Residential Satisfaction, Psychological Well-Being and Perceived Environmental Qualities in High- vs. Low-Humanized Residential Facilities for the Elderly

The rapid aging of the global population, represented by the number of about 901 million over-60 year olds worldwide (Global AgeWatch Index, 2015), has dramatically increased the risk of health problems in older adults (World Health Organization, 2013), thus enhancing the need for long-term care in this population (Cavrini et al., 2010). Current European policies on housing for the elderly focus mostly on remaining at home for as long as possible, even though both the decline in health and the lack of an informal network of assistance might transform one’s home into a confined and unsuitable place (Del Aguila, Cox, & Lee, 2006; Rubinstein & De Medeiros, 2004). Thus, alternative solutions, such as relocation to a long-term facility, need to be considered.

Doubtless, relocation may provoke a complex and stressful experience having both cognitive and affective implications, especially for older people and particularly if the relocation concerns a residential healthcare facility. In spite of the general older adult preference for remaining in the familiar context of their own home (Callahan, 1992; Scanlon & Devine, 2001), some studies have shown the positive effects of relocation on elderly quality of life, especially in the areas of autonomy and social relations (Nygren & Iwarsson, 2009; Oswald, Schilling, Wahl, & Gäng, 2002). A residential facility could allow both maintenance of previous relationships with significant people, such as parents and friends, and facilitation of positive affective bonds with the new context of life, including its spatial-physical aspects. In this regard, as reported in the literature (Cesta et al., 2007; Löfqvist, Slaug, Ekström, Kylberg, & Haak, 2016; Scopelliti, Giuliani, & Fornara, 2005), assistive technology plays a key role in facing impaired visual and auditory senses and reduced capacity in autonomous ambulation, in order to improve personal independence, safety, and perceived well-being (Crews, 2005).

Residential facilities for older people may differ in various aspects, such as the level of care, social and caregiving support, physical features, and accessibility (Fornara & Manca, 2017). Studies were carried out in order to identify which home characteristics can be considered to be good predictors of residential satisfaction in older persons (Prieto-Flores, Fernandez-Mayoralas, Forjaz, Rojo-Perez, & Martinez-Martin, 2011), or rather to detect relationships between residential satisfaction and “objective” attributes of the environments at different age stages (Carp & Carp, 1982; Christensen, Carp, Cranz, & Wiley, 1992). Regarding the latter, residential satisfaction is an example of a “subjective” measure, because it relies on self-report tools through which the individual expresses her/his own perception or assessment, whereas “objective” measures involve tools of technical disciplines or expert ratings (Fornara, Bonaiuto, & Bonnes, 2006).

Specific tools were developed for measuring perceived quality of urban neighbourhoods (e.g., the PREQIs, Perceived Residential Environment Quality Indicators: Bonaiuto et al., 2015; Fornara, Bonaiuto, & Bonnes, 2010) and healthcare settings (i.e., the PHEQIs: Perceived Hospital Environmental Quality Indicators: Fornara et al., 2006; Andrade, Lima, Fornara, & Bonaiuto, 2012). Each of these indicators is represented by a set of items concerning the subjective assessment of environmental quality attributes, of either a spatial-physical or social-relational nature.

Regarding the physical attributes of buildings, they seem to be relevant in determining residential satisfaction (Aragonés, Amérigo, & Pérez-López, 2017; Cerina, Fornara, & Manca, 2017). However, psychological well-being and satisfaction toward one’s own home seem to be largely influenced, especially in older adults, by the possibility to choose where to stay, to reach a person-environment fit (Carp, 1987; Safran-Norton, 2010), and to control the environment by reinforcing personal autonomy (Hwang, Cummings, Sixsmith, & Sixsmith, 2011). Regarding the latter, the perception of poor control over the environment, which often characterizes hospitalization or institutionalization experiences, may provoke a range of physiological effects in the user, such as an increase in blood pressure and performance reduction of the immune system (Ulrich, 1991).

A relocation aimed at improving health (or a general enhancement of well-being) is likely to be ineffective if the residential structure’s design features fail to support the users' requirements. This assumption is mirrored by an increasing attention, in the field of healthcare design, toward the evaluation of those environmental features supporting the particular needs of the users. In this regard, following a “user-centered” design perspective (Gifford, 2002), the organization of healthcare and residential settings should aim to improve those physical spaces that are perceived as inadequate, in order to reduce users' stress and anxiety, to improve their level of residential satisfaction, and to promote, by this means, health processes. With reference to the older population, an improvement in life quality is often associated with i) greater autonomy in behaviors such as dressing and eating, ii) the reduction of time spent in their own room, and iii) a simultaneous increase in time spent walking and in social interactions (Fornara & Manca, 2017).

