Space & Design

The spatial design and layout of an inpatient psychiatric setting is a key aspect of treatment. The following selection of literature explores:

• How different aspects of physical design of an inpatient unit can affect a patient’s experience during a hospitalization as well as contribute to his/her healing.
• Research on closed vs. open nursing station design.
• How a unit’s design affects how nurses, and all staff disciplines, provide care.
• The effect of the environment of a psychiatric milieu from a quality perspective, i.e. incidence of seclusion, restraint, violence and falls.

To comply with current regulatory requirements calling for a ligature-resistant environment, various protocols and building configurations must be designed to maintain safety and minimize risk of harm, and yet foster a therapeutic and pleasant milieu. While behavioral health units and facilities should be designed to appear comfortable, attractive, and as residential in character as possible, this focus on patient and staff safety has often pushed the aesthetics of these units toward the appearance of a prison environment.

Balancing these variables is challenging. Patients and staff are often caught in the tension between therapy and safety. Hence it is critical to understand the important aspects of the environment that facilitate feelings of safety and self-control when designing the physical space of an inpatient unit. In addition, this information is important to assist the psychiatric mental health nurse in structuring an interpersonal environment that fosters health and healing among hospitalized patients.

References:

Bayramzadeh, S., Portillo, M., & Carmel-Gilfilen, C. (2019). Understanding Design Vulnerabilities in the Physical Environment Relating to Patient Fall Patterns in a Psychiatric Hospital: Seven Years of Sentinel Events. Journal of the American Psychiatric Nurses Association, 25(2), 134–145. https://doi.org/10.1177/1078390318776086

“The influence of the physical environment on patient falls has not been fully explored in psychiatric units, despite this patient population’s vulnerability and the critical role of the physical environment in patient safety. The research objective is to describe the spatial and temporal pattern of falls occurrences and their location in relation to the levels of safety continuum model. The physical environment plays an often-unexamined role in fall events and specific locations. These results are deserving of further research on design strategies and applications to reduce patient falls in psychiatric hospital settings.”

Chrysikou, E. (2019). Psychiatric Institutions and the Physical Environment: Combining Medical Architecture Methodologies and Architectural Morphology to Increase Our Understanding. Journal of Healthcare Engineering, 2019. https://doi.org/10.1155/2019/4076259

“Dangerousness and perception of risk for harm or self-harm still dominate the design of mental health facilities in the UK. The pluralism that characterized the development of psychiatric services around the world created a variety of policies, care models and building types, and fostered experimental approaches. Increased complexities of care, institutional remnants, stigma, and the limited diagnostic and interventional accuracy of psychiatric treatments resulted in institutional behaviors surviving, even in newly built facilities. This is the case despite the optimism that surrounded psychiatric rehabilitation movements. The paper presented findings highlighting potential connections between policies, care regimes, spatial configuration, and the social fabric in psychiatric institutions.”

Jovanović, N., Campbell, J., & Priebe, S. (2019). How to design psychiatric facilities to foster positive social interaction – A systematic review. European Psychiatry, 60, 49–62. https://doi.org/10.1016/j.eurpsy.2019.04.005

“There is a lack of understanding how to design environments for staff, patients and visitors to engage in positive social interactions (e.g. conversation, sharing, peer support). A systematic literature review was conducted on which architectural typologies and design solutions facilitate helpful social interactions between users of psychiatric facilities. Several interventions were identified such as choosing a community location; building smaller (up to 20 beds) homelike and well-integrated facilities with single/double bedrooms and wide range of communal areas; provision of open nursing stations; ensuring good balance between private and shared spaces for patients and staff; and specific interior design interventions such as arranging furniture in small, flexible groupings, introduction of plants on wards, and installing private conversation booths. These interventions range from simple and non-costly to very complex ones. The evidence should inform the design of new hospitals and the retrofitting of existing ones.”

Nicholls, D., Kidd, K., Threader, J., & Hungerford, C. (2015). The value of purpose built mental health facilities: Use of the Ward Atmosphere Scale to gauge the link between milieu and physical environment. International Journal of Mental Health Nursing, 24(4), 286–294. https://doi.org/10.1111/inm.12138

“This study investigated changes in the ‘atmosphere’ of an acute adult mental health setting following relocation to a new purpose-built facility. The Ward Atmosphere Scale (WAS) was designed and validated for specific use in hospital-based psychiatric facilities, and measures several dimensions of an environment. Interestingly, it was found that consumers noted less ‘staff control’ in the new setting, raising the question of the differences in understanding of control. For staff only, there was a perception of greater levels of consumer ‘involvement’ in the new facility. Despite the minor differences in perception, the study does confirm that architecture is an important influence on the ‘atmosphere’ of a health facility, for both staff and consumers.”

