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Ryan Schwartz: The title of this session is Unexposed, co-creating new models for care, community wellness and dignity. So what does that mean? I think that’s kind of up to us as a group. We’re going to be discussing these kinds of problems and questions. So maybe by the end of this session we’ll kind of have an idea and answer to that question. But the goal for today’s chat from the OAA’s perspective was to have a discussion about long-term care and how that relates to the facilities themselves, the experiences of the users and the staff, and also the regulations and the policies, the decisions that get made at the top and end up affecting us as architects and how we work and ultimately the people that really live in those buildings.
So the format of this session, as mentioned, we’ll get the ball rolling up here with a few questions and then we’ll have a little breakout session where we can get into some small groups, discuss some questions that we’ll provide, and then we’ll come back as a group and discuss those together.
So, just to make sure everyone is awake and ready to go here, with a show of hands who has worked on a long-term care facility or a retirement home nursing home in their professional career? Just out of curiosity. Quite a few, actually. OK. That’s probably about half the audience. And then another show of hands. How many people here have at least spent time in a long-term care facility visiting friends, families, visiting grandma, that kind of thing? OK. Almost everyone. And who here plans on spending a portion of their life living in a nursing home? No one. OK. That’s a trick question because that should be basically everyone here. Right? And as a follow-up to that, then, assuming everyone here does have to spend some time in a long care facility, with a show of hands who is excited about living at a nursing home? One person. One. He likes playing bridge, I bet.
So that just kind of paints a picture. It’s an important topic because it really does affect everyone. We’re all going to essentially live in a long-term care facility at some point, fingers crossed, but no one is excited about it. Right? So there’s obviously some room for improvement – some serious room for improvement. And luckily we’re joined by four experts here today. Let me introduce our guests.
So we have Dr Terri Peters. She’s an assistant professor at the Toronto Metropolitan University, department of architectural science, where she teaches and supervises graduate students in both the architecture and building science programs. Dr Peters is a registered architect in the UK. She holds a WELL AP designation and is a member of the 2021 WELL concept advisory for lighting. Her current research focuses on building performance in health environments pre and post occupancy evaluations and the intersections between architectural quality and inhabitant quality of life in long-term care homes. She’s an affiliated researcher at the l'Institut du Savoir Montfort in Ottawa – pardon my French – and she’s authored and edited numerous publications including more than 20 peer-reviewed publications about sustainable housing, and she was part of the jury for the OAA’s shift 2023 health and architecture challenge.
We also have Tamara Daly – pardon me – Dr Tamara Daly who is a feminist political economist and health services researcher and professor at York University. She’s the director of the York University Centre for aging research and education and the social sciences and humanities research council partnership for age-friendly communities. Her research focuses on gender, health access and outcomes, improving conditions in long-term care – long-term residential care and promoting policies for health equity for older adults and their caregivers. She’s authored more than 100 publications and received numerous awards including the faculty of health dean’s research award, the Canadian Institute of Health Research and Mental Health Commission of Canada People’s Choice Award.
Next we have my Mike Ladyk. He’s a partner here at a local studio, 3rdLine.Studio in Sudbury where he’s worked since 1995. Over his 22-year career Mike has successfully completed numerous projects across a range of sectors including commercial, industrial, institutional, First Nations and residential. Notably Mike was involved in the redesign of the Wikwemikong Elders Lodge and Manitoulin Island, where he worked closely with the Wikwemikong First Nation to create a culturally appropriate design that addressed the community’s needs. In addition to his professional work Mike is also an active member of several local boards reflecting a commitment to the community here in Sudbury.
And we also have Nicole Pearce. She’s an architect and a graduate of the University of Waterloo’s architecture program. She previously worked at HOK and KWC architects on large scale public renovation projects. In 2010 she founded the design firm Architecture and C to foster collaboration and communication between clients and contractors. Nicole’s personal experience as a caregiver for her parents led her to focus on creating environments of care and proposing a new person-centred architecture that empowers architects to speak for the value of architecture and the spaces of people’s lives.
So to kick things off and kind of frame this discussion, I thought it was important to kind of start with some broader themes in terms of long-term care. So the first point here that I wanted to bring up was: what should we all expect, ourselves and for other people, when dealing with the final stages of life? Like, what values and priorities are important when considering long-term care? Who wants to jump in first?
Mike Ladyk: I think this is on. Can everybody hear me OK? I think one of the comments that we were just talking about before the conference here started was – and it’s just [really a? 00:05:54] statement – long-term care isn’t a place to go and die; long-term care is a place to go and live. So how do we do that? Right? And, you know, we started talking about that and it just kind of spurred on a whole lot of discussion.
