Architecture for Residential Care and Ageing Communities: Spaces for Dwelling and Healthcare [1 ed.] 9780367358730, 9780367358716

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ARCHITECTURE FOR RESIDENTIAL CARE AND AGEING COMMUNITIES

Architecture for Residential Care and Ageing Communities confronts urgent architectural design challenges within residential innovation, ageing communities and healthcare environments. The increasing and diversified demands on the housing market today call for alterability and adaptability in long term solutions for new integrated ways of residing. Meanwhile, an accentuated ageing society requires new residential ways of living, combining dignity, independence and appropriate care. Concurrently, profound changes in technical conditions for home healthcare require rethinking healing environments. This edited collection explores the dynamics between these integrated architectural and caring developments and intends to envision reconfigured environmental design patterns that can significantly enhance new forms of welfare and ultimately, an improved quality of life. This book identifies, presents, and articulates new qualities in designs, in caring processes, and healing atmospheres, thereby providing operational knowledge developed in close collaboration with academics, actors and stakeholders in architecture, design, and healthcare. This is an ideal read for those interested in health promotive situations of dwelling, ageing and caring. Sten Gromark, Dr., Full Professor of Architecture at the Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden, Architect SAR/MSA as a member of Architects Sweden, and Director of the research environment AIDAH, Architectural Inventions for Dwelling, Ageing and Healthcare supported by Formas from 2013 to 2019. His focus is on critical interpretations of contemporary residential architecture based on humanistic and social science-oriented perspectives. Björn Andersson, PhD in Social Work, Associate Professor at the Department of Social Work, University of Gothenburg, Sweden. His research focuses on social relations in urban public space, outreach approaches in social work and social sustainability in urban planning.

ARCHITECTURE FOR RESIDENTIAL CARE AND AGEING COMMUNITIES Spaces for Dwelling and Healthcare

Edited by Sten Gromark and Björn Andersson

First published 2021 by Routledge 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2021 Taylor & Francis The right of Sten Gromark and Björn Andersson to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Gromark, Sten, editor. | Andersson, Björn, 1952 April 23– editor. Title: Architecture for residential care and ageing communities : spaces for dwelling and healthcare / edited by Sten Gromark and Björn Andersson. Description: New York, NY : Routledge, 2021. | Includes bibliographical references and index. Identifiers: LCCN 2020020026 (print) | LCCN 2020020027 (ebook) | ISBN 9780367358730 (hardback) | ISBN 9780367358716 (paperback) | ISBN 9780429342370 (ebook) Subjects: LCSH: Domestic architecture for older people. | Barrier-free design for older people. | Housing and health. | Health promotion. Classification: LCC NA2545.A3 A73 2021 (print) | LCC NA2545.A3 (ebook) | DDC 720.84/6—dc23 LC record available at https://lccn.loc.gov/2020020026 LC ebook record available at https://lccn.loc.gov/2020020027 ISBN: 978-0-367-35873-0 (hbk) ISBN: 978-0-367-35871-6 (pbk) ISBN: 978-0-429-34237-0 (ebk) Typeset in Bembo by Apex CoVantage, LLC

CONTENTS

Foreword D. Kirk Hamilton Preface and Acknowledgement Sten Gromark and Björn Andersson with Peter Fröst, Inga Malmqvist and Ola Nylander List of Contributors Introduction: Exploring Architectural Validity: Health Promoting Situations of Dwelling, Ageing and Caring Sten Gromark and Björn Andersson with Peter Fröst, Inga Malmqvist and Ola Nylander

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SECTION I

Dwelling

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1 The Multipurpose Use of Social Sustainability—A Swedish Case; Brf Viva 2019 Björn Andersson and Sten Gromark

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2 Criteria List of Housing Architecture Properties—A Way to Promote Residential Quality? Ola Nylander

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Contents

3 Can Residential Architecture Constitute a Part of a Human-Enriched Environment and Contribute to Recovery, Prevention and Stress Reduction? Hanna Morichetto and Michael Nilsson 4 Adaptability of Apartments—A Bottom Up Concern: Two Narratives of Life Course Spatial Adaptability Anna Braide 5 Design as a Preventive Approach in Residential Settings— On Fall Injuries, Suicidal Situations and The Role of Architecture Charlotta Thodelius 6 The Future of ADL Dwellings—Experimental Re-Designs for the Impaired Helena Casanova and Jesus Hernández

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SECTION II

Ageing

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7 ‘Health Care is Be-Coming Home’—In Research and Pedagogical Practice Inga Malmqvist

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8 Environments for Care Provision in Ordinary Housing— A Transdisciplinary Exploration of Pros and Cons Cecilia Pettersson and Helle Wijk

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9 Assisted Living for the Elderly—Features of a Swedish Model Morgan Andersson

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10 Available Space—Architectural Agency and Spatial Decision-Making in a Caring Organization Catharina Nord

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11 Supporting the Elderly Population: New Strategies for Housing in Italy Francesca Giofrè and Livia Porro

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12 Sociodemographic Plastics—From Housing and Institutions for the Elderly to Urban Lifestyle Products for the Young-Old Deane Simpson

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SECTION III

Caring

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13 Designing with Nature for Ageing: Health-Related Effects in Care Settings Garuth Chalfont and Roger S. Ulrich

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14 Design-Driven Dialogues for Healthcare Architecture Peter Fröst

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15 It Takes More Than Evidence to Inform the Healthcare Architect Stefan Lundin

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16 Design of High Technology Environments—Intensive Care Units (ICUs) Maria Berezecki Mårtensson

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SECTION IV

Methodological Considerations

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17 Interventions and Mixed Methods Research Design for a Person-Centered and Safe Environment in Old Age Helle Wijk

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18 The Home as a Place for Rehabilitation—What Is Needed? Marie Elf, Maya Kylén and Elizabeth Marcheschi 19 The Puzzle of Combined Evidences—Piecing Knowledge Together with Professionals in Urban Development Joakim Forsemalm and Magnus Johansson

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20 AIDAH—Editors’ Post Scriptum Björn Andersson and Sten Gromark

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Index

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FOREWORD D. Kirk Hamilton

Welcome, dear reader, to this volume of wonderful essays from the Architectural Inventions for Dwelling, Ageing and Healthcare Project, or AIDAH, that has been developing through a number of efforts occurring in and around the Chalmers University of Technology in Gothenburg, Sweden. Excitement about the interdisciplinary topic has come from researchers in architecture, engineering, and a mix of the social and caring sciences involved with the Centres for Healthcare Architecture and Residential Architecture at Chalmers, along with partners at Gothenburg University and Dalarna University. Chalmers hosted the CIB (International Council for Research & Innovation in Building and Construction) W069 Residential Studies Commission in 2015, which launched some of the efforts now being reported. The AIDAH Project has been framed around an integrated concept for a continuum of residential building typologies that serve situations of dwelling, along with aspects of ageing and caring. This continuum ranges from one extreme, dwelling at home, to the other extreme at an institution of some sort. Along the continuum, researchers are working with the most independent and personal version of dwelling in private residences, through elderly housing and residential healthcare to patient hotels, hospital wards, and ultimately, intensive care units at the extreme of least personal independence. The researchers are addressing this continuum of dwelling sites in the context of an ageing population’s needs over time, and the requirements for caring which also vary over time. Creating an understanding of this continuum, with its overlays of issues associated with ageing and caring, requires an interdisciplinary perspective. The world’s housing situation is subject to increasing demands for society’s sustainable urban future, and an ageing society has evolving needs that include access to appropriate social and medical caring. Populations are ageing

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across the globe and there are not enough suitable settings to accommodate all the projected need. Powell Lawton’s environmental press theory suggests that behavior observed during ageing is based on a dynamic relationship between an individual’s cognitive, physical, and psychological competence, and the ‘press’ of the environment. As these competencies decline in the natural course of ageing, there is a growing need for appropriate environments for the elderly. What could be more important and timely than increasing our understanding of these complex issues? We are offered here a fascinating, mostly Nordic and European, view of issues that can lead to innovative projects grounded in a fresh transdisciplinary framework that encourages action and commitment based on the new knowledge, along with international implementation of relevant policy leading to new public and private programs. The AIDAH Project has been addressed in this volume by researchers and scholars who have focused on three topics organized into Working Groups, loosely coordinated with sections in this book. The work of the first Working Group, described as Emerging Ways of Residing, is found in Section 1 and emphasizes innovative aspects of dwelling, especially towards the personal, private, and independent end of the continuum. The second Working Group, Architecture for an Ageing Society, finds their submissions in Section 2. Their scholarship, focusing on the middle of the continuum, targets changes in the residential model as ageing and the demands of caregiving impact both residents and staff. The third Working Group, Health Care Architecture, whose papers are found in Section 3, looks at the more institutional forms of the environments where direct care is provided in settings like hospitals. Finally, this volume contains one more block of papers in Section 4, to touch on the methods of scholarship and theories employed by some of these researchers, including using these topics in teaching at the universities involved. The material in this volume involves both qualitative and quantitative methods aimed at a research-informed or evidence-based model of design for environments suited for dwelling, ageing, and caring.

Dwelling The papers from Working Group 1, Emerging Ways of Residing, explore ways to improve the current models of habitat for populations that are ageing and in need of caring. Björn Andersson and Gromark provide a case study from a cooperative housing association in Gothenburg, Sweden. The project of more than 100 f lats focuses on residential resilience, f lexibility, alterability, and social sustainability through initiatives such as limited parking, electric carpooling, rooftop photovoltaic cells, and a number of shared common facilities like a winter garden. Nylander offers a hypothesis that if explicit criteria for housing quality can be implemented, the inventory of available housing can be improved, thus better serving residents. Working with the Centre for Housing

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Architecture at Chalmers, Nylander provides an example, exploring one of eight proposed quality criteria for a municipally owned company acting as an apartment developer. Morichetto and Nilsson provide information on the role of residential environments in the important areas of stress reduction, illness prevention, as well as recovery from illness. They deal with the concept of enriched environments and how the brain is affected by environmental stimulation. Braide explores the adaptability of apartments to meet the demand for dwelling solutions responsive to demographic transformation. Braide notes that current typologies expect a household to move when mobility issues or living situations change, and proposes that adaptable dwelling space can better serve a household’s changing spatial needs. Thodelius elaborates further with explicit consideration of residential design as a factor in prevention of mental and physical illness. Casanova and Hernández provide a Dutch perspective during a time of policy change in the Netherlands challenging the quality of independent lives for the elderly and people with disabilities. Their study reports on findings related to homes, units, and housing clusters with robust ADL (activities of daily living) capabilities, concluding that there continues to be a need to fund construction of these typologies.

Ageing The papers from Working Group 2, Architecture for an Ageing Society, deal with aspects of design to accommodate the elderly. Malmqvist notes that private homes of the elderly are increasingly workplaces for staff involved with providing care, described as homecare or home healthcare, which can include simple improvements that support the new situation. Pettersson and Wijk explore the way environments support, or fail to support, provision of care in ordinary housing, allowing for ageing in place as an alternate to institutionalization. They provide a helpful guide to transdisciplinary research methods. Wijk also has a design research chapter in the methodology section. Morgan Andersson describes a model of assisted living for the elderly, which in Sweden is a municipal responsibility, although there is a growing private sector. He concludes that the concept needs to be updated with more aspects of home, diversity, and freedom of choice, along with service in caring. Nord explores the role of architectural and spatial decision-making in caring organizations that have responsibilities for the elderly, using a comparison of two municipal departments. Nord contends that architectural space, especially available space, is an active, generative force behind organizational change. Giofrè and Porro provide an Italian perspective with a paper on new housing strategies that emphasize socially inclusive co-housing. Simpson provides a perspective on ageing, considering the so-called third age in which persons have a higher probability of living to 70 and beyond, relating the consequences to be observed in a revealing American urban project.

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Caring The papers from Working Group 3, Health Care Architecture, address the more institutional forms of habitation. Chalfont and Ulrich provide a chapter on how designing with nature improves care and health for an ageing population, including some examples from the United Kingdom. After descriptions of benefits found in well-designed gardens, they offer evidence-based guidelines for designing hospitals with elements of nature. Chalfont and Ulrich’s piece is an important reminder of how to minimize the institutional character of caring environments like hospitals, nursing homes, and health facilities. Fröst’s chapter describes the way meaningful dialogues about complex design can enhance the implementation of a co-design methodology for the planning of healthcare architecture. He proposes an interactive and participatory dialogue to tackle wicked and complex problems featuring teams of professionals from multiple disciplines working with physical models. The method has now been used for more than 100 projects. Because simulation of complex problems cannot always be predictive, and the context is always changing, Fröst proposes an iterative process involving a larger group through a series of workshops in which subsequent versions of a design come closer to satisfying the intended outcome. Lundin’s chapter builds further on the idea of design dialogues. Lundin reminds us that artistic creativity, intuition, and tacit knowledge often play a key role in healthcare design, along with decisions based upon evidence. He uses an example from an inpatient psychiatric facility in Gothenburg, Sweden that has been identified by an expert as including nine of ten known evidence-based design concepts, and yet not surprisingly, the designer was unaware of the research-informed scholarship on the topic. Lundin proposes vibrant dialogue among members of a multi-disciplinary working group to obtain the best results. Mårtensson focuses her chapter on evidence from literature on the intensive care patient room, in which the occupant has little independence or personal control. The presence of family and friends can mitigate some of the anxiety produced in this high stress environment dominated by intrusive technologies.

Methods The scholars and researchers participating in the AIDAH Project have used a varied number of methods, including both qualitative and quantitative research designs, along with mixed methods. There are examples of surveys, field observations, interviews, focus groups, design experiments, document and literature reviews, and other data collection techniques. Multiple methods are appropriate for exploring the topics from a variety of perspectives. Wijk offers a chapter on evidence-based and practice-based residential care interventions to support safe and person-centered care for older persons with declining functional capabilities. Elf, Kylén, and Marcheschi take on the complex person-environment

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issues surrounding rehabilitation of stroke patients in their changed physical environments. They provide several theoretical frameworks to address multilayered aspects of the environment which deal with individual behavior, social roles, and the natural and built elements of the setting. Forsemalm and Johansson offer a method for evaluating urban development that combines research evidence, professional evidence, organizational evidence, and stakeholder evidence in an interconnected model. The editors and their invited authors are offering us a fresh view of improved residential quality across a spectrum of environments that are each profoundly inf luenced over time by the ageing of residents and their changing health status. Static solutions are clearly not up to the task. This complex proposition requires f lexibility, adaptability, resilience, and sustainability in design that ref lects the focused insights of the social and clinical sciences. It should be obvious that the path forward must be enthusiastic collaboration across disciplinary boundaries, always keeping in mind the perspectives and needs of the stakeholders, users, and residents. Multiple research methods will be useful in the study of these phenomena. This volume is one of the important roadmaps we will need to achieve this noble, humane future.

PREFACE AND ACKNOWLEDGEMENT Sten Gromark and Björn Andersson with Peter Fröst, Inga Malmqvist, and Ola Nylander

This book has been made possible due to substantial funding, from 2013 to 2019, to the AIDAH interdisciplinary research environment at Chalmers ACE provided by Formas, A Swedish Research Council for Sustainable Development, together with additional support from academic, external professional partners and involved contributing businesses and societal stakeholders enabling a transdisciplinary way of enacting, exploring and confronting projects. The editors equally want to express their gratitude towards all contributing members of the AIDAH team including external collaborators for the dedicated work they all offered for the project during the preparation of this text collection.

CONTRIBUTORS

Björn Andersson, PhD in social work, is an associate professor at the Department of Social Work, University of Gothenburg, Sweden. His research focuses on social relations in urban public space, outreach approaches in social work and social sustainability in urban planning. Morgan Andersson, PhD, is an architect in residential healthcare and an

adjunct professor at the Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden. His research encompasses housing and care for an ageing society and healthcare architecture, from a usability perspective. Maria Berezecki Mårtensson, Architect SAR/MSA, was an architect until

2018, also researcher at Department of Architecture and Civil Engineering (ACE), Chalmers University of Technology. Maria’s research area encompasses high-tech healthcare environments and their impact on users. She is now a practicing healthcare design consultant at Tyréns. Anna Braide, PhD, is an architect, lecturer and researcher; Division of Building Design, Department of Architecture and Civil Engineering (ACE), Chalmers University of Technology, Gothenburg, Sweden. Currently focused on adaptable dwelling design and how adaptable space can affect social qualities in living situations. Helena Casanova, Msc, is a senior architect, urban planner, landscape archi-

tect, curator, project manager and director of Casanova+Hernandez, a firm that was founded in 2001 in Rotterdam, the Netherlands. She also has broad

Contributors xv

experience as a guest professor in different institutions, such as the Berlage Institute and TU Delft. Garuth Chalfont, with extensive experience in design-build of dementia greencare spaces (www.chalfontdesign.com), Garuth now focuses on holistic health, specifically dementia prevention and treatment through non-pharmacological personalized medicine. He translates scientific evidence into healthy environments and lifestyle approaches at a grassroots community level. Marie Elf, RN, PhD in architecture, is a professor in nursing at Dalarna Uni-

versity, School of Education, Health and Social Studies. Her research focuses on the physical environment and its impact on health and wellbeing for persons with frail health. Joakim Forsemalm, is an associate professor in ethnology at Radar architecture

in Gothenburg. Joakim’s research focuses on professional planning cultures, organizational learning capacities and everyday urban life. Joakim is active in the interface between research and practice. Peter Fröst, PhD, is an architect and artistic professor at Chalmers Uni-

versity of Technology, Sweden. His professional experience is composed of both 35 years as a practicing architect at SWECO and researcher at Chalmers. In his cross-disciplinary work, Peter has developed and implemented a dialogue-based approach to early stages of architectural projects—Design Dialogues. Francesca Giofrè, PhD, is an architect and associate professor at the Faculty of Architecture, Department Architecture and Design, Sapienza University of Rome. Francesca has been a member of Inter-university Research Center TESIS “Systems and Technologies for Social, Health and Education Structures” since 2006. Sten Gromark , PhD, Architect SAR/MSA, is a full professor, at the Depart-

ment of Architecture and Civil Engineering (ACE), Chalmers University of Technology, and director of AIDAH research environment supported by Formas 2013–19. Sten focuses on critical interpretations of contemporary residential architecture based on humanistic and social science-oriented perspectives. D. Kirk Hamilton, PhD, FAIA, FACHA, FCCM, EDAC, is Beale Professor of

Health Facility Design, Texas A&M University. He is known for his advocacy of evidence-based practice and expertise in design for critical care. He is founding co-editor of Health Environments Research & Design.

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Magnus Johansson, PhD in pedagogy, is a senior researcher at Research

Institutes of Sweden (RISE), sustainable cities and communities. His research focuses on professional development and organizational change related to sustainable urban transition. Maya Kylén; PhD, is an occupational therapist. Her research concerns humanenvironment interaction, with a specific focus on home and neighborhood contexts. She is currently doing research exploring environmental factors, relationships between these factors and outcomes for people with stroke. Stefan Lundin, Architect SAR/MSA, is an architect at White Arkitekter AB,

also PhD-student at Chalmers University of Technology, Center for Healthcare Architecture. Since 2000 he has mainly worked with facilities for psychiatric health. As a doctoral student he researches the possibility of “Healing Architecture”. Inga Malmqvist, PhD, is a professor and architect at the Department of Archi-

tecture and Civil Engineering (ACE), Chalmers University of Technology. Inga focuses on multipurpose buildings and housing and care for seniors. Elizabeth Marcheschi, PhD in environmental psychology, is a lecturer and researcher at the Department of Work Science, business economics, environmental psychology, SLU Alnarp, and Chalmers University of Technology, Gothenburg. Her research focuses on vulnerable groups of society and their perception of healthcare settings. Jesus Hernández Mayor, Msc., is an urban planner and landscape architect.

Jesus is a former guest professor at the Berlage Institute among other institutions. Hanna Morichetto, Architect SAR/MSA, PhD, is an architect at the Depart-

ment of Architecture and Civil Engineering (ACE), Chalmers University of Technology, and Erséus Architects. Her research focuses on residential architecture and its potential health promotive effects through environmental enrichment and multisensory stimulation. Michael Nilsson; Professor, MD, PhD, is the Director of the Centre for Rehab

Innovations and Global Innovation Chair of Rehabilitation Medicine at the University of Newcastle, Australia. He investigates the effects of the environment on well-being and recovery in individually tailored rehabilitation programs in community and home settings. Catharina Nord, Architect SAR/MSA, is professor in Spatial Planning. She has carried out research about care and architecture. She is currently working

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on architectural space and care practices in assisted living facilities and about ageing in African urbanities. Ola Nylander, is a professor in Housing Design, at Chalmers ACE. Ola has

been Director of Centre for Housing Architecture since 2017. Ola’s research focuses on housing with FoU projects for, among others, HSB, public housing companies, the tenants’ organization. In 2018 he published the book Swedish Housing 1850–2000. Cecilia Pettersson, PhD, is an occupational therapist, lecturer and researcher at Örebro University, School of Health Sciences, Örebro, Sweden. Cecilia’s research focus is home and healthcare in ordinary housing, use of assistive technology specifically mobility device use and discrimination, and reablement. Livia Porro, PhD, is an architect and researcher. Her research and work are

focused on universal and inclusive design. She is a member of the collective Architutti and of the board of the NPO CERPA Italia Onlus. Deane Simpson, Dr Sc., Architect MAA, is a professor at the Royal Danish

Academy of Fine Arts (KADK). His research addresses social and environmental sustainability, and the spatial implications of demographic transformation. His publications include: Young-Old: Urban Utopias of an Aging Society. Charlotta Thodelius, PhD in Architecture, MA in Criminology, BA in Sociology, is a researcher at Department of Architecture and Civil Engineering (ACE), Chalmers University of Technology, Gothenburg, Sweden. Her research focuses on situational prevention in relation to crime, disorder, and injury events. Roger S. Ulrich, PhD, EDAC, is a professor emeritus of architecture at Texas

A&M University and has been guest professor of architecture at Chalmers University of Technology. A behavioral scientist, much of his research has focused on the effects of healthcare buildings and nature on patient medical outcomes. Helle Wijk is a registered nurse, senior lecturer and professor at Gothenburg University, and Sahlgrenska University Hospital. She is also a guest professor at Chalmers University of Technology, ACE and the principal investigator for the research group Care environment at Gothenburg University. Her research focus is on effects and experiences of environments where health care is provided.

INTRODUCTION Exploring Architectural Validity: Health Promoting Situations of Dwelling, Ageing and Caring Sten Gromark and Björn Andersson with Peter Fröst, Inga Malmqvist and Ola Nylander

Research findings presented in this text collection are intended to confront three urgent interrelated societal challenges that ultimately require a broad intra-, inter- and transdisciplinary approach to envisage and to enable valid future integrated responses in terms of new residential healthcare and architectural design. First of all, we witness increasing, diversified and articulated demands on the housing market that call for alterability and adaptability in long term solutions for new integrated ways of residing with added appropriate supports for continued independent living as late in life as possible. Meanwhile an accentuated ageing society requires new ways of living together with others that combine dignity with appropriate and secure forms of healthcare provisions that furthermore constitute sound working environments for personnel acting increasingly in home situations. Profound changes in technical conditions for caring and medical treatment in residence necessitate rethinking patterns of traditional healthcare provision fostering new healing environments. These are ranging continuously from one end in advanced medical care effectuated in homes and elder residences to patient hotels, specialty clinics or intensive care units in hospitals on the other end. Issues of sustainability at stake in patterns of residential behavior related to such mentioned settings must be considered to have paramount importance in any healthcare strategy for a resilient urban future of any longevity. Authors of this book provide different aspects and complementary perspectives while exploring health promoting residential situations. The combined dynamics of integrating architectural and caring inventions are intended to envision reconfigured environmental socio-spatial designs that can create significant

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new welfare and ultimately improved quality of life in the utmost societal pursuit of wellbeing and happiness.

The Profile of the AIDAH Environment—The Backdrop to the Book The members of the AIDAH1 research environment, active from 2013 to 2019, provide the backdrop to the concept of this book’s collection of texts. The intention behind this publication is to demonstrate, throughout the book structure, a cohesive image of the project’s main concept and outcome while also including contributions by external collaborating researchers in the field. As an illustration, the CIB W069 Chalmers midterm conference in October 2015, arranged by the team,2 served, during sessions and key notes with discussions that followed, not only as a testing ground to provide an expression of conceptual unity but also to initiate academic transgression around common key issues; in short, to bring seemingly diverse themes and academic profiles knitted more closely together by building new bridges (Gromark et al. 2014). This environment was set up to initiate research focused on the crossing points between the three interlinked societal challenges as related to residential situations in urban contexts. We departed from a general perception of the societal challenge researching for more appropriate market offers and solutions, meeting the demands and aspirations of an emerging new mosaic of diversified lifestyles, to be accessible within reasonable economical limits of affordability. Secondarily, we saw the paramount challenge of rising demands for different residential qualities and more adequate home care services in the response to an ageing society. In addition, we connected this to the related challenge of how to respond to the accentuated necessity for new ways of providing advanced and relevant healthcare in residence at the same time as homelike qualities while in a lasting or even a transient healthcare situation, conceived as promoting healing environments. The latter situation is due to the double tendency consisting in shortened as well as prolonged, but more care-intensive, stays in hospital wards. We argue that architectural projects for home healthcare must support patient-focused and evidence-based conceived care processes. Supplementing this approach, we also regard as a vital issue the quality of residence from the perspective of staff involved in residential healthcare or elderly care in homes, representing for these professionals a predominant professional working environment. Research has been developed amidst these three focused topics organized in Working Groups, defined in relation to theoretical problems, methodologies and challenges within the field at large. The WG#1 Emerging Ways of Residing examines and develops research on evolving new residential situations of dwelling and of long term adaptability, incorporating common perspectives on integrated living, integrative ways of residing and aspects of residential wellbeing and health promotion; WG#2 Architecture for an Ageing Society focuses on

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residential solutions for the elderly and when homes become a workplace for staff in care and healthcare; while WG#3 Health Care Architecture has a focus on residential and institutional healthcare situations like hospital wards and intensive care units. Each of these three combined research and educational teams were furthermore able to actively include international students in their research efforts within directly linked and profiled master’s studio projects focused on design inventions. The main ambition behind the AIDAH project, as for this book, has been the attempt to bring these divergent perspectives into one unified integrative research structure, bridging our efforts in scientific terms as well as in conceptual and methodological terms and furthermore, ultimately, to be implemented seamlessly in projective designs within the whole spectrum as illustrated in Figure 0.1 below. On the basis of these concerted, conf luent efforts, the intention behind the present book is to provide relevant and operational new knowledge for architects and planners as well as for medical decision-makers within these interlinked fields, based on the combination of scientific methodological approaches applied to residential situational contexts. These methods range in a spectrum from evidence-based design, EBD, to qualitative oriented socio-cultural critical interpretations of user aspirations and desires. We intend to provide relevant new knowledge able to support the formulation and further implementation of policies, programs and actions ultimately resulting in state-of-the-art practical realizations of experienced residential quality. Our joint efforts carry the ambition of providing valid contributions to the initiation of such potential innovative projects in transdisciplinary practice. We situate these efforts towards an enriched context of visions of residential futures combined with empirical analyses of identified best projective practices already on the ground. Our main ambition is specifically to foster the discovery of valid new integrative residential

AIDAH’s Project Concept of Integrative Ways of Residing—The Research Field as a continuum of residential typologies with inter-related situations of dwelling, ageing and caring.

FIGURE 0.1

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solutions and the necessary paths to reach these ultimate objectives in experienced spatial and social reality. The initiated unique dialogue among and across members of the enacting different disciplines evidently unfolded during the project period—between the fields of architecture design and architecture humanities; urban residential sociology; social work; caring sciences and experimental psychology—and was intended to bridge gaps, and to locate prospects for new creative modes of knowledge co-production together with external partners. The book identifies, presents and articulates new qualities in designs, in caring processes and healing atmospheres, thereby providing operational knowledge developed in close collaboration with actors and stakeholders in business and society. The intended scientific integration in conceptual and methodological terms is thus a tool to build new bridges and to initiate transgressive academic approaches, exploring new modes and paths of transdisciplinary knowledge co-production and co-creation (Doucet and Janssens 2011; Hemström 2018; Klein 1990; Gromark, Andersson, and Braide forthcoming 2020; Bernstein 2015). Considerable added international research collaboration has provided further valid strategic evidence-based design support for decision makers in planning, building and medical services. The environment has responded to the priorities of current challenges relating to qualities of life in the built environment in physical as well as in psycho-social terms. It has intended to further develop theories, concepts and methodologies for the articulation and the deeper understanding of integrative residential structures in its relation to the specifically focused challenges. The environment explores in particular the dynamic relations between quantitative and qualitative research methods in a variety of methodological approaches of EBD and architectural humanities research, in architectural design practice, actively including master’s level education, also in healthcare sciences, all devoted to the study of and the improvement of the built environment. Together with international researchers within the field like the Chalmers Guest Professor Roger S. Ulrich, together with expert advisers Professor Katrin Paadam, Professor D. Kirk Hamilton, and with Professor Michael Nilsson, the team has built a coordinated effort throughout the active five yearproject period that we hope will further stimulate interdisciplinary as well as transdisciplinary approaches. This way we have hopes, in particular, to clarify the profile of singularity characterizing design research in architecture in relation to other academic fields commonly joined in collaboration (Fraser 2013; Gromark 2000). The AIDAH environment indeed offered all of us a unique occasion to experience the act of going beyond existing academic and professional barriers to encounter new research frontiers and to provide an inspiring image of how it can be done: an image that we hope this book may convincingly relay to the reader.

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Collaborative Context—National, Nordic, European and International The interdisciplinary team of researchers from architectural design, social and caring sciences is based on the one hand at the Chalmers Centre for Healthcare Architecture, CVA, serving as an early initiated forerunner of a university organizational model, and on the other hand at the recently established, as a part of the AIDAH environment support, the Centre for Residential Architecture, CBA.3 Each hub directs master’s class studio environments within the Division of Building Design. On the international level, a long term collaboration has unfolded within the CIB W069 Commission Residential Studies, (Gromark et al. 2017)—with the critical interpretations of residential situations ( Paadam and Gromark 2019; Gromark and Paadam 2016)—and hosted by Chalmers, combined with related recent active team participation also in EU-funded COST Action Intrepid from 2015 to 2019 (Gromark, Andersson, and Braide forthcoming 2020; Fokdal et al. forthcoming 2020). Collaboration on a national level has also been important with the participation in the Formas-supported parallel strong research environment Architecture in Effect hosted by KTH, Stockholm (Gromark, Mack, and van Toorn 2019a). Another locally integrated partner extension has been the MSB-funded ArchSafe project, focused on risk analysis and residential injury prevention, criminology and place analysis (Thodelius 2018). The AIDAH team organized and hosted an international CIB W069 Conference in October 2015 and a Nordic workshop on Architectural anthropology, supported by VR and coordinated by SBi Aalborg, Denmark, in May 2019. Along with these major events, several other related minor seminars and conference occasions have been organized to present information on new research findings and promote exchanges of mutual experiences among researchers and local external stakeholders, also to be considered as examples of general outreach efforts and ambitions. The shared and mutually confirmed theoretical and methodological conceptual frames have been discussed in several PhD and master’s class research training course seminars with contributions by, among many others, our international guests and expert advisory team collaborators. These activities have been intended to promote architectural design innovations supported or informed by evidence-based knowledge or evidence-informed design practice, providing directions towards the undertaking of adequate built environments while exploring the validity of architectural design strategies in healthcare situations. The AIDAH project has—besides having included supporting senior researchers and teachers from fields other than architecture like social work, urban sociology and caring sciences4 —included two postdocs involved in transgressive academic exchanges within the constituted collaborative environment

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(Marcheschi et al. 2017; Pettersson et al. 2019), while also subsidizing PhD projects resulting, so far, in four conferred doctoral degrees within the theme ( Thodelius 2018; Braide 2019; Morichetto 2019; Miedema 2020) as well as five licentiate degrees (Eriksson 2013; Berezecka 2015; Lundin 2015; Karlsson 2019). In relation to the team, in other constellations, based on other sources of subsidies, several other thematically closely related licentiate degrees and PhDs have been conferred with AIDAH team members involved.

Theoretical and Methodological Orientations—Crossing Research Frontiers The involved project teams provide different and complementary perspectives focusing on the shared notion of quality of residence considered in its architectural, spatial and experiential properties of built environments for housing and healthcare contexts. The applied conceptual and theoretical framework focuses on architectural and caring innovations for reconfigured spatial situations that enhance sustainable caring and improve health and well-being to promote new welfare and enhanced quality of life.5 Our research effort has particularly focused on identifying and characterizing strategies directed towards the integration of different ways of residing intended for the inclusion of all phases of life courses, of all walks of life, and of all ages. This approach, to be considered the main feature and orientation of the project, is well aligned with the overarching principle of ‘health care is coming home’, as formulated in a report by the American NRC (National Research Council) in 2011. Our research strategy has come to adhere to this general perspective. It was further developed in a workshop organized in 2015 by the NRC under the title The Future of Home Health Care (NRC 2015). The conclusions thereby derived underlines the strategic, long-term reaching and crucial importance of the home in a healthcare future-proofing context confronted with raised costs and diminishing resources. In the report it is acknowledged that although the costs are one driver of this change, the delivery of health care at home is valued by individuals and can promote healthy living and wellbeing if it is managed well. (NRC 2015) Our approach is predominantly also running along those lines. Conceptually it is spanning over the integrated spectrum or axis from ‘acute care via residential care towards home care’ in congruence with the figure presented in the same future projections workshop by Eric Dishman of Intel Corporation in 2014.6   Researchers in the collaborating AIDAH teams apply a wide range of theories on socio-physical relationships and methodologies applied either in contemporary

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architectural research (Groat and Wang 2013; Fraser 2013) and qualitative research methods or within the relevant medical field of operation related to healthcare sciences and EBD (Evidence-Based Design). Our focus is fixed on the desired integration and crossover exchanges in our research practice and in our doctoral and master’s education activities between these complementary, as we see them, and mutually supporting methodological and epistemological approaches. Current research within the framework establishes a relationship between the physical environment in healthcare architecture and acts of caring as well as medical outcomes for enhanced well-being and quality of life. New design principles have been developed, aimed at promoting healing environments that can contribute to patient recovery, reduce infections and falls, help staff to cope better with stress and increase patient and family involvement in the care process.7 The AIDAH team, through the Centre for Healthcare Architecture, CVA, has actively contributed to and established strong affiliations with the relevant international research context in particular represented at Chalmers by Guest Professor Roger S. Ulrich (Ulrich 2006; Ulrich, Lundin, and Bogren 2012). This collaboration has offered a unique position to advance research in the field on the international level, fostering a critically oriented, socially engaged and responsible architectural research, linked with advanced master’s level education and projective, innovative practices. The situation calls for research and education to renew its commitment towards socially responsive and reality based architectural design. Another component is represented by qualitative and critical interpretive perspectives like critical interpretation, and similar research methods including professional design intuition concerned with the notion of tacit knowledge. This orientation is departing from a social constructivist epistemological approach, inclined towards interpretations of experienced or projected experiential qualities applying biographical interview methods as well as exploring visual interpretative aspects assessing figurative empirical artefacts such as genealogy of apartment plans along household life trajectories (Berger and Luckmann 1984 [1966]; Charmaz 2014; Silverman 2013; Rose 2016; Silverman 2011; Seale et al. 2004; Rabinow and Sullivan 1987 [1979]; Emmison, Smith, and Mayall 2013; Patton 2002; Wertz et al. 2011; Gromark, Mack, and van Toorn 2019b). In accordance with this position taken we perceive of the notion of qualitative research that typically aims ‘to develop a complex picture’ that ‘involves reporting multiple perspectives, identifying the many factors involved in a situation and generally sketching the larger picture that emerges’ following Creswell (2007) while referring in turn to Groat and Wang (2013). In full: Qualitative researchers try to develop a complex picture of the problem or issue under study. This involves reporting multiple perspectives, identifying the many factors involved in a situation, and generally sketching

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the larger picture that emerges. Researchers are bound not by tight cause-and-effect relationships among factors, but rather by identifying the complex interactions of factors in any situation. (Creswell 2007, 39) And as Charmaz characterizes the original ‘constructivist grounded theory’ as an approach that ‘adopts a relativist epistemology and seeks interpretive understanding rather than a variable analysis that produces abstract generalizations separate from the specific conditions of their production, rather, constructivist grounded theorists aim to create interpretative understanding located in these particularities—of time, space and situation—and to take into account how the researcher and research participants’ standpoints and positions affect our interpretations’ furthermore they ‘take into account the research situation and how data are produced within it’ and ‘view data as mutually constructed by the researcher and the researched. Neither data nor the subsequent analyses are neutral’ while constructivist grounded theory of a later date, again according to Charmaz ‘engage in ref lexivity and assuming relativity throughout the inquiry’ (Charmaz in Wertz et al. 2011, 168–169). An important contribution to the field of research on particularly the key notion of ways of residing and to the respective current disciplinary context on residential situations are the ontological, epistemological, theoretical and methodological considerations established by the AIDAH-affiliated expert, Professor of Urban Residential Sociology Katrin Paadam, based on early initial conceptualizations introduced by residential sociologist Jim Kemeny (Kemeny 1992; Paadam 2003; Paadam and Gromark 2010; Paadam 2014; Paadam, Gromark, and Ojamäe 2011; Gromark et al. 2017; Paadam and Gromark 2019). The residential life spheres and life courses of citizens are thus to be regarded as the fundamental or primordial space of everyday life, heavily charged with value projections of ontological, or even cosmological, nature (Bourdieu 1972). The residential experience crystallizes profound expressions and realizations of lifestyles in material culture, carrying quality-oriented aspirations. These are not merely directed towards basic sensual wellbeing, but they also incorporate the desires of becoming and self-actualization in residence, utmost and ultimately expressed in the pursuit of happiness.

A Shared Conceptual and Case Referential Frame—Health Promoting Residential Situations The current residential situation of the Western world at large could, in many regards and according to many sources, be characterized by processes of equally accelerating individualization and accentuated mosaic fragmentation, as well as thriving proliferation of almost tribal-like, highly differentiated lifestyles. Our strategy has therefore primarily been oriented towards residential solutions

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promoting integration. We are searching for integrative8 ways of residing in renewed patterns of hybridization (e.g., bringing different complementary user demands together in new synergetic urban residential contexts), with special attention paid to including aspects of ageing and health promoting strategies within a deeper life course time frame of constantly evolving, accelerated transformations of co-habitation patterns in a culturally perceived liquid reality ( Ebner 2007; Becker et al. 2015; Eleb and Bendimérad 2018; Bauman 2007; Schittich 2007). Recently articulated extended demands on housing encountered by providers and users alike have led to several experimental residential realizations at the very critical edge of radical invention. These could be considered encompassing situations of dwelling, ageing and healthcare in new ways and surprising constellations of programmatic components. When life spheres and life phases perceived in a deeper time frame are brought together in urban residential situations, in different hybrid combinations, it becomes very clear in what way and to what extent they can potentially make a significant difference in sustainable healthcare terms. The virtually added value and decisive impact resulting from these integrative ambitions, in terms of resilient residential quality, becomes strikingly evident especially when supported by qualitative and innovative— structural, architectural and esthetical—contributions of sometimes thoroughly symbolic, emblematic character (cf. Schittich 2007, 11; Ebner 2007). These features may apply equally to a variety of multifold situations. It can be while in a hospital for healthcare treatment for shorter or longer periods or in continued residential medical healthcare. It can mean residing in homes for the elderly with extended multi-faceted services or in different kinds of ‘elder cohousing and other self-directed intentional communities’ (Glass 2013, 2014). It can apply to many other diverse typologies of dwellings for all ages and walks of life, for many different atypical household constellations, encountered throughout all life’s different evolving phases, ages or intense momentary situations. Of this kind, as attempts to establish and promote best practices, members of the research group have taken part in three significant and valid transdisciplinary situations of co-production of new knowledge, during collaborations in practice with societal and business stakeholders. First, the Brf Viva social sustainable cooperative housing experiment in Göteborg (Andersson and Gromark 2016; Gromark, Andersson, and Braide forthcoming 2020). Second, the significant alternative structure of health supportive design of the Stockholm Neonatal Family Centered Care ( White, Smith, and Shepley 2013; Ortenstrand et al. 2010; Fröst 2004).9 Third, the design process 2010–2020 for Östra Psychiatric Wards ( Lundin 2015; Ulrich et al. 2018; From and Lundin 2009). These projects, as mentioned above, were conceived towards a wider screen of Nordic, EU and international exchanges and research on similar, related innovative realizations. They provide reference points considered as attempts at best practices, appearing in a landscape of emerging invention, some of

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which—pointing only towards a few examples among several other possible to mention here—are indicated below as examples of inventive health promoting residential situations.   Among the most exceptional and foremost emblematic cases of extreme integrative ways of residing, embracing different households and manifold categories of people—of all ages—should be acknowledged a remarkable initiative unfolding in the town of Eching, southern Germany, starting in 1995 under the dedicated leadership of the director, Siglinde Lebich. This multigenerational project provides an impressive meeting point between the young and the elderly—the ASZ Eching; Alten Service Zentrum—Mehr Generationen Haus—based on institutional residential healthcare for patients suffering from Alzheimer’s or dementia. Judging from conference presentations and a rich accessible web documentation, this project must be counted as the foremost achievement of its kind conceived as a best practice ( Kärnekull et al. 2013; “Alten Service Zentrum” n.d.; ASZ 1995). A very similar project, built on the same cross-programmatic concept of bringing diverse resident constellations together, is the Sarg fabrik in Wien, Austria, 1996. It has been met with an exceptionally widespread professional reception and high esteem in the world of social architecture, celebrated as an intrepid example of radical rethinking in terms of a stunning architectural critical expression of new ways of residing, forwarding a priority on healthcare and social communication. The architects here were BKK-2 Architektur ZT GmbH. The responsible initiating project team members behind this endeavor has even adopted, in this context, the revealing name of their organization as the Association for Integrative Lifestyle (Ebner 2007, 11; Fitz 1996). Another recent as well as noticeable experimental example mixing different categories as inclusion of the physically impaired amongst elderly and conventional family households was developed by Casanova+Hernandez Architects with a typical integrative project in Groningen 2012. It is partly a stepwise or incremental late result of the Europan 6 urban competition (Kort 2013).10 The cases mentioned earlier are all trying to break barriers between different categories of people within the boundaries of a residential project in order to create new relations in everyday life situations. These desired recombinations are audaciously breaking barriers in acts of transgression between otherwise highly separated life-worlds. Referring to the same objectives it has become a common ambition of childcare institutions situated next to or integrated with residences for the elderly to create new ties between generations, the very young and the very old, to the benefit of both. This is now regarded as a quite common applied formula in Sweden according to frequent case reports in local news media. A master’s thesis run by one of the AIDAH’s studio environments has explored how a similar relation between young adult university students at

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FIGURE 0.2 AND 0.3 Master’s Thesis Studio integrative residential project by Anna Metryka (2014), MPARC master’s student at Chalmers Architecture. Apartments and facilities shared in community by students and elderly. This is situated on the Chalmers campus as a remedy for loneliness. Ground f loor plan and perspective of complex. Examiner Sten Gromark and supervisor Jonas Lundberg (Metryka 2014).

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Chalmers and the retired elderly could be projected in a comprehensive building design, conceived as an effort of social sustainability with the main focus on fighting loneliness.11 During the last decades and since the early 60s the search for an extended residential community has resulted in a proliferation of exceptional situations of hybrid household constellations beyond the conventional nuclear, elementary family. One such example is the feminist elder co-housing community inserted into a structure of shared conviviality, imbricated within a larger council housing block context in France, developed since 1999, called the Babayagas.This has become a famous and extensively media projected case, thoroughly described and analyzed in related exceptional research by Eleb and Bendimérad under the general title Together and apart—Spaces for co-habitation (2018). Under the title Elder Co-housing and Other Self-Directed Intentional Communities: Looking out for each other as we grow old, another researcher is also looking into these phenomena of ageing communities (Glass 2014, 2013). This is a phenomenon with several current parallel examples of a similar kind unfolding in Sweden. Sometimes they are directed towards the elderly and on other occasions offered to young professionals. These new options, perceived as commercially valid offers on the market for new ways of living, late or early in life courses, are described in recent journalistic features telling the story under the typical title ‘We want to become old together’ (Zaitzewsky-Rundgren 2019; Hellekant 2019). Furthermore, a master’s thesis within the AIDAH team has recently revisited and documented the current status of legendary and radical experiments in Sweden of such residential communities and design participation, unfolded since the radical years of the late 70s, still in place and in action after 50 years, carrying the characteristic title Together on our own: the meaning and position of the residential community (Axelsson 2014). A recent publication provides insights to a new but recurring Swedish generation of ten residential communities with similar features, also actively building together, from 2005 to 2020 (Westholm 2020). Giofrè and Porro relate, in their chapter in this book, a number of Italian cases, and they describe, also based on former studies, how acts of caring for the elderly is taken over in spontaneous constellations of alternative self-help local initiatives when traditional family based patterns of caring are no longer naturally available (2016). As a final illustration of the extent of the growing concern for residential conditions for the elderly in an ageing society that is entering the world of architecture and design, we could consider the fact that for the first time, as a unique occasion, a jury nominee by Architects Sweden for a National Prize in 2017 ultimately awarded best housing design of the year to the authors, Marge Architects, for their project Trädgårdarna, ‘The Gardens’, with assisted living dwellings offering unusually high residential qualities, described here by the authors:

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The design for “Gardens” has its background in contemporary research that indicates elderly people’s well-being in care centers is strongly correlated with attractive green outdoor environments and social interaction. Therefore, important parameters in our spatial design were to arrange comfortable homes for the elderly with easy access to their own gardens, outdoor spaces and shared facilities.12 Yet, on a more general international level, projects of a similar programmatic content and strong community orientation are evidently entering the world scene of architecture. One illustration is the Kampung Admiralty, designed by WOHA architects in Singapore 2017, under the heading ‘first integrated public development’ and considered ‘a prototype for meeting the needs of Singapore’s ageing population’ (Toh 2017).   Judging from this collected material, we conceive that the impacts of changes in the residential life world of citizens, at large, as we have conceptualized it— embracing the spectrum or continuum from the private home sphere to ordinary social housing to elder residences as healthcare institutions and further on to hospital environments extending to the ultimate design of ICUs—represent huge values at stake: losses or gains in social, economic or sustainable terms for local communities and nations as well as for life opportunities of residents. Moreover, these changes and trends are to a large degree conditioning, or at worst delimiting, future opportunities and everyday life prospects. The sustainable issues at stake in patterns of residential behavior must be considered of paramount importance in any strategy for a resilient urban future, with drastic effects on the healthcare sector, as more and more reliant upon the home as a spatial base configuration for healthcare provisions. At the same time, the importance of changing social and cultural behavior patterns in everyday residential situations—taking care of the elderly or those temporarily or constantly in need of medical care or responding to vague desires and aspirations to materialize symbolically a specific new way of life, fighting the dread of involuntary loneliness—cannot be underestimated. These aspects are generally far too neglected components in sustainable policies compared to the often-exaggerated focus on purely technological innovations. They deserve great societal attention and profound re-consideration. This book, we hope, will bring inspiration and provide the basis for initiating such a well-informed, evidence-oriented, and animated discussion.

Conclusion—The Primacy of the Be-Coming Health Care Home Findings as they are presented here, emanating from a manifold of interfoliated branches of the AIDAH project with its extension and international

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Sahlgrenska University Hospital, Psychiatric inpatient care, Gothenburg, Sweden. Atrium at common patient areas; the light room, Östra Hospital, 2010–2020.

FIGURE 0.4

Source: White arkitekter; Photo ©Hans Wretling

ramifications, do, in sum, entail a valid illustration of how a consistent transdisciplinary and interdisciplinary—as well as intradisciplinary13 —research strategy can be formed as dedicated to provide and to co-create new knowledge for implementation of sustainable measures in health promoting urban residential built environments, largely elaborated in close collaboration with societal and business stakeholders. This is most evidently exposed in previously mentioned academic contributions by the teams to Riksbyggen’s experimental innovation project Positive Footprint Housing©. The residential block Brf Viva built on Chalmers University campus was inaugurated in September 2019 considered of high relevance in an international and ERA R&I environment (Gromark, Andersson, and Braide forthcoming 2020; Andersson and Gromark 2016; Braide 2019). The same can be said about the Stockholm Neonatal Family Centered Care14 ( White, Smith, and Shepley 2013; Ortenstrand et al. 2010; Fröst 2004) and in particular concerning the design process of Östra Psychiatric Wards 2010–2020 (Lundin 2015; Ulrich et al. 2018; From and Lundin 2009).  

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Our main general conclusion underlines specifically the crucial primacy, priority and position that should be attached to the home in future healthcare policies and strategies, stressing the need for raised long term alterability and adaptability of architectural designs to accommodate yet unforeseen drastic future transformations of demands and aspirations. In sum, what we consider as the primacy of residential quality, in a process where Health Care is Be-Coming Home, is based on a specific assumption: if residential environments in general become more able to promote processes of healing—that fully respond to demands and desires for resilience and empowered identities— the higher the quality of urban life. What follows is less room for expensive and inadequate residential solutions for the ageing elderly. And furthermore, due to enhanced situational conditions in future acts of dwelling, ageing and caring, we see as a consequence, due to improved somatical and mental well-being, the considerably reduced likelihood of ending up in healthcare hospital wards.

Notes 1. AIDAH, Architectural Inventions of Dwelling, Ageing and Healthcare 2. Title theme for the CIB W69 Residential Studies conference 2015, was Explorations on Urban Residential Qualities: Situations of Dwelling, Ageing and Healthcaring. Inquiries of Transdisciplinary Nature. 3. Web address CVA; www.chalmers.se/en/centres/cva/Pages/default.aspx CBA; www.chalmers.se/en/centres/cba/Pages/default.aspx 4. Professors Marie Elf and Helle Wijk, Caring sciences and Associate professor Björn Andersson, Social work, all with contributions in this volume. 5. For an interesting approach on strategies for new welfare cf Cottam 2018. 6. Cf. Dishman 2014 as presented in a seminar keynote Feb 20, 2019, at Chalmers ACE/CVA by prof Michael Nilsson; University of Newcastle and HMRI, Australia 7. See for some illustrations of present discussions and projections in academia and media Kimmelman 2014; Hamilton 2014; Lubick 2018; Ulrich 2013 8. integrative adj. 1. Of or relating to integration. 2. Tending or serving to integrate. 3. Relating to a multidisciplinary, holistic approach to medicine that combines conventional treatments with alternative therapies such as homeopathy or naturopathy. (Source: The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000) 9. Cf. also Accessed February 12, 2020 www.chalmers.se/sv/centrum/cva/nyheter/ Sidor/standarder-neonatal.aspx 10. Cf. chapter in this book p 88 11. For a recent internationally observed realization of this concept in Sweden cf. www.bbc.com/worklife/article/20200212-the-housing-project-where-youngand-old-must-mingle; Accessed March 7, 2020 12. Web address: Accessed February 12, 2020 http://en.marge.se/projekt/vaardboendetraedgaardarna/?lvl=23; 13. Intradisciplinarity: internal, inward-directed, academic condensation, consolidation and reinforcement, theoretical and methodological, cf. a case related in Gromark, Mack, and van Toorn, 2019a. 14. Cf. also Accessed February 12, 2020 www.chalmers.se/sv/centrum/cva/nyheter/ Sidor/standarder-neonatal.aspx

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References ‘Alten Service Zentrum’. n.d. Accessed January 20, 2020. https://adresse.dastelefon buch.de/Eching/1-Krankenpf lege-Alten-Service-Zentrum-Eching-Bahnhofstr. html. Andersson, Björn, and Sten Gromark. 2016. “Social Sustainability in Residential Solutions—A Swedish Case. [Paper Presentation].” Sustainable Housing 2016. International Conference on Sustainable Housing Planning, Management and Usability. Book of Abstracts, 16–18 November, Porto, Portugal. ASZ. 1995. “Alten Service Zentrum—MehrGenerationenHaus 1995.” Accessed January 21, 2020. www.asz-eching.de/index.php/mehrgenerationenhaus. Axelsson, Jens. 2014. “Together on Our Own: The Meaning and Position of the Residential Community.” Master’s thesis, Chalmers Architecture MPARC, Göteborg. Bauman, Zygmunt. 2007. Consuming Life. Cambridge: Polity Press. Becker, Annette, Laura Kienbaum, AA Projects, and Peter Cachola Schmal, eds. 2015. Bauen und Wohnen in Gemeinschaft—Ideen, Prozesse [Architektur/Building and Living in Communities: Ideas, Processes, Architecture]. Deutsches Architekturmuseum in Frankfurt/Main: Birkhäuser. Berezecka, Maria A. 2015. “Den fysiska vårdmiljöns påverkan på vårdpersonal och patienter på operationsalar och intensivvårdsavdelningar.” Licentiate diss., Institutionen för Arkitektur; Avd Byggnad, Chalmers Tekniska Högskola; Institutionen för Arkitektur; Avd Byggnad. Berger, Peter L., and Thomas Luckmann. 1984 [1966]. The Social Construction of Reality: A Treatise in the Sociology of Knowledge. Harmondsworth: Penguin Books. Bernstein, Jay Hillel. 2015. “Review: Transdisciplinarity: A Review of Its Origins, Development, and Current Issues.” Journal of Research Practice 11 (1): Article R1. Bourdieu, Pierre. 1972. Esquisse d’une théorie de la pratique, précédé de trois études d’ethnologie kabyle. Genève: Éditions Droz. Braide, Anna. 2019. “Dwelling in Time. Studies on life Course Spatial Adaptability.” PhD diss., Dep of ACE, Building Design, Chalmers ACE. Charmaz, Kathy. 2014. Constructing Grounded Theory [2nd ed.]. London/Los Angeles: SAGE Publications. Cottam, Hilary. 2018. Radical Help: How We Can Remake the Relationships Between Us & Revolutionise the Welfare State. London: Virago LittleBrown. Creswell, John W., ed. 2007. Qualitative Inquiry & Research Design: Choosing among Five Approaches [2nd ed.]. Thousand Oaks, CA: SAGE Publications. Dishman, Eric. 2014. “Strategy for Innovation.” By Intel Corporation, presented October 1, 2014. IOM-NRC Workshop on “The Future of Home Health Care”. Doucet, Isabelle, and Nel Janssens, eds. 2011. Transdisciplinary Knowledge Production in Architecture and Urbanism: Towards Hybrid Modes of Inquiry. New York: Springer USA. Ebner, Peter. 2007. “Integrated Living.” In Housing for People of All Ages, edited by Christian Schittich, 10–23. Munich: Detail/Birkhäuser. Eleb, Monique, and Sabri Bendimérad. 2018. Ensemble et séparément. Des lieux pour cohabiter. Bruxelles: MARDAGA. Emmison, Michael, Philip Smith, and Margery Mayall. 2013. Researching the Visual [2nd ed.]. London: SAGE Publications. Eriksson, Johanna. 2013. “Architects and Users in Collaborative Design.” Licentiate diss., Department of Architecture/CVA, Chalmers University of Technology.

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Fitz, Angelika. 1996. “Village within the City—Sargfabrik.” Accessed January 21, 2020. www.wohnmodelle.at/index.php?id=90,81,0,0,1,0. Fokdal, Josefine, Liis Ojamäe, Olivia Bina, Prue Chiles, and Katrin Paadam, eds. forthcoming 2020. Enabling the City: Inter and Transdisciplinary Encounters. London: Routledge. Fraser, Murray, ed. 2013. Design Research in Architecture: An Overview. London: Ashgate. From, Lena, and Stefan Lundin, eds. 2009. Arkitektur som medicin—arkitekturens betydelse för behandlingsresultatet inom psykiatrin. Stockholm: ARQ. Fröst, Peter. 2004. “Designdialoger i tidiga skeden/Design Dialogues in Early Phases of Building Projects.” PhD diss., Chalmers tekniska högskola. Giofrè, Francesca, and Livia Porro. 2016. “People with Health Vulnerability: Strategies and Designs for Housing. [Sapienza University of Rome, Italy. Paper Presentation].” Sustainable Housing 2016. International Conference on Sustainable Housing Planning, Management and Usability. Book of Abstracts. 16–18 November, Porto, Portugal. Glaser, Barney G., and Anselm L. Strauss. 1999 [1967]. The Discovery of Grounded Theory: Strategies for Qualitative Research. New York: Aldine de Gruyter. Glass, Anne P. 2013. “Lessons Learned From a New Elder Cohousing Community.” Journal of Housing for the Elderly 27 (4): 348–368. ———. 2014. “Elder Cohousing and Other Self-Directed Intentional Communities: Looking Out for Each Other as We Grow Old.”. Accessed November 9, 2018. www.geron.uga.edu/eic/elderintentionalcommunities.html. Groat, Linda, and David Wang. 2013. Architectural Research Methods [2nd ed.]. Hoboken, NJ: John Wiley. Gromark, Sten. 2000. “The Singularity of Architectural Research.” In Research by Design Conference Book, edited by Anneloes Nieuwenhuis and Marieke van Ouwerkerk. Delft: Faculty of Architecture, Delft University of Technology. Gromark, Sten, Björn Andersson, and Anna Braide. forthcoming 2020. “Explorations on Residential Resilience—brf Viva 2011–2019 [COST Intrepid publication].” In Enabling the City: Inter and Transdisciplinary Encounters, edited by Josefine Fokdal, Liis Ojamäe, Olivia Bina, Prue Chiles, and Katrin Paadam, 90–110. London: Routledge. Gromark, Sten, Mervi Ilmonen, Katrin Paadam, and Eli Støa, eds. 2017. Ways of Residing in Transformation—Interdisciplinary Perspectives [reedition in paperback]. London: Routledge. Gromark, Sten, Jennifer Mack, and Roemer van Toorn, eds. 2019a. Architecture in Effect Vol #1 (2): Rethinking the Social in Architecture—Making Effects. Barcelona and New York: Actar. ———. 2019b. “Rethinking the Social in Architecture: Making Effects—Editors’ Introduction.” In Architecture in Effect Vol #1(2): Rethinking the Social in Architecture— Making Effects, edited by Sten Gromark, Jennifer Mack and Roemer van Toorn, 18–35. Barcelona and New York: Actar. Gromark, Sten, Inga Malmquist, Peter Fröst, Ola Nylander, Helle Wijk, Marie Elf, and Catharina Thörn. 2014. “Integrative Ways of Residing: Health and Quality of Residence. A Concerted Trans-Disciplinary Research Effort—AIDAH ’14-’18. Architectural Inventions for Dwelling, Ageing and Healthcare.” The International Conference ARCH 14 on Research on Health Care Architecture, November 19–21, 2014, Helsinki SF Aalto University. Gromark, Sten, and Katrin Paadam. 2016. “Social Housing Renewal Challenged: La tour Bois-le-Prêtre, Paris 2012.” In Ways of Residing in Transformation—Interdisciplinary

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Perspectives, edited by Sten Gromark, Mervi Ilmonen, Katrin Paadam, and Eli Støa, 172–197. London: Ashgate/Routledge. Hamilton, Kirk D. 2014. “Intuitive Hypothesis and the Excitement of Discovery.” HERD Health Environments Research & Design Journal 7 (2): 140–143. Hellekant, Johan. 2019. “Framtidens bostäder: Ny satsning för att lösa krisen: moderna kollektiv.” SvD, August 13, 2019. Hemström, Kerstin. 2018. Verktyg för gemensam kunskapsproduktion: Exempel från Mistra Urban Futures plattform i Göteborg 2010–2016. Mistra Urban Futures Report 2018:2. Göteborg: Mistra Urban Futures. Karlsson, Saga. 2019. “Framtidssäkring i vårdbyggnadsprojekt.” Licentiate diss., Chalmers ACE Building design CVA Chalmers University of Technology. Kärnekull, Kerstin, Ingela Blomberg, Bengt Ahlqvist, and Nathan Large, eds. 2013. Äldres boende i Tyskland England Nederländerna och Danmark. Stockholm: Svensk Byggtjänst. Kemeny, Jim. 1992. Housing and Social Theory. London: Routledge. Kimmelman, Michael. 2014. “In Redesigned Room, Hospital Patients May Feel Better Already.” New York Times, August 22, A1. www.nytimes.com/2014/08/22/arts/ design/in-redesigned-room-hospital-patients-may-feel-better-already.html?_r=0. Klein, Julie T. 1990. Interdisciplinarity: History, Theory, & Practice. Detroit: Wayne State University Press. Kort, Robert-Jan de. 2013. Urban Symbiosis with an Open End/Casanova+Hernandez Architects. Rotterdam: Europan Nederland. Lubick, Naomi. 2018. “Ljus påskyndar tillfrisknandet.” SvD, February 14, 2018. Lundin, Stefan. 2015. “Healing Architecture: Evidence, Intuition, Dialogue.” Licentiate diss., Chalmers Architecture, Building Design, Centrum för vårdens arkitektur, Chalmers Tekniska Högskola/Chalmers University of Technology. Marcheschi, Elizabeth, Lena Von Koch, Helene Pessah-Rasmussen, and Marie Elf. 2017. “Home Setting after Stroke, Facilitators and Barriers: A Systematic Literature Review.” Health and Social Care in the Community 26 (4): e451–e459. https://doi. org/10.1111/hsc.12518. Metryka, Anna. 2014. “Housing for Elderly Suffering from Loneliness.” Master thesis, Chalmers Architecture, Göteborg: Chalmers University of Technology. Miedema, Elke. 2017. “Health Promotion and Healthcare Architecture—Conceptualizations of Health Promotion in Relation to Healthcare Building Design.” Licentiate diss., Building Design, Chalmers ACE. ———. 2020. “Health-Promotive Building Design—Exploring Perspectives on Building Design for Health Promotion in Healthcare Settings.” PhD diss., Building Design, Chalmers ACE. Morichetto, Hanna. 2019. “Bostadens arkitektur och berikad miljö [Residential Architecture and Enriched Environments].” PhD diss., Building Design, Chalmers University of Technology ACE. NRC. 2015. “The Future of Home Health Care—Workshop Summary.” Accessed June 27, 2019. www.nap.edu/read/21662/chapter/2. Ortenstrand, Annica, Björn Westrup, Eva BerggrenBroström, Ihsan Sarman, Susanne Akerström, Thomas Brune, Lene Lindberg, and Ulla Waldenström. 2010. “The Stockholm Neonatal Family Centered Care Study: Effects on Length of Stay and Infant Morbidity.” Pediatrics 2 (125): 278–285. Paadam, Katrin. 2003. “Constructing Residence as Home: Homeowners and their Housing Histories.” PhD diss., Tallinn Pedagogical University, Tallinn Pedagogical University Dissertations on Social Sciences 6.

