Assessing the Value of Outdoor Space in Nursing Homes: A Case Study for Athens Geriatric Home (Greece) Vissilia, Anna-Maria, North Dakota State University, Department of Architecture and Landscape Architecture, [email protected] Porfyraki, Theodora, Agricultural University of Athens, Laboratory, [email protected] Papadopoulos, George, Agricultural University of Athens, [email protected] ABSTRACT This study investigates how the outdoor environment at the Athens Geriatric Home is experienced by its residents and staff. Results are used to gain knowledge with implication for landscape design. The aim is to raise awareness of the role that the outdoor environment plays and how this affects experience and use of elderly people living in care facilities in Greece. Access to green outdoors is widely documented in an increasing number of studies to have multiple physical and psychological benefits on humans in a number of international case studies. However, the evaluation of outdoor space usage as an important component to improve health and quality of life at Greek senior care settings is still given no attention and there is no record of research on environmental preferences of outdoor environments at nursing homes. In Greece, long-term geriatric care services not only are dramatically few in number but also are reported to having Issues of lack of outdoor space, underuse, and poor maintenance. Very few of Greek elderly people are privileged to access and enjoy an outdoor environment, even if it is not successfully designed. In this context, the authors conducted a pilot research on the Athens Geriatric Home situated in the urban core of Athens, the oldest one in Greece (1873), in order to collect information on size, placement and quality of green spaces, using the Seniors' Outdoor Survey. The study is based on literature review and data assessment, collected from responses of both residents and staff. Keywords: Outdoor environment, gerontology, landscape architecture, elderly people, environmental assessment The authors are solely responsible for the content of this technical presentation. The technical presentation does not necessarily reflect the official position of the Council of Educators in Landscape Architecture (CELA), and its printing and distribution does not constitute an endorsement of views which may be expressed. Citation of this work should state that it is from a CELA conference paper. EXAMPLE: Author's Last Name, Initials. 2019. Title of Paper. Sacramento, CA: CELA. For information about securing permission to reprint or reproduce this paper, please contact CELA at [email protected] CELA 2019 | UC Davis 522 INTRODUCTION The value of outdoor space in seniors housing For thousands of years, spending time in natural surroundings has been assumed to have a positive effect on human health (Stigsdotter & Grahn, 2002). Plants and landscapes can enhance human well- being by causing positive physiological and psychological responses, which affect human behavior (Relf & Lohr, 2003, Cox et al., 2004, Detweiler et al., 2008, Murphy et al., 2010). Researches show that nature plays an important role in the mental, emotional and physical health of the elderly and helps them recover better from illnesses such as blood pressure, heart problems, stress, soreness, dementia, absorption of vitamins, mental fatigue, as well as reduce any possible fall incidents. Outdoor areas in retirement communities and homes for the elderly have been found to be an important component of elderly’s well-being, satisfaction, improvement of mood and quality of sleep, and increase of life expectancy, especially to those with disabilities or mobility problems (Talbot and Kaplan, 1991, Browne, 1992, Stoneham & Jones, 1997, Takano et al., 2002). A garden can cause a sense of distance and excitement, thus distracting the elderly from pain (Melzack, 1996), simply by looking at a sunset, snow patterns, or listening the sound of the leaves when they are moved by the air whereas exposure to sunlight has been shown to have an effect on the diurnal rhythm, bone growth, vitamin status, etc. (Kuller & Kuller, 1994, Kuller & Lindsten, 1992, Kuller & Wetterberg, 1996) and in most cases, the outdoors air is of better quality than air indoors, even in heavily trafficked urban areas (Bramryd & Fransman, 1993, Grahn, 1991). Moreover, contact with nature causes excitement to recall memory and develop sociality. The visual appeal of nature is important for encouraging the elderly to walk outdoors. Plants trigger social interaction and networking through joint activities and provide themes for conversation (Erja Rappe, 2005). They could also contribute with a significant improvement in the elderly's satisfaction and an increase in communication amongst them (Oguz et al., 2010), as well as a decrease in the perception of loneliness and provide an increase and a change in their daily activities (Mimi Mum Yee Tee, 2008). Finally, people exposed in open air areas had lower scores in terms of anger, aggression, and fear, than those exposed in an urban environment (Ulrich, 1999). Design issues of outdoor space in seniors housing The main reason why many elderly people rarely or never visit outdoors spaces in care facilities as they would like seems to be linked to design issues related to location, accessibility and/or attractiveness of landscape design (Iwarsson & Ståhl, 2003). In addition, a number of studies has revealed that other obstacles include physical constraints, lack of help by the staff and unpleasant weather conditions (Cohen-Mansfield & Werner, 1999; Cutler et al., 2006). The most concise report on the linkage between various design features of the physical environment and their influence on the elderly’s use of outdoor areas is that of Susan Rodiek in 2003. These features include the abundance of walkways to access outdoor landscaped areas, the substantial shade and seating along the walkways, abundant vegetation, the appearance of “a small park” and access to views looking beyond the facility boundaries, the presence of windows adjacent to out-door entries and developed areas near entries for pre-viewing outdoor spaces. Participants reported that external use was discouraged by the poor transition between indoor and outdoor spaces (for example large corridors, heavy doors), poor hiking areas and inadequate wheelchair space. Instead, they were attracted by CELA 2019 | UC Davis 523 comfortable seating areas, sun protection, pedestrian walkways, crossings, plant material, water features and pets (Rodiek, 2003). Other studies also found that problems at the doors and entrances prevent the transition to green spaces. The most common was the range opening of the doors or doors that closed very quickly. In addition, the thresholds that were difficult to access and the automatic doors made it difficult or impossible for older residents to re-enter the interior after their visits to outdoor spaces (Rodiek et al., 2014). However, little empirical investigation has been conducted to confirm residents’ preference for these features and to systematically test outdoor preferences using visual assessment methods with assisted elderly people (Kane et al., 2003). Elderly people in Greek society: role and community programs The amount of care for elderly people, constitutes one of the criteria of any society's culture. The emersion of the "third age" as a state and as a symbolic category is a sign and proof that modern societies capture and perceive their components, distinguish their members’ phases in life and distribute certain obligations and rights. In fact, “elderly people” constitute an important part of societies. Although in recent years, there has been an intense concern for this subject worldwide, in Greece statistics reflect a negative attitude towards aging. Elderly’s social role is shrinking, a phenomenon that is mostly observed in the urban environments. This numerically large social group seems to fall aside, and its role to degrade, both in society and within their families. They often feel unwanted, strangers in a world intended only for young people and rejected as non-productive individuals. Elderly people encounter many difficulties, but at the same time deal with problems related to both physical and mental health. Many become members of clubs, organizations and seek community activities and volunteerism. Some of the community programs in Greece consist of Open Seniors Protection Centers, Day Care Centers for the Elderly, Friendship Clubs, Nursing Homes Asylums and Sanatoriums of Chronic Diseases. Greece ranks among the lowest places in Western Europe (79th place) between 96 countries, with a percentage of the population over 60. In Greece, the elderly care is largely an exclusive family matter. Nevertheless, in our country 243 care units for the elderly operate. Most of them are in Attica (110), followed by Central Macedonia (29) and Crete (20). According to data from the Ministry of Health, Welfare and Social Insurance, there are now 113 nursing homes in Greece, including church and charity associations. There have also been established 20 State Chronic Illness Therapeutic centers. Their total capacity reaches 15,000 elderly people. The self-serving incidents constitute a small minority, either because elderly people nowadays contribute to the family budget with their small pension or because this small pension does not cover the cost of their stay even in an affordable unit. In Greece, the percentage of people aged over 65 is