INSIGHTS PIECE – Penny Spiers | Design Principal
COVID-19 is currently presenting unprecedented, life threatening challenges to aged care providers, their staff and residents.
As a designer who has spent many years designing landscapes for health and aged care facilities, I can attest to how a great, green space for refuge can positively impact the sense of loneliness and social isolation that is often felt, at the best of times, by many residents who live in aged and health care facilities.
However, now things are exacerbated with the onset of COVID-19, further significant changes to residential health care communities have required residents, operators and their staff to accept and manage the personal, social and potential health impacts differently – and it cannot be ignored.
It is an unfortunate situation that the social isolation and activity restrictions implemented will have negative consequences for the health and wellbeing of the residents they are serving to protect. The innate human need for social interaction and connectedness, alongside access to outdoor green space, is essential for good health, longevity and combating loneliness and depression.
Pre COVID-19 research revealed that nearly 17 per cent of Australians over the age of 65 experience loneliness (Relationships Australia, 2018) and with more than 4 million Australians falling into this age bracket, this already presents a major health issue. Self-isolation could exacerbate loneliness and depression, both of which have been linked to poorer health and higher death rates.
There are distinctions between social isolation and loneliness; social isolation is having minimal contact with others, whereas loneliness is characterised by negative feelings due to a lower level of social contact than desired (Peplau & Perlman 1982). The two are not necessarily linked – a person in social isolation may not be lonely or someone well connected may still suffer from loneliness.
Loneliness is surprisingly common even amongst younger people – 51% of Australians reported feeling lonely for at least 1 day each week (Australian Psychological Society 2018). Relevant to the COVID-19 pandemic, disconnection from community and dissatisfaction or concern about a person’s current financial situation are serious risk factors for loneliness, (Relationships Australia 2018; Baker 2012). The impact of loneliness has been well documented; being linked to premature death (Holt-Lunstad et al. 2015), poor physical and mental health and dissatisfaction with life.
Similarly, social isolation can lead to premature death, poor mental and physical health, mental illness, emotional distress, suicide, the development of dementia, smoking, physical inactivity, poor sleep, high blood pressure and poorer immune function (Holt-Lunstad et al. 2015). The risk of premature death associated with social isolation and loneliness is akin to the risk of premature death associated with obesity.
Under normal circumstances family engagement and visitor levels vary greatly in aged care facilities, dependent on a range of factors. Consequently, tackling social isolation and loneliness has been a key focus for aged care providers for many years, where residents, without the means to form relationships in the same way they would in the outside community, are offered greater support. A number of strategies for combating loneliness and isolation have been in practice for a while; whilst some new and innovative responses have materialised during the COVID-19 pandemic.
Access to a courtyard, a view towards green space or a garden outlook all contribute to improved health and wellbeing for residents in aged care. Design responses range from communal open spaces, private courtyards off independent living unit’s (ILU’s), secure (dementia) courtyards and Juliet balconies that afford immobile or bed-ridden residents wide views to open space to provide a sense of being outdoors.
Many facilities are already well prepared in this regard both in terms of open space provision and ensuring residents get daily access to sunlight and fresh air outdoors, and whilst social distancing probably suggests some scheduling of resident’s times spent in open space, largely, access to green space could continue as a relief from isolation.
Pets are known to provide companionship for people at risk of loneliness. Pet ownership in Australia is quite high (around 60% of households, 2016), mostly comprising dogs or cats, often referred to as ‘part of the family’. Under normal circumstances, pets also increase social contact through regular outings walking a dog or trips to the dog park, particularly if your dog (like ours) has a sizeable social network that spans multiple dog parks and quite a large number of trees.
In an aged care or retirement setting during social isolation, companion animals would help to inject some happiness and comfort for residents and pet owners, alleviating feelings of loneliness and concern. Our next door neighbours have sent notes to us under their dog’s collar, via a shared ‘beer gate’ in the past. Who’s to say a dog can’t be used in the same manner in a retirement facility?
Overcoming social isolation, some inspiring stories have started to emerge for how aged care providers, their staff and residents are dealing with social isolation. We have seen street or end of driveway parties happen, where residents pull out chairs and bring food and drinks, enjoying music and being out with friends and neighbours whilst adhering to social distancing rules.
Entertainment (musicians and performers) being brought in by operators, located in a central open space and residents in adjacent ILU’s singing and dancing “together” on their own balconies. Other providers have started adapting board games to be played from a distance and installed games on the televisions in resident’s rooms. At a basic level, playing music or old films to evoke memories and bring some level of nostalgia and familiarity may bring comfort during periods of isolation.
One of the first lessons in design at university that has always stuck with me, is the concept of ‘prospect and refuge’ – that is, being in a place where you felt a sense of refuge, whilst still being able to overlook the wider area or lay of the land. It’s something many people seek out in our outdoor spaces without probably recognising it, particularly if they are alone, and likely stems back to feelings of personal safety whilst maintaining a level of privacy.
Designing for prospect and refuge, for individual reflection, for spaces to sit alone and recuperate, eat or read, can manifest itself in a simple bench seat, prospect achieved through an elevated position, refuge achieved through a garden bed or hedge behind and perhaps to the sides of the seat. It is something I have tried to provide in most outdoor settings including aged care spaces, and these separated seating areas would now serve to achieve the separation required, but still allow residents to feel like they are part of the greater setting, especially if they can see other people from either within their community, or people utilising the streets or public spaces beyond their fences. Even though they are not directly interacting with each other, the sense of seeing and being seen is enough to combat loneliness and isolation.
Exercise or engaging in an active or passive activity – the increased volumes of people pounding the pavement, or riding their bikes in my neighbourhood alone is evidence of people’s desire to be outside, getting some fresh air and keeping healthy and active.
In aged care and retirement facilities, this has been a focus for a long time, particularly to address the issues of movement and exercise to prevent / address limited mobility and incorporating regular exercise or activities for mental health and overall wellbeing. Designed elements to support activity or exercise that individuals could partake in include pathway loops, activity tables and bench seats, edible gardens with tools/water at hand, flexible outdoor shaded spaces for gentle stretching or yoga. Other facilities, such as pools, bowls rinks, bocce or fitness stations would be available in some centres, however current restrictions for use and access would need to be considered.
These design principles are transferable across a multitude of private or public open spaces; whether we are working for private clients or on public projects, as landscape architects we have an obligation to champion design led responses that will help tackle many of the challenges that face our communities such as those brought about by the COVID-19 isolation measures. We need to be advocating for, amongst other things, healthy communities and the key role that open spaces play in community, physical and mental health, and wellbeing.