The design revolution: unshackling nursing homes from the medical model - interview with Benyamin Schwarz - Interview

Nursing Homes, July-August, 1996 by Laura Bruck

Even in this era of tightening resources, nursing homes continue to remodel, renovate or even build new. With so much oppportunity for creative architectural minds to upgrade and modernize, one might assume that the American nursing home is well on it's way to becoming what it always should have been - a comfortable, and comforting, residence designed to meet the physical and emotional needs of people in their final years.

Wrong!, says Benyamin Schwarz, PhD, assistant professor of Environmental Design at the University of Missouri-Columbia. In his recently published book Nursing Home Design: Consequences of Employing the Medical Model (Garland Publishing, New York, NY), Dr. Schwarz pulls no punches in his criticism of nursing home design in this country. He refers to its "ideological contradictions," the "misguided architectural model of nursing homes" and the "wicked compromises" made throughout the design process. Strong views, and recently Nursing Homes Managing Editor Laura Bruck asked Dr. Schwarz to expound upon them, and what went wrong, and how it can be made right.

Bruck: You paint a fairly grim picture of the state of American nursing home design. Just how bleak is it?

Dr. Schwarz: Walk into many nursing homes and your impression is of a place to die, rather than a home in which to spend your final years. Nursing homes are simply not the type of structures that elders and their families want or need. Consequently they're disliked, even dreaded, by the very people for whom they're supposed to be designed.

In my book, I relate the story of a man who actually jumped from the window of his independent living apartment rather than move into a nursing home. While this example is extreme, it is horrifying to think that anyone might be more afraid of living in such an environment than of death itself.

Bruck: What is it about the physical design of nursing homes that causes this sense of "dread"?

Dr. Schwarz: In my admittedly biased view, nursing home design is simply based on the wrong model - the medical model. While this might be suitable for acute care settings, where people stay briefly and then return to their former lives, it's entirely inappropriate for the nursing home, which is supposed to be the residents' final home.

The medical model approach to design manifests throughout the facilities, beginning with institutional, double-loaded corridors designed to allow caregivers easy access to the residents - in other words, to meet the needs of the staff rather than the residents. That sends a clear message about design priorities.

Then there are the resident rooms. After 80 years of living in their own homes, people are put in "semi-private" rooms - truly an oxymoron - and expected to be enthused about the prospect of spending the rest of their lives with a stranger, separated only by a partition that provides minimal visual privacy and seriously compromises all other forms of privacy.

What makes all of this especially frustrating are the regulations that force designers to create those spaces according to specifications that emphasize the institutional feel of the buildings. In doing so, we create an environment based on short-term acute care rather than a residential model - one that isn't very suitable for the way people should live the last chapter of their lives.

While I'm not telling your readers anything new, I'm compelled to offer this kind of criticism after seeing so many facilities around the world that are far superior, and so many other models that are so much more suitable than the American nursing home model.

Bruck: It seems, though, that everyone is going to great lengths to make their facilities more homelike and less institutional. Hasn't any headway been made?

Dr. Schwarz: As long as the industry is regulated the way it is, I think we'll remain very far from achieving that goal. As of 1987, the birth date of OBRA, long-term care has been the most regulated industry in the country. Those regulations force us to create "creatures" we don't like - and when we do want to provide a better environment, we're forced to venture into the world of waivers. In my mind, this system is nothing short of ridiculous: we create regulations in order to get waivers in order to create the environments we'd like to have to begin with.

There are, however, some positive strides being made in some settings, specifically assisted living residences that are modeled after facilities in Europe.

Bruck: How do those other models differ from ours?

Dr. Schwarz: First of all, the rooms, which, in many cases, are actually suites or units, are private in the true sense of the word. In Denmark, for example, small apartments open onto residential hallways rather than double-loaded corridors. All the amenities are much more residential than what we're used to seeing.

A case in point - people are not only permitted to bring in their own furniture and belongings, there is space built into the facilities for them to do so. In my travels, I visited a number of facilities in which people who didn't need hospital beds had brought in their own beds from home. If a hospital bed is someday needed, it is provided by the facility. Surrounding yourself with your own belongings, especially your own bed, is a great source of comfort and security, and goes a long way toward making a new environment a real home.