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JDC Asks...

Mon 06 Jan 2020

JDC Asks...

Do “environmental lies” like fake bus stops and murals in care homes play an important role in delivering person-centred care or do they simply sow confusion?


In many care homes murals have been used to brighten up hallways and provide topics for conversation. However, thinking is moving away from introducing such design features because people living with dementia have said “why is it when we are at our most vulnerable, you make us more confused by making us believe we are somewhere we are not?” When we debated this topic recently at the UK Dementia Congress (UKDC), I spoke about the confusion and frustration that results from making a hallway look like a street with murals of shops or from a painted wall depicting the seaside with sound effects of waves crashing. The same goes for “bus stops” where buses will never come, or fake windows showing scenes that have no bearing on where the care home is located and where it is always daylight! These are “environmental lies”. This is not to say we should no longer create nostalgia themed rooms, yet when we do we need to make sure that the “fake” pub, cinema or shop has real function in so much as the pub serves drinks, the cinema shows films and the shop is where people can “buy” items and take them away in a basket. If a café mural is introduced it should be located where a couple of tables and chairs can be placed so drinks, cakes and savouries can be served. The mural then becomes the backdrop for meaningful activity. As a care home manager said “This has really opened my eyes! It’s true we shouldn’t be further confusing our residents with deceptive fake environments.” 

Graham Stokes is director of memory care services at HCOne


We must be honest about lying: not all lies are bad. I agree that a sweet shop with no sweets, a telephone box with no phone, a garden tearoom with no tea, or night staff always wearing pyjamas are all misleading. But, in a care home, large and costly design judgements must be made that will benefit the majority. An indoor garden room with clouds and blue sky on the ceiling, plants, comfortable chairs, activities and the option of birdsong being played can support certain residents at certain times, providing staff know the resident in detail. These are environmental lies which are in fact positive environmental untruths for different people at different times. Astroturf - clearly an environmental lie - may mean people can go outside to a space where grass cannot grow. Using door disguises everywhere is institutional poor practice, but carefully placed they will improve a person’s wellbeing.  I know of a lady who was reluctant to eat and would spend all her time caring for “her baby”. Staff decided to put a highchair next to her at mealtimes with a bowl of baby food. Now, the baby sits in the highchair, the lady offers her food and then eats her own meal, happy in her reality. Person-centred care has been defined as involving “understanding the world from the perspective of the service user.” This may require staff to enter their reality and use environmental lies to augment the care they deliver.

Lynne Phair is an independent consultant nurse



Beneath my thin veneer of confidence, I have a number of fears for my future life with dementia, one of which is the kind of care I will receive if/when I am a resident in a care home. Central to this is my wish that my person-centred care will be based on respect and truth, and delivered by well trained and honest staff in whom I can build and then maintain confidence. Clearly with dementia, one’s cognitve understanding declines but one’s emotional engagement does not, and I am fearful that in my more lucid moments the realisation that I am being lied to would greatly damage the trust and faith I have in those charged with my care. My experience of visiting care homes and discussing this issue widely, including as part of the Mental Health Foundation’s Truth Inquiry and at UKDC, is that where environmental lies are employed, they are seldom for the benefit of those who hold the same views as mine. Instead they are often in place to enable hard pressed staff to paper over the cracks in their care provision. No one affected by dementia wants to hear harsh or brutal truths, but the truth can be compassionately expressed. Staff should be trained to tell “better truths” not to work in an environment where care is based in part on lies, either spoken or environmental. Small lies in a culture, if accepted, soon form a slippery slope to bigger lies.

Keith Oliver is an Alzheimer’s Society Ambassador and KMPT NHS Dementia Envoy


Fifteen years ago mum suffered a stroke and was admitted to hospital, developing vascular dementia and needing to go into a care home. Having no awareness of dementia and with little information, I chose a home I thought would provide the best care. Now I have worked in a care environment for three years, reflecting back I see that dementia was not as well understood as it is today. In mum’s early stages, she constantly walked corridors wishing to leave by fire exit doors. No amount of distraction would deter her and she ended up being exhausted and upset. If there had been vinyl depictions of bookcases or other scenes overlaid on doors, her anxiety would have eased immensely, reducing stress levels and positively affecting her wellbeing. Mum loved to visit the cinema and a cinema room, now a part of many care homes, would have been something mum would have really enjoyed and engaged in. The experience of going to watch a film gives people pleasure and is associated with happy memories. The same can be said of having a “sweet shop” or “pub” in a care home. Although facilities are in the home, it doesn’t mean that they can’t provide meaningful experiences for residents and families. I now see how beneficial it is when we incorporate these “environmental lies”. From my own experience if it helps to give that person peace of mind and some semblance of normality in their reality, then surely this can only be a good thing.

Catherine Naj-Dyke works in care and was a family carer


After leaving the “environmental lies’ debate at UKDC to go back to my hotel, I called into a pub. Once inside I found myself in a Victorian-themed establishment, with dark panels and bookshelves with real books. After an alcohol-free drink in this pleasant atmosphere, I drove to my hotel. On the wall of my racecourse-themed accommodation, I had horses’ heads and their rear ends hanging on the walls, alongside other horsey paraphernalia. Mindful of the debate earlier I wondered how someone with dementia might perceive these two environments. I concluded that these settings had both been made interesting and stimulating by the addition of environmental lies. On further reflection, I think that residential environments should be primarily designed to meet people’s needs. But we should be more sophisticated in how we use them, working with our environments actively rather than passively. Indeed, ideally, environments should be used as therapeutic backdrops, promoting activities, memories and conversations. A good analogy is the use of the television, as it can either be merely noise pollution or a portal into a “new reality” when used actively by an engaged caregiver. Unadorned care home environments are often boring, so we need to add things to the settings to promote engagement. I believe environmental manipulations, including false windows, have their place if we use them in a more sophisticated way. The windows can be used to promote discussions during the day, while one of the residents can take pride in her responsibility of drawing the curtains each evening.

 Ian James is consultant clinical psychologist at Northumberland, Tyne and Wear NHS Trust

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