91̽»¨

Background

In sustainable cities and communities, all individuals should be able to live and participate on equal terms, regardless of physical and/or cognitive abilities, and in both indoor and outdoor environments. A recognised need in urban planning is the development of outdoor environments that are adapted for older people and care staff.

Nature 91̽»¨ and Outdoor Activity

91̽»¨ with nature and time spent outdoors promote health in general, and particularly among older adults. In care settings, such as residential care facilities and day centres, outdoor environments are often difficult to access from indoor spaces and are not designed to accommodate outdoor activities or the provision of care, support, and rehabilitation. At present, there are no national regulations in place to ensure access to outdoor environments for older people in the final years of life, nor are there guidelines for outdoor time for those unable to move independently between indoor and outdoor spaces. 91̽»¨ with nature and outdoor time also promote staff well-being, which may be reflected in the relocation of some tasks outdoors or the provision of designated outdoor areas for staff use during breaks.

Design of Physical Environments

Awareness of the role of the physical environment in promoting physical and psychological well-being is high on the political agenda, both nationally and internationally, and includes environments for healthcare, social care, and rehabilitation. In Sweden, increasing attention is being paid to individuals whose disabilities and diagnoses require special consideration in the design of physical environments. Healthcare systems are becoming increasingly evidence-based, and there is a growing demand for research-informed practice in environmental design. This includes the development of evidence-based design strategies for physical environments used in care and rehabilitation as a means of ensuring quality and efficacy.

Aim

To conduct sub-studies that enhance knowledge of the physical outdoor environments where older people live and where care staff work. Furthermore, to explore outdoor time, person-centred walking interventions, and person-centred care, support, and rehabilitation delivered in outdoor settings.

Objectives

• To improve the quality of life for older adults in residential care facilities, assisted living, and day centres by increasing access to outdoor environments and opportunities for outdoor activity in a broad sense.
• To enable care staff to provide care, support, and rehabilitation in outdoor environments, thereby supporting the health and well-being of both staff and residents.

Completed Sub-Studies

• Older adults’ needs and wishes for contact with outdoor environments at residential care facilities
  Older adults living in residential care facilities express a desire to use outdoor areas as a natural part of daily life – ideally every day and throughout the year. Those who are unable to move independently between indoor and outdoor areas report that they do not receive the personal support from staff required to access the outdoors as often as they would like.
  Liljegren, M., Bengtsson, A., Lindahl, G. & Wijk, H. (2024). Older adults’ needs and wishes for contact with the outdoors at residential care facilities: Implications for theory and practice. Health Environments Research & Design Journal, 17(4), 132–149.
  
   
• Care staff reflections on using outdoor environments as settings for person-centred care, support and rehabilitation
  Care staff see significant potential in using outdoor environments for the delivery of person-centred care, support, and rehabilitation. They believe that this approach meets fundamental human needs – among both older adults and staff. However, they also report organisational barriers, such as a lack of support from managers and decision-makers, and limited access to adequately designed outdoor spaces.
  Liljegren, M., Bengtsson, A., Lindahl, G. & Wijk, H. (2024). Introducing the outdoor environment as an arena for person-centred care and rehabilitation at residential care facilities for older adults – a care worker’s perspective. Journal of Aging and Environment, 1–17.
   

• Matrix and manual for mapping access to outdoor environments for older adults and care staff at residential care facilities
  A matrix consisting of 26 variables has been developed to assess access to outdoor environments in terms of windows, entrances, balconies, patios, gardens, and surrounding areas. An accompanying manual supports the mapping process.
  Liljegren, M., Bengtsson, A., Lindahl, G. & Wijk, H. Developing a matrix and manual for mapping access to outdoor environments for older adults and care workers at residential care facilities. Submitted to journal

   

• Lack of outdoor environments at residential care facilities
  There is a lack of accessible outdoor environments at Swedish residential care facilities. In particular, there is insufficient access to patios, balconies, conservatories, and private gardens – that is, the outdoor areas closest to where residents live. The absence of such environments results in a lack of everyday outdoor settings for residents and a lack of outdoor arenas for care staff to deliver person-centred interventions. Consequently, both older adults and care staff miss out on the well-documented health benefits of outdoor activity, as well as having a basic human need left unmet.
  Liljegren, M., Bengtsson, A., Lindahl, G. & Wijk, H. Lack of access to outdoor environments as part of everyday life at residential care facilities. Submitted to journal
   