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———. 2014. “About the Ways of Residing, Time and Expectations.” MAJA Estonian Architectural Review 79 (1): 20–25. Paadam, Katrin, and Sten Gromark. 2010. “Converted Residences—Re-Inventing Urban Heritage. A Sociological-Architectural Enquiry—The Fahle Case.” Paper presented to the 24th AESOP Conference ‘Space is Luxury’ July 2010, Helsinki. ———. 2019. “Voices from the Inside: Residents’ Experiences in the Bois-le-Prêtre Alteration Project, Paris, 2013.” In Architecture in Effect Vol #1(2): Rethinking the Social in Architecture—Making Effects., edited by Sten Gromark, Jennifer Mack and Roemer van Toorn, 213–231. Barcelona and New York: Actar. Paadam, Katrin, Sten Gromark, and Liis Ojamäe. 2011. “Consuming Quality— Residential Prospects in Interdisciplinary Focus. The Fahle Maja Case.” In The World Economy: Contemporary Challenges COPE Conference Singapore 2011, edited by I K Hejduk and W M Grudzewski, 317–332. Warsaw: Difin SA. Patton, Michael Quinn. 2002. Qualitative Research & Evaluation Methods [3rd ed.]. London/Los Angeles: Sage Publications. Pettersson, Cecilia, Inga Malmqvist, Sten Gromark, and Helle Wijk. 2019. “Enablers and Barriers in the Physical Environment of Care for Older People in Ordinary Housing: A Scoping Review.” Journal of Aging and Environment. https://doi.org/10.1 080/02763893.2019.1683671. Rabinow, Paul, and William M. Sullivan, eds. 1987 [1979]. Interpretive Social Science: A Second Look. Berkeley, CA: University of California Press. Rose, Gillian. 2016. Visual Methodologies: An Introduction to Researching with Visual Materials [4th ed.]. London: SAGE Publications. Schittich, Christian, ed. 2007. Housing for People of All Ages. Munich: Detail/Birkhäuser. Seale, Clive, Giampietro Gobo, Jaber F. Gubrium, and David Silverman. 2004. Qualitative Research Practice. London/Los Angeles: SAGE Publications. Silverman, David. 2011. Interpreting Qualitative Data. SAGE Publications. ———. 2013. A Very Short, Fairly Interesting and Reasonably Cheap Book about Qualitative Research [2nd ed.]. London/Los Angeles: SAGE Publications. Thodelius, Charlotta. 2018. “Rethinking Injury Events. Explorations in Spatial Aspects and Situational Prevention Strategies.” PhD diss., Building Design, Chalmers ACE. Toh, Wen Li. 2017. “Singapore’s First ‘Retirement Kampung’ is Self-Contained with Many Practical Features.” Accessed January 20, 2020. www.straitstimes.com/ singapore/housing/kampung-admiralty-stirs-to-life-as-residents-move-in. Ulrich, Roger S. 2006. “Evidence-based Health-Care Architecture.” The Lancet— Medicine and Creativity 368: 538–539. ———. 2013. “Designing for Calm.” New York Times, January 11, SR12. Accessed January 22, 2020. www.nytimes.com/2013/01/13/opinion/sunday/building-aspace-for-calm.html?_r=0. Ulrich, Roger S., Lennart Bogren, Stuart K. Gardiner, and Stefan Lundin. 2018. “Psychiatric Ward Design Can Reduce Aggressive Behavior.” Journal of Environmental Psychology 57 ( June): 53–66. Ulrich, Roger S., Stefan Lundin, and Lennart Bogren. 2012. “Toward a Design Theory for Reducing Aggression in Psychiatric Facilities.” Paper presented at ARCH 12: Architecture/Research/Care/Health Conference, November 12–14, 2012, Chalmers University of Technology, Gothenburg, Sweden. Wertz, Frederick J., Kathy Charmaz, Linda M. McMullen, Ruthellen Josselson, Rosemarie Anderson, and Emalinda McSpadden, eds. 2011. Five Ways of Doing Qualitative Analysis. New York: Guilford.

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Westholm, Helena. 2020. DE BYGGDE GEMENSKAP—Erfarenheter från tio bygg- och bogemenskaper i Sverige. Rapport. Centrum för boendets arkitektur och Divercity. Stockholm: Svensk byggtjänst. White, Robert D., Judith A. Smith, and Mardelle M. Shepley. 2013. “Recommended Standards for Newborn ICU Design, Eighth Edition.” Journal of Perinatology 33: S2–S16. https://doi.org/https://doi.org/10.1038/jp.2013.10. Zaitzewsky-Rundgren, Maria. 2019. “Vi vill åldras tillsammans.” ÅRET RUNT 32: 20–22.

SECTION I

Dwelling

1 THE MULTIPURPOSE USE OF SOCIAL SUSTAINABILITY—A SWEDISH CASE; BRF VIVA 2019 Björn Andersson and Sten Gromark

Introduction Today, housing contractors are often expected to integrate sustainability as a vital part of intended residential projects, and many actors in the field try to develop their interpretations and applications of the concept. The municipalities in Sweden have the benefit of a monopoly on planning, and increasingly land allocation for housing construction is connected to requirements of sustainability plans. This forces construction companies and other entrepreneurs to investigate how their projects can be developed in order to meet these new demands. In this chapter we will describe and ref lect upon experiences from taking part in a collaboration project in Gothenburg, Sweden, called Positive Footprint Housing© (PFH), initiated by the cooperative housing association Riksbyggen EF (2020). This project investigates sustainability solutions in residential contexts, both in a general sense and in relation to an actual construction project, in this case the Brf Viva project. The effort will be described more in detail later in the text. In particular, the aspect of social sustainability has been central to both PFH and Viva, and we will concentrate on this in the following.

Social Sustainability “Social sustainability” is a concept that has been on the agenda for several years. The discussion started with a reference to the Brundtland Report in 1987 (World Commission on Environment and Development), though the concept was never mentioned in this text. It was in the following adaption of the report that the well-known three dimensions of sustainability, social, ecological and economic, were delineated. In 2008 the Marmot report, “Closing the gap in

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a generation” (World Health Organization), fueled the discussion and offered a partly new entry by connecting social sustainability to a health promotion perspective. Of the three dimensions outlined, the social is often considered the most difficult to define and give substance to; it becomes the “missing pillar” (Boström 2012). Efforts made to create definitions have often resulted in very generic and common-sense solutions. Stephen McKenzie (2004) has made an ambitious attempt and ends up with the following suggestion: Social sustainability occurs when the formal and informal processes, systems, structures and relationships actively support the capacity of current and future generations to create healthy and liveable communities. Socially sustainable communities are equitable, diverse, connected and democratic and provide a good quality of life. (McKenzie 2004, 18) Definitely, McKenzie manages to encapsulate a vision of a fair and inclusive society, but, nonetheless, the definition does not give much practical guidance regarding how this may be achieved. For one thing, there is the question of which goals that social sustainability shall aim at: Social sustainability is a wide-ranging multi-dimensional concept, with the underlying question ‘what are the social goals of sustainable development?’, which is open to a multitude of answers, with no consensus on how these goals are defined. ( Dempsey et al. 2011, 290) And further, as Lehtonen points out: Different geographical and temporal scales as well as situational contexts require their own frameworks, which do not necessarily provide a coherent picture but a mosaic of partly contradicting views of reality. (2004, 211) As an alternative to general definitions, keywords are often used to signify the meaning of the concept. Murphy (2012) has made an extensive review of documents and literature concerning social sustainability and claims that the general discussion can be summarized in four dimensions: equity, social cohesion, awareness for sustainability and participation (2012, 15). Others have followed the same track; Weingaertner and Moberg, for example, provide a list of 17 “social sustainability aspects in the urban context” (2014, 125). The keywords displayed in these various lists tend to overlap one another. This signals at least some basic agreement concerning which direction to travel

The Multipurpose Use of Social Sustainability 25

in and what challenges that have to be met in order to move towards social sustainability. One important aspect is that the lists of keywords, as well as McKenzie’s definition, contain concepts covering both substantial and processoriented dimensions of social sustainability. Boström recognizes this and distinguishes between substantive aspects, dealing with the “what-question”, and procedural aspects, related to “how” these could be achieved and maintained (2012, 6). To be useful in a more concrete context the concept of social sustainability must be further clarified and operationalized. At another level we can see this being done through the development of a range of models and standards. It should be noted that the validity of the three-pillar model has been put into question (Kates et al. 2005, 19) and that many writers underline the importance of connecting the different aspects. Murphy stresses that environmental goals need social arrangements to be fulfilled and suggests a “social/ environmental framework” (2012, 19). Peterson, in an overview, has pointed at “the integrated approach to sustainability” that local studies often result in and concludes that forcing complex and unprecedented socio-environmental problems into three, four, or seven distinct containers represents an outdated, unduly modernist way of problem-solving that tends to approach environmental, economic, and social issues as independent, and consequently, their solutions as separate. (2016, 3) Two things that most writers in the field seem to agree upon are the difficulty to find a consistent general definition of social sustainability and the need to connect the understanding of the concept to specific situations. In a recent article Shirazi and Keivani point to this as a possibility: We argued that the lack of solid definition and conceptual framework is not a disadvantage; it ref lects the complexity of the social dimension of sustainability and also allows researchers to develop case-specific and place-specific formulations. (2017, 1539) On the basis of this, they suggest that an important step forward would be that local authorities and city administrations should establish collaboration with research institutions, direct community concerns and questions to be researched, facilitate empirical research at the community level . . . towards achieving social sustainability. (2017, 1539)

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In many ways this is a description of what the collaborative project Positive Footprint Housing has tried to accomplish. We will now move on to present some results and aspects of the PFH and Viva project thus far.

Positive Footprint Housing Positive Footprint Housing was set off in 2011 by the cooperative housing association Riksbyggen EF (2020), a big and well-known actor in the housing market in Sweden. The project is located in Gothenburg and the aim is to create “a transdisciplinary knowledge hub” in order to increase the possibilities of ecological, social and economic sustainability (cf. riksbyggen.se). One important part of the PFH is that it contains best practices “demonstration projects”, that is, actual housing projects in relation to which ideas and knowledge concerning sustainability can be tested and developed. As mentioned, the planning of the residential quarter Brf Viva has thus far been the main practical employment for the PFH.1 The organization of the PFH is quite simple. Participants in the project carry out their missions either individually or in small groups. However, important for the work process is that most activities and results are reported and discussed in a transdisciplinary work group. This work group was formed in 2012 and has had meetings every month. The group has also organized seminars and special sessions open to the public or to invited guests. Regular members of the working group have been representatives of Riksbyggen, Chalmers, the University of Gothenburg, the architects working with the Viva project, the City of Gothenburg, the Technical Research Institute of Sweden and Johanneberg Science Park. In addition, a number of actors have occasionally taken part in the discussion. It has, to a large degree, been the same people taking part in the work group since the start-up. This has been important for the continuity of the process. Also, the mode of working has emphasized that every group member should take part in all discussions, no matter the subject. One goal of the project is to investigate the connections between different aspects of sustainability and therefore it has been understood as important that the discussions have a crosssectoral and transdisciplinary approach. It should be underlined that the work group has no authority to make decisions concerning the project. The PFH is led by Riksbyggen, and this organization also provides the main contribution of project resources.

The Viva Project and the Guldheden Area The Viva urban residential project is a moderate building project, comprising 132 f lats, with Riksbyggen as the main contractor. The project is located in the outer parts of the central city as part of a residential area called Guldheden,

The Multipurpose Use of Social Sustainability 27

built in the 1940s and 1950s, and close to the campus of Chalmers University of Technology. Viva is projected to have an experimental design and the intention is to meet high standards when it comes to sustainable planning and housing. There is a long tradition of engagement in residential issues among people living in Guldheden. Several local housing co-operatives are active in the area. Also, two local activist organizations have been working with housing and environmental issues for many years. Their goal is to preserve what they consider to be essential qualities in the district, especially the well-ordered balance between built areas and green zones. For this reason, these organizations, called “Maintain Guldheden” and “Save the Bog”, oppose any densification in the area. The planning process of Viva began formally in January 2012 with an intial meeting at the City Planning Office in Gothenburg. In December 2014 the Land and Environmental Court approved the plan and after that Riksbyggen obtained building permits for the project. The construction started in late 2017 and the residents moved in from 2018 to 2019.

Viva—Substantive Goals This aspect concerns conditions for sustainable living in the residential area. There is an emphasis on ecological goals, but it is very clear that there is a strong connection between ecological and social sustainability. One central part of the effort to make Viva stand out as an example of environmental awareness is that the residents are expected, and encouraged, not to have private cars. In principle, this is difficult to forbid, but this intention is clearly communicated when the apartments are offered for sale. It is also underlined by the fact that there are no private parking spaces on the premises. The city has a standard regulating the number of private parking spaces that must be offered when a new housing area is built, but Viva has been exempted from this. It should be mentioned that the availability of public transportation is very good in the area. There are alternative transportation arrangements for the residents of Viva. All members of the housing cooperative have access to a vehicle pool, which includes electric cars, bicycles and cargo bicycles. There is also a lot of space allocated for the storage of bicycles, and there is a so-called “bicycle hub”, which is a place equipped with tools for repairs. This hub can also be used for repairs of other things, such as furniture. Some spaces are designed to combine utility functions with the possibility of social contacts. One such place is called the “recycle-room”, where people can leave and exchange belongings, for example, clothes and toys that they no longer need. Another example is the “postal and delivery room”, where the residents fetch mail and where they can also have goods and groceries delivered to. These can be left in locked cabinets, which means that there is no need to be present at the time of delivery.

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Several areas and rooms are designed for social gathering and meetings. There is a greenhouse that offers opportunities to cultivate plants as well as an orangery, which is partially kept at a controlled temperature during the winter season. This can be booked for private events. One common space has been labelled “the life room”. It is equipped with a large-screen TV, has a small kitchen and can be booked for private purposes. Viva is designed to be a plus-energy housing complex; it will produce more energy than it consumes. Solar panels, insulation and systems of heat exchange distribution are important means to accomplish this, together with the building materials used. New ways of producing and transporting the concrete have been developed, which will lead to significantly reduced environmental impact during the construction process, compared to normal conditions. There is also a special storage system for electricity, where used car batteries are recycled. The intention is that Viva, during certain periods of the year, will be able to deliver energy to surrounding buildings. Viva is organized as a local housing cooperative, which means that the apartments are acquired by paying a share and then a monthly rental maintenance fee. All residents are members of a local housing association and exert through this body their inf luence over the management of the buildings and the neighborhood. Such local associations are often connected to a larger cooperative organization, like Riksbyggen, which offers services and property management. The residents do not really own their apartment but rather a proportion of the housing cooperative corresponding to the apartment. Despite this, the apartment, or actually rather the share, can be sold on the property market. The development in major Swedish cities has been that the cost of such shares has increased sharply for a number of years, which has contributed to the socioeconomical segregation of residential areas. Viva is no exception in this regard. The cost of a share is high and, as a result, only groups in good economic conditions can meet the demand. To somewhat counteract this, Riksbyggen is trying a new model of solidarity for some apartments of Viva. Six integrated one-bedroom apartments have been sold with certain special conditions. For these, the price of the share is set considerably lower than the market price. At the same time, the monthly rent is somewhat higher. These six apartments are not available on the market, but are offered to young people between 18 and 30 years old. The residents have been selected from the housing queue that the city of Gothenburg administrates. Whoever moves in can also stay after the person concerned has turned 30, but the apartment will again be offered with the special conditions once someone has moved away. The price of the share will then be calculated on an indexbasis, so there will not be any possibility for the shareholder to make a profit. The residents of these apartments are full members of the housing association and have the right to use all common areas and assets in the neighborhood. This construction concerns only a small part of the total number of apartments,

The Multipurpose Use of Social Sustainability 29

but it represents a generally appreciated attempt to contribute to more socially equalizing solutions on the housing market.

Viva—Procedural Goals The planning process of a new housing project is in many ways quite regulated and routinized. As mentioned, all planning of new residential areas is controlled by the municipalities and directed by the City Planning Office, most often carried out in dialogue with contractors and developers. Information is displayed in public, and meetings are held in order to give different stakeholders the opportunity to follow the planning process, contribute with information and ideas, and ensure that their interests are taken into account. During the planning dialogue of Viva, the City Planning Office took part in some of the meetings in the work group of PFH. Riksbyggen also put an effort into organizing a number of extra opportunities for individuals, groups and organizations to participate in the planning process. Partly, this was quantitative in character; there were more meetings of the same kind as the ones organized by the Planning Office. However, there are also examples of more innovative communication strategies. For one thing, two extra meetings were organized with residents in the local neighborhood. There are a couple hundred people living in the close vicinity, so there was the possibility of a quite large audience. However, these meetings were attended by no more than 15 to 20 people, most of them coming from another housing association in the neighborhood. The existing housing area that is most affected by the Viva buildings is a neighborhood with rental apartments. Since just one person from this area attended the open meetings, some special meetings were arranged in this neighborhood. The meetings were held in a locale on the premises, organized with the local caretaker and advertised to each household. Still, just two residents turned up. There was also a special meeting organized with the two interest groups in the area that try to maintain what they feel are essential qualities of Guldheden. These groups are generally very interested in green issues and local housing policy matters. Due to that, the members of the interest groups in many ways seconded the ambitions of PFH and the Viva project. However, as they considered Viva to be misplaced, the groups opposed the intentions, and one member appealed against the building plan. In this appeal, interestingly enough, social sustainability arguments were used against the Viva project. Other stakeholders, in relation to whom meetings were arranged, include politicians from the District Council and officials from the District Administration. Central thematic meetings have been organized, focusing on issues like carpools, participation and common public spaces in the neighborhood. These meetings have often been arranged as combinations of expert presentations and

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workshops. The invited have sometimes been representatives of organizations working with, for example, housing or green issues. Some participants have simply been people interested in the project. There has been a Facebook site organized for the Viva project and some people have attended meetings due to information they have gathered there. The public has been addressed through media coverage, including newspaper articles, films and commercials, and through conferences and open meetings. In addition to these exchanges master’s students from Chalmers Architecture have been involved in making residential designs for the site that have also been presented to Riksbyggen and the responsible architects in order to open a creative dialogue on specific experimental topics. On the request of Riksbyggen a seminar with a number of other local architects was also arranged mid-way through the process in order to stimulate a critical assessment of the project at that stage.

Brf Viva—Considered from a Health Promotion Perspective As mentioned, Marmot (World Health Organization 2008) has done much to connect social sustainability to a health perspective. One important question for the AIDAH research project, presented in this volume, has been the connection between the built environment and health: To what extent can architectural design promote people’s social well-being at all levels? In an overview of the literature on social sustainability and health, Emmelin and Eriksson (2012) emphasize the connection between health and social capital, both on an individual and a collective level. Social capital is about people’s social networks, their access to social support and opportunities to engage in social life. This is connected to material and social resources, among these the built environment and where we live. As a result of their overview, Emmelin and Eriksson investigate the possibilities to “build” social capital into residentials areas, and they identify five major ways. The first is to facilitate social interaction, which includes the creation of “third places” (2012, 25). The concept of “third places” was coined by Ray Oldenburg (1989) and based on the idea that social relations are facilitated and enriched if people have access to another kind of meeting place aside from work and home. This may be not only places like cafés and bars but also, from a residential perspective, all kinds of spaces that allow neighbors to meet. The second way is to invest in attractive parks and recreational areas. To meet the need for safety is a third possibility, and to improve the reputation of exposed areas a fourth. Finally, Emmelin and Eriksson mention the need to create balance between bonding and bridging social capital. Often neighborhoods are characterized by a high degree of bonding capital, that is, that people with similar conditions and preferences tend to dominate a certain area. However, it is important to facilitate meetings across social borderlines, that is, to create bridging social capital. This opens up

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opportunities to learn and gain insight into people who live, act and think differently from oneself, which, at best, leads to mutual respect and understanding. In a number of ways, the Viva project corresponds well to these five criteria. There are several spaces and facilities designed to encourage social meetings and gatherings: the greenhouse, the “life room” and the recycle-room, for example. Also, much effort has been put into turning the outdoor surroundings into green and attractive areas. The cooperative organization of residential life in Viva and the far-reaching investment in ecological sustainability are structures that have the capacity to promote joint action and collective identity. So, in relation to these aspects, the Viva project has “built in” a good capacity to support improved health profiles among its residents. The balance between bonding and bridging capital is, however, a critical point. As mentioned earlier, Viva represents a segment of the Swedish housing market that can only be afforded by a wealthy middle-class. So, there is definitely the risk of imbalanced bonding social capital. The only “built in” effort to contradict this are the six apartments with certain conditions intended for young people. These are also affordable for young people outside the middle class. Considering the number of apartments, it is obvious that their possible impact on the balance of social capital will be minor. It is a step in this direction, but more fundamental changes of the housing market must take place before newly-built residential areas will be characterized by a balanced social capital in the sense Emmelin and Eriksson (2012) are referring to.

Discussion Today, in early 2020, Viva is fully occupied, and from a survey conducted among the residents it can be shown that the outcome is as expected. The residents are middle-class, well-educated and have good economic resources as members of an emerging and thriving residential community. The project has been awarded prizes for its approach to sustainability. In 2019 it won the prize “This Year’s Environmental Building” by the Sweden Green Building Awards, and in 2017, Viva, as one of five projects, represented Sweden at the SBE17 conference in Hong Kong, a world-leading conference on sustainable construction. Ultimately, as a major recognition, the project was awarded the prestigious National Kasper Salin Prize for best architecture 2019. Obviously, PFH/Viva has been carried through as a top-down project. It was initiated by Riksbyggen and mirrors an interest from the corporation to investigate how it can develop sustainable strategies and practices, both when it comes to the development of new inventive housing projects and the maintenance and service of existing ones. One basis for this interest is Riksbyggen’s background as part of the cooperative social movement and its ambition to function as a “developer of society”. The ideology of the cooperation movement fits very well into the ideas of sustainability. Actually, one could argue

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that the cooperative movement was “sustainable” long before the concept had come into use. However, there is also another fundamental reason for Riksbyggen to engage in sustainability issues, and this has to do with the trademark of Riksbyggen and its convertibility into values and positions on the housing market. It is important for a housing actor like Riksbyggen to have its name and reputation connected to symbols that convey an image of being socially committed and well established at the frontiers of residential inventions. Initiating research-based knowledge production like the organization of PFH and carrying through an experimentally designed housing project like Viva are also parts of this picture. It helps to sell the product. This was demonstrated when the Viva apartments were offered on the market. There was an overwhelming interest for the project resulting in an almost immediate sell-out. Quite clearly, the orientation towards the cooperative ideology and the endeavor to be a successful market actor are not always easy to combine. During presentations and discussions that we have had with the Riksbyggen Corporation, it has become obvious that different segments of the organization emphasizes diverse values and strategies. To some, the PFH/Viva engagement represents a long-wanted effort to enliven the cooperative roots of Riksbyggen. Others have been more skeptical: “How can we sell this?” This says something about the three pillars of sustainability. In many ways, the Viva project demonstrates the closeness between the environmental and the social pillars, just as Murphy (2012) underlines. However, it seems much more complicated to integrate the economic aspects. In the beginning of the Viva procedure, economy played a very marginal role in the discussions. It was as if this would have restricted the creative process. But the longer the process progressed, economy was introduced and the people representing this perspective critically engaged in what was really possible to implement. This led, for example, to a slimming down of space for common purposes in the suggested housing plan and to fewer experiments with building materials in the construction. So, the question is, “Do the three pillars really support the same building?” The top-down character of PFH/Viva limits the opportunities for stakeholder participation. Given all the invested interests from Riksbyggen, the aim that the buildings should have an experimental, conspicuous and challenging design plus the ambition to build the housing project on research documentation and knowledge, there is really not much left to inf luence. The efforts made during the planning process with extra meetings and targeted sessions were serious but did not result in an over-whelming response. As in many similar planning procedures, most of the partakers represented well-to-do stratums of society who had their own, sometimes project-negative, agenda (Lindholm et al. 2015). There were steps taken in order to engage other groups, but with poor results. It is possible that a more outreach-based and dialogic method could have produced more contact and better communication. However, there

The Multipurpose Use of Social Sustainability 33

were no resources or preparation for that kind of strategy inside the PFH organization, and it would probably have been difficult to combine with the other activities in the project. The discussion about participation as an important part of social sustainability has its focus on external relations, that is, on how to create relationships with actors outside the core group that organizes the planning process. The experience from the PFH/Viva project is that internal relations are also vital: how the project is kept together and how different partners and participators can express their views and stimulate one another in the process. This is especially valid for a project that contains both independent research activities as well as a concrete-making effort. As mentioned earlier the work group of PFH has played an important role for how the project has developed. A core group of participants, among them the authors of this chapter, have taken part in the work group for a long time and engaged in mutual discussions across professional background and expertise. This has created continuity in the project and formed a basis for collective understanding as well as a major occasion for academic transgression, for transdisciplinarity in action, involving academia, education and business stakeholders. From a research point of view this is not an uncomplicated situation. On the one hand it has given us a position from which we have been able to follow internal processes and discussions that would have been concealed to an outside observer. On the other hand, one must be aware that proximity in the work group creates bonds. Over time a collective belonging is formed, and it is difficult for the individual member to see how this impinges on his or her judgment and actions. It is of course even more obscure for an external observer. We have tried to counteract the latter problem by always emphasizing our role as researchers and never representing any organizational body other than our academic institutions. We have never taken part in any decisions and never positioned ourselves as responsible for any part of PFH/Viva. On the basis of existing knowledge, we have given advice and come up with ideas, but we have continuously made clear that a central part of our mission is undertaking a critical interpretation and evaluation of the whole project.

Conclusion When concluding the experiences from the PFH/Viva effort in relation to the concept of social sustainability, it is striking how many purposes and contexts that social sustainability is used in relation to. As part of a planning effort, both substantive goals of qualified sustainable living in the housing block and procedural efforts to facilitate stakeholder participation are formulated through an understanding of what social sustainability implies. But the concept also has important symbolic functions. Social sustainability is used as a key expression to position a project as an interesting experiment on the housing market; it signifies

Brf Viva 2019—General overview

Source: ©Photo: Ulf Celander; Architects: Malmström Edström

FIGURE 1.1

34 Björn Andersson and Sten Gromark

Brf Viva 2019—Garden and community bicycle rooms

Source: ©Photo: Ulf Celander, Architects: Malmström Edström

FIGURE 1.2

The Multipurpose Use of Social Sustainability 35

Brf Viva 2019—Common facilities—the Orangerie

Source: ©Photo: Ulf Celander, Architects: Malmström Edström

FIGURE 1.3

36 Björn Andersson and Sten Gromark

The Multipurpose Use of Social Sustainability 37

a trend. Further, social sustainability is a trademark for the entrepreneur: a brand that helps to visualize the image that the company wants to be associated with. Then, with the critical activist groups among the inhabitants of the area, we can see how social sustainability can be a vantage point for opposition used to articulate resistance to a certain project, even when this is presented in terms of sustainability. Finally, we should not forget ourselves; social sustainability is a tool for research work. In this context it is framed by the criteria that apply in scientific work. This versatility of social sustainability points at the importance of a contextual or situational understanding of the concept. There is an inherent vagueness of general formulations, especially concerning social sustainability, and our study shows the importance of doing research directly in the conf licting social fabric where sustainability goals are negotiated and given a concrete significance.

Note 1. The authors provide a specific critical interpretation from a transdisciplinary conceptual point of view on the Brf Viva project in another recent publication, cf. (Gromark, Andersson, and Braide forthcoming 2020).

References Boström, Magnus. 2012. “A Missing Pillar? Challenges in Theorizing and Practicing Social Sustainability: Introduction to the Special Issue.” Sustainability: Science, Practice, & Policy 8 (1): 3–14. Dempsey, Nicola, Glen Bramley, Sinéad Power, and Caroline Brown. 2011. “The Social Dimension of Sustainable Development: Defining Urban Social Sustainability.” Sustainable Development 19: 289–300. Emmelin, Maria, and Malin Eriksson. 2012. Kan socialt kapital “byggas in” i våra bostadsområden och därmed förbättra invånarnas upplevda och mentala hälsa? Malmö: Kommissionen för ett socialt hållbart Malmö. Gromark, Sten, Björn Andersson, and Anna Braide. forthcoming 2020. “Explorations on Residential Resilience—brf Viva 2011–2019 [COST Intrepid publication].” In Enabling the City. Inter and Transdisciplinary Encounters, edited by Josefine Fokdal, Liis Ojamäe, Olivia Bina, Prue Chiles, and Katrin Paadam, 90–110. London: Routledge. Kates, Robert W., Thomas M. Parris, and Anthony A. Leiserowitz. 2005. “What Is Sustainable Development?” Environment 47 (3): 9–21. Lehtonen, Markku. 2004. “The Environmental—Social Interface of Sustainable Development: Capabilities, Social Capital, Institutions.” Ecological Economics 49: 199–214. Lindholm, Teresa, Sandra Oliveira e Costa, and Sofia Wiberg, eds. 2015. Medborgardialog— demokrati eller dekoration? Stockholm: Arkus, no. 72. McKenzie, Stephen. 2004. Social Sustainability: Towards Some Definitions. Hawke Research Institute Working Paper Series, no. 27. University of South Australia, Magill, South Australia. Murphy, Kevin. 2012. “The Social Pillar of Sustainable Development: A Literature Review and Framework for Policy Analysis.” Sustainability: Science, Practice, & Policy 8 (1): 15–29.

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Oldenburg, Ray. 1989. The Great Good Place: Cafés, Coffee Shops, Community Centers, Beauty Parlors, General Stores, Bars, Hangouts and How They Get You Through the Day. New York: Paragon House. Peterson, Nicole. 2016. “Introduction to the Special Issue on Social Sustainability: Integration, Context, and Governance.” Sustainability: Science, Practice, & Policy. 12 (1) Published online May 31, 2016. Riksbyggen EF. 2020. “För en mer hållbar framtid.” Accessed January 31, 2020. www. riksbyggen.se/om-riksbyggen/hallbarhetsarbete/positive-footprint-housing/ Shirazi, M. Reza, and Ramin Keivani. 2017. “Critical Ref lections on the Theory and Practice of Social Sustainability in the Built Environment—A Meta-Analysis.” Local Environment 22 (12): 1526–1545. Weingaertner, Carina, and Åsa Moberg. 2014. “Exploring Social Sustainability: Learning from Perspectives on Urban Development and Companies and Products.” Sustainable Development 22: 122–133. World Commission on Environment and Development. 1987. Our Common Future. UN Documents. World Health Organization. 2008. Closing the Gap in a Generation. Geneva: World Health Organization.

2 CRITERIA LIST OF HOUSING ARCHITECTURE PROPERTIES— A WAY TO PROMOTE RESIDENTIAL QUALITY? Ola Nylander

Today there is no effective way of ensuring architectural quality in the processes involved in housing construction. The hypothesis outlined in this chapter is that we can remedy this by developing a clear and simple list of criteria formulating housing project quality requirements which are then referenced and applied in the planning stage, during the construction phase and when reviewing the finished product. Through evidence-based research, a broader understanding of the relationship between architecture and health has emerged in recent years. Researchers have discovered that the shape of the hospital room, materials, color, daylight, and not least a beautiful view, affect patients’ health. Good architecture promotes positive effects such as faster recovery and less medication. This is the background to and also the ambition of the criteria list. Housing with high quality architecture affects its residents in many positive health promoting ways. Empirical data for this project was gathered at the Centre of Housing Architecture (CBA), which was founded in 2017 at Chalmers Architecture and Civil Engineering. Chalmers has extensive long-time experience in processing and expanding knowledge through workshops, user participation (Olivegren 1975, 221), self-help construction (Nylander 2018a, 234) and housing behavior surveys (Nylander and Granath 2019, 54). CBA advances that tradition further by having researchers review the qualities of contemporary dwellings through plan analysis, site visits, interviews with residents and architects, external surveys and statistical analysis. The focus of CBA’s housing research is put on the resident and his or her experiences and assessments regarding materials, f loor plans, and dwellings; evidence-based knowledge of residential qualities and life experiences.

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This chapter explores the possibility of grading three qualities of the dwelling; namely axiality, movement and space and geometry. These form subcategories of the criteria list item spaciousness of the home which is one out of a total of eight main criteria-concepts. The criteria list consists in total of the following items, with our focused topics here for in-depth exploration indicated in bold: • •

Functionality of the home Spaciousness of the home • • •

• • • • • •

Axiality Movement Space and geometry

Daylight in the home Flexibility of the home Atmosphere and well-being in the home Organization of space Communication and structure of the residential house The yard and its territories

Ongoing research within the CBA is linked to items on this list. PhD Kaj Granath researches housing functions using compilations of earlier research from the 1960s through the 1990s (Granath 2018). Professor Ola Nylander researches qualities in housing architecture using the seven concepts of quality presented in his dissertation of 1998 (Nylander 1998, 215). Future research efforts to be linked to the criteria list are the city’s and the apartment’s f lexibility through Anna Braide, PhD (2019, 46) and the atmosphere and the wellbeing of the dwelling through doctoral student Hanna Morichetto (2019, 199): both with support from the AIDAH environment funded by Formas. An ongoing collaboration with researcher Eva Minoura explores the subject of the yard and its territories (2019, 43). The balcony and the relationship between exterior and interior are investigated in a research project led by architect Kajsa Crona (Crona 2019).

The Concept of Axiality Axiality is the first out of three sub-categories which together make up the criteria list item spaciousness of the home. In his book Limitless Light, the poet Magnus William-Olsson describes how active participation inf luences the way we experience art and how poetry has the ability to affect us. William-Olsson states that there is a decisive difference between the silent reading of poetry and vocalizing it (1997, 54), where reading out loud causes us to, intuitively and subconsciously, become affected in a more

Criteria List of Housing Architecture 41

pervasive way. The act of reading the poetry out loud is important, according to William-Olsson, because it is only when the body, through the act of speech, and the mind are both actively participating that the full artistic experience can take place (1997, 56). William-Olsson describes the ability of the artistic experience to make us feel present in the moment of now—to bring about a sense of reality. Poetry shares this ability with other art forms such as film, music and even architecture. The body-mind synthesis achieved through declaiming poetry, which William-Olsson means is important for obtaining the full and complete artistic experience, is paralleled in the field of architecture in the strong emotion and elevated experience one perceives whilst traversing an axiality of architectural space. The visual impressions of an axiality create expectations and, through motion, a sequential physical experience of light, materiality and different vistas. In moving along the axiality line we are active participants in an artistic experience of the geometric characteristics of space, light and materiality offered by the different rooms and vistas encountered. Housing surveys provide us with evidence-based knowledge showing that residents deem axiality an important part of residential quality for wellbeing.

Identification of Axiality Axiality is based on the visual connection between rooms which in turn is made possible by doors and openings. Axiality can be defined as a sequence of at least three rooms connecting architecturally important parts of a dwelling through arches and doorways. Axiality in a dwelling also inf luences how we move between rooms. The length of the axis as well as the number of rooms connected are important for the gravity of the axiality (Nylander 2002, 25). Axiality which extends through multiple rooms becomes extra clear, and wide openings further increase this clarity. It is a quality to be able to not only see through several rooms but also connect the interior and the exterior. The start and end points of an axiality are important; an axiality which clearly connects important parts of the apartment obtains high dignity. An axiality connecting the opposite facades is an example of important points being bound together. This kind of axiality where the apartment’s entire length is utilized also creates clarity and identity (Nylander and Forshed 2011, 71). An axiality can be strengthened by a window or by a translucent door opening out to the exterior as part of a room sequence. Simply having transparency between two rooms is not, however, axiality, nor is being able to catch glimpses of different places in an apartment through one or more of the rooms. Axiality takes on different characteristics depending on the nature of the rooms connected. For example, rooms where the openings are located next to

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the facade and receive outside light through windows form a room sequence with completely different axial character than an axiality placed further into the darker interior of the apartment. An axis stretching between rooms of similar size, material and light is given a strong axial expression. A variation in small and large rooms affects the movement through those rooms. The presence of axialities of different character within the same dwelling is in itself a quality.

Example of Axiality in a Floor Plan The plan shown in figure 2.1 illustrates part of a building constructed in 2010 in Eriksberg, a newer part of Göteborg. It consists of four rooms plus a kitchen and exhibits a very rich axial expression. There are two transverse axes that connect the balconies on either side of the building. The transverse axes extend through the dark center towards the living room and kitchen to include the exterior room with the two balconies. A total of four rooms inside the apartment and two rooms, the balconies, outside the apartment. There is also variation in terms of large and small rooms, enclosed and open rooms and dark and bright rooms. In the upper part of the apartment there is a longitudinal axis covering the two bedrooms and the living room. The openings are placed in the dark parts of the room. In the middle of the apartment there is also an axiality that connects the entrance, an inner hallway and a passage. Multiple spots in the apartment offer vistas from inside to outside, through the balconies and further out into the exterior space.

FIGURE 2.1

Floorplan from 2010. Eriksberg, Göteborg. White architects.

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Valuation and the Criteria List Axiality is a n important aspect of a residential space. In the criteria list, the respective quality is graded using a simple scoring system, and thereby used in many different ways as described in the following list. Axiality is judged here according to the following: • • • • •

Axiality where at least three rooms, or parts of rooms, are connected. This awards one point. Two axialities where at least three rooms, or room parts, are connected. This awards two points. Three or more axialities where at least three rooms, or room parts, are connected. This awards three points. Axiality extending throughout the whole length or width of the apartment. This awards one point. Axiality that includes balconies, terraces or other outdoor spaces. This awards one point.

A note regarding variations in apartment size—the small one-bedroom apartment has limited preconditions for axiality whereas a larger apartment provides completely different possibilities to design for axiality. In a final version of the criteria list these varying preconditions will be considered and compensated for.

Movement and the Floor Plan Movement is the second out of three sub-categories which together make up the criteria list item spaciousness of the home. A wide range of choices in terms of possible movements within a residence is a quality of space. It enrichens the experience to be able to reach and see the various rooms from different directions and viewpoints and to be able to progress through the geometry in a multitude of ways; it makes the residence be perceived as more spacious (Nylander 1998, 78). Housing surveys show that this multitude of choices, as well as circular loops, are qualities appreciated by the residents (Nylander and Fänge 2007, 101). In the criteria list the focus will be on the experiential qualities of the movement and on being able to navigate the dwelling from room to room in a circular loop. The circular loop (movement through several enclosed rooms) is a way of creating a feeling of great volume and sense of spaciousness even in a small apartment. The circular loop movement requires rooms with several openings and creates f lexibility. The length of the circular loop, the number of rooms traversed and the contrast in room size inf luence the overall effect (Nylander 1998, 78).

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In her dissertation Room and Human Movement, architect researcher Inger Bergström examines the relationship between the body and the room, and develops a theory around the choreographic effect of movement opportunities (Bergström 1996, 72). Bergström highlights the differences in movement patterns in small versus large rooms. In a small room we can easily orient ourselves while walking and so traverse it with ease whereas in a larger room we will stop and gather sensory information in order to orient ourselves and achieve a sense of security before we move on. Movement through the dwelling therefore has a rhythm which is directly inf luenced by the size, light and shape of the rooms. What Bergström describes is a bodily or embodied relation to the size of the room that affects the movement. Movement also defines the architectural experience as a whole, something Elias Cornell, professor of Chalmers architecture in the 1960s and 70s, highlights. According to Cornell, the movement is a prerequisite for experiencing architectural space: In order to experience a building, we must stay in front of it and in it. . . . The building invites you to act, to come forward and take it into possession. . . . Our mind is tuned to expectation. We look forward to a continuation. (Cornell 1968, 67) Perception of architecture and space is connected to the ways we used to move through rooms during different historical eras formed by different architectural ideals (Edberg 1976). Such knowledge of architectural transformations is described by architect Bruno Zevi in his book Architecture as Space (1957, 98).

Identification of Movement, and the Circular Loop Movement, in terms of the circular loop, can be assessed using the following three categories: • • •

Small circular loop, often around a storage unit, kitchen bench or something similar. Large circular loop that includes connections between three or more larger rooms in the dwelling. Thoroughfare rooms. Structural circular loop, where the f loor plan structure as such is designed around a circular loop. Often around a core in the center of the f loor plan.

Small Circular Loop—First Example An example (figure 2.2) of the small circular loop is the possibility of moving around a kitchen unit, a set of cabinets or something similar. In the Alfa

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FIGURE 2.2

Floorplan of Block Alfa, Göteborg, by Kub Arkitekter, 2014.

FIGURE 2.3

Floorplan of Ekensberg, Stockholm, Bryde Arkitekt. 1983.

housing block in Göteborg, designed by Kub Arkitekter in 2014, there is such a small circular loop around a cabinet unit. It is a minor spatial feature and is not of great importance for the character of the f loor plan (Caldenby and Nylander 2019, 18).

Large Circular Loop—Second Example A large circular loop includes at least three of the major rooms of an apartment. The f loorplan of Ekensberg, built in 1983 in Stockholm (figure 2.3), has a large circular loop in which one of the bedrooms is accessed through another room.

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FIGURE 2.4

Floorplan of Filmstaden Solna, by Brunnberg & Forshed, 2004.

Two doors become a necessity in order to prevent activities in the kitchen and living room from interfering with the function of the bedroom. In this case the circular loop is the result of older Swedish building regulations in SBN 80 which mandated that at least one of the bedrooms to be reachable directly from the entrance, but which also recommended an additional bedroom to be reachable from two of the communal rooms: the kitchen and the living room.

Structural Circular Loop—Third Example A third type of circular movement is based on the structure of the apartment with movement through passages, halls and corridors around a core in the f loorplan—a circular loop which is an integral part of the spatial organization of the apartment. This loop is systematic and cannot be altered or questioned without making radical changes to the housing plan. In an apartment in Filmstaden Solna, designed by Brunnberg & Forshed Arkitekter in 2004 (figure 2.4), the hallway and passage leading up to the kitchen and living room create a roundabout stretching around a core of storage, washing area and bathroom. The private bedrooms, the private parts of the apartment, are accessed through this passage. The circular movement around the middle part is of central importance in this f loor plan (Nylander and Fänge 2007, 39).

Valuation and the Criteria List Movement, like the previously described Axiality, is an important property of a residential space. In the criteria list, the respective quality is graded in a simple scoring system and thereby used in many different ways. Movement is judged here according to the following:

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• • •

•

Small circular loop—the possibility of moving around a kitchen unit, a set of cabinets or something similar. This awards one point. Large circular loop—a loop which involves at least three of the larger rooms of the apartment. This awards two points. Structural circular loop—movement is based on the structure of the apartment and is built up through passages, halls and corridors around a core. This awards two points. Circular loop which includes a relationship between interior and exterior. This awards one point.

The Concept of Space and Geometry Space and geometry is the last out of three sub-categories which together make up the criteria list item spaciousness of the home. One quality in residential architecture is geometric clarity in the design of the different spaces of the apartment. The clarity of the room shape is created by contour and overall effect of the space. The design of the boundaries of a room through corners, thresholds, suspensions and displacements are all factors which affect the contour of the room. Bachelard describes the space in The Poetics of Space in the following way: Every corner in a house, every angle in a room, every inch of the individual space in which we usually hide or pull us back in ourselves, is a symbol. . . . The reason and creation for the room or the house. (Bachelard 1964, 122) The boundaries of a room can also be non-physical and defined by its relationships with other rooms or through directional contrast between two rooms. A small room situated between two larger ones can receive its spatial definition as a function of the relationship between the rooms. Sections of wall, thresholds, openings and ceiling height can clarify the design of a small space. Relevant to the discussion of the shape of space is architect Arne Branzell’s exploratory work in the licentiate paper Something about O, where Branzell develops a notation system for the boundaries and directions of architectural space (1995, 12). Branzell uses this notation system to describe the difference between physical space and the perceived, architectural, space. Physical space boundaries in the form of f loors, walls and ceilings envelop the architectural space, but through openings of various kinds, spaces can interact with other spaces, creating a divergence between the two. The architectural space can have a direction. With the help of space bubbles Branzell describes architectural space and its interaction with corners, thresholds, windows and doorways. Space bubbles can be described as a visual representation of architectural space projected upon a visual representation of the physical space (i.e., a f loor plan).

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Researcher Fredrik Wulz similarly identifies room boundaries in his analysis of urban spaces, where he explores the characteristics of the experienced room and the fields of spatial tension created when different spaces meet. Wulz describes the difference between the physical room we perceive with our eyes and the experienced, invisible, architectural room. It is the invisible volume of the air that is the room. . . . The visible form of a piece of design. The invisible is its value. Fredrik Wulz, The Façade & the City Room (1991, 45–49)

Identification of Openness and Enclosure in Floor Plan Examples Branzell, in his licentiate thesis, discusses the ability of the architect to analyze this type of phenomena using space bubbles. Figure 2.5 shows an apartment situated in Lindholmen, Göteborg, where the relative enclosure and openness of the respective rooms are shown using space bubbles. In the bay window, the apartment’s most open rooms, there is a collaboration between interior and exterior rooms. Overall character is created by the design of the wall sections; distinct corners and large sections of wall are important in the shaping of the room. Fixed interior elements such as wardrobes, kitchen cabinets and other similar components need to be a constituent part of the room’s design or otherwise risk the shape of the room being ruined by arbitrarily placed freestanding units. The interaction between different rooms within the larger whole is another quality. In the figure shown earler, the living room, kitchen, dining area and balcony all form a large room consisting of different parts—rooms within rooms. They have varying shapes and almost seamless borders between one another— on a functional level they are separate units, and appear as rooms due to the designed borders of architectural space that separate them. An example of this is the balcony indented into the large room where it constitutes a spatial

FIGURE 2.5 Floorplan of an apartment in Lindholmen, Göteborg, with Branzell’s space bubbles. White arkitekter, 1991.

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clarification of the border between living room and kitchen. The storage unit separating the passage from the kitchen, as well as the living room from the active part of the kitchen, has a similar delimiting function. The part of the large room where the different spaces interact has varying degrees of direct and indirect light as well as of interior-exterior connection.

Spatial Proportions The second assessment variable concerning the geometric shape of the room is its proportion. There exists a long tradition of theories, rules and analyses of proportions and what they mean for the experience of architectural space, with the golden ratio being one of the most prominent rules. Historically, proportions in the geometry of residential spaces has often been around 0.7 to 0.8. This width-length ratio can be found in traditional vernacular housing typologies, bourgeois apartments, modernism and Swedish housing architecture during the 1940s and 50s. The shape and area of traditional residential rooms were often determined by the materials and the technology locally available. The length of the tree trunk and possible spans were directly ref lected in the shape of built homes. The rooms in single and couple cottages usually had dimensions of around 4 × 4 meters, although significantly larger rooms were made possible by employing timbering techniques. The rooms of vernacular houses were spacious enough to function as either a kitchen, parlor or bedroom. Similar room sizes were used in the workers’ homes which started being constructed in many Swedish cities towards the end of the 19th century. This type of general-purpose room is also found in housing dating from the early decades of the 20th century (Nylander 2018a, 30). During the 1940s and 50s hygienic requirements were essentially guiding residential architecture regarding regulations of room sizes and housing quality. Diseases like tuberculosis had, only a couple of decades previously, been linked to poor homes where a lot of time was spent in dark and poorly ventilated rooms. Designing spacious bedrooms generously lit by sunlight was a way of promoting good hygiene in the new modern dwellings. The minimum requirement in the regulations and standards of 1942 were 10 m 2 bedrooms in small apartments. In apartments of three rooms plus a kitchen and larger, one of the rooms being 7 m 2 was accepted. Although proportions were not expanded upon in the regulations, prescribed minimum dimensions were closely related to Alberti’s recommendation on proportions of small and large rooms. The 12 m 2 room, with minimum dimensions to accommodate a double bed, has a spatial ratio of 0.6. The 10 m 2 room has a ratio of 0.62. The 7 m 2 room, 0.57. The living room of 20 m 2 and a minimum width 3.6 has a ratio of 0.64. These are measures that are close to the golden ratio of 0.62, or 5:8.

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Example of Space and Geometry in Floor Plans In the criteria list the shape of the room is reviewed by looking at the geometric clarity of the room’s contour, the boundaries of the room and the proportions of the room. It is architecturally advantageous if the contour of the room is clear. The contour consists of the room’s shape, its meeting with adjacent rooms, the highlights of the room in the form of corners and other similar things. The overall effect of the room’s wall sections is significant for the contour. It is likewise a qualitative advantage if the boundary of a room is clearly evident in relation to nearby rooms. These boundaries can be clarified by thresholds that mark the shape of the room, such as wall sections reaching from the ceiling to the top of the openings, and smaller sections of the wall creating corners marking where the rooms end. Window arches and mullions serve a similar function. Long internal communication corridors can instead be designed as sequences of small rooms. If these small spaces are separated by sections of wall and designed as three rooms, then the long corridor is transformed into a sequence of spaces. The relationship between rooms can also be defined by their directionality, allowing large open physical spaces to be defined as separate architectural spaces. In the meeting of two perpendicular rooms the boundaries between them is clarified by differences in directional space.

Valuation and the Criteria List Space and geometry, like the previously described axiality and movement, is an important property of a residential space. In the criteria list, the respective quality is graded in a simple scoring system, and thereby used in many different ways. The room and its geometrical form are judged here according to the following: • •

•

A f loor plan where over 75 percent of the rooms have undisturbed room contour. This awards one point. A f loor plan where smaller rooms such as entries, passages and corridors have been designed with physical or imaginary boundaries. This awards one point. A floor plan where over 75 percent of the rooms have proportions of 0.6 to 1. This awards one point. Here, passages, corridors and halls are not counted.

Discussion Although this chapter presentation of the research project is limited to describing just one out of the eight criteria on the list as a sample, it serves well to illustrate its potential.

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The criteria list is designed in a research project where a municipally owned housing company is the client. The company, in its role as a developer, wants to formulate a criteria list for quality which can be used as a basis for setting up requirements when planning and constructing new housing projects. This is a tool with which to ensure future apartments maintain high architectural quality from the user perspective. This list of criteria is a way to collaborate with the industry on architectural research. By compiling housing research into simple and effectively defined concepts and levels of quality, evidence-based research findings can be used as tools by housing company representatives in their communication with architects and other involved parties during the planning and design process. In parallel with working on the criteria list, the research group at CBA works on a research project for Boverket, the National Board of Housing, where the criteria are going to be digitalized. Hopefully, this will result in a digital tool capable of analyzing architectural qualities using a f loor plan, a tool similar in functionality to the way currently available software can be used to easily analyze, for example, sunlight values. The criteria list is delimited to housing architecture and is based on research concerning the home, the residents and their perception of what is good residential architecture and a good home. The construction of poor housing exacerbates problems of high costs, alienation, segregation, inequalities and poor health in the housing market. The criteria list promotes the residents, the community and the builders, and is a step towards a more sustainable housing construction crucial for wellbeing and improved long-term future health prospects. Through evidence-based research, a broader understanding of the relationship between architecture and health has emerged in recent years. Among other things, researchers have found that the shape of the hospital room, materials, color, daylight and not least a beautiful view affect patients’ health. Good architecture produces positive effects such as faster recovery and less medication. This is the background and the ambition of the criteria list. Housing with high quality architecture affects its residents in many positive ways.

References Bachelard, Gaston. 1964. The Poetics of Space. Boston: Beacon Press. Bergström, Inger. 1996. “Rummet och människans rörelse [Impact of Spatial Formations on Human Motion].” PhD diss., Chalmers Architecture, Chalmers University of Technology, Göteborg. Braide, Anna. 2019. “Dwelling in Time. Studies on Life Course Spatial Adaptability.” PhD diss., Dep of ACE, Building Design, Chalmers ACE, Göteborg. Branzell, Arne. 1995. Något om O. Göteborg: Chalmers. Caldenby, Claes and Ola Nylander. 2019. Rita bostäder. Stockholm: Media förlag. Cornell, Elias. 1968. Architectural History. Stockholm: Gebers förlag,

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Crona, Kajsa. 2019. “Glasade strukturer, ett forskningsprojekt för Boverket, CBA, Chalmers, 2019–2021.” Göteborg. Edberg, Gösta. 1976. Metoder för rumsanalyser. Stockholm: KTH. Granath, Kaj. 2018. “Kvalitetskriterier—bostadens arkitektur.” In The Good Housing, Report to the Minister for Housing and Finance, edited by Ola Nylander, 59–66. Göteborg: Chalmers ACE. Minoura, Eva. 2019. Bostadsgården, territoriell arkitektur. Lund: Studentlitteratur. Morichetto, Hanna. 2019. “Bostadens arkitektur och berikad miljö [Residential Architecture and Enriched Environments].” PhD diss., Building Design, Chalmers University of Technology ACE, Göteborg. Nylander, Ola. 1998. “Bostaden som arkitektur.” PhD diss., Chalmers University of Technology, Göteborg. Nylander, Ola. 2002. Architecture of the Home. London: Wileys. Nylander, Ola. 2018a. Svensk bostadsarkitektur. Lund: Studentlitteratur. Nylander, Ola. 2018b. The Good Housing, Report to the Minister for Housing and Finance. Göteborg: Chalmers ACE. Nylander, Ola and Kaj Granath. 2019. Förtätning på Främlingsvägen. Göteborg: Chalmers University. Nylander, Ola and Maria Fänge. 2007. Filmstaden—erfarenheter av ett bostadsprojekt. Stockholm: Svensk Byggtjänst. Nylander, Ola and Kjell Forshed. 2011. Bostadens omätbara värden. Stockholm: HSB. Olivegren, Johannes. 1975. “Klostermuren, ett litet samhälle föds.” Chalmers PhD diss., Göteborg. William-Olsson, Magnus. 1997. Obegränsningens ljus. Stockholm: Gideons förlag. Wulz, Fredrik. 1991. Fasaden och stadsrummet [The Façade & the City Room]. Stockholm: Arkus. Zevi, Bruno. 1957. Architecture as Space. New York: Horizon Press.

3 CAN RESIDENTIAL ARCHITECTURE CONSTITUTE A PART OF A HUMAN-ENRICHED ENVIRONMENT AND CONTRIBUTE TO RECOVERY, PREVENTION AND STRESS REDUCTION?1 Hanna Morichetto and Michael Nilsson

The physical environment and its importance to human health is a subject of growing interest, research, and knowledge. One way to understand what this link potentially could look like is to study the concept of the enriched environment (EE). EE has long served as a model for studying the diverse effects of the environment on mental health underpinned by changes to the structure and function of the brain (Sale, Berardi, and Maffei 2009). In animal models, the concept rests on three fundamental pillars: physical, cognitive, and social stimulation. Principally, EE is resting on multisensory stimulation through a combination of sensorimotor and/or cognitive stimulation and socialization. A nonenriched environment in different animal models can, on the contrary, be classified as either deprived or standard in their character (Nithianantharajah and Hannan 2006) and, therefore, EE should be viewed in relative terms. The scientific body of evidence from animal models is strong (Hebb 1947; Johansson and Ohlsson 1996; Kempermann and Gage 1999; Kempermann, Kuhn, and Gage 1997; Rozenzweig et al. 1962; van Praag, Kempermann, and Gage 2000). In an overview from 2007, Nilsson and Pekny note that the findings from various animal models point to EE as a powerful concept both in prevention and recovery from injuries and diseases of the central nervous system. In the intact central nervous system, EE also constitutes a useful concept which can be applied with the purpose of improving cognitive performance or, alternatively, to counteract the negative effects of various stressors (Nilsson and Pekny 2007).

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Research also demonstrates the importance of the different modalities of EE to interact. These stimuli exert their effects individually, but when acting together, the combined effect is even greater because they inf luence several complementary processes related to plasticity in the brain (Corbett, Nguemeni, and Gomez-Smith 2014). The concept has been tested in clinical settings and is regarded to be promising in healthcare and rehabilitation contexts, but despite the overwhelming evidence from animal models, there is still limited evidence for a defined, corresponding model for humans in clinical settings ( Janssen et al. 2018). Evidence for EE-based stimulating environments outside the health care sector is even sparser. However, there is now emerging interest related to the architecture and design of residential homes and workplaces being health promoting or restorative (Prochorskaitė and Malienė 2013; Burzynska and Malinin 2017; Cassarino and Setti 2016). In order to translate existing knowledge of EE into clinical strategies and programs, an array of related factors of importance for rehabilitation outcome need to be studied more closely, for example, motivation, joyful activities, sense of coherence, and social structures and their impacts (Nilsson and Pekny 2007). In a bio-psycho-social context, these aspects would tentatively become enhancing co-factors which would work in synergy with the multimodal components of EE to exert its preventive and restorative effects. The EE concept provides interesting inroads to different health promoting aspects of the home and the built environment in general: in what ways can architecture contribute to motivation, security, and stress reduction? A recently conducted review (Morichetto 2019) of architecture and EE summarizes current scientific literature with a goal of further understanding how relevant publications are presented within the field and highlight existing knowledge gaps. From this work, it is obvious that comprehensive studies on the understanding of EE translated to human settings is, in general, largely missing. The literature review further demonstrates that studies specifically aimed at understanding the potential health promoting role of the physical environment in the sense of general housing is more or less nonexistent. Within the existing literature, there is also a lack of clarity of the conceptual approach, reported outcome measures vary, and the contexts of the studies are divergent. Furthermore, the relative importance of the different attributes of the physical environment has not been defined. Thus, it is currently impossible to draw any conclusions with respect to any potential links between the physical environment and EE. The what, why, when, and how questions of how various factors interact will be critical for further research. A clear definition of the concept in relation to the physical environment will no doubt be required. Despite the fact that clear and scientifically evaluated examples of how residential architecture can provide an EE are lacking, the literature reveals a number of essential factors for how the physical environment—often in a healthcare context—can have an impact on health from different perspectives. For example,

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these studies focus on access to and views of nature, good lighting, daylight, good acoustics, orientation and overview, the sense of control, the ability to regulate social interaction, and opportunities for recovery and stimulation.

Change and Stability: On Challenging the Brain Some important aspects of EE include that it is dynamic, has a degree of complexity, and offers chances to discover change and novelty. If an EE stops changing and varying, it ceases to be enriching. However, at the same time, enrichment is about providing a measured amount of change, and finding a balance between two extremes. An environment can be experienced as secure, stressful, comfortable, and developing—all at the same time. In this context, there is an interesting link to the so-called salutogenic perspective and to the understanding of a certain kind of stress as a positive factor in different contexts (Antonovsky 1979). There are also tentative links to the theories introduced by Evans and McCoy (1998) regarding stimulation, control, and restoration, and how the eight perceived sensory dimensions (Grahn and Stigsdotter 2010) are partly renamed and grouped in oppositional pairs according to Stoltz (2020). The boundaries are resting on individual choices, and Burzynska and Malinin (2017) note that one can offer several overlapping layers of enrichment that can be utilized depending on capacity and motivation. The above reasoning is also in line with theories about experience dependent plasticity (Alwis and Rajan 2014; Janssen et al. 2018) which provide plausible, important explanations for why EE has positive effects. Experience-dependent plasticity is rooted in the idea that EE, at a behavioral and cognitive level, provides repetitive exposure to mild sources of stress. By developing a positive and adapted response to these stressors, various coping strategies can be developed and resilience can be built, preparing the body for future stress events.

What Can Transform Residential Architecture Into an Enriched Environment? Architecture can contribute to EE on various levels. It can provide purely experiential stimulation to varying degrees and in different ways. The design of the built environment can provide the conditions for social interaction, but design can also allow people to determine the amount of social interaction they engage in through individual choice. Through its design, the built environment can encourage physical activity and stimulate people, for example, to go outside. Although enrichment rests on three fundamental aspects through the physical, cognitive, and social stimulation, there are no clear boundaries between them. On the contrary, they interact in an interesting way, for example, through motivation. Here architecture can play an essential role through various aspects and scales of the built environment providing opportunities and inspiration.

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Research also indicates that the social component of EE is of primary importance and precedes the other two. In other words, social stimulation can be a precondition that allows people to be motivated to want to and be able to take advantage of other stimuli.

Generalizability and Preference But is there at all possible to think of general aspects of the built environment that would have the potential to create an EE? How does it relate to personal preference and needs? A certain degree of generalizability can probably be acknowledged, with an additional layer of inf luence from personal preference, personality, prior experiences, and what is perceived as motivating (Janssen et al. 2018). Opportunities for activity, stimulation, positive distraction, control over one’s closest surrounding environment, and opportunity for social stimulation are generally positive within a clinical context ( Janssen et al. 2018). The eight perceived sensory dimensions (Grahn and Stigsdotter 2010), with examples such as spaciousness and security (Bengtsson and Skärbäck 2018a, 2018b), also exemplify the generalizable aspects of the physical environment.

Concepts for an Enriched Environment in Residential Architecture In a recently defended thesis, Morichetto (2019) develops three categories of studiable concepts providing an enriching experience of the home. The concepts describe various aspects of residential architectural qualities that preferably contribute to cognitive stimulation. Three main categories are identified: spatial extension, movement, and materials and detailing. The theoretical and empirical underpinnings for the concepts are drawn from several scientific fields, and a variety of methodological approaches are used.

Spatial Extension The first category of concepts addresses the importance of spatial extension. The configuration of views of the outside, views through the home, and axes provided is important to the experience of the home. Different aspects of spatial extension can be important to various experiences in the home. These include the perception of spaciousness, the feeling of protection, and the way the physical environment can create conditions for stress reduction or opportunities for stress management. The environment can create positive distraction, offer varying degrees of stimulation, and foster a sense of control. Views in multiple directions, the horizontal and vertical extension of those views, and views through interior and exterior spaces can create a feeling of

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FIGURE 3.1 Concepts

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spaciousness. Contrast and variation in the character and expansion of the views can provide stimulation and a complexity of experience, but also a feeling of spaciousness. The impression (of spaciousness) also depends on the opportunity to look out to the world outside, and is enhanced if one can look out in multiple directions from a single place inside the home. The design of the interface between the home and its surroundings, and the link between that interface and the interior rooms of the home, create the conditions for a feeling of contact, security, and control. The experience of spaciousness and access to views can be described as a quality of the environment. However, an important condition for it being a quality is that residents must be able to determine the degree of seclusion and protection themselves. A home needs all kinds of views, including “nooks” in which one can feel protected watching over things in different directions from a protected position (Morichetto 2019). Alongside their importance for the perception of spaciousness, views and their configuration are also important in reducing stress by providing positive distraction through views of nature and exposure to daylight (Ulrich et al. 2018).

FIGURE 3.2 Diverging views. Some examples of views in diverging directions from the same spot. Brf Rosendahl, drawing by KUB arkitekter, 2018, analysis by Morichetto.

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Converging views. Some examples of views from many different spots towards one spot. Brf Rosendahl, drawing by KUB arkitekter, 2018, analysis by Morichetto.

FIGURE 3.3

Diverging and Converging Views Two concepts put forward in the spatial extension category are diverging and converging views. The assumption is that a variation of experience generated by different views that diverge and converge is of importance. Analyzing these views can be a useful tool in understanding qualities of an apartment layout as they create a plethora of experiences.

Variation and Events Variation and events represent two other concepts within the category of spatial extension. In the studies conducted (Morichetto 2019), it emerges that variation in sight lines is particularly important in a small home. Stimulation, which is closely related to events, can be about complexity and mystery, and corresponds to the degree of variation, diversity, and to the fact that not everything is visible at first glance (Evans and McCoy 1998). A certain degree of exploration to gather information about the room is also important for the experience (1998).

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Horizontal and Vertical The experience of spaciousness can be achieved in a variety of ways. Of particular importance are the direction as well as the horizontal and vertical extension of the views. Also important is how contrast in both the views and their extension create a sense of spaciousness. Furthermore, the importance of contrasting spatial relationships for an experience of spaciousness emerges in the studies (Morichetto 2019), although not primarily in relation to views, but rather in terms of size of rooms, their height, depth, and spatial relations.

Interface How the interior of the home meets the exterior—how the interface between the two is designed and how it is integrated into the rest of the home—is essential to the residents’ experience. Through a conscious design, an experience of a space both closely integrated with the home inside, simultaneously establishing contact and belonging with the surrounding world, can be created. In the studies (Morichetto 2019), this is illustrated through a residential design where a secure and private “border space” is created by integrating the space within the home and its surroundings, simultaneously creating spaces enabling a sense of control. Angling of facades, spatial integration between the inside and the outside, clear boundaries, and the creation of spatial depth in the “border space” all exemplify measures taken for experiencing different degrees of privacy. Of importance is also how views and movement opportunities are created and support the residents’ ability to take shelter in privacy while watching over their surroundings.

Movement The second category of concepts addresses the importance of movement and how circulation through the home is configured. A movement that can be varied has an impact on both perception and practical function. A home that offers opportunities for complexity in movement can be perceived as exciting and stimulating. Variation and contrast can be created through variations in circulation loops—by offering different sized loops or by varying the character of the spaces through which those loops pass. Variation can also be created through changes in the direction of movements. The opportunity to make loops through rooms can be particularly important for creating a perception of spaciousness (Caldenby 2019). The importance of movement is also pointed out by Burzynska and Malinin (2017), who assert that whether an environment can offer complex circulation patterns is an important aspect of EE. Rhythm is another important aspect of movement and can create a stimulating experience. The movement between the home and its surroundings—the

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passage—is yet another important element of movement in the home. Providing many connections between the home and the outside world creates a feeling of freedom as well as a sense of spaciousness. Making contact with the outside accessible and visible can also provide a reminder and encouragement for residents to go out.

Variation and Rhythm Possible movement patterns in a home can be more or less complex and provide different degrees of variation and rhythm. Complexity of circulation patterns can be achieved not only through a variation of directions of movement, the size of circulation loops, and the cores around which they revolve but also through how circulation paths are located at varying distances from the exterior wall or if there are many different paths available. All this will have an effect on the experience as well as practical functions of the home.

