Making a Place for Joy

From the desk of Ryan Loveday, Director

How Will our Elders Live?

Designing for the future of Aged Care.

Over the last 25 years our practice has built up a significant specialty in community architecture- specifically complex education, health, aged care and cultural projects. It’s challenging and rewarding work. I presented this article as a short seminar at our recent small aged-care forum in Brisbane.

1. Start with a Question

The title theme of our forum was…Dazed or Dazzling: How Will our Elders Live?

So lets start there… or to make it more personal ‘how would you like to live, when you get there? Because lets face it, we are all getting older and the time will come.

And perhaps the more important question is… ‘How would you like to die?’

2. Uncomfortable Conversations

Lets face some facts.

You are getting older, and we are all generally living longer- which also means being old for longer.
As we continue to live longer- it’s a fact that our minds aren’t necessarily lasting as well as our bodies. Living and coping with dementia is and will be one of the big issues of our time.
And, you will eventually die.
Aging, dementia and death are each in themselves quite confronting and uncomfortable subjects to talk about. And I don’t expect this audience will be any more comfortable than the usual.

On the whole, our society has developed the habit and the infrastructure of quietly removing people from public view when they get old, or infirm, or just difficult. And mostly, we don’t think about those people until the circumstances touch us directly, usually as our own parents age.

The truth is often that we are not equipped to deal with our own unease about these things, so we don’t know how to talk meaningfully about them.

Of course, if we’re going to design for it (for aging, for dementia and for palliative care) we have to talk about it. And at the very least, the people responsible for providing those facilities have to be prepared to grapple with their own demons.

As architect’s we can’t pretend to be expert in all of the subject matter included here, there is very good empirical research on all this by others. And I don’t necessarily think it’s the job of the architect to be the smartest person in the room, but rather I think our role is to be an expert listener and translator, into a built outcome.

3. Background

To set up the discussion, let me briefly paint the background context for aged care as we understand it:

Demographics. We know demand for aged care is increasing. We know the baby boomers and gen x’s who’ll follow them have high expectations of the quality of care they’ll accept to live with- far higher expectations than previous generations.

We also know most of them will stay in their own homes as long as they can (and the commonwealth government is certainly supporting that) and when do enter formal care they will be in their 80’s and as a result they will have more acute care needs. They will probably be in care for less than 2 years- in which case aged care is really palliative care.

At the same time we are seeing a rise in the number of residents presenting with complex mental health issues, particularly depression and dementia, sometimes arising from substance abuse and related issues. In many cases these residents are relatively fit, strong and can present very challenging behaviours.

Along with that, the Carers themselves are also getting older, the average age is 48 (as opposed to 40 generally) and it’s difficult attracting and retaining new staff in an environment of low wages, hard, emotionally taxing, often thankless work, with low staff morale.

Financially the landscape is difficult- while demand for services is huge, government policy is very reactive and funding is subject to the political cycle. The operational viability of facilities is constantly under stress.

In the bigger scene, Housing Affordability for older people is a growing problem and has a flow on effect for the way operators structure their fees, around RAD/ DAPS. And fundamentally moving into care is a financially stressful experience.

In terms of the building stock- Historically the aged care sector has transformed slowly. In the 50’s aged care was still very much a hospital situation, with hospital attitudes. The 60’s and 70’s saw mostly low-care hostel and group home type facilities and the 80’s and 90’s the more familiar high-care.

As it stands, the industry is typified by buildings over 25 years old. Mostly very rigid and outmoded. When the most significant cost of running a facility is your staff, the pressure of nursing and servicing efficiency makes it quite difficult for many of these older facilities to remain viable.

4. Making a Place for Joy

This is a tough environment to operate in. These are very complex facilities. They need to be really well thought-out and planned to the inch to make them viable. But it’s important that while you’re doing that, you don’t lose sight of why you’re doing it.

Transitioning into care (and out of care) is a highly emotional environment, characterised by financial stress, anxiety, guilt, sense of loss. For staff this is a very procedural environment, but for the resident and their family it is anything but.

We used this phrase “Making a place for Joy’ in a recent submission, and we like the slightly corny pun because Joy is both an emotional quality and a person, and you need to think about both.

So how do you design for joy?- what makes the elderly happy? What makes anyone happy?

living with limitations
It is the patronising nature of youth to look at the old and determine that they can’t possibly have much life to enjoy. For us it’s unimaginable to live with being sick, being weak, being deaf, having incontinence, having dementia, needing to be bathed and helped to do most things.

But it’s our own discomfort at those things that leads us to treat the elderly in certain ways. None of those things are much fun but when you spend time with the residents themselves they are mostly much better adjusted to it that we are. Like us, they tend to focus on what they can do, not what they can’t, and they retain a deep capacity to be happy.

And the ingredients of happiness aren’t complicated…

  • Acceptance and belonging
  • Active and connected

Aging is often characterised by a gradual retreat from the world, of gradually losing connections to family and friends, and a loss of mobility and confidence- which limits normal human interactions.

At the same time the world slowly pushes you away- as less capable, less valuable, less important.

So if we want to make places that overcome those, that provide for joy, we need to think about the architectural implications…

5. Ideas Worth Fighting For

The biggest challenges I think, are philosophical ones.