Papoulias, C., Csipke, E., Rose, D., McKellar, S., & Wykes, T. (2014). The psychiatric ward as a therapeutic space: Systematic review. In British Journal of Psychiatry (Vol. 205, Issue 3, pp. 171–176). Royal College of Psychiatrists. https://doi.org/10.1192/bjp.bp.114.144873

“Hospital care is still an integral part of mental healthcare services. But the impact of ward design on treatment outcomes is unclear. The aim of this study was to review the effects of ward design on patient outcomes and patient and staff well-being. A systematic review of literature was carried out on Medline, Embase and PsycINFO. Twenty-three papers were identified. No strong causal links between design and clinical outcomes were found. Private spaces and a homely environment may contribute to patient well-being. Different stakeholders may experience ward design in conflicting ways; design has a symbolic and social dimension for patients. Data on the impact of design on treatment outcomes are inconclusive. Rigorous randomized controlled trials, qualitative studies and novel methods are called for. Different stakeholders’ responses to the ward as a symbolic environment merit further investigation.”

Shattell, M., Bartlett, R., Beres, K., Southard, K., Bell, C., Judge, C. A., & Duke, P. (2015). How Patients and Nurses Experience an Open Versus an Enclosed Nursing Station on an Inpatient Psychiatric Unit. Journal of the American Psychiatric Nurses Association, 21(6), 398–405. https://doi.org/10.1177/1078390315617038

“The inpatient environment is a critical space for nurses and patients in psychiatric settings. In this article, we describe nurses’ and patients’ perceptions of the inpatient environment both before the removal of a Plexiglas enclosure around a nurses’ station and after its removal. Nurses had mixed feelings about the enclosure, reporting that it provided for confidentiality and a concentrated work space but also acknowledged the challenge of the barrier for communication with their patients. Patients unanimously preferred the nurses’ station without the barrier, reporting increased feelings of freedom, safety, and connection with the nurses after its removal. It is important to consider the implications of environmental decisions in inpatient settings in order to promote a healthy workplace and healing environment for all community members”.

Southarrd, K., Jarrell, A., Shattell, M. M., Mccoy, T. P., Bartlett, R., & Judge, C. A. (2012). Enclosed Versus Open Nursing Stations in Adult Acute Care Psychiatric Settings: Does the Design Affect the Therapeutic Milieu? By: Journal of Psychosocial Nursing Mental Health Services, 50(5), 28–34.

“The purpose of this study was to examine the effect of nursing station design on the therapeutic milieu in an adult acute care psychiatric unit. A repeated cross-sectional, pretest-posttest design was used. Data were collected from a convenience sample of 81 patients and 25 nursing staff members who completed the Ward Atmosphere Scale. Pretest data were collected when the unit had an enclosed nursing station, and posttest data were collected after renovations to the unit created an open nursing station. No statistically significant differences were found in patient or staff perceptions of the therapeutic milieu. No increase in aggression toward staff was found, given patients’ ease of access to the nursing station. More research is needed about the impact of unit design in acute care psychiatric settings.”

Ulrich, R. S., Bogren, L., Gardiner, S. K., & Lundin, S. (2018). Psychiatric ward design can reduce aggressive behavior. Journal of Environmental Psychology, 57, 53–66. https://doi.org/10.1016/j.jenvp.2018.05.002

“The article describes a conceptual model proposing that aggression in psychiatric facilities may be reduced by designing the physical environment with ten evidence-grounded stress-reducing features. The model was tested in a newer hospital in Sweden having wards with nine of the ten features. Data on two clinical markers of aggressive behavior, compulsory injections and physical restraints, were compared with data from an older facility (replaced by the newer hospital) that had only one stress-reducing feature. Another hospital with one feature, which did not change during the study period, served as a control. The proportion of patients requiring injections declined (p<0.0027) in the new hospital compared to the old facility but did not change in the control hospital. Among patients who received injections, the average number of injections declined marginally in the new hospital compared to the old facility, but increased in the control hospital by 19%. The average number of physical restraints (among patients who received at least one) decreased 50% in the new hospital compared to the old. These findings suggest that designing better psychiatric buildings using reasoned theory and the best available evidence can reduce the major patient and staff safety threat posed by aggressive behavior.”