Passage The way circulation patterns create connections to the home’s interface and passage to the outside world is also important for the experience of the home. In the studies (Morichetto 2019) it becomes clear that this is not just a matter of views of the outside but also access to doors and how multiple connections to the outside from different rooms create a sense of freedom. The studies also point out that access to several exits from the building has the potential to enlarge the home. That depends not only on the movement itself but also on the awareness of the opportunity and the sight of an open door with the f loor continuing towards the outside. The result is an extension of the space into the exterior. Access to views and opportunities for movement can also be a reminder for residents to go out: the exterior is more likely to be used if it is visible and accessible (Van Hecke, Van Steenwinkel, and Heylighen 2019).

Materials and Detailing Materials and detailing constitute a third category of aspects that are important to the experience of the home. In the studies conducted (Morichetto 2019), two fundamentally different ways to regard materials, their joining, and their detailing are defined. Materials can either make an impact on the purely concrete plane by directly stimulating the physical senses and visual impressions or through association and indirect, abstract mechanisms. Various principles for how materials and detailing can have an effect are defined: touching, in both concrete and abstract ways and association.

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The abstract touch is about the fact that when we observe touching (even between inanimate objects), the same parts of our brains are activated as when we are ourselves touched, which could tentatively make for interesting links to architecture in relation to sensory stimulation (Ebisch et al. 2008; Mallgrave 2018). This gives an indication that the configuration, joints, and detailing of materials is of great importance to our experience of architecture (Mallgrave 2018). Consequently, not only does the tactile experience of material provide sensory stimulation, but the mere sight of a meeting of materials can also convey a sense of touch. The choice of materials and the feeling it can convey, or the way materials are detailed and joined together, thus becomes important. Association addresses how we can be positively impacted by materials or when they connect us with meaningful aspects of, for example, nature. It may happen through, for example, fractals, complexity, and variation (Bengtsson and Skärbäck 2018a, 2018b). A central concept that also emerges in the conducted studies is care. Care can be seen in the selection of materials, the execution of the construction, and the way different materials come together and details are designed. But can also be seen in how different materials, surfaces, and even forms work together through various sensory impressions to create a total experience. The fact that details are executed in a way that demands a higher level of precision and gives a certain impression is put forward in one of the studies as a sign of care. But materials can also convey a certain type of care because of their close proximity to the body. They can create a feeling, convey a message, and work together with spatial character and the other sensory impressions made by an environment.

Future Research The formulated concepts all describe potential aspects of residential architecture as it can provide multisensory stimulation. Further studies will elucidate to what extent these aspects can affects residents’ experiences and also how these aspects group together. Future studies will be carried out using a multidisciplinary approach where both qualitative and quantitative methods focusing on factors such as stress reduction, control, and motivation are used.

Concluding Remarks Globally, health care systems are challenged by increasing demand, an aging population with a growing incidence of chronic and complex conditions, and higher expectations by consumers. Meeting this challenge will require envisioning the potential value of home-based health care, creating pathways for health promotion and home-based care including rehabilitation to maximize its potential, and integrating it fully into the health care systems. We propose that architecture and design are critically important components in an emerging holistic health care concept where the home is set to be a new epicenter for personalized care.

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Note 1. This chapter is largely based on a recently published PhD thesis (Morichetto 2019) and the proposed concepts for an enriched environment in residential architecture build upon the analyses conducted within that research.

References Alwis, D. S., and R. Rajan. 2014. “Environmental Enrichment and the Sensory Brain: The Role of Enrichment in Remediating Brain Injury.” Frontiers in Systems Neuroscience 8 (156). https://doi.org/10.3389/fnsys.2014.00156. www.frontiersin.org/ article/10.3389/fnsys.2014.00156. Antonovsky, A. 1979. Health, Stress, and Coping. 1st ed. San Francisco: Jossey-Bass. Bengtsson, A., and E. Skärbäck. 2018a. Avstämning inom Vinnova-projektet kring restorativa arbetsplatser. Alnarp: Movium. ———. 2018b. Projektparter i restorativa arbetsplatser samlades till workshop. Alnarp: Movium. Burzynska, A., and L. Malinin. 2017. “Enriched Environments for Healthy Aging: Qualities of Seniors Housing Designs Promoting Brain and Cognitive Health.” Seniors Housing & Care Journal 25 (1): 15–37. Caldenby, C. 2019. “En bostadsritarkultur.” In Rita bostäder, edited by C. Caldenby and O. Nylander, 171–204. Stockholm: Arkitektur Media. Cassarino, M., and A. Setti. 2016. “Complexity As Key to Designing CognitiveFriendly Environments for Older People.” Frontiers in Psychology 7 (1329): 1–12. www.frontiersin.org/article/10.3389/fpsyg.2016.01329. Corbett, D., C. Nguemeni, and M. Gomez-Smith. 2014. “How Can You Mend a Broken Brain?—Neurorestorative Approaches to Stroke Recovery.” Cerebrovascular Diseases 38 (4): 233–239. https://doi.org/10.1159/000368887. www.karger.com/ DOI/10.1159/000368887. Ebisch, S. J. H., M. G. Perrucci, A. Ferretti, C. Del Gratta, G. Luca Romani, and V. Gallese. 2008. “The Sense of Touch: Embodied Simulation in a Visuotactile Mirroring Mechanism for Observed Animate or Inanimate Touch.” Journal of Cognitive Neuroscience 20 (9): 1611–1623. Evans, G. W., and J. M. McCoy. 1998. “When Buildings Don’t Work: The Role of Architecture in Human Health.” Journal of Experimental Psychology 18: 85–94. Grahn, P., and K. S. Stigsdotter. 2010. “The Relation Between Perceived Sensory Dimensions of Urban Green Space and Stress Restoration.” Landscape and Urban Planning 94: 264–275. Hebb, D. O. 1947. “The Effects of Early Experience on Problem Solving at Maturity.” The American Psychologist 2: 306–307. Janssen, H., J. Bernhardt, F. R. Walker, N. J. Spratt, M. Pollack, A. Hannan, and M. Nilsson. 2018. “Environmental Enrichment: Neurophysiological Responses and Consequences for Health.” In Oxford Textbook of Nature and Public Health: The Role of Nature in Improving the Health of a Population, 71–78. New York: Oxford University Press. Johansson, B. B., and A. L. Ohlsson. 1996. “Environment, Social Interaction, and Physical Activity as Determinants of Functional Outcome after Cerebral Infarction in the Rat.” Experimental Neurology 139 (2): 322–327. https://doi.org/10.1006/exnr.1996.0106. Kempermann, G., and F. H. Gage. 1999. “Experience-dependent Regulation of Adult Hippocampal Neurogenesis: Effects of Long-term Stimulation and

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Stimulus Withdrawal.”Hippocampus 9 (3): 321–332.https://doi.org/10.1002/(sici)10981063(1999)9:33.0.co;2-c. Kempermann, G., H. G. Kuhn, and F. H. Gage. 1997. “More Hippocampal Neurons in Adult Mice Living in an Enriched Environment.” Nature 386 (6624): 493–495. https://doi.org/10.1038/386493a0. Mallgrave, H. F. 2018. From Object to Experience, The New Culture of Architectural Design. London: Bloomsbury Visual Arts. Morichetto, H. 2019. “Bostadens arkitektur och berikad miljö.” Doktorsavhandling, Institutionen för Arkitektur och Samhällsbyggnadsteknik Chalmers tekniska högskola. PhD diss., Chalmers University of Technology. Nilsson, M., and M. Pekny. 2007. “Enriched Environment and Astrocytes in Central Nervous System Regeneration.” Journal of Rehabilitation Medicine 39 (5): 345–352. https://doi.org/10.2340/16501977-0084. www.ingentaconnect.com/content/mjl/ sreh/2007/00000039/00000005/art00001. Nithianantharajah, J., and A. J. Hannan. 2006. “Enriched Environments, Experiencedependent Plasticity and Disorders of the Nervous System.” Nature Reviews Neuroscience 7 (9): 697–709. https://doi.org/10.1038/nrn1970. Prochorskaitė, A., and V. Malienė. 2013. “Health, Well-being and Sustainable Housing.” International Journal of Strategic Property Management 17 (1): 44–57. Rozenzweig, M. R., D. Krech, E. L. Bennett, and M. C. Diamond. 1962. “Effects of Environmental Complexity and Training on Brain Chemistry and Anatomy: A Replication and Extension.” Journal of Comparative and Physiological Psychology 55: 429–437. Sale, A., N. Berardi, and L. Maffei. 2009. “Enrich the Environment to Empower the Brain.” Trends in Neuroscience 32 (4): 233–239. https://doi.org/10.1016/j.tins.2008.12.004. Stoltz, J. 2020. “Perceived Sensory Dimensions: A Human-Centred Approach to Environmental Planning and Design.” Doktorsavhandling, Institutionen för naturgeografi, PhD diss., Stockholm University. Ulrich, R. S., L. Bogren, S. K. Gardiner, and S. Lundin. 2018. “Psychiatric Ward Design can Reduce Aggressive Behavior.” Journal of Environmental Psychology 57: 53–66. https://doi. org/10.1016/j.jenvp.2018.05.002. www.scopus.com/inward/record.uri?eid=2-s2.0-85 053150288&doi=10.1016%2fj.jenvp.2018.05.002&partnerID=40&md5=e295435195f 354d7529dfcd27d82d917. Van Hecke, Liesl, Iris Van Steenwinkel, and Ann Heylighen. 2019. “How Enclosure and Spatial Organization Affect Residents’ Use and Experience of a Dementia Special Care Unit: A Case Study.” HERD: Health Environments Research & Design Journal 12 (1): 145–159. https://doi.org/10.1177/1937586718796614. https://journals.sage pub.com/doi/abs/10.1177/1937586718796614. van Praag, H., G. Kempermann, and F. H. Gage. 2000. “Neural Consequences of Environmental Enrichment.” Nature Reviews Neuroscience 1 (3): 191–198. https://doi. org/10.1038/35044558.

4 ADAPTABILITY OF APARTMENTS—A BOTTOM UP CONCERN Two Narratives of Life Course Spatial Adaptability Anna Braide Adaptable Apartment Space and Demographic Transformations The ongoing demographic transformations result in significant changes in population structure and imply an increased societal complexity (Dyson 2010, 217–220). At the same time, these transformations are difficult to forecast, and the future demographic conditions can be seen as unclear or even as unknown (Schneider and Till 2007, 37–38). Adaptable apartment space is, in this context, emphasized as a design strategy that can increase the apartment’s spatial capacity for diverse uses. This quality is regarded as essential as it contributes to dwellings that can better counter future unknown demographic conditions, and in the long run this will also contribute to a more sustainable housing stock (Schneider and Till 2007, 37–38). The relevance of the apartment’s spatial capacity to counter the household’s changed spatial needs is ref lected in the following presentation of two narratives of dwelling situations derived from recent research on adaptable apartment space related to social qualities (Braide 2019). Focus for the research is set on a Swedish housing context with apartments in multi-family residential buildings. The Swedish housing authorities foster the belief that for the housing stock to remain sustainable in the long term it needs to build upon knowledge of future demographic conditions. They describe housing as an important asset and a precondition for people’s lives, making housing production a central societal issue, and making the longevity of the housing stock and the geographical immobility of housing a challenge (Boverket 2016). To address the question of sustainability of the housing stock, Swedish municipalities today make projections of

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changing demographics to make it easier to plan for the forms of housing that are the most urgent to be built (Boverket 2018). At the same time, they admit that these projections can be difficult to forecast because they depend on many conditions that change over time (Boverket 2016, 8). In this context, there is unfortunately no ref lection with concerns for the need of a dwelling design that sets focus more on increased spatial capacity of dwellings to host different household types or needs, as current dwelling design have other priorities.

Corner Stones for Current Dwelling Design The current dwelling design in Sweden has been developed as part of the modern movement in the 1930s, and it still relates to some of the corner stones from this design tradition. The first part of the 20th century in Sweden was marked by severe housing conditions (Nylander 2013, 65). To confront the crisis, the modernistic design movement focus was on affordable, small and qualitative dwellings. Adaptable apartments were also forwarded as one of the strategies to achieve this goal, but eventually this track was lost, and other qualities became guiding principles. The small efficient dwelling space organized as rooms with specific functions became a strong tendency for dwelling design. In the book Acceptera, a Swedish modern architecture manifesto published in 1931, the ideal configuration of the home was described as the smallest possible area divided into rooms for different functions: eating, social gathering and sleeping (Asplund 1980). These three functions were identified as the basic features of modern housing construction (Asplund 1980, 59). As dwelling design developed, the focus came to be set on function defined rooms assembled into static room configurations. Ref lecting upon the directives for some of the currently applied housing norms, it is clear that today’s apartment design is still profoundly indebted to early modernism’s understanding of housing design and its conception of how space is used in the home (Boverket 2015). From this perspective contemporary dwelling design does not deal with the question of a sustainable housing stock, as it does not fully recognize the need for dwellings to increase spatial capacity to host different household types or dwelling needs. The norms we have today are based on the apartment as a spatial structure of rooms with specified functions for sleeping, eating, hygiene and social gatherings (Boverket 2015, 37–66; Swedish Standards Institute 2006a; Swedish Standards Institute 2006b). The apartment’s fixed size and the conception of rooms as static entities mean that apartment f loor plans are tailored to fit fairly specific housing needs. Focus is also on a preconceived conventional family configuration even though this is not outspoken. The norms result in dwellings with the parent’s bedroom (with space for two twin beds) and the children’s bedroom(s) (with space for one twin bed each). Certain qualities are gained by relying on this preconceived design standard, but the labelled, functionally dimensioned rooms also exclude some other uses of the spaces and might inhibit residents’ ability to arrange their

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homes as they see fit or to change the room labels, since the living room, bedrooms and kitchen are all carefully dimensioned for specific uses. The reliance on a preconceived family configuration can also be seen as limiting the apartment’s spatial capacity to support diverse household types. There is also one more factor setting the model for the current dwelling design. As a household’s spatial needs change over time, expanding or contracting, there is an expectation that the household will relocate. The idea that households respond to changes in their housing needs generated by life course changes by moving is widely accepted today (Coulter and van Ham 2013; Clark and Huang 2003; McHugh 1984; McLeod and Ellis 1982; Rossi 1955), but other research also shows that the issue of mobility is more complex. The “mobility with changed spatial needs” concept can also be seen as limiting the spatial use in the home for the household, and the idea of how the household relates to the home space can be seen as an oversimplified understanding of the household’s living process and spatial use in the home.

The Household’s Living Process—Understanding Spatial Use and Social Dimensions What then are the reasons for staying and not moving? For the household, social qualities in the dwelling situation can be a pretense for not seeing relocation as a solution to meet changed spatial needs. Social factors are found to exert an important inf luence on decisions to move or not move (Lundholm et al. 2004, 59). Life course changes and related social dimensions are identified as inf luencing factors in this context. Settled people (people who stay a long time in the same apartment) are found to be more strongly committed to their jobs, household members and established social networks, while the lack of such commitments makes mobility more feasible at a younger age (Fischer and Malmberg 2001, 358, 368). Having children, owning a house, being married and being employed are conditions that constrain mobility. This means that the distribution of such commitments over periods of working, family life, home ownership and so on strongly affects the distribution of residential mobility over different life courses (Fischer and Malmberg 2001, 368). Other research findings also point in this direction (Braide 2019; Braide and Eriksson 2016). For households with children, social dimensions linked to everyday life in the neighborhood as well as continuity in schools were relevant factors for the decision to stay and not to move to another area. Altogether the factors involved in the issue of household mobility are various and complex. When a household’s life course conditions changes, one response is certainly to move to a different apartment. But the decision to stay and solve the changed spatial need in place is an important alternative. This relation between the family life course of households, the changed spatial needs and the wish to preserve social qualities constitutes a better understanding of dwelling space from a living process perspective.

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The Household’s Living Process and the Use of Adaptable Space—A Study The situation in which the household chooses to stay to attain continuity with experienced life qualities has been studied in my research. The study is a qualitative empirical study of households’ living processes in the home, consists of interviews with ten households and is supported by furnished projections of apartment f loor plans. The inquiry includes realized examples of apartments with adaptable design solutions as a way to understand the relevance of adaptable apartment space and how it can provide qualitative homes. The selected apartments are from three multi-family residential buildings with different adaptable design solutions. The concept of the adaptable apartment is understood as an apartment that can expand and contract following the household’s changing spatial needs and have a spatial capacity to host diverse household types and dwelling situations over time. Thus, in the study, adaptability is understood in light of the common condition of expanding and contracting household size, with the sequence of periods in life during which there are children living in the home, growing up and eventually moving out. This time span is referred to as the family life course, and involves the process of the household’s expanding and contracting. The aim for the study has been to understand the relevance of adaptable apartment space in living process situations within an extended time frame, and also to understand in what way adaptable apartment solutions can provide qualitative adaptable space as well as how this correlates to social aspects of the close immediate neighborhood area. The study takes on both a theoretical and a designdirected approach, building upon the three adaptable space design strategies of generality, flexibility and elasticity applied as design concepts. Two narratives from this study are presented next.

Two Narratives of Spatial Use in the Home The narratives presented are from the same multi-family residential building, Landshövdingehuset. This is a multi-family residential development from 1931, located in central Gothenburg, consisting of a number of perimeter-block buildings surrounding two courtyards. The housing was developed by HSB, a tenant-owned, cooperative national housing organization, and designed by the locally distinguished architect Erik Friberger. Together the apartments form a condominium. The buildings in the complex are a local Gothenburg building type known as landshövdingehus that was common in the early 20th century. Typical for these buildings, it is three stories high, with the ground story built of brick as a fire precaution strategy. These types of multi-family buildings originally housed working-class households in small apartments, often in crowded conditions

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( Nylander 2013, 59–60). The apartments have rooms with general space quality (a room with the size of approximately 3.6 to 4 meters), which can be used as multipurpose rooms. It is common today that small households live in landshövdingehus, and occasionally the apartments are also merged to form larger apartments. The units in this complex were originally studio and one-bedroom apartments of 30–35 m 2 and 40–44 m 2 respectively, but the apartment sizes have changed over the years (Ingrid Bexell Hultén, personal communication, March 28, 2019). The apartments in this complex demonstrate rare examples of how adaptability can allow residents to reorganize the space of their homes. The genesis for this adaptability strategy in the complex started with the matter of the apartment sizes. The small size of the original apartments was leading to considerable turnover as households sought larger units with more space. This meant that growing families moved out, which resulted in poor continuity among the residents. To change this the condominium board decided to keep an open attitude toward refurbishment aimed at expanding the small apartments. Today this strategy has meant that many of the households have expanded and stayed many years in their apartments, thereby increasing the continuity in the buildings. This is seen as a quality by most of the households: Interviewer: How do you see the issue of housing over time if you compare the way you live here with a standard housing situation that doesn’t allow you make these kinds of changes? Do you think that would have worked just as well? Frida, 52: No, it wouldn’t have been as good. We didn’t know that when we moved in, that this place with these apartments, usually with wooden walls, that it’s pretty easy to modify. And there’s a permissive board in the condo association—that’s definitely been one of the reasons. I have to admit, it’s been fantastic. The constant ongoing process of adapting apartment space means that apartments are continually being altered to become larger and smaller. The apartments are expanding or contracting, combining both vertically and horizontally with adjacent apartment space. The process is handled through negotiation among the neighbors in the condominium. Some households do the refurbishment themselves, while others hire contractors. The strategy to let the households govern their own dwelling space is perceived by the residents I spoke with as an important quality. However, it is essential to note that this type of renovation and expansion can be exercised because these are owner-occupied condominium units; it is not likely to take place in rental apartments. Still, the example stretches the boundaries

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of what adaptable space can be. One of the residents, Mia, talks about the homeowner situation. Mia is 49 and rents out apartment space to afford the life of an artist: Now I can afford to keep [my studio] because I can rent out [part of the apartment]. It’s generous to be able to do that. . . . It’s almost like they allow us to be kind of like homeowners here in the association, I think. That creates almost the feeling that I have a house where I can kind of do as I like. . . . But most of all it’s the continuity. When you create that kind of f lexibility, you know it means you can keep living there longer because I have the freedom to kind of do whatever I want. And that means I can maintain that contact with all the friends I’ve made since I moved here in ’91. And then for [the child], too, so there’s stability because his parents aren’t moving around so much. The f loor plan example presented above shows two apartments of 35 m 2 each on either side of a stairwell where the rooms have a general layout solution (Figure 4.1). The rooms in this type of apartment were originally used for multiple purposes due to the lack of living space. When a family of four or five lived in a studio or one-bedroom apartment, all the rooms served as bedrooms at night and for social gathering and daily chores during the day (Nylander

Landshövdingehuset, example of apartment f loor plan showing two apartments. The apartments are merged hall to hall (arrow), but also room to room. The rooms in the apartments have the general space quality of multipurpose rooms.

FIGURE 4.1

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2013, 40). The rooms in the apartment are organized around a neutral space, the hallway, with the entrance to the unit. The original apartment layouts offered generality but no other intended adaptability. In recent years, however, residents have been expanding and contracting the size of their apartments through a strategy of elasticity. This kind of spatial adaptation presupposes that the building is constructed with framing and finishing materials that make it fairly easy to merge units, and also that the configuration of rooms allows for qualitative room sequences after the merger. The elastic adaptation also depends upon mutual agreement between neighbors, which can be a difficult challenge to meet.

Narrative 1 The household has chosen to stay in place and adapt their home as their spatial needs have changed in order to benefit from the social qualities conferred by the neighborhood. They moved to the apartment when the children were small, and since that time the parents have divorced, and two of the three children have moved away from home. The parents share joint custody of the children, and today the household consists of one parent and one teenager every other week. The diagram below illustrates the changing use of space in the apartment over time (Figure 4.2). This household has addressed its changing needs by expanding when the family was growing, incorporating space from adjacent apartments, and contracting when divorce decreased its spatial demands. The example shows a living process that spans 27 years in which the household finds its own adaptable solutions to its spatial needs during the expanding and contracting sequence of family life. The original layout of the floor plan for the apartments, with its central corridors and the generality of the rooms allowing diverse uses, provides a good base for the changes in the apartment configurations. On this foundation the households have developed a model for how to expand and contract the space of the home, making it elastic, even though this was not in any way the originally intended spatial use. From my interviews with residents, I can understand the adaptable-space culture as a type of dwelling culture, a project that empowers the residents. This project means residents share their ideas of expected spatial qualities with one another, and home renovation becomes a popular topic among neighbors in the block as different ideas are realized, discussed and evaluated. From this perspective, adaptability can be seen as a do-it-yourself residents’ project, a permissive laboratory for spatial use in which the households can find their own ways of adapting the space of the home. The self-governance of the home space provides a control over the living situation and the future dwelling plans, a kind of social safety control.

FIGURE 4.2 Present household: Single parent, 60 years old, and teenager, 17 years old (every other week). Apartment: varies in size through the years. Time in the apartment: 27 years.

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Narrative 2 The second narrative from Landshövdingehuset offers a rare example of a household occupied by an 83 year old woman who has lived there her entire life. She grew up in the apartment with her parents and her sister, and later also lived there with her own family and her mother. After some time she divorced, and when the child became a teenager and moved away from home, she lived with her mother in the apartment. Today she lives alone. During this living process, the household has solved its spatial needs entirely within the original footprint of a one-bedroom apartment. The spatial diagram below (Figure 4.3) portrays the apartment as an unchanged space through all the years despite spatial needs that have been acute in years when the family was at the most expanded state. This example reveals a totally different approach to spatial use than the previous one. It shows a process of using the space in the home over the course of 83 years in which the household addresses its spatial needs during the expanding and contracting sequence of family life entirely within the original apartment footprint. The layout of the f loor plan features general rooms that have been used as both bedrooms and living rooms, for social life during the day and for sleep at night. The living situation has at many times been crowded, but it appears to have been a natural situation for this woman. Her attitude toward spatial use ref lects the way we used to live in Sweden before the rapid rise in housing standards. Jane, the resident, cannot see the benefits of the dwelling culture that dominates attitudes in the block today, with expanding and contracting apartment space; she finds this a strange way to use space. She appears to be convinced that to refurbish and expand or contract the apartment space is “not the right thing to do.”

Staying and Adapting Space—A Bottom-Up Dwelling Reality The two narratives show the households’ need to adapt dwelling space due to spatial needs occurring over time in the home, but they also show the households’ incentive to solve the situation. The first narrative shows that staying in the apartment and adapting the space of the home to emerging spatial needs is a priority for the household due to the social benefits of staying in the same neighborhood, even when this means a crowded situation. The driving force for these spatial adaptations tends to be the desire to give each child his or her own room. In response to this desire, apartment space is adapted without regard to the original design’s intended spatial use. The households use the space available in the apartment however they can to adapt to their changing spatial needs. In practice this means that both

FIGURE 4.3

Present household: Elderly woman, 83 years old. Apartment: 44 m 2 . Time in the apartment: 83 years.

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adaptable design solutions (general space quality) and do-it-yourself solutions (merging adjacent apartment space) are employed to address the situation when the spatial needs change over a household’s life course. But the social benefits to stay in the neighborhood are not the only social qualities discovered in the example. The enabling of adapting space spurs the residents’ empowerment and contributes to the development of a dwelling culture and a strong dwelling community. The second narrative shows an example of how dwelling space was used in earlier times. The household did not have many options to solve their dwelling situation due to financial reasons. The apartment was considered a qualitative living space at that time, the best solution possible for their financial situation. Also, to live in a crowded situation was, at this time, a common experience. The general space in the apartment has functioned as bedrooms at night and for social gathering and daily chores during the day and yet other needs. The apartment space was not physically altered during the family life course sequence but was still used in various ways for different spatial needs. The two narratives both display dwelling situations where the households’ spatial needs change over time and where these are solved in the ways they find possible. The living process and life course situations affect the households’ spatial desires and needs, and they respond by making spatial arrangements regardless of whether the design provides adaptability or not. These consequently implemented realizations of spatial changes in response to the living process and life course situation suggest a strong bottom-up perspective. Then how can the household’s need to expand or contract and the issue of adaptability be understood in relation to the current dwelling design practice? The narratives presented earlier suggest that apartment design today uses a topdown perspective. The function-based apartment and “mobility with changed spatial needs” concept does not see to the social qualities related to the situation where the household needs to adapt space to stay in the same apartment with obtained valuable social qualities. The current dwelling design denies the household’s need to adapt apartment space; still, these spatial adaptions are realized. Not seeing the household’s living process as a precondition for the design of apartments means housing with less spatial capacity to respond to staying and not moving. Consequently, this also means that social qualities that could have been developed and attained are lost. This situation also affects the aspirations for a sustainable housing stock: the present neglect of adaptable space in current dwelling design means dwellings with less spatial capacity to counter diverse dwelling needs as well as unknown future demographic situations.

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Future Research The continued research effort addresses the issue of strategies for adaptable apartment space and develops further results from this realized research (Braide 2019). The aim is to introduce a number of design models that can convey strategies for the design of adaptable apartment f loor plans. The objective is to contribute to increased social qualities in the households’ living situation, and to a long-term sustainable housing stock. The design models are to be used in the planning and design work with new dwellings to develop apartments with an increased spatial capacity. The research is aimed at stakeholders in the housing development field, people who work with planning, construction and design in the housing sector and more specifically at developers and architects. The methodological approach is qualitative, using a benchmarking study and research by design in master’s studios.

References Asplund, Gunnar (ed.). 1980 [1931]. Acceptera. Stockholm: Tiden. Boverket. 2015. Regelsamling för byggande. Karlskrona: Boverket. Boverket. 2016. Reviderad prognos över behovet av nya bostäder till 2025. Karlskrona: Boverket. Boverket. 2018. “Kommunernas bostadsförsörjning—en handbok.” www.boverket.se/ sv/kommunernas-bostadsforsorjning/underlag-for-bostadsforsorjningen/ Braide, Anna. 2019. “Dwelling in time, studies on life course spatial adaptability.” PhD diss., Chalmers University of Technology. Braide Eriksson, Anna. 2016. “Residential usability and social sustainability: towards a paradigm shift within housing design.” Licentiate thesis, Chalmers University of Technology. Clark, William A.V., and Youqin Huang. 2003. “The life course and residential mobility in British housing markets.” Environment and Planning 2: 323–339. doi: 10.1068/ a3542. Coulter, Rory, and Maarten van Ham. 2013. “Following people through time: an analysis of individual residential mobility biographies.” Housing Studies, 28(7): 1037– 1055. doi: 10.1080/02673037.2013.783903. Dyson, Tim. 2010. Population and development: The demographic transition. London: Zed. Fischer, Peter A., and Gunnar Malmberg. 2001. “Settled people don’t move: on life course and (im-) mobility in Sweden.” International Journey of Population Geography 7: 357–371. Lundholm, Emma, and Jörgen Garvill, Gunnar Malmberg, Kerstin Westin. 2004. “Forced or free movers: the motives, voluntariness and selectivity of interregional migration in the Nordic countries.” Population, Space and Place 10: 59–72. McHugh, Kevin. 1984. “Explaining migration intentions and destination selection.” The Professional Geographer 36: 315–325. McLeod, P.B., and J.R. Ellis. 1982. “Housing consumption over the family life cycle: an empirical analysis.” Urban Studies 19(2): 177–185. Nylander, Ola. 2013. Svensk bostad 1850–2000. Lund: Studentlitteratur.

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Rossi, Peter H. 1955. Why families move: a study in the social psychology of urban mobility. Glencoe: Free Press. Schneider, Tatjana, and Jeremy Till. 2007. Flexible housing. Oxford: Architectural Press. Swedish Standards Institute. 2006a. Byggnadsutformning bostäder invändiga mått SS 91 42 21. Stockholm: SIS förlag. Swedish Standards Institute. 2006b. Byggnadsutformning bostäder funktionsplanering SS 91 42 22. Stockholm: SIS förlag.

5 DESIGN AS A PREVENTIVE APPROACH IN RESIDENTIAL SETTINGS—ON FALL INJURIES, SUICIDAL SITUATIONS AND THE ROLE OF ARCHITECTURE Charlotta Thodelius Injuries, and especially fall injuries and suicides, are still, on a global level, leading causes of morbidity and mortality (Haagsma et al. 2016). This is despite research showing that these types of injuries are preventable using social, spatial and environmental countermeasures (Krug, Sharma and Lozano 2000; Peek-Asa and Zwerling 2003). Injury research, especially concerning injury prevention, is a research field marked by great complexity, mainly since multiple risk factors correlate at micro-, meso- and macro levels. Fall injuries, for example, have over 400 risk factors listed (Bueno-Cavanillas et al. 2000). These risk factors include a wide range of factors, from individual traits and immediate social and physical factors to structural elements, resulting in a feeling that “everything matters” (cf. Matza 1964, 22). Thus, undoubtedly, injury prevention is a complex phenomenon. In this chapter, based on the work conducted in my PhD thesis (Thodelius 2018), I will highlight why architects are important actors in preventive work. I will also point to the necessity of having an interdisciplinary approach in preventive work in order to reduce the number of fall injuries and suicides in residential settings. One way to reduce complexity is to have a more theory-driven approach (Sawyer 2003) and to recognize injury situations, rather than just the injured persons. By using fall injuries and suicides as examples, I will argue that there is a need to start with defining injury events in a broader theoretical framework. Then, based on this, a theoretical adaptation is necessary to see which premises situational prevention needs to relay on from an architectural perspective. Lastly, concrete preventive strategies need to be formulated, which can be implemented by sensitive and responsive design in residential settings.

Conceptualizing Injury Events and Injuries To enable a conceptualization of injury events on a general level, the difference between injury events and accidents needs to be laid out, even if we scarcely

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separate them in mundane language. Accidents are transformative and include an extensive categorization of events—from a collapsed nuclear plant (disaster), to being hurt in a car crash (damage) to spilled milk (unfortunate circumstance). By dividing and defining different events included in the term accident—such as disasters, damages and unfortunate circumstances—research can be more precise and also work more stringent (cf. Green 1997). Thus, disasters differ from injury events, and injury events differ from unfortunate circumstance in many ways, mainly in consequences. Also, and even more importantly, accidents seem to be fatalistic, unpreventable and rule out rationality and causes (Green 1997, 130). By changing this and instead using a definition of injury events, the event becomes preventable. Injury events can be explained as events occurring in conjunction with a sudden incident with direct connection to a pathological condition (Langley and Brenner 2004). There are, so to speak, distinguished temporal phases in an injury event: pre-event, event and post-event. Discernable factors, such as person, time and place, interrelate and interact here (Haddon 1980). Therefore, injury events need to be defined as specific forms of situations (Goffman 1963) with a specific outcome, namely injuries, and not random events which are unpreventable or lacking causation. Injuries can be divided into unintentional and intentional and, in addition, the intentional injury can be divided into intra- and interpersonal injuries. Intentional intrapersonal injuries are caused by self-harm, and intentional interpersonal injuries are caused by another individual (e.g., violence). On the one hand, this divergence is related to the degree of intention or motive on the individual level, and on the other hand, it also relates to the difference between behavior and action (Weber 1983). Behavior is understood here as un-ref lected bodily movements, while action includes ref lection and agency. Thus, to go to the kitchen for a glass of water and trip over the threshold can be seen as more related to behavior, compared to jumping off a roof with an intent to commit suicide, which indeed is an action. This links to the term rationality (e.g., the extent to which the behavior and the action are related to knowledge), and even if all behavior and all actions are rational within their contexts (Felson 1986), they can have different degrees of rationality. An unintentional injury can be seen as having a lower degree of rationality, thus connected to behavior or habits, while an intentional injury is more rational since it is related to ref lected action. With that said, injuries can be seen as the result of specific situations with three possible outcomes: unintentional, intentional intrapersonal or intentional interpersonal injuries. However, they are also embedded in a moral framework on a structural level. Unintentional injuries can be said to contain ideal victims or victims who have misjudged the situation or their everyday routine, since the individual did not have an intention to get injured during the event (cf. Christie 1986). Intentional intrapersonal injuries, or self-harm, are defined as deviant acts in the moral framework, since in this case the individual has an intention to get injured. This might not be juridically illegal, but it violates social norms

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Table 5.1 Definition of injuries related to intention, rationality and moral framework.

 

Degree of intention (individual level)

Degree of rationality (individual level)

Moral framework (structural level)

Unintentional injury

Low

Routines

Intrapersonal injury

High

Interpersonal injury

High

Low (Behavior) High (Action) High (Action)

Deviance Crime

(cf. Durkheim 2004). The intentional interpersonal injury is in fact illegal and therefore labelled as a crime, including both victim(s) and perpetrator(s). For example, by separating unintentional falls and intentional self-harm in this way, we can see that intention, degree of rationality and moral framework will differ between them (see Table 5.1). So, instead of using transformative concepts, such as accidents or similar vague expressions, systematic work with definitions and conceptualizations make us see how multifaceted injury events can be, and also how they can be related to both each other (taxonomy) and related concepts such as routine activities, deviant events and crime events. This approach is especially important in relation to the construction of a theoretical framework for injury prevention, since it requires both theoretical adaptation and theoretical integration to truly capture the essence of injury events.

Theoretical Integration and Adaptation of Concepts: From CPTED to IPTED In relation to our cases, fall injuries and suicides in residential settings, there are two different starting points in our theoretical approach. Thus, we need to find theories that equally address both behavior and action and also routines and deviance (see Table 5.1 above). In my own research, I found this link by integrating and adapting the criminological concepts of Crime Prevention Through Environmental Design (CPTED) and Routine Activity Theory (RAT). In this section, I will brief ly summarize how my theoretical work was conducted. Both CPTED and RAT will be presented in relation to injury events, and then I will describe how they evolved into the concept of Injury Prevention Through Environmental Design (IPTED). CPTED has, in previous research, been proven to have injury reduction as a diffusion of benefits or as an unexpected consequence (cf. Ceccato 2016). CPTED originates from architectural theory and praxis, and is based on the work of Jane Jacobs (1961), Ray Jeffrey (1971) and Oscar Newman (1972). They focus on the inf luence of the built environment in relation to crime occurrence

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and the feeling of safety in residential areas. As argued in this work, space and place matter, and the built environment can both hinder and facilitate everyday actions. For example, Jacobs (1961) discusses the importance of eyes on the street and denotes that buildings cannot turn backs or blank sides to the street and blind these “eyes”. What this means is that social control and buildings correlate, and design and street layout are two important factors for the feeling of safety (to see and be seen). Likewise, Newman (1972) stresses the importance of so-called “defensible space design”—housing design that creates both territoriality and informal social control, which affects the behavior of both residents and visitors. Over time, CPTED has developed and integrated additional factors, such as socio-economic and demographic profiling of place (Cozens and Love 2015), and has also moved from vulnerability-led planning to activitysupporting planning (Ceccato 2016). Also, in relation to architecture and situational prevention, this is one of the few preventive strategies that combines and emphasizes the important inf luence of place, the built environment and situational factors (Cozens and Love 2015). However, to be useful in injury prevention, the core concepts of CPTED, which are natural surveillance, access control, territoriality reinforcement, active support and maintenance, need to be reduced to suit these two specific injury situations, namely fall injuries and suicides. Theoretical adaption and integration are necessary. Initially, there is a need to define the similarities between unintentional fall injuries and suicides, since the former is quite different from the latter. Apparently, these injury events are closely connected to everyday life; thus both fall injuries and suicides usually occur in the residence or in the immediate vicinity of the residence (Ferrante, Marinaccio and Iavicoli 2014; Lester and Stack 2015, 73 ff.). Besides place similarities and everyday life occurrence, these injury situations also share some similarities with a crime situation if they are interpreted in the framework of RAT (Cohen and Felson 1979; McCollum, Seifert and Anderson 2009). Crime situations, according to Cohen and Felson (1979), tend to occur in the convergence between three elements: a suitable target, a motivated offender and the absence of a capable guardian. The third aspect, absence of suitable guardians, should in this context be interpreted as an insufficiency of preventive measurements, such as a lack of discouragement by people or by devices, guarding, monitoring or managing the event (Felson 1995; Thodelius 2018, 23–26). By defining crime situations as a result of these convergences, there is a possibility of adapting this theoretical model to an injury situation. Thus injuries also contain three elements: action or behavior (replacing target), prospective victim (replacing motivated offender) and absence of capable guardians. To clarify, we can compare three events, a theft, a fall injury and a suicide, to test the theoretical analogues: •

A young male (motivated offender) steals a handbag (suitable target) left on a table in an empty café (absence of capable guardians).

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•

A young male (prospective victim) trips over a threshold in the same café while speaking on the cell phone since he did not notice it (behavior and lack of capable guardians). A young male (prospective victim) climbs on the roof of the café in the middle of the night to commit suicide (action); the café is closed, and the streets are empty (absence of capable guardians).

•

As seen earlier, the absence of capable guardians links RAT’s explanatory model of crime situations to injury situations, and, in addition, stresses the importance to correct this by the creation or facilitation of capable guardians. This is one of the most important prerequisites in situational prevention and especially in CPTED. In CPTED this is conducted by constructing interventions targeting practical matters (such as locks and fences), psychological matters (how the perpetrator experiences certain places, such as light and visibility) or personal matters (to delay, deter or detect the perpetrator through inventions related to informal and formal control; see Ekblom and Hirschfield 2014). This is also possible in relation to injury situations by using design and the built environment to target practical matters (e.g., factors that play a role in an injury event) and personal matters (e.g., informal control or interventions related to certain risk situations). We need to acknowledge how individuals interact with the social and physical environment instead of why some individuals get injured. And by the adaption and integration of explanatory models and perspectives from criminology, we can ascertain the unforeseen or unintended injury opportunities of place (e.g., injury risks facilitated by the place) and acknowledge place as an actant in injury events (cf. Latour 1996). Moreover, this also emphasizes the importance of defining Injury Prevention Through Environmental Design (IPTED). Earlier I have pinpointed some important factors in this approach. Firstly, architects need a clear concept of injury events and a strong definition of injuries. Secondly, they must acknowledge that injuries are situated. And thirdly, that prevention relays upon creating or facilitating capable guardians, something that needs to be systematically developed in relation to empirical cases, previous research and theory with a focus on causation ( Thodelius 2018, 25).

Testing IPTED on Fall Injuries and Suicides To understand how preventive strategies can be managed in residential settings by IPTED, the research conducted needs a methodological framework with a f lexible research design and the use of mixed methods to handle the question of causation (Layder 1993; Creswell 1994; Ekblom 2011). Causation, or causes of injury, in this perspective are more interesting compared to causes of causes (e.g., individual background factors, see Wikström 2006, 61 ff.), since the prevention is targeting place and not person (e.g., how instead of why injury events occur).

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Different spaces inf luence the probability of injury occurrences in different ways and therefore condition the interventions. Different spaces also limit the possibilities to do research, due to both time aspects and ethical perspectives. Therefore, I decided to investigate fall injuries with a blend of qualitative and quantitative methods to narrow down high-risk locations ( Thodelius 2018, 47–54). In the analysis, the following pattern of places for fall injuries appeared: entrances, stairways and outdoor areas in the vicinity of the dwelling units. These locations can all be seen as shared spaces and also semi-private. They seem suitable, even when badly managed, for non-disabled in a higher degree than compared to disabled persons. For example, as one respondent said regarding the landlord not fixing the uneven f looring in the entrance: ‘[T]his might not be fixed since it is not a problem for others [who can walk], but for me and others [with wheelchairs, canes or bad balance] it is really problematic’(Thodelius et al. 2016). In addition, some of the respondents also expressed that they were afraid of complaining, since they thought that they would then lose their apartments. And in some cases, they had started to normalize these situations, as one said: ‘It has always been like this’ (Thodelius et al. 2016). In brief, the interventions suggested for these locations are related to three aspects: inclusive design, transitional zones and re-localizations of “risky activities”. Inclusive design, in terms of equitable use, f lexibility in use and design with tolerance for mistakes, is one way to reduce the consequences of injuries, by allowing people to have “bad days” or “making blunders”. For example, this strategy can include design solutions with a large entrance area so you can enter with different types of aids (such as wheelchairs or a Permobil). It is also important to consider lighting solutions, contrast marks and the like to visualize dangers or to use a f looring that is able to reduce damage in case of falls (Thodelius 2018, 71–72). Transitional zones, in contrast to inclusive design, are a way to design for ownership, maintenance and management by organizing the built environment in order to clearly define whose area it is and to avoid vagueness in actual responsibility for a specific location. To re-localize activities is a third way to use design in injury prevention, and to contain ways to re-locate unsafe activities to safe places and vice versa, for example, how things are stored in a building. Do belongings need to be in the basement or attic (unsafe places) or can they be placed in the staircase? Suicides, in contrast to fall injuries, were addressed in a problem-oriented approach in my research, stressing how adolescent suicides could be reduced in specific places, so-called hotspots. In the quantitative analysis of committed suicides (Thodelius 2018, 59), only age seemed of importance, which made this study more driven by qualitative data, consisting of interviews with first responders, suicidal acts streamed online and place analysis of hotspots identified in the interviews ( Thodelius 2018, 36). This might seem an unorthodox way to conduct suicide research, mainly since suicide in previous research is considered to be caused by intrinsic factors, such as depression. But I argue that

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suicides are also dependent on extrinsic factors, such as place and available products (e.g., modus), since suicides take place and cluster in places independent of individual traits, motives or other intrinsic factors (cf. Lester 2009). As a valid example here, I will discuss the study of a train station which is located in the vicinity of a residential area. This train station has one major platform, which is accessible from two different directions. It is used regularly by adolescents for travel to the inner-city area, school and similar destinations. It can be defined as a node of importance in everyday life for many. Designwise, this platform works well during the day, but during evenings and nights its design is “misused” and becomes suicidogenic, mainly due to the interrelation between three things: the high degree of accessibility, the knowledge of the station (e.g., routine) and the fact that the place and its surroundings are (almost) empty after work hours. This low f low of people makes this public place a location with a low risk for detection of not only deviant acts, such as suicides, but also other deviant acts such as vandalism and drinking. In contrast to fall injury prevention as described earlier, where the mechanic elements in the environment were the target of the intervention (e.g., indirect or direct inf luence on the outcome), in the case of suicides the precipitate elements are targeted (e.g., inf luence on the occurrence) (Ekblom 2011). The opportunity structure to commit suicide is, so to speak, related to the previous one since the person knows the place but also knows when it is empty and not used to a certain extent at risky times (Felson and Eckert 2018). Furthermore, the platform gives both a place to commit suicide and a modus operandi (e.g., jumping in front of a train), which gives the platform a double function. Therefore, the prevention needs to target one or more of these factors, such as work with accessibility and/or deterrence (e.g., making it hard to commit suicide) or with detection (e.g., increasing the amount of “eyes on the street” and visibility). Suitable strategies here seem to be about working with fences (making it hard to reach the tracks), lightning on the platform (to make a suicidal situation visible in the surroundings) and to attract other people to the surroundings by, for example, opening a kiosk, making a nice path or a park for dog owners or using the ground f loor in the buildings for some kind of activity. This will increase the amount of “eyes on the street” as part of an imaginative urban architecture design strategy of prevention (Thodelius 2018, 75–76).

Closing Thoughts Instead of placing focus on dissimilarities in fall injuries and suicidal situations, I argue we look at similarities. As addressed earlier, the main similarities are the absence of capable guardians and the fact that injuries always have a place of occurrence. Also, as argued in IPTED, the architect has a crucial role in the preventive work—both by researching injuries and by translating the result into praxis through finding ways to design out injuries. As seen in this chapter, there

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is a need to be specific and systematic in injury research. Instead of considering correlates as causalities (Matza 1964, 22–25), situational causes should be discussed more firmly. And by looking at situations, place will matter to a far greater extent. However, this research relays two things: to acknowledge causes and context. In my examples earlier, and mainly in relation to suicide, the local context matters a lot, and therefore the next step, after analyzing injuries on an abstract level, needs to be adapting prevention strategies to the “real world”. As addressed in this chapter, effective injury prevention needs to include four aspects. Firstly, architects need to work with concepts and definitions to enable a common understanding of injury events and their similarities and disparities. This should be closely related to concepts such as accidents and crime, looking beyond the moral framework related to different injury types. Secondly, architects also need to work with theories to reduce the complexity surrounding injuries and contextualize them in a framework that gives a denomination of causality. This demands an interdisciplinary and transdisciplinary approach, and also research work related to theoretical integration and adaptation. Thirdly, architects need to analyze data suitable for the theoretical framework. As suggested here, a combination of big-n statistical data and low-n local qualitative data may be a way to analyze causality. This is by bridging “how and why” and handling the problems with a multi-causation of risk factors (Layder 1993, 38, 72, 109–112). Finally, architects need to be specific in their preventive approach and clarify for whom a specific intervention will lower the risk of injuries, in what type of space, which elements in the injury situation should be targeted and within which prevention discourse (Ekblom 2011). By limiting scope or the target group, the chance to develop suitable design prevention strategies can be increased, and these should also be possible to evaluate for use in future situations.

References Bueno-Cavanillas, Aurora, Francisco Padilla Ruiz, José J. Jiménez-Moléon, A.C. Pienado-Alonso, and Ramón Gálvez-Vargas. 2000. “Risk Factors in Falls Among the Elderly According to Extrinsic and Intrinsic Precipitating Causes.” European Journal of Epidemiology 16(9):849–859. Ceccato, Vania. 2016. “Har stadsmiljön betydelse för säkerheten? CPTED-metodens möjligheter och utmaningar.” In Urbanismer. Dagens statsbyggande i retorik och praktik, edited by Krister Olsson, Daniel Nilsson, and Tigraan Haas, 99–120. Lund: Nordic Academic Press. Christie Niels. 1986. “The Ideal Victim.” In From Crime Policy to Victim Policy, edited by Fattah Ezzat A., 17–30. London: Palgrave Macmillan. Cohen, Lawrence E. and Marcus Felson. 1979. “Social Change and Crime Rates Trends: A Routine Activity Approach.” American Sociological Review 44(4):588–608. Cozens, Paul and Terrence Love. 2015. “A Review and Current Status of Crime Prevention through Environmental Design (CPTED).” Journal of Planning Literature 30(4):393–412.

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Creswell, John W. 1994. Research Design: Qualitative, Quantitative and Mixed Methods Approaches. Thousand Oaks, CA: SAGE. Durkheim, Émile. 2004 [1897]. Suicides: A Study in Sociology. New York: Free Press. Ekblom, Paul. 2011. Crime Prevention, Security and Community Safety. Basingstoke: Palgrave Macmillan. Ekblom, Paul and Alexander F. Hirschfield. 2014. “Developing an Alternative Formulation of SCP Principles—The Ds (11 and Counting).” CrimeScience 2(2):1–11. Felson, Marcus. 1986. “Routine activities, Social Controls, Rational Decisions and Criminal Outcomes.” In The Reasoning Criminal, edited by Cornish Derek and Ronald V.G. Clarke, 302–327. New York: Springer. Felson, Marcus. 1995. “Those Who Discourage Crime.” In Crime and Place: Crime Prevention Studies, Vol. 4, edited by John E. Eck and David Weisburd, 63–66. Monsey, NY: Criminal Justice Press. Felson, Marcus and Mary A. Eckert. 2018. Introductory Criminology: The Study of Risky Situations. New York: Routledge. Ferrante, Pierapaolo, Alessandro Marinaccio, and Sergio Iavicoli. 2014. “Epidemiological Risk Analysis of Home Injuries in Italy (1999–2006).” International Journal of Environmental Research and Public Health 11(4):4402–4416. Goffman, Erving. 1963. Behavior in Public Places: Notes on the Social Organization of Gatherings. London: Free Press. Green, Judith. 1997. Risk and Misfortune: Social Construction of Accidents. London: UCL Press. Haagsma, Juanita A., Nicholas Graetz, and Ian Bolliger. 2016. “The Global Burden of Injury: Incidence, Mortality, Disability-adjusted Life Years and Time Trends from the Global Burden of Disease Study 2013.” Injury Prevention 22:3–18. Haddon, William. 1980. “Advances in Epidemiology of Injuries as a Basis for Public Policy.” Public Health Reports 95(5):411–421. Jacobs, Jane. 1961. The Death and Life of Great American Cities. New York: Vintage. Jeffrey, Ray C. 1971. Crime Prevention Through Environmental Design. Beverly Hills: SAGE. Krug, Etienne G., Gyeanedra K. Sharma, and Rafael Lozano. 2000. “The Global Burden of Injuries.” American Journal of Public Health 90(4):523–526. Langley, John and Robert Brenner. 2004. “What is an Injury?” Injury Prevention 10(2):69–71. Latour, Bruno. 1996. “On Interobjectivity.” Mind, Culture and Activity 3(4):228–245. Layder, Derek. 1993. New Strategies in Social Research: An Introduction and Guide. Cambridge, UK: Polity Press. Lester, David. 2009. Preventing Suicides: Closing the Exits Revisited. New York: Nova Science. Lester, David and Steven Stack. 2015. Suicide as a Dramatic Performance. New Brunswick, NJ: Transaction Publisher. Matza, David. 1964. Delinquency and Drift. New York: John Willey & Sons. McCollum, David, Sara Seifert, and Evelyn Anderson. 2009. “Patient Charting: Turning Routine Activity into an Opportunity for Injury Prevention.” Minnesota Medicine 92(8):46–48. Newman, Oscar. 1972. Defensible Space. New York: McMillian. Peek-Asa, Corinne and Craig Zwerling.2003. “Role of Environmental Interventions in Injury Control and Prevention.” Epidemiologic Reviews 25(1):77–89. Sawyer, Keith R. 2003. “The Mechanism of Emergence.” Philosophy of the Social Science 34(2):260–282.

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Thodelius, Charlotta. 2018. Rethinking Injury Events. Explorations in Spatial Aspects and Situational Prevention Strategies. PhD diss., Chalmers University of Technology, Gothenburg. Thodelius, Charlotta, Jörgen Lundälv, Göteborgsavdelningen DHR, Förbundet unga rörelsehindrade Göteborgsavdelningen, HSO Göteborg, and Göteborgsavdelningen Reumatikerförbundet. 2016. Minirapport från en forskningscirkel. Skaderisker och riskhantering i bostadsmiljön ur ett funktionshinders-perspektiv. [Swedish report]. Gothenburg: Chalmers University of Technology. Weber, Max. 1983. Ekonomi och Samhälle. Förståelsesociologins grunder I. Sociologiska begrepp och definitioner. Translation: A. Lundquist. Lund: Argos. Wikström, Per-Olof H. 2006. “Individuals, Setting, and Acts of Crime: Situational Mechanism and the Explanation of Crime.” In The Explanation of Crime: Context, Mechanism and Development, edited by Per-Olof H. Wikström and Robert J. Sampson, 61–107. Cambridge, UK: Cambridge University Press.

6 THE FUTURE OF ADL DWELLINGS—EXPERIMENTAL RE-DESIGNS FOR THE IMPAIRED Helena Casanova and Jesus Hernández

Introduction This chapter presents the process and findings of an interdisciplinary research project that has taken place in the Dutch context, and that was initiated by our office, Casanova+Hernandez in Rotterdam, at a time when subsidy policies in the Netherlands were changing, leading to clear social welfare cuts. The main motivation for us to initiate and develop this research was the firm conviction that the combination of two factors, the possibility of leading a quality independent life for people with disabilities (and the elderly) on the one hand, and the constant adequate day-care assistance of these people on the other hand, results in more sustainable communities, which has a positive long-term effect on society as a whole. We were convinced that promoting budget cuts in the fields of social housing and day-care assistance for vulnerable groups, such as impaired people and the elderly, was the wrong strategy to follow, not only from the social point of view, but even from a financial perspective. Reducing the options of these groups for living in healing environments with adequate assistance, would not only marginalize them (again), but it will also increase healthcare costs on the long term. Having built one housing tower in the Netherlands with ADL houses placed among standard apartments, we could understand first-hand the needs of the different users of this kind of ‘cluster’. Thanks to our experience as university mentors and the collaboration with professors from other disciplines, we could apply academic methodological research tools to our research. We were able to use both our direct building experience and a theoretical analytical approach in our research, which gave us enough freedom and backup to support our conclusions.

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FIGURE 6.1A AND 6.1B Casanova+Hernandez architects, ADL cluster in Groningen, the Netherlands; ( Kort 2013)

Source: Photo © Theo Bos, photographer

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Some Definitions The Fokus Concept The Fokus concept comes from Sweden where, during the sixties, Professor Brattgård, a wheelchair user himself, had the vision of how impaired people could live freely and self-standing, which at that time was still far from reality. In that period people with disabilities had to live in special institutions, segregated from society. In 1974 a group of people with physical disabilities founded the Fokus organization in the Netherlands, with the aim of integrating people with a severe physical disability into society by offering independent living spaces (ADL housing) with 24-hour on-call assistance (ADL unit). Shortly after, the Dutch government started providing funds for building those ADL (Algemene Dagelijkse Levensverrichtingen/ General Daily Life activities) houses and providing ADL assistance.

What Is an ADL Cluster? An ADL cluster consists of a number of houses, ranging from 12 to a maximum of 24, and an ADL unit in their vicinity, from which assistance is organized. ADL clusters offer people with a severe physical disability the opportunity to live among other non-impaired people and therefore to be fully integrated into society. Generally, ADL providers try to ensure that ADL houses are, as much as possible, mixed with standard houses that do not have special requirements.

What Is an ADL Home? An ADL home is a one-story house, adapted and wheelchair accessible, with extra surface area for easy maneuvering for wheelchairs all around the house. ADL homes are designed on the basis of a set of program requirements specific to this group of people and defined by the former CVZ (Dutch College for Health Insurance). One of these requirements states that all homes are directly connected via an alarm intercom system to an aid station, the ADL unit. There are various ADL typologies besides the one-story house: for example, a single-family home or a home in an apartment complex. The houses usually have three or four rooms so that clients can also live together with their partner, family or a pet. The rent of a Fokus home is arranged through a housing association. Despite the extra f loor space, clients pay the regular rent.

What Is ADL Assistance? ADL assistance is personal assistance (available 24 hours per day) with those general daily life operations (ADL) that the impaired person (the client) cannot

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do because of a physical disability. Among others, the assistant can help with washing, dressing and undressing the client; movements in and around the house; toilet visit; food and drink; and simple nursing procedures. One important aspect of the ADL assistance system is that the client decides how he or she lives, in his or her own rhythm and in his or her own way. He or she makes a request for assistance via the intercom system that links the houses with the ADL unit, and also defines what has to be done and, more importantly, how things should be done. In this way the client always keeps his or her independence and control over his or her own life.

Who Is Eligible for an ADL Home? ADL homes are inhabited by people with severe physical disabilities who need assistance at least 5 hours per week. It is important that the target group can manage their own lives, move easily within the house with a wheelchair and call for assistance and live independently. If this is not the case, they cannot apply to live in an ADL cluster.

Which Organizations Realize ADL Clusters in the Netherlands? Currently, there are various providers that offer assistance in ADL clusters. Fokus is the largest organization of these providers. The other ones are Nieuw Amstelrade and Stichting Wassenaarse Zorg. They jointly provide care to approximately 1,400 clients under the subsidy scheme.

Recent Development in The Netherlands Related to ADL Housing In recent years, some relevant changes have taken place in the Netherlands related to regulations in the care sector as well as to the way new ADL projects can be defined or financed. On the one hand, the subsidy for the construction of new ADL houses was abandoned in 2009. On the other hand, the very strict program of building requirements that had been defined during that subsidized period dates from 2006, and have since become obsolete. This set of regulations doesn’t ref lect the f lexibility of uses and the housing typologies demanded by contemporary society. The care providers and the housing associations who eventually could be interested in the construction of new ADL housing clusters, or in the restoration of existing ones, are demanding the Dutch government to provide new updated programs and construction regulations that could allow them more freedom of choice and f lexibility in the definition of future new ADL clusters. Although social demands are high, the parties related to the care sector and to the construction of new ADL houses must deal with the reorganization and

Comparative analysis of existing ADL clusters in the Netherlands.

Source: © Casanova+Hernandez architects.

FIGURE 6.2

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optimization of the public financing system that has been taking place since the latest big financial crisis. But in 2007 the Netherlands signed the UN Convention on the Rights of Persons with Disabilities (UN 2006),1 according to which people with disabilities should be guaranteed that they can ‘live independently and fully participate in all facets of life’. This automatically means that in order to guarantee the full integration in society of all people with disabilities on all levels, more attention should be placed on the design of their living environments and their dwellings. The debate about ADL houses is an active one in the Netherlands, and recently the Dutch Minister of Health, Welfare and Sports, Mr. De Jonge, has sent to the House of Representatives on June 5, 2019 a letter in which he acknowledges the special position of the ADL concept as complementary to the supply from the Wlz (Wet Langdurige Zorg/Long-term Care Law), the Zvw (Zorgverzekeringswet/Health Insurance Law) and the Wmo (Wet Maatschappelijke Ondersteuning/Social Support Law).2 In his letter, Minister De Jonge underlines as well that there is a major shortage of adapted social rental housing making living with care currently more difficult in the Netherlands.

Research Initiated Out of Necessity In 2012 our office realized one ADL cluster in Groningen, in the north of the Netherlands. This cluster provided 16 ADL homes that are consciously mixed with other kinds of housing typologies within the housing block in order to avoid the segregation of the vulnerable target group inside the building. The special apartments are spread throughout the whole building and on all its levels, as far as possible from each other, in order to promote social integration within the block. After being involved in the construction of this block, our office continued conducting research and teaching at different universities on this and other social issues. In 2016, together with the sociologist Dr. M.I.M. Schuurman and Dr. van de Klundert, economist and professor of the Erasmus School of Health Policy & Management, at Erasmus University, our office promoted a collaboration project and received research funds from the Creative Industries Fund NL to conduct interdisciplinary research on how building regulations and typologies for ADL clusters in Netherlands could be updated and, furthermore, better respond to emerging demands of the current society. The goal was to be able to develop new ADL housing projects in the future with a new optimized program of requirements, developed with special attention on new ways of living (Schuurman 2007; Schuurman et al. 2016; Casanova and Hernández 2008, 2015). During the months of research, Casanova+Hernandez worked intensively with many different stakeholders who believed that it was essential for our society to guarantee the proper integration of people with disabilities, regardless

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of the financial crisis and other aspects of the political agenda. We developed different scenarios to be tested and applied in the future, considering not only architectural aspects but also sociological and financial ones. On the one hand, Dr. M.I.M. Schuurman provided relevant input from a sociologist’s perspective on how these new scenarios could be used to strengthen social sustainability on the basis of new behavioral patterns in the Netherlands, participation in ADL clients’ society and participation in cultural life in general. On the other hand, economist van de Klundert made proposals for the feasibility of financing new ADL projects in the Netherlands, considering the value delivered by ADL cluster projects in society. He looked for possibilities for financing the extra costs that all ADL projects bring along to be compared with a regular housing project, in a time when all extra governmental support for new developments was abandoned. The research consisted basically of two differentiated parts: 1. 2.

Comparative analysis of case studies Recommendations for the construction of future ADL clusters

Comparative Analysis of Case Studies For this part of the research, nine case studies were analyzed on three different scales: the ADL home and ADL unit, the ADL cluster (the building/ensemble), and the neighborhood. The analysis was made through direct observation, studying the different architects’ graphic information and through interviews with all kinds of users: impaired people (clients of ADL services), ADL assistants and location managers, which gave us an interesting first-hand view of their updated needs. In order to be able to propose a new set of optimized construction regulations and uses, it was important to first understand which design aspects should remain in all future ADL clusters developments and which aspects could be changed. The physical aspects (‘hardware’) and the human-psychological aspects (‘software’) of the case studies were under critical dissection.

Physical Aspects Analyzed (Hardware) On the scale of the home and of the ADL unit, we analyzed aspects such as the type of access from the collective areas, number of rooms and their dimensions, relevant interconnections between spaces, size and type of interior doors, presence of outside space and its relation to the interior of the house, position and dimensions of windows in relation to interior space, home automation (the standard package) and the individual home automation (personalized per resident).

ADL housing block in Groningen; typical f loor with ADL housing on the two corners below.

Source: © Casanova+Hernandez architects.

FIGURE 6.3

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On the scale of the building, we analyzed aspects such as the cluster or building type (single-family dwelling, gallery block, central core, etc.), number of f loors, functions within the ensemble, number of ADL homes per f loor, position of ADL homes within the ensemble, ratio of ADL homes compared to other housing typologies, distance to the ADL unit, collective spaces, type of outdoor spaces within the ensemble (private, collective, public), routing from public to private domain, accessibility from the street, position of storage, position of parking spaces for electric wheelchairs, parking (including social safety), number and type of lifts, visibility of ADL homes in the ensemble and presence of special elements within the ensemble for the disabled residents. On the scale of the neighborhood we analyzed aspects such as the urban typology of the ADL cluster, the location of ADL homes within the urban context, distance and distribution of homes within the ensemble, connection of privatepublic outside areas, types of public spaces for disabled residents, presence of landscaping and presence of relaxation facilities for social interaction.

Interviews (Software) The list of questions of the interviews was fixed according to different topics, running from social aspects to more purely functional ones. The first part of the interviews addressed to the ADL clients was focused on general aspects, such as their day-night routines, whether they were living alone or with family, and so forth. All those topics were important to understand whether features such as age, gender or marital status inf luenced their answers. The first part of the interviews addressed to location managers and assistants was focused as well on their daily routines and on general issues related to the functioning of the assisting working team. After this first part, each interview for all interviewees was focused on spatial aspects related to three different scales also present in the physical analysis: the scale of the house and the ADL unit, the scale of the building and the scale of the neighborhood.

Recommendations for the Construction of Future ADL Clusters as a New Generation of ADL Dwellings The revision of the current ADL model, considering also social and economic aspects, opens a wide field for experimentation by exploring topics such as the current diversity of ways of living of people with disabilities, living and working at home, collective living and participative society that will need new architectural solutions related to topics such as a wider diversity of ADL housing typologies, new models of collective housing, f lexible and adaptable dwellings and the personalization of the house.

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The innovative solutions should not only come unilaterally from the part of the so-called experts but should also be developed with close consideration of the real daily needs and the priceless advice of the ADL clients and ADL assistants themselves. Co-creation design processes can acquire a special relevance in this kind of project. If we understand innovation as the application of better solutions that meet new requirements, unarticulated needs or existing market needs, then it becomes clear that we should face the described situation with innovative solutions on very different levels, capable of also taking into account both social and financial circumstances. These are the three main levels on which innovation has to be applied: 1. 2. 3.

