a quarter of the residents, it is worth it. And our hunch is that the non speaking clientele may value it even more.
• It must necessarily cost more. In terms of capital costs and square feet per resident, yes, there is an increase, but it is a modest one.
• It will not change reimbursement formulas. Quality of environment is increasingly becoming a part of reimbursement formulas, and more and more insurance companies are beginning to pay attention to the importance of the physical setting and other quality-care issues.
• It's less efficient for supervision. It is not less efficient for supervision, but it does require more efficient supervision: dynamic, periodic, human. Nurses cannot and should not view everything from a stationary position.
• It's harder to maintain. There is no evidence to suggest that a better-designed facility will increase maintenance requirements.
• The state standards won't value it. The states vary considerably in this respect, and we believe strong inroads are slowly being made in state standards that will acknowledge an individual's right to privacy as well as choice of community.

 

In the design of a nursing home, a half-dozen criteria are usually paramount, not one of which is privacy:

• Layout and configuration of the nursing unit: Can all corridors and even doors be seen from one supervision point?
• Functionality: Are all our utility rooms (for laundry, storage, medication, nourishment) well placed and sized for staff's use?
• Maximum distances: Are all distances from any room door to the nurses' station as short as possible, presumably for speed of response?
• Code compliance: Are all life safety requirements met with regard to smoke compartmentalization, ratings of partitions, and positioning of exits and stairs?
• Ease of servicing community spaces: How easily can the dining room and lounge be seen by staff and serviced by food carts, etc.?
• Optimal unit size for nursing efficiency: This may be 40 or 35-40 or 40-45 beds per unit, depending on the jurisdiction.

 

Other, more recent requirements imply, if not directly discuss, privacy and self-reliance:

• Accessibility requirements: These vary as different states incorporate part but not necessarily all of the federal standards established by the American National Standards Institute. In any case, accessibility requirements inside the bedrooms and bathrooms are directly affected by size and layout.
• Room mix: This is usually varied, more because of market data and reimbursement realities than because of state minimum standards. The proportion of private rooms is likely to be anywhere between 10 percent and 33 percent of the total number of rooms.

 

In addition, for cost containment purposes, some jurisdictions have imposed not only minimum space standards but also maximum space standards per bed capacity. These numbers, which may be in the 400- to 500-gross-square-feet/bed range, are supposed to include all support space, infrastructure, recreation, therapy, maintenance, and administration. More than any other working criteria, these maximum standards nearly negate any appropriate private space for the residents. In fact, coupled with accessibility standards, such requirements are contradictory and puzzling. In effect, there is very little to design and plan. The ground rules, enforced by law, are prescriptive.

A few examples will illustrate how such rules can sometimes defy good practice and common sense.

• Sponsor A wishes to widen the corridor significantly around the waiting area to the dining room so that it can operate as a waiting lounge without walls. This is not possible because 1) a defined 8'-O" corridor with handrails on both sides is required; and 2) open lounges are not allowed without rated walls, windows, and doors. None the less, the built space becomes crowded with residents anyway.
• Sponsor B wishes to provide resident rooms with doors that residents may open themselves. This entails a pair of doors, one 3'10' and the other a panel beside it to be opened in emergencies for the bed to be moved. This is not possible because 1) doors and frames must both be rated; 2) a manufacturer cannot be found to provide them; and 3) costs are thought to be prohibitive. Thus, doors to resident sleeping spaces are often left open because they are too hard for the resident to close and because the staff likes to save time on supervision.
• Sponsor C wishes to provide accessible, open, outdoor porches on every nursing unit, where residents can go out safely by themselves. This seems to require automatic doors, a railing or barrier at the terrace/porch's edge, and a location directly across from the nurses' station for supervision. Such spaces often disappear from the program or are locked most of the time.
• Sponsor D wishes to allow residents some ability to move their bedroom furniture around. Specifically, requests are to align the long side of the bed with the wall to have more space for the chair in the window, the visitor's chair, places for writing, storage, etc. This is not possible because the bed must be accessible on three sides to allow clinical staff access with equipment or a stretcher, even though beds are on rollers and can be easily moved.
• Sponsor E is asked by family members if they may stay with their relative overnight or until some crisis passes. This is not possible because their relative's roommate is already significantly disturbed by all of the commotion, no private rooms are available, and even if such rooms were available, there is no provision or space for visitors. Although sponsor offers a guest room elsewhere on the premises, family decides to stay anyway, using a chair in the room.

 

A concerted emphasis on providing privacy and promoting self-reliance as essential ingredients to a resident's quality of life might alter these outcomes as follows:

• Sponsor A would indeed provide a waiting room/social lounge by the dining room. In fact, such queuing spaces would be incorporated into the state's standards, much as prefunction space is planned in hotel and dormitory design.
• Sponsor B would install small room doors, manageable hardware, etc., as the marketplace meets the demand with new products and lower prices.
• Sponsor C would be able to offer protected outdoor spaces with assistance from visual access technology devices.
• Sponsor D would be able to demonstrate a half-dozen different possible room arrangements in the skilled nursing setting with easily accessible emergency equipment and improved industrial design of hospital beds and their accoutrements. Sponsors would be able to offer a short term room suite arrangement in special circumstances.

 

Future Prospects

"The man who goes alone can start today, but he who travels with another must wait until the other is ready."

Thoreau, Walden

In our view, to pursue defining what the richest, most varied, and most fining settings are for older persons, changes in many of our current practices are necessary:

• We must relocate the physical center of the universe from the nurse and clinical support staff to the individual resident.
• We must raise privacy to the same level of importance as enforced community and supervision.
• We must find new room layouts from outside the institutional tradition and try them out in the worlds of hotel, college dormitory, private residence, or even group home designs (see Figures 5 and 6).
• We must turn a critical eye toward codes and standards, and be prepared to oppose and change their stipulations.
• We must demand that what is often a person's last home offers that person the opportunity to flourish, not merely to survive.
• We must understand that the quest for privacy on the large scale of the nursing home or congregate housing context may be a long journey but an inevitable responsibility of those of us who believe in the importance of creating places where people can live and thrive, and where the essential right of privacy is preserved, even after the age of 80.

 

 

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