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Space, Choice and Control, and Quality of Life in Care Settings for Older People

Originally Published:
Key Point Summary
Key Point Summary Author(s):
Dickey, Andrew
Key Concepts/Context

In Britain, residential care and nursing homes for elderly patients have been subject to changing design regulations over several decades. These regulations take into account the “gradations of space” allotted to patients, meaning the extent to which the buildings themselves provide public, semiprivate, and private spaces for the patients. The amount of freedom a patient may exercise by choosing to inhabit these different gradations of space is seen as an indicator of both the quality of care provided and the quality of life experienced by the patient. Previous research exploring how design features in elderly care facilities affect patients’ quality of life has often been anecdotal or small in scale.


To investigate whether or not gradations of space and daytime location are associated with quality of life with respect to care home residents, regardless of their levels of dependency.

  • This study used a random sample of 452 permanent residents who had been living in 38 different care homes for over one month. Care homes were divided into groups by size: small (fewer than 31 beds), medium (31 to 40 beds), and large (41 or more beds).
  • Three types of information were gathered on the permanent residents: demographics (date of birth, length of stay in the home, and gender), Clifton Assessment Procedure for the Elderly Behavior Rating Scale scores (CAPE-BRS, a numerical score from 0 to 36 assessing patient dependency), and resident quality of life.
  • Resident quality of life included the well-being or ill-being of residents, the proportion of time spent in activity, and their ability to exercise control in their environment. Field researchers using Dementia Care Mapping (DCM) assessed levels of activity and well-/ill-being.
  • Two measures were taken to assess use of space: first, the Gradation of Space Scale, which uses a percentage to measure the range of spaces that are public or private using a 12-item questionnaire (for example, a kitchenette being present or absent), and second, information on the amount of time residents spent in certain daytime locations, which was provided by key care workers at the care homes.
  • Additionally, fieldwork was done during two-day visits to each care home. Twelve residents from each home were randomly selected for detailed studies. Demographic information, CAPE-BRS, and daytime location information were gathered from key care workers. The DCM was used during patient observations conducted at 15-minute intervals for two-hour periods, once in the morning and again in the afternoon. Observations were made in all areas of the home where residents could be viewed by the researcher. The researcher also completed the Gradation of Space Scale through physical inspection of the buildings.
Design Implications
Residential care and nursing home structures should offer a variety of spaces - some stimulating, some private and quiet - in order to endow residents with greater levels of control over their personal space. Even when considering patients with high dependency levels, such as patients with dementia, designers should think of offering a variety of different accessible daytime locations to help improve the quality of patient life.

Results indicated that quality of life was associated with gradation of space and the daytime location of patients; the more locations patients could choose to inhabit during the day, the higher their quality of life ratings. Even when controlled for dependency, it was found that residents who spent more time in their private quarters were more often engaged in active behavior. The author asserts that this is because the patients had the ability to be passive in stimulating areas, like public lounges, before choosing to return to their rooms to engage in activities such as reading or watching television. The study was also found that public spaces were important for high-dependency patients, such as patients with dementia, because this made them easier to supervise.


The authors cite several limitations within the study. The study was conducted while many changes were occurring in the British residential care sector, making older and smaller residential homes vulnerable to closure; this ultimately made including smaller homes in the study more difficult. Information on daytime locations and quality of life was not gathered for all sampled residents. It is unclear if homes with higher gradations of space are related to quality of life due to the large variety of spaces available and how exactly those spaces are used.

Design Category
Building location/site optimization|Room configuration and layout|Unit configuration and layout
Other healthcare facilities|Residential healthcare facilities
Outcome Category
Patient / resident health outcomes|Patient / resident satisfaction and comfort|Patient satisfaction
Environmental Condition Category
Patient Satisfaction and Comfort|Physical proximity/density
Key Point Summary Author(s):
Dickey, Andrew
Primary Author
Barnes, S.
Paper Type