Typological and constructive innovation Social innovation Financial innovation

Typological and Constructive Innovation The standard ADL houses have been conceived and designed so far based on the standard design principles of regular housing projects on the Dutch market. The regular housing block and the regular house type are taken as references and adapted afterwards to the particular needs of people with disabilities. On the scale of the block, the accessibility of the conventional housing block is improved by making the corridors a bit wider, by creating areas in the corridors where people on wheelchairs can turn around or by designing lifts bigger than normal. On the scale of the house, the standard housing types are adapted by making bigger corridors, wider doors and so forth, but the houses have been built following conventional housing layouts, construction systems and elements, which have seldom provided f lexible spaces easily adaptable for all kinds of ADL clients in a feasible way. In the current times, and considering in parallel sociological studies about how people want to live today, it would be necessary to promote innovative design solutions for both ADL blocks and housing typologies based on general social trends and relevant issues.

Scale of the Block: New Design Possibilities The housing block can be consciously designed to promote social interaction among residents of all kinds. There are new social developments that indicate that more and more people are willing to initiate collaborative projects and share all kinds of collective activities such as urban gardening, cooking together, co-working spaces, sharing the care of children as communities,

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parent participation crèche or students who provide homework support on their own initiative. The housing blocks of the new generation of ADL projects should be conceived and designed with consideration of all these new possibilities, equipping the buildings with f lexible spaces to develop collective activities and to promote inhabitants’ interaction. This design attitude is already applied successfully when, for instance, some new office spaces are built, but can also be easily translated into the housing sector as is already happening successfully in countries such as Germany and Denmark. Creating f lexible spaces in the block that can be used by all target groups will strengthen social networks and will improve the possibilities for social integration and the inclusion of impaired people. ADL clients can participate more actively in these social networks, much more than the way they now participate in the existing ADL clusters, provided that housing blocks are not only understood and designed for living but also for promoting daily working and collaboration activities. The presence of those collective spaces in the block could allow in parallel for the introduction of smaller ADL typologies than the so far standard ones, especially concerning the large number of singles that are currently occupying ADL houses with two or three sleeping rooms. In the most conservative scenarios, these collective spaces of the block can be just working and relaxing areas, where residents can meet each other in a relaxed environment, can exchange experiences and/or help each other with specific tasks. In the most radical scenarios, though, the collective spaces can be conceived as kitchens, eating places and living rooms. These scenarios could be interesting ones to promote among young ADL users, mainly students, though it would be advisable to mix these typologies with more conservative ones in the block to improve the integration of very different social groups within it. When the block is consciously designed to balance the extra cost generated by the construction of the ADL dwellings, the use of collective spaces helps to balance this cost by drastically reducing the necessary surface area of each ADL dwelling, optimizing the total building cost. The use of collective spaces could also reduce the total construction cost not only by minimizing the total built surface of the ADL program, but also by optimizing installations, circulation areas and constructive elements such as walls and doors. It is important here to mention that the general optimization of the layout of the block, and the disposition within the block of some facilities in a more compact way, could give good results in terms of sustainable performance of the building.

Scale of the House: New Design Possibilities While conducting interviews with ADL clients of very different ages and backgrounds, it was immediately clear that, although the common factor among all clients is that they depend on a wheelchair to move around, each person has

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a very specific vision of how he or she would like to live and how his or her house should be adapted to his or her specific patterns of movement within the house. Most of the interviewed ADL clients have quite often presented interesting suggestions about how to spatially improve their own living environments. Even though the majority of the interviewees have declared they feel comfortable in their houses, they have also mentioned that more f lexibility and more options in terms of housing typologies would be much appreciated while making it further possible to better choose where and how to live. The standardization in architecture, which was characteristic of the modern movement due to Fordism production system in the construction sector, has already been questioned in general for some time in the Netherlands. As our times are characterized by a consumer attitude, according to which everybody can personalize almost everything (from digital devices to cars) at any moment, the field of designing housing should make an effort as well and should pay more attention to individual wishes and aspirations. For quite some time, several design experiments concerned with topics such as flexibility and personalization of residential buildings have taken place. Some of these experiments have solely been formulated on a theoretical level, but some of them have been put into practice. The already built knowledge in this field should also be put into practice in the field of ADL houses in order to offer ADL clients more typological variation and better adaptable spaces f lexible enough to answer to different necessities, taking into consideration as well the consecutive occupation of the house by different clients in the long run. On the one hand, houses with less fixed partitions and doors could help facilitate routing and maneuvering inside the houses, free of thresholds. Freedom of movement, which is essential for ADL clients, could improve the feeling of well-being and promote a healing environment within the living areas. On the other hand, the use of movable partitions, sliding elements or even curtains to separate spaces can help in providing f lexibility to the layout of the dwellings when rental houses pass from one ADL client to the next one. The f lexibility in the layout of the houses seems to be a relevant aspect to take into account when designing future ADL clusters. As it is understood, this not only facilitates the adaptation of the house to different ADL clients, but also the adaptation of the house according to one specific ADL client along his or her personal situation and evolution. The possibility of improving the variety of ADL housing typologies is also a relevant issue to be addressed. Knowing that, as it is also visible in general in society nowadays, most of the ADL houses are inhabited by single people. This leads to a very interesting field of experimentation with different housing typologies more suitable for this group of ADL clients. Not only can the ADL dwellings in general be smaller, but spaces, especially designed for ADL clients, can also be added to other

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housing typologies in order to create, for instance, kangaroo-houses, with two different entrance doors and where living areas are shared by an ADL client and by a family or by students and/or colleagues who can also play some daily role in helping the ADL client. Hybrid typologies like the kangaroo-house3 that can combine a normal dwelling with an ADL dwelling, as a smaller dwelling within a dwelling, can be developed as a one-f loor apartment, a maisonette or a duplex, within a housing block, as a semidetached house, as a house on the ground f loor with direct access from the street or as a patio house. The use of hybrid typologies in housing blocks allows experimenting with many different housing layouts, different kinds of symbiotic relationships between the inhabitants of the block and many solutions to promote the social integration of the ADL dwellers. When speaking about single people or couples, an open loft typology can answer the wish as well for more ‘spaciousness’ that is often mentioned by ADL clients. This typology can include very light partitions, responsible for changing the interior layouts depending on the time of the day, thus creating spatial variation as well. The success of a compact, f lexible and attractive ADL loft typology is directly linked to the development of a series of smart and modern interior elements. The use of standardized elements such as light partition and sliding elements, adaptable furniture, domotica and so forth, especially designed for an ADL loft can lead to cost optimizations when these elements are applied to several ADL projects at the same time. Obviously, such an investigation can afterwards also lead to further use of some of those elements on the regular housing market.

Social Innovation In recent years, little by little, the dismantling of the welfare state has been taking place in the Netherlands. When the Dutch king, on Prince’s Day in 2013, made it clear that ‘the traditional welfare state is slowly but surely changing into a participation society. Everyone who can do that is asked to take responsibility for his or her own life and environment,’4 he opened the door for intensive debates about what this should imply in reality and how the different Dutch institutions should react to this call. A lot has already been written about this issue. Some people are in favor, some are against it, or, at least, clearly skeptical about it. Setting aside political discussions, it is a fact that not only Dutch society but also traditional Western societies have changed in recent times. Citizens are more prone to organize themselves and to promote small to medium scale initiatives, which are not necessarily unsuccessful as skeptics tend to think. The more people get used to organizing themselves, the more ‘muscle’ they show in doing it and in getting stable social initiatives done and developed within a longer time frame.

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What is also known as the DIY—‘do it yourself ’—democracy in academic circles has spread throughout Western countries, already bearing fruit in some cases. It is especially getting through in citizens’ and politicians’ ways of thinking. In the Netherlands these changes have been on the political agenda for several years already, but the participation society can only succeed if citizens themselves want it. This cannot be implemented and forced from the top down. When speaking about architecture, and especially about integration projects, such as the ADL ones, this trend in society can be facilitated by creating spaces where people can collaborate, share activities and help each other. Collective spaces within ADL projects can provide the needed ‘hardware’ to make social interaction (social ‘software’) possible among ADL clients and other residents of the block. In order to create ‘alive’ collective spaces, participative monitoring agents and developers are needed, information f lows should be well-kept and involved citizenship should be promoted as well. In the generation of participative ADL projects the municipalities should play a relevant role in promoting social participation. Working together with sociologists, they could encourage citizens to create groups based on a good mix of ADL clients and other collectives. Municipalities could facilitate the creation of new social networks, identify already existing active social organizations that might be interested in sharing facilities and exchanging experiences with ADL clients, open an advice desk to put into contact individuals (ADL clients, students, expats, people living alone, etc.) who might be interested in exchanging some kind of volunteer services and/or in creating groups to develop activities together, and identify or even promote groups of possible ADL clients and other people interested in creating collectively commissioned projects. There are plenty of possibilities to explore if there is the political will for them.

Financial Innovation One of the main challenges to be faced nowadays is the unquestionable fact that there have been relevant budget cuts in the healthcare sector in recent years. Nowadays, creative solutions are needed to finance new ADL projects in order to make them financially feasible again. On the one hand, the already mentioned critical ref lection of the existing program requirements and the existing housing typologies can lead to more optimized houses, which should not necessarily directly mean extra costs in comparison to regular houses. In some cases, even this critical approach could eventually lead to ADL houses with costs comparable to those of a regular house. By making this optimization possible, some of the main financial obstacles argued to avoid initiating new ADL projects these days could be eliminated or, at least, partly softened.

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The financing of the construction of the ADL unit still remains an issue because, obviously, this space is an extra one which is not needed in regular housing blocks. Due to that fact, as well as the fact that the subsidies to rent the ADL unit by the ADL assistance organization have been eliminated, the general question of how to finance ADL units remains problematic. One way to minimize this problem is to review the program requirements of ADL units. For instance, the built surface of the ADL unit could be optimized considering that the big bathrooms adapted for wheelchairs of ADL units are, more often than not, unused by ADL clients. This measure, though, would not yet eliminate the current problem of how to finance the rent of the space by ADL assistance organizations, which is one of the topics repeatedly addressed by some of the interviewees during the research. Another way is to understand that these units could disappear almost completely or could be combined with collective areas within the housing block. In that way, these spaces can be financially maintained in part by the whole community of the block. One important aspect to mention here is that the cost-effectiveness of an ADL project should not only be measured in the short term, which is just looking at direct construction costs. Considering that the majority of the ADL houses are rental ones, the cost-effectiveness of an ADL project should be done by always taking into account long-term factors, such as maintenance and adaptability of the house when new ADL clients occupy the house in future consecutive situations. On the other hand, more creative financial models should be found based on the promotion of a bigger number of privately and collectively commissioned projects. At the moment, self-initiated private projects running under the ADL model are the exception, while through a better organization of human and information resources, municipalities could play a key role in putting interested people in contact and in facilitating self-initiated building processes by providing help in guiding design and building processes from the very first moment until the project is realized.

Conclusion This research has shown the importance and the social necessity of continuing the program of construction of new ADL dwellings. It has described and analyzed several case studies of ADL projects built in the past years in the Netherlands with the objective of building knowledge about the past experience. The interviews with the ADL users and ADL assistants in the different projects combined with the comparative analysis between all the case studies have underlined the positive and negative aspects of each project. The conclusions of the analysis have been compiled into a set of recommendations at different scales, from the urban scale related to the neighborhood to the small scale of

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the house, focused on creating the ideal model of the ADL dwelling based on built experience. But, as the artist Willem de Kooning once mentioned, “Very often we have to change to stay the same.”5 The social and economic context in which this model was created has changed in the last years, forcing us to revise it to make it feasible again. Paradoxically, although there are some radical changes in ways of understanding the ADL dwellings, which in principle do not follow the current ideal model of ADL dwellings, far from these changes being perceived as something negative by the analysis of several experts, they are understood as positive inputs that open the field of new possibilities for the future ADL dwellings. This research points out that, in order to create a sustainable model, the next generation of ADL projects will require innovative solutions that should revise not only the program requirements and the design of the ADL dwellings, but also the social and financial aspects of each project, linking innovative design with new social patterns and creative financial solutions.

Notes 1. According to the un.org website: the Convention on the Rights of Persons with Disabilities and its Optional Protocol (A/RES/61/106) was adopted on 13 December 2006 at the United Nations Headquarters in New York, and was opened for signature on 30 March 2007. There were 82 signatories to the Convention, 44 signatories to the Optional Protocol, and 1 ratification of the Convention. This is the highest number of signatories in history to a UN Convention on its opening day. It is the first comprehensive human rights treaty of the 21st century and is the first human rights convention to be open for signature by regional integration organizations. The Convention entered into force on 3 May 2008. 2. ‘Toekomstigevisie ADL-assistentie’: letter sent by the Minister of Health, Welfare and Sports (Volksgezondheid, Welzijn en Sport), Mr. De Jonge, to chairman of the House of Representatives on 5th June 2019, published in fokuswonen.nl. 3. A kangaroo home is a combination of two (independent) homes or housing units under one roof. The living areas each have a separate front door and have an internal lockable connecting door. Also referred to as a pouch home or multi-generation home. In the Netherlands, several municipalities have kangaroo homes available for rent. Housing associations sometimes offer “kangaroo dwellings”. These are, for example, linked rental homes for a family and a parent in need of care who still can live independently. 4. Dutch prince Willem-Alexander was proclaimed king in September 2013. In his very first speech addressing Dutch parliament he spoke about the end of Dutch welfare state and the implications of that situation. 5. This is a frequently quoted adage from the artist Willen de Kooning.

References Casanova, H. and J. Hernández Mayor. 2008. “Woningidentiteit en individualisering.” de Architect (NL) (April): 16–21. Casanova, H. and J. Hernández Mayor. 2015. Building Knowledge in Interdisciplinary Design. Seoul, South Korea: Damdi Publishers.

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Kort, R.-J. de. 2013. Urban Symbiosis with an Open End/Casanova+Hernandez Architects. Rotterdam: Europan Nederland. Schuurman, M. I. M. 2007. “European Study on the Specific Risks of Discrimination against Persons in Situation of Major Dependence or with Complex Needs.” Country Report: The Netherlands, edited by Kalliope Consult, Nieuwegein. Schuurman, M. I. M., J. Hoekman, and A. Visserman. 2016. “Improvement of SelfDetermination in Young Persons with Intellectual Disabilities. Results of Longitudinal Research.” Presentation at Congress IASSIDD, Melbourne, August 2016.

SECTION II

Ageing

7 ‘HEALTH CARE IS BE-COMING HOME’—IN RESEARCH AND PEDAGOGICAL PRACTICE Inga Malmqvist

Background—Ageing Societies The ageing societies in most developed countries around the world form the backdrop to this study. If society in the future shall be able to handle the increasing amount of elderly in the population, new solutions for housing and care of the elderly need to be developed. The private home for the elderly is already, and will increasingly become, the workplace of staff in healthcare and home care. There is a need for research and innovations regarding new, as well as existing, housing areas promoting comfortable life in old age. Residential healthcare is a new research area that faces a lack of knowledge on ordinary housing when care and healthcare are delivered. There is a need for research and innovation regarding new as well as existing housing areas promoting comfortable life in older age (Wiklund and Melin 2013). Preconditions for care and healthcare in ordinary housing for elderly is the subject of this chapter. 

The demographic situation around the world, with a growing proportion of elderly people, stresses the need for innovative thinking. The demographic development in Sweden will have a great impact on planning and economy in the municipal sector, which is responsible for the eldercare. In Sweden approximately 94 percent of people over 65 years old are living in ordinary housing, many with assistance from homecare (SKL 2019). For the majority of people over 65 years old that is also how they prefer to live. The elderly population in Sweden is increasing. Between the years 2015 and 2035, the number of people 80 years old or more is expected to increase by 76 percent, from approximately 500,000 people to almost 890,000 (SCB 2016).

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For society to be able to manage care and healthcare at today’s level, a huge expansion of eldercare is needed (SCB 2016). At the same time almost half of beds in inpatient wards in Sweden were closed between 1992 and 2007 (Vårdförbundet 2014). More care and healthcare need to be delivered in people’s private homes. A state investigation forms the basis for the municipalization of Home Health Care in Sweden (SOU 2011:55). With increased lifespan, it is now suitable to see the human life cycle in four stages instead of the traditional three. The stages Childhood and Adulthood remain, but the stage Old Age is now replaced by two stages: the Young-Old age when personal fulfillment is important and the Old-Old age when dependence becomes considerable. They can also be named The 3rd and The 4th Age according to Simpson (2015). There is, of course, no exact limit between those stages, but usually the human competencies begin decreasing at approximately the age of 85. It is in this stage of life that people often have multiple diseases and need more care. The proportion of sick elderly who receive comprehensive health and social care interventions and are still living at home increased from 67 to 74 percent from 2008 to 2013. Healthcare in hospitals has become more specialized and the intensity of new technology is increasing. By this trend, care in hospitals becomes more expensive, and as a result the number of days spent in hospital is decreasing. For elderly patients there is often a gap in care chains, a situation that is now beginning to be addressed. The possibilities for home-healthcare are increasing for people of all ages, and many kinds of treatments can be performed in people’s homes, some of them in combination with the rapid development of the digital support of health care, now called E-health (Sandström 2009).

Previous and Related Research A comprehensive literature search on home care based in the physical environment that was conducted at Chalmers in 2017 revealed that research was almost entirely non-existent, although several other researchers have presented studies in similar topics (Pettersson et al. 2019). A group of researchers from the UK states in a review that the behavioral sciences have overlooked the importance of architecture and the buildings used in healthcare. However, their study covers only buildings intended for health care, not for housing (Martin et al. 2015). Another group of researchers from the Netherlands studied how special measures by the architect could support the realization of new visions for care, but they studied a building for nursing homes (Van Steenwinkel et al. 2017). Several Swedish studies have conducted interviews with close relatives of patients cared for at home by a home health care team. They felt secure and safe, and the sick person received an improved quality of life by being able to live out the rest of their life in a home environment (Borgstrand and Berg

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2009). Studies have also been done on patients’ experiences of caregivers in the private home. Thus, for example, it is stated that high demands are placed on caregivers to start from the patient’s perspective (Olsson 2010). People’s private homes can be meaningful in many ways. They can mean a place for intimacy, security, anchor, self-determination and social communities. The researcher Gunnar Lantz describes the concept of home as a practical and functional reality, but it also carries a somewhat emotionally related identity (Lantz 2007). The practical identity may include a place for rest, meals and socializing. The home is private territory and gives people the opportunity to exert complete control of their lives in the home. This control helps people organize their lives and bring about order, predictability and stability in their lives. If there are two people in the household, how will the situation be experienced by the healthier spouse or partner in the household? He or she must be able to live a normal life alongside his or her spouse or partner receiving regular care at home. In an article on health care in the home, published as long ago as 1999, the researcher Maare Tamm asked the existential question, “When does a home cease to be a home and become a workplace for working professionals?” ( Tamm 1999) To be offered help and healthcare in your own private home is fundamentally positive as it gives the sick or elderly person more of a private life than being in a hospital. But the total experience may also very well include more negative factors. Experiences from next-of-kin to persons that have had care and healthcare in their home describe how the home had been transformed into a healthcare facility. It was hard to have the normal life of a family, both because of all the technical equipment that was needed and the fact that the home was felt to be invaded by numerous staff coming and going (Borgstrand and Berg 2009). To be able to offer good housing settings in the future, we need more knowledge about how apartments can be designed to support the new needs in better ways. Thus, more knowledge about housing situations for the elderly is increasingly requested by many different stakeholders like the Swedish municipal sector, by construction clients commissioning housing facilities and by architects and planners responsible for physical design, including the crucial interface between the local building and the urban scale.

Residential Care When care is moving into the private dwelling it is given a supplementary function in addition to the initially intended to offer good housing for a household, namely, to also constitute the physical environment for various types of care work. The need for health care after surgery or treatments will increasingly be delivered out of the hospitals, in patient hotels, rehabilitation clinics and the

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like and also in private homes. More patients will be frail and in need of longer time of care for recovery. The private home for the elderly is already, and will increasingly become, the workplace of staff in healthcare and home care (Socialstyrelsen 2015). What happens to the older person’s home when it simultaneously becomes a workplace for others? Usually it is not only one, but several staff in nursing and home care. The benefits of care provided within or adjacent to the homes of people are, of course, obvious, including reduced medical travel, less anxiety in patients and reduced healthcare costs. For this combination of activities to work well, however, it is required that both apartments and neighborhoods are designed to also meet the demands of caregivers. There must be a balance between the elderly person’s privacy and integrity on the one hand and the necessary conditions for the work of caregivers on the other hand. The situation becomes, perhaps, even more complex when there is more than one person in the household. Residential care is a complex issue, and often it is ultimately about the older person’s own wishes and preferences. However, as architects and planners we can improve the opportunities for good living for the elderly in care by anticipatory and adaptable f loor-planning designs of apartments.

Collaboration Between Different Stakeholders In the new situation, when an increasing amount of care is performed in private homes, collaboration between the completely dominant care organizations in Sweden—county councils or regions and municipalities—is required, as the municipalities since 1992 have been responsible for care of the elderly residents. Furthermore, right now a new form of collaboration is also needed between healthcare organizations and the sector in the municipalities responsible for housing provision (e.g., the municipalities’ planning body for the physical environment and municipal and private housing companies). If they do not enter into direct cooperation, these two main actors are required to consult each other.

New Buildings and Existing Housing Stock Respectively When dealing with concrete solutions in individual housing, different ways are needed to solve problems for new constructions and changes in the existing housing stock. For all new residential buildings in Sweden it is necessary to comply with the solid regulations set out in the Swedish National Board of Housing, Building and Construction’s instructions for new construction in Sweden (Boverket 2011). The requirement that is considered the most necessary is that the housing is accessible, meaning that it is both as simple as possible to reach the apartment and easy to move around properly inside the home. In many cases, measures for increased accessibility are met partly by reducing level differences outdoors and partly by addressing obstacles to indoor accessibility,

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such as thresholds. Improvements in the already built housing stock preferably consist of simpler measures such as adjustments for level differences, removal of thresholds and sets of support handles and handrails, for example. Home modification intervention is very often used in Sweden as a way to overcome obstacles in the physical environment, and it is regulated by law (SFS 1992). The costs are, however, high (Pettersson 2009), and sometimes costs for removal of the interventions are also included. In existing rental multifamily housing units, it might be possible to change function between different rooms and to simply not use a door. If the apartment or house is owner-occupied there are more possibilities to make modifications, for example by making new openings between rooms. Analysis of accessibility can be done by the assessment tool Housing Enabler (Iwarsson and Ståhl 2003). But there are some barriers to accessibility and good functioning in one’s own home such as furniture, fixtures and other loose furnishings. Too much furniture or fixtures may also result in poor daylighting. These aspects are more related to the resident’s use than to the design of apartments.

Residential Healthcare Home healthcare, or residential healthcare, concerns the increasing tendency of more healthcare activities to take place in private homes. It is increasing in two ways. First, by the possibilities of today to perform qualified treatments. Even simple procedures with laparoscopic surgery (e.g., surgical operations carried out by means of a telescopic instrument introduced into the body) can now be performed in private homes. Secondly, the amount of care activities is increasing. Eighty-five percent of the entire home care effort is made to people over 85 years old. This shows a considerable development, but the situation is not without its problems. The Swedish National Board of Health states in an evaluation from 2008 that home healthcare is suffering from a shortage of skilled personnel, that it is divided into several principals and that home healthcare assignments are often very unclear (Socialstyrelsen 2008). Care for the elderly already cost about 70 percent of all social services costs of 126 billion SEK in total in 2001. About two-thirds of the cost was for assisted living (AL) with 24 hour assistance, the form which thus contains only about 6 percent of the population over 65 years old (Socialstyrelsen 2002). Internationally, one can roughly assume that 50 percent of the cost of medical care goes to people over 65 years old. If you could see the cost of elderly care services from a larger perspective, it appears to be clear that society has much to gain from efforts for those who remain in their normal home, instead of more elderly people being forced to move to assisted living. Some areas are particularly important for healthcare in the home. One must, for instance, ask the question of where it is provided. Home nursing can act in all dwelling areas as needed. Re-dressing of wounds is often done

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in the patient’s bed. It is therefore quite important for an apartment to enable healthcare activities to take place just like in a hospital room. Some functional dimensions and measures are however particularly crucial. For instance most critical are hygiene rooms and bedrooms where the better part of the care and healthcare work is done. The hygiene room needs, for example, at least 60 cm of space for care staff on both sides of the toilet. Such a requirement, on the other hand, involving sanitary rooms, is perceived as excessive and therefore unsafe for elderly people who can function without care staff but need support while they are moving. In the bedroom, space is required at both sides of the bed. 120 cm provides space both for care staff and for the patient to maneuver a wheelchair or other mobility devices. 

On a more general level the AIDAH transdisciplinary environment has argued that impacts of changes in the residential sector at large—encompassing the spectrum from ordinary social housing to healthcare institutions and residences for the elderly—represent huge values at stake—losses or gains in social, economic or sustainable terms—for local communities and nations as well as for life quality opportunities of residents. Moreover, changes and trends mentioned earlier are, to a large degree, conditioning or delimiting future opportunities and everyday life prospects. The sustainable issues at stake of residential possibilities must be considered as of paramount importance in any strategy for a resilient urban future. At the same time, the importance of changing social and cultural behavior patterns in everyday residential situations—taking care of the elderly or those temporarily or constantly in need of medical care—cannot be underestimated. There is thus a demand for in-depth insights in order to fully understand the effect of these changes on the quality of residence from a long-term perspective. These aspects are generally far too neglected components in sustainable policies compared to the often-exaggerated focus on purely technological innovations. They deserve great societal attention and profound reconsideration (Gromark et al. 2014).

Residential Healthcare in Research and Education Residential healthcare is a new research area concerned with a situation where more healthcare activities take place in private homes. This research has dual perspectives in two dimensions: Dual User-perspectives in creating good every-day space for the elderly in normal housing and at the same time good working conditions for care-staff. Dual Building-perspectives implies that we have to add new qualities in new buildings, while in existing buildings we often need to find simple solutions. One theoretical point of departure is Lawton and Nahemow’s so-called Ecological Model, where the relation between the individual and the environment is

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fundamental (Scheidt and Norris-Baker 2004). The person can be defined by a set of competences and the environment by its demands. The environmental demands have a higher impact on persons with lower competences (Lawton and Nahemow 1973). Researchers in this area can apply a range of sociophysical methodologies applied in contemporary architectural research (Groat and Wang 2004) and qualitative research methods or within healthcare science and evidence-based design (EBD). Current research establishes the firm relation between the physical environment in healthcare architecture and medical outcomes. The overall aim is to cover different aspects of the opportunities and obstacles in healthcare and care in residential environments. It is also to improve knowledge and ideas on how to build the new healthcare situation in two ways: how neighborhoods should be designed to facilitate patient care in the home, and how and where new devices for simple housing-related care can be designed. The aspects of social sustainability are profound in finding good solutions for a dignified life in your private home which will also offer good working conditions for care-staff.

BAVO—An Interdisciplinary Research Project In collaboration between the disciplines of care, physiotherapy and architecture a study called Housing as an Arena for Healthcare and Care (BAVO) was conducted from 2017 to 2018 (Pettersson et al. 2019). The aim was to explore and discuss what possibilities f loor plan layouts in housing for the elderly can play to facilitate the work of care and homecare in apartments. The elderly themselves are, of course, the main stakeholders, but the aspects of workspace for care-staff are also important. We conducted a mixed-methods research enquiry: observations in ongoing care-work, interviews and focus-groups (Fraser 2014). The main research question for this study was formulated: What are the obstacles and opportunities when care and healthcare are performed in home environments? A further research question is: How can apartments and common spaces be designed to fill the double purposes of housing and care?

The Private and Privacy Traditionally the more public areas of the dwelling are usually planned closest to the entrance. In his seminal book A Pattern Language, Christopher Alexander describes it as the layout creating a continuing sequence where the most public parts of an apartment starting at the entrance, to slightly more private parts ending in the most private domains (Alexander et al. 1977). In living rooms and kitchens, you meet your guests and friends, while the bedrooms are considered the more private zones, and normally this is not where guests are expected to enter.

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Findings from this project were related to the physical proximity of the bedroom and the bathroom, while other findings were related to possibilities of separating private from less private spaces in the apartment. When a person needs care in his or her home, the situation is completely reversed in relation to the traditional situation; then it is in the bedroom and the bathroom that other people enter as this is where most of the care actions take place (Pettersson et al. 2019). Thereby the bedroom and the bathroom now become the more public spaces of the home. This situation also has an aspect of safety and security. Another study concerning injuries in private homes was recently concluded. A total of 832 professional individuals who had witnessed accidents responded to an online survey. The data was analyzed from a mixed-method approach, using descriptive statistics, correlations and textual-analysis. One clear finding shows that bedrooms and bathrooms are the rooms in which accidents are most likely to occur among the elderly in private homes (Lundälv et al. 2019).

Research and Education—A Research by Design Studio on Elderly Housing In parallel with the research, the team also ran a master’s level student project studio exploring the situation of care moving into private homes. This was an application of the method connecting research and education for architects that has been frequently used at Chalmers. Students in the fourth year of architecture have, for eleven years, had the opportunity to work with these design research questions. Several generations of students at the master’s level in architectural education at Chalmers University of Technology designed dwelling units for seniors in the ordinary housing stock between 2006 and 2013. Students worked in design projects with apartments for seniors applied to real planning situations in early stages. Knowledge of older people and their needs was channeled through lectures by various specialists, practitioners and researchers, and through field trips, literature studies and seminars. Students have, in their work with apartment plans, continuously received supervision from researchers and practitioners of different disciplines. The group of students represented many different countries. This led to interesting discussions concerning different cultures of care solutions for the elderly. We also had discussions on different ways of solving f loor plans corresponding to the addressed research questions shared among students, teachers and researchers. Students also had, every year, the opportunity to present their final results for people responsible for the planning for elderly care and housing and real estate companies in different towns and city-districts. In sum, through this procedure, one can confidently say that the proposals have been designed in a proper and realistic manner. The students’ design-solutions illustrated and addressed research questions identified by the research team. As researchers in architecture, we can use design as empirical work material, and thereby the research project can be

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implemented as a project using research by design methods. The students had been asked to address the following questions in their research: • • •

What type of layout can support both the elderly and caregivers by distinguishing between private and semi-private zones? How can you design to ensure the privacy of a patient living with a partner when the patient receives care? How can you design f lexible usable apartments, which can be transformed from one larger apartment for a couple into two separate apartments for one person, and vice versa?

The situation of someone’s home also becoming the workspace of other people opens up a complex context that could possibly lead to conf lict. With regard to personal hygiene, sometimes what is a benefit for a disabled person may be difficult for staff providing care: for example, the grab bar to sit in the way of staff use. A balance between the demands of the individual elderly person’s convenience and those of the staff must take place. The needs of the staff in various residential health care jobs need to be investigated regarding implications for the architecture of the apartments. • •

How can their legitimate requests for a good working environment be met in residential areas? How can we as architects and planners rethink new construction?

Architecture has several properties and values that can be measured. Some of these are directly related to the layout of apartments. An apartment must work well for the elderly, even when they receive care and healthcare in their own home. In these situations the most significant values are considered to be accessibility, which is also related to possibilities to arrange furniture in different ways, to the concept of usability and adaptability to functional measures indicated in regulating norms. An analysis of accessibility can be done by using the assessment tool Housing Enabler in the reduced version (Iwarsson and Slaug 2010). According to a definition of accessibility presented by the researchers Iwarsson and Ståhl (2003), accessibility is a complex concept indicating the relation between a person’s physical capacities and the design and demands of the physical environment or settings in terms of environmental obstacles.

Findings from Research by Design Explorations— Some Samples Findings from the research project supported by the education mentioned earlier led to the following discussions on the research questions in three examples presented below.

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#1 What Type of Layout Can Support Both the Elderly and Caregivers in Distinguishing Between Private and Semi-Private Zones? The physical environment has a significant impact on health and safety. Concerning the layout of bedroom and bathroom, evidence-based results on research can be found in the related area of healthcare facilities. Donna Alcee studied 2009 cases of fall injuries in hospitals and found that 30 percent of these occurred when the patients were trying to use the toilet (Alcee 2000). In the article Safety by Design, Safe Design of Healthcare Facilities, Reiling presents a list of safety design features aimed at creating a safe, high quality, patient-centered environment in the patient room (Reiling 2006). One of the features is “proximity between bed and bathroom, with railing support to reduce the potential risk for patient falls.” In the assessment of f loorplan layouts the proximity between the bedroom and the bathroom was found to be most important, as most activities in care take place either in the bedroom or in the bathroom. This kind of layout then serves both the older person and the staff.

#2 How Can You Design to Ensure the Privacy of a Patient Living With a Partner at Times When the Patient Receives Help? It is difficult to have a normal life in a family when the home is invaded by staff who come and go. That was the result of a Swedish research project some years ago: “It is difficult to have a normal life in a family when the home is invaded by staff who come and go” (Borgstrand and Berg 2009). The traditional way of designing private apartments is to separate the most private area from rooms where you socialize with friends and family. And the result almost everywhere in Sweden has been to design the kitchen and the living room, where you

FIGURE 7.1A

FIGURE 7.1B

‘Health Care is Be-Coming Home’—In Research

FIGURE 7.2A

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FIGURE 7.2B

normally socialize, closest to the entrance to be the rooms first encountered when you enter the apartment. If you instead have one bedroom and the bathroom closest to the entrance, staff will not be forced to pass through all rooms in the apartment to be able to perform the care activities, and the other spouse does not have to be disturbed in the other rooms during the care activities. Another idea, if you are designing a house with external galleries, is to add an extra entrance door directly into the bedroom. If this entrance is not used by care-staff, it can be used as a small extra workspace or as a storage space.

#3 What About Flexible Usable Apartments, Which Can Be Changed From One Larger Apartment for a Couple Into Two Separate Apartments for One Person, and Vice Versa? Here the most important aspect is that it is not the question of rebuilding or making huge alterations. It is merely about how you by simple improvements, —such as adding one extra door or hiding the kitchen furniture—can open for alternative use, either with two small apartments or one bigger and vice-versa. Or as the figure shows, by adding an internal staircase between two apartments over each other you can have very good contact between two generations. Advantages will be the option, when you get old, to stay near your younger family so it will be easier to, for example, have a meal together.

Conclusion Healthcare in housing is increasing and resulting in new situations that are affected by how apartments are designed. For example, a bedroom and bathroom near the residence’s entrance can make it easier for both the sick person and the care staff. Therefore, it is important that architecture students are given the opportunity to meet these situations in their education.

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FIGURE 7.3

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References Alcee, Donna. 2000. “The Experience of a Community Hospital in Quantifying and Reducing Patient Falls.” Journal of Nursing Care Quality, 14 (3): 43–53. Bo bra . . . 2008. Bo bra hela livet. SOU 2008:1. Alexander, Christoffer, Sara Ishikawa, and Murray Silverstein. 1977. A Pattern Language. New York: Oxford University Press. Andersson, Morgan, Nina Ryd, and Inga Malmqvist. 2014. “Exploring the Function and Use of Common Spaces in Assisted Living for Older Persons.”Health Environments Research & Design Journal, HERD, 7 (3). Borgstrand, Ingabritt, and Linda Berg. 2009. “Närståendes erfarenheter av ett palliativt hemsjukvårdsteam (Next-of-kin Experiences from a Palliative Home Nursing Team).” Vård i Norden, Publ. 95, 29 (4): 15–19. Boverket. 2011. Regelsamling för byggande. BBR 2011, kapitel 3. Cabrera, Gabriel, and Sanna Efazat. 2010. Närståendes upplevelser av hemsjukvård, En litteraturstudie. Ersta Sköndal: Ersta Sköndals Högskola, Institutionen för vårdvetenskap. Fraser, Murray. 2014. Design Research in Architecture: An Overview. London: Ashgate Publishing. Groat, Linda, and David Wang. 2004. “Architectural Research Methods.” Nexus Network Journal, 6 (1): 51–53. Gromark, Sten, Inga Malmquist, Peter Fröst, Ola Nylander, Helle Wijk, Marie Elf, and Catharina Thörn. 2014. Integrative Ways of Residing: Health and Quality of Residence. A Concerted Trans-Disciplinary Research Effort—AIDAH ’14-’18. Architectural Inventions for Dwelling, Ageing and Healthcare. The International Conference ARCH 14 on Research on Health Care Architecture, Helsinki SF Aalto University 19–21 November 2014. Iwarsson, Susanne, and Agneta Ståhl. 2003. “Accessibility, Usability and Universal Design—Positioning and Definition of Concepts Describing Person-Environment Relationship.” Disability and Rehabilitation, 25 (2): 57–66. Iwarsson, Susanne, and Björn Slaug. 2010. The Housing Enabler Screening Tool—Short Manual. Lund, Staffanstorp, Sewden: Veten & Skapen HB och Slaug Enabling Development. Lantz, Göran. 2007. ”Hemmets betydelse.” In Hemmets vårdetik—om vård av äldre i livets slutskede, edited by Gunilla Silverberg, 31–46. Lund: Studentlitteratur. Lawton, Powell M., and Lucille Nahemow. 1973. “Ecology and the Aging Process.” In The Psychology of Adult Development and Aging, edited by C. Eisdorfer and M. P. Lawton 619–674. Los Angeles: American Psychological Association. Lifvergren, Svante. 2013. Quality Improvement in Healthcare: Experiences from Two Longitudinal Case Studies Using an Action Research Approach. PhD diss., Department of Technology Management and Economics, Division of Quality Sciences, Chalmers University of Technology, Gothenburg. Lindahl, Lisbeth, Maria Martini, and Inga Malmqvist. 2009. Vem ska värna tillgängligheten? Stockholm: Hjälpmedelsinstitutet HI. Lundälv, Jörgen, Inga Malmqvist, and Charlotta Thodelius. 2019. “Professional Voices on Risk and Accidents in Home Care—A Swedish Survey Study.” Facilities, 2019 (3). Martin, Daryl, Sarah Nettleton, Christina Buse, Lindsay Prior, and Julia Twigg. 2015. “Architecture and Health Care: A Place for Sociology.” Sociology of Health & Illness, 37 (7):1007–1022. Nylander, Ola. 1999. Bostaden som arkitektur. Stockholm: Svensk byggtjänst.

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Olsson, Erika. 2010. Patienters upplevelser av bemötande från hemsjukvårdens vårdare. 2010:83. Borås: Högskolan i Borås, Institutionen för vårdvetenskap. Pettersson, Ingela. 2009. Everyday Life and Home Modification for Older Adults—Impacts, Concepts and Instrumental Development. Rapport Dept of Neurobiology, Care sciences and Society, Division of Occupational Therapy. Stockholm: Karolinska Institute. Pettersson, Cecilia, Inga Malmqvist, Sten Gromark, and Helle Wijk. 2019. Article to be published (forthcoming) in Journal of Housing for the Elderly. Reiling, John. 2006.” Safety by Design. Safe Design of Healthcare Facilities.” Quality & Safety in Health Care, 15 (Suppl I): 34–40. Sandström, Göran. 2009. Smart Homes and User Values—Long-Term Evaluation of ITServices in Residential and Single-Family Dwellings. Diss., KTH Stockholm, Sweden. SCB.2016. Stora insatser krävs för att klara 40-talisternas äldreomsorg, Statistiska Centralbyrån. Scheidt, Rick James, and Carolyn Norris-Baker. 2004. “The General Ecological Model Revisited: Evolution, Current Status, and Continuing Challenges.” Annual Review of Gerontology and Geriatrics, 24: 34–58. SFS. 1992. Svensk författningssamling 1992:1574. Simpson, Deane. 2015. Young—Old Urban Utopias of an Aging Society. Zürich: Lars Müller Publishers. SKL. 2019. Ekonomirapporten, maj 2019, Om kommunernas och regionernas ekonomi, Sveriges kommuner och landsting. 2019. Socialstyrelsen. 2002. Jämförelsetal för socialtjänsten år 2001. Socialstyrelsen. 2008. Hemsjukvård i förändring, En kartläggning av hemsjukvård i Sverige och förslag till indikatorer. November 2008. Socialstyrelsen. 2011. Kommunaliserad hemsjukvård. SOU 2011:55. Socialstyrelsen. 2015. Tillståndet och utvecklingen inom hälso- och sjukvård och socialtjänst— Lägesrapport 2015: 120. SOU. 2011. Regeringskansliet, Kommunaliserad hemsjukvård. SOU 2011:55. Tamm, Mare. 1999.” What Does a Home Mean and When Does It Cease to Be a Home? Home as a Setting for Rehabilitation and Care.” Disability and Rehabilitation, 21 (2): 53. Van Steenwinkel, Iris, Bernadette Dierckx de Casterlé, and Ann Heylighen. 2017. “How Architectural Design Affords Experiences of Freedom in Residential Care for Older People.” Journal of Aging Studies, 41: 84–92. Vårdförbundet. 2014. När vården flyttar hem—den kommunala hälso- och sjukvårdens sjuksköterska i vårdens paradigmskifte. Göteborg. Västra Götalandsregionen. 2011. Det goda livet för sjuka äldre i Västra Götaland; Regional handlingsplan 2012–2014 med särskilt fokus på de mest sjuka äldre. Wiklund, Gabriella, and Stefan Melin. 2013. Bo bra på äldre dar—kunskap, kreativitet, kvalitet. Stockholm: AB Svensk Byggtjänst.

8 ENVIRONMENTS FOR CARE PROVISION IN ORDINARY HOUSING—A TRANSDISCIPLINARY EXPLORATION OF PROS AND CONS Cecilia Pettersson and Helle Wijk Ageing in Place—A Global Trend Home- and healthcare services for older people are expanding. However, ordinary housing is not designed for these services, and privacy can therefore seldom be respected. In line with the ageing population in most developed countries around the world, multiple solutions for housing and care of older people as well as health and safety for home- and healthcare staff must be developed. There is a need for research and innovations regarding how new, as well as existing, housing areas can promote a comfortable life in old age. In Sweden, almost 20 percent of the population was over 65 years old in 2016, and the same group is estimated to represent 25 percent of the population in 2060 (National Board of Health and Welfare 2018). This will have a great impact on planning and economy in the municipal sector, which is most often responsible for home- and healthcare. In recent years, more and more healthcare activities have been taking place in ordinary housing. In Sweden, 169,000 people 65 years or older living in ordinary housing received interventions from home care in 2018 (National Board of Health and Welfare 2019). This increasing tendency, together with the population getting older, puts pressure on the home- and healthcare sector to offer a safe working environment for its staff. In addition, this development also highlights the situation for next-of-kin living with people in need of home- and healthcare, who may experience their home being transformed into a health care institution due to medical equipment needed and staff coming and going (Borgstrand and Berg 2009).

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Accessibility not only from the residents’ perspective, but also from the staff ’s perspective, is a crucial issue in studying how residential apartments can be designed to meet requirements in situations where staff in home- and healthcare services perform care in ordinary housing. The quality of working environments is affected by the extent to which rooms are made for work to be properly undertaken. Two important questions concern the layout of apartment plans. How does the f loorplan affect the ability of home healthcare services staff to perform care work, particularly given that such work is often carried out in bedrooms and bathrooms? What opportunities do residents have to maintain privacy despite the performance of care work in their home? In addition, it is important to consider not only the rooms in which healthcare tasks are performed but also the extent to which staff need to pass through other rooms in the home. The possibility of personal privacy is particularly important when the household includes people other than just the person who is receiving care. In Sweden, the Swedish Work Environment Authority recently stated that to work within health care and social care sectors by helping people in their daily activities such as patient transfer, dressing, toilet visits and showering brings with it problems with, for example, the back, shoulders and arms as a result of sudden or long term strain. ( The Swedish Work Environment Authority 2014, 7) This authority has undertaken inspections of workplaces within the health care sector, with specific focus on risk assessment in patient transfers. Based on these inspections, they concluded, “The employer should investigate and assess the working conditions with focus on ergonomics during the different working efforts that occur in the operation” (The Swedish Work Environment Authority 2014, 7). Furthermore, due to the complexity of work, it is difficult to put forward guidelines that cover all transfers of people in home- and healthcare. Due to the complex and unsafe environment, there are also difficulties in recruiting staff to many of the jobs available in home- and healthcare services. Thus, to ensure a safe working place for staff in home- and healthcare as well as age-friendly ordinary housing for older people, more knowledge of house- and interior design features in new, as well as in existing, housing needs to be investigated.

The Transdisciplinary Perspective on Ageing in Place There is a growing interest in transdisciplinary research (Mobjörk 2010). Transdisciplinary research (TD) is described in different ways in the literature: for example, Gromark, Andersson, and Braide (forthcoming 2020) and Klein (1990). In this chapter, we consider the description by Mobjörk appropriate, which states, “Transdisciplinarity can be understood as an extended knowledge

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production process including a variety of actors and with an open perception of the relevance of different forms of information produced by the scientific and lay community” (2010, 866). Furthermore, in descriptions in the literature on the transdisciplinary research approach, the terms problem focus and problem solving are common, and are often used in research in general (Mobjörk 2010). She further argues that the approach to the problem characterizes transdisciplinary research, as for example the actors and perspectives chosen for the process. Likewise, a problem-solving approach is appropriate for studies on health and housing in specific areas (Lawrence 2004; Mobjörk 2010). Furthermore, Lawrence (2006) argues that disciplinary research has dominated, and as related to health and residential environments, too few interdisciplinary studies and even fewer transdisciplinary studies contribute to the state of the knowledge. According to Brown and colleagues (Brown, Harris, and Russell 2010), for an open transdisciplinary inquiry, it is important to understand the problem in depth and to understand the width and complexity of issues addressed. With a view to addressing an identified gap between an expanding level of demand for home- and healthcare services for older people, and a housing stock that has not been designed to meet the requirements of such services nor to respect personal privacy in their delivery, we believe that a transdisciplinary approach is of utmost importance. To identify the specific requirements of the physical environment when home- and healthcare are performed for older people living in ordinary housing, it is important to obtain input from researchers from different disciplines and involvement from relevant actors such as staff in home- and healthcare and different stakeholders, which is in line with Mobjörk’s view (2010). Adopting a transdisciplinary approach in research on enablers and barriers in the physical environment for the delivery of home- and healthcare, in this chapter, we present how a mixture of professionals’ perspectives and different actors’ involvement can contribute to transdisciplinary research. In line with transdisciplinary research, to support the process of healthy ageing in ordinary housing, and a safe working environment for the staff, it is important to conduct transdisciplinary studies. Such studies should involve a team, comprised of researchers in architecture, care science and occupational therapy as well as older people living in ordinary housing, staff in home- and healthcare services, and stakeholders in municipalities.

The Involved Researchers’ Perspectives Perspective of Architecture From an architectural research and design point of view, related to residential solutions for the elderly in question here, it is important to address the general notion of adaptability from a long-term perspective: as an important enabling

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factor. How could an apartment plan be designed in order to have the capacity and residential resilience to smoothly adapt to a radically new and sudden home healthcare situation, as it happens, preserving the integrity and privacy of the resident patient and the whole household as well as the efficacy and dignity of personnel acting in an appropriate spatial arrangement? This aspect should be included in the design process—along with details on design f laws and potential major barriers in this context, or on injury prevention, insights as findings from a transdisciplinary research process—as an important quality criteria standing in parallel with spatial elasticity that should be equally provided for households’ life course transformations. As the process towards home healthcare is so much accentuated today and for tomorrow, this aspect takes on a specific gravity and longevity.

Perspective of Care Sciences From the perspective of caring science, environmental research is aimed to investigate the surrounding environment’s importance for health and wellbeing. The health care environment research focuses on the experiences of patients, family, and employees. Furthermore, hospital-related injuries— psychosocial and physical—are investigated as well as health-economic factors that can be linked to the environment. The experience of the environment of a room is personal. Individual perceptual conditions such as sight, hearing, and sense of touch have an impact on how we perceive and understand a room. Moreover, our different backgrounds, understanding, and experience also play a role. The scents, sounds, materials, and views are also perceived and valued differently and may inf luence, consciously or unconsciously, our experience of the environment as attractive, pleasant, and welcoming, or the opposite. A person-centered approach is crucial in the planning and adaptation of health care facilities where individual preferences, singular desires, and needs are to be met.

Perspective of Occupational Therapy An occupational therapy perspective can be defined as “a way of looking at or thinking about human doing” (Njelesani et al. 2014, 233), and is based on specific knowledge about the complex relationships between person, environment and activity. Among occupational therapists, the Canadian Model of Occupational Performance and Engagement (CMOP-E) ( Townsend and Polatajko 2007) is a well-known theoretical model, focusing specifically on the components of person, environment, and activity that interact in a dynamic relationship. Overall, a client-centered approach is vital in occupational therapy. This entails clients being involved in making decisions about their rehabilitation together with their therapist, in

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accordance with their needs and experiences. Occupational therapists are well qualified to contribute to an enhanced understanding of challenges in person-environment-activity transactions in the home and society. To enable an optimal working environment for staff in home- and healthcare, and considering older people’s perspectives, it is important to contribute with this specific knowledge. The transdisciplinary research approach provides important knowledge for housing companies and architects as well as for medical decision makers in home- and healthcare, based on the combination of scientific methodological approaches applied to residential situational contexts. Here the aim is to improve knowledge and to include ideas from different actors on how to build the new home- and healthcare situation. The aspect of social sustainability will be profound in finding good solutions for a dignified life in your private home that will also offer good working conditions for staff.

Exploring Physical Enablers and Barriers for Home- and Healthcare Services Design and Data Collection To get an overview of the state of the knowledge, a scoping review can be conducted to start with in order to constitute a basis in planning for the study ( Pettersson et al. 2020). The transdisciplinary research groups’ understandings shall be taken into consideration throughout the process of planning for the study. A crucial factor is to combine quantitative and qualitative methods in a mixed method design in order to grasp the transdisciplinary approach (Freshwater 2007; Groat and Wang 2002; Patton 2002). A summarized description of the study is presented here; for a more detailed description see the study protocol article (Pettersson et al. 2019). The methodological strengths of this kind of study include the combination of (i) observations of staff performing interventions in home- and healthcare (ii) interviews with older people receiving home- and healthcare services with (iii) focus group interviews with staff, which together will provide important complementary information and understanding. As shown in Figure 8.1, using a transdisciplinary approach opens for a variety of data such as:

Qualitative Data • • •

Observations of staff performing interventions in home- and healthcare Interviews with older people living in ordinary housing and receiving home- and healthcare Focus group interviews with staff in home- and healthcare

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FIGURE 8.1

The different steps in the transdisciplinary research study

Quantitative Data • • •

Document studies regarding the layouts of actual apartments, with info on usage over time by residents and mappings of furniture room configurations Data on the ordinary housing: type, building year, size, number of rooms, f loors, communication structure, elevator and staircases Data on the magnitude of accessibility problems for each person in their specific home environment

Sampling The ordinary housing that will be studied should be selected based on areas where the researchers are allowed to conduct observations of staff when they perform interventions in home- and healthcare, and areas that ref lect the composition of existing housing in Sweden such as different social status, of different sizes and ages and constructed during the last 100 years. Multi-dwelling

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residential buildings are relevant for this type of study. This is because singlefamily houses make up a smaller proportion of the housing stock, and because the f loorplans of single-family homes often are sufficiently varied for the researcher to be able to draw consistent conclusions. The aim is to provide architects and planners with new knowledge regarding the planning of apartments in multi-dwelling residential buildings that are suitable for older people in need of home- and healthcare.

Procedure The observations of home- and healthcare staff and interviews with older people could preferably be performed by an occupational therapist with extensive experience of home- and healthcare, meeting people with functional limitations and mobility device use.

Data Analysis Researchers with different perspectives such as architecture, care science, occupational therapy and physiotherapy should conduct the data analysis, and different methods for triangulation should be used.

Ethical Considerations All ethical principles for human research in the relevant Swedish national legislation (i.e., the Act Concerning the Ethical Review of Research Involving Humans (SFS 2003, 460) and the Personal Data Act (SFS 1998, 204) and the World Medical Association Declaration of Helsinki (World Medical Association 2001) must be followed. Various authors in the literature describe different benefits and drawbacks in performing transdisciplinary research. However, in this chapter, our ambition is not to present the state of knowledge but to present benefits and drawbacks as related to taking a transdisciplinary research approach in order to explore enablers and barriers in the physical environment for delivery of home- and healthcare services. For example, Brown presents some aspects of relevance for that kind of research. He argues that open transdisciplinary research includes different principles, stating “the need for the relationships between researchers, researched and research to be transparent and equitable” (Brown, Harris, and Russell 2010, 105). Further, by use of a collective inquiry, dialogue and trust are important in the relationships between researchers. As related to practice, Brown (Brown, Harris, and Russell 2010) describes a continuum of relationships between researchers and researched. Brown also describe challenges in transdisciplinary research as threefold such as: a broad data collection process; synthesize, analyze and interpretation, including open ontology, epistemology and ethics. Additionally,

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Brown describes how to select a transdisciplinary research strategy in three steps. The first step is to question if the research methods are appropriate for different environments, contexts or concepts in focus. The second step is about decisionmaking and how to identify the participants involved in decisions. Finally, the third step is about selection of research strategy and tools.

Lessons Learned Ref lecting on our experiences of using a transdisciplinary research approach in our study, some aspects should be mentioned. First, we found it important to plan for meetings on a regular basis. In these meetings, we were made aware of and respected our different perspectives and the need to strive for openness in our discussions. It became clear that we did not use the same terms and concepts. Thus, we spent some time reaching agreement on such aspects. We had meetings throughout the planning phase for the study and shared our different perspectives in constructing the interview guides for the individual and focus group interviews, in planning for performing the data collection and data analysis and writing publications. These meetings were characterized by an openness between the involved researchers and stakeholders in the municipality who were involved early in the process. We were aware that if researchers with different perspectives conduct data analyses together, this might be timeconsuming. However, this will generate a deeper understanding of enablers and barriers when home- and healthcare are performed in ordinary housing. Based on our experiences, it is important, in an early stage, to discuss the data that the data collection is expected to generate, and to create a transparent structure for those who have the main responsibility in respect of which data to be analyzed, and when other researchers in the study should be involved. Likewise, it might be time-consuming if researchers with different perspectives should interpret the results and how they should be presented. However, this will probably generate a deeper understanding of the research problem in question. Another important experience is that stakeholders in the municipality have relevant important knowledge of importance in enabling safe working environment when home- and healthcare is performed. Thus, such stakeholders are important actors in terms of conveying knowledge to others. One of the most important challenges in society is dealing with impacts on the growing proportion of older people who need home- and healthcare. To meet this challenge, it is important to have knowledge of the needs to be addressed. In our transdisciplinary research study, this means not only the experts who provide home- and healthcare but also those older people receiving such services.

Conclusion To support actors in home healthcare services to older people living in ordinary housing, it is important to conduct studies with a transdisciplinary perspective.

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Therefore, a team of researchers in architecture, caring science and occupational therapy are involved to study the interaction between staff, older people and their living environments. To be able to explore the complex residential situational context in ordinary housing, it is important to include older people, staff and stakeholders. Our experiences of using a transdisciplinary research approach showed that it is important to plan for meetings on a regular basis, and to respect people’s different perspectives. We had meetings throughout the planning phase for the study, and these meetings were characterized by openness. Based on our experiences, it is important at an early stage to discuss the data that the data collection will generate and to create a transparent structure for those who have the main responsibility with respect to which data is to be analyzed, and when other researchers in the study should be involved. Since one of the most important challenges in society is dealing with the growing proportion of older people who need home- and healthcare, it is important to have knowledge of the needs to be addressed. In our transdisciplinary research study, this means a close participation not only with the experts who provide home- and healthcare but also the elderly who receive service and care in their private home.

References Borgstrand, I., and L. Berg. 2009. “Närståendes erfarenheter av ett palliativt hemsjukvårdsteam (Next-of-kin Experiences from a Palliative Home Nursing Team).” Vård i norden Publ 29: 15–19. Brown, V.A., J.A. Harris, and J.Y. Russell. 2010. Tackling Wicked Problems through the Transdisciplinary Imagination. New York, NY: Earthscan from Routledge. Freshwater, D. 2007. “Reading Mixed Methods Research: Contexts for Criticism.” Journal of Mixed Methods Research 1 (2): 134–146. https://doi.org/10.1177/ 1558689806298578. Groat, L., and D. Wang. 2002. Architectural Research Methods. New York: John Wiley & Sons, Inc. Gromark, S., B. Andersson, and A. Braide. forthcoming 2020. “Explorations on Residential Resilience—brf Viva 2011–2019.” In Enabling the City. Inter and Transdisciplinary Encounters, edited by Josefine Fokdal, Liis Ojamäe, Olivia Bina, Prue Chiles, and Katrin Paadam, 90–110 [COST Intrepid publication]. London: Routledge. Klein, J. T. 1990. Interdisciplinarity: History, Theory, and Practice. Detroit: Wayne State University Press. Lawrence, R. J. 2004. “Housing and Health: From Interdisciplinary Principles to Transdisciplinary Research and Practice.” Futures 36 (4): 487–502. https://doi.org/ 10.1016/j.futures.2003.10.001. Lawrence, R. J. 2006. “Housing and Health: Beyond Disciplinary Confinement.” Journal of Urban Health 83 (3): 540–549. https://doi.org/10.1007/s11524-006-9055-4. Mobjörk, M. 2010. “Consulting versus Participatory Transdisciplinarity: A Refined Classification of Transdisciplinary Research.” Futures 42 (8):866–873. https://doi. org/10.1016/j.futures.2010.03.003. National Board of Health and Welfare. 2018. Kvalitetsregister i kommunal hälso- och sjukvård Täckningsgradsjämförelser och resultat av sambearbetningar med Socialstyrelsens register. Artikelnummer 2018–2–17.

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National Board of Health and Welfare. 2019. Statistik om socialtjänstinsatser till äldre 2018. Accessed September 30, 2019. www.socialstyrelsen.se/globalassets/sharepointdoku ment/artikelkatalog/statistik/2019-5-7.pdf Njelesani, J., A. Tang, H. Jonsson, and H. Polatajko. 2014. “Articulating an Occupational Perspective.” Journal of Occupational Science 21 (2): 226–235. https://doi.org/ 10.1080/14427591.2012.717500. Patton, M. 2002. Qualitative Research and Evaluation Methods. London: Sage Publications Inc. Pettersson, C., I. Malmqvist, S. Gromark, and H. Wijk. 2019. “Study Protocol: The Physical Environment and Home Healthcare Services: The development and Content of a Study Protocol to Explore Enablers and Barriers for the Delivery of Home Healthcare Services.” Nordic Journal of Architectural Research 31 (2): 105–122. Pettersson, C., I. Malmqvist, S. Gromark, and H. Wijk. 2020. “Enablers and Barriers in the Physical Environment of Care for Older People in Ordinary Housing: A Scoping Review.” Journal of Aging and Environment: 1–19. https://doi.org/10.1080/02763 893.2019.1683671. SFS 1998:204. Personuppgiftslag [Swedish Personal Data Act]. Stockholm: Swedish Ministry of Justice. SFS 2003:460. Lag om etikprövning av forskning som avser människor [Swedish Act concerning the Ethical Review of Research Involving Humans]. Stockholm: Swedish Ministry of Education and Research. The Swedish Work Environment Authority. 2014. Ergonomics in Women’s Work Environment—Inspections with Focus on the Risk Assessment of Patient Transfer within the Health Care and Social Care Sectors. Report 2014:5 Eng. Accessed September 30, 2019. Townsend, E., and H. Polatajko. 2007. Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well-being and Justice through Occupation. Ottawa: Canadian Association of Occupational Therapists. World Medical Association. 2001. “World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects.” Bulletin of the World Health Organization 79(4): 373.

9 ASSISTED LIVING FOR THE ELDERLY—FEATURES OF A SWEDISH MODEL Morgan Andersson

Introduction In Sweden, the provision of assisted living (AL) for older people is a municipal responsibility, according to the Social Services Act (SFS 2001, 453). Older people are here defined as 65 or older and the oldest old as 80 or older. Most of the care provision is given directly by the municipalities, but a fast-growing private sector is providing AL both on procurement by the municipalities and as private care providers. To define Swedish AL for elderly people, it is necessary to compare with other comparable countries in the industrialized world, and we find major structural similarities (Anderzhon et al. 2012; Kalymun 1991; Paulsson 2002; Zimmerman and Sloane 2007). It is generally regarded as a housing option, special housing, with care staff around-the-clock. In Sweden, like in most comparable countries, the target group is 65 or older. The similarities also include a subdivision into smaller units, or groups with shared spaces for social interaction. However, AL also belongs structurally to an institutional tradition, like hospitals, nursing homes and prisons (Goffman 1961; Gubrium 1975; Martin 2002; Nord 2013; Åman 1976). AL typically contains small apartments of 30–40 m 2, horizontal communication areas (corridors), common spaces for a group of residents, common spaces for communal activities and spaces for staff. In Sweden, AL apartments are always rented apartments. AL has three main objectives (Andersson 2013, 2). First, it is a home for the resident. Secondly, it is a form of care provision. Increasing longevity, more elderly people and, partly as a result of this, increasing costs of hospital care, currently results in more care provision in both ordinary housing and AL and puts stress on the municipal care provision. It also entails more people in

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advanced age in AL, with multimorbidity, including dementia. Thirdly, the AL provides necessary service to the resident, both in terms of assisting the residents in their daily lives and the provision of domestic services such as meals or cleaning. These three purposes represent both the residential, or home, perspective and the workplace perspectives. To these three objectives, it is necessary to add one perspective concerning the physical environment: the building perspective. This entails both the construction phase and the long-term management and maintenance of the building. To live in AL is to have your notions of the home concept challenged. Jan Paulsson (2002) describes four dimensions of home or housing. First, the practical dimension which concerns location and design and other physical characteristics. Second, the social dimension—to choose to be alone or to socialize. Third, the communicative dimension, which concerns communication and way-finding—the home as a means of communicating yourself to others. The fourth is the existential dimension, related to the subjective perception of the place and to place attachment (Schumaker and Taylor 1983). Increased care needs, dependence on help from others and the inevitable, the drastic down-sizing from ordinary housing to AL and the seclusion from the “ordinary” society contribute to this disengagement process (Cumming and Henry 1961, 37–75). Today (December 31, 2018), 81,289 people in Sweden live permanently in AL, which is approximately 0.8 percent of the total population of 10,182, 291, or 4 percent of all people 65 or older (SCB 2019). The share of private providers

FIGURE 9.1

Common sitting room in a Swedish AL facility built in 2014.

Source: ©Photo: The Author.

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is currently increasing and in 2017, 23 percent of the home care services and 21 percent of the AL was performed by private providers (Ekonomifakta 2019). This is an increase by 50 percent, compared with 2006.

Models for Housing and Care Provision Residential purposes, care and service are the three main objectives of the AL in Sweden today. They also represent “models” for residential care: the housing unit, the care institution and the service provision. These models or key concepts are represented by different building types with different content and are generalizable in comparison with most Western countries (Andersson 2017, 127–142). The dwelling unit, or the home, is associated with privacy and control (Hauge and Heggen 2008, 461). The concept of home is relevant to discuss in all settings where people are dwelling for periods, even in intensive care and hospital care (Andersson, Fridh, and Lindahl 2019; Lindahl and Bergbom 2015). The care institution is represented by both the surveilling and controlling “total institution” as it is described by Goffman (1961, 4–5) and a healing environment that is specialized in getting people well (Ulrich et al. 2008, 101). The service provision is part of both housing and care provision, but currently, there is a trend moving from the “care concept” in AL and towards a “service concept” (Nord 2011b). The obvious exponent of the service concept is of course the hotel, with its cozy, but not personal, layout, reception areas and lounges (Avermaete and Massey 2013). In Swedish AL facilities this is an evident trend in recent production, with reception desks, cafés and lounges. In many other countries, such as the USA and the UK, a large private market with senior housing, nursing homes, retirement communities, and so forth, has been available for elderly people. In many of these facilities, the service concept is present in hotel-like layouts and design, reception desks, lounges, and so on (Anderzhon et al. 2012; Feddersen and Lüdtke 2009). There are few housing options directed towards elderly people within the ordinary housing market. Host-assisted senior housing facilities are built by municipalities or private providers and offer a daytime host and a common facility for communal activities. Senior housing facilities are mainly privatelyowned apartment blocks or terraced houses, with varying tenure. This has opened for new approaches to housing for the elderly in many countries (Huber 2008). Neither host-assisted senior housing nor senior housing have any legal regulations concerning construction or the provision of apartments, but they are constructed with good physical accessibility. Builders have long been granted state subsidies for the construction of AL as well as host-assisted senior housing facilities (SFS 2007, 159).

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Table 9.1 Comparison between different concepts for housing and care directed towards elderly people. The comparison shows differences between residential, workplace and care aspects.