And it’s interesting when you start looking at that because we oftentimes put ourselves or should be putting ourselves in our own buildings. And I know that sounds strange in a way. But what we found over the past is that, you know, buildings are designed without any real consequence to the end user or any regard for the end user. So in the case of Wikwemikong, for example, we’ve had a variety of consultations. We meet every two weeks and it’s been awesome.
We just – unfortunately they had an incident in the community yesterday. We were supposed to have a public consultation with the actual community. But we had one recently which was quite – it was eye opening in a lot of ways. We actually did a consultation with the residents. We had a dining room and I’m not sure if a lot of you are familiar working with First Nations but First Nations sometimes you can have people as young as 45 in a long-term care facility. So it’s not just for 80-year-olds and we have the stigma with people with problems and things like that. That’s not actually true.
So it was really engaging and we had a lot of really good discussion and a lot of good takeaways from that that informed the design process. And the process itself has been really good because we’ve been able to take some time to go through it. It hasn’t been a rush.
We started the feasibility study I think in 2017. So we’ve done a lot of work with the community over the years. The pandemic put a little bit of a sidebar to it. But a lot of good things. Things like, you know, there was this one incident that was kind of funny – not funny – but we started talking about the landscape plan for the project and how the where the facility was going to be and of course the orientation and the cardinal points and things like that. But a lot of the residents in Wikwemikong is pretty dynamic. They actually had this outdoor performance but they really have nowhere to do that at the nursing home. So they did it in the parking lot right out front of the nursing home. So they had a live band and they had – it was rock and roll that was pretty cool and I saw the video and it was just – it was amazing.
So they had all the residents out there in this parking lot and people would be walking by on the sidewalk and those people would come in and they’d join the barbecue, listen to the music and things like that. And everybody that we were talking with in that room couldn’t stop talking about that. It was engagement. It was life. It was being a part of the community.
Another portion of that was the location of the building, for example. Sorry I’m rambling here a little bit but, you know, a lot of the people said, well, how come you didn’t locate it with a big view? Well, you talk to the residents; they don’t want a big view. They want to be engaged. They want to be in the community. I think we had about 10 or 15 different comments that loved the fact that I could walk to the hardware store. Because some of them, again, they’re not bedridden; they’re living. They need a place to live. So a lot of this is also some form of social housing as well.
But that’s kind of where we started so I don’t want to take up all the mic time.
Respondent 2: I think it’s important to consider the long-term [care? 00:09:24] home as a place that’s part of the community. So often it’s walled off from what other people in the community are doing and it’s not a place that’s seen as terribly accessible.
One of the things that we were talking about is the way in which the ministry regulations stipulate what has to be logged, who can access what, and there’s certain good reasons for some of that. But I’ve been to long-term care homes around the world and not everybody thinks about long-term care the way we do in Ontario. And in particular lots of places, and I’ll think about – I’m thinking about Norway here in particular – they see the long-term care home as a place to bring the community. So the library is collocated with the long-term care home. The local pool. The gym. A place for young children to come and practice their ballet lessons and kids come for their clubs. There’s always constant movement in and out.
One of the things that we learned as well is we tend to think of giving people very, very nice views and lovely views. Your conversation about the parking lot reminds me that in some long-term care homes the most popular rooms are the ones that overlook the parking lot. And there’s a good reason for that; it’s because people go there to live and they also want to see other people living. So people coming and going into the long-term care is one of the most, you know, the best views that you can have in the facility.
And the last thing that I would say is not only is it a place for living but it should also be a place for joy. So dignity, yes, but also joy and flexibility. So this idea of using the parking lot. There’s lots of ways that we should be thinking about being able to flexibly use space so that it can be creative.
Nicole Pearce: I support everything you guys have said. My mom had Alzheimer’s so we didn’t actually use long-term care for very long; we tried it for a few months. So she’s one of these needs-based residents. But I think that what I saw, and this includes the people who are working there, we’re entrusting them with this huge burden and responsibility but we don’t recognize their humanity in the process.
When you’re coming to your third job for the day you need to be able to have a space for yourself to recuperate and recover before you engage in supporting the needs of the people that are there, and we don’t think in terms of the people. We don’t really seem to understand what the needs are either. I think partly because we’re trusting that others are giving us those – that information, that they understand what the needs are, and you get handed a program and what we’re really doing is relying on them to say that their resource management problem or their scheduling problem is the most important thing and they’re using a spatial relationship to solve it. But that really is our expertise. We should take back that role where we understand people’s needs and their relationship to their environment. And when something is not working we understand how that environment can shift or change or respond in order to support their needs.
One of the legacies of person-centred learning was person-centred care, which recognized that behaviours and issues like you were saying wandering, and so policy says lock it off. But that comes about because of an environmental condition. And if we understand the needs that are at the heart of that, the need for a sense of safety, a sense of belonging, then we can actually provide those options. Instead of thinking of function we can think of the activity at the centre.