The promotion of a friendly atmosphere - similar to the home environment - in healthcare and residential structures, taking into account both sensory limitations and the fear of getting lost often found in older adults, may produce positive consequences and improve those skills that help to carry out the normal tasks of everyday life (Landefeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995). Such effects are connected with the setting’s design “humanization”, i.e., a construct that refers to the satisfaction of psychological needs of specific categories of users, concerning spatial and sensorial comfort, social interaction, orientation, perceptual consistency, control over space, clear affordance, sense of welcome, privacy, and restorativeness (Fornara et al., 2006). In order to fulfil these needs, design fallacies that should be avoided include a lack of clues for orientation, low degree of personal space, excessive noise, the presence of unpleasant smells, inadequate temperature and ventilation, a lack of views of green spaces, and poor or excessive intensity of artificial lighting (Fornara & Andrade, 2012). This latter feature is prominent for institutionalized elders, since they are often forced to spend a lot of time indoors and are exposed to specific pathologies such as cataracts, glaucoma and senile miosis (Schweitzer, Gilpin, & Frampton, 2004). Regarding the importance of green views, their influence - both from the outside (e.g., gardens) and from the inside (e.g., indoor plants, pictures of natural landscapes on the walls) - on health outcomes has been largely evidenced within the restorativeness literature (Staats, 2012), also with reference to healthcare (Ulrich, 1984) and residential settings (Wells & Rollings, 2012).

Following these premises, interventions that have proven to be useful are “de-institutionalization” of the environment (e.g., removal of barriers or other visual impediments, introduction of carpets in corridors, the possibility to personalize room spaces in order to increase the sense of continuity in their life, allocation of areas for carrying out activities such as cooking or art), an increase in perceptive clues that make orientation easier, continuity of paths, access to external spaces such as gardens and other green areas, and the design of areas for socialization and recreational activities (Ulrich, Zimring, Joseph, Quan, & Choudhary, 2004). Regarding the latter, these spaces seem particularly relevant for the older population, since significant relationships have been found between “active” aging (i.e., where elders are engaged in leisure activities) and positive outcomes in terms of health, self-esteem, self-fulfillment, feelings of freedom, social contacts, and personal well-being (Booth, Owen, Bauman, Clavisi, & Leslie, 2000; Coleman & Iso-Ahola, 1993).

Method

Results

Findings of preliminary analyses showed no significant influence of socio-demographic and users’ experience in the facility on Residential Satisfaction and Psychological Well-being, except for Gender and one’s own vs. others’ choice. Specifically, women appear more satisfied than men, F(1,111) = 4.66, p < .05, and one’s own choice to move to a residential facility is positively associated with both Psychological Well-being, F(3,110) = 3.74, p < .05, and Residential Satisfaction, F(3,110) = 2.84, p < .05.

Regarding H1, significant differences between high- vs. low-humanized facilities emerged for all the dependent variables, except for the Views and Lighting factor (see Table 1).

More specifically, older residents of high-humanized facilities showed a significantly higher perceived quality in Orientation, F(1,111) = 57.48, p < .001, and Comfort, F(1,111) = 34.74, p < .001. Significant differences also emerged in perceived quality of Socio-relational Features, F(1,111) = 5.53, p < .05, that is, higher in high-humanization facilities.

For other psychological responses, older residents in high-humanization structures expressed both a higher Psychological Well-being, F(1,111) = 7.58, p < .01, and Residential Satisfaction, F(1,111) = 5.53, p < .05, than older residents in low-humanization structures.

Regarding H2, that is, the relationships between perceived environmental qualities and the molar psychological responses, the results are shown in Table 2.

The correlation matrix showed a general picture where perceived environmental qualities were significantly related to the other psychological responses. More specifically, Orientation and Comfort were positively related to both Psychological Well-being (respectively, r = .43, p < .001; r = .26, p < .01) and Residential Satisfaction (respectively, r = .47, p < .001; r = .38, p < .001), but no relationship emerged with Views and Lighting, which is significantly related only to Comfort. Thus, the higher the perceived comfort and orientation, the higher the perceived well-being and satisfaction toward the facility. The correlation matrix showed a similar pattern of relationships between perceived quality of socio-relational features and the other psychological responses. In fact, Socio-relational Features were positively related to Psychological Well-being (r = .35, p < .001) and Residential Satisfaction (r = .56, p < .001). Thus, respondents with a better perception of socio-relational attributes in the facility felt higher levels of well-being and satisfaction toward the facility.