Assisted living

Host-Assisted Senior Housing

Senior housing

Residential unit: Workplace: Care provision:

Apartment and unit Care staff 24/7 In the building

Apartment

Apartment — Ambulating home care

Facilities:

Tenure:

Common spaces and facilities Dependence, care Rented

Concept:

CARE

Host daytime Ambulating home care Common facilities Independence, service Rented or owned SERVICE

Dependence:

Common facilities Independence, service Rented or owned RESIDENTIAL

At-Homeness, Place and Control What kind of a place is an AL facility? Is it possible to make it your home, and to make a home out of it? Three factors are discernable for the possibilities to create a place of your own—a home. First of all, the space or room is a facilitator or preventor of the possibilities to create a life-space and live a good daily life in AL (Nord 2011a; 2011b; 2013). A place is something to which you have an experiential relation, with an absolute relation to time. The place is thus continuously recreating itself as a new place (Anderson and Wylie 2009, 328). The room or place, or the experience of it, is associated with a number of factors. Who has access to it? Is it personal or general? What is the scale? What is the condition? What senses are stimulated by the room? Secondarily, temporal aspects affect the way you perceive a place. Have you been here for long? Can you come and go? Can you decide how long you will stay? Thirdly, but not least, the capabilities, or competence, of the person determines what actions can be performed and how they are perceived. Lawton and Nahemow (1973) present “The Ecological Model of Ageing”, where congruence between the complexity of a task and the competence of the performer is necessary for the wellbeing of the performer. What is your health status and your prognosis? How dependent are you on help from others? What are your experiences, your identity, and your preferences? Translated to the physical reality of AL facilities, these experienced aspects must be regarded in relation to the existing spaces that constitute the physical environment. If the apartment is the most private and offers most at-homeness;

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the communal facilities in the building (e.g., shop, hairdresser, hall for communal gatherings) are the most public spaces. Previous research has shown that the common spaces on the units are more problematic, since they either are perceived as neither private nor public—ambiguous spaces—or as spaces that are not part of the home (Andersson, Ryd, and Malmqvist 2014; Andersson 2017; Nord 2011a; 2011b). Following this argumentation, I suggest that there are many interacting factors related to residential, workplace and care issues affecting the effectivity and usability of AL facilities, both regarding private and common spaces.

Challenges Regarding both new and existing AL facilities, there are many challenges. One mega-trend is, obviously, the changing demography worldwide with an increasingly older population. This trend is related to urbanization, mass migration, improved health status, medical progress and growing economies. On the other hand, more older people in society means fewer in production and, as a result, shrinking tax incomes. One meso-trend on a global level is changing family structures. Improved economy, urbanization, absence of war, global migration, and so on make individual development possible and promote alternative ways of living and residing. The homo-, bi-, trans-, and queer sexual movement and groups lobbying for better conditions for people with disabilities have, amongst others, facilitated more inclusive approaches to housing and residency. This is a strong reason for discussing different models for dwellings for the elderly and for promoting diversity and the freedom of choice as overarching guidelines for future housing production. In Sweden, there are some specific issues related to demographic and economic factors. The Swedish eldercare model directs the responsibility for the eldercare to the 290 municipalities, which varies a lot in terms of geographical area and population size. The very different prerequisites between the municipalities and the low degree of cooperation between them, in combination with demographic and economic factors, entails a crisis in eldercare provision, with increasing costs and shortage of staff. Another related issue is the shift from hospital care to home care and, hence, the increased care provision in AL. Besides hygienic and spatial issues (van Hoof 2010), dementia and housing design (Imamoglu 2007; Marquardt and Schmieg 2009; Parker et al. 2004; Utton 2006), along with security and safety issues in home care, need more attention (Harrison et al. 2013). Also, both in institutional care and home care, it has been shown that many people experience an overwhelming sense of loneliness ( Jansson, Karisto, and Pitkälä 2019; Schittich 2007). In Swedish eldercare, loneliness is also one of a number of criteria for moving into AL.

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The historically small Swedish private eldercare sector has increased steadily during the last 15 to 20 years (Ekonomifakta 2019). Ordinary housing options directed towards the elderly in the ordinary housing market has never been successful at large. Studies show that elderly Swedes wish to remain in their homes as long as possible (Abramsson and Niedomysl 2008; Bodin 2012; Gothenburg Region 2012). Another typical Swedish profile is the large housing stock from 1960 to 1980, including AL facilities. These buildings often have deficiencies in quality, material, design and energy consumption and often have a low space effectivity.

Environmental Indicators and Trends There are currently a number of environmental indicators and trends that affect how we adapt different concepts to AL or other housing options for the elderly. One problematic issue is the prevention of contagious diseases. In housing facilities for groups of people, there may be a need for isolating individuals. Other issues are how we prepare ordinary housing for better physical accessibility and for more advanced care administration, which is related to area size and design. There are currently several health-promoting trends impacting the design and management of AL facilities. One is the nature trend; to be in nature is proven to be beneficial for all people, regardless of age (van den Berg 2005; Chalfont 2008; Minton and Batten 2015). Closely related to this trend is the garden trend: accessible therapeutic environments and healing natural environments for the elderly (Rodiek, Lee, and Nejati 2014; Wang 2014). Physical activity is proven to be beneficial for all, regardless of age, and much can be done in the physical environment to facilitate activity (Benjamin et al. 2014; Cunningham and Michael 2004; Zimring et al. 2005). The feel-good trend is about creating value with sensory impressions beyond the necessities of everyday life with good food, wine, spa, music, art, and so forth. Except that these feel-good activities, to a great extent, constitute and define us as cultural individuals, they also promote health and well-being. Dementia villages have been an international trend for a decade. One inf luential dementia village has been de Hogeweyk in Weesp, the Netherlands, built in 2009. It is a form of gated community, also described as a “dementia-caring neighborhood” (Anderzhon et al. 2012, 145) where people with dementia have greater opportunities to move more or less freely within the facilities, with access to shops, hairdressers, restaurants, pubs and so on. The main critiques, though, are that the residents are presented with a false reality and that there are similarities with old institutions, where everything was provided within the facility ( Johnson 2019).

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FIGURE 9.2 Trädgårdarna assisted living (AL) in Örebro, Sweden from 2017 by Marge Architects. Not a dementia village, but clearly inspired by the idea. Winner of several national architectural prizes.

The global population growth and urbanization is a mega-trend. As a consequence, we see densification programs in most Western cities and increased competition for the available spaces. In Sweden, the insufficient long-term coordination of spatial resources dedicated to old people may result in deficiencies in quality and effectivity concerning the delivery of eldercare facilities. The development in information and communication technologies offers greater possibilities for individual independence. It also facilitates an effective and efficient care provision (Caleb-Solly et al. 2019; Erden et al. 2016). But it can also exclude people from participation (Mahmood et al. 2008; Rosenberg et al. 2009). Assistive technology for functional variations is also developing rapidly. This development will inevitably affect the design of housing facilities for the elderly.

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Discussion and Conclusion To create generally good home environments in AL for elderly people is a complex task. There are several schemes and design principles applicable to this context. There are also many issues and trends affecting the mindset regarding AL. The many challenges related to demographic and economic issues put severe strain on Swedish eldercare organizations at present. Efforts to increase the popularity and attractiveness of eldercare professions must include appealing physical environments along with long-term and nationally orchestrated planning. The concept of AL as a housing option needs to be updated, incorporating aspects of home, diversity, freedom of choice, service and care. It is necessary to make it a viable option in the housing career of residents (as they move in a lifelong trajectory from one residential situation to another). Economic restraints and geographical inequalities should, in an ideal world, result in increased cooperation, long-term planning and development of the concept to fit current demands and ensure good housing quality. The expansion of private providers and the emergence of alternative ordinary housing options can ease the pressure on the municipalities. Co-housing, residential communities, different forms of tenure and improved housing accessibility, both in existing stock and in new production, offer great opportunities— far from the current situation. Here, the municipalities have great possibilities for innovation with regard to their planning monopoly. Discussing the concept of home is relevant wherever people dwell for shorter or longer periods. In AL it is, to a great extent, a spatial discussion. Design strategies must take into account the different objectives for apartments, common spaces and communal facilities and create attractive and effective rooms, based on actual use and not a notion of how the rooms should be used. Considering the complexity of the assisted living concept, there are many directions for further research. One would be aspects of attractivity. Another would be issues concerning effectivity and usability. A third direction would incorporate different forms of tenure design schemes. Given the increasing societal importance and economic consequences, research efforts could widely improve both production planning processes in the early stages and the management of existing facilities.

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10 AVAILABLE SPACE— ARCHITECTURAL AGENCY AND SPATIAL DECISION-MAKING IN A CARING ORGANIZATION Catharina Nord

Introduction Space tends to go unnoticed because of its self-evident presence in which people and activities are enmeshed. Despite its vague and intangible nature, space also has considerable impact on decisions people make to the extent that it can be regarded as an agent in itself (Gieryn 2002). Even a mundane and invisible architectural agent—available space—may have considerable impact on people’s activities and decisions. It has been argued that architecture “never accomplishes what it intends” (Lash et al. 2009, 10). Architectural space is never complete, and neither are organizations (Clegg, Kornberger, and Rhodes 2005). Organizational change may happen in incremental, step-by-step adaptations of existing organizational structures, or in discontinuous introductions of innovations that introduce something entirely new in the organization (Scott et al. 2000). This paper presents a process without beginning and end in the development of a healthcare organization in which an architectural agent works in highly invisible ways, but nevertheless makes radical contributions to change in organizations. It feeds on contingency when conf lated with multiple alternatives in a co-emergent organization. Thus, the organization intersects with architectural space in manners that are neither fully controllable nor foreseeable simply because space was available. The case in the narrative is a municipality organization that delivers care services to older people, where healthcare architecture integrates housing and care. The aim is to show that although it may be relatively small-scale, architectural space has an impact on transformations of healthcare organizations. The case through which this issue will be explored is care work in extra-care housing in Sweden. The second aim of this paper is to challenge the view of human agents as the sole actors in organizational change.

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This will be achieved by introducing a dynamic perspective with support of theories on spatial agency.

Architectural Space as an Agent A point of departure is thus that architectural space is an active, generative component and a driving force behind organizational change (Kornberger and Clegg 2004; Beyes and Steyaert 2012; Dale and Burrell 2007). Organizations and space are entangled in interlinked networks of dependencies and affections. Continuous organizational changes occur throughout a building’s life, enmeshed in its spaces ‘in becoming’ where organization happens in simultaneously constituting processes (Clegg, Kornberger, and Rhodes 2005, 153). In such a perspective, agency—the driving force in these processes—is distributed among a number of involved components and it is thus possible to bestow agency on non-sentient matter, such as buildings and building components ( Yaneva 2008). Architectural space becomes a subjectivity that acts (Brott 2013). The architectural agency contributing to organizational becoming is elusive and arbitrary. The outcome of spatial and organizational co-changes comprises a significant component of contingency (Kornberger and Clegg 2004, 1098– 1099). Brott (2013, 3) writes that architectural subjectivity “does not mean that buildings .  .  . become persons, but that architecture works by entering into anonymous processes of subjectivity . . . Lived experience is altered as a result”. However, Brott (2013, 2) also notes that “the impersonal effects can always become re-personalized in their derivative mode where architecture becomes objectified . . . where subject/object relations are restored”. These perspectives may explain how architectural agency is received and interpreted in organizational change. While the architectural agent may suggest certain steps, the human agent must consider these suggestions in light of development plans of the organization or of upcoming organizational concerns. The architectural subject then becomes an object that is available for consideration. Architecture is a result of compromises and negotiations (Till 2009; Yaneva 2008). Gieryn (2002) presents two concepts that illuminate the complex situation that gives architecture form and the capacity to respond: ‘heterogeneous design’ and ‘interpretive f lexibility’. Heterogeneous design is a compromise between material, diverse social demands and interests, and technical, functional, and organizational aspects. Interpretative f lexibility implies the degree to which a building can accommodate adaptations to novel uses of importance to organizational change, either discursive or material. Buildings then become involved in processes of transformations and adaptations that constitute arenas where organizations change. The case in this paper is a caring organization (i.e., an organization with a long-term commitment to providing care). It is dependent on its spatial assets for quality and the provision of its services. Architectural space contributes to a caring organization by actively engaging in

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care through the coproduction of organizational performances where changes may take place (Nord and Högström 2017). The paper builds on a qualitative study in an extra-care housing residence with nine months of fieldwork in which individual interviews, observations and shadowing were the main data collection methods (for details see Nord 2018). It links to a post-humanist epistemology in which networks, becomings and multiplicities are the focus of interest (Law 2004; Vannini 2015). In order to capture the relationality and networked aspects of various situations, the application of a symmetrical perspective on matter and people bestowed agentic capacity to architectural space in the search for associations and relationships between organizational change and architectural space. Available space emerged as an essential concept in this analysis.

Transformations of an Extra-Care Housing Residence Extra-care housing was introduced as a housing option for older people in Sweden in a governmental report in 2008 (SOU 2008, 113). Extra-care housing should comply with certain requirements, age restrictions—targeting people age 70 and older—and the provision of common facilities for dining and socializing. Residents are expected to use the home care services available to all elderly people in Sweden. The extra-care housing in this paper offered a similar level of care as residential care in which 24-hour care is provided by permanent staff. This is a highly unusual case in Sweden. However, as will be evident below, the extra-care housing residence underwent a significant reorganization, changing from a permanently staffed facility to a residence served by home care services. This reorganization will illustrate the links between architecture and change in healthcare organizations. Available space was an agent with considerable inf luence on these transformations. The extra-care housing residence comprised two three-story buildings standing at 90-degree angles to each other that embraced a park-like garden (Figures 10.1 and 10.2). In the immediate urban context were terraced houses occupied by many other elderly people that did not belong to the extra-care housing. The two residence buildings were connected by an inbuilt passage link on the second f loor. One of the buildings (A) contained f lats on the first and second f loors. Initially there were offices on the ground f loor for the residence management and the municipality’s home healthcare nurses, as well as a physiotherapy clinic and a coffee shop run by a volunteer group for the elderly. The other building (B) had f lats on all three f loors. The residents’ dining room with its adjacent common living room and the staff office were located on the ground f loor at one end of the corridor. The extra-care housing staff had their meals and took their breaks in the residents’ common living room next to their office. On the top f loor the home care service team had a staff facility in a former student f lat. The home care service team was a department that

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also belonged to the greater municipality elder care service organization, but it operated independently from the extra-care housing and all of its clients were outside the residence. The extra-care housing residence, which was owned by the municipality housing company, was not specifically designed for this purpose, but it was available when the plans for an extra-care housing facility materialized. Most municipalities in Sweden own many premises in several real estate companies for a variety of purposes, such as schools, office buildings, healthcare facilities and housing. Together, these are linked in a loosely coupled spatial organizational field defined by ownership where spatial reorganizations are possible. Prior to the transformation to extra-care housing, the building had contained student accommodation. As such, it had a low degree of interpretive flexibility, since its architectural structure with small f lats lent itself only with difficulty to purposes other than housing, and thus could not accommodate all types of residents; for example, the availability of only small, one-bedroom f lats excluded families from moving in. The former student accommodation presented a possible match with the spatial idea of an extra-care housing by offering a favorable spatial structure for independent living for older people: small f lats, with a

FIGURE 10.1

Extra-care housing residence Building B.

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FIGURE 10.2

The extra-care housing residence. First f loor.

reasonable rent, that were easy to maintain. The two buildings did not require extensive reconstruction but could be used as they were for older residents. This favorable match had a high degree of contingency; as serendipity would have it, a building in limbo was reasonably compatible with the spatial structure. This available building may even have created the possibility to open an extra-care housing unit. Thus, considering that the reconstruction that took place was minor, the buildings in this study underwent a considerable change in use when the younger residents were replaced by older people. The dining room and the staff office were accommodated in two reconstructed f lats. The in-between passage link, which was the biggest and most costly addition during the repurposing of the buildings, provided easy internal communication that was convenient for the elderly. A home care service team was accommodated in an existing f lat that needed no reconstruction except a hygienic facility added adjacent to it. After the change of tenants from young students to older people, the buildings emerged discursively and materially as extra-care housing. This was an innovative discontinuous element that introduced a major organizational change in the greater municipality elder care service organization because the space was available.

Organizational Transformations in Space When the fieldwork started, the local council of the Swedish municipality in which the residence was situated had recently decided against continuing to operate in its present organizational form, according to the director of the municipality elder care services. Rather than being staffed around the clock

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with permanent care workers, the care of the older residents would be taken over by home care services with a more limited capacity to provide care services to individuals with greater care needs. There was a considerable diversity in the residence as regarded the 24 residents’ individual care needs. Some required very little support, while others depended on the staff for almost everything.

FIGURE 10.3

Outside the dining-room

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The extra-care housing was destined to change into a residence for elderly people with fewer care needs and with a lower level of caring services. Since none of the present residents would be forced to leave the extra-care housing residence because of the organizational change, according to the residence manager, it could take quite some time before the new organization was completely in place, possibly several years. The two staff groups—the permanent staff and home care service team—would work in tandem during this transition period, and the permanent staff members would slowly be replaced by home care service staff. The results of the study suggest that the director used available spatial resources offered by the architecture to address organizational issues. Several spatial mechanisms drove the director’s maneuvers; some of these were beneficial to the overarching goal to implement the new organization in the extracare housing, while others were less so. The architectural agency of available space acted together with other components, of which the local home care service team was among the most important. Of particular interest is that the home care service team had moved once for reasons of space, in conf lict with the overarching goal of transforming the extra-care housing, and another move was planned during the fieldwork—this time also for reasons of space, but also for organizational optimization, to effectively put a strategy into action in line with the goal. As mentioned above, the home care service team had initially had their base in Building B of the extra-care housing residence, but they did not have any clients in the extra-care housing. The team left in September, moving to a former old age home about two kilometers away because they had outgrown the f lat they occupied in the residence. This move was thus prompted by a restricting architectural agent, while available spaces in a former old age home offered a solution to an organizational problem. However, because the team was scheduled to begin taking over the care work in the extra-care housing four months after the move, this counteracted the overarching goal by making access to the extra-care housing more inconvenient. This move did not contribute to organizational optimization. While they had not had any clients while based in the extra-care housing, the team moved out just shortly before they were supposed to start supporting residents there. The implementation of the new organization started with the New Year, when the team would take care of new residents moving in. This happened quickly. The recruitment of new residents began after the deaths of four of the residents with the highest care needs at Christmas time. They were replaced by new residents in better health and with fewer care needs who could do without support around the clock, although they needed home care services. Thus, the transformation started with an inconvenient situation in which the staff had to return daily to where their former team base had been located because they moved to spaces that were available.

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The decreased workload also prompted organizational changes involving the permanent staff group in the extra-care housing residence. The management allocated tasks to the permanent staff during their work shifts, sending them to temporarily join the home care services that worked with home care receivers who lived independently in houses in the vicinity. This organizational move was facilitated by spatial conditions; in other words, the availability became a spatial agent. These home care receivers were people living just next door, and it was easy for a staff member to leave the extra-care housing residence, assist these people and come back again within a reasonable amount of time, often less than half an hour. The ambiguous work situations became increasingly complex during the next months of ongoing transition. Residents living in the residence were served by staff from different caring organizations at different occasions throughout the day. For instance, people whose contract was with the home care services were picked up for lunch by a home care service staff member and helped back by a member of the same staff afterward. The people who were part of the extra-care housing organization were assisted to and from lunch and dinner by the permanent staff. However, they were all served lunch by the permanent staff. One somewhat absurd event took place when a former

FIGURE 10.4

The veranda waiting for the summer

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member of staff returned as a substitute for a couple of hours one day: she was now employed in the home care services, and during her short visit, she went in and out of the two roles as home caregiver and extra-care housing staff several times when she promised to bring a person back from lunch (in the capacity of a home care employee), although she was temporarily employed as an extra-care housing staff on that particular day.

Towards Organizational Optimization Although the organizational blending may seem considerable, the cooperation between the two staff groups functioned reasonably well during the first months of transition, and was without serious conf lict. It is possible to propose that the heterogeneous design of the organization, its people, place, space and buildings were able to conceal different interests. In this staff solution, several different components coalesced with the space into a favorable organization. The extra-care housing residence constituted a clearer part of the greater municipality care organization by partly joining the home care services. The highly mobile home care service staff arrived to work in the residence every day while the permanent staff both continued to work in the residence and assist elderly in the nearby community. This could well have continued throughout the entire transformation during which home care service staff would replace permanent staff. However, according to the residence manager, a long-awaited opportunity arose, with great implications for the whole organization, when certain spaces became available. A sudden but not totally unexpected occasion emerged when the county council that occupied the spaces where the physiotherapists were located on the ground f loor of Building A decided to leave these premises. This suddenly available space made it possible for the home care team to return to the extra-care housing residence only a year after their first move. This coincided auspiciously with the transformation to a residence served by home care services and optimized spatial and staff resources. Furthermore, this architectural possibility opened a more radical possibility to gather the whole staff, both the permanent staff and the home care service team, in one location, an incremental but important change. According to the interviews with the managers, the spatial reorganization entailed that the present staff would share staff facilities, offices and a meeting room in Building A until the whole transformation was finalized. The building had enough interpretive f lexibility to accommodate this by occupying the rooms the physiotherapist had used. This comparatively small spatial change opened up for a better accommodation of the two staff groups together. The manager suggested that, ultimately, when the home care service team was available in the building the difference between the present state with permanent staff would not be very dramatic.

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Available Space and Organizational Change Available architectural space may seem minor and trivial in this study. It appeared only in second-hand spaces—a former student accommodation, an abandoned old age home, a clinic space where a physiotherapist had received her clients, and the ordinary homes of the elderly living in the community. Despite this triviality and small-scale, the study results indicate that available space can nevertheless be of decisive importance to organizational change in a healthcare organization. Available space contributed to discontinuous change, introducing innovations and incremental small step changes (Scott et al. 2000). The former was the creation of the extra-care housing and the crossing of departmental borders. The latter was the home care service team’s moves. Available space inf luenced staff reorganizations in this study. A significant factor is that these spaces were associated with the municipality by ownership or by legally defined caring responsibilities. A bigger organization has more resources at hand by involvement in richer organizational networks (Scott et al. 2000). The healthcare organization in the study also benefitted from spatial resources outside municipality ownership. This implied the crossing of departmental borders, while juridical borders of the Social Services Act were a gathering factor that made this crossing possible (cf. Giesbrecht et al. 2016, 22; SFS 2001,452). Permanent staff in the extra-care housing accessed elderly people’s private homes as home care service staff because these homes were easily available in the immediate neighborhood surrounding the extra-care housing residence. Other territorial issues appeared in these results. Although a county council and a municipality are geographically overlapping, they share borders defined by their respective responsibilities in medical care provision to the elderly, forming an organizational field (Scott et al. 2000). In this study, a rental contract with the county council hindered access to a minor but decisive spatial agent—the physiotherapist’s clinic, which, when available, optimized the caring organization in the study. The managerial use of available spaces suggests that the management made use of the spatial possibilities in an objectified manner, planning how to organize parts of the greater organization into a favorable whole. However, architectural means had to be available, in vision or practice, before they could become subject to planning and organizational considerations in ‘the derivate mode’, according to Brott (2013, 19). This may seem obvious; however, in the case of architecture, the self-evident often conceals spatial aspects of significance (Gieryn 2002). Thus, available architectural spaces involved managerial intention, including identification and assessment of what is available and useful, demonstrating an objectified relationship to architectural space in which spatial means were ref lected on (Brott 2013; Scott et al. 2000). However, while managerial intentions put objectified architectural space at the center of responses to the development of the care organization, organizational change also depended on an architectural agent that the management did not fully control (Till 2009;

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Yaneva 2008). The significant prerequisites for organizational planning and design—available spaces—appeared in unexpected situations as architectural agency prompting new organizational solutions by expanding or restricting the range of managerial responses to change in the here and now. In the study, this is represented by the home care service team’s first move, which partly counteracted an optimal and desired development to change the work organization in the extra-care housing. This was dependent on circumstances and negotiations. Architectural space indeed provides opportunities, although these may be imperfect. Spatial agency may steer responses to problems passively, by stubborn inertia, and crave an adaptation to the available contingent spaces (Gieryn 2002). However, architectural spaces may be occupied simply because they are available and offer a solution to a problem that is urgent at the present moment, “entering into anonymous processes of subjectivity” (Brott 2013, 2). In such cases, being satisfactory may be sufficient, although the same solution might not be deemed appropriate in another context. The moves of the home care team show how the second spatial solution rejected the first within a very short time frame of less than a year. The initial move to the old age home was a sufficient spatial solution until it was viewed in light of the second move, which appeared the preferable solution. It is important to note that both moves were underpinned by spatial availability. Available space is a highly invisible but inf luential agent in organizational decision-making. Even if it is subject to intentional considerations, it feeds on contingency when conf lated with multiple alternatives in a co-emergent elderly care organization.

Conclusion The impact of architectural agency—a space that suggests organizational changes—can have advantages as well as disadvantages. Though generally a faithful and loyal companion, space can also lead astray at times. It is thus of importance to identify suggestions as spatial in order to use them optimally in everyday organizing and decision-making.

References Beyes, Tim, and Chris Steyaert. 2012. “Spacing organization: Non-representational theory and performing organizational space.” Organization 19, no. 1: 45–61. https:// doi.org/10.1177/1350508411401946. Brott, Simone. 2013. Architecture for a Free Subjectivity: Deleuze and Guattari at the Horizon of the Real. Farnham: Ashgate Publishing. Clegg, Stewart R., Martin Kornberger, and Carl Rhodes. 2005. “Learning/becoming/ organizing.” Organization 12, no. 2: 147–167. https://doi.org/10.1177/135050840505 1186. Dale, Karen, and Gibson Burrell. 2007. The Spaces of Organisation and the Organisation of Space: Power, Identity and Materiality at Work. Basingstoke: Palgrave Macmillan.

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Gieryn, Thomas F. 2002. “What buildings do.” Theory and Society 31, no. 1: 35–74. Giesbrecht, Mellissa, Valorie A. Crooks, Heather Castleden, Nadine Schuurman, Mark W. Skinner, and Allison M. Williams. 2016. “Revisiting the use of ‘place’ as an analytic tool for elucidating geographic issues central to Canadian rural palliative care.” Health & Place 41: 19–23. https://doi.org/10.1016/j.healthplace.2016.06.006. Kornberger, Martin, and Stewart R. Clegg. 2004. “Bringing space back in: Organizing the generative building.” Organization Studies 25, no. 7: 1095–1114. https://doi. org/10.1177/0170840604046312. Lash, Scott, and Antoine Picon. 2009. “Agency and architecture: How to be critical.” Footprint 8 (Spring): 7–19. Law, John. 2004. After Method: Mess in Social Science Research. London: Routledge. Nord, Catharina. 2018. “Resident-centred care and architecture of two different types of caring residences: A comparative study.” International Journal of Qualitative Studies on Health and Well-being 13, no. 1: 1472499. https://doi.org/10.1080/17482631.2018. 1472499. Nord, Catharina, and Ebba Högström, eds. 2017. Caring Architecture. Institutions and Relational Practices. Newcastle upon Tyne: Cambridge Scholars Publishing. Scott, W. Richard, Martin Ruef, Peter J. Mendel, and Carol A. Caronna. 2000. Institutional Change and Healthcare Organizations: From Professional Dominance to Managed Care. Chicago: University of Chicago Press. SFS. 2001:452. Social Services Act. Ministry of Social Services. SOU. 2008:113. Bo bra hela livet [Live well throughout life]. Swedish Government Official Report: Ministry of Health and Social Affairs. Till, Jeremy. 2009. Architecture Depends. Vol. 55. Cambridge, MA: MIT Press. Vannini, Phillip. 2015. “Non-representational research methodologies: An introduction.” In Non-Representational Methodologies: Re-Envisioning Research, edited by Phillip Vannini, 2–18. New York: Routledge. Yaneva, Albena. 2008. “How buildings ‘surprise’: The renovation of the Alte Aula in Vienna.” Science & Technology Studies 21, no. 1: 8–28. https://sciencetechnologystudies. journal.fi/issue/view/3883.

11 SUPPORTING THE ELDERLY POPULATION New Strategies for Housing in Italy Francesca Giofrè and Livia Porro

Introduction Italy is the first country in Europe and the second in the world, after Japan, with the highest proportion of elderly people. This trend is rapidly growing more apparent. According to demographic forecasts, in 20 years there will be 265 elderly people (over 65) for every 100 young people (under 14), around 93 people more than in 2018 (ISTAT 2018, 139). The accentuated Italian population-ageing trend is due mainly to three factors: the increase in life expectancy, resulting in changes in improved ability and autonomy, the development of different new care needs, and the continuous fall in birth rates. This scenario causes a strong and critical generational imbalance and a strain on the Italian welfare system. The ‘demographic debt’ contracted by Italy is high with respect to future generations in terms of social security, health care costs and assistance. Traditionally in Italy, self-sufficient elderly or low-care elderly lived by themselves or with their families, supported by the informal care network based mainly upon the contribution of women. Nowadays, due to demographic and socioeconomic changes, these networks are confronted with a structural crisis. The main factors behind this crisis are largely common to all developed countries in contributing to the erosion of the potential of informal caregiving within the family: the reduction in household size, the decline in family ties and the increased women labor-force participation on the job market (Lippi Bruni and Ugolini 2013, 1–36; Carrera et al. 2013, 23–52). With this scenario as context, the chapter discusses Italian population data concerning elderly people, its structure and relational networks in order to identify the ‘users’ profile and the ‘residential’ solutions provided by the public and private healthcare system. The presentation focuses on emerging strategies

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for cohousing and introduces four success stories of residential architectural projects promoting residential quality for elderly people who are able to live autonomously or have low care needs. The chapter describes the Italian scenario as a review and an elaboration of statistical documents, literature, laws, and projects. It opens up a debate on the emerging necessity to identify new strategies and architectures for the elderly that need low to intermediate level care as well as solutions able to improve their quality of life and to promote new welfare.

An Ageing Population: Structure and Needs In Italy about 23 percent of the population are 65 or over (13,783,580 people on 1st January, 2019); among them 13 percent are female. The life expectancy is greater for women, at 85.2 years, than for men, at 80.8 years, but this difference is constantly decreasing. According to the new trend, we can divide this part of the population in four more categories: ‘young elderly’ (65–75 years); elderly (76–84), ‘big elderly’ (85–100) and centenarians (100 years and over). This statistical cohort has the following distribution: the ‘young elderly’ are 53 percent; the elderly, 32 percent; the ‘big elderly’ 16 percent and the centenarians, 0.1 percent. Italy is also the European country with the highest number of centenarians: there are 14,456, mostly female (84 percent in 2019). In ten years (2009–2019) the centenarians in Italy drastically increased from 11,000 to 14,000, while people 105 years old passed from 472 to 1,112, an increase of 136 percent. The territorial distribution of the elderly in the country, due to its geography and to the localization of the cities, is varied: the majority, 48 percent, live in the north; in the center and in the south live 21 percent each; and 10 percent on the islands (ISTAT 2019, 1–6). The constantly increasing proportions of elderly and the successive reduction of the size of the family, because of the fall in birth rates, has a big impact in terms of social networks made up by relatives, friends or neighbors that can help in daily life chores. 23.6 percent of people age 65 living alone at home declare they do not have anyone close to rely upon (ISTAT 2018, 156–157). The literature confirms the strategic role of the social network for healthy ageing, and it is widely known that with increasing age and declining health, the elderly feel impacts of loneliness and social isolation, and they need support in their daily life activities. During the course of their lives, the elderly increase relationships with neighbors and decrease relationships with friends because of the physical distance from their homes (ISTAT 2018, 156–157). According to recent studies, in Italy, disabled people, or the physically impaired, amount to 4,360,000, and among them 2,600,000 are people over 65 (Osservatorio Nazionale 2017). These numbers take into account all those who live alone or with family, have functional limitations in the physical sphere, and

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lack autonomy in daily routines and communication. Furthermore, we have to consider the largest number of the elderly with disabilities who live in public or private residential structures. The daily limitations include having great difficulty or not being able to carry out the daily activities of personal care without receiving any help, such as eating alone, even cutting food, lying down and getting out of bed or sitting down and getting up from a chair, getting dressed and undressed and using the restroom, taking a bath or shower (11 percent of those over 65 years old). 30.3 percent of those over 75 have great difficulty with or are unable to use the telephone, take medicine and manage economic resources, prepare meals, do shopping, perform light domestic tasks and occasionally perform heavy domestic activities (Battisti and Rosano 2018, 233). In this scenario, the traditional responses in terms of ‘housing for care’ that can match the different needs of the elderly are going to fail because the huge number of elderly drives a growth in the demand for long-term care. The housing for longterm care must answer the different needs of care: high, medium and low level. Nowadays in Italy there exist different kinds of housing options for elderly people who have a serious reduction of their autonomy. Sometimes, however, there is the need to identify new innovative forms of housing for the elderly that are in need of a low or medium level of care, the so-called ‘intermediate low care housing’. This kind of residential solution is for the elderly who do not need continuous care: people who, for various reasons, can no longer live in their own home, and who are not targeted as part of the standard residential offers for the elderly (Gori 2017, 11–29). The solution for the intermediate low care housing is a real challenge, and, as we discuss later, it is difficult to identify only one preferable solution or one single typology—even the best one—as we will introduce most varied results from some emerging new strategies applied in Italy.

Housing Care for Elderly: Institutional and Informal The housing solutions adopted in Italy for elderly people are of two kinds: institutional and informal care. The institutional one is considersed full-time placement in care units. Informal care falls under the responsibility of the family, friends, and neighbors, people without any professional training and formal status (UNECE 2015, 4). In the informal solution the role played by caregivers is important. They are private assistants at home, usually migrants and women, privately engaged to face the needs of support and to care for the elderly at home. Their contribution “overcomes the contribution of ‘formal’ care supplied by public or private organizations, in all the fields of action except the field of healthcare” (Di Santo and Ceruzzi 2010, 3–5). In some cases informal care is supported by health services provided in residential settings as the integrated home care assistance (Assistenza Domiciliare Integrata—ADI) or/and the social home care assistance (Assistenza Domiciliare Sociale—ADS), managed by

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public authority at the local level. Most of the elderly live with family, and only a residual part is taken care of by the institutional long-term structures. These structures are public, accredited private or totally private. Among the institutional long-term structures there are: nursing home—health social structures (Residenza Sanitaria Assistenziale—RSA), directly managed by the Italian National Health Service, and old age-homes—social structures (Residenza Assistenziale—RA), partially managed by the Italian National Health Service. The main difference is related to the level of care and services delivered to the elderly. The nursing home delivers a medium level of medical service integrated with a high level of home care. It hosts non-self-sufficient elderly people according to their psycho-physical conditions. The national laws regulate the dimensions, the requirements, and the typologies of services of the nursing home (Italian State Law n. 67/1988 and Decree of the President of the Italian Republic, 14 January 1997). It has to be situated, preferably, in urban areas to prevent isolation and reduce difficulties for relatives to visit. It has to be organized in 4 to a maximum of 6 modules hosting 20–25 non-selfsufficient elderly people. The smallest module for 10–15 persons is for people with dementia. Each Italian region, within the national laws’ framework, can locally adapt the services for elderly matching the specific needs of their elderly population, according to its characteristics. The old age-home is a general term to identify different kinds of structures for seniors as common housing, retirement home, hotel home, housing community and so forth. These deliver services for self-sufficient elderly people who do not need specific health assistance. In accredited old age homes, general medical services, nursing and rehabilitation activities are paid by the National Health Service and the cost for lodging by the guests. In recent years the number of totally private old age homes increased because they represent an excellent investment (Auser 2011, 1–6; Ires 2017, 2–8). This phenomenon is out of institutional control, and, in some cases, we have noticed a lack of quality of the services delivered as irregularities and abuses of the elderly. It is really hard to have a clear overview and reliable data on different kinds of available structures, which are useful, moreover, to orient the choices of relatives on behalf of their elderly. Starting from 2018 the Pensioners’ Italian trade union opened an online database on ‘housing for aging’, where information is available on 6,500 Italian structures, including nursing and old age homes. In general terms, elderly people often prefer to keep their habits unchanged and their homes for as long as they are able to, even if it is necessary to transform the dwelling situation in order to tackle the new needs. This choice can cause a sense of isolation: as well as living with family, or in a facility exclusively inhabited by other elderly people, it can be an obstacle to the construction of paths of participation and inclusion in social life. The authors believe that the concept of ‘ageing in place’, due to the reasons argued earlier, will change in the foreseeable future for the ‘self-sufficient

Residential services for elderly: typologies of structures, level of home care between institutional and informal care.

Source: ©Authors.

FIGURE 11.1

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elderly’. The ‘place’ will be, over time, a new solution of intermediate low care ‘solidarity cohousing’, recognizing that older people are not a homogeneous group. The architecture of that ‘place’ changes, and this plays a crucial role (Giofrè and Porro 2016). In the following part we discuss four case studies in order to investigate how solidarity cohousing and cohabitation can represent a valid model and a conscious choice of intermediate to low level care, enabling and promoting healthy and active ageing. In what way can they be considered not only as successful alternatives to improve independence, quality of life and dignity for the elderly but also as the means to fight social isolation?

Solidarity Cohousing in Italy: Policies and Main Actors The term cohousing, according to the definition of the Cohousing Association of the United States (CohoUS n.d.), usually stands for “people living together in neighborhoods designed for community interaction and personal privacy”, which has the advantage of providing to its inhabitants some services and amenities. These practices of shared residence are gaining new attention in Italy thanks to the potential that they have of promoting the integration and the active life of vulnerable sectors of the population. In particular some regional laws actually promote cohousing initiatives from two points of view: the first, and most common, is the regeneration of the built heritage and the revitalization of urban pattern (e.g., Tuscany Regional Law 2015); the second involves social policies for the support of vulnerable categories (e.g., Emilia Romagna Law 2014). The Region of Lazio (2016) brings together in one single law both the social and the urban perspectives, emphasizing the connection between these two aspects. In other regions the housing foundations also play a key role supporting cohousing interventions. These foundations are made up of both private and public bodies. For example, the Region of Lombardy, the local branch of ANCI (National Association of Italian Municipalities) and the Cariplo Foundation (a bank foundation) are partners of “Fondazione Housing Sociale”, based in Milan. It promotes interventions of regeneration of the territory, with a focus on supportive forms of housing. The social cooperatives are often active in these processes, especially when people with health vulnerabilities are involved, playing the role of manager of socio-medical services. They mediate between local bodies and final users of residential facilities.

Solidarity Cohousing for the Elderly: Italian Situations and Experiences In the following we will describe and discuss four interventions of solidarity cohousing for elderly people—named Struttura Del Moro, Borgo Sostenibile,

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FIGURE 11.2

Struttura Del Moro. View of historic city center from an apartment

window. Source: ©Fondazione Casa Lucca.

Namasté Residential Network and Casa alla Vela—chosen among all as recent best practices in Italy. The analysis aims to identify their main features, discussing their points of strength and adding some critical aspects.

Struttura Del Moro The project Struttura Del Moro—“Del Moro Structure”—is placed in the historic center of the city of Lucca, Tuscany, about 80 km from Florence, and it has been inhabited since 2015 (Fondazione Casa Lucca n.d.). The cohousing involves elderly people, over 65 years old, left alone but with a high level of independence. They can be either single individuals or couples. The building has been completely refurbished and consists of three f loors. It includes 13 single or double rooms with private bathrooms and shared living rooms. The project offers two residential typologies: the autonomous single

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FIGURE 11.3

Struttura Del Moro. Common dining room on the first f loor.

Source: ©Fondazione Casa Lucca.

room apartments and the proper cohousing, composed of two or three private rooms with bathrooms and shared living room and kitchen. Both typologies benefit from the use of further common spaces on the first f loor, where we find a bathroom, a laundry room, a kitchen with dining room and a reading and TV room. On the ground f loor is located the headquarters of the volunteer organization “Arciconfraternita di Misericordia”, specializing in first aid and medical services. Periodically, social operators are present to support integration among inhabitants, organize cultural activities and manage collaboration with the families. They also manage care services if necessary. Elderly who are living in Lucca can join some entertainment activities. The project is the result of cooperation between the public foundation “Casa Lucca” and the volunteer organization “Arciconfraternita di Misericordia”, with the financial contribution of the foundation “Cassa di Risparmio di Lucca” and of the Province of Lucca. Rental expenses vary according to the chosen residential typology and include all the services offered in the structure. There are also some commercial arrangements with local shops. This organization promotes new relational paths and an active fruition of the city center utilities.

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Borgo Sostenibile The Borgo Sostenibile—“Sustainable Village”—is a new district in Figino, a historical neighborhood on the west side of Milan (FHS n.d.). The village was inaugurated on June 2015 and hosts several people in its 321 apartments. Near the new square there is a senior cohousing residence. People involved in the cohousing are elderly, alone and without support networks, but with a considerable level of autonomy. The village consists of residences of different sizes (from two to five rooms, simplex and duplex) and also includes shopping areas, facilities, and a park with a playground. There are also several common places used for parties, meetings and events. The creation of collaborative services, like neighborhood babysitting, carpooling, a film club, and solidarity purchasing groups, is encouraged and promoted. The senior cohousing is made of ten studio apartments and a common living room. There is also a strict relationship between the cohousing and the village because elderly living in the cohousing can benefit from services provided in the “Borgo Assistito” (“Assisted Village”) like medical assistance and daily recreational and rehabilitation activities. Furthermore, the cohousing is placed near the new square, a strategic place for the arrangement of soft mobility paths in the neighborhood. The whole project has been financed by a partnership

FIGURE 11.4

Sustainable village. View of outdoor spaces.

Source: ©Elena Galimberti.

Sustainable village. Plan of senior cohousing.

Source: ©Authors.

FIGURE 11.5

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among the Milan Municipality and some private foundations (Cariplo Foundation and Social Housing Foundation). The senior cohousing and the “Borgo Assistito” are managed by the social cooperative Spazio Aperto Servizi, and by the non-profit organization Genera. The social manager plays a strategic role managing the integration of all inhabitants of the new neighborhood, handling the property and facility management, and promoting social cohesion inside the community.

Namasté Residential Network The “Namasté” Residential Network offers apartments in a building located in San Paolo d’Argon, Bergamo, 60 km from Milan (Namasté n.d.). The residence-sharing project was launched in 2005. People who take part in this residency project have different needs: 12 inhabitants with mild intellectual disabilities from 18 to 40 years old, boys and girls with very slight disabilities between 18 and 22 years old, young people in need of help as they are separated from their families, and some elderly inhabitants. In this case elderly people living in other f lats of the apartment block are involved because they can benefit from the services and support offered by the “Namasté” social cooperative, which manages the cohousing. In fact, the residents with disabilities collaborate on activities of common utility, such as the cleaning service of stairs and the gardening of adjacent open spaces. “Namasté” guarantees to elderly people the presence of two shared family assistants and has made a common laundry room and an elevator available for all residents. Furthermore, the apartments of the elderly and the ones of the disabled people are connected with an intercom, allowing elderly people to always have, especially at night, safe and immediate support. People with disabilities live in three apartments, in a building made from 14 units. The biggest apartment hosts a kitchen equipped to serve meals to all the inhabitants of the building in case of necessity, especially to elderly living in other units of the block. The project aims to develop a care network community among all the inhabitants of the building: this purpose promotes residential wellbeing for all people, regardless of the specific limitations. The support paths dedicated to the elderly allow residents to avoid resorting to institutional care and optimize economic resources through the sharing of services.

Casa alla Vela The “Casa alla Vela”—“Vela House”—is a three-story building placed in Trento suburb, in the north-eastern Alpine region, in Vela district (SAD n.d.). The project was launched in 2014 and is an intergenerational cohousing. People residing in the apartments are partially-autonomous elderly and students attending the University of Trento. Five people over 80 years old and six students between 20 and 30 dwell in the unit. In addition, two family caregivers

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FIGURE 11.6

Casa alla Vela. External view.

Source: ©Cooperativa SAD.

support the non-autonomous residents. The support network also includes transport service, cultural and social entertainment, and sanitary operators. Elderly people are distributed in two apartments, while the third is dedicated to students. Particular attention has been put on the organization of spaces in order to find a balance among sharing and privacy needs: the students have their own rooms and a separate kitchen, while the elderly live downstairs and share common spaces on the ground f loor. Also, there are shared bathrooms in each f lat. The apartments are without architectural barriers, and some devices allow a safe residential experience (e.g., fall detection sensors). The spaces are welcoming and friendly, as the rooms can be furnished and decorated by each inhabitant. The Social Cooperative “SAD” is the owner of the building; it has also financed the renovation, and manages and runs the project thanks to the support of some voluntary organizations active in the area. To access a room in one of the apartments, the elderly guests share the costs of the rent, utilities, the food, and remuneration of the family caregivers. On the other hand, students offer some hours of their time as volunteers with the elderly residents and pay a reduced rent. They can also decrease the costs of their stay with some additional tasks useful to the House, earning a salary. In 2015 the project “Casa alla Vela” was mentioned in a publication by the United Nations Economic Commission for Europe (UNECE 2015, 14) among

Casa alla Vela. Birthday party in the common spaces.

Source: ©Cooperativa SAD.

FIGURE 11.7

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the best 11 European good practices in the field of social policies, particularly among innovative care strategies for the elderly population. The figure below compares the main features of the structures analyzed. We observed in the relation between the structure and the territorial context that among the four residential situations, three projects are in an urban context, while one is in a town suburb, near the countryside. Three projects are in refurbished buildings and just one is in a new construction. Moreover, with respect to the age of inhabitants, we can identify two models: senior cohousing and some forms of intergenerational cohousing with cooperation between young inhabitants and elderly people. There are also two different models to organize the apartments: the traditional one, consisting of a private home space and some shared common areas, and a more recent interpretation that implies the sharing of the entire apartment and considers people who may have different needs, and who can take benefit from mutual help, living in the same apartment. Regarding the financial management of the projects, we notice that in two cases there is a synergy between a private and a public body. In the other two cases they are completely funded with private resources. The analysis shows that is difficult to identify only one strategy or one architectural typology, even the best one, and that the Italian scenario is constantly evolving with considerable diversity and multitude.

Conclusion In the future the number of elderly people will increase, and the weak family structure will not be able to support them. In light of this the solidarity cohousing, based on the mutual support that people with different needs can give to and receive from the community, is a real solution to prevent social isolation and to improve the quality of life of the elderly, preventing institutionalization and segregation. Despite this, many differences exist among local policies of each Italian region: the access to these models of residential utilities is not homogeneous along the country territory. They are all in the center or north of Italy, and there is no national coordination. The cohousing projects discussed above are intended for the young elderly and the elderly with a medium to high autonomy level. People who are not self-sufficient can count on different typologies of formal structure. Therefore, the aim of these projects, rather than to offer medical assistance, is to recreate neighborly relations, and to promote mutual help and actions of integration and participation. It is important to underline that the majority of the projects analyzed are situated in existing buildings, after adapting the apartments to the new inhabitants’ needs with a refurbishment. Such solutions fit perfectly in the Italian context, with its old historical town center, and may also represent an efficient tool and an important opportunity for the requalification of the built heritage.

Source: ©Authors.

Italian cohousing examples: main features.

R

SU - town suburb-

Casa alla Vela 2014

FIGURE 11.8

R

U -small village-

Namasté Residential Network 2005

N

R

U -metropolis-

U - historical city center-

Struttura Del Moro 2015

AGE OF INHABITANTS

TYPOLOGY OF APARTMENTS

MANAGEM ENT

IC

IC

SC

SC

AS

TC

TC

TC- AS

M

PRIV

PRIV

3 apartments for inhabitants with disabilities -on 14 total3 apartments -5 elderly + 6 students -

M

10 studio apartments -on 321 total-

13 single or double rooms

Traditional Private cohousing (TC) Senior cohousing (SC) (PRIV) Apartment sharing ACCOMMODATION Intergenerational New building (N) Mixed (M) (AS) cohousing (IC) Refurbishment (R) CAPACITY

TYPOLOGY OF INTERVENTION

Borgo Sostenibile 2015

Urban (U) Semi-Urban (SU) Rural (R)

PROJECT NAME - Launch year

LOCATION

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These introduced projects represent for Italy the first attempts to innovate the residential offer for elderly people. They have been launched in the last 15 years, with a delay with respect to some similar Northern European models. The reasons behind this delay are to be found in the significant role traditionally played by familiar structures in informal care and assistance of the elderly. The authors therefore presume that in the immediate and foreseeable future the cohousing model will be considered a real option and opportunity in Italy. Moreover, we believe in the participation of elderly inhabitants in the design process as a necessary ingredient for guaranteeing the success of cohousing experiences. This involvement produces a better knowledge of their needs and helps to build social identity and the feeling of being at home in the new accommodation. In this chapter we took a picture of the contemporary Italian situation, but in the future the elderly generations will change, as also the medical and information technology will progress. The designers will have to include more and more devices for Ambient Assisted Living as part of daily life of the elderly, making them more safe and self-dependent (Kubitschke and Cullen 2010, I–V), but, as architects, we must not forget to prefigure models and strategies for the city and for housing suitable for the elderly, improving their social dimension and position in society. Design means anticipating the future, and this is the real challenge.

References Auser—Associazione per l’invecchiamento attivo. 2011. “Le case di riposo in Italia. Prima Ricerca Nazionale Auser sulle Case di Riposo 2011.” Accessed July 1, 2019. www.abitareeanziani.it/wp-content/uploads/2016/07/Auser-ricerca-case-riposo. pdf. Battisti, Alessandra, and Aldo Rosano. 2018. “Disabilità.” In Rapporto Osservasalute 2017, edited by Università Cattolica del Sacro Cuore, 233–250. Italy: Università Cattolica del Sacro Cuore. www.osservatoriosullasalute.it/osservasalute/ rapporto-osservasalute-2017 Borgo sostenibile. n.d. Accessed July 2, 2019. www.borgosostenibile.it. Carrera, Francesca, Emmanuele, Pavolini, Costanzo, Ranci, and Alessia Sabbatini. 2013. “Long-Term Care Systems in Comparative Perspective: Care Needs, Informal and Formal Coverage, and Social Impacts in European Countries.” In Reforms in Long-Term Care Policies in Europe. Investigating Institutional Change and Social Impacts, edited by Costanzo Ranci, Emmanuele Pavolini, 23–52. New York: Springer. CohoUS—The Cohousing Association of the United States. n.d. “What is Cohousing?” Accessed July 20, 2019. www.cohousing.org/what-cohousing/cohousing. Decree of the President of the Italian Republic. 14 January 1997. Approvazione dell’atto di indirizzo e coordinamento alle regioni e alle province autonome di Trento e di Bolzano, in materia di requisiti strutturali, tecnologici ed organizzativi minimi per l’esercizio delle attività sanitarie da parte delle strutture pubbliche e private. GU S.O. 20 n. 42, 1997. Accessed August 8, 2019. www.salute.gov.it/imgs/C_17_normativa_1163_allegato.pdf.

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Di Santo, Patrizia, and Francesca Ceruzzi. 2010. “Migrant Care Workers in Italy. A Case Study.” Accessed September 20, 2019. http://interlinks.euro.centre.org/sites/ default/files/WP5_MigrantCarers_FINAL.pdf. Emilia-Romagna Region. “Regional Law 23/07/2014, n.19 Norme per la promozione e il sostegno dell’economia solidale.” Bollettino ufficiale, no. 267, 2015. Accessed September 13, 2019. http://demetra.regione.emilia-romagna.it/al/articolo?urn=er:asse mblealegislativa:legge:2014;19. FHS—Fondazione Housing Sociale. n.d. “Cohousing anziani—Figino.” Accessed July 3, 2019. www.f hs.it/progetti/abitare-leggero/cohousing-anziani-figino. Fondazione Casa Lucca. n.d. “Cohousing del Moro.” Accessed July 31, 2019. www. fondazionecasalucca.it/portfolio/cohousing. Giofrè, Francesca, and Livia Porro. 2016. “People with Health Vulnerability: Strategies and Designs for Housing.” In Sustainable Housing 2016. International Conference on Sustainable Housing Planning, Management and Usability, edited by Rogério Amoêda and Cristina Pinheiro, 369–378. Portugal: Green Lines Institute for sustainable development. Gori, Cristiano. 2017. “Introduzione. L’età dell’incertezza.” In L’assistenza agli anziani non autosufficienti in Italia. 6° Rapporto 2017/2018. Il tempo delle risposte, edited by Network Non Autosufficienza, 11–29. Italy: Maggioli. IRES Lucia Morosini-Istituto di Ricerche Economiche e Sociali. 2017. “L’Osservatorio sulle residenze per gli anziani in Italia.” Accessed August 5, 2019. www.grusol.it/ informazioni/27-10-17.pdf. ISTAT-Italian National Institute of Statistics. 2018. “La popolazione, le reti e le relazioni sociali.” In Rapporto annuale 2018. La situazione del paese, edited by ISTAT, 135– 169. Italy: Istat. ISTAT-Italian National Institute of Statistics. 2019. “I centenari in Italia.” Accessed July 3, 2019. www.istat.it/it/files//2019/07/Statistiche_Today-I-centenari-in-Italia.pdf. Italian State Law n. 67/1988. Disposizioni per la formazione del bilancio annuale e pluriennale dello Stato (legge finanziaria 1988). Art. 20. GU S.G. no. 61, 1988. Accessed September 13, 2019. www.gazzettaufficiale.it/eli/id/1988/03/14/088G0117/sg Kubitschke, Lutz, and Kevin Cullen. 2010. “ICT & Ageing. European Study on Users, Markets and Technologies.” European Union. http://ec.europa.eu/information_society/ newsroom/cf/dae/document.cfm?doc_id=952. Lazio Region. “Regional Law 10/08/2016. Sistema integrato degli interventi e dei servizi sociali della Regione Lazio.” BUR, no. 86, 2018. www.consiglio.regione.lazio. it/consiglio-regionale/?vw=leggiregionalidettaglio&id=9293&sv=vigente Lippi Bruni, Matteo, and Cristina Ugolini. 2013. “Delegating Home Care for the Elderly to External Caregivers? An Empirical Study on Italian Data.” Quaderni—Working Paper DSE, no. 905 (September 2013): 1–36. http://doi.org/10.2139/ssrn.2334299. Namasté, Cooperativa Sociale. n.d. “Appartamenti protetti per persone con disabilità.” Accessed July 18, 2019. www.coopnamaste.it/aree-di-intervento/area-disabilita/ appartamenti-protetti-per-persone-con-disabilita. Osservatorio Nazionale sulla salute della Regioni Italiane. 2017. “La condizione delle persone con disabilità in Italia.” Accessed July 1, 2019. www.quotidianosanita.it/ allegati/allegato4880055.pdf SAD, Società Cooperativa Sociale. n.d. “Casa alla Vela.” Accessed July 9, 2019. www. cooperativasad.it/servizi/servizi-privati/casa-alla-vela.

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Tuscany Region. 2015. “Atto di Indirizzo per interventi in ambito urbano. I progetti di Innovazione Urbana (PIU).” Accessed September 10, 2019. www301.regione. toscana.it/bancadati/atti/DettaglioAttiG.xml?codprat=2015DG00000000054. UNECE—United Nations Economic Commission for Europe. 2015. “Innovative and Empowering Strategies for Care.” In Policy Brief on Ageing, no. 15 (February 2015): 1–20. www.unece.org/fileadmin/DAM/pau/age/Policy_briefs/ECE-WG.121-PB15.pdf.

12 SOCIODEMOGRAPHIC PLASTICS—FROM HOUSING AND INSTITUTIONS FOR THE ELDERLY TO URBAN LIFESTYLE PRODUCTS FOR THE YOUNG-OLD Deane Simpson

From Housing and Institutions for the Elderly to Urban Lifestyle Products for the Young-Old As comprehensive lifestyle products directed specifically toward the needs and utopian desires of a single demographic segment, urban entities such as Sun City, Arizona, founded at the beginning of the 1960s, and The Villages, Florida, established at the end of the 1980s, would fulfill, in spatial terms, one of the classic treatises of late capitalism: Wendell Smith’s 1956 theory of market segmentation (Smith 1956, 3–8). Smith would argue for a paradigm shift in the development of products and the construction of consumers who would purchase them, from standardized products marketed to a mass audience based upon the logic of “bending demand to the will of supply,” toward a rationale in which products would be specifically designed to satisfy the particular demands of smaller segments of similar consumers. Through the analogy of the layer cake, Smith would describe the earlier paradigm as one focused on securing a single full layer of the mass-market cake, and the subsequent shift toward an alternative principle based on taking a single deep slice of the market cake. The construction of differentiated market segments consisting of smaller groups of consumers with similar characteristics would necessitate more precise understandings of consumers, their needs and desires, as well as where and how they could be located and addressed. Demography—which describes in statistical terms the characteristics of populations such as age, gender, race, ethnicity, education, and disposable income—would play a central role in the instruments of market segmentation along with the burgeoning field of consumer surveys and consumer behavior studies. Advancements in information technology facilitating the collection and processing of large volumes of consumer data, such

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as purchasing behavior databases, online behavior data, and other transaction records, would combine with the spatialization of that data to achieve higher levels of precision in the identification of specific market segments. The deployment of these instruments in identifying not only homogeneous customer segments but also their spatial concentration within mixed demographic environments would represent a kind of emergent form of socio-spatial “reading of territory” that would inf luence actions of suppliers, in their “site selection, product distribution, media planning and overall resource allocation” (PRIZM 2011). It is in relation to these practices of “reading” or scanning for homogeneity within heterogeneous mixtures (with the inherent and unavoidable inefficiencies linked to such approaches) that age-segregated communities such as The Villages become particularly attractive to developers and suppliers—most notably in the way they enact a kind of urban-scale “writing” of spatially concentrated market segments at extremely high levels of homogeneity. In other words, not only does The Villages operate as an urban lifestyle product marketed toward a specific and highly studied demographic segment but the resulting scale and spatial consolidation of that same segment also results in an extremely efficient and profitable market for the sale of goods and services. In these terms, The Villages may be envisioned as a form of sociodemographic plastic—or urbanism as a kind of sociodemographics in matter.1 The implications of this urban ‘writing’ are apparent in the extent of the developer’s ownership of local media and advertising markets, commercial property, as well as a large number of businesses such as banks, mortgage companies, real estate companies, golf-cart dealerships, liquor stores, furniture stores, movie theaters, and restaurants, and their undisclosed but evident profitability (Blechman 2008, 111). The homogeneity of more than 110,000 residents of similar sociodemographic features would extend not only to the often-observed characteristics of spatial sorting such as race/ethnicity and income, but, additionally, age. The world’s largest retirement (“55+ active-adult” in developer parlance) community would stretch out across an urbanized area comparable in size to that of the borough of Manhattan or European municipalities such as Zurich or Copenhagen (Coffey 2012).2 It would operate as an experimental petri dish for highly instrumentalized forms of urbanity—constructing, in the words of its developer Gary Morse, “a Disney World for active retirees,” a place in which “Retirees’ Dreams Come True” (Morse 2007). In spatiotemporal terms, The Villages is conceptualized and marketed by its developer not as a housing product, but rather as an idealized lifestyle and a “way of life”—one capable of reconciling, through the sheer volume of one single demographic segment, two previously irreconcilable utopias: according to Marco D’Eramo, those of “low suburban density and the abundant services typical of cities” (2007, 80). The spatiotemporal framework for this abundance revolves around an extensive recreational and entertainment infrastructure— the latter being centered upon three “downtowns.” Surrounded by restaurants,

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cafes, bars, cinemas, stores, as well as sales centers, the downtowns function as the key symbolic public spaces and social hubs of the area offering a nightly happy hour, free live music, and entertainment and dancing, 365 evenings of the year. Designed by the architect of the Universal Studios theme park in Orlando, Florida, the downtowns are comprehensively themed structures aimed at realizing the developer’s slogan: “Florida’s Friendliest Hometown.” This occurs through the emulation of the small towns common to the contemporary cohort of retirees’ period of youth, not only in terms of the imitations of historical buildings and urban spaces but also in an extensive range of programs and entertainment activities coordinated by the developers that refer back to the residents’ youth. The former including, for example, late 19th-century Spanish Mission-themed buildings, fabricated ruins of railway stations on fictitious railway lines, or ruins of industrial areas that similarly never existed; while the latter would comprise events such as classic car cruise-ins, small-town parades, cheerleading performances, and programs such as 1950s themed drive-in diners. With those under 19 years of age actively discouraged from spending periods of time in the environment (limited to visits of a maximum of 30 days per year and rigorously policed by neighbors), it becomes increasingly evident that The Villages functions as a spatiotemporal scaffold for a utopia of youthfulness, but one necessarily predicated on the elimination of youth. Such an infrastructure of ‘resilient time’ conforms to the needs of one of the three population typology profiles described by gerontologist Irving Rosow: those with “deviance” patterns of age identification who evaluate their own behavior and appearance based on comparisons with the young, and therefore maintain more a positive self-image and behavior when within an age-segregated environment (Golant 1985, 24–25). These mechanisms exhibit some parallels to findings of Harvard-based psychologist Ellen Langer’s “counter clockwise” study. In 1981, she would immerse eight men in their 70s in the environmental cues of 1959. After five days, considerable psychological and physiological improvements were documented. Just as Langer’s group temporarily re-inhabited their younger selves within their own temporally transformed environment of youth, the self-described “re-birth” of many of The Villages’ residents perhaps operates according to similar mechanisms—producing a range of conditions and by-products. The most emblematic of those plays out in the mid-2000s with an outbreak of sexually transmitted infections in the community: Doctors said sexually transmitted diseases among senior citizens are running rampant at a popular Central Florida retirement community, according to a Local 6 News report. A gynecologist at The Villages community near Orlando, Fla., said she treats more cases of herpes and the human papilloma virus in the retirement community than she did in the city of Miami. (WKMG Local 6 News, Orlando, Florida 2006)

URBAN TEXTURE

Communal/recreational Leisure/tourist site Cinema

Hard surface

Meeting place

Mid cultivated green

Water

High cultivated green

Downtown. Lake Sumter Landing Market Square, The Villages, Florida.

THE VILLAGES, F

FIGURE 12.1

B.1.12

Information center

Shopping

Retail

Restaurants

Real estate sales

Bar

Commercial (non-retail) Office

Security

Planting

Parking areas

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Opening ceremony of the Florida Senior Olympics featuring The Villages’ Cheerleaders, Lake Sumter Landing Market Square, The Villages, Florida, 2005.

FIGURE 12.2

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FIGURE 12.3

Typical residential urban texture, The Villages, Florida.

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Local medical professionals would attribute this emerging public health issue to three factors: the extensive use of Viagra in the community; the low risk of pregnancy; and the dearth of sex education amongst residents of that age group ( WFTV 2014). Such an explanation brings to the fore characteristics of a particular cohort whose formative years occurred prior to the first sexual revolution, the later emergence of HIV, and who are subject to the relatively recent construction of a new “ageless consumer” (Katz and Marshall 2003, 12). Sociologists Stephen Katz and Barbara Marshall relate this latter development—of a posthuman subject emancipated from decline—to a larger set of tendencies that include: “broadening connections between the new and sexually-fit aging; the marketing, pharmaceutical, and consumerist industries that cater to it; and the concurrent neoliberal political agendas that require people to adopt riskaversive, active, self-reliant lifestyles” (ibid, 4). Just as a “first sexual revolution succeeded in detaching sexuality from reproduction,” this suggests, according to Katz and Marshall, a second, “aimed at liberating sexual performance from whatever limits the aging body might impose on it through disease, genetics, or physical defection” (ibid, 12). While this outlines important medical and societal explanations for transforming sexual behaviors late in life—it is necessary to address missing elements of that narrative, in particular, the contribution of the specific spatiotemporal construction of The Villages, introduced above, in asserting an “ageless” citizenry directed toward youthful behavior. Here, the radical scale and format of age-segregation provides a foundation for interaction between the emerging social conditions (emblematized in the infamous STI outbreak), and particular spatiotemporal ones. In other words, the spatiotemporal staging of this utopia of youthfulness—through themed architecture, age-segregated urban planning, intensive nostalgic programming of ‘downtowns’ and the extensive golf cart infrastructure supporting post-‘happy hour’ drinking and driving with relative impunity—is perhaps as significant in its contribution to this particular social milieu as products such as Viagra or other over-the-shelf aids, like Big Ox, a canned-oxygen product commonly used as a hangover cure by residents. The idealized freedoms and possibilities aligned with this relatively new sociodemographic group defines an experimental practice that is emancipatory and utopian in nature. This is based on a lack of existing protocols and therefore the need to invent new models for how, where and with whom to live; and the central role of the deployment of idealized representations of utopian life forms at the intersection of urban design, demographics, and marketing practices. Whether utopias of youthfulness (without youth); or utopias of low density with urban abundant services (D’Eramo 2007, 80); or the utopia of the vacation that never ends; or climatic utopias positioned within what Juan Palop Casado refers to as the “Geometry of Paradise” (Simpson 2015, 276–277)—the utopian emancipatory impulse here relates less to a classical place vs. non-place discourse, but rather toward Ruth Levitas’ conception of utopia as a “method” of experimental engagement in challenging the status quo (Levitas 1990).

