The evidence in support of SAGE Design Principles

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.

Beyond physical safety, people generally want to feel emotionally secure as well. While aggressive and disruptive behaviors can have many etiologies, clearly they often stem from residents feeling insecure. Numerous research projects have explored environmental factors that impact agitation or aggression. Larger unit sizes and the absence of a family kitchen area are associated with increased agitation among residents with dementia. There is also evidence that people with dementia are less agitated and may require less behavior-controlling medications when they have a private room versus a shared room. Relaxing music has been shown to decrease disruptive vocalizations, which are usually a sign of agitation. Numerous studies have explored the impact of both higher ambient lighting and treatment with bright light, both of which appear to reduce agitation (though nursing homes often have significantly lower light levels than what is recommended). Finally, having direct and unrestricted access to the outdoors has been shown to reduce agitation and decrease violent episodes in individuals with dementia.

Environment as a Therapeutic Resource

SAGE believes that all aspects of the environment (physical, programmatic, and organizational) should serve as a resource for healing and improved functioning. There is clear evidence that maintaining or increasing physical activity has a wealth of positive benefits, including prevention and treatment of chronic illnesses, reduced disabilities, and better physiological and psychological health.

For instance, it has been demonstrated that participation in a low-impact exercise and continence-management program significantly affects several clinical outcomes (strength, endurance, and urinary and fecal incontinence). Regular exercise has also been shown to reduce agitation in individuals with dementia. Most of the research in this area explores program interventions (e.g., exercise programs), although there is also some evidence (mostly from CCRCs) that the design of the physical environment itself impacts physical activity among adults. Well-laid-out walking paths with level surfaces, as well as access to wellness facilities (pool, exercise room, etc.), are associated with increased physical activity among residents, and there is evidence that providing covered pathways and courtyard gardens increases outdoor activity. One study even found that people walked further and faster when they listened to music while walking.

Nursing home residents are at significant risk for nosocomial infections. They contract 1.5 million infections per year, with each resident facing a 5 to 10% risk per year of acquiring an infection. Commonly acquired conditions include pneumonia, influenza A, and methicillin-resistant staphylococcus aureus (MRSA). Pneumonia is the leading cause of death among nursing home residents, with overall mortality rates reported between 20% and 50%, and as high as 80% in some studies. Pneumonia is also the major reason for hospital transfer among nursing home residents. A 1998 estimate for the national costs of treating pneumonia in nursing homes was $436 million.

While most studies of nosocomial infections have been conducted in hospital settings, several nursing home studies clearly show increased rates and risk of developing an infection associated with sharing a room. It is likely that the most effective way to reduce nosocomial infections is to provide each resident with a private room. One study found a 3.07 relative higher risk of developing Influenza A for people living with a roommate versus residents in a private room, while another found that 84% of nursing home residents who developed acute nonbacterial gastroenteritis during an outbreak lived with a roommate, whereas only 16% of residents who became ill lived in private rooms.

Sleep is, of course, related to overall health. There is strong evidence that older adults, particularly those living in nursing homes, have significantly disrupted sleep cycles, which impacts daily functioning. This is partly due to operational factors (staff coming in and checking on residents every two hours, which is disruptive to both the resident being checked and the roommate), and partly due to environmental factors (high noise levels and lack of exposure to sufficient light during the day to maintain one's circadian rhythm). However, the research on minimizing noise at night has not been shown to make a difference on sleep patterns.

While some research has looked at the impact of increased time spent outdoors during the day, the more promising research (in terms of significant results) has been conducted with bright light therapy. Having residents sit next to a light box (2000 lux) for as little as 30 minutes or as long as 2 hours has been shown to improve sleep hygiene at night. Some studies suggest the light should be administered in the morning, while others found success with evening-administered bright light therapy.

