Captured in most explanations of holistic assessment is the idea that the process not only focuses on the symptoms or issues but widens out to consider their impact on the whole person and their life. And by taking this 360-degree view of the person, we are more likely to succeed in providing interventions and solutions that are more effective and sustainable. For those of us who use adaptations as an intervention to improve health and well-being, a holistic approach is essential if we are to avoid a final design that fails to deliver what the older or disabled person needs.
In writing this article, we reflect on a holistic approach to the assessment within a bathroom design. To do this, we have been challenged to untangle the different threads that make up the bundle of thoughts that shape our professional reasoning. No doubt there will be gaps in thinking, but hope what follows is helpful, particularly for those new to this area of practice.
First things First – Separating my two assessment hats:
One of the most important lessons we’ve learnt over the years is to differentiate between the assessment of need from the assessment that informs the design of the solution.
The assessment of need occurs before any design process. It helps us to understand what is important to the person, what occupations are the focus of the issues and how this impacts health and well-being. We’re also analysing the cause of the issue(s) by observing the person’s interaction with their home environment. At the end of the assessment, working with the older or disabled person to decide the right intervention pathway with them, which may or may not be an adaptation.
If identifying that an adaptation is the right intervention, then the second assessment hat we wear is working with the person to develop a design brief that helps my building colleagues take those recommendations and develop a plan or scheme. Again, this must be holistic; otherwise, it is easy to forget something that will result in the final design not meeting the person’s needs.
Use a model of practice to help my holistic assessment within bathroom design:
Are you that occupational therapist who can be cynical about the usefulness of models of practice? We don’t blame you if you are, as it is easy to question their relevance when so much of what we do and recommend is shaped by eligibility criteria and legislation. However, ‘holistic’ thinking is thanks to a model of practice adopted into our work about ten years ago – the Occupational Therapy Intervention Process Model (OTIPM). The OTIPM is a type of PEO model. So, using the headings of Person, Environment, and Occupation, I will attempt to untangle and articulate the thought processes.
Thinking about the Person within bathroom design:
One of the first things we need to understand is how a person’s current motor, processing, and sensory skills impact their function. By understanding this, we can then recommend fixtures, fittings, and products that will maximise their performance in the tasks they are doing. For example, if the person has limited hand function, we will consider the fixtures and products that will enhance what the person can do or compensate for what they can’t do. So, we might recommend extended lever taps so that we can make the most of the gross motor skill they do have. We will also think about those factors when recommending the overall layout of the space – including the heights and position of products. Again, this is about ensuring that the layout maximises the person’s participation in the task.
As part of thinking about the person, take time to understand their preferences around the design’s ‘look and feel’, in other words, the aesthetics. There is now a wealth of evidence that links the importance of aesthetics to designing a successful adaptation. This is because aesthetics reflects our values and beliefs and is a meaningful way we express our identity. If we don’t capture this, we are in danger of designing something that will cause the person a great deal of dissatisfaction.
Thinking about the Environment within bathroom design:
As part of a holistic approach, we consider not only the physical but also the socio-economic environment.
In fact, before we even step into the bathroom, our first priority is to assess how the budget or funding route will influence the design decisions that need to be made. So, for example, when we are looking at a Disabled Facilities Grant to fund the adaptation, we should explain to the person how this will influence the choices and recommendations that can be made. By doing this, we are better able to manage expectations, and the person can then make an informed decision about what solutions or recommendations will work for them, given the parameters of the funding constraints.
The other important factor, under the ‘environment’ heading, is who else lives at the property. This is an essential part of the assessment as these influence how flexible we might need to be in the recommendations or design. A good example of flexible design is when working with multi-generational families – where both a shower and a bath might need to be recommended to meet the needs of everyone at the property.
Once we do step into the bathroom, the focus becomes the existing layout and whether any architectural barriers will prevent us from achieving the optimum design solution. Where there are architectural barriers, inevitably, compromises have to be made. However, when compromises must be made, we need to decide with the person if they are tolerable and aren’t detrimental to the overall goal of achieving their independence in those activities that are important to them. While we pick up some building knowledge over the years, we should always be mindful that getting this part of the assessment process right requires a collaborative approach with building colleagues.
Thinking about the Occupation or Task in bathroom design:
In assessing the occupations or tasks that take place in the bathroom, evaluate a number of factors. One of the first factors is the space required for the person to carry out the various tasks they will be doing in the bathroom. Alongside space, the time it takes to complete the task needs to be taken into account, as this affects the design in terms of ensuring sufficient heating and ventilation. Or if a person is sitting for prolonged periods, do we need to consider pressure relief in those seating surfaces?
When analysing the occupation, the sequence of the steps involved in the task and the objects used must be assessed. From this information, additional fixtures & fittings and storage requirements can be identified – alongside the most efficient layout of those items. For example, if a person is shaving, where will they store the shaver, is the shaving cream in reach, and what height does the mirror need to be at for them to see it from a seated position.
The final element under occupation is the question of future changes in how the person will perform the task, which can change for several reasons, such as the ageing process or the progression of conditions such as Multiple Sclerosis. Here, we consider the compatibility of fixtures and fitting with equipment that might be needed in the future, such as toileting chairs. Or if it is likely the person will have carer support in the future, is there sufficient space to perform moving and handling tasks.
This article has shown that holistic assessment in bathroom design is complex. However, practice models like OTIPM can bring order to this process. Using such models ensures that we take a robust approach that will ultimately lead to a bathroom design that provides a space where an older or disabled person can carry out those activities that are important to them.