You know, like, a meal is about nourishment and pleasure and connection but you get a functional program that says design a multi-purpose space because, and I’m paraphrasing what I’ve heard, I have $9 a day to feed these people and I only have this much staff. So I got to wheel them in twice a day and if they eat that’s great; if they don’t that’s too bad. And that is a baked-in understanding of people’s needs and movements that even if you design the most beautiful multi-purpose space it’s not going to provide the activity at the centre which is nourishment to most of those residents.
So when we talk about dignity we’re really saying what do you expect at the end of your life? I expect to be treated like a human being with human needs – the need to belong, the need to have meaning, the need to have relationships, and how can we actually nourish that and nurture it through our response to that? We do have a place. We are very necessary.
Even recently I was in a hospital and I took a picture of the signs there. You know? No abuse is tolerated. Because when you see those signs that’s a sign that failed – that space has failed, right? Because it’s nurturing the wrong behaviour from us. It’s nurturing dehumanization, dissociation. There were signs that said we see you, you’re on camera, go this way – with arrows. You know? These are signs that tell us that we’re not actually considered in that space. But the women who gave me permission to take the pictures were so relieved to feel like someone saw that what they were enduring working there was also not OK.
And I think for us as architects we really we need to believe in the significance and necessity of architecture and the wellbeing of people’s lives because if we’re not speaking for it then who do you imagine is actually going to do that? Right? So that’s –
Respondent 4: I think building on these points it’s also designing spaces that we want to visit. So we’ve – I think it seems like everyone in the audience has visited someone in long-term care, been in that role where you’re trying to socialize there. Maybe you’re trying to bring little kids there or you’re trying to talk to and visit with the person that’s living there. We often don’t design those spaces as places that people would want to visit. So maybe the long-term care home isn’t in a location that’s convenient. Maybe it is sort of not connecting well with the street and the kind of environment. So collocating it is such a wonderful idea.
And I agree we – there are many examples from around the world. Also thinking of several projects in Chicago that have a library collocated with seniors’ housing and I believe also long-term care. But I think bringing more – the building into the community. And I think that must be frustrating for architects who put up their hands that they’re working in this type of project where you don’t get to choose the location. You don’t get to choose the connection with the community. So how can you design a building that will somehow make those connections or improve the connectivity of the building to the community so that it’s somewhere we want to visit, so that it’s somewhere we want to take our kids or could we come by with the dog. Or is there any way we can connect to people walk around the grounds, go for a walk, sit by the fountain. Connecting to other people.
Respondent 2: It’s also about size. So there’s this emphasis on making sure that the units are bigger and bigger. And in fact the most homelike environments tend to have fewer residents who are located around a space that’s akin to a great room. And in some of the best places where I’ve been there are long wooden tables that people might gather to eat.
In Germany, in the one home I’m thinking of, there were big bowls of fruit and big pitchers of water everywhere; you’d never see that in an Ontario long-term care home. I’ve seen it in Nova Scotia as well.
So there’s different models; sometimes these are referred to as household models. But it’s a place that is more comforting and residents naturally want to congregate in these spaces. It then becomes more – there’s a kitchen generally associated with it, so it enables dining that is more akin to people’s natural flows. As people age the time that they’re awake and tired is different. Some people need to sleep quite late in the morning. So being able to prepare small meals in a kitchen that is on the unit makes their lives toward the end much more pleasant and it enables them to be able to not be forced to get up and to get into the dining room quickly.
So part of reimagining how we do long-term care is about thinking about how the space could be one where it’s possible for people to come together and to actually want to spend time together, so it’s not alienating in that way.
Ryan Schwartz: Sorry. I just going to say, Nicole, you mentioned policy and I think that’s an important thing to bring up and how that relates to these decisions that are made at the top and it’s – it all trickles down. And then trying to reconcile that with humanizing these people. So how do we bring those two together or bridge that gap?
Mike Ladyk: That’s a tough one. And it’s that slow oil tanker moving in the sea, right? And I think it can happen, you know, with every little – so we’re very fortunate right now. So we’re partnered with Snyder architects out of Toronto. Working closely with Rochelle and Doug. And I think Doug is one of those champions that have been slowly breaking down that that long-term care model. He calls it the lodge model and we’ve kind of adopted that in a lot of our work working with them.
So we’ve got a 96-bed to [unintelligible 00:19:53] full circle here, but. So we got a 96-bed facility that’s broken down into three wings of 32 that’s broken down again into six wings of 16. And each one of those wings doesn’t have a big, long corridor that, you know, it’s a bowling alley right down to the end. It’s got a unique sort of set of private rooms, a centre core that you can walk around with a lounge at the end, an activity space, a small home kitchen and a dining facility for – [audio ends]
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