While the industry is (mostly) driven by deeply compassionate mission-based providers, in many ways these are still often manifested as very conservative, risk-averse, nursing-driven, and quietly patronising attitudes.

Regardless of the starting point- there are some key ideas that we think are important and that we try very hard to advocate for and preserve during the design process.

Idea 1: The Blurry Edge

Most aged care exists as a kind of island community, in the neighbourhood but not part of the neighbourhood. As often said, ageing is often about by a gradual withdrawal from the outside world, and usually means losing a lot of normal human interaction- driving, going to the shops or the movies or the hairdresser, buying a paper…

Everyone and particularly the very vulnerable, the marginalised, those with dementia and mental illness, crave a sense of belonging and connectedness- we need community.

So how do we design for that?…

  • Make the entry as deep into the site as you can.
    Provide the opportunity for the outside world to interact, overlap, permeate the site- create blurry edges. Often this is realised as a front of house café, community centre/ community street, function rooms for hire, access for mothers groups and community groups. A place to drop in- where family and friends can take pleasure in visiting.

The opportunities for larger campus style master planning can make a huge impact, co-location with churches, schools, child care centres, crossed by bike paths and other human activity can be genuinely uplifting.

External and internal site security is still important but that can be effectively and discreetly managed!

  • Colour and movement – any activity is good activity.
    Aged care homes can be very lonely places. If the residents can’t get to the street, bring the street to them. Create destination points- places to go within the facility.

Don’t waste a single opportunity to give colour and movement. Anything that can add to movement, put it on show!- admin offices, hairdresser, physiotherapy, kitchens, laundries…it’s often hard to find the staff in these places, so don’t hide them away. Don’t allow dead space- by way of empty rooms and blank doors. Design in every opportunity you can to capitalise on the vibrancy of normal life and activity.

Idea 2: Home not Hospital

This one’s fairly obvious…

The overall shift in aged care has been from a hospital model to a much more resident centred ‘home’ oriented philosophies- Montessori, Eden Alternative etc.

Why? Because it makes us happier. Familiar residential cues reduce stress.

At one end of the spectrum this means simply staying in your own home as long as possible, but at some point there may come a time to enter formal care.

This is all about removing institution cues, answering the question simply-

Would I see this in my home?

Things like- the endless corridors, identical rooms, trolleys everywhere, the nurse station, bump rails and corner protection, even the choice of finishes and lighting can all scream institution! All those security and service components may need to be there but discreetly located. And technology will advance that in future.

Key to this is the idea that good design for dementia is good design for everyone. This includes- simplifying choices, good line of sight, using light for way-finding, good signage and visual cues, objects rather than colour for orientation, reducing distressing noise, textures and contrasts, familiar domestic cues, familiar and meaningful tasks, safe outdoor space, unobtrusive service and safety elements.

Idea 3: Choice and Self Determination

Aged care facilities are ‘routine machines’ and most often nursing decisions are imposed on residents. Most residents just do as they’re told.

Marguerite Kelly- Senior Research Fellow at the University of Western Sydney- refers to the concept of residents giving up their ‘Agency’, that is they no longer feel like they have purpose, relevance, or control of their lives.

The Commonwealth Government has placed more control directly in the hands of residents, with the policy of Consumer Directed Care- residents are no longer just ‘in the system’.

To be happy, we need the ability to make normal adult choices. Choices about when I’ll get up, when I’ll eat, where I’ll spend my day and who I’ll spend my day with. Some choices include risk. Architecturally we need to provide reasonable ability to make those choices. The ability to move about the building safely- rather than locked wards. A variety of environments and destinations- café, town hall, lounges, sitting rooms, nooks to choose from. And always with natural light and an outlook and things to see.

6. Half the Story

Our experience is that successful projects need to deal with all of these issues. They need to reduce the isolation and dislocation from community, they need to design for dementia with safety and dignity, they need to provide normalcy of choice and self-determination, and they need to be ‘home’ rather than hospital.

We need to build places that are safe and efficient yes- but we need places that are filled with space and light and people and joy.

  • Architecture can only go so far.
    While as designers we can respond to all those ideas architecturally, fundamentally these are not mechanical things that can be built or scheduled, they have to be nurtured within our organisations. And what we know is…
  • Staff have the biggest impact.
    Good architecture can’t guarantee a good facility, it can only support excellent care staff in creating a good quality of life for their residents.

The ideas, philosophies and attitudes around quality of life, have to be grown purposefully in organisations, and embedded from the top down…and they are slow to change. Culture wins over QA, every time.

  • Every project is a renewal
    There’s a reciprocal relationship between building projects and organisational change, they always go together. Change drives new building, new building drives change. Designing buildings means designing systems, which means thinking about how people behave, which means thinking about what outcomes you actually want- to think about your why.
  • Make an emotional connection
    Designers can’t stand apart, they need to make an emotional connection- to empathise with the people who will live and work in their buildings.

The future success of aged care, whatever shape it takes, will be in applying human wisdom and compassion to make the last part of our lives as meaningful and joyful as the first part…and to support that with really great buildings!

So to finish with the question we began with…

7. How will we live?

I believe the answer we want is…‘as normally as possible’.

In other words we expect to have all things we take for granted now.

We want to be in a safe space, we want choices, we want to be connected…we don’t want to be alone. And we want the ability to extract every possible bit of joy from life we possibly can.

At least that’s my plan.