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Urban Typology Innovation: The Strip Hospital This field of social and spatial experimentation at The Villages extends also to the field of health care—in the form of what could be described as a ‘strip hospital’ along the primary artery (US Highway 27/441) bringing traffic in and out of The Villages. The formal planning of the community within this area focused on a strategy of locating “professional plazas”—concentrations of largely single-story mall-like commercial spaces with adjacent parking lots accessible from the main highway—leased primarily to health professionals. 3 While the professional plazas have been located along the access corridor, the commercial shopping centers and the “downtown” entertainment districts have been located away from this line but in close proximity to the main thoroughfare. The developer strategy in this case has been the concentration of commercial activity with the potential for attracting traffic from the surrounding area to the “edge” of the community while preventing heavy traffic penetrating the “quiet” interior of The Villages. These professional plazas include a wide range of medical offices and clinics specializing in cardiology, dentistry, oncology, gynecology, chiropractic, dermatology, lung medicine, sleep disorders, and so forth. A smaller number of more generic retailers are located along the strip, many of which focus on fulfilling support functions for the nearby professional plazas, such as the Walgreens drugstore branches with their large prescription counters and drive-in prescription windows. All professional plazas and shopping centers along The Villages segment of the strip are accessible not only by car but also by golf cart. Golf cart paths as well as lower-speed dual-use car/golf cart roads feed the plazas and shopping centers. Golf cart accessibility along the strip was considerably improved by the construction of a highway overpass in the early 1990s. Such amenities and specifically the provision of “medical and professional plazas” feature prominently in advertising brochures and on websites intended for both customers and potential professional tenants: The Villages’ .  .  . residents embrace an active lifestyle which places a premium on excellent healthcare. With over 33 golf courses, 55 tennis courts, 48 swimming pools, 9 softball fields, 3 fitness clubs, a wellness center and 1,200 other sanctioned activities per month, residents enjoy staying in good health! And they do it all in their golf carts. In fact, golf carts is the form of transportation most of your patients will use to get to your office, which is just one of many unique aspects of bringing your practice to The Villages. In addition to the 287,000 square feet of medical office space, the Villages community is currently home to a 198-bed acute care Hospital with a 90,000-square-foot VA specialty clinic as well as an extended care hospital both currently under construction. ( The Villages 2014)

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As the expansion of The Villages accelerated substantially in the 1990s, other smaller piggyback communities developed nearby. These include Del Webb’s Spruce Creek Country Club to the north and Stonecrest Retirement Community to the northwest in Marion County. This created a substantially larger and dispersed base of Young-Old consumers along a more heavily trafficked corridor, leading in turn to the expansion of less-regulated strip development to the northwest and southeast of The Villages’ controlled segment of US Highway 27/441.4 While extensive signage advertises the various health-related services to passing motorists within the professional plazas leased by The Villages, there is a certain level of aesthetic control defined by the developer attempting to contain the size and number of signs. In the areas not owned by the developer, there is a more lively and diverse use of signage and billboards intended to attract customers “off the street.” This is evident in the considerable increase in the scale of signs, the use of extravagant sales pitches, neon lighting, and LEDs on billboards. For example, one LED advertisement along the strip f lashes the following announcement: “Memory Loss? Gait Imbalance? Look No Further!!” To a large extent, this particular commercial development along the highway corresponds to what has been termed “the strip,” the automobile-based urban

FIGURE 12.4 Various signage along “hospital strip,” US Highway 27/441, The Villages, Florida.

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typology described and analyzed by Robert Venturi, Denise Scott Brown, and Steven Izenour in their seminal study Learning from Las Vegas. Venturi et al. describe a general condition of strip architecture—labeled “big sign and little building”—in which the sign is scaled and located according to the speed and direction of the automobile (1977, 13). Signs on buildings are also based upon their orientation toward the strip. Thus, side façades assume a more important role than back façades, as they are viewed more easily and for a longer period traveling up and down the strip. This is also the case at The Villages, particularly along the length of the highway immediately outside those portions of the strip that are not owned by the developer. While particular forms of economic rationalization have led to an increase in store size producing the phenomenon known as the “big box,” the organizational protocols determining traffic movement, parking, and the use of signage of the generic American strip are relatively unchanged since Learning From Las Vegas. To a large extent, the prevalence of the strip has expanded within the increasingly decentralized, nonhierarchical, and dispersed exurban condition of the American city. Of relevance in comparing the strip at The Villages to that of Learning From Las Vegas and the more generic contemporary American strip is less its conformity to this organizational logic than its particular novelty in programmatic terms (1977, 20). Although there is a limited presence of conventional strip retail franchises along The Villages’ 5-mile (8.2-km) strip (e.g., McDonalds, Wal-Mart, Home Depot), it is remarkable for the dominance of programs dedicated to the maintenance, reparation, and enhancement of the aging body, distributed at a frequency of approximately 35 clinics per mile (22 per km). The precedent for such a programmatic concentration of health-related services may be clearly identified in the typology of the hospital. In these terms, therefore, it is possible to frame the strip hospital not only as a programmatic mutation of the strip mall but also an organizational mutation of the hospital. The history of the hospital typology is commonly characterized as a progressive reduction of “privacy and individuality” for the patient: the Enlightenment hospital’s rationalized and centralized institutionalizing; as healing machine, the modernist hospital’s submission of the body; and in the contemporary megastructure hospital, the loss of spatial frames of orientation and reference, or sense of place (Schaefer 2006, 202). These tendencies, combined with the mental association with illness and death, attribute strong negative connotations to the institutional image of the centralized mega-hospital. Since the 1980s, many hospitals and hospital designers have reacted to these challenges by supporting a shift “away from highly centralized, overscaled facilities and toward smaller, decentralized facilities” (Verderber and Fine 2000, 126). The strip hospital at The Villages may be positioned as an extension of that shift of understanding. Where general hospital decentralization has seen an opportunistic and sometimes random distribution of clinics across an urban

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territory, the hospital strip at The Villages is organized linearly as a line accessible by automobile and golf cart and within close reach of the community. Such a solution challenges the negative stigma associated with the iconography of a centralized institutional megabuilding while adhering to both the concept of decentralized clinics and the organizational logic of the highway. Just as the modernist hospital is organized according to types of procedures and corresponding body parts—assembling a centralized and coherent body— the hospital strip redistributes this body into collected fragments along the strip. This distributed linear logic of commerce represents a conscious alternative to the involuntary patienthood associated with the institutional megabuilding that has become the contemporary hospital. Its replacement with an ethos of individual empowerment and consumer choice over the slow but inevitable decline of the aging body is one in which ailments are understood at the scale of the body and the city as isolated, manageable conditions over which the Villager appears to maintain ascendancy. In these terms, US27/441 spatializes a transition from passive patient to active consumer that corresponds to the distinction between health-care predicaments typically associated with the third and fourth phases of life. This is evident, for example, in competing advertisements of several chiropractors along a two-mile stretch of the road. The emergence of this typology of the strip hospital may therefore be understood within the context of a series of factors: the increasing dominance of the private automobile (and in the case of The Villages, the inclusion of the golf cart); the corresponding growth of the strip as one of the most dominant and familiar urban typologies supporting consumption; the specific demographic concentration of the young-old at The Villages, which in turn produces a particularly active market for the consumption of health and body-related services; and, most importantly, the desire to remake the image and performance of an institution that in modern times has been so closely associated with disease and death—themes often framed as taboo by the young-old.

Dystopian Tendencies While active as an emancipatory site for experimental spatial engagement for this particular social group, a critical perspective on these developments is essential in addressing the resilience of The Villages as a senior housing model. It is in these terms that one can frame The Villages as a fourfold dystopia of segregation, securitization, privatization, and denial. Like many “Active Adult” settlements, the community’s aggressive marketing and planning focusing specifically on the needs of the young-old, frames a conscious denial of the realities for care within the final phase of life (Simpson 2015, 248–251). Its developer exploits formats of private governance throughout that contribute to: economic corruption; the undemocratic consolidation of control over local political discourse through the developer’s ownership and censorship of local media outlets; the

Strip Hospital. The programmatic mutation of the American commercial strip typology toward the functions of the hospital at The Villages represents an urban mutation that is based on the spatial explosion, vehicularization, and commercialization of the architectural typology of the hospital.

FIGURE 12.5

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general disempowerment of local residents; and environmental abuses inf licted by the developer on the territory (Simpson 2015, 236–242). Further to the introduction of age-segregation mechanisms in The Villages described above, the community may be considered as an emblem for increasingly securitized and segregated space in general—in which the ‘secure’ isolation of large-scale segregated urban territories articulates the trumping of the agenda of community over that of society. As presented in many high-profile cases of retirement communities voting politically against school bond measures,5 this points to the vulnerability and fragility of intergenerational solidarity, and of the coherence of our societies as a whole, under the weight of these spatial processes so aligned to late capitalism.

Acknowledgements Parts of this chapter have been previously published in Deane Simpson (2015), Young-Old: Urban Utopias of an Aging Society (Zürich: Lars Müller Publishers).

Notes 1. This term is adapted from Eyal Weizman’s Political Plastic and inf luenced by Joseph Beuys notion of ‘Soziale Plastik’; see Eyal Weizman, Hollow Land: Israel’s Architecture of Occupation, London, 2007, p. 5. 2. The area of The Villages, at 33 square miles (85.4 sq. km) covers almost the same area as Manhattan at 33.8 square miles (87.5 sq. km). Similar municipality areas include Copenhagen: 34.1 square miles (88.3 sq. km) and Zurich: 33.9 square miles (87.9 sq. km). 3. As of January 2008, sixty-five distinct health professional and related businesses were located along the segment of US Highway 27/441 within The Villages, many of which had been established since the mid-1990s. 4. As of January 2008, there were an additional 108 health professionals and supporting businesses along the highway to the northwest and southeast of The Villages. 5. Two well-known examples include: a twelve-year sequence of seventeen votes by Sun City residents starting in 1962 against school bond measures. See Andrew Blechman, Leisureville: Adventures in America’s Retirement Utopias, New York, 2008, p. 133; and Sue Anne Pressley, Residents of Retirement Havens Resist Paying Taxes for Schools, The Washington Post, March 15, 1998.

References Blechman, Andrew. 2008. Leisureville: Adventures in America’s Retirement Utopias, New York: Atlantic Monthly Press. Coffey, Brendan. 2012. “Billionaire Morse Behind Curtain at Villages,” Bloomberg News, June 5, 2012, www.bloomberg.com/news/2012-06-04/hidden-billionairemorse-a-man-behind-curtain-at-villages.html (accessed April 2, 2014). D’Eramo, Marco. 2007. “Bunkering in Paradise (or, Do Oldsters Dream of Electric Golf Carts?),” in Evil Paradises: Dreamworlds of Neoliberalism, edited by Mike Davis and Daniel Bertrand Monk, New York: The New Press.

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Golant, Stephen. 1985. “In Defense of Age-Segregated Housing,” Aging (348): 24–25. Katz, Stephen, and Marshall, Barbara. 2003. “New Sex for Old: Lifestyle, Consumerism, and the Ethics of Aging Well,” Journal of Aging Studies (17). Levitas, Ruth. 1990. The Concept of Utopia, London: Syracuse University Press. Morse, Gary H. 2007. “Yesterday, Today and Tomorrow!,” The Villages Daily Sun. Pressley, Sue Anne. 1998. “Residents of Retirement Havens Resist Paying Taxes for Schools,” The Washington Post, March 15, 1998. PRIZM. 2006. “PRIZM NE: Lifestyle Segmentation System,” Claritas, brochure, www. dr4ward.com/files/lifestyle-segmentation_c1045v2.pdf (accessed July 2, 2011). Schaefer, Markus. 2006. “Building Hospitals—Hospital Buildings,” in The Architecture of Hospitals, edited by Cor Wagenaar, Amsterdam: Netherlands Architecture Institute (NAi Uitgevers/Publishers). Simpson, Deane. 2015. Young-Old: Urban Utopias of an Aging Society, Zürich: Lars Müller Publishers. Smith, Wendell R. 1956. “Product Differentiation and Market Segmentation as Alternative Marketing Strategies,” Journal of Marketing 21, no.1 ( July 1956):3–8. Venturi, Robert, Denise Scott Brown, and Steven Izenour. 1977. Learning from Las Vegas: The Forgotten Symbolism of Architectural Form. Cambridge, Mass.: MIT Press. Verderber, Stephen, and Fine, David J. 2000. Healthcare Architecture in an Era of Radical Transformation, New Haven: Yale University Press. The Villages, 2014. “Medical and Professional Plazas,” The Villages, www.thevil lagescommercialproperty.com/ProfessionalPlazas.asp (accessed May 22, 2014). Weizman, Eyal. 2007. Hollow Land: Israel’s Architecture of Occupation, London: Verso Books. WFTV. 2014. www.wftv.com/news/news/doctors-in-retirement-community-seeingincrease-in/nFB8g/ (accessed March 4, 2014) WKMG. 2006. “www.local6.com/news/9283707/detail.html STDs Running Rampant in Retirement Community: Doctor Blames Viagra, Lack of Sex Education.” Posted May 27, 2006. WKMG Local 6 News, Orlando, Florida. www.local6.com/ news/9283707/detail.html

SECTION III

Caring

13 DESIGNING WITH NATURE FOR AGEING Health-Related Effects in Care Settings Garuth Chalfont and Roger S. Ulrich

Introduction Nature was intrinsic to early human settlements for dwelling, ageing and health as evidenced by physic, monastery, and medicinal gardens through the ages. As well as nature for medicine, a nature-rich environment facilitated health, livelihood and meaning. Even though conventional Western medicine and air-conditioning have side-lined nature in current care settings, a movement towards the greening of healthcare through enlightened design criteria invites nature back into spaces for dwelling and healthcare (Irvine and Warber 2002). Drawing on international research and practice, this chapter highlights how designing with nature improves care and health for ageing. Nature-based outdoor experiences promote mental, physical, emotional and spiritual well-being in countless ways. Benefits include fresh air, vitamin D, exercise and mental and emotional well-being (Bragg and Atkins 2016), encounters with others and appreciation of the countryside (Duggan et al. 2008). Benefits for people with dementia also include lowered agitation (Whear et al. 2014), reduction in falls and use of psychotropic drugs, improved sleep and well-being (Gonzalez and Kirkevold 2014), and improved mood (White et al. 2017). Many older people with chronic health conditions live at home with support and maintain good cognitive function into old age, but physical frailty or cognitive impairment hasten a move into long-term care. Green care promotes health, well-being, and social and educational benefits through a range of nature-based activities, with green care farms as exemplars (De Boer et al. 2017). Effective environmental co-design between people and place facilitates activities that can ameliorate problems of frailty and ill health by reducing loneliness and isolation, which can lead to cognitive decline, depression and dementia (Duggan et al. 2008).

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Design can be an antidote to the perils of ageing if enabling nature contact. As architecture connects people and nature environments in meaningful ways, this helps mentally and emotionally by providing opportunities that lift the spirit, enhance the mood, and stimulate the senses, increasing overall wellbeing and quality of life (Bossen 2010; Edwards, McDonnell, and Merl 2013).

Architectural Features The less able the person, the more likely that architecture governs their relationship with the outside world, as they may need support to go out. Architectural components and features must enable easy physical and visual access to the outdoors as well as invite in natural elements, such as daylight, sound and views. The more physically frail or cognitively impaired a person becomes, the more the architectural environment needs to facilitate both an active and passive connection to nature and participation in nature-based activities (Gibson et al. 2007; Chalfont and Walker 2013). This section explores design features from micro to macro, beginning with ‘edge spaces’ (Chalfont 2006). Features at the edge of indoors and outdoors include complex windows, porches, windowed corridors or covered walkways, conservatories and garden rooms. Complex windows contain two hinged windows that can open separately, with space and air between each. As well as providing insulation from wind and cold, the space between the two windows can act as a mini greenhouse for plants or a spot for a birdfeeder. Porches (glazed, screened or open) at external doors modulate the temperature between the indoors and the outdoors and provide sensory stimulation. Being near the door provides a person emotional comfort and security, but with benefits of passive nature contact (smells, sounds, breezes and sunshine) that are inherently therapeutic. A transition space builds confidence in a person with declining physical or cognitive ability, affording them independent access to outdoors. A large ‘wrap-around’ porch affords nature from different directions. As the sun moves through the day, it provides seating choices to accommodate more residents. A wrap-around porch provides room to walk about. If the porch accesses interior rooms, it enables forward movement without dead ends. Covered walkways encourage sheltered mobility and outdoor seating. Windowed corridors provide thermal comfort and shelter from the elements and a warm sunny indoor space with year-round views of the outdoors. They support activity in winter, and open windows provide fresh air, sound and fragrance. Adding chairs or a ‘glider’ will increase the enjoyment of residents, staff and families. A sunroom may be improperly sited and inadequately heated, shaded, or ventilated for the climatic conditions—too hot in summer and too cold in winter, limiting its comfortable use. Optimal placement of a conservatory captures morning to mid-day sunlight and heat. Automatic adjustment of sunshades, ventilation and heating will further regulate internal comfort levels.

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A building invites natural daylight to interior spaces through skylights and clerestory windows. Natural daylight levels regulate circadian rhythms and enhance sleep-wake cycles, as opposed to f luorescent and other artificial lighting (Wright et al. 2013). Absorbing natural wavelengths of light, particularly early morning and late evening, produces health benefits. Artificial light at night suppresses melatonin, misaligns circadian rhythms, may have negative effects on psychological, cardiovascular and/or metabolic functions (Cho et al. 2015) and has been linked to cancer (Al-Naggar and Anil 2016). To be the most effective, garden rooms must have a visual and physical connection with the outdoors. Seeing and accessing outdoor spaces from indoors is critical for both independently and assisted use (Chalfont and Walker 2013).

Gardens and Architecture Stepping back from the details, we now consider site design that integrates the building and the landscape to facilitate connection to nature. Landscape and buildings designed concurrently will enable suitable positioning of the building on the site. Design must take into consideration sun and shade patterns throughout the day, which can make comfortable microclimates adjacent to the building. A warm, sunny ‘sitting-out spot’ or ‘suntrap’ that is seen and accessible from activity rooms and lounges are magnets that pull staff, families, and residents into the gardens—but only if visible from indoors. Such design features attract garden use by residents and motivate healthful physical movement. A reliable, validated assessment tool that provides a way to evaluate and compare the supportive potential of outdoor spaces for longterm care residents is the Seniors’ Outdoor Survey (SOS) tool (Bardenhagen et al. 2017). The survey addresses access to nature, outdoor comfort and safety, walking and outdoor activities, indoor-outdoor connection and connection to the world. The tool is internationally applicable to residential long-term care and assisted living settings and adaptable to different countries and cultures. A survey of 60 nursing homes in Milan, Italy, collected information on size, conditions and quality of green spaces. Despite a good quantity of outdoor space, there was scope for improving quality (Fumagalli et al. 2017). Site design must help older people maintain skills and independence for as long as possible. Even so, poorly designed gardens are routinely used if residents feel empowered to go outside, and if health and safety issues are tackled (Chalfont 2013). Research of under-utilized care home gardens (UK) found that people, and not the garden, inf luenced how active and meaningful the garden was for residents. Good design requires care practice involvement to address the difficulties in care culture that undermine outdoor usage (Carroll and Rendell 2016). The design and layout of indoor and outdoor spaces is key, in addition to enabling staff to promote connections to nature (Evans et  al. 2019). An integrated approach to garden use that addresses the architecture and

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the sociocultural aspects will ensure that people for whom the space is designed will maximize its use and benefits (Chalfont 2007). To translate this natureenriched environmental philosophy, a sketch scheme design drawing plays a critical role in communicating ‘how’ the space might be used. More heart-warming than physical forms are the meaningful experiences that await. Examples of design for ageing in the UK include 1) extra-care housing; 2) dementia nursing care homes; and 3) hospice, palliative or end of life care. 1.

2.

Extra-care housing accommodates retired people with care and support as needed. Outdoor spaces for nature activities promote independence for as long as possible. Brookside in Ormskirk, England, contains 111 flats, some specifically designed for people with dementia and their partners. Two large gardens visible to adjacent flats are accessible from corridors and lounges. The third garden is adjacent to a dementia day center. (Figure 13.1) A community garden, wildlife area and a public park with a large pond are located next door. The second type of setting is the dementia nursing care home. The ground f loor would have access doors to planting beds, seating areas, lawns, a covered walkway, a greenhouse, a shed and a water feature. Upper f loors would have balconies. Lounges would have direct access to a garden with a greenhouse, shed, planting areas, lawn, raised beds and a variety of seating. A single-story design resonates at a domestic scale allowing potential for daily family life, full of nature engagement for residents, relatives and staff. (Figure 13.2)

Details of a nature-enhanced inner courtyard in a nursing home are also shown in Figure 13.3. 3.

The third setting we consider is the hospice for palliative and end of life care. In the UK, the King’s Fund program, Enhancing the Healing Environment, worked with almost 30 hospitals and 35 hospices to support the design of healing environments, many with a focus on gardens (Buck 2016). At Penny Brohn UK in Exeter, the garden is a metaphor of The Hero’s Journey (Campbell 1990), a mythology for the patient health journey. The gardens facilitate mindfulness with health and well-being, stress management, exercise and eco-therapy. The gardens help patients connect through nature to the soul—opening to the transpersonal side of nature (Porter 2013).

Integrative Potential Interdisciplinary collaboration could potentially evolve care environments into health-enhancing spaces. For instance, we can now address chronic disease with integrative or ‘whole systems’ medicine (Mills et al. 2017) to activate the body’s healing mechanisms to treat the root cause of illness. This 21st-century integrative approach utilizes conventional medicine alongside personalized lifestyle assessments to modify diet, exercise, sleep, stress and cognitive stimulation to affect underlying causes of disease, rather than suppress symptoms

Source: © Chalfont Design and Environmental Associates, 2019

FIGURE 13.1 Extra-care housing example, UK—Garden Plans and Design Criteria. Four bespoke gardens designed with a wide range of familiar, domestic, recreational, social and therapeutic spaces catering to a diversity of needs within 111 f lats and a dementia day centre. The design portfolio became a training tool for staff workshops held prior to the building opening.

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Source: © Chalfont Design, 2019]

FIGURE 13.2 Dementia specialist care home, UK—Family Living Concept, Middleton Hall, November 2016. This sketch scheme was drawn to illustrate the ethos of this innovative development to generate interest with staff and families ahead of the new build.

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Source: © Chalfont Design, 2019

FIGURE 13.3 Dementia nursing care home, UK—Courtyard garden renovation in an existing home. This small space was looked upon from all angles and needed separated areas for activity, privacy, productivity and social space but still allowing good visibility for staff to observe residents unobtrusively. Sun and shade patterns varied widely through the day and required careful design integration of activity spaces. This drawing hung on the wall in the staff room as a teaching tool to encourage and support initiative. They raised funds and built the garden in phases, inspired by the drawing.

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(Chalfont et al. 2019; Bragin et al. 2012). Connection to nature is one tool that encompasses this integrative multimodal therapeutic approach.

Nature in Hospitals As mentioned, the belief that nature and gardens are beneficial for people with illness dates back thousands of years across widely different cultures. During the Middle Ages in Europe, for example, monasteries created elaborate gardens to bring soothing distraction to the ill. By the mid-1800s European and North American hospitals commonly contained gardens as prominent features. However, gardens and nature began to disappear from hospitals during the early decades of the 1900s as rapid advances in medical science caused physicians and healthcare designers to concentrate on creating buildings that would reduce infection risk and serve as functionally efficient platforms for new medical procedures and technology (Ulrich 1999). In recent years there has been a marked revival of interest in designing hospitals with gardens and prominent nature. A key factor in this resurgence has been a growing body of scientific research suggesting that exposure to gardens and nature in hospitals reduces stress and pain and can improve other clinical outcomes.

Effects of Nature Views on Stress and Pain The great majority of hospitalized patients experience stress, and many suffer severe stress. Stress is also prevalent among nurses and other healthcare staff, and can be a major burden for families of patients, especially those with loved ones hospitalized in high-acuity units (Ulrich et al. 2019). The evidence-based Theory of Supportive Design for healthcare facilities ( Ulrich 1999) holds that one important way design can improve clinical outcomes is by achieving stress reduction via access and exposure to nature. Several scientific studies of patient and non-patient groups have found that simply viewing plants, f lowers, or other nature for a few minutes—but not most environments lacking nature—can produce substantial psychological and physiological recovery from stress (Ulrich et al. 1991). Physiological restoration from stress is evident, for instance, in reduced blood pressure and stress hormone levels. These and other beneficial physiological changes are accompanied by elevated positive emotions and diminished levels of negative feelings such as anxiety, sadness, and anger. Apart from reducing stress, there is considerable scientific evidence showing that viewing nature can produce substantial and clinically important reduction of pain (Ulrich 2008). For example, a study of patients recovering from surgery found that those assigned to rooms with a bedside view of nature (trees), compared to matched patients with windows overlooking a brick wall, suffered less pain as indicated by needing far fewer doses of

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strong narcotic pain medications (Ulrich 1984). Furthermore, the nature view patients had shorter hospital stays, better psychological well-being, and endured fewer minor clinical complications such as persistent headache or nausea (Ulrich 1984).

Hospital Gardens Although nature views can significantly lessen stress and pain in patients, physical access to a garden may be even more effective in fostering stress recovery and improvements in other clinical outcomes (Lottrup, Grahn, and Stigsdotter 2013). Gardens in hospitals not only provide stress-reducing nature views, but also can alleviate stress and improve outcomes through a number of other mechanisms (Ulrich 1999). For example, gardens that are accessible to patients provide pleasant spaces for sitting with family, socializing, and deriving healthful social support. Gardens also provide pleasant spaces for seeking privacy. Well-designed gardens can create enticing spaces for patients to engage in movement, physical activity, or rehabilitation ( Ulrich 1999). The notion that pleasant gardens help to motivate patients to engage in physical activity, as well as alleviate their emotional duress and stress, has led an increasing number of hospitals to design rehabilitation gardens that enable physiotherapists and horticultural therapists to treat specific categories of patients, such as those recovering from orthopedic surgery, stroke, and burns. A growing amount of research has confirmed that patients, family visitors, and healthcare staff who use well-designed hospital gardens report reduced stress, enhanced emotional well-being, and higher satisfaction with overall quality of care (Whitehouse et al. 2001; Sherman et al. 2005). A recent study found that a garden with abundant plants and f lowers located close to an intensive care unit (ICU) was effective in mitigating distress in stressed family members of ICU patients, and was somewhat more effective than indoor hospital areas expressly designed for family respite and relaxation (Ulrich et al. 2019). Research on nurses found that those having access to a nearby garden for daily breaks experience lower work-related stress and burnout than employees without garden access (Cordoza et al. 2018).

Evidence-Informed Guidelines for Designing Hospitals With Nature 1.

Architectural siting and design should provide window views of nature and gardens from patient rooms, waiting rooms, staff workspaces, and other interior hospital areas where stress is a problem. Providing nature window views in treatment and procedure spaces where stress and pain are burdens also warrants high priority (Ulrich 2008).

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2.

3.

4.

Hospital gardens should be located close to targeted groups, unlocked, and have accessible paths for users with walkers or wheelchairs, for them to be frequently used and effective in improving clinical outcomes (Marcus and Sachs 2014; Ulrich et al. 2019). However, locked and inaccessible gardens can decrease sense of control and may worsen stress in treatment facilities ( Ulrich et al. 2019). Gardens designed in informal natural styles with prominent vegetation and f lowers are more effective in reducing stress than formal or geometric spaces with little nature and predominant hardscape such as concrete ( Twedt, Rainey, and Proffitt 2016). Other garden design features that researchers have linked to stress reduction and user satisfaction include options of comfortable movable seating to promote socializing, access to privacy, shade access, visual connections (large windows) from interior spaces such as hallways to attract users to the garden, and a play area for children (Marcus and Sachs 2014; Ulrich 1999; Sherman et al. 2005).

This chapter has drawn from research and practice to highlight how settings designed with nature improve care and health for ageing. However, this is not without challenges. A recent sociological exploration with architects revealed difficulties and opportunities within the design-build of health and social care architecture (Buse, Martin, and Nettleton 2018). Hence, implementing emerging evidence into landscape design, architecture and care practice opens bold new therapeutic avenues. The essence of healthy ageing is to feel engaged in the world around us. 21st-century science now knows that everything is energy, and health is an energetic coherence between the body and the mind. The designer’s task is to facilitate experiences in the natural world. Design invites us to take this journey, to shape a mindful environment, to engage the staff, families and older people in the use and enjoyment of their space, and by so doing, to open the door to enhanced health and wellbeing in later life.

References Al-Naggar, R. A., and S. Anil. 2016. “Artificial light at night and cancer: Global study.” Asian Pacific Journal of Cancer Prevention 17 (10): 4661–4664. Bardenhagen, E., S. Rodiek, A. Nejati, and C. Lee. 2017. “The Seniors’ Outdoor Survey (SOS Tool): A proposed weighting and scoring framework to assess outdoor environments in residential care settings.” Journal of Housing For the Elderly 32 (1): 99–120. Bossen, A. 2010. “The importance of getting back to nature for people with dementia.” Journal of Gerontological Nursing 36 (2): 17–22. Bragg, R., and G. Atkins. 2016. A Review of Nature-based Interventions for Mental Health Care—Natural England Commissioned Reports #204. http://publications.naturaleng land.org.uk/publication/4513819616346112 . Accessed 2016/09/28.

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Bragin, V., M. Chemodanova, I. Bragin, N. Dzhafarova, I. Mescher, P. Chernyavskyy, M. E. Obrenovich, H. H. Palacios, and G. Aliev. 2012. “A 60-month follow-up of a naturalistic study of integrative treatment for real-life geriatric patients with depression, dementia and multiple chronic illnesses.” Open Journal of Psychiatry 2 (2): 129–140. https://doi.org/www.ncbi.nlm.nih.gov/pubmed/23910656. Buck, D. 2016. “Gardens and health: Implications for policy and practice.” National Gardens Scheme. www.kingsfund.org.uk. Accessed 2019/11/01. Buse, C., D. Martin, and S. Nettleton. 2018. BUILDINGS IN THE MAKING: A Sociological Exploration of Architecture in the Context of Health and Social Care. University of York (York). www.york.ac.uk/sociology/research/current-research/nettleton,daryl-martin-chrissy-buse. Accessed 2019/02/01. Campbell, Joseph. 1990. The Hero’s Journey: A Biographical Portrait. New York: Harper Collins. Carroll, D., and M. Rendell. 2016. “Promoting the optimal use of outdoor space.” The Care Home Environment 1 (2): 27–31. Chalfont, G. 2006. “Connection to Nature at the Building Edge: Towards a Therapeutic Architecture for Dementia Care Environments.” PhD, School of Architecture, University of Sheffield. http://etheses.whiterose.ac.uk/id/eprint/1241. Accessed 2019/11/01. ———. 2007. “The Dementia Care Garden: Part of daily life and activity.” Journal of Dementia Care 15 (6): 24–27. ———. 2013. “Beyond risk: The rewards of nature.” Journal of Dementia Care 21 (6): 32–34. Chalfont, G., J. Simpson, S. Davies, D. Morris, R. Wilde, L. Willoughby, and C. Milligan. 2019. “Personalised medicine for dementia: Collaborative research of multimodal non-pharmacological treatment with the UK National Health Service (NHS).” OBM: Geriatrics 3 (3). https://doi.org/10.21926/obm.geriatr.1903066. Chalfont, G., and A. Walker. 2013. “Dementia Green Care Handbook of Therapeutic Design and Practice.” Safehouse Books. http://chalfontdesign.com/books.html Free download PDF. Cho, Y. M., S.-H. Ryu, B. R. Lee, K. H. Kim, E. Lee, and J. Choi. 2015. “Effects of artificial light at night on human health: A literature review of observational and experimental studies applied to exposure assessment.” Chronobiology International 32 (9): 1294–1310. https://doi.org/https://doi.org/10.3109/07420528.2015.1073158. Cordoza, M., R. S. Ulrich, B. J. Manulik, S. K. Gardiner, P. S. Fitzpatrick, T. Hazen, and R. S. Perkins. 2018. “Impact of nurses taking daily work breaks in a hospital garden on burnout.” American Journal of Critical Care 27: 509–512. De Boer, B., J. P. H. Hamers, S. M. Zwakhalen, F. E. Tan, H. C. Beerens, and H. Verbeek. 2017. “Green care farms as innovative nursing homes, promoting activities and social interaction for people with dementia.” Journal of the American Medical Directors Association 18: 40–46. Duggan, S., T. Blackman, A. Martyr, and P. V. Schaik. 2008. “The impact of early dementia on outdoor life: ‘A shrinking world?’.” Dementia: The International Journal of Social Research and Practice 7 (2): 191–204. Edwards, C., C. McDonnell, and H. Merl. 2013. “An evaluation of a therapeutic garden’s inf luence on the quality of life of aged care residents with dementia.” Dementia: The International Journal of Social Research and Practice 12 (4): 494–510. Evans, S. C., J. Barrett, N. Mapes, J. Hennell, T. Atkinson, J. Bray, C. Garabedian, and C. Russell. 2019. “Connections with nature for people living with dementia.” Working with Older People. https://doi.org/10.1108/wwop-01-2019-0003.

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Fumagalli, N., G. Senes, C. Ferrara, A. Giornelli, S. Rodiek, and E. Bardenhagen. 2017. “Gardens for seniors—A case study in nursing homes in Milan (Italy).” ISHS Acta Horticulturae 1189 (67). www.accesstonature.org/resources.html. Accessed 2019/11/01. Gibson, G., G. E. Chalfont, P. D. Clarke, J. M. Torrington, and A. J. Sixsmith. 2007. “Housing and connection to nature for people with dementia: Findings from the INDEPENDENT project.” Journal of Housing for the Elderly 21 (1/2): 55–72. Gonzalez, M. T., and M. Kirkevold. 2014. “Benefits of sensory garden and horticultural activities in dementia care: A modified scoping review.” Journal of Clinical Nursing 23 (19/20): 2698–2715. Irvine, K. N., and S. L. Warber. 2002. “Greening healthcare: Practicing as if the natural environment really mattered.” Alternative Therapies in Health and Medicine 8 (5): 76–83. Lottrup, L., P. Grahn, and U. K. Stigsdotter. 2013. “Workplace greenery and perceived level of stress: Benefits of access to a green outdoor environment at the workplace.” Landscape and Urban Planning 110: 5–11. Marcus, C. C., and N. A. Sachs. 2014. Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces. Hoboken, NJ: John Wiley. Mills, P. J., S. Patel, T. Barsotti, C. T. Peterson, and D. Chopra. 2017. “Advancing research on traditional whole systems medicine approaches.” Journal of Evidencebased Complementary & Alternative Medicine 22 (4): 527–530. https://doi.org/10.1177_ 2156587217745408. Porter, C. 2013. “HOSPICE GARDENS—MORE THAN THE SUM OF THEIR PARTS: Meanings and perceptions surrounding the therapeutic environment and what they mean for landscape designers developing hospice gardens.” Master of Research (M Res.) in Landscape, School of Architecture, University of Plymouth. Sherman, S. A., J. W. Varni, R. S. Ulrich, and V. L. Malcarne. 2005. “Post-occupancy evaluation of healing gardens in a pediatric cancer center.” Landscape and Urban Planning 73: 167–183. Twedt, E., R. M. Rainey, and D. R. Proffitt. 2016. “Designed natural spaces: Informal gardens are perceived to be more restorative than formal gardens.” Frontiers in Psychology 7: 1–10. Ulrich, R. S. 1984. “View through a window may inf luence recovery from surgery.” Science 224 (4647): 420–421. ———. 1999. “Effects of gardens on health outcomes: Theory and research.” In Healing Gardens, edited by C. C. Marcus and M. Barnes, 27–86. New York: John Wiley. ———. 2008. “Biophilic design of healthcare environments.” In Biophilic Design for Better Buildings and Communities, edited by S. Kellert, J. Heerwagen and M. Mador, 87–106. New York: John Wiley. Ulrich, R. S., M. Cordoza, S. K. Gardiner, B. J. Manulik, P. S. Fitzpatrick, T. M. Hazen, and R. S. Perkins. 2019. “ICU patient family stress recovery during breaks in a hospital garden and indoor environments.” Health Environments Research & Design. Epub. https://doi.org/10.1177/1937586719867157. Accessed 2019/11/01. Ulrich, R. S., R. F. Simons, B. D. Losito, E. Fiorito, M. A. Miles, and M. Zelson. 1991. “Stress recovery during exposure to natural and urban environments.” Journal of Environmental Psychology 11: 201–230. Whear, R., J. T. Coon, A. Bethel, R. Abbott, K. Stein, and R. Garside. 2014. “What Is the impact of using outdoor spaces such as gardens on the physical and mental wellbeing of those with dementia? A systematic review of quantitative and qualitative evidence.” Journal of the American Medical Directors Association 15 (10): 697–705.

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14 DESIGN-DRIVEN DIALOGUES FOR HEALTHCARE ARCHITECTURE Peter Fröst

Introduction The chapter has its starting point in a Swedish experience where design research has been implemented in healthcare design projects from 2005 to 2015. In 2004, a framework for conducting design-driven dialogues with user groups in architectural design was presented at Chalmers University of Technology (Fröst 2004). The framework was based on knowledge from the research and practice area Participative Design (PD), applied in interaction design and other practice areas. The thesis studied and described the application of these methods and tools within the architect’s field of work. In cooperation with the architectural branch at the Swedish/international consulting firm Sweco, the framework was translated into a coherent design-driven dialogue methodology under the name “Design Dialogue” and as such, integrated into its service delivery. Since then, “Design Dialogue” has been practically applied in over 100 projects, of which more than half are in healthcare architecture in Sweden and internationally (Fröst et al. 2017).

Healthcare—A Complex Dynamic System Many have argued that Healthcare should be viewed as a complex dynamic system. “Complex” is today a term that is widely used. But everything that is manifold and large isn’t complex. In order to express the concepts, we need to turn to systems theory (Andersson and Törnberg 2018). According to this, there is an important difference between what is complicated and what is complex. And this difference affects how we should try to solve problems with one or the other property.

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Although complicated systems are difficult to understand, they are still solvable and possible to predict how they will behave, if you only have sufficient knowledge of the components and their interrelationships. Examples of complicated systems are machines designed by man. Even phenomena in nature are predictable; for example, planetary orbits around a star can be understood as complicated systems. This view of systems as mechanical and predictable was long seen as the ideal of natural science, from Newton’s classical mechanics to the birth of quantum mechanics and chaos theory in the 20th century. Complex systems, on the other hand, are characterized by many parts where knowledge of the parts’ properties is not sufficient to explain the whole system’s properties. These are qualitatively different from the constituent components and cannot be reduced to data and deterministic formulas. They can only be described with approximate rules that can change over time. These are qualitatively different from the constituent components and cannot be reduced to data and deterministic formulas. Complex systems can be simulated to some extent but cannot be fully predicted, so they are not deterministic. A complex system like healthcare is filled with hundreds of moving parts and scores of players of varied expertise and independence. It does not have a “mission control” that runs all these different parts within an ever-changing political, economic, and societal environment (Zimmerman 2005). Additionally, the system is in permanent change. Complicated and deterministic models have often been used as a parable outside natural science within many areas in society (e.g., the construction industry or for man’s supposedly rational behavior in the economy, social life, work). When it comes to complex problems, this risks a mechanistic view. Complex problems need to be addressed with a different approach than the complicated ones where you need to narrow the problem and turn to experts that just need all the relevant information to be able to find a solution. Complex problems instead need to be widened and extended to a larger group of stakeholders.

Design Process for Complex Challenges Hence, a traditional step-by-step “analysis-synthesis-evaluation” design method is insufficient for handling both complexity and constant change of requirements. In such a complex and ever-changing activity that healthcare actually is, design issues are accordingly very multidimensional. The care environment, the organization, the technology, the care process, the forms of treatment, the patient’s perspective, the staff interests and more must be considered together as an entirety. The healthcare design process therefore needs to be iterative/ dynamic and collaborative to address complexity and constantly changing programmatic requirements. Traditionally, a process where healthcare first describes its needs and then architects design buildings that support these is preferred. However, many

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significant changes in healthcare practices occur simultaneously with the planning and design of new or altered buildings. When planning of new buildings begins, you need to consider care environment, organization, technology, healthcare process, modes of treatment, patient perspective, work environment and so forth as an entirety. The meeting of different perspectives—medical, organizational and architectural—creates new images of the conditions that exist. Innovations and new opportunities must be captured in this design process. The arena that is created around the design process includes several different areas and involves a meeting between various disciplines and is also an important platform for the creation of new knowledge and innovation (Sanders 2008).

Healthcare Architecture Design In healthcare design, knowledge about the needs of healthcare is largely found in doctors, nurses, and other healthcare professionals. User groups in healthcare design therefore consist of several stakeholders and professions. The user groups are both cross disciplinary and multi-professional. At the same time, the healthcare operations are in constant change due to internal and external driving forces. The awareness that a participatory design process helps ensure the designer is well informed, and that professional knowledge from healthcare in that way can be integrated into the planning process, is growing (Burton 2014). The knowledge about how these changed conditions affect care models and the way work is being done, for example, needs to be described. The organization’s requirements and needs are usually not fixed from the start, but they are formulated at the same time as solutions and ideas are worked out, from which you gain new insights on how things could be. In this way, the process when designing the care environment also acts as an arena for a parallel organizational development process (Argyris and Schön 1992). In order to formulate its specific requirements, healthcare needs to review what it actually does, how f lows and processes work and what is prioritized. This leads directly to attempts to see how things could be done differently and better; one needs to be open-eyed enough to formulate goals for the future. At the same time, it is difficult to translate organizational goals into spatial solutions. The risk is that you repeat the spatial structure you are used to and formulate needs that mainly ref lect today’s working methods. Then organizational problems may be wished to be solved with more and larger rooms. In a traditional design process, it is the architect’s job to try to handle this dynamic complexity. If then locked into a rigid step-by-step process, there is a great risk that many re-runs and revisions are required, which generates delayed schedules and high costs. To construct and build hospitals is complicated but to design them is a complex challenge. The latter is characterized by not having definitively correct solutions but rather “best possible” solutions. These are negotiated with a balance

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between a variety of mostly contradictory factors that are agreed upon. Many actors with different perspectives are involved so that no one has the full power to choose the solution herself. In a design process that is adapted to the complex and dynamic reality of care, it is accepted that the insight into what is possible to achieve will gradually emerge in the design process. As concluded before, the problem needs to be extended to a larger group instead of being narrowed down (Granath 1991).

Design-Driven Dialogues Design-driven dialogues belong to the field of research and practice named Participative Design (PD), which also includes Co-Design with several approaches. These have emerged from a variety of sources and backgrounds to handle complex design tasks where groups work together to develop design solutions in different areas. Participative design processes (PD) in various forms take place in many different design fields, such as interaction design, product design, industrial design, service design, architecture and more. A design-driven dialogue is about the joint creation of design artifacts that sketch the future building, district, or organization. Design-driven dialogues are part of a family of multiparty design processes where experts and users collaborate around joint design work and where the dialogue is the focus. There are many other descriptions of these collaborative design processes like User Participation, PD/Participative Design, Co-Design and others. Within the area there are both different research and practice/design fields (Simonsen and Robertson 2013). What they all have in common is that they use methods and techniques to develop, investigate and ref lect in a group through “ref lection-in-action” (Schön 1995). This involves design work around models. Participants typically assume the dual roles of both users and designers through mutual understanding and learning about needs and goals. They aim to let knowledge and values in dialogue form confront, complement and inf luence each other until something distinctively new comes up that they have created together. It then becomes important to create tools to support such dialogues that can bridge the different participants’ “language games” and frame of reference. With this approach, the design process is a learning process for the participants. The design work generates new knowledge, new common language, and new goals (Cross 2011). Design-driven dialogues are based on the conviction that everybody has something important to contribute in design processes. It is based on what matters to them and they can become co-creators in shaping their own future physical environment or workplace. Here, the user or citizen moves from being an informant about their needs to being a legitimate and respected participant in the design process. It involves both a dialogue-based ethics and a practical dialogue-based relationship with other people. The aim of the design-driven

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dialogue is both to improve the quality of the product (i.e., building/district) and the quality of the process. By including how you will work, work in new rooms, and do so with a clear goal of improvement, design-driven dialogues also have a visionary and emancipating mission (Fung and Wright 2003).

What Characterizes Design-Driven Dialogues Design-driven dialogues, in relation to several other dialogue methods is characterized by singularity in the sense that they explicitly work with design methodology to deal with complexity in the preparation of solutions and architectural proposals. Architects and other spatial designers work with design methods. They typically have a clear result as their goal—to create a concrete architectural proposal of a facility, building or site that is designed and described. The design-driven dialogues thus often result in a higher degree of detail than results from many other dialogue methods. It is not enough to agree on the qualities you want to achieve, but you also are requested to agree on how these qualities actually are manifested in a specific architectural solution. An important point in a design-driven dialogue is that it allows actors to start developing and visualizing ideas and proposals before analyzing and clarifying all the preconditions in detail. Working with visualized solutions is a way to explore and frame the problem in a complex situation. In this way you reduce the complexity but always work with the entirety simultaneously (Dark 1984). Through the proposals you see future opportunities but also what is missing and what doesn’t work. This approach challenges the established project process in the construction industry but is far closer to how design work really happens. A design-driven way of working requires an interactive process going from detail and entirety in order to be able to handle complex projects with unclear and diffuse objectives that involve many different actors and issues (Fröst 2005).

“Design Dialogue” As described in the introduction, a framework of design-driven dialogues has been developed into a coherent methodology and an architectural service with the brand “Design Dialogue” that has been completed in more than 100 architectural projects (Fröst et al. 2017). The methodology is based on interactive and participatory dialogue processes with multidisciplinary teams and expands the traditional design process with various tools and activities to support staff and patients as well as different experts in their development work. “Design Dialogues” are driven forward in a fixed structure with purpose, content and expected results defined in each part.

FIGURE 14.1

Schematic illustration of the phases in a “Design Dialogue.”

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The dialogue process is built around a series of workshops where various steps are discussed in the way healthcare works. It is about how to formulate goals, to identify the needs for functions and relationships, to develop solutions, and to ref lect upon them. The workshops use different methods and tools such as photos, film, design games and scenarios to support the work. The dialogue around the co-work with these different design materials is at the heart of the “Design Dialogue.” Between the workshops, the discussions are documented, processed and interpreted and the results processed into new design material. “Design Dialogue” is based on extensive pre-, parallel- and post-work. The purpose is that the time spent by the participants in and between workshops should be limited and effective. In each project, the process is designed in detail together with the client in order to adapt to the context. Therefore, the first step in a “Design Dialogue” is to create a process map. This means a timetable in which the various steps and the organization with their different groups—workshop group, dialogue management, steering group and so on—are graphically coordinated. A “Design Dialogue” is always led and conducted by a team of architects/ designers. It typically consists of two or three people taking on different roles. Someone takes on the role of dialogue manager with responsibility for planning,

Participants in a “Design Dialogue” are playing a Design game concerning a new healthcare facility.

FIGURE 14.2

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preparation and facilitation during the workshops. Someone else takes responsibility as an architect/designer with specialist knowledge in the area that the project is about, for example, healthcare, school or urban design. In order to be able to take a position on and evaluate various solutions, the participants are given assistance in illustrating, visualizing and supplementing information afterwards. At each new workshop, a step is taken further in the level of detail and concretization. The participants build on what has been discussed at previous workshops and the design material the “Design Dialogue” team is working on. The team’s task will also be to summarize and transform the outcome from each workshop as an interpreted and processed design material into the next workshop. A typical process involves a series of three to five workshops. These have the same basic plan, but a different focus depending on each project’s needs and how far they have reached: from the present situation (starting point), inspirations and visions to the evaluation and prioritization of alternatives, to a more and more detailed and concrete architectural proposal.

Design-Driven Dialogues—Why They Work A design-driven dialogue is a way for architects and other spatial designers to develop solutions by means of co-design work with users around the design of rooms and spaces. One of the reasons that dialogue around rooms and spaces is so powerful is that we are always spatial. Rooms, and how we use them, are, of course, obvious because we are always physical. On the other hand, the rooms are at the same time complex representatives of who we are and what we want, through symbols, location and design. This is a central driving force in the design-driven dialogues, partly because it is a working method based on dialogue and partly because that it is based on dialogue around the physical space where we do what we do. The patient meets the healthcare in its premises; this is where care takes place. This is also the reason architects are involved in this way of work, regardless of style or form; space is the architect’s responsibility in the same way that healthcare staff is responsible for care processes. In the meeting between different professionals and users, new common knowledge about space and operations can be developed. In the design-driven dialogues, users and their knowledge are involved in a strategic and operational way in the design process. The methodology involves active collaboration between clients, users, other stakeholders and architects. The idea is to create, at an early stage, shared images of what the future should be like. By describing a physical future and not just an organizational or future process, activities and procedures are concretized into rooms and buildings and the participants are given support in realizing and visualizing what the future situation might be. The future, desired situation becomes not only a description of how to do it, but also of where to do it. This is made possible by gathering a

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group of stakeholders together with those directly affected by change and starting from their experiences and knowledge. The design-driven dialogue offers tools and methods for identifying, developing and formulating future needs. Goal formulation and need determination are emerging in the meeting between healthcare operation and the planned building. These are not formulated at the beginning of a project but are developed in parallel with architecture. The focus is on the site, the physical environment and the premises, but also deals with content, culture, organization and above all the use of built environment. In an evaluation by Chalmers of the “Design Dialogue,” the importance of participation and continuity is pointed out (Eriksson 2013). The evaluation included 26 informants from 7 care projects to varying degrees of completion. The informants represented architects, clients and business representatives from projects where the methodology was used at an early stage. The interviewed participants argued that the Design Dialogue became the starting point of a development discussion about the business and its needs, a discussion that carried throughout the entire planning process and well into moving in. The goals and visions that the group formulated at the beginning of the Design Dialogue were stable. Stability was lifted both as a positive and as it sometimes stood in the way of actually landing in decisions. The Design Dialogue creates a starting point for the continued work that is then done in other constellations in the business. Experience from the Design Dialogue indicates that the working method results in an improved organizational preparedness for the future changes the environment is expected to undergo. As the Design Dialogue offers focused and structured work for a very limited period of time, representatives from several projects eventually expressed that they had experienced a failure in the ongoing process. When the ordinary planning process began, it was perceived as closed, unstructured and slow in relation to the exploratory phase constituted by the Design Dialogue. “We had high expectations for the future, but the pace was lost,” one participant says. “At first it was too fast to make informed decisions, then the structure was missing, and all decisions were pulled out at the time,” says another, frustrated participant.

Conclusion Let us summarize aspects of, and possible explanations for, all the experiences that appear to indicate that a design-driven dialogue approach to managing complex design tasks with interprofessional user groups in the early stages works considerably well. •

Design tasks are characterized by the search for a valid solution in a complex “wicked” situation confronted with “wicked problems” where many parameters and interests must be considered. Those are problematic situations

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where it is initially unclear what is to be expected or to be achieved. With a design approach, you gain knowledge of the complexity of the problem by developing preliminary, conceptual solutions and proposals, before clarifying all the pre-conditions. You not only solve problems—you formulate them too. This means that complex problems can be handled by working with a designerly iterative and cyclic approach (Cross 2011) and successively, step by step, discovering the problems by means of design, while the entirety, to varying degrees of detail, is constantly present. Design means working with some type of physical model. Using design material (sketch paper and pen, cardboard pieces, 3D programs), a design process builds up a representation of an imagined reality (i.e., a kind of virtual world that can be explored as if it were for real). The design work itself can be seen as a ref lective conversation with this design material as a responding counterpart (Schön 1992). It is therefore at the center of the design work through joint creation and ref lection. Model creation means that the problem is simplified so that it becomes possible to deal with it thoughtfully. Developed solutions are tested against the entirety; analyzed, evaluated and condensed in a successive process. Model creation is a way to make the problem manageable without losing the entirety. In this way you can also manage the activities and needs of the organization and the rooms and functions of architecture at the same time. In cross-professional groups with different perspectives, the design material can act as boundary objects (Star 1989) and thereby facilitate cooperation. In this way, an integrated organizational and spatial development is possible in a dynamic interplay. The validity of a solution is a quality that is largely determined by dialogue. The core of the design-driven dialogue is therefore the conversations that take place around various design materials and design artefacts (post-its, design games, sketches, models, drawings, 3D visualizations, etc.). Visual work methods using different design materials help participants to keep large and complex amounts of information active and at the same time be able to change/revise/manipulate them and propose solutions. When something becomes physically concrete as a projection of material reality in a model or a sketch, what is meant or said is better comprehended and any differences become fully clear. The creation of models, in this particular context, has an exceptionally crucial function that is very important for the quality of end results.

References Andersson, Claes, and Petter Törnberg, 2018. Wickedness and the anatomy of complexity. Futures, Vol. 95, pp. 118–138. Argyris, Cris, and Donald Schön, 1992. Theory in Practice: Increasing Professional Effectiveness. San Francisco, CA: Jossey-Bass.

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Burton, Adrian, 2014. Gardens that take care of us. Lancet Neurol 2014. www.thel ancet.com/neurology. Published online March 26, 2014. http://doi.org/10.1016/ S1474-4422(14)70002-X Cross, Nigel, 2011. Design Thinking: Understanding how designers think and work. Oxford: Berg/Bloomsbury. Dark, Jane, 1984. The primary generator and the design process, in Cross, N. (ed.), Developments in Design Methodology. Chichester: John Wiley, UK. Eriksson, Johanna, 2013. Architects and users in collaborative design. Licentiate thesis, Chalmers University of Technology. Fröst, Peter, 2004. Designdialoger i tidiga skeden. (English translation: Design dialogues in the early stages of architectural projects). PhD diss., Chalmers University of Technology. Fröst, Peter, 2005. Representing space—Designing arenas for human action, in Thomas Binder and Maria Hellström (eds.), Design Spaces. Helsinki: Edita IT-Press. Fröst, Peter, Johanna Eriksson, Anna Gustavsson, and Göran Lindahl, 2017. Designdrivna dialoger för arkitektur och samhällsbyggnad (English translation: Design-driven dialogues for Architecture and Urban Design). Chalmers University of Technology. Fung, Archon, and Erik Olin Wright, 2003. Deepening Democracy—Institutional Innovations in Empowered Participatory Governance. London & New York: Verso. Granath, Jan Åke, 1991. Architecture, Technology and Human Factors, Design in a SocioTechnical Context. PhD diss., Chalmers University of Technology. Sanders, Elizabeth B.-N., and Pieter Jan Stappers, 2008. Co-creation and the new landscapes of design. Codesign, Vol. 4, No. 1, pp. 5–18. Schön, Donald A., 1992. Learning to design and designing to learn, talk delivered to the International Conference on Theories and Methods of Design, May 1992, Gothenburg. Nordic Journal of Architectural Research Vol. 1, pp. 55–70. Schön, Donald A. 1995. The Reflective Practitioner: How Professionals Think in Action. Aldershot: Arena. Simonsen, Jesper, and Toni Robertson, ed., 2013. Routledge International Handbook of Participatory Design. New York: Routledge. Star, Susan Leigh, 1989. The structure of ill-structured solutions: Heterogeneous problem-solving, boundary objects and distributed artificial intelligence. Distributed Artificial Intelligence, Vol. 2, pp. 37–54. Zimmerman, Brenda. 2005. Complexity, A Conversation with Brenda Zimmerman. Interview by Tamarack Learning Centre. www.outcomemapping.ca/resource/complexitya-conversation-with-brenda-zimmerman

15 IT TAKES MORE THAN EVIDENCE TO INFORM THE HEALTHCARE ARCHITECT Stefan Lundin

Focus on Evidence For the last ten years or more, in Sweden, evidence has been regarded as the most important way to improve healthcare outcomes through building design. The risk of arbitrary proposals was supposed to be, if not totally avoided, then at least heavily diminished using evidence. But after years of great expectations of and trust in evidence, some people have realized that the amount and quality of evidence is limited. There are also other conditions that have a crucial impact on successful design of healthcare buildings, and to which we must pay greater attention in the future. Some of today’s architects and researchers have shown a renewed and increased interest in these matters, once again influenced by a tradition colored by artistic and humanistic thinking. Old statements from architects, earlier highly questioned among persons raised in, what I consider, a modernistic and rationalistic tradition, are slowly shown renewed interest. Notions like artistry, intuition, tacit knowledge and so forth are subject to renewed investigation. The pendulum of history swings back and forth between rational and romantic influences in order to inspire and offer new fruitful perspectives upon our endeavors. During the 1970s and 80s several people in the US reacted to dull, anonymous, difficult to navigate hospitals lacking daylight and surrounded by vast parking areas. Were these buildings the proper answer to people’s wish for pleasant premises, where we might have to face some of our most vulnerable situations in life? If not, who is to blame? The clinics, the real estate owner, or even the architect? Patients, next of kin, architects and others gathered to advocate new principles for hospital design. One group, which later became one of the most important proponents for evidence-based design (EBD), was the Center for Health Design (CHD). They had their first gatherings at the end of the eighties asking themselves, in a more structural and scientific way, if building design could

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improve healthcare outcomes. In 1998, five years after the formal foundation of CHD, the first research review of the connection between physical interventions and healthcare outcomes was performed (Rubin et al. 1998). The number of articles that passed the Johns Hopkins scientific requirements was 84. 78,677 were rejected with reference to the lack of scientific approach. A new review in 2004, under the supervision of Roger Ulrich, was based on approximately 650 articles (Ulrich et al. 2004). Its positive attitude and expectation were mirrored in the title, The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. The future looked bright with new findings and a large increase in the amount of high-quality scientific articles. In the revised review from 2008 the number of articles had gone up to nearly 1,200 ( Ulrich et al. 2008). This review reports that there are six design strategies or environmental interventions that can lead to eleven different healthcare outcomes according to especially strong evidence from multiple rigid studies. For example, single-bed rooms, access to daylight and views of nature can reduce hospital-acquired infections and depression but also improve sleep (Ulrich et al. 2008, 148). However, the evidence grade in general was low compared to traditional medical research. A Cochrane study from 2012 questioned the rigor and did not, in all parts, agree with Ulrich et al.’s positive interpretations in the 2008 review (Drahota et al. 2012, 4). An ongoing research review (2019–2020), performed by The Center for Healthcare Architecture (CVA) in a study named Evidensbas för vårdens lokaler 2.0 (Evidence-Base for Healthcare Architecture 2.0), includes peer reviewed articles published in English after 2010 and counts about 460 new articles according to one of the participant researchers. An important influence for the use of evidence in the design of health-care buildings (Evidence-based Design, EBD) was the rise and success of Evidence-based Medicine (EBM) developed at McMaster University in Canada during the nineties. The term was more formally defined by Sackett et al. in 1996. By doctors using databases, accessible via the internet, every patient should now, in theory, be examined and treated according to actual research. Kirk Hamilton, one of EBD’s first and most eager advocates, made a definition of EBD together with David Watkins, and introduced the EBM principles for building design. The implementation and use of evidence “became a must” in many, widely differing fields. However, it was not always as successful, especially in the field of social work (Bohlin 2011).

The Fear of Arbitrary Decisions The introduction to the 1998 research review was written by David O. Weber. He had, what I will call, a technical-rationalistic approach showing great expectations for future research: Continued expenditure for structures whose layout, ambience, and appurtenances are informed by guess, fad, or the personal preferences

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of designers, administrators, healthcare professionals, or even patients themselves—absent solid efforts for aesthetic leanings and unsupported theories with outcomes data to the extent scientifically possible—is frivolity we can no longer afford. (Weber 1998, ix) Again, reading the introduction almost two decades years later, I still feel kind of insulted. Architecture is not a personal method of self-fulfillment. It handles functional and economic issues with great respect, although it also defends personal and esthetical values. There was, “at the start of the evidence era”, a fear of personal and subjective arguments, fear of arbitrary proposals. That was partly why the demand for a higher degree of rigor in the planning process was raised. Perhaps the architects’ first use of evidence also led them to a greater respect in the medical sphere. Writings by later EBD-proponents in the first decades of the 21st century did also exhibit suspicion towards architects in general. Perhaps it was in some way a relevant critique in a US context. But in Sweden, the architect definitely had no such strong position to make hospital designs a subject for personal esthetical preferences.

Could Good Design Be Achieved Without Evidence? However, our experience tells us that good architecture can be created without any knowledge of previous and present research. How is that? One example is the in-patient psychiatric facility at SU Östra in Göteborg, Sweden (2006), for which I was one of the lead architects. The new building replaced an older mental facility, from the seventies, situated in the outskirts of the city. Data on compulsory injections and physical restraints are two clinical markers of aggressive behavior. Compulsory injections showed a decrease, and the average number of physical restraints (among patients who received at least one) decreased by 50 percent, and the decrease in injections was robustly significant (Ulrich et al. 2018). An internal employee survey also showed a decrease in sick leave among staff, as well as a reduced experience of threats and violence (From and Lundin 2009, 145). Roger Ulrich, with his team, later described this decline as a function of an improved physical environment as the staff were substantially the same, as were medication and treatment. The study showed that the architect, namely my colleagues and I, used nine out of ten forms of evidence known from research in the proposal (Ulrich et al. 2018). We had not, at that time, had any contact with either research or evidence in the context of healthcare design. But if good work could be done without any knowledge from research, from where did our skill emerge? I claimed it possible to create good architecture “due to the use of my intuition and a dialogue with the clinic’s management and end-users” (Lundin 2015a). Kirk Hamilton, a figurehead within the EBD-movement, picked up the question in an issue of Health Environment Research and Design, or HERD. I first

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met Hamilton in a Swedish workshop at Chalmers 2012 and since then we have had a fruitful and ongoing discussion in seminars, articles and conferences where we both have improved our thinking and attitude. In his first editor’s column Hamilton was skeptical to my use of the notion intuition and wrote, His designer’s intuition, knowledge of the client, and empathy for the patients had led him to a design solution that had, apparently entirely by coincidence, matched the research-informed guidelines produced by a recognized scholar. An intuitive decision need not be a poor decision. ( Hamilton 2014) I was, of course, challenged by his “apparently entirely by coincidence” and in my comment I maintained the importance of intuition and dialogue. Nowadays our opinions are more closely aligned. Evidence is not enough, and intuitive proposals are a natural part of the design process given the fact that they are discussed and questioned in multidisciplinary working groups (Hamilton 2019). Today, more than 13 years after the inauguration of SU Östra psychiatric clinic, there is a Post Occupancy Evaluation (POE) going on.