• Proposal for a national strategy on access to outdoor environments and outdoor time for older adults in residential care
  This document presents a proposal for a national strategy aimed at ensuring access to outdoor environments and opportunities for outdoor activity among older adults living in Swedish residential care facilities. The proposal is addressed to politicians, decision-makers, and public authorities and is intended as a foundation for recommendations and national guidelines. The strategy is based on a synthesis of current research and the results of three workshops involving researchers, public agencies, interest organisations, and key stakeholders in residential elder care.
  Bengtsson, A., Landin, H., Liljegren, M., Lindahl, G., Nordin, S., & Wijk, H. (2025). Proposal for a national strategy on access to outdoor environments and outdoor time for older adults in residential care.

Ongoing Research within the OUT-FIT Project

• Access to outdoor environments and outdoor time in residential care facilities for older adults – insights based on three national Swedish mapping studies.
• Development of an evidence-based guideline on key environmental qualities for older adults and care staff in residential care facilities.
• Translation of the evidence-based guideline into a practical, evidence-based working method for the design, planning and evaluation of outdoor environments in connection with new construction or renovation of residential care facilities.
• Regular person-centred outdoor walks and their impact on behavioural and psychological symptoms of dementia (BPSD) among older adults living in residential care facilities.
• How reductions in BPSD among residents affect staff working conditions following the implementation of regular person-centred outdoor walks in residential care facilities.
• Mapping access to outdoor environments for older adults living in assisted housing.
• Outdoor environments as lunch settings – how contact with nature and time spent outdoors supports health, recovery, and work capacity among care staff.

Participating Institutions and Contributors 

University 91̽»¨ / Chalmers University of Technology

• Helle Wijk: Nurse and Professor at the Institute of Health and Care 91̽»¨s, University 91̽»¨, and Visiting Professor at the Department of Architecture and Civil Engineering, Chalmers University of Technology. Role: Principal Investigator.
• Madeleine Liljegren: Physiotherapist at the Institute of Health and Care 91̽»¨s, University 91̽»¨, and at the Department of Architecture and Civil Engineering, Chalmers University of Technology. Role: Joint PhD candidate.

University 91̽»¨

• Kateryna Fursa: Institute of Health and Care 91̽»¨s, University 91̽»¨. Role: Research Assistant.

Chalmers University of Technology

• Göran Lindahl: Architect and Professor at the Department of Architecture and Civil Engineering, Chalmers University of Technology. Role: Researcher.

Swedish University of Agricultural 91̽»¨s (SLU)

• Anna Bengtsson: Landscape Architect and Senior Lecturer at the Department of People and Society, SLU. Role: Researcher.
• Helene Landin: University Lecturer and Master's Student at the Department of People and Society, SLU. Role: Research Assistant.
• Kristina Alsadius: Master's Student at the Department of People and Society, SLU. Role: Thesis Project.
• Yrsa Fossgreen: Master's Student at the Department of People and Society, SLU. Role: Thesis Project.
• Amanda Sandsborg: Master's Student at the Department of People and Society, SLU. Role: Thesis Project.

University of ³Òä±¹±ô±ð

• Eva Dahlkvist: Nurse at the Institute of Health and Care 91̽»¨s, University 91̽»¨. Role: PhD Candidate.
• Eva Bergsten: Associate Professor of Occupational Health 91̽»¨ at the Faculty of Health and Occupational Studies, University of ³Òä±¹±ô±ð. Role: Researcher and Assistant Supervisor.

Dalarna University

• Susanna Nordin: Nurse and Senior Lecturer at the Department of Health and Welfare, Dalarna University. Role: Research Leader for the Day Centre Subproject.

Linnaeus University

• Susanne Knutsson: Nurse and Associate Professor at the Department of Health and Caring 91̽»¨s, Linnaeus University. Role: Researcher.

Reference Group 

The project includes a reference group that provides input on various issues and acts as a discussion forum. Members represent the following organisations:

• Older adults' interest organisation: SPF Seniorerna
• Experts: Dalarna University and Jönköping University
• Authorities: The National Board of Health and Welfare, The National Board of Housing, Building and Planning, and the Swedish Association of Local Authorities and Regions
• Physical environments: Branak, GoodGarden, Ikano Bostad, Liljewalls, and the Programme for Technical Standards
• Health care, social care, and rehabilitation: Professional organisations Fysioterapeuterna and Sveriges Arbetsterapeuter, and the Municipality of Lund