Moreover, Socio-relational Features were positively related to both Comfort (r = .57, p < .001) and Orientation (r = .47, p < .001), whereas no significant association emerged with Views and Lighting (r =.17, p = ns). The correlation matrix also showed that Residential Satisfaction was positively related to Psychological Well-being (r = .53, p < .001).

Regarding the results of the two multiple regression analyses, the first, with Residential Satisfaction as a criterion and perceived environmental qualities as predictors (R² = .38, p < .001), controlling for Length of Stay, showed a significant weight of Orientation (ß = .28, p < .01) and Socio-relational Features (ß = .43, p < .001), whereas both the other predictors and the covariate were not significant. The second one, with Psychological Well-being as a criterion and perceived environmental qualities as predictors (R² = .22, p < .001), controlling for Length of Stay, produced analogous results, since again Orientation (ß = .37, p < .001) and Socio-relational Features (ß = .21, p < .05) were the only significant factors. It should be noted that, given the high intercorrelation between Comfort and, respectively, Orientation (r = .57) and Socio-relational Features (r = .57), it is not unlikely that the emergence of the two significant predictors could have suppressed the possible effect of Comfort.

Discussion

The purpose of the current study was to analyze the relationship between residential facilities showing different levels of design quality and psychological responses of older users who have experienced them. Specifically, assessments of older people living in low-humanization vs. high-humanization residential facilities were compared. Such assessments concerned both specific environmental qualities (i.e., comfort, orientation, views and lighting, and socio-relational features) and more general patterns, such as satisfaction toward the residential experience and psychological well-being.

On the whole, the research findings confirmed the hypotheses of the study.

Firstly, the outcomes highlighted a substantial congruence between ‘‘expert’’ (or “technical”, or “objective”) evaluation, based either on objective physical measures or on expert judgments, and “lay” (or “observational”, or “subjective”) evaluation, based on either users’ observations or on users’ perceptions (see Fornara et al., 2006). Confirming H1, the more a facility responds to criteria of high-humanization, the better the older users’ perceived environmental quality related to different attributes. Older residents in high-humanized structures also expressed higher levels of both psychological well-being and residential satisfaction than older residents in low-humanization structures. These outcomes confirm previous evidence that emerged for healthcare environments (e.g., Devlin, 1995; Fornara et al., 2006), and represent further support for those claims stressing the importance of design features for users’ well-being and place satisfaction (Evans & McCoy, 1998; Nagasawa, 2000).

Furthermore, as hypothesized, specific perceived environmental qualities were related to the molar psychological responses of older users (H2). In fact, in line with results of other studies (Ulrich et al., 2004; Schweitzer et al., 2004), significant positive correlations emerged between elders’ psychological well-being and perceived environmental qualities, in both spatial-physical and social-relational terms. In other words, the better the perceived quality of spatial-physical features (e.g., way finding and sensorial comfort, adequacy of temperature and ventilation) and socio-relational features (e.g., the possibility to have positive social interactions, relationships with other residents and the staff), the higher the psychological well-being of older residents. Similarly, perceived environmental features also emerged as positively related to satisfaction toward the elders’ experience in the facility. Therefore, an improvement in the quality of features concerning the design of the residential community environment can have a positive role in both users’ satisfaction (Fornara et al., 2006) and their psychological well-being, which are fundamental antecedents of “successful aging” (Steverink, Westerhof, Bode, & Dittmann-Kohli, 2001). In this regard, the creation of a friendly atmosphere similar to the home environment (Anderson, 2011; Cerina et al., 2017; Leith, 2006) and the promotion of positive relationships with both the staff and other residents may contribute to reducing the negative and stressful impact of a relocation (Booth et al., 2000; Nygren & Iwarsson, 2009). In fact, it seems fundamental to help elders in their elaboration processes of adaptation to a new environment, in order to reduce, as much as possible, threats to both their identity and their sense of continuity (Brown & Perkins, 1992).

A further interesting result is the positive relationship between the quality of comfort and orientation and social-relational aspects, that is, the higher the degree of design humanization, the better the perceived quality of social and relational dimensions. This association could be due to a mutual bi-directional influence (Fornara et al., 2006). In other words, attention toward design features would reflect an overall consideration for older users’ well-being, also expressed by the organizational and relational climate. At the same time, a good design would facilitate the functioning of the facility management and, consequently, increase older users’ well-being and satisfaction.