There is a fair amount of research that environmental elements—ranging from the basic layout of the building to the design, placement, and use of signage—can support orientation and wayfinding for seniors in nursing homes. Unfortunately, the linear, double-loaded corridor plan that was used for decades as the basis for designing nursing homes contributes to confusion and disorientation among residents (and often visitors, especially in buildings that were added to over time). There are ways to address this basic limitation, such as creating noticeable and distinctive landmarks or reference points, enhancing visibility to the outdoors, differentiating similarly designed hallways with distinguishing architectural elements and décor, and creative use of signage. There is some evidence that teaching staff to routinely refer to signage and landmarks in discussions with residents increases their effectiveness as cues.

We know that older adults require two to three times the amount of light to see something as well as a younger person does. The evidence is clear that increasing the amount of light and contrast at place settings in the dining room can improve independence in eating and increase caloric intake. Other studies have shown that serving food on bright-colored plates (e.g., red and blue) also increased caloric intake.

Holism and Well-Being

For SAGE, the principle of holism focuses on the needs and desires of the whole person—social, emotional, spiritual, physical, vocational, and intellectual. While there are many ways the environment can support this by providing opportunities to develop meaningful relationships and engage in meaningful activities, there is less research that specifically examines how the physical environment impacts this holistic perspective of personhood. However, when the setting is, generally speaking, less institutional and more residential, evidence shows that residents are less agitated and aggressive, able to maintain better motor functions, have increased food intake, and required less psychotropic medication.

The challenge with this body of research is that each study tends to define “less institutional/more residential” in slightly different ways, although the definition generally includes personalized rooms, residential-style furniture and décor, and natural elements (plants and animals).

Perhaps the most extreme example of “more residential” is the Green House project, spearheaded by pioneering gerontologist and Eden Alternative founder Bill Thomas. Each Green House is a freestanding home for 10 to 12 individuals who require nursing home level of care and support. Each resident has a private room that opens onto a shared living room, dining room, and kitchen area. Green Houses call for substantial operational changes relating to how they're staffed, and the research has not been able to single out the design of the environment in terms of its impact on staffing.

The first Green House, in Tupelo Mississippi, was intensively studied over a two-year period, and the results demonstrated statistically significant differences in self-reported dimensions of quality of life that favored the Green House over one or both comparison groups. The quality of care in the Green Houses at least equaled and, in terms of functional status improvement, exceeded the comparison nursing homes. A copy of this research paper is available at: JAGS_June07.pdf.

Individual Rights and Personal Autonomy

Some of the earliest environmental research in long-term care settings was conducted on privacy. The research discloses a relationship between the degree of privacy and perceived degree of control (ability to control with whom one interacts and when) and participation in social behavior. Several studies have shown that people required to share a bedroom lack a sense of privacy and feel less at home in their own bedrooms—they are sharing a room with someone who is often a stranger. These individuals feel less secure and, when occupying shared social spaces, tend to withdraw socially and participate less in activities. Research has demonstrated quite clearly that people who have a private bedroom are more socially engaged than those occupying shared rooms.

Communities and Relationships

Even though people are generally social by nature, a variety of forces combine to inhibit social interaction among nursing home residents. First, the physiologic changes that occur with aging, such as impaired hearing, poorer vision, and difficulty in simply turning and facing a conversation partner make the simple act of communication more difficult. Second, nursing homes have traditionally had large multipurpose social spaces, with poor acoustics and little to no privacy for personal conversations. At the macro level, the overall size of the facility may also be important. There is evidence that older and frailer individuals tend to socialize more in smaller facilities, while younger, more independent residents are more active in larger communities with a more diverse and challenging activity program. On a smaller scale, the arrangement of furniture is important: chairs placed side by side tend to inhibit conversation while chairs placed at right angles to each other tend to promote it.

Function-Enhancing Technology

Assistive technology plays a vital role in the lives of older individuals. There is a steep increase with age in the number of people who report problems with activities of daily living (ADLs). Assistive technology designed to compensate for limitations in ADLs (whether from aging or injury) ranges from commonly used products such as canes, eyeglasses, magnifying glasses, and hearing aids, to uncommon (and often expensive) medication distribution systems, and sensor systems designed to alert caregivers to unsafe behavior (e.g., getting out of bed unassisted). Because of the scope of these types of technologies, it is not feasible to do a complete review in this article, and only a few examples will be highlighted.

