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The evidence in support of SAGE Design Principles

March 1, 2008
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“Evidence-based” is more than a buzzword for LTC design

People are no longer willing to accept that nursing homes have to be institutional, staff-centric facilities based solely on a medical model of care. This is partly due to the rise of assisted living, which has provided a long-term care alternative that is much more appealing, with greater individuality, control and autonomy, and an emphasis on continuity of familiar patterns of behaviors and activities. Consumers are asking the nursing home industry to follow this model, and create places to live, where healthcare needs are supported but do not drive every decision.

This is often referred to as the culture change movement or person-centered care, which emphasizes the need to have nursing homes be places where people actually feel at home. At the same time, there is increased demand from consumers—and by consumers, we are referring to not only seniors and their families, but also to care providers and designers—for evidence-based information relating to the design of nursing homes, assisted living, and other shared-residential settings. The good news is that there is a growing body of research that examines the impact of different design elements on residents and staff in various facility settings. The bad news is that this information is often hard to access or evaluate and, as a result, providers and designers may not be making the best use of it.

This article reflects the new partnership between the Society for the Advancement of Gerontological Environments (SAGE) and the Center for Health Design (CHD). For more than a decade SAGE has been promoting through this annual DESIGN publication and other efforts, the creation of positive and therapeutic environments for older adults, particularly in the nursing home setting. SAGE espouses a set of design principles that reflects a person-centered care philosophy. Meanwhile CHD, through research, education, advocacy, and technical assistance, supports healthcare and design professionals in their quest to improve the quality of healthcare through evidence-based design of acute care-related facilities. CHD is becoming increasingly engaged with long-term care, however. Using several resources, primarily a paper written by coauthor Anjali Joseph, director of research at CHD, called “Health Promotion by Design in Long-Term Care Settings,” this article examines the growing evidence base that supports SAGE's Design Principles. We choose not to include references for each topic, but at the end of the article you will find a list of five excellent resources, two of which are available for free download, that will provide all the detailed references a reader might want.

Physical Safety and Psychological Security

Just as Hippocrates counseled physicians “As to diseases, make a habit of two things—to help, or at least to do no harm,” so should the built environment “help, or at least do no harm.” People who live in nursing homes are among our country's most frail citizens, but Joseph identifies two areas of research that illustrate ways the physical environment can be designed to minimize physical harm or psychological insecurity.

First, falls are common among nursing home residents. In Minimum Data Set (MDS) data reported for the third quarter of 2007, 43% of residents had fallen within the prior six months. It should be noted that there is evidence that the MDS underreports falls, so the actual fall rate may have been even higher. Also, most of the research on falls focuses almost exclusively on intrinsic or person-related factors. Research that considers extrinsic or environmental factors tends to do so in combination with other factors, so it's difficult to ascertain the exact impact of any environmental interventions on falls.

Nevertheless, there is evidence that certain interventions are effective in reducing falls. First and foremost, improving lighting levels, especially at night, can make a difference. The highest number of falls occurs in the bedroom and bathroom, often when people are getting up at night to use the bathroom. Increasing night lighting between the bedroom and the bathroom and making sure there is a clear path to the bathroom are important steps toward safety.

There is conflicting information about flooring, with some studies suggesting that seniors ambulate better on vinyl flooring, while others suggest that good, tight-weave commercial-grade flooring will not negatively impact balance and movement. There is evidence that carpeting is associated with fewer fall injuries. Betrabet Gulwadi and coauthor Calkins recently completed a comprehensive review of the literature on environmental correlates of falls in healthcare facilities, which is available from the CHD's Web site (

There is modest research on low-tech strategies to keep individuals with dementia from leaving the building or area unattended by staff (more technology-related systems that address this will be discussed later). There is conflicting evidence about whether visual deterrents, such as highly contrasting lines on the floor in front of the door, are effective in discouraging residents from using an exit. Placing a piece of fabric attached with Velcro™ to the door frame so it hides the door handle has been shown to be effective, but this is not always allowed by state codes.