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Staff perspectives on the role of physical environment in long-term care facilities on dementia care in Canada and Sweden

Originally Published:
Key Point Summary
Key Point Summary Author(s):
Abushousheh, A.
Key Concepts/Context

Physical environment design interventions are used to benefit people with dementia living in care settings, but the influences on those providing care is unknown. Care settings that support care practices for people living with dementia have both positive and negative effects on social interaction and care practice. The results of this study suggest that, in contrast to the negative impacts of institutional building types, an open-plan layout that is residential in character with access to nature positively impacts staff perceptions.


The qualitative study aimed to explore the perspectives of caregivers about the physical environment's ability to support the provision of care for residents living with dementia in long-term care facilities in Canada and Sweden.


The study methods were based upon the qualitative analysis of focus group interviews (n=24) that were convened as a part of a larger study in four dementia care facilities: two in Vancouver, Canada (n=9, n=6) in 2013, and two in Stockholm, Sweden (n=4, n=5) in 2018. Site selection was based upon achieving the highest variation in physical environment features across three categories: (i) spatial layout (e.g., corridor length and bathroom size), (ii) interior design (e.g., lighting, flooring, and furnishings), and (iii) sensory stimulus (e.g., noise, smell, and tactile properties). Focus group recruitment of personnel who worked closely with residents resulted in an all-female sample of nurses, care aides, and recreation staff. One focus group interview, preceded by the distribution of preparatory open-ended questions one week earlier, were carried out at each of the four facilities to explore perspectives of three aspects of the built environment. Research team members audio recorded, transcribed, and translated each of the 60-minute focus group interviews prior to an iterative and consensus-based thematic analysis.

Design Implications
The design has the potential to 1) Positively affect staff and resident trust, relationship building, motivate and improve care for residents, and increase staff job satisfaction with homelike ambiance, open spatial layouts, and outdoor stimulus; 2) Afford unobtrusive observation and decrease staff walking load fatigue with open floor plans; 3) Promote staff and resident social interaction and relationships by enabling unrestricted access to stimulating outdoor environments; 4) Avoid jeopardizing staff safety and resident well-being with negative stimulation and limitations of the physical environment.  

Participants in both countries strongly agreed on the notion that the physical environment has a significant impact on staff care practices and residents’ well-being. The analysis of focus group responses revealed that staff considered features of the built environment to be necessary to provide high-quality care within three general themes:

  • Design ambiance enables and limits social and care interaction. The character, comfort, and continuity of the aesthetic, furnishings, outdoors, and expressions of self were considered important for fostering connections. Conversely, small, cluttered, and cramped spaces were seen as a risk to safety and institutional aesthetics and negatively impacted the staff's psychosocial caregiving approach.
  • Space arrangements facilitate and hinder the effectiveness of care delivery. Clear sightlines for unobtrusive monitoring and opportunities for frequent and ongoing interactions in small-scale settings helped to promote effective team communication and collaboration for resident autonomy and self-determination. In contrast, large-scale buildings with long and dead-ended corridors resulted in staff frustration and fatigue due to the inability to efficiently or effectively monitor and respond to residents.
  • Sensory stimuli have a direct impact on residents. Staff considered positive stimuli (e.g., outdoor views and access and familiar music) to foster connections. Negative stimuli, especially noise, were seen as a source of compounding stress and reciprocal agitation for residents and staff. A lack of environmental stimulation was also problematic for staff because of resident boredom, restlessness, and exit-seeking behavior.

Differences between respondents’ levels of satisfaction were correlated with the physical aspects of the working environment, such as an open space plan, residential character, and comfortable spaces supportive of daily activities and social connection.


The small sample size, use of subjective perspectives and similar characteristics of the respondents make it difficult to generalize outcomes broadly. Despite geographic distribution and purposeful sampling, the extended timeframe between focus group sessions may also compromise the comparability of responses.

And also...

The authors include photographs of the public spaces with their descriptions.

Key Point Summary Author(s):
Abushousheh, A.
Primary Author
Lee, S. Y.