A number of different types of devices have been designed to reduce the incidence of and injuries caused by falls, which are common among nursing home residents. A monitor consisting of a patch with audible alarm applied to residents’ legs significantly reduced the number of falls in one study, and the investigators noted that residents with cognitive impairment frequently sat down again when they heard the alarms in their rooms. There is also solid evidence that the risk of hip fracture can be reduced in frail elderly adults with the use of an external hip protector.

Several studies have examined the effectiveness of mobile locators used to track individuals with dementia who might walk away from the facility unattended. The results are somewhat mixed, in part because they test different products. One study found that a mobile locator unit was well received and described as “easy to use” by family members caring for a loved one in the community, while another study found that the signals sent by the mobile locator unit often could not be read by the satellites, particularly in urban areas, and the unit was thus ineffective.

An excellent Web site providing information and resources about a broad range of assistive technologies used in long-term care settings can be found at https://www.Tech

Support for Caregivers

Today the effects that the nursing shortage and the high turnover rates of nursing assistants have on providers are well known. While most change needed is operational in nature, some studies have examined the impact of the environment on work stressors. For example, unit size once again plays an important role. Staff working in larger units experience increased time pressures that negatively impact their job satisfaction. A correlated finding is that residents’ quality of life is higher in smaller units; this in itself may make care tasks easier or more pleasing to do because of better staff-resident relationships. There is also evidence that a setting offering more social-recreational aids, prosthetic aids, and diversity (more and different places in which to spend time) reduces staff turnover. Separate studies have shown that an environment rich in support for residents (artwork, good orientation cues, support for physical functioning, furniture arranged to support conversation) also improves morale and satisfaction for staff.

It is important to understand how physically grueling this work is. Nursing homes and personal care homes continue to be a leading industry with respect to incidence of total nonfatal occupational injury and illness, with 187,000 work-related injuries or illnesses reported in 2002, representing an incidence rate of 12.6 per hundred workers. Patient lifting is the primary cause of workers’ compensation claims. Reducing injuries that result from resident-lifting tasks not only saves significant dollars in workers’ compensation claims and lost workdays, but also reduces pain and suffering. Ceiling lifts, which can be either permanent or portable, may be the most effective environmental strategy because the lift is always available when needed. Staff in one study reported they perceived themselves to be at less risk for injury when using the ceiling lift compared with any other methods for lifting and transferring residents, and these facilities experienced fewer workers’ compensation claims. Provision for ceiling lifts can, therefore, be an important design consideration.


There is a need for more studies in this field, especially ones with larger sample sizes and appropriate control groups. Clearly, however, the evidence is growing that creating person-centered, residential-scaled nursing home environments will have a variety of positive influences on both residents and staff. D

Margaret P. Calkins, PhD, is a member of the Board of SAGE and is President of the consulting firm IDEAS, based in Kirtland, Ohio.

For further information, e-mail https://www.mcalkins.IDEASConsultinginc or visit Anjali Joseph is Director of Research at the Center for Health Design, San Francisco, California. For further information, visit To send your comments to the authors and editors, e-mail https://www.calkins08d.ltlmagazine.

Suggested Reading

  1. Betrabet Gulwadi G, Calkins M. Environmental correlates of falls: Implications for design of healthcare facilities. Concord CA:Center for Health Design.In press.
  2. Calkins MP, Cassella C. Exploring the cost and value of private versus shared bedrooms in nursing homes. The Gerontologist 2007; 47 (2): 169-83.Available at:
  3. Day K, Calkins MP. Design and Dementia. In: Bechtel Churchman A (Eds.), Handbook of Environmental Psychology. New York:John Wiley & Sons, 2002.
  4. Day K, Carreon D, Stump C. The therapeutic design of environments for people with dementia: A review of the empirical research. The Gerontologist 2000; 40 (4): 397-416.
  5. Joseph A. Health promotion by design in long-term care settings. Concord, CA: Center for Health Design, 2006. Available at:

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