Intuition Intuition is thus one of the things that has a crucial impact on successful design for healthcare architecture. But what is intuition? Most of the decisions we make in connection with the design of our healthcare facilities are not based on evidence but on earlier experience from prized buildings, what we often call best practice. At the same time, our experience tells us that some architects succeed better than others in their endeavor to design well-functioning and appreciated buildings. These people have an ability, an added knowledge that “informs them” and helps them to make good interpretations of posed design questions. It is this kind of information and interpretations that we try to capture by notions as intuition, artistry or tacit knowledge. Intuition is sometimes regarded as a relic from days gone by that has no place in “rational contemporary thinking”. Sometimes it is described as “a bolt of lightning out of the blue”. This quote should here be interpreted as the insight coming suddenly, but not understood as though ideas come from nowhere. In this sense, there is no “free imagination”. Robert M. Pirsig expresses this relationship in the following way: “It’s not just intuition, not just unexplainable ‘skill’ or ‘talent’. It’s the direct result of contact with basic reality” (Pirsig 1974, 284). The comparison with lightning tends to mystify rather than explain the real sources of intuition as it actually is based on our interaction with reality through our senses—in the way we interact with our surroundings and store our impressions in the indivisible unity of mind and body—allowing ourselves to be led by our feelings which actually gives us more ability to handle the design problems we face. That is why intuition is a tool for innovation and

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progress that precedes science and evidence. During the seventeenth century René Descartes claimed, “Nothing is in the imagination that was not first in the senses” (Descartes 1996 [1641]). Thus, it must be considered unscientific to exclude using intuition as part of a working tool (for a more detailed discussion see Lundin 2015b). More and more people have realized the importance of an intuitive way of working. Albert Einstein, in his search for universal laws of nature, was one of them, and stated, “There is no logical path to these laws; only intuition, resting on sympathetic understanding of experience, can reach them” (Einstein 1918). However, of course, feelings might lead us in the wrong direction. I guess this is one of the explanations why evidence proponents feared arbitrary decisions in the shadow of dominant architects, perhaps particularly in the US context, but even elsewhere. But this expected arbitrariness can be avoided if the architect’s proposals are subject to scrutiny and discussion, a co-creative dialogue within multidisciplinary workings groups.

Dialogue How to enforce a vibrant dialogue among members in a multidisciplinary working group is the second, important and crucial aspect of creating a successful design that this text addresses. The design of healthcare buildings belongs to the number of problems we may call complex, as they are unambiguous due to multifaceted issues. The traditional linear design process suggest that the program should be drafted before the architects’ design work begins. However, from design-theory we derive the idea that both the prerequisites and demands should be explored, and deepened, at the same time along with the design process. This is the hallmark of a Design-driven dialogue: the use of different design artefacts like principal sketches, conceptual models, renderings and so on (Fröst et al. 2017). A process where the end-users are supposed to participate or even co-create in multi-disciplinary or transdisciplinary working groups. In this way the unconscious practical or tacit knowledge, which is a part of every profession, can inform the project and the architect in creating more and more complete proposals over time. It is this kind of knowledge, among the hospital management and end users, that can become more explicit and conscious, to inform the architect’s work in a way that goes beyond the traditional program. That is what happened at the SU Östra psychiatric clinic, referenced earlier, where the design dialogue was widespread and guided by the hospital management. This provided good working conditions and led to a design where the physical environment supported medical outcomes: to put it another way, less coercive measures towards the patients. In Sweden there is a long tradition of consultation in healthcare design, at least since the seventies. The dialogue-process becomes more advanced in public projects and is applied, in some form in almost all of today’s healthcare projects. The design-driven dialogue forms a partly new process for the architect as he or she initially is the one to prepare appropriate tools and tasks. But it also seems

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that the participants in the working groups think the work is fun, engaging, and also feel a sense of ownership of the proposals. At its best, the design-based dialogue improves organizational and local requirements at the same time—they walk “hand in hand”. So far, the experiences within the industry are limited and are rarely subject to ref lection or research. There ought to be a change.

Conclusion Today there is still a strong focus on evidence in the context of healthcare building design. However, evidence has not come to change hospital design in such a revolutionary way as some proponents of the EBD-movement had foreseen and hoped for. Despite the increase of research and a growing number of articles, the evidence for physical environments impacting healthcare outcomes has not grown or made a major change in hospital planning as supposed. Despite this, the search for evidence, of course, must continue. In every larger hospital project in Sweden today research is observed to some degree. Personally, in every project I am involved with, I try to find and fight for measured outcomes—both for medical and building’s performance. This is more or less a logical consequence of today’s achievement to improve the quality of our work. A positive side-effect of using evidence in the design process is that medically trained staff feel more comfortable in discussions with architects. Architects have, through this process, gained increased credibility and status, as EBDproponents predicted. On the other hand, evidence has in some cases been used as a simplified “tick box” by project managers, property owners and builders often raised in a rational and technical environment in education and profession. Today, evidence is not regarded as the only and absolute basis for good architecture. During the past decade the idea of a design based on evidence (Evidencebased Design—EBD) has been modified and progressed toward an attitude where design should be informed by evidence (Research-informed Design—RID). As shown above, evidence is not the only type of knowledge engaged in hospital design. There are also other forms of knowledge, like intuition/tacit knowledge and design-driven dialogues, that are of paramount importance in the design process. One of today’s challenges is to better understand how we can foster this to further inform the architect’s work, creating new knowledge connected to the design object at hand. Regarding the text above, future research, in order to support physical interventions to improve healthcare outcomes, also ought to focus on: • •

better understanding of how architects learn and incorporate general experiences, from education and every-day life, to improve architectural skills improvement in design-driven dialogues between architects, management, and end users in multidisciplinary working groups in order to create and improve project-specific knowledge to inform the architects in designing healing environments.

Sahlgrenska University Hospital, psychiatric in-patient care, Gothenburg, Sweden. Bench outside patient room. White arkitekter.

Source: ©Photo: Hans Wretling

FIGURE 15.1

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Source: ©Photo: Hans Wretling

FIGURE 15.2 Sahlgrenska University Hospital, psychiatric in-patient care, Gothenburg, Sweden. A small room (veranda) close to patients’ rooms. White arkitekter.

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Sahlgrenska University Hospital, psychiatric in-patient care, Gothenburg, Sweden. The entrance to the ward. Atrium in the front, nurse station to the right. White arkitekter.

Source: ©Photo: Hans Wretling

FIGURE 15.3

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Sahlgrenska University Hospital, psychiatric in-patient care, Gothenburg, Sweden. Sketch, patient room. White arkitekter.

FIGURE 15.4

References Bohlin, Ingemar. 2011. “Evidensbaserat beslutsfattande i ett vetenskapsbaserat samhälle. Om evidensrörelsens ursprung, utbredning och gränser.” In Evidensens många ansikten. Evidensbaserad praktik i praktiken, edited by Ingemar Bohlin and Morten Sager, 31–68. Lund: Arkiv. Descartes, René. 1996 [1641]. Meditations on first philosophy. Internet Encyclopedia of Philosophy, 1996. This file is of the 1911 edition of The Philosophical Works of Descartes (Cambridge University Press), translated by Elizabeth S. Haldane. Accessed January 31, 2020. http://selfpace.uconn.edu/class/percep/Descartes Meditations.pdf Drahota, Amy, Derek Ward, Heather Mackenzie, Rebecca Stores, Bernie Higgins, Diane Gal, and Taraneh P. Dean. 2012. Sensory environment on health-related outcomes of hospital patients. Cochrane Database of Systematic Reviews, Issue 3. Art No.: CD005315. https://doi.org/10.1002/14651858.CD005315.pub2. Accessed January 31, 2020. www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005315.pub2/full Einstein, Albert. 1918. “Principles of Research”. Remarks by Albert Einstein in his paper given at Max Planck’s sixtieth birthday celebration in 1918. Accessed January 31, 2020. www.site.uottawa.ca/~yymao/misc/Einstein_PlanckBirthday.html

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From, Lena, and Stefan Lundin, eds. 2009. Architecture as medicine: The importance of architecture for treatment outcomes in psychiatry. Gothenburg: ARQ Architecture Research Foundation. Fröst, Peter, Anna Gustafsson, Johanna Eriksson, and Göran Lindahl. 2017. Designdrivna dialoger för arkitektur och stadsbyggnad. Gothenburg: Center for Healthcare Architecture, Chalmers, Architecture and Civil Engineering. Hamilton, Kirk. 2014. “Intuitive hypothesis and the excitement of discovery.” HERD: Health Environments Research& Design Journal 7 (2): 140–143. Hamilton, Kirk. 2019. “Evidence, intuition, and experiment: Partners in the design process.” HERD: Health Environments Research & Design Journal 12 (3): 66–71. Lundin, Stefan. 2015a. “In search of the happy balance-intuition and evidence.” HERD: Health Environments Research & Design Journal 8 (2): 123–126. Lundin, Stefan. 2015b. Healing architecture: Evidence, intuition, dialogue. Licentiate thesis. Göteborg: Chalmers University of Technology. Pirsig, Robert Maynard. 1999 [1974]. Zen and the art of motorcycle maintenance. New York: Random House. Rubin, Haya R., Amanda J. Owens, and Greta Golden. 1998. Status report (1998): An investigation to determine whether the built environment affects patients’ medical outcomes. Baltimore, MD: Quality of Care Research, The Johns Hopkins University: The Center for Health Design. Ulrich, Roger S., Lennart Bogren, Stuart Gardiner, and Stefan Lundin. 2018. “Psychiatric ward design can reduce aggressive behavior.” Journal of Environmental Psychology 57: 53–66. Ulrich, Roger S., Xiaobo Quan, Craig Zimring, Anjali Joseph, and Ruchi Choudhary. 2004. The role of the physical environment in the hospital of the 21st century: A once-in-alifetime opportunity. Concord, CA: The Center for Health Design. Ulrich, Roger S., Craig Zimring, Xuemei Zhu, Jennifer DuBose, Hyun-Bo Seo, Young-Seon Choi, Xiaobo Quan, and Anjali Joseph. 2008. “A review of the research literature on evidence-based design.” HERD, Health, Environment, Research and Design 1 (3): 101–165. Weber, David O. 1998. “Introduction.” In Status report (1998): An investigation to determine whether the built environment affects patients’ medical outcomes, edited by Haya R. Rubin, Amanda J. Owens, and Greta Golden, viii–x. Baltimore, MD: Quality of Care Research, The Johns Hopkins University: The Center for Health Design.

16 DESIGN OF HIGH TECHNOLOGY ENVIRONMENTS—INTENSIVE CARE UNITS (ICUS) Maria Berezecki Mårtensson

Introduction This chapter deals with the problems related to intensive care design, especially the intensive care room, and is based on literature study within ICU design that was conducted to create a broad foundation and insight into the research as well as highlight issues in this area. The study included results from both quantitative and qualitative studies. This approach and method are presented more broadly in a Chalmers licentiate thesis publication concerned with impacts of environmental designs on hospital staff and patients (Berezecka 2015). The rapid development of diagnostics, treatment and medical devices affects both practice and the experience of the care environment. This is especially true in environments where large quantities of advanced medical device equipment are in daily use, such as intensive care units (ICUs). Poorly designed ICU environments can have negative side effects and cause stress in patients, staff and relatives. This, in turn, can adversely affect treatment outcomes (Hamilton and Shepley 2010; Zimring, Joseph, and Choudhary 2004). Research results in, among other things, health care and environmental science show that design of the environment can contribute to health outcomes as well as affect the patients’ well-being, need for medicine and time for hospital stay. Environmental design affect patients’ and relatives’ satisfaction with care, as well as staff performance ability (Hamilton and Shepley 2010). In the last few decades, the importance of the design of the care environment has been recognized as a resource for care. ICU environments in health care are resource-demanding in terms of financial investments, operating costs and human resources. Proper design that supports healthcare and care processes also leads to financial gain, for example, in the form of shorter hospital stays and fewer absences among staff due to sickness.

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Design of High Technology Environments: Intensive Care Units (ICUs) At the same time as progress in surgery was accelerating, the importance of post-surgery care began to be realized. Knowledge about how to design environments for advanced patient care began to be formulated in the late 1800s. The pioneer was Florence Nightingale (Gillette 1996), who first wrote down basic recommendations and guidelines for the care of patients who underwent surgical procedures. They would be cared for and monitored in special rooms located near the operating room (Nightingale 1992). Nightingale worked from a holistic perspective and was aware of the patient’s needs and the importance of a good physical environment. Among other things, she wrote about such aspects as hygiene and the importance of daylight, views of nature and fresh air. During the 1940s, the first departments for severely ill patients who needed special monitoring and concentrated care services were started. The need for intensive care increased thanks to the development of medicine, especially surgery and anesthesia, and monitoring technology such as ECG monitoring and heart rate measurement. The most obvious breaking point in the development of intensive care was the invention of the respirator, which was constructed in the early 1950s in response to the polio epidemic. The use of respirators spread very quickly since there was a great need for respiratory assistance, as the polio epidemic first hit many people in Europe and then in the USA. Intensive care units (ICUs) arose when grouping intensive care to improve care efficiency. ICUs are usually located in immediate proximity to surgery departments and emergency units. In Sweden, there are both single and multi-patient rooms. Intensive care rooms are specially equipped with advanced technical equipment, and patients are constantly observed by the healthcare staff. Intensive care rooms differ from ordinary care rooms in several ways. For example, the rooms’ dimensions are based on requirements for monitoring facilities, technical equipment, the possibility of activating the patient and for relatives’ stays (the last requirements have been added in recent years). The rapid development of treatment methods and progress in medical technology has in recent years been followed by research on how patients experience, and are affected by, their stay in the intensive care environment, how relatives perceive their role in the care process and how the work environment affects the staff (Olausson, Ekebergh, and Lindahl 2012; Eriksson, Bergbom, and Lindahl 2011; Fridh, Forsberg, and Bergbom 2009; Zimring, Joseph, and Choudhary 2004). Despite the fact that design of intensive care rooms has an impact on the patient’s ability to recover, on staff performance and on the satisfaction of relatives, the design of ICU rooms has not ref lected this. A number of intensive care units’ environments are still characterized by large quantities of technological aids such as medical devices and advanced

Example of patient room with workstation on ICU

Source: ©(Berezecka-Figacz et al. 2013).

FIGURE 16.1

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monitoring equipment around the patient, high noise levels, bad placement of the washbasin and bed, bad lighting conditions and lots of visual stimuli. There is a great complexity linked to healthcare environments where advanced technology is used and, where patients are critically ill, out of control over the environment, under the inf luence of medication and often after a traumatic experience. Therefore, it is very important that the environment is designed with consideration to the patient in the first place. In addition, positive improvements in the environment for the healthcare staff and relatives are of great importance for the patient’s ability to recover. Healthcare professionals who are satisfied with their workplace do their job better. Relatives who can stay longer can support and mobilize the patient during their ICU stay. ICU design is one of the factors that are important for a successful care result. The physical environment can be seen as a whole, consisting of a number of smaller parts that work together. These are, for example: light level, air quality, temperature and humidity, noise, access to daylight, lighting conditions, f loor plan, and access to nature. The literature studies show that patient rooms in an ICU should be single rooms ( Teltsch et al. 2011). According to several researchers, there are both economic (e.g., shorter hospital stays) and ethical reasons that speak for single patient rooms (Harris et al. 2006; Zimring, Joseph, and Choudhary 2004). Single patient rooms can, among other things, help reduce infections, reduce the risk of medical errors and reduce noise levels. Single patient rooms make it possible to carry out different treatments directly in the room, thus avoiding patients being moved. When patients are moved for diverse treatments to different rooms, the risk of medical errors increases (Hendrich, Fay, and Sorrells 2004; Zimring, Joseph, and Choudhary 2004). The results of a study by Hendrich, Fay, and Sorrells show that moving patients can increase costs, reduce the quality of care and decrease satisfaction for both patients and staff (Hendrich, Fay, and Sorrells 2004). There are also researchers who consider that the overall results from various studies on the effects of healthcare architecture in different clinical and economic areas are sufficient to argue that future investments in health care departments should be made with single patient rooms (Chaudhury, Mahmood, and Valente 2005; Malkin 2003). One of the most important arguments for single patient rooms is reduced infection risk and shortened hospital stay. This has been shown, among other things, in a randomized study (Teltsch et al. 2011). The researchers compared the proportion of infections in an intensive care unit before and after the change from multi-patient rooms to single rooms. Before the rebuild there were 24 ICU places in two large rooms with 12 beds in each with four associated sinks. In addition, there were four single rooms. After rebuilding, there were 24 single patient rooms, each with their own sink and two sinks in the area outside the rooms. A nearby hospital with 25 ICU places in multiple patient rooms was used as a control to isolate effects

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from other changes. The hospitals had common infection control and working methods and similar trends in outbreaks of bacterial infections. The key ratio of “patient-nurse” was constant throughout the study. The results showed that infections after the change to single rooms decreased by 50% for three bacterial species: methicillin-resistant Staphylococcu aureus (MRSA), Clostridium difficile (C.difficle) and vancomycin resistant enterococci (VRE). In addition, reduced hospital stays of 10% were observed in the ICU after the change to single rooms. Similar conclusions are shown by Cepeda et al. in a study published in 2005, where it was found that single patients reduce the risk of transmission of infections with resistant bacteria because staff are not moving simultaneously between different patients within the same room (Cepeda et al. 2005). There are a number of environmental elements linked to treatment in a single patient room which can increase the patient’s satisfaction with care (Chaudhury, Mahmood, and Valente 2006). The environment can be customized more individually according to the patient’s needs. Everyone staying in an ICU is exposed to noise. High noise levels can be a source of stress, irritation and headaches. This leads to lower performance in the work of the healthcare staff and longer recovery time for patients (Duckworth 1987). In the single room the number of appliances and alarms is reduced. In multi-patient rooms, the sound levels are higher as there are several sound sources, and patients can also experience worry about sounds associated with life-saving activities around fellow patients (Johansson, Bergbom, and Lindahl 2012). Patients can be affected negatively. Hearing is the sense that is last affected by sedative drugs. The patient who appears to be sleeping can still hear and be affected by noise. Noise also causes patients’ sleep in an ICU to be adversely affected (Freedman et al. 2001). The study shows that in connection with noise, the patient is subjected to fragmentary sleep and loss of sleep stages. Research shows that noise leads to irritation, insomnia and high blood pressure in patients and has negative effects on recovery (Hilton 1985). The main source for noise is the sound of technical equipment, alarm signals and conversations. The majority of health care professionals also experience noise as a problem and cause of stress, irritation, fatigue, tension headaches and concentration (Ryherd, Waye, and Ljungkvist 2008). This can lead to disruptions in communication and make it easier to commit mistakes. A bad sound environment can lead to lower performance at work, and in this way affects even patients negatively (Duckworth 1987). The acoustic environment can be changed using sound-absorbing materials or materials that can spread the sound, and by using silent alarms. Single patient rooms also support better acoustic environments compared to multi-patient rooms. The number of sound sources is reduced, the patient sleeps better and is not disturbed by activities and conversations related to other patients cared for in the same room. Sound can also have a positive impact on the patient’s condition. It can act as a positive distraction, and helps to reduce stress, anxiety and to decrease

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experienced pain (Diette et al. 2003). Natural sounds, such as birdsong or water effects, can provide a soothing effect (Marcus and Barnes 1995; Ulrich 1999; Ulrich et al. 2008). In an ICU, it is standard practice for healthcare professionals to talk to patients when they take care of them, even when they are sedated. Pleasant sounds (e. g., caregivers’ conversations, the voice of the relatives) can give the patient a sense of presence. If possible, the opportunity to choose music, listen to the radio and so on can increase the feeling of control over the surroundings. In single rooms the staff can focus all their attention on just the patient who is in the room, and thus the patient experiences that he/she receives more attention from nurses and doctors. The number of medical errors also decreases when healthcare professionals concentrate on one single patient (Chaudhury, Mahmood, and Valente 2005, 2006; Harris et al. 2006). In single rooms, it is also generally easier to safeguard privacy and the integrity of the patient and his/her relatives in sensitive situations (e.g., patient at the end of life) compared to multi-patient rooms. Single rooms also provide better opportunities for social support. Relatives can stay longer and can have more unimpeded time with the patient. In a properly designed intensive care environment, relatives do not feel that they interfere with other patients or that they interfere with the care staff in their work. The presence of close relatives reduces anxiety in patients and supports recovery (Wåhlin, Ek, and Idvall 2009a). In their study, Wåhlin compared how patients experience the support they receive with how relatives and care staff perceive the support they provide. The study has shown that both relatives and caregivers tended to perceive the patient as less conscious than the patient perceives himself/herself to be. For the patient, the presence of relatives has played an important role in providing the will to get better and not give up. Another study describes how relatives themselves experience their situation in the intensive care unit (Wåhlin, Ek, and Idvall 2009b). Through a number of interviews with close relatives, the researchers show that even close relatives, when accessing intensive care units, can experience trauma with feelings of shock, fear, anxiety and vulnerability. At the same time, they experience a genuine desire to help and relieve the patient’s suffering as well as protect the patient. The presence of close relatives not only reduces the patient’s suffering but can often facilitate communication between the patient and the care staff (Bergbom and Askwall 2000). The relatives are often willing to support the patient during the treatment period, which can result in the patient feeling less stressed and reduce the need for sedative medication (Engström and Söderberg 2004; Tarkka et al. 2003; Eriksson, Lindahl, and Bergbom 2010). The presence of relatives means an increased need for accommodation, toilets with shower, kitchenette, a dining area and a day room (Chaudhury, Mahmood, and Valente 2005, 2006). It is important that relatives have a place in the ward, especially when children are visitors to the patient. It is then very important that the environment does not seem scary to the child (Knutsson et al. 2008).

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Medical technology equipment has changed the image of health care environments and inf luences working environment conditions and the experience of the health care environment. In the technology-intensive care environment the relationship between the caregiver, technology and patient is complicated. Both human and machine are important, powerful tools in the care process and in treatment. The amount of advanced technology in healthcare that we are experiencing today is something new and difficult to handle. In the ICU, the staff feels that the patient “disappears” behind the technology. It is important to maintain reasonable balance so as not to reduce a human to a part of the medical technological machinery. Lots of close relatives try to adapt to the new intensive care environment, protect their relatives (the patient), assist in nursing and learn to understand the technical devices (Ågård and Harder 2007). Often, they perceive the technology around the patient as positive as it helps the patient recover (Eriksson, Bergbom, and Lindahl 2011). It is important that the healthcare staff constantly inform relatives of what is happening and can answer their questions. Relatives involved in the care process have greater acceptance of the situation (Fridh, Forsberg, and Bergbom 2009). There is a need for smaller meeting rooms where families can receive information and education. Researchers in a study from University Hospital Gasthuisberg in Belgium investigated differences in perceptions of the patient’s need for close relatives’ assistance through a questionnaire addressed to relatives, doctors and nurses. It was generally found that both the need for information and proximity to one’s relative (the patient) were underestimated by physicians and nurses ( Bijttebier et al. 2001). In critical situations, when the patient is dying or in a life-threatening situation, relatives should have the opportunity to be with the dying person or the seriously ill patient (Fridh, Forsberg, and Bergbom 2007). If the patient dies, it is important that their close relatives can have a worthy and dignified parting. The farewell room is where relatives can say goodbye to their relative (the patient). The farewell room must be large enough, provided with seating and have a calm and neutral atmosphere. Care must be taken that the patient’s relatives may come from different cultures and may have different cultural traditions/manners (Fridh, Forsberg, and Bergbom 2007; Høye and Severinsson 2008). Even in these situations, single rooms provide more integrity for the relatives and the patient. They also negate the need for the patient to experience the trauma of other patients within the same room nearing the end of their lives: to not need to experience the death of other patients. Negative experiences whilst under intensive care can cause occurrences of ICU delirium in patients. ICU delirium is an acute and f luctuating disturbance of consciousness and cognition, an acute brain dysfunction in critically ill patients in an ICU. ICU delirium is recognized as a significant contributor to morbidity and mortality, longer hospital stays and longer recovery time for patients that experience it than for patients who do not.

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Several of the symptoms of ICU delirium can also be triggered by failure in the designed environment around the patient. Therefore, one should eliminate or try to hide anything that may undesirably affect the patient negatively. There are examples where patients’ experiences in an ICU are so horrible that it can be compared to torture (Eriksson, Bergbom, and Lindahl 2011). Several nurses who have interviewed patients in connection with follow-up visits say that patients tell of experiencing recurring dreams/hallucinations with dangers and threats from large animals, ghosts and black holes that would catch them. When patients were invited to visit the ICU ward afterwards and confronted the environments in which they were treated, they realized that the nightmares were the brain’s interpretation of the environment (Eriksson, Bergbom, and Lindahl 2011). Examples of design and equipment that may adversely affect the patient’s experience during the ICU stay may be perforated or patterned ceilings, ceiling lifts, ceiling-hung scales, lighting fixtures, ventilation grilles or light from computer screens. Abstract art and decoration can seem disturbing and negatively affect patients (Ulrich 1993). Ulrich conducted an experiment to investigate whether art can improve the recovery ability of ICU patients who have undergone cardiac surgery. Reactions were observed in three groups of patients: (1) patients exposed to abstract art, (2) patients exposed to figurative art with natural motifs and (3) patients not exposed to any art at all (i.e., a control group) (Ulrich 1993). In this study, it was found that patients exposed to natural, figurative motives did not need as much pain-relieving medication and experienced less anxiety compared to the control group. It was also observed that the group of patients exposed to abstract art showed increase need for pain-relieving and sedative medication compared to the control group (Ulrich 1993). Even colors can awaken both psychological and physiological reactions in the body. There is research showing that different colors can enhance different emotional reactions and affect patients’ emotional states. With color schemes one can stimulate emotions such as calm, worry, joy and excitement (Starkweather, Witek-Janusek, and Mathews 2005). Therefore, color can be used to relieve stress (Fontaine, Briggs, and Pope-Smith 2001). Examples of color with stress-reducing and calming effects are light shades of blue, green and violet. Strong colors with a high color of red, orange and yellow can cause negative psychological and physiological reactions (stress, anxiety, etc.). They can provoke tension, increase blood pressure and cause fatigue in patients (Starkweather, Witek-Janusek, and Mathews 2005; Fontaine, Briggs, and Pope-Smith 2001). A significant number of studies indicate that the opportunity to view nature in the built environment has a positive impact on humans. It contributes to reducing stress, promoting more positive emotions and supporting recovery in patients (Ulrich et al. 2019; Whitehouse et al. 2001). The possibility to view nature in the intensive care unit can affect the staff ’s performance and increase their well-being (Ulrich 1999; Verderber 1986; Maller et al. 2006).

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For relatives, spontaneous meetings with views of nature outside the windows can seem like a positive diversion and help reduce stress. Views of nature affect patients’ recovery, sleep, intake of pain-relieving drugs and time of hospital stay. Nature and greenery serve as a positive distraction for the patient (Zimring, Joseph, and Choudhary 2004). The fact that views of greenery and nature stimulate positive emotions in the patient while reducing negative feelings has been shown in several studies (Ulrich 1984; Keep, James, and Inman 1980). They have studied how windows facing the green environment affects the patient’s condition and ability to recover. Both studies showed positive effects when the patient had a view of nature from the bed (Keep, James, and Inman 1980; Ulrich 1984; Ulrich 1993). Ulrich implemented a retrospective study where he compared journals for 23 patients who had views of nature, and 23 patients who had views of a brick wall. When the journals were reviewed and compared, one could note that patients with a view of nature had an average hospital stay of 7.96 days, compared with 8.7 days for patients with views of the brick wall. It was also noted that there were more positive notes in medical records for patients with views of nature compared to patients with a view of a brick wall as well as a difference in the intake of pain-relieving and sedative medication. There was also a tendency for less post-operative complications in patients with a view of nature. The beds in patient rooms should be placed with the side facing the window, and windows need to be placed so the patient can look out. But it is also important, when the patient room is planned, that it is not possible to see into the room from outside. The amount of daylight allowed in should be adjustable, and the room should be darkened, if necessary. Access to daylight increases humans’ well-being, ability to handle stress and performance (Boyce, Hunter, and Howlett 2003). For staff it is of great importance that there are windows in all rooms where work is constantly performed (Leather et al. 1998). Visual contact with daylight and outdoor environments can give a sense of control and context. Mroczek, with colleagues, implemented a study that showed that staff perceive natural light as an element of the environment that has the most positive impact on working life (Mroczek et al. 2005). Another study showed that staff with more than three hours of daylight exposure during their working hours experienced higher satisfaction with their work compared to staff with less daylight exposure (Alimoglu and Donmez 2005). For patients, access to sunlight is important for their experience of pain (Walch et al. 2005). Another study in which patients were placed either on the sunny or shady side of a building after a surgical procedure showed that patients on the sunny side experienced less stress and used less pain medication. This also resulted in lower drug costs (Walch et al. 2005). In an ICU, daylight can also help patients retain their perception of time and daily rhythm. There is research to suggest that the absence of windows leads to a higher incidence of ICU delirium in patients (Keep, James, and Inman 1980).

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The patient room also functions as a treatment room and should therefore have good, varied lighting with both direct light and general light (Barach, Potter, and Forbes 2009). Studies show that poor lighting can be a problem, whilst lack of daylight can increase the likelihood of errors in drug handling and dosing (Buchanan et al. 1991). According to researchers, one can inf luence the work performance of the staff through adequate adaptation and light distribution (Boyce, Hunter, and Howlett 2003). Studies also show that the age of caregivers and, linked to that, vision impairment, as factors affecting the need for increased light (Edwards and Torcellini 2002). Insufficient lighting and a chaotic environment can increase the risk of errors. Good lighting is important when handling drugs. In a study conducted by Buchanan et al. there is a clear link between drug delivery errors and brightness (Buchanan et al. 1991). However, there are no studies that investigated lighting in the workstation in relation to work performance or error rate. The work area should be very well illuminated with light sources positioned so that one reduces or removes sharp shadows. However, it is important that, where possible, lighting is placed in a way that does not disturb the patient. The patient is disturbed by strong light at night during sampling or examination and the care staff experience it as uneasy to disturb the patient. Lighting should be adapted as much as possible to the patients’ needs and wishes without risking insufficient lighting in the work area of the healthcare staff. Several departments also practice “cyclical” lighting that helps the patient follow the circadian rhythm (Ohta, Mitchell, and McMahon 2006; Engwall et al. 2014). Also, humidity and temperature have an impact on the patient’s experience of the environment in the hospital ward. Unfamiliar or unpleasant smells can increase stress on patients. This can be reduced by good ventilation and/ or access to fresh air from outside (Zimring, Joseph, and Choudhary 2004; Malkin 1992). Fragrances in the environment stimulate the sense of smell and can evoke feelings, images and immediate and physiological reactions (Buckle 2001). The usual scents in a hospital environment elicit strong reactions. The “hospital smell” in the background can cause anxiety, increased heart rate and breathing frequency. This also applies to the smell of blood, vomit, feces and disinfectants, which are present in a hospital environment. It is difficult to control these stressful smells (Malkin 2003). Well-dimensioned and functional ventilation can remove disturbing odors and reduce the risk of spreading airborne contamination. Good hygiene is important for patient safety. Hygiene is the interaction of several factors such as behavior, routines, ventilation and even the design of rooms and technical equipment; easy to clean surfaces and materials can help facilitate the best conditions for maintenance and good hygiene. Several studies show that hygiene has a decisive inf luence on length of treatment, patient wellbeing and rehabilitation time (Vernon et al. 2003; Muto, Sistrom, and Farr 2000; Hota et al. 2009). Hota et al. investigated the spread of water drops within the

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ordinary handwash and showed that the spread was up to two meters from the sink (Hota et al. 2009). Technology-intensive care environments are relatively new, and the architect’s role in designing these environments is also new. So far, the architect’s work has concentrated on creating the technical conditions in the building, organizing f lows and surfaces so that medical technology equipment can be set up and other necessary devices fitted. The task today is to simultaneously design environments that support healthcare processes and healing and recovery in patients.

References Ågård, Anne Sophie, and Ingegerd Harder. 2007. “Relatives’ Experiences in Intensive Care—Finding a Place in a World of Uncertainty.” Intensive and Critical Care Nursing 23 (3): 170–177. Alimoglu, Mustafa Kemal, and Levent Donmez. 2005. “Daylight exposure and the other predictors of burnout among nurses in a University Hospital.” International Journal of Nursing Studies 42 (5): 549–555. Barach, Paul, Mary Forbes Potter, and Ian Forbes. 2009. Designing Safe Intensive Care Units of the Future. Intensive and Critical Care Medicin, edited by P.D. Lumb, A. Gullo, J. Besso, and G.F. Williams. Milano: Springer. Berezecka, Maria Alicja. 2015. Den fysiska vårdmiljöns påverkan på vårdpersonal och patienter på operationssalar och intensivvårdsavdelningar. Chalmers Tekniska Högskola, Licentiate thesis. Institutionen för Arkitektur, Göteborg. Berezecka-Figacz, Maria., Eva Ek, Peter Fröst, and Jan Gustén, 2013. “Högteknologiska vårdmiljöer Intensivvård och operation.” Evidensbaserade konceptprogram. Göteborg: Chalmers tekniska högskola, Centrum för vårdens arkitektur. Bergbom, Ingegerd, and Ann Askwall. 2000. “The nearest and dearest: a lifeline for ICU patients.” Intensive and Critical Care Nursing 16 (6): 384–395. Bijttebier, Patricia, S. Vanoost, D. Delva, Patrick Ferdinande, and Eric Frans. 2001. “Needs of relatives of critical care patients: Perceptions of relatives, physicians and nurses.” Intensive Care Medicine 27 (1): 160–165. Boyce, Peter, Claudia Hunter, and Owen Howlett. 2003. The benefits of daylight through windows. Troy, New York: Rensselaer Polytechnic Institute. Buchanan, Terry L., Kenneth N. Barker, J. Tyrone Gibson, Bernard C. Jiang, and Robert E. Pearson. 1991. “Illumination and errors in dispensing.” American Journal of Hospital Pharmacy 48 (10): 2137–2145. Buckle, Jane. 2001. “Aromatherapy and diabetes.” Diabetes Spectrum 14 (3): 124–126. Cepeda, Jorge A., Tony Whitehouse, Ben Cooper, Janeane Hails, Karen Jones, Felicia Kwaku, Lee Taylor, Samantha Hayman, Barry Cookson, and Steve Shaw. 2005. “Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensivecare units: Prospective two centre study.” The Lancet 365 (9456): 295–304. Chaudhury, Habib, Atiya Mahmood, and Maria Valente. 2005. “Advantages and disadvantages of single-versus multiple-occupancy rooms in acute care environments: A review and analysis of the literature.” Environment and Behavior 37 (6): 760–786. ———. 2006. “Nurses’ perception of single-occupancy versus multioccupancy rooms in acute care environments: An exploratory comparative assessment.” Applied Nursing Research 19 (3): 118–125.

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Diette, Gregory B., Noah Lechtzin, Edward Haponik, Aline Devrotes, and Haya R. Rubin. 2003. “Distraction Therapy with Nature Sights and Sounds Reduces Pain during Flexible Bronchoscopy: A Complementary Approach to Routine Analgesia.” Clinical Trial Chest 123 (3): 941–948. Duckworth, Douglas H. 1987. “Behavior, health, and environmental stress. By S. Cohen, GW Evans, D. Stokols and DS Krantz. Plenum Press, New York, 1986. No. of pages: 284. Price£ 20. ISBN 0-306-42138-0.” Applied Cognitive Psychology 1 (3): 219–219. Edwards, L., and P. Torcellini. 2002. Literature review of the effects of natural light on building occupants. Golden, CO: National Renewable Energy Lab. Engström, Åsa, and Siv Söderberg. 2004. “The experiences of partners of critically ill persons in an intensive care unit.” Intensive and Critical Care Nursing 20 (5): 299–308. Engwall, Marie, Isabell Fridh, Ingegerd Bergbom, and Berit Lindahl. 2014. “Let there be light and darkness: Findings from a prestudy concerning cycled light in the intensive care unit environment.” Critical Care Nursing Quarterly 37 (3): 273–298. Eriksson, Thomas, Ingegerd Bergbom, and Berit Lindahl. 2011. “The experiences of patients and their families of visiting whilst in an intensive care unit—A hermeneutic interview study.” Intensive and Critical Care Nursing 27 (2): 60–66. Eriksson, Thomas, Berit Lindahl, and Ingegerd Bergbom. 2010. “Visits in an intensive care unit—An observational hermeneutic study.” Intensive and Critical Care Nursing 26 (1): 51–57. Fontaine, Dorrie K., Linda Prinkey Briggs, and Briggit Pope-Smith. 2001. “Designing humanistic critical care environments.” Critical Care Nursing Quarterly 24 (3): 21–34. Freedman, Neil S., Joost Gazendam, Lachelle Levan, Allan I. Pack, and Richard J. Schwab. 2001. “Abnormal sleep/wake cycles and the effect of environmental noise on sleep disruption in the intensive care unit.” American Journal of Respiratory and Critical Care Medicine 163 (2): 451–457. Fridh, Isabell, Anna Forsberg, and Ingegerd Bergbom. 2007. “End-of-life care in intensive care units—family routines and environmental factors.” Scandinavian Journal of Caring Sciences 21 (1): 25–31. ———. 2009. “Close relatives’ experiences of caring and of the physical environment when a loved one dies in an ICU.” Intensive and Critical Care Nursing 25 (3): 111–119. Gillette, Veronica A. 1996. “Applying nursing theory to perioperative nursing practice.” AORN Journal 64 (2): 261–270. Hamilton, D. Kirk, and Mardelle McCuskey Shepley. 2010. Design for critical care: An evidence-based approach. Amsterdam/New York: Elsevier/Architectural Press. Harris, Debra D., Mardelle M. Shepley, Richard D. White, Kathleen J.S. Kolberg, and James W. Harrell. 2006. “The impact of single family room design on patients and caregivers: Executive summary.” Journal of Perinatology 26 (3): S38–S48. Hendrich, Ann L., Joy Fay, and Amy K. Sorrells. 2004. “Effects of acuity-adaptable rooms on f low of patients and delivery of care.” American Journal of Critical Care 13 (1): 35–45. Hilton, B. Ann. 1985. “Noise in acute patient care areas.” Research in Nursing & Health 8 (3): 283–291. Hota, Susy, Zahir Hirji, Karen Stockton, Camille Lemieux, Helen Dedier, Gideon Wolfaardt, and Michael A. Gardam. 2009. “Outbreak of multidrug-resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design.” Infection Control & Hospital Epidemiology 30 (1): 25–33. Høye, Sevald, and Elisabeth Severinsson. 2008. “Intensive care nurses’ encounters with multicultural families in Norway: An exploratory study.” Intensive and Critical Care Nursing 24 (6): 338–348.

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Johansson, Lotta, Ingegerd Bergbom, and Berit Lindahl. 2012. “Meanings of being critically ill in a sound-intensive ICU patient room-A phenomenological hermeneutical study.” The Open Nursing Journal 6: 108. Keep, Philip, Josephine James, and Michael Inman. 1980. “Windows in the intensive therapy unit.” Anaesthesia 35 (3): 257–262. Knutsson, Susanne, Ingrid Pramling Samuelsson, Anna-Lena Hellström, and Ingegerd Bergbom. 2008. “Children’s experiences of visiting a seriously ill/injured relative on an adult intensive care unit.” Journal of Advanced Nursing 61 (2): 154–162. Leather, Phil, Mike Pyrgas, Di Beale, and Claire Lawrence. 1998. “Windows in the workplace: Sunlight, view, and occupational stress.” Environment and Behavior 30 (6): 739–762. Malkin, Jain. 1992. Hospital interior architecture: Creating healing environments for special patient populations. New York, NY: Van Nostrand Reinhold Company. ———. 2003. “The business case for creating a healing environment.” Center for Health Design Business Briefing: Hospital Engineering & Facilities Management 1. Maller, Cecily, Mardie Townsend, Anita Pryor, Peter Brown, and Lawrence St Leger. 2006. “Healthy nature healthy people: ‘Contact with nature’as an upstream health promotion intervention for populations.” Health Promotion International 21 (1): 45–54. Marcus, Clare Cooper, and Marni Barnes. 1995. Gardens in healthcare facilities: Uses, therapeutic benefits, and design recommendations. Concord, CA: Center for Health Design. Mroczek, Jana, George Mikitarian, Elizabeth K. Vieira, and Timothy Rotarius. 2005. “Hospital design and staff perceptions: An exploratory analysis.” The Health Care Manager 24 (3): 233–244. Muto, Carlene A., Maria G. Sistrom, and Barry M. Farr. 2000. “Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic.” American Journal of Infection Control 28 (3): 273–276. Nightingale, Florence. 1992 [1859]. Notes on nursing: What it is, and what it is not. Philadelphia: Lippincott Williams & Wilkins. Ohta, Hidenobu, Amanda C. Mitchell, and Douglas G. McMahon. 2006. “Constant light disrupts the developing mouse biological clock.” Pediatric research 60 (3): 304. Olausson, Sepideh, Margaretha Ekebergh, and Berit Lindahl. 2012. “The ICU patient room: Views and meanings as experienced by the next of kin: A phenomenological hermeneutical study.” Intensive and Critical Care Nursing 28 (3): 176–184. Ryherd, Erica E., Kerstin Persson Waye, and Linda Ljungkvist. 2008. “Characterizing noise and perceived work environment in a neurological intensive care unit.” The Journal of the Acoustical Society of America 123 (2): 747–756. Starkweather, Angela, Linda Witek-Janusek, and Herbert L. Mathews. 2005. “Applying the psychoneuroimmunology framework to nursing research.” Journal of Neuroscience Nursing 37 (1): 56–62. Tarkka, Marja-Terttu, Eija Paavilainen, Kristiina Lehti, and Päivi Åstedt-Kurki. 2003. “In-hospital social support for families of heart patients.” Journal of Clinical Nursing 12 (5): 736–743. Teltsch, Dana Y., James Hanley, Vivian Loo, Peter Goldberg, Ash Gursahaney, and David L. Buckeridge. 2011. “Infection acquisition following intensive care unit room privatization.” Archives of Internal Medicine 171 (1): 32–38. Ulrich, Roger. 1984. “View through a window may inf luence recovery.” Science 224 (4647): 224–225. ———. 1993. “Biophilia, biophobia, and natural landscapes.” The Biophilia Hypothesis 7: 73–137.

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———. 1999. Effects of gardens on health outcomes: Theory and research. Chapter in C.C. Marcus and M. Barnes (Eds.), Healing gardens: Therapeutic benefits and design recommendations. New York: John Wiley. Ulrich, Roger, Makayla Cordoza, Stuart K. Gardiner, Bette J. Manulik, Paul S. Fitzpatrick, Teresia M. Hazen, and R. Serene Perkins. 2019. “ICU patient family stress recovery during breaks in a hospital garden and Indoor environments.” HERD: Health Environments Research & Design Journal 13 (2): 83–102. Ulrich, Roger, Craig Zimring, Xuemei Zhu, Jennifer DuBose, Hyun-Bo Seo, YoungSeon Choi, Xiaobo Quan, and Anjali Joseph. 2008. “A review of the research literature on evidence-based healthcare design.” HERD: Health Environments Research & Design Journal 1 (3): 61–125. Verderber, Stephen. 1986. “Dimensions of person-window transactions in the hospital environment.” Environment and Behavior 18 (4): 450–466. Vernon, Michael O., William E. Trick, Sharon F. Welbel, Brian J. Peterson, and Robert A. Weinstein. 2003. “Adherence with hand hygiene: Does number of sinks matter?” Infection Control & Hospital Epidemiology 24 (3): 224–225. Wåhlin, Ingrid, Anna-Christina Ek, and Ewa Idvall. 2009a. “Empowerment in intensive care: Patient experiences compared to next of kin and staff beliefs.” Intensive and Critical Care Nursing 25 (6): 332–340. Wåhlin, Ingrid, Anna-Christina Ek, and Ewa Idvall. 2009b. “Empowerment from the perspective of next of kin in intensive care.” Journal of Clinical Nursing 18 (18): 2580–2587. Walch, Jeffrey M., Bruce S. Rabin, Richard Day, Jessica N. Williams, Krissy Choi, and James D. Kang. 2005. “The effect of sunlight on postoperative analgesic medication use: A prospective study of patients undergoing spinal surgery.” Psychosomatic Medicine 67 (1): 156–163. Whitehouse, Sandra, James W. Varni, Michael Seid, Clare Cooper-Marcus, Mary Jane Ensberg, Jenifer R. Jacobs, and Robyn S. Mehlenbeck. 2001. “Evaluating a children’s hospital garden environment: Utilization and consumer satisfaction.” Journal of Environmental Psychology 21 (3): 301–314. Zimring, Craig, Anjali Joseph, and Ruchi Choudhary. 2004. The role of the physical environment in the hospital of the 21st century: A once-in-a-lifetime opportunity. Concord, CA: The Center for Health Design.

SECTION IV

Methodological Considerations

17 INTERVENTIONS AND MIXED METHODS RESEARCH DESIGN FOR A PERSON-CENTERED AND SAFE ENVIRONMENT IN OLD AGE Helle Wijk

Supportive Care and Stimulating Environments for Health and Well-Being The rationale for studying the impact of physical interventions in buildings for healthcare is to investigate the surrounding environment’s importance for health and well-being. The environmental aspect covers both the objectively visible aspect of the health-care environment around us as well as the subjectively perceived environment, the so-called psycho-social dimension of the surrounding environment, which can be more challenging to define. Objective aspects are measurable and comprise features such as the size of the room and the distance between them, whether it has daylight, is light or dark, hot or cold and if there are views of nature. The psycho-social environment refers to the atmosphere and ambience of the room, the way it feels to actually be there, which are so important but also more challenging to measure and define. How we perceive and interpret a room is personal and dependent on individual perceptual conditions such as sight, hearing and sense of touch, which all separately and in combination have an impact on how we experience and understand a room. Moreover, different backgrounds, understandings and former experiences of being in health-care environments also play a role and shape our expectations and perceptions. It follows that since scents, sounds, materials and views are perceived and valued differently, it may inf luence, consciously or unconsciously, our experience of the environment as attractive, pleasant and welcoming, or the opposite. When we face the patient role (e.g., being vulnerable due to disability or disease), we are particularly dependent on an environment that can be easily interpreted and understood, and which contributes to feelings of safety, autonomy and well-being. Therefore, the same environment

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can be perceived completely differently by people related to the particular situation. This is crucial to be aware of when planning for new facilities and for improvements of existing health-care buildings where individual preferences, desires and needs are to be met in conjunction with claims of functionality, staff working environment and cost-effectiveness. Nevertheless, to increase the knowledge base of how we can create environments that strengthen vulnerable peoples’ independence, self-esteem and well-being and support their health and recovery, we need to take on a person-centered approach.

What Is a Person-Centered Approach in Health Care? The effective healthcare of today is able to treat a multitude of solitary diseases, even though it comes at ever-increasing health-care costs. At the same time, health-care services are criticized for lacking the big picture of the patient and his/her perspective, experiences, knowledge and participation. With person-centered care, society’s resources can be used more effectively, as research has shown that it can reduce hospital stay and make patients feel less dependent (Ekman et al., 2011, 248–251). Person-centeredness is an ethical standpoint that guides our practical actions as fellow human beings and professionals. The approach always exists in a context and claims a physical health-care environment that can support the co-creation of care. It requires a firm awareness of every independent action, good routines and working procedures, close teamwork between all stakeholders involved in care and that the environment and organization are adapted for this. Talking about person-centered care doesn’t entail a conf lict with the word patient. We are all patients at different times in our lives, many of us often. Nevertheless, even in these situations, we are first and foremost people and fellow human beings. Therefore, it is important to use the term person-centered care and, in that effort, consider how the physical environment where this is supposed to take place can support this approach.

A Person-Centered Health Care Environment The physical environment is believed to inf luence patients’/inhabitants’ well-being and rehabilitation by providing support for declining functional capabilities and strengthening preserved resources (Brovall et al., 2013). The main purpose of a facility meant for healthcare or residential care is to act as a place for promoting health and recovery for the patients as well as to act as a home for the inhabitants. Nevertheless, most facilities are still designed and constructed with a traditional institutional layout with single-bed rooms located alongside long double-loaded corridors with a priority on their effectiveness as work-places for staff rather than on habitability for patients (Haglund et al., 2006, 387–394). A healthcare/residential care environment consists of

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both physical, psycho-social and cultural dimensions, which individually and collectively contribute or withhold patients’ well-being by capitalizing or preventing particular strengths while reducing or increasing limitations (Ulrich et al., 2004). In recent years, a stronger research focus has therefor been placed on considering the relationship between the physical healthcare environment, patient well-being and staff work-satisfaction (Dijkstra et al., 2006, 166–181), emphasizing how poorly designed environments constitutes a risk, inhibiting functioning and social well-being. The older population is growing rapidly throughout the world and it is a challenge to meet the complex needs of older people. Old age is associated with multiple chronic conditions and functional disabilities (Barile et al., 2013; Barnett et al., 2012, 37–43; Kirchberger et al., 2012), which leads to an increasing need for a supportive environment. In Sweden, the municipality has the responsibility for providing social services and basic home healthcare for all people who need care, and home healthcare and municipal care are publicly financed and mainly publicly provided (Szebehely and Trydegård, 2012, 300–309). These health-care efforts are available to all citizens regardless of their ability to pay and are based on need. Additionally, municipal care recipients have the right to choose a private provider who has service agreements with their municipality (Longo and Notarnicola, 2018, 1303–1316). During the last few years, home care has been a common long-term care solution for older people, as it meets older people’s desire to be cared for at home. Furthermore, it facilitates the caregivers’ opportunity to integrate care to a wider group of people with complex needs (Grabowski et al., 2010, 82–101; Stall et al., 2013). In summary, the increasing number of older people in need of safe and personcentered environments either at residential care facilities or in their ordinary home leads to the need for a better understanding of how this can be accomplished. However, the research in this field is limited.

Theoretical Underpinnings for Interventions Supporting a Person-Centered and Safe Health Care Environment According to Powell Lawtons’ Ecological Model of Ageing ( Lawton & Nahemow, 1973, 619–674), an adaptation of the environment to meet individual needs may be expressed as well-being and independent behavior. The ecological model of environmental fit has provided a theoretical background for understanding the need for environmental adaptions in order to match individual abilities. This model suggests that an individual’s behavior and well-being is a result of the interaction between the complexity of personal abilities and their adaptation to the environment. Optimal fit occurs when someone’s capacities are consistent with the demands and opportunities within that person’s environment. However, if the demands of the environment exceed or undercut the person’s abilities, there is a person-environmental incongruity.

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Another pioneer within the field is Roger Ulrich, known for his design theory of environmental strategies to reduce stress. The theory strives to explain the relation between threat and violent behavior in the environment due to levels of stress (Ulrich et al., 2012, 12–14). According to his approach, stress could be related to strain, which in turn can provoke abnormal behaviors. The strain could be explained by certain environmental aspects in the institutional or residential setting. A third theoretical model that relates to the environmental impact on rehabilitation and psychosocial climate is the Health Environment Inventory (HEI) by Küller (Küller, 1991, 78–95). The model focus on the match between environmental characteristics and its users’ needs, where the more positive inf luences on well-being outcomes can be expected the greater the match is according to the human-environment fit. The model posits that people’s emotional response and overall well-being are affected by the interaction with physical and social environments, by the activities of engagement and by their personal characteristics and resources.

A Salutogenic Approach in Caring for Older Persons The models above share an approach in common by taking an interest in the preserved environmental perception in old age instead of its losses, which in turn is a way to reconsider caring for the elderly from a focus on risk factors for pathology to a focus on health-promoting issues instead. This approach, also named the salutogenic way of caring (Antonovsky, 1979), advocates that the health of various degrees, always to be found within everyone, should be the focus of caring instead of the disease. By focusing on preserved function, and by implementing this knowledge in the environment and care of the old, it is assumed that the patient’s opportunity to behave independently arises. An excellent example of how to practice this approach can be seen in the design of the outdoor environment at some special units for residents with cognitive decline due to dementia. By putting the garden in the middle of the premises surrounded by the buildings, the outdoor environment is easily accessible for everyone whenever wanted, but still 100 percent safe.

Interventions Towards a Person-Centered and Safe Environment for Older People Physical environments that are perceived to be supportive for users’ social interaction, privacy regulation and restoration are associated with the development of positive social climates, mental health and quality of life outcomes ( Evans, 2003, 536–555). We can see an increase of research studies focusing on the physical aspects of the environment as an important dimension of caring, with the assumption that some of this control may be built into the way the

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residential facility is designed (Lawton et al., 2000, 28–38). Environmental factors are highlighted due to the possibility of having both a supportive and hindering effect on adequate performance, interaction with family, fellow residents and staff, and promoting or hindering the feeling of security and safety ( Day et al., 2000, 397–416). Adapting the environment with the intention to match the needs of the user can be considered a non-pharmacological treatment, as environmental factors can be easier to alter than pathological factors inf luencing the life situation of the person with dementia (Zeisel, 2013, 45–52). In several studies the ability to interact and perform actions are used as cut off variables, that is, interaction and prevalence of adequate performance have been accounted as a measure of the success of an environmental intervention. An increase of knowledge about the interaction between the people residing in the environment and their living environment per se can be crucial for planning, designing and evaluating caring environments for people in old age. According to Lawton et al. (2000, 28–38), there are four general categories of presumed user needs: Decreasing disturbing behavior, increasing social behavior, increasing activity and increasing positive feelings and decreasing negative feelings. In line with this, Liebowitz et al. (1979, 59–61) were able to demonstrate an increase in social activities and an interest in the physical surroundings as a result of intervention such as color-coding the bedrooms and using bright colors to attract the person’s attention at an institution for confused people. Küller (1991, 78–95) described similar effects as a result of a more home-like design at an institution for individuals with dementia, and the importance of an easy f loor plan configuration together with concrete signs and symbols has also been highlighted ( Passini et al., 1998, 133–151). The avoidance of glare and pastel colors and a more frequent use of contrasting colors to facilitate orientation and functioning have been proposed as important (Cannava, 1994, 45–49), and Passini et al. (2000, 684–710) reported that even patients with severe cognitive decline were able to reach certain destinations in a way-finding experience performed with individuals suffering from advanced Alzheimer’s disease. Critical features in the environment were the implementation of environmental information that was readily accessible, a great number of reference points and the avoidance of f loor patterns and dark lines that could increase anxiety. Sandman (1986) indicated that an observed improvement in Activities of Daily Living (ADL)-functions after relocation to a more positive environment for people with dementia could be related to the model. He meant that an environment more adapted to the individual’s competence could lead to an increase of the individual’s inherent capacity. The same was seen regarding increasing function in meal behavior among patients with dementia after adaptation of the environment to meet their capacity (Sandman, 1986). Gustavsson (1996) takes another approach when referring to the model by modifying the activities instead of the environment. Her study concerns quality of life and functional capacity during locomotor disability where she points out that the patients were at a high risk

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of being hindered in behavior by their disability. With alterations of activities the pressure from the environment could become positive instead of negative. Karatza (1995, 1–102) emphasizes the importance of using color contrasts to increase visibility, color coding and cueing to support object identification and a conscious color scheme to make the environment attractive. Cooper (1999, 186–92) were able to show that neutral colors and lack of contrast minimize attention contrary to strong color cues, which seemed to attract attention. The former was suggested to prevent undesirable behavior such as walking into restricted areas, and the latter was suggested as a means of improving the visual distinction of environmental objects especially for persons with low vision and as a mnemonic device. Studies by Wijk (2001) also recommend a more frequent use of contrasting colors in order to accomplish visual distinction in the environment, to support depth and spatial perception and to simplify object recognition. Colors similar in lightness could be juxtaposed when the purpose is to camouf lage and minimize attention. It is quite common that elderly people have insufficient illumination in their homes, which unnecessarily can have a negative effect on their quality of life ( Brunnström et al., 2004, 274–280). For elderly people still living at home the most important action is to change or complement the existing illumination with a better and more functional quality. Nursing homes are often lacking in variation and f lexibility considering the illumination of the rooms in common. In the dining room illumination that supports both activities and a nice atmosphere is needed. Over the kitchen table a good lamp focusing on both the table and the food is crucial for independence during the meal. Sounds that are not recognized by the residents should be avoided or camouf laged, and good sounds that support recognition and joy should be promoted. Using mobile phones should be avoided as well as playing music not familiar to the residents. An important intervention is to control for the need of hearing aids. Playing soft background music during dinner can be an alternative to decrease anxiousness and agitation at the nursing home. It is quite common that the effect of music in the caring environment is underestimated, but as crucial as its positive effects mentioned earlier is also the consciousness of the un-controlled music’s negative effects (Ragneskog, 1998). There are of course many factors inf luencing how we perceive and are able to function in the environment. The feeling of safety is one major concern when designing environments for the elderly, which has been shown to be a very complicated task. Safe care is also usually referring to hospital care, which is not always easily transferred to municipal care or care in ordinary housing, even though there are many similar challenges regarding patient safety and care quality in residential and home healthcare. However, elderly care often requires interventions that are tailored to their specific situation and needs. The studies that describe safety of care for older people relating to the building have mainly focused on the use of technologies and assistive devices in order to make the

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care safer; these are predominately from a staff perspective (Kane and Levin, 1998, 76–81; Olsson et al., 2012, 104–112; Harrison et al., 2013, 148–160). But aspects such as type of walking surface, visual aspects and ambient conditions must interact with those aspects of ageing which involve visual and auditory perception, balance, orientation and cognition. In summary, the concepts of environmental pressure are used to predict the outcome in individual cases where salient individual characteristics in the models are coping, competence and personality traits. Many older people strive to maintain control and the opportunity to make decisions that ensure their living environment is a safe place (Tong et al., 2016, 214–220), managing everyday life with flexible, predictable, and competent support (Lang et al., 2009, 97–101). Difficulties in adapting the environment and coordinating care to the recipient’s needs can therefore affect the way patients experience a person-centered and safe care. Although the importance of ensuring safe care within municipal care of older people is high on the global political agenda, systemic improvements in the safety of care are limited and the evidence-based knowledge is lacking. Therefore, the need for research to develop and implement evidence-based methods based on communication between relevant stakeholders is emphasized.

A Mixed-Method Research Design Approach in Order to Capture the Physical and Psychosocial Dimensions of the Environment Research studies should be designed to increase awareness of adaptation to each person’s unique skills and the outcomes regarding behavior, utility and wellness. As the healthcare environment is a complex system, studies require a complex mixed-method research design approach, involving both quantitative and qualitative methods such as questionnaires, register studies, interviews, observations and photo-voice. Many environmental assessment instruments are comprised of descriptive materials that do not easily fit into an evaluative framework that determines how well a design element performs in meeting users’ needs. Therefore, methodological development of better environmental assessment instruments is also needed. In order to confirm or reject existing preconceptions (e.g., that a poorly designed environment has a negative inf luence on patients’ and staff ’s perceptions) a systematic description of (1) ward atmosphere, (2) quality of care, and (3) staff possibility to perform person-centered care can be conducted by using questionnaires before and after an environmental intervention. But in order to also capture the patients’ experiences of the physical alteration of the environment another strategy is needed, that is, choosing an explorative qualitative approach. Data could be collected by photo-voice, which is characterized by a combination of interviews and photos. Photo-voice is a methodology rooted in social

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science, invented in order to empower and give voice to vulnerable or marginalized people in society (Olausson et al., 2013, 234–243). Using patients’ own photos in interviews implies a way to facilitate ref lection on the subject and to put their thoughts into words. Interventions to support this approach can be conducted through workshops together with the older residents and the staff. Another approach is ‘Sketch and Talk,’ which is a method where the researcher uses the technique of sketching (and noting) to facilitate specific documentation and raises the mutual level of consciousness of the physical environment ( James and Olausson, 2018, 127–141). It allows a shared exposition of private space and enables zooming of activities, situations or other phenomena that reveal themselves to be essential in the open-ended interview and aim to identify hidden essentials and contribute to an understanding of objects and their meaning ( James and Olausson, 2018, 127–141). Participatory observational study refers to the researcher as an active participant in an activity while observing it. The method is common in anthropology and sociology and gives an ability to experience events from the inside with the possibility of an in-depth understanding of the group members and their activities (DeWalt and DeWalt, 2011). The focus group interview is a method of gathering information about experiences, raised in interaction between the participants and the researchers in discussions with a special focus (Kitzinger, 1994, 103–121; Kitzinger, 1995, 299). The dynamic in the group may stimulate participants to explore and express themselves in ways that would not have come about in an individual interview ( Watts, 1987, 25–34). The method typically uses open-ended questions with permission to express opinions on a sensitive topic. The use of physical models of both space/interior design and furniture is a suitable and explicit way to try out ideas in dialogue. Support by mind maps, mood boards, and existing spaces where furniture can be moved around, simple models in, for example, cardboard to visualize and try out ideas can be accomplished. Based on workshops and material produced, a next step could be to build a mockup room to try functionality together with the partners of the project. The data generated from the methods brief ly described above, are subject of qualitative analysis. The method of analysis depends on the richness of the data concerning meaning and content (Kvale and Brinkman, 2009).

Conclusion This chapter highlights some issues to consider during interventions and follow ups of environmental studies, which, if implemented in the environment, are of importance for the function and well-being of the aged. An example of application, rooted in research and implemented in practice, is a spatial design of the residential care facility where the apartments are placed in a circle around the general center of activities (e.g., the kitchen and the living room), supporting recognition and inclusion for the residents when coming out from their

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apartments. The effect of such a strategy can easily be followed up by observing how much time the residents spent alone in their apartments compared to socializing with others in the common spaces. The use of color contrasts and cues to support orientation and attention is another evidence-based strategy easily practiced, which can be followed up by measuring the rate of disorientation and confusion before and after such an intervention. Sharp contrasts in the f loorings is another well-known hazel which can cause confusion when suffering from dementia, and in turn can lead to the risk of falling. Eliminating these risks with the use of an even f loor color can be followed-up by measuring the number of falls before and after this intervention. However, for a good result the starting point is always a close collaboration between actors from architecture and caring science for a better understanding of special users’ needs.

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18 THE HOME AS A PLACE FOR REHABILITATION—WHAT IS NEEDED? Marie Elf, Maya Kylén and Elizabeth Marcheschi

Introduction One would think that, with all the development of new effective and hightechnology treatments for stroke survivors, care and rehabilitation are topnotch. However, there are still many quality goals that must be achieved for people following a stroke, especially when it comes to integrating the home environment as an important aspect to support recovery and health. This chapter aims to contribute to an understanding of the physical environment as an important part of the rehabilitation process for stroke survivors who are rehabilitated at home. It is important to increase our knowledge of the home as a care environment since health care is transformed from shorter stays in hospitals and more care and rehabilitation take place at home. The new healthcare reform assumes that persons prefer that care and rehabilitation take place at home, but this assumption neglects the diversity of personal needs and the different meanings people attach to their homes. Importantly, the environmental design, which may have an impact on functional recovery as well as on social, emotional and physical aspects of daily life is necessary to consider but most often neglected in research as well as in clinical practice. The shift towards care and rehabilitation in the home also means that stakeholders such as policymakers, planners and architects need to gain knowledge about what it means to be cared for at home and how the environmental design can contribute to and support care and rehabilitation. To further develop evidence-based care models for rehabilitation at home and incorporate person-environment dynamics, an understanding of how environmental factors relate to everyday life and recovering at home is crucial, especially for persons with long-term conditions, such as stroke survivors. As

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on a general level we witness increasing, diversified and articulated demands on the housing market that call for alterability and adaptability in long term solutions for new integrated ways of residing with added appropriate supports for continued independent living as late in life as possible.

The Stroke Survivor Stroke survivors are a vulnerable group who struggle with sudden changes in life and often lack experience of both their illness and the healthcare system (Wissel, Olver, and Sunnerhagen 2013; Thrift et al. 2017). Strokes are an increasing health problem and a leading cause of disability ( Johnson et al. 2016; Johnson et al. 2019; Riksstroke 2018; Sumathipala et al. 2012), while worldwide over 50 million people have a stroke each year ( Johnson et al. 2016). For the individual, a stroke is a serious neurological disease that can lead to life-long disability due to, for example, limb weakness, communication barriers, problems with attention and interpreting space and time ( Jones et al. 2017; Sumathipala et al. 2012), and can create changes in personality and mood (Kulnik, Hollinstead, and Jones 2019). For many persons, a stroke means a long and demanding rehabilitation period and contact with healthcare. As many as 80 percent of stroke survivors have reported that they have experienced a side effect: for example, falls during the first year after hospital discharge (Ostwald et al. 2013; Sumathipala et al. 2012), and many report unmet emotional and social needs. In addition, many stroke survivors report that they feel abandoned after the acute care phase and when discharged to their home (Ostwald et al. 2013; Ytterberg, von Koch, and Erikson 2019). They often state that the post-discharge period is stressful and challenging when adjustments are made to the new situation and new life roles (Kulnik, Hollinshead, and Jones 2019). Many also testify that they have not been allowed to participate in care and treatment decisions (Krishnan et al. 2019; Lindblom et al. 2019).

Stroke Care and Rehabilitation Is a Complex Process Rehabilitation can be defined as “a process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimal physical, psychological and social functions” (Wade 1992). This means that rehabilitation can be viewed as a learning process, when the person should internalize living with a new situation. In this process, the healthcare professionals are an important source of support for the patient and the family. They should listen, discuss, give information about the condition and needed service and encourage the person toward self-management. Shorter lengths of stay in acute care settings means that more stroke survivors are discharged to their homes earlier during their recovery and may require ongoing rehabilitation services in the home and community (Miller, Lin, and Neville 2019).

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The care transition from the hospital to the home can be seen as a complex set of actions associated with a risk for poor quality outcomes for patients and their families (Almborg et al. 2009; Chen et al. 2018; Cott, Wiles, and Devitt 2007). There is a lack of knowledge of how the environment should be integrated into the care context for the future care in the home, and little attention has been paid to which aspects of the environment are perceived as supportive for rehabilitation processes (Marcheschi et al. 2018; Jellema et al. 2016). There are studies that have shown that stroke survivors can have a bad experience of the transition from hospital to the home as a result of a poorly designed healthcare system that, in the worst cases, results in remaining health problems. Frequently described problems are poor communication between patients and caregivers (Pindus et al. 2018), inadequate follow-up after hospital discharge, problems with continuity of care between inpatient and community-based services, lack of knowledge of available community services and support, limited access to health and social services after discharge, lack of participation in decisions about their care, and lack of knowledge and confidence in their ability to self-manage (McKevitt et al. 2011; Walsh et al. 2015; Chen et al. 2019). Stroke survivors often testify that they are unprepared for self-management and are forced to navigate in an unknown healthcare system, resulting in a lack of resources for participating in life in ways they wish ( Woodman et al. 2014; Fletcher et al. 2019). Rehabilitation in the home has proven to be valuable if good and evidencebased care and rehabilitation models are used and care is based on the needs of the individual patients (Fisher et al. 2019; Langhorne, Baylan, and Trialists E.S.D. 2017). Early Supported Discharge (ESD) has been reported to have positive health outcomes for people who suffered mild to moderate strokes ( Langhorne, Baylan, and Trialists E.S.D. 2017). In this model, patients’ transition to home should start at the hospital and be supported by multidisciplinary team members (i.e., physiotherapists, speech therapists, physicians) who are experts in stroke rehabilitation and organized at community or hospital levels (Bråndal and Wester 2013). The model has been recommended since it implies the opportunity for real-world practice as opposed to rehabilitation intervention in the hospital, where tasks can only be simulated. It allows problem solving and planning in a more meaningful context of the patient’s home. Performing real tasks in the home rather than simulating the tasks in an unfamiliar environment is motivating and makes the intervention relevant to individuals and their careers. In addition, ESD have been shown to be associated with not only a patient’s participation in the rehabilitation process (e.g., shared decisionmaking) but also in the development of a positive atmosphere between the caregiver and the patient (Meijer and van Limbeek 2005; Rousseaux, Daveluy, and Kozlowski 2009). Strategies for stroke rehabilitation are currently

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being studied, but little attention has so far been paid to the role and importance played by the physical environment (i.e., built and natural dimensions) to support rehabilitation outcomes.

The Home as a Place for Care and Rehabilitation The change in healthcare towards increased care and rehabilitation in the home environment places great expectations on the individual to manage and take responsibility for their own health condition (Clark et al. 2018). Several authorities have reported an urgent need to develop better support for people living with long-term conditions such as stroke survivors (Fratiglioni et al. 2010; WHO 2016), and these new models must integrate the environment as an important factor for promoting rehabilitation in the home (Stiernstedt, Zetterberg, and Ingmanson 2016). Going back home after suffering from a stroke is to enter a different environment than the one the person experienced prior to having a stroke (Hodson, Aplin, and Gustafsson 2016). It is therefore vastly important that healthcare providers acknowledge the environment in the planning of rehabilitation at home and engage the individual patient and her/his significant others in a decision-making process where housing-related issues are raised and discussed. The home and immediate surroundings such as the neighborhood are important to support autonomy, authority and choice for the person (WHO 2016; Stiernstedt, Zetterberg, and Ingmanson 2016). In order to enable a person to live the life she/he desires it is important to understand people’s perceptions of the home where care and rehabilitation activities are to be performed (Kvæl et al. 2018). Moreover, for the home environment to be perceived as safe and good for the person it is also important that healthcare is coordinated between in- and outpatient care and that all parties are aware of the possibilities that the home offers as well as the barriers. However, it is important to note that the private home cannot easily be transformed into a caring and rehabilitative place. The home is part of a person’s identity, associated with feelings of attachment, security and belonging. A home also has social meaning as it is a place where family members gather, and is thus also important for the well-being of the entire family. But, on the contrary, the home may also be associated with opposite feelings: where safety is replaced by uncertainty, for example, when health is fragile through decline of physical or mental well-being and abilities (Tryselius, Benzein, and Persson 2018). The feeling of security in the home can also be challenged as the home develops into a care facility, as it often is when technical equipment is needed for care and treatment in the home. This shift towards a wider use of the home for care and rehabilitation is a challenge for society and healthcare, and creates a need for increased

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knowledge of the complexity of person-environment interactions (Landers et al. 2016). With increased knowledge in this area the various physical and social environmental factors that determine the outcomes of stroke rehabilitation in the home can be identified and incorporated in clinical practice.

Person and Environment Interaction The environment is multi-layered and includes physical as well as social environmental aspects (Küller 1991) which inf luence and give meaning to human behavior and social roles. The physical dimension of the environment includes both natural and built surroundings, whereas the social environment encompasses the type and quality of the social relationships occurring in a given context (Küller 1991). Moreover, the environment offers opportunities and resources, demands and limitations. In this sense, the effect of the environment on a person’s health and ability to perform daily activities depends on the person’s capability (cognitive and physical) and the demands of the environment as well as the ongoing interaction between the two (Kielhofner 2002). Thus, as people have different functional capacities the same environment may facilitate activity for one person and also be a barrier to another. Furthermore, people’s interaction with the environment generates an experience with the overall setting, which in turn affects health-related outcomes (Küller 1991). Despite the fact that theories from nursing science, occupational therapy and environmental psychology have addressed the importance of considering the interaction between people, health and the environmental setting, the physical environment as an area of intervention is largely overlooked. In terms of rehabilitation at home, several studies have examined the experience from the perspective of stroke survivors, their families and health care staff (Osborne and Neville 2019), although they are seldom explicitly addressed from an environmental perspective. In other words, there is evidence that home rehabilitation may be a positive and viable option for stroke survivors (Langhorne, Baylan, and Trialists E.S.D. 2017), but we know very little about the mechanisms that inf luence the outcomes, especially which factors within the environment can play a role in a person’s process towards health and recovery (Marcheschi et  al. 2018). This is particularly true for care and rehabilitation in the home, where research has predominantly focused on how the physical environment can support activity and mobility (Jellema et al. 2016; Marcheschi et al. 2018). Moreover, there is a growing body of research showing that care environments tailored to the individual’s personal needs are important for providing high quality care, and that the physical environment is associated with improved health and well-being (Edvardsson, Winblad, and Sandman 2008; Stiernstedt, Zetterberg, and Ingmanson 2016; Küller 1991; Henriksen et al. 2007; Marcheschi et al. 2018). For example, previous research focusing on strokes has demonstrated that it is important to consider barriers in the physical environment (e.g., stairs, uneven

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sidewalks), as these may impede a person’s ability to function at home and limit possibilities of participating in community activities (Keysor et al. 2006; Rochette 2001). The impact of the physical environment can also be seen in light of the large number of housing adaptations provided to stroke survivors after they are discharged from the hospital (Sørensen et al. 2003). Yet, we are only in the early stages of grappling with implications for the design of different care environments and public policy, indicating an urgent need for more research in this domain.

Useful Theories of Person-Environment Relationship There are several theoretical frameworks that can be used to increase our understanding of the complex relationship between the person and the environment, and as this relates to health and well-being. These different theoretical approaches provide a diversity of clinically oriented, geographical, philosophical and methodological lenses revealing the depth and richness of a person’s interaction with the environment.

International Classification Framework A common framework in clinical practice, and in research in stroke care, is the WHO’s International Classification Framework (ICF) (Cieza and Stucki 2008), which underscores the significance of the environment for people’s health and well-being, viewed as an outcome of the complex dynamic interaction between function (i.e., bodily functioning/activity/participation) and contextual factors (i.e., personal and environmental factors). The model explains how the physical environment for stroke rehabilitation can either be perceived as a facilitator or barrier for people’s functioning. The environment is both described as the immediate setting of the home and its surroundings (i.e., neighborhood) (Grill et al. 2011). In a person-centered rehabilitation process, it is important to understand a person based on the physiological condition (i.e., medical model) and to include a person’s experience of their illness in the context of their life (i.e., psychosocial model). This means that the dynamics of the relationship between the person and their environment becomes important (Kylén et al. 2017; Oswald et al. 2007; Wahl, Iwarsson, and Oswald 2012). It is not only the biomedical or social factors that are relevant but also the incorporation of and relationship between all aspects of a person’s life situation that are important for improved rehabilitation outcomes. This strategy ref lects the main principles of the ICF.

Theory of Salutogenesis The contemporary view on health ref lects the transformation from the biomedical model emphasis on disease and mortality to a humanistic understanding of health that includes ecological, salutogenic and holistic perspectives. For

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example, the theory of salutogenesis (Antonovsky 1987) focuses on resources for health and health-promoting processes rather than on disease about pathogenesis. In salutogenesis, experiences of health and well-being are hypothesized to depend on general resistance resources, which are postulated to be personal factors that also include the assets available in people’s environment. Hence, health can be promoted by creating environments that support people in identifying their internal and external resources and learning how to use and reuse them in order to achieve vital goals in their everyday lives. Importantly, the theory of salutogenesis acknowledges that it is not only the physical environment (e.g., home and neighborhood characteristics) but also the various social processes and relationships that make a vital contribution to health and positive rehabilitation outcomes ( Taule et al. 2015).

The Ecological Theory of Ageing As mentioned previously, one of the major challenges of providing rehabilitation and care at home after a stroke is determining how the physical environment should be designed to best fit a person’s needs and changing health condition. The most inf luential theory in this quest is the Ecological Theory of Ageing [ETA] (Lawton and Nahemow 1973; Scheidt and Norris-Baker 2003). According to ETA, a person’s behavior is a result of the dynamic relationship between the competence of the individual (e.g., cognitive, physical and psychological skills) and the press of the environment. Negative outcomes are seen when the demands from the environment are too high or too low in relation to a person’s level of competence. For example, a house with stairs may demand too much from a stroke survivor returning home after inpatient care, resulting in an increased risk of falling, restricted possibilities of moving outside, which in turn may lead to isolation, and ill health. Thus, the lower the competence of the individual the more vulnerable he or she is to the demands of the environment (Lawton and Nahemow 1973). A key message in this theory is that a good fit, and consequently improved health outcomes, between the person and the environment can be accomplished by adjusting one or both parts. In this view, the physical environment is acknowledged to be an important factor in increasing awareness of limitations after a stroke (Kerstin, Bernspång, and Anne 1999; von Koch et al. 2000) and also in developing personal strategies to address crucial environmental aspects of everyday life (von Koch et al. 2000).

Place Attachment and Meaning of Home While features of the physical environment can explain variability in a person’s level of independence and recovery after a stroke, there are other symbolic and experiential dimensions of the environment that also need to be taken into account (Nanninga et al. 2015). The transition from inpatient care to

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rehabilitation at home is regarded as a very difficult period associated with functional decline, depression and social isolation. The meaning of home is no longer the same. A house is purely a space and a building, while a home is a place filled with personal experiences, meaning and social relationships that, over time, transform space (house) into place (home) (Oswald and Wahl 2005). Such emotional and cognitive bonds are closely related to well-being and identity, and this is especially true for persons facing functional decline, as the home can serve to preserve independence in everyday life (Oswald and Wahl 2005). The concept of place attachment can here be used to describe these complex person-environment dynamics. Place attachment is defined as an emotional bond between an individual and a place, which supports the development of feelings such as sense of safety, self-efficacy, belonging and connectedness ( Nanninga et al. 2015). The meaning that a home has for a person is related to place attachment and refers to symbolic representations of space and place and personal meanings related to one’s home. That is, the home represents individual meanings related to the individual’s personality and experience and is not only considered to fulfill objective functions. Thus, outcomes of rehabilitation in the home are inf luenced by the emotional bonds people assign to their environments and health care staff should therefore make efforts to support stroke survivors and their significant others in meaning-making processes ( Nanninga et al. 2015).

Life-Space Mobility It is not only the home environment that is important for favorable rehabilitation outcomes. Stroke survivors place a strong emphasis on re-establishing former identity and being able to participate in activities outside the home environment (Lord et al. 2004). Still, research has shown that, in general, stroke survivors take fewer community trips than healthy adults do (Robinson et al. 2011). Thus, being able to participate in activities outside the home is important, and limitations in this domain are associated with poorer health outcomes (Leach et al. 2011; Jacobs et al. 2008). One framework specifically addressing this issue is Life-Space Mobility, which has been conceptualized as the capacity of the person to move around within their home environment and beyond (Fry and Keyes 2010). Life-Space Mobility is structured into different mobility zones, commonly extending from the bedroom. Marking a person’s mobility pattern, moving outwards across life-space zones such as the house, neighborhood or town provides information about the maintenance of activities of daily life and social participation after a stroke. Life-Space Mobility also considers the level of independence in terms of assistance or mobility aids as well as frequency of the movements. A vast majority of stroke survivors have restricted Life-Space Mobility (Tashiro et al. 2019). Also, pain, walking difficulties and depressive symptoms have proven to be negatively associated with Life-Space Mobility

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( Rantakokko et al. 2018), which makes it even more important to consider physical environmental aspects beyond the home in rehabilitation after a stroke.

Shared Decision Making—A Key Component of Person-Centered Care In Sweden and globally, the person-centered perspective is central within health care services (Stiernstedt, Zetterberg, and Ingmanson 2016), where the major aim is to empower the person by taking self-identified goals as its point of departure in terms of rehabilitation and by including the individual as a partner in a patient’s rehabilitation process (Fletcher et al. 2019). The philosophy of a person-centered care is therefore that of doing things with people, rather than to them, which implies taking into consideration people’s values and desires as well as family and social circumstances (Lawrence and Kinn 2012; Mead and Bower 2000). The rehabilitation process is defined as the process after a stroke, where the person is engaged to attain her/his vital life goals and achieve an optimal degree of social well-being and functioning supported by health services and social networks (Kulnik et al. 2018). It includes supporting the discovery and awareness of disabilities, learning problem-solving strategies, addressing and solving everyday problems, planning and performing activities needed to reach goals and ref lecting on goal attainment, i.e., self-management ( Kulnik et al. 2018). Furthermore, a key element in person-centered care is shared decision making (Weston 2001), a process whereby health care professionals and patients work jointly to make health care choices while considering the best available clinical evidence as well as patients’ values and preferences (Légaré and Witteman 2013). A theory analysis of shared decision making has shown that the collaboration between several health care providers, patients and their families are seldom addressed (Stacey et al. 2010). That is, the roles of the multidisciplinary teams and how they may contribute to the decision-making process are most often neglected in current theories. In the context of home rehabilitation after a stroke, where multiple health care providers and significant others are involved, it is thus important to advance these theories. In addition, current shared decision making outcome measures do not consider the role of the environment ( Kylén et al. 2019). As people living with complex conditions such as stroke survivors are more vulnerable to the demands posed by their residential and community environment, this knowledge gap needs to be addressed.

Conclusion The theories (including conceptual models and frameworks) mentioned earlier clearly show that physical and perceived environmental aspects need to be considered in the creation of person-centered stroke care and rehabilitation at

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home. Yet, the question of which factors in the environment either facilitate or hinder person-centered care and promote health and wellbeing in stroke survivors is insufficiently investigated, and therefore little is known. The use of theories to develop study designs about stroke rehabilitation at home is important to obtain more reliable clinical guidelines about the actual impact that objective and subjective experience of the home environment have on rehabilitation processes. Furthermore, the integration of theories that account for a more holistic view of person-environment interaction is also important to ensure a common vision among the many people involved (e.g., policymakers, multidisciplinary teams, in and out-patient care providers, significant others).

Some Suggestions for the Future We have identified some essential actions for the future: • •

•

•

Integrate the built environment as a crucial factor for a person-centered rehabilitation process in the home. Generate knowledge of the home as a place for care and rehabilitation from stroke survivors, healthcare professionals, decision makers, architects and urban planners and researchers to optimize the dwelling for care and rehabilitation. Take on a transdisciplinary research approach to develop theory, concepts and methodologies of relevance that can provide a holistic understanding of the person-environment interaction and health-related outcomes. Systematic, high-quality investigations to generate the evidence of the home as a place for care and rehabilitation is needed to inform policy makers and healthcare practices.

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19 THE PUZZLE OF COMBINED EVIDENCES—PIECING KNOWLEDGE TOGETHER WITH PROFESSIONALS IN URBAN DEVELOPMENT Joakim Forsemalm and Magnus Johansson

Introduction In urban development today, there is really no lack of research knowledge regarding what ought to be done in terms of achieving more socially or environmentally sustainable cities, or how to make urban plans that support healthier lifestyles. Neither is there any shortage of good examples of how cities, real-estate companies, landowners or construction companies are already reorganizing, re-arranging, or re-forming buildings, environments and management structures (Simon 2016). To a great extent, in terms of up-scaling benchmarked good examples as well as putting valid research findings into practical use, maybe we need knowledge facilitators to piece together the puzzle of urban sustainability. In this chapter, we will describe how we went about as a form of “cultural brokers” ( Jezewski and Sotnik 2001) working for the municipally owned housing company Bostadsbolaget in Gothenburg, Sweden, to produce, and use, various forms of evidences to improve social life, the housing situation and the physical environment in two districts troubled by distress.1

Evidence-Based Practice: Four Types of Information Combined In our role as researchers in the initiative (i.e., a new and more long-term approach to property management and community development as defined by the project owner Bostadsbolaget), our work focused on managing the professionals involved to develop working methods based on distinct knowledge. Our source of inspiration was a model developed by organisational researchers Eric Barends, Denise Rousseau and Rob Brinner, who define evidence

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as all information that helps professionals make better decisions (Barends and Rousseau 2018). Their model (developed into the visual model showed in figure 19.1) combines four types of evidence: scientific, stakeholder, professional and organisational evidence. The first two are widely known. Typically, scientific evidence is what comes to mind when you talk about evidence-based practice. This is referred to as “hard evidence” (i.e., the results of a research community’s aggregated work), assumed to be true for a given period of time. An important aspect of professional competence is to make use of and apply such knowledge. Stakeholder evidence is all the local knowledge that is vested, not only in residents, but also in the actors with whom they collaborate (companies, associations and organisations) and on which they depend for success. Professional evidence consists of the experience, quiet or tacit knowledge, and skills vested in professionals. Finally, organisational evidence encompasses all

FIGURE 19.1

2018).

From (Forsemalm et al. 2019) with reference to (Barends and Rousseau

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the data and information produced within and through organisational practices that provide an image of an organisation’s capacity to exert effects on change, their scope for coming up with a solution. Working with evidencebased urban development means that the four types of evidence need to be interconnected, which is challenging and supporting each other at the same time, in order to address professional problems.

Challenges for the Professional in the New “Wickedness” When talking about various forms of evidence-based practice, such as evidencebased urban planning, one issue frequently referred to is that practitioners should make greater use of research results in practising their profession (Nutley et al. 2007). Professionals are entangled in local practices, where they must serve specific clients and stakeholders, with clear demands on what should be done and delivered. Established routines, legislation, and institutional structures can prevent professionals from adopting alternative working methods, in spite of their access to research results or effort to consider the wishes of residents in an urban development process (Cooper and Symes 2008). Professionals’ skills are, in general, understood as something that slowly develops from personal experiences of a practice. Here, systematic ref lections over results are crucial. Professional knowledge is also often understood as situated (Schön 1984; Wenger 1998). Professional expertise is acquired from a growing body of experience. Expert knowledge is, to a large extent, tacit and embodied. A true expert may not be able to fully explain why he or she acts in a certain way in order to solve a problem (Dreyfus and Dreyfus 1986). However, the development of such expertise presumes situations that are stable. A carpenter or a bricklayer can develop a broad range of knowledge based on previous experience and successively make decisions based on routines. In the end, a house must follow some basic rules when it comes to construction and production. A carpenter or a bricklayer also works in a practice where it is relatively easy to get “feedback from the material”. You will notice if you fail when you build a wall. But how could you be sure that you contribute to build a more sustainable neighbourhood? According to Rittel and Webber (1973), (urban) planning problems are wicked in their character: multi-layered, complex, non-linear and tangled into other problems. Any attempt to solve such problems will also change them. In that sense, “wicked problems” could not be finally solved, only temporally handled by intertwining different strands of knowledge and perspectives through different forms of transdisciplinary approaches (Brown et al. 2010) and co-production of knowledge (Polk 2015). So, if urban planning practice is characterized by “wicked issues”, how is it possible to develop tacit, experiencebased professional knowledge? How could you develop skills from “learning by doing” if it is hard (or impossible) to evaluate actions based on the results?

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How can we work systematically with knowledge in a practice where we face new challenges and situations over and over again? A further dimension that complicates this is the fact that our understanding of sustainable urban development, to a large extent, is based on scientific knowledge. It is hard to grasp climate change without understanding and accepting scientific facts. Sustainable urban development, in the context of this chapter, which deals with the development of two city districts facing both physical and socio-economic challenges, must be an evidence-based practice. Our intention with this chapter is not to suggest a return to modernistic and reductionist ways of urban planning, which by default put scientific facts before professional experience and community knowledge. We do, however, think there is a need for a more systematic approach to planning that is based on the methodological use of a broad range of knowledge, here conceived of as evidences. Urban planning may be a “wicked problem” (Rittel and Webber 1973), implying that it is difficult for professional planners to learn from previous experiences (Schön 1984). However, we do believe that there are better or worse ways for professionals to handle these wicked problems.

Professional Work as a Process of Structuring Problems In a workplace, complex and chaotic situations always arise, but they still need to be addressed. Schön (1984) describes this as a twofold process of naming and framing, in which professionals apply a frame to a field of experience. This frame enables professionals to highlight distinct features of the situation, including specific symptomatic challenges. At the same time, they must ignore, or single out, certain other features of the situation as “noisy” or irrelevant. In the end, professionals bind together the salient features of the situation, including the relevant worries, into a pattern that is coherent and graspable. Formulating problems necessarily means delimiting possibilities for resolution. Creating sustainable cities requires new ways of working. It requires you to reformulate the problems you need to resolve with your work (i.e., to find new ways of naming and framing). We need to relearn things and create new images from which we can act (i.e., make detailed plans, planning programs and building permits). Per-Erik Ellström (2001) argues that there is an inherent conf lict in all workplaces in performing one’s job effectively and at the same time being innovative. Ellström distinguishes between three situations which create different conditions for learning. In the first situation, we know what tasks we need to perform, how we should perform them and what results we can expect. Here, you learn through adaptation: we must adapt and repeat what others have done before us. Learning to drive a car is one example. In the second situation, the task is predetermined, but it can be resolved in different ways, and there are

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different ways of achieving success. This creates a scope for development-based learning. Ellström calls the last form of learning “creative” or “innovative” learning. Here, we start with a situation that is completely open-ended. To make sustainable urban development a success, we need to create a scope for more development-based learning. This requires that we question our procedures and experiences, and that we develop new ways of naming and framing what tasks we need to perform. This means that we must learn to formulate problems in new ways. However, being creative and innovative is not enough. We must not only “name” problems in new ways but also find different ways to frame them. This means defining and making decisions to resolve problems in our professional lives, such as the challenge of creating sustainable, climatefriendly, and socially inclusive cities. Our model, as visualised above, is the suggestion of a new frame for such questions and challenges. Now, when we face wicked problems, we must strive for much more openended learning. Rob Hoppe (2011) distinguishes between four types of problems, with varying degrees of complexity, described in figure 19.2. When professionals work to solve problems, they look for the type of problems found in the figure’s upper left-hand corner, i.e. naming and framing problems to give them a well-defined structure. In other words, they “corner up” the problem. You structure a wicked problem—and make it possible to solve it—at the expense of cutting out opportunities for developmental and creative learning. An evidence-based practice, as presented here, could be a way of structuring problems, by using different forms of evidence for the necessary acts of naming and framing a problem. But the risk inherited in these necessary acts, as addressed by Rittel and Webber (1973), is that you exclude aspects and perspectives that are relevant but not understood or accepted as “evidence” in the specific case. So, professional problem-solving is described as a move from unstructured, wicked problems towards more structured problems which are possible to solve, a process during which one must exclude aspects and perspectives of a complex, “wicked” problem. The contested and complex nature of urban development implies that this could result in situations where we have solutions that, in the long run, cause new problems (a “sub-optimizing” process). In figure 19.3 (seen later), our approach to evidence-based planning suggests a movement between different forms of naming and framing problems (Schön 1984): adaptive and creative learning, or wicked versus structured problems. Here, we argue that different forms of evidence, whether they are derived from statistical records, professional experiences or stories collected among residents around a development project, address different ways of naming and framing, which results in a more dynamic approach to structuring (wicked) problems. Based on the model illustrated in Figure 19.2, an evidence-based approach as discussed here means

2011).

FIGURE 19.2

Unstructured “wicked” problems

Far from agreement on norms and values at stake

Moderately structured problems Discussions about acceptable goals

Far from certainty on required and available knowledge

Norms and values, certain and un-certain knowledge. From (Forsemalm et al. 2019), with reference to (Hoppe

Close to certainty on required and available knowledge

Structured problems

Moderately structured problems Discussions about suitable means

Close to agreement on norms and values at stake

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(2011).

FIGURE 19.3

Unstructured “wicked” problems

Far from agreement on norms and values at stake

Moderately structured problems Discussions about acceptable goals

Far from certainty on required and available knowledge

A dynamic approach: opening and closing problems. From (Forsemalm et al. 2019), with reference to Hoppe

Close to certainty on required and available knowledge

Structured problems

Moderately structured problems Discussions about suitable means

Close to agreement on norms and values at stake

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using a broad setup of information to open up and close problems in assignments. This also means a movement between innovative and adaptive learning.

Using Evidence as a Way of Supporting Professional Learning In the spring of 2016, we received a commission from Bostadsbolaget AB, a public housing company operating in Gothenburg, Sweden. We became involved under the premise that we should contribute to the company’s efforts of refurbishments by providing knowledge support. We decided to try to tackle urban development, relying on evidence to a greater degree than ordinary practice would demand. Harnessing the capabilities of professionals and grasping opportunities to work in innovative ways are the keys to sustainable urban development. Bostadsbolaget owns the majority of the 2,800 apartments located in Hammarkullen, a city district home to approximately 8,000 inhabitants in Gothenburg’s north-eastern outskirts. This district is one of 23 categorized by the national police as “particularly vulnerable”, marked by high crime rates, high unemployment, poor school results, low general trust, low average income and, on top of that, low health standards. When Bostadsbolaget started the process, they faced not one but several challenges: how to renovate older apartments in a way that did not result in high rents forcing tenants to move; how to increase the energy efficiency of older apartment buildings; how to increase the feeling of safety and belonging among the inhabitants in a socioeconomically vulnerable neighbourhood; and how to make room for new buildings and more privately-owned condominiums without gentrification. In short, Bostadsbolaget needed to address the issue of how to support sustainable development in its widest sense. Dialogues were not enough—there was a need for new approaches. Learning from previous failed attempts to address these issues, representatives of the housing company concluded that they needed a long-term presence and support on site. The company president, together with representatives from public sector administrations, signed a letter of intent for long-term responsibility. Our role was to ensure that all involved learned to work in new ways. All professionals involved, from Bostadsbolaget and different city departments, among other stakeholders, should develop new forms of professional skills, and new ways of understanding how to work with urban development in these kinds of areas. But how could they know that their proposed decisions and actions would result in a more sustainable and health-promoting neighbourhood? We started our work of mapping and describing organisational and professional evidence for this programme with a series of interviews with practitioners and several walkshops that saw us walking around the neighbourhood with representatives from the participating organisations (local authorities) involved in the management, maintenance and development of Hammarkullen and Norra

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Biskopsgården. This allowed us to identify a variety of physical boundaries and areas of conf lict that could be attributed to organisational contradictions. One example was physically interconnected areas—lawns, bicycle lanes, car parks—being maintained differently because they were intersected by invisible administrative boundaries (i.e., because several local authorities own different parts of the public space). This may seem like a minor detail, but it is something that was a source of irritation among the residents. Take snow clearance as an example: on what appears to be the same public surface, snow had been cleared within a certain area only, with no clearance beyond it. To begin with, two different authorities were given different time intervals or amounts of snow for clearance. Overall, residents who did not know this were annoyed with the local authority. Since most were not aware that two different local authorities were involved, they believed a single local authority was serving the neighborhood. The discussions between various actors both during the initial walks in the area, and those that took place subsequently, highlighted several other challenges and approaches, which, in the next stage, provided a starting point for possible common solutions. When decisions regarding maintenance were discussed, each actor started out with different views and information, and—if we translate this to our method—we could say they approached the matter with different forms of organisational and professional evidence. The conversations we had with the large number of practitioners created a common understanding, i.e., we developed new forms of professional and organizational evidence. We moved from an unstructured problem to one that increasingly became structured, agreeing on some elements and disagreeing on others and, so, that is how we landed in the upper left-hand corner of Figure 19.2. These discussions, which provided a forum for us to ref lect on available knowledge, increased our organisational capacity to solve the problem, which Bostadsbolaget had initially defined and had declared needed to be resolved with an “initiative”. Research literature on challenges and opportunities linked to urban development in socially and economically vulnerable areas is extensive and multifaceted. In general terms, we can distinguish between two ways of using research results: a conceptual one, to open up new perspectives and issues, and, an instrumental one, to resolve well-defined and specific problems (Nutley et al. 2007). Our challenge was to identify research that not only problematised the issues (and pushed down into the lower right-hand corner of Figure 19.2) but could also support professional planners in making better decisions and reaching the upper left-hand corner. Our solution was to use UN-Habitat’s five principles for sustainable urban development (U.N. Habitat 2014). In this case, we used the principles as a basis for a discussion with representatives from the various local authorities on how to develop the neighbourhood. We did not set out to persuade Bostadsbolaget to slavishly follow the principles: regardless of which well-tested measure or knowledge one leans towards, each and every one of

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them constitutes only one part of the total evidence-based knowledge. The purpose behind our choice of this particular scientific point of departure (the tool is based on some 70 research articles and national policies) was to contrast with, and perhaps to some extent challenge, established ideas about how a suburban neighborhood could and should be developed and spatially structured, according to professional and organisational evidence. We also conducted dialogues with the residents in order to map, collect and systematise different forms of stakeholder knowledge, which could support both scientific and professional conclusions to some extent. One example in this regard is that many of the people who participated in the dialogue wrote that they would like to own their homes—which is contrary to what seems to be the accepted conclusions in sections of the research community and among stakeholder organisations representing tenants. Working with urban development based on evidence means providing professional methods and approaches to become better at dealing with complex issues in our professional lives. We deliberately opted for the concept of evidence, rather than “knowledge” or “experience”, to emphasise that we mean knowledge and experience perceived to be “true”. If one works in property management for many years, one will have “true” knowledge of how the work should be done, which we describe here as professional evidence. In that case, a researcher citing his or her scientific evidence will be of no help to a practitioner if it contradicts their professional evidence. Evidence-based urban development starts from the premise that, fundamentally, there are many different “truths”—many different types of evidence—without necessarily resorting to relativism. Rather, it is about constructivism: the conversation about how to build with quality sustainable, inclusive, and fair cities is an ongoing one that may never produce a definitive answer. “Truths” are constantly constructed and deconstructed in various forms of dialogues and cultures. Professional evidence (“This is how we have always done it and what we know works”) must be challenged by scientific evidence in its various forms, such as the principles of UN-Habitat, Gehl architects’ measurement methods for urban life, or perhaps tools for measuring the green space factor. Similarly, scientific evidence must be challenged by other forms of evidence so it can be adapted to local needs and circumstances. We cannot apply the principles of UN-Habitat in the same fashion in Hammarkullen as we can in Nairobi—but they can still provide a point of departure for a comparative dialogue about the benchmarks and premises that sustainable urban development can and should use. There are no shortcuts to a sustainable city. Professionals must learn to work in new ways. However, this process will see our professional lives becoming more complex. To avoid getting caught up in the complexity, we must also get down to the business of shutting down and defining. Ultimately, innovative visions have to become manifest in the form of houses, roads, infrastructure and parks.

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Evidence-based work means to systematically raise and shut down issues by combining different forms of evidence, which in turn creates new scopes for learning, thus boosting our prospects of building healthy environments and more sustainable cities.

Discussion Lessons learned from working on this project have been that when it comes to the quest for new ways of arranging urban development—in particular urban districts facing a variety of (wicked) problems that are separated from each other epistemologically—not only is there a need for new types of knowledge but there is also a need for ref lection concerned with how new ways of organizing requires humility and openness. The typical hierarchical systems of urban development cannot harness the diversity of issues that is inherent of the “new complexity”. Our suggestion, then, is to turn to methods, the evidencebased approach to urban development, that appraise information in a wider sense as important for us to piece a clear-cut puzzle of urban needs and ambitions together. We believe, as a result of having recent practical experiences, that this approach to knowledge makes it easier to make well-grounded decisions from a wide range of sources. This might help us close perpetually openended projects and processes and get on with the important tasks of sustainable development.

Note 1. The project was led by urban development and strategy companies Radar architecture and Urbanivation with support from RISE, Research Institutes of Sweden.

References Barends, Eric, and Denise M. Rousseau. 2018. Evidence-based Management: How to Use Evidence to Make Better Organizational Decisions. London: Kogan Page Publishers. Brown, Valerie. A., Johan A. Harris, and Jacqueline, Y. Russell (Eds.). 2010. Tackling Wicked Problems Through the Transdisciplinary Imagination. London: Earthscan. Cooper, Ian, and Martin Symes, eds. 2008. Sustainable Urban Development: Changing Professional Practice (Vol. 4). London: Taylor & Francis. Dreyfus, Hubert L., and Stuart E. Dreyfus. 1986. Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer. Oxford: Basil Blackwell. Ellström, Per-Erik. 2001. “Integrating Learning and Work: Problems and Prospects”. Human Resource Development Quarterly, 12(4), 421–435. Forsemalm, Joakim, Magnus Johansson, and Paul Göransson. 2019. Evidensbaserad Stadsutveckling—Bortom Urbana Anekdoter. Stockholm: Dokument Press. Hoppe, Rob. 2011. The Governance of Problems: Puzzling, Powering and Participation. Bristol: Policy Press.

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Jezewski, Mary Anne, and Paula Sotnik. 2001. Culture Brokering: Providing Culturally Competent Rehabilitation Services to Foreign-born Persons. Buffalo, NY: Center for International Rehabilitation Research Information and Exchange. Nutley, Sandra M., Isabel Walter, and Huw T. O. Davies. 2007. Using Evidence: How Research Can Inform Public Services. Bristol: Bristol University Press. Polk, Meritt. 2015. “Transdisciplinary Co-production: Designing and Testing a Transdisciplinary Research Framework for Societal Problem Solving.” Futures, 65, 110–122. Rittel, Horst W. J., and Melvin M. Webber. 1973. “Dilemmas in a general theory of planning.” Policy Sciences, 4, 155–169. Schön, Donald A. 1984. The Reflective Practitioner: How Professionals Think in Action. New York: Basic Books. Simon, David, ed. 2016. Rethinking Sustainable Cities: Accessible, Green and Fair. Bristol: Policy Press. U.N. Habitat. 2014. A New Strategy of Sustainable Neighbourhood Planning: Five Principles. Nairobi, Kenya: United Nations Human Settlements Programme. Wenger, Etienne. 1998. Communities of Practice: Learning, Meaning and Identity. Cambridge: Cambridge University Press.

20 AIDAH—EDITORS’ POST SCRIPTUM Björn Andersson and Sten Gromark

AIDAH—Editors’ Post Scriptum The AIDAH research project has been built upon the basic assumption that, confronted with the major challenges that societies face in terms of housing needs, an ageing population and radically changing healthcare conditions, architectural interventions must be inventive, audacious and explorative in their approaches. At the foreground of our work has therefore been the notion of a health promoting architecture. In this context, health is to be considered in a broad sense, that is, architecture as the promotion of wellbeing and thriving social living conditions in general, even though AIDAH has had a special focus on caring, not least with respect towards the growing older part of the population. As we now summarize the project in this volume, there are a number of important aspects to highlight when it comes to the characterization of this vision of an inventive and health promoting architecture. The first major aspect concerns the need for the architectural project to be both embedded in contemporary realities and able to envision unforeseeable futures. Today’s solutions must incorporate and enable the potential opportunities and the still unknown needs and desires of tomorrow. For one thing, this is ref lected in today’s comprehensive requirements for social sustainability; the built environment should last for a long time and serve a vast variety of needs, securing longevity and persistence. But it is also a key prerequisite for residential adaptability where expected life-course changes are built into the housing design as a malleable spatiality. There is a long tradition of radical, f lexible solutions in modern architectural history, open to serve as important sources of inspiration. Studies done within AIDAH of individual residential situations show an impressive abundance of inventiveness when it comes to changing

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one’s own dwelling in relation to constantly renewed living conditions. This is partly about the development in a family where children growing up need new, appropriate spatial solutions. But it also applies in order to meet the new demands of an ageing population. Increasingly, the home becomes an environment for caring activities, which means that both private life desires and professional needs must be equally and appropriately addressed. In order to handle such tasks, architects need to be deeply involved in the development and conceptualization of qualitative design aspects of their own contributions. One way to do this is as shown to express quality in the form of design practice-oriented criteria, such as axiality and movement, or perspectives like enriched environments. These properties can serve both as points of departure to guide the design work and as standards for evaluation of existing buildings and apartments. A consequence of the above reasoning puts forth a third requirement for the architectural project, namely that it must be adequately knowledge-based or research informed. AIDAH has worked a lot on the foundation of the evidencebased knowledge that has developed during the last decades, concerning architecture’s potential for health promotion, wellbeing and stress reduction. A number of such situations are presented as illustrations in this volume. However, at the same time, we have also investigated concepts that try to capture unmeasurable qualities like the rewarding experience of perceivable and stimulating environments, which are usually not so well represented in the evidence-based perspective. Notions like intuition and tacit knowledge have also been referred to. In all, this illustrates the great multitude of architecture as a professional practice and the need to strike a creative balance between the two interrelated aspects of the same coin. A development in the direction that we are pointing to here puts several demands on architecture as a discipline and the future professional profile of the architect. At the same time, it is obvious that if architecture is going to be transformed as much as an academic subject as a design practice, we strongly advocate that it must also move outside its disciplinary boundaries while at the same time preserving and reinforcing its intradisciplinary unity and identity, its singularity as a field of research. So, one important lesson to be learnt from the AIDAH project is that a stance of multidisciplinarity must be further unfolded, strengthened and embraced by the architectural community. In part, this is about interdisciplinary work, mainly in the fields of health and social sciences. In AIDAH this has been quite prominent where representatives of, for example sociology, social work and care sciences have participated in mutual exchanges with architects. But, just as important, it is about transdisciplinarity: to find new ways where researchers and health workers can meet and function together with external societal and business stakeholders towards critical edges of invention. In the ambition to tackle the complex challenges ahead, such a multi-faceted approach

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becomes crucial. This becomes evident in the dialogue-oriented approach to planning as argued here, but also towards the backdrop of the predominant trend that both general healthcare and care for the elderly are, increasingly, actually performed in people’s homes. The consequence is that architects must engage in an effort of transdisciplinarity exactly in the interface between the dwelling as a home and as a workplace for caring. In several studies, AIDAH has provided knowledge of what happens when the caring professional’s need for accessibility is intermingled with the private need for intimacy. What brings us great hope and well-grounded expectations for the future, in this context, is the growing number of valid examples of health promoting architecture conceived as best practices that exist on the ground around the world, with some of them referred to in this volume. The issues of health promoting architecture indisputably have global urgency, relevance and scope. It is our wish that the presented account of our research environments’ contributing findings will inspire further advances of this recent joint academic and professional movement. Björn Andersson & Sten Gromark, editors Göteborg, Sweden; March 3, 2020

INDEX

Page numbers in italics indicate figures and page numbers in bold indicate tables on the corresponding page. abstract art and decoration, in intensive care units 231 abstract touch 62 Acceptera 66 accessibility: assisted living and 133; home care and 110–111, 115, 122; senior housing compared 134 accidents 78–79; locations in private homes 114 acoustic environment, of ICU rooms 228 adaptability 123–124, 279 adaptable apartments 65–76, 124; concept defined 68; corner stones for current dwelling design in Sweden 66–67; demographic transformation 65–66; elasticity 71; home care and 117; household’s living process 67–68; narratives of spatial use in the home 68–73; spatial capacity 65–67; staying and adapting space 73, 75 adaptive learning 270, 274 ADL assistance 90–91 ADL cluster 88– 99, 89, 92; comparative analysis of existing in the Netherlands 92; def ined 90; recommendations for construction of future 96– 97 ADL home 93–94, 96; defined 90; eligibility for 91

ADL housing: collective spaces 96, 98, 101; comparative analysis of case studies 94, 96; definitions 90–91; experimental re-designs for the impaired 88–103; financial innovation 101–102; f loor plan 95; physical aspects, analysis of 94, 96; recent development in the Netherlands related to 91, 93; recommendations for construction of future ADL clusters 96–97; scale of building 96; scale of home 94, 97, 98–100; scale of neighborhood 96; scale of the block 97–98; social innovation 100–101; typological and constructive innovation 97 ADL unit 90–91, 94, 96, 102 ageing in place: environments for care provision in ordinary housing 121–129; as global trend 121–122; in Italy 157; transdisciplinary perspective on 122–129 ageing societies 107–108 agency, architectural 142–152 age-segregation 173–174, 178, 184 AIDAH 13, 30, 40, 112; Architecture for an Ageing Society (working group) 2 –3; collaboration 5 – 6; Emerging Ways of Residing (working group) 2; Health

Index

Care Architecture (working group) 3; integrative ways of residing (concept) 3, 3, 6; profile of environment 2 – 4; project summarized 279–281; studio environments 10–12, 11; theoretical and methodological orientations 6 – 8; working groups 2 –3 Alcee, Donna 116 Alexander, Christopher 113 Alzheimer’s disease 245 Ambient Assisted Living 169 “analysis-synthesis-evaluation” design method 203 apartments: adaptable 65–76, 124; assisted living 131, 134 arbitrary decisions, fear of 214–215, 217 architectural agency 142–152 Architectural anthropology (2009 workshop) 5 architectural space 142–152 Architecture as Space (Zevi) 44 Architecture in Effect 5 artistry 213, 216 assisted living: at-homeness, place and control 134–135; challenges regarding facilities 135–136; dementia villages 136, 137; environmental indicators and trends 136–137; models for housing and care provision 133, 134; service concept 133; Swedish model 131–138, 132 assistive technology 137 association, materials and 62 ASZ Eching 10 available space 142–152 axiality 40– 43, 280; concept of 40– 41; f loor plan example 42, 42; identification of 41– 42; valuation and the criteria list 43 Babayagas 12 Barends, Eric 267 barriers 124, 256–257 Bergström, Inger 44 best practices 9 –10, 216, 281 biomedical model 257 BKK-2 Architektur ZT GmbH 10 border space 60 Borgo Sostenibile 162, 162–163, 164, 168 Bostadsbolaget 267, 274–275 boundaries, room 47–50 Branzell, Arne 47– 48 Brf Viva 9, 14, 23–37; garden and community bicycle rooms 35; health promotion perspective

283

30–31; Orangerie 28, 36; overview 26–27, 34; procedural goals 29–30; substantive goals 27–29; as top-down project 31–32 Brinner, Rob 267 Brown, Denise Scott 181 Brunnberg & Forshed Arkitekter 46 Canadian Model of Occupational performance and Engagement (CMOP-E) 124 caring organization, architectural space and 142–152 Casa alla Vela 164–167, 165f–166f, 168 Casado, Juan Palop 178 Casanova+Hernandez Architects 10, 88, 89, 93 causation, injury 82 Center for Health Design (CHD) 213–214 Centre for Healthcare Architecture (CVA) 5, 7, 214 Centre for Residential Architecture (CBA) 5, 39– 40, 51 CIB W069 Chalmers midterm conference (2015) 2 CIB W069 Commission Residential Studies 5 circadian rhythm 191, 233 circular loop 43– 47, 45–46; enriched environment and 60– 61; large 44, 45, 45– 46, 47; small 44– 45, 45, 47; structural 44, 46, 47 clerestory windows 191 CMOP-E (Canadian Model of Occupational performance and Engagement) 124 co-design 205 cognitive stimulation 56 cohousing: intergenerational 164, 167; meaning of term 159; see also solidarity cohousing collaboration 5 – 6 collective spaces 96, 98, 101 color-coding 245–246 colors: contrasting 245–246, 249; designing environments and 245–246; in intensive care units 231 combined evidences 267–277 complex systems 202–203, 247 complex windows 190 complicated systems 202–203 condominium 68– 69 constructivist grounded theory 8 contour of the room 50

284

Index

converging views 59, 59 cooperation movement 31–32 co-production of knowledge 269 Cornell, Elias 44 corner stones for current dwelling design in Sweden 66– 67 corridors, windowed 190 COST Action Intrepid 5 covered walkways 190 creative learning 271 crime 80, 80– 82 Crime Prevention Through Environmental Design (CPTED) 80– 82 criteria list of housing architecture properties 39–51; axiality and 43; components of list 40; movement and 46– 47; space and geometry 50 critical interpretations 7 Crona, Kajsa 40 CVA (Centre for Healthcare Architecture) 5, 7, 214

205; process for complex challenges 203–204; qualitative aspects 280 design dialogue 202, 206–209, 207–208, 210, 217–218 design-driven dialogue 202–211, 217–218; characteristics of 206; design dialogue 202, 206–209, 207–208, 210; overview of 205–206; participative design 202, 205; schematic illustration of phases in design dialogue 207; why they work 209–210 detailing, enriched environment and 61–62 development-based learning 271 deviance 80, 80– 81, 84 dialogue-oriented approach to planning 281 directionality 50 Dishman, Eric 6 diverging views 58, 59 DIY democracy 101 downtowns 173–174, 175, 178

daylight 39– 40, 51, 55, 58, 190–191, 213–214, 225, 227, 232–233 decision making, shared 260 defensible space design 81 de Kooning, Willem 103 dementia: adapting environment to individual’s competence 245, 249; design of outdoor environment for residents with 244; home-like design at an institution for individuals with 245 dementia nursing care home, designing with nature 192, 194–195 dementia villages 136, 137 democracy, DIY 101 demographics: ageing societies 107–108; of elderly in Italy 154–156; sociodemographic plastics 172–184 demographic transformation 65– 66 D’Eramo, Marco 173 Descartes, René 217 design: “analysis-synthesis-evaluation” design method 203; evidence-based design (EBD) 3–4, 7, 213–215, 218; heterogeneous 143; of high technology environments 224–234; inclusive 83; intensive care units 224–234; interventions and mixed methods research 241–249; intuition 213, 215–218; nature, designing with 189–198, 214; participative 202,

Early Supported Discharge (ESD) 254 EBD (evidence-based design) 3 – 4, 7, 213–215, 218 EBM (evidence-based medicine) 214 Ecological Model of Ageing 112–113, 134, 243, 258 edge spaces 190 E-health 108 Einstein, Albert 217 elasticity 71 Ellström, Per-Erik 270–271 energy: plus-energy housing complex 28 enriched environment 53– 62, 280; architecture’s contributions to 55–56; change and stability 55; evidence from animal models 53–54; generalizability and preference 56; materials and detailing 61– 62; movement 60– 61; social stimulation 55–56; spatial extension 56– 60, 57–59 environment: enriched 53– 62, 280; person-environment interaction 256–257 environmental pressure 246–247 environments for care provision in ordinary housing 121–129 errors, medical 227, 229, 233 ESD (Early Supported Discharge) 254 ethical considerations for human research 127–128 events, spatial extension and 59

Index

evidence: combined 267–277; focus on 213–214, 218; good design achieved without 215–216; organisational 268, 268–269; professional 268, 268, 276; puzzle of combined evidence 267–277; scientific 268, 268, 276; stakeholder 268, 268; types of 268, 268–269, 276–277; using as way of supporting professional 274 evidence-based design (EBD) 3 – 4, 7, 213–215, 218 evidence-based knowledge 5, 39, 41, 247, 276 evidence-based medicine (EBM) 214 evidence-based practice 267–271 evidence-based research 39, 51 evidence-based urban development 268–269, 276, 286 experience-dependent plasticity 55 expert knowledge 269 explorative qualitative approach 247 extra-care housing residence 144–152, 145–147, 149; designing with nature 192, 193 fall injuries 78, 80– 81, 116; locations for 83; stroke survivors 253 family configuration, housing design and 66– 67 family life course 68 family structures, changing 135 farewell room 230 feel-good trend, in assisted living facilities 136 f loor plan: ADL housing 95; axiality and 42, 42; extra-care housing residence 146; identification of openness and enclosure in f loor plan examples 48, 48– 49; landshövdingehuset 70, 72, 74; large circular loop 45; movement and 43– 47, 45–46; private and public areas 113–114; residential healthcare and 113–114, 116, 116–117, 118; small circular loop 45; space and geometry example 50; structural circular loop 46 focus group interview 248 Fokus concept 90 Friberger, Erik 68 Future of Home Health Care, The (NRC) 6 gardens: architecture and 191–192; hospital 197–198; placement of 244 garden trend, in assisted living facilities 136

285

geometry see space and geometry “Geometry of Paradise” 178 golf carts 178–179, 182 Granath, Kaj 40 green care 189 Groningen 10 Hamilton, Kirk 4, 214–216 health: connection with architecture 39; connection with built environment 30–31; connection with social capital 30; enriched environment and 53– 62; as focus of caring instead of the disease 244; nature and 189–198 healthcare: architecture design 204–205; environment as complex system 247; viewed as complex dynamic system 202–203; see also home care; residential healthcare “Health Care is Be-Coming Home” 13–15, 107–118 healthcare organizations, architectural space and 142–152 Health Environment Inventory (HEI) 244 health promoting architecture 279 hearing 228 Hero’s Journey, The 192 heterogeneous design 143 high technology environments, design of 224–234 home: concept of 132, 138; dimensions of 132; feeling of being 169; meaning of 259; as place for rehabilitation 252–261 home care 107–118, 242; accessibility and 110–111, 115, 122; collaboration between stakeholders 110; cost of 111; environments for care provision in ordinary housing 121–129; previous and related research on 108–109; shortage of skilled personnel 111; space requirements 112 home modification intervention 111 hospice 192 hospital: gardens 197–198; stay length, reduced in ICU single patient rooms 227–228; strip hospital 179–182, 180, 183 host-assisted senior housing 133, 134 household’s living process: spatial use and social dimensions 67; use of adaptable space 68 housing: criteria list of housing architecture properties 39–51;

286

Index

dimensions of 132; extra-care housing residence 144–152, 145–147, 149; host-assisted senior 133, 134; intermediate low care 156, 158, 159; sociodemographic plastics 172–184; solidarity cohousing 158, 159–167, 160–163, 165–166, 168; see also ADL housing Housing as an Arena for Healthcare and Care (BAVO) study 113 Housing Enabler (tool) 111, 115 HSB 68 human life cycle, stages of 108 humidity, in intensive care units 233 hygiene, in intensive care units 233–234 ICF (International Classification Framework) 257 ICU delirium 230–231, 232 ICUs see intensive care units (ICUs) identity, home and 109 illumination see lighting inclusive approaches to housing and residency 135 inclusive design 83 infection control, in intensive care units 227–228 injury: causation 82; hospital-related 124; intentional 79– 80, 80; interpersonal 79– 80, 80; intrapersonal 79– 80, 80; unintentional 79– 81, 80 injury events: accidents as different from 78–79; conceptualizing 78– 80, 80; defined 79; temporal phases in 79 injury prevention 78– 85 Injury Prevention Through Environmental Design (IPTED) 80, 82– 4 injury situations 78, 85 innovation 204; intuition as tool for 216 innovative learning 271 integrated home care assistance 156 integrative ways of residing 3, 3, 6, 9 –10 intensive care units (ICUs) 224–234; abstract art and decoration 231; colors 231; daylight 232; humidity 233; hygiene in 233–234; infection control 227–228; lighting 233; location of 225; noise 228; patient room with workstation, example of 226; single patient rooms 227–230; smells 233; sound and 228–229; temperature 233; ventilation 233; views of nature 231–232; windows in 232

intentional injury 79– 80, 80 interdisciplinarity/interdisciplinary 4 -5, 78, 85, 88, 93, 113, 123, 192, 280 intradisciplinarity 14, 280 interface of interior and exterior 60 intergenerational cohousing 164, 167 intermediate low care housing 156, 158, 159 International Classification Framework (ICF) 257 interpersonal injury 79– 80, 80 interpretative f lexibility 143, 145 interventions: theoretical underpinnings for interventions supporting a person-centered and safe health care environment 243–244; towards a person-centered and safe environment for older people 244–247 interview: focus group 248; open-ended 248 intrapersonal injury 79– 80, 80 intuition 213, 215–218, 280 IPTED (Injury Prevention Through Environmental Design) 80, 82– 4 Italy: demographics of elderly in 154–156; informal housing care for elderly 156–157, 158; institutional housing care for elderly 156–157, 158; new strategies for housing in 154–169; solidarity cohousing 158, 159–167, 160–163, 165–166, 168; structure and needs of ageing population 155–156 Izenour, Steven 181 Jacobs, Jane 80– 81 Jeffrey, Ray 80 Kampung Admiralty 13 kangaroo-house 100, 100n3 Katz, Stephen 178 Kemeny, Jim 8 knowledge: co-production of 269; expert 269; piecing together with professionals in urban development 267–277; professional as situation 269; scientific 270; tacit 7, 213, 216–218, 269, 280; true 276 knowledge-based project 280 Kub Arkitekter 45 landshövdingehus 68– 69, 70, 72, 73, 74 Langer, Ellen 174 Lantz, Gunnar 109 Lawton, Powell 243

Index

287

learning: adaptive 270, 274; creative/ innovative 271; development-based 271 Learning from Las Vegas 181 Lebich, Siglinde 10 Levitas, Ruth 178 life cycle, stages of human 108 Life-Space Mobility 257–260 lighting: designing environments and 246; injury prevention and 83; in intensive care units 233 Limitless Light (William-Olsson) 40– 41

sketch schemes 192; stress and pain, effect of nature views on 196–197; UK examples 192, 193–195 nature sounds 229 nature trend, in assisted living facilities 136 nature views 55, 58, 196–197, 214, 225, 232, 241 Newman, Oscar 80– 81 Nightingale, Florence 225 noise 228 nursing home 157

Marge Architects 12 market segmentation 172 Marshall, Barbara 178 materials, enriched environment and 61– 62 McKenzie, Stephen 24 medical errors, ICU design and 227, 229, 233 Metryka, Anna 11 Minoura, Eva 40 mixed-method research design approach 247–248 “mobility with changed spatial needs” concept 67, 75 modernistic design movement 66 Morse, Gary 173 movement 280; ADL housing and 98–99; circular loop 43– 47, 45–46; direction of 60– 61; enriched environment and 60– 61; f loor plan and 43– 47, 45–46; identification of 44; Life-Space Mobility 257–260; rhythm 60– 61; spaciousness of the home and 43– 47; valuation and the criteria list 46– 47; variation 60– 61 moving see relocation moving patients 227–228 multidisciplinarity 280 music 246

occupational therapy 124–125 old age-home 157 Oldenburg, Ray 30 organisational evidence 268, 268–269 organizational optimization 150 organization change, architectural space and 142–152 Östra Psychiatric Wards 9, 14, 14, 215–217, 219–222

Namasté Residential Network 164, 168 naming and framing process 270–271 nature, designing with 189–198, 214; architectural features 190–191; daylight 39– 40, 51, 55, 58, 190–191, 213–214, 225, 227, 232–233; evidence-informed guidelines for designing hospitals 197–198; gardens and architecture 191–192; hospital gardens 197–198; integrative potential 192, 196; nature in hospitals 196;

Paadam, Katrin 4, 8 pain reduction, nature views and 196–197 Participative Design 202, 205 participatory observation study 248 passage 61 patient transfers 122 Pattern Language, A (Alexander) 113 Paulson, Jan 132 person-centered health care environment 242–244 person-centered perspective/approach 242, 260–261 person-centered rehabilitation process 257 person-environment interaction 256–257; ecological theory of ageing and 258; International Classif ication Framework (ICF) 257; meaning of home and 259; place attachment 259; salutogenesis and 257–258; theoretical frameworks, useful 257–260 photo-voice data collection 247 physical interventions see interventions Pirsig, Robert M. 216 place attachment 259 plasticity, experience-dependent 55 Poetics of Space, The (Bachelard) 47 poetry, vocalizing 40– 41 polio 225 population growth, global 137

288

Index

porches 190 Positive Footprint Housing© 14, 23, 26, 29, 31–33 preserved function, focus on 244 prevention: design as a preventative approach in residential settings 78– 85; enriched environment and 53– 62; theoretical approaches 80– 85 privacy 60, 110, 113–117, 121–124, 133, 159, 165, 181, 197–198, 229, 244 problem focus 123 problems 272–273; opening and closing 273, 274; structuring 270–274; types of 271 problem-solving approach 123 process map 208 professional evidence 268, 268, 276 professional plazas 179–180 professionals, challenges for 269–270 professional work, as process of structuring problems 270–274 proportion 49 psycho-social environment of a room 241 qualitative design aspects 280 qualitative research 7– 8 quality requirements, criteria list of housing architecture properties 39–51 rationality 79– 80 RAT (Routine Activity Theory) 80– 82 recovery, enriched environment and 53– 62 “ref lection-in-action” 205 rehabilitation: defined 253, 260; home as place for 252–261 re-localizations of risky activities 83 relocation: social factors 67; spatial needs and 67 research by design studio on elderly housing 114–118 Research-informed Design (RID) 218 research informed project 280 residential healthcare 107–118; collaboration between stakeholders 110; f loor plans 113–114, 116, 116–117, 118; new buildings and existing housing stock 110–111; private and public areas 113–114; research by design studio on elderly housing 114–118 residential situations: critical interpretations of 5; current in

Western world 8 –9; health promoting 1, 8 –10; in urban contexts 2 Residenza Sanitaria Assistenziale-RSA 157 respirator 225 rhythm 60– 61 RID (Research-informed Design) 218 Riksbyggen 26, 28–32 Room and Human Movement (Bergström) 44 rooms: contour of 50; function defined 66– 67; within rooms 48; sizes of 49; see also f loor plan Roscow, Irving 174 Rousseau, Denise 267 Routine Activity Theory (RAT) 80– 82 RSA-Residenza Sanitaria Assistenziale 157 safe health care environment: interventions toward 244–247; theoretical underpinnings for interventions supporting a safe health care environment 243–244 Sahlgrenska University Hospital (SU Östra psychiatric facility) 14, 14, 215–217, 219–222 salutogenesis 55, 244, 257–258 Sarg fabrik 10 scientific evidence 268, 268, 276 scientific knowledge 270 security, home and 255 self-harm 79– 80 senior housing 133, 134 Senior’s Outdoor Survey (SOS) tool 191 service concept 133 sexually transmitted infections 174, 178 shape of space 47 shared decision making 260 ‘Sketch and Talk’ method 248 sketch scheme 192 skylights 191 smells, in intensive care units 233 Smith, Wendell 172 social capital: bonding and bridging 30–31; building into residentials 30–31; connection with health 30 social home care assistance 156 social interaction: ADL housing 97–98, 101; assisted living and 131; enriched environment and 55–56; facilitating 30 social support, in ICUs 229–230 social sustainability 12, 125, 279; concept of 23–26; definitions of 24–25; goals

Index

of 24; keywords 24–25; multipurpose use of 23–37; residential healthcare and 113; symbolic functions 33, 37; three dimensions/pillars of 23–25, 32 sociodemographic plastics 172–184 solidarity cohousing 158, 159–167, 160–163, 165–166, 168; Borgo Sostenibile 162, 162–163, 164, 168; Casa alla Vela 164–167, 165f–166f, 168; Namasté Residential Network 164, 168; Struttura Del Moro 160–161, 160f–161f, 168 Something about O (Branzell) 47– 48 sound: designing environments and 246; intensive care units and 228–229; noise 228; positive impact of 228–229 space: available 142–152; border 60; organizational transformations in 146–150; shape of 47 space and geometry: concept of 47; f loor plan example 50; identification of openness and enclosure in f loor plan examples 48, 48– 49; valuation and the criteria list 50 space bubbles 47– 48 spaciousness: ADL housing 100; movement and perception of 60– 61 spaciousness of the home: axiality 40– 43; enriched environment and feeling of 57, 58; movement 43– 47; space and geometry 47–50 spatial capacity for diverse uses 65– 67 spatial decision-making 142–152 spatial extension 56–60, 57–59; converging views 59, 59; diverging views 58, 59; horizontal and vertical extension of views 60; interface of interior and exterior 60; variation and events 59 spatial proportions 49 spatial sorting 173 special housing 131 staff work satisfaction, physical environment and 243 stakeholder evidence 268, 268 Stockholm Neonatal Family Centered Care 9, 14 stress reduction 244, 280; colors and 231; enriched environment and 53–56, 58; nature and 196, 198, 231–232; social support and 229; sound and 228–229 strip hospital 179–182, 180, 183 stroke survivors 252–261; care and rehabilitation as complex process

289

253–255; care transition from the hospital to the house 254, 258–259; Early Supported Discharge (ESD) 254; ecological theory of ageing and 258; home as place for rehabilitation 252–261; Life-Space Mobility 257–260; meaning of home and 259; overview of 253; person-centered care 260–261; person-environment interaction and 256–260; place attachment and meaning of home 258–259; salutogenesis and 257–258 Struttura Del Moro 160–161, 160f–161f, 168 subjectivity, architectural 143 sub-optimizing process 271 suicide 78– 85; hotspots 83; prevention 84– 85 Sun City, Arizona 172 sunlight see daylight sunroom 190 SU Östra psychiatric facility 215–217, 219–222 sustainability 1, 112; cooperation movement 31–32; ecological 23, 31–32; economic 23, 32; of housing stock 65– 66; urban development 267, 270, 274; see also social sustainability sustainable village 162, 162–163, 164 Sweco 202 systems theory 202 tacit knowledge 7, 213, 216–218, 269, 280 Tamm, Maare 109 temperature, in intensive care units 233 third places 30 thresholds 50, 111 touching, materials and 61– 62 Trädgårdarna 12–13 transdisciplinarity 122–123, 269, 280 transdisciplinary perspective on ageing in place 122–129; architecture, perspective of 123–124; care sciences, perspective of 124; ethical considerations 127–128; exploration of physical enablers and barriers 125–127; occupational therapy, perspective of 124–125; qualitative data 125; quantitative data 126; research design and data collection 125; sampling 126–127; steps in research study 126 transitional zones 83 “truths” 276

290

Index

Ulrich, Roger S. 4, 7, 214–215, 231, 244 U.N. Habitat 275–276 UN Convention on the Rights of Persons with Disabilities 93 unintentional injury 79– 81, 80 urban development: evidence-based 268, 268–269, 276; piecing knowledge together with professionals in 267–277; sustainable 267, 270, 274; “wicked problems” in planning 269–270 urbanization 137 user needs, general categories of presumed 245 user participation 205 utopia 172–174, 178 variation: of ADL housing typologies 99–100; spatial extension and 59 ventilation, in intensive care units 233 Venturi, Robert 181 views: converging 59, 59; diverging 58, 59; horizontal and vertical extension of 60; of nature 55, 58, 196–197, 214, 225, 232, 241; spatial extension and 56– 60, 57–59; variation in sight lines 59

Villages, The, Florida 172–184, 175–177, 180, 183 Viva project see Brf Viva walkshops 274 walkways, covered 190 Watkins, David 214 Weber, David O. 214 WHO’s International Classification Framework (ICF) 257 wicked problems 269–270, 271, 272–273, 277 William-Olsson, Magnus 40– 41 windowed corridors 190 windows: clerestory 191; complex 190; in intensive care units 232 WOHA architects 13 workplace of staff, private home as 3, 107, 109–110, 112–113, 115–117, 122, 281 workshops, “Design Dialogue” 208–209 wrap-around porches 190 Wulz, Fredrik 48 Zevi, Bruno 44