Design in mind: eliciting service user and frontline staff perspectives on psychiatric ward design through participatory methods

The Role of the Built Environment as a Therapeutic Intervention in Mental Health Facilities: A Systematic Literature Review

OBJECTIVES

This systematic literature review synthesizes and assesses empirical research concerning the use of the built environment as a therapeutic intervention in adult mental health inpatient facilities. The review explores the impact of facility design on patient outcomes.

BACKGROUND

There is a growing recognition that the built environment in mental health facilities must strike a balance between ensuring safety and providing a therapeutic atmosphere. A review addressing how facility design contributes to this therapeutic environment is warranted.

METHODS

Database searches were conducted in CINAHL, Embase, PsychInfo, PubMed, and Web of Science from inception up to March 10, 2022. The Scottish Intercollegiate Guidelines Network (SIGN50) critical appraisal checklists were used to assess the quality of included studies.

RESULTS

Of the 44 peer-reviewed studies identified from nine countries, several factors emerged as vital for the therapeutic environment in mental health inpatient facilities. These included personal spaces prioritizing privacy and control of the environment, daylight-optimized spaces, versatile communal areas promoting activities and interaction, designated areas for visits and spiritual/contemplative reflection, homelike environments, the inclusion of artwork in units, open nursing stations, and dedicated female-only areas. Yet, there is a need for research yielding stronger evidence-based designs harmonizing with therapeutic needs.

CONCLUSION

This review offers initial guidance on designing mental health facilities that foster a therapeutic environment, while highlighting that the influence of facility design on mental health inpatients is considerably under-researched.

Impact of the design of adult mental health inpatient facilities on healthcare staff: a mixed methods systematic review

OBJECTIVES

Mental health inpatient facilities are increasingly focusing on creating therapeutic, person-centred care environments. However, research shows that this focus may have unintended consequences for healthcare staff. Designs that do not pay attention to staff needs may risk contributing to stress, burnout, job dissatisfaction and mental exhaustion in the work environment. This systematic review aims to identify and synthesise current research on the design factors of adult mental health inpatient facilities that impact healthcare staff.

DESIGN

A mixed method systematic review was conducted to search for empirical, peer-reviewed studies using the databases CINAHL, Embase, PsycINFO, PubMed and Web of Science from their inception up to 5 September 2023. The Joanna Briggs Institute's critical appraisal checklists were used to assess the methodological quality of the eligible studies. Data were extracted and grouped based on the facility design factors.

RESULTS

In our review, we included 29 peer-reviewed empirical studies that identified crucial design factors impacting healthcare staff in adult mental health inpatient facilities. Key factors included layouts providing optimal visibility, designated work and respite areas, and centrally located nursing stations. Notably, mixed perceptions regarding the benefits and challenges of open and glass-enclosed nursing stations suggest areas requiring further research. Facilities in geographically remote locations also emerged as a factor influencing staff dynamics. Additionally, although only supported by a limited number of studies, the significance of artwork, sensory rooms for respite, appropriate furniture and equipment, and access to alarms was acknowledged as contributory factors.

CONCLUSION

Through the synthesis of existing research, this review identified that the design of mental health facilities significantly impacts staff well-being, satisfaction, performance and perception of safety. Concluding that, in order to create a well-designed therapeutic environment, it is essential to account for both service users and staff user needs.

PROSPERO REGISTRATION NUMBER

CRD42022368155.

Co-producing research on psychosis: a scoping review on barriers, facilitators and outcomes

INTRODUCTION

Co-production is a collaborative approach to service user involvement in which users and researchers share power and responsibility in the research process. Although previous reviews have investigated co-production in mental health research, these do not typically focus on psychosis or severe mental health conditions. Meanwhile, people with psychosis may be under-represented in co-production efforts. This scoping review aims to explore the peer-reviewed literature to better understand the processes and terminology employed, as well as the barriers, facilitators, and outcomes of co-production in psychosis research.

METHODS

Three databases were searched (MEDLINE, EMBASE, PsycINFO) using terms and headings related to psychosis and co-production. All titles, abstracts and full texts were independently double-screened. Disagreements were resolved by consensus. Original research articles reporting on processes and methods of co-production involving adults with psychosis as well as barriers, facilitators, and/or outcomes of co-production were included. Data was extracted using a standardised template and synthesised narratively. Joanna Briggs Institute and the AGREE Reporting Checklist were used for quality assessment.

RESULTS

The search returned 1243 references. Fifteen studies were included: five qualitative, two cross-sectional, and eight descriptive studies. Most studies took place in the UK, and all reported user involvement in the research process; however, the amount and methods of involvement varied greatly. Although all studies were required to satisfy INVOLVE (2018) principles of co-production to be included, seven were missing several of the key features of co-production and often used different terms to describe their collaborative approaches. Commonly reported outcomes included improvements in mutual engagement as well as depth of understanding and exploration. Key barriers were power differentials between researchers and service users and stigma. Key facilitators were stakeholder buy-in and effective communication.

CONCLUSIONS

The methodology, terminology and quality of the studies varied considerably; meanwhile, over-representation of UK studies suggests there may be even more heterogeneity in the global literature not captured by our review. This study makes recommendations for encouraging co-production and improving the reporting of co-produced research, while also identifying several limitations that could be improved upon for a more comprehensive review of the literature.

Development of "The Safe Psychiatric Ward Battery"

This study reports the development process and psychometric testing of the safe environment in psychiatric wards instrument. In this mixed-methods study, the concept of a safe environment was explained with a qualitative study by performing semi-structured interviews with patients and staff and ward observation. Then, the items of the instrument were designed using qualitative data and a literature review. Content and construct validity, internal consistency, stability, and inter-rater agreement were evaluated. This study produced an instrument consisting of two sections. The first section was a scale (α = .920). Exploratory factor analysis of the scale identified two dimensions of "engagement" (α = .931) and "perception" of the physical environment (α = .760). The second section was a checklist with two dimensions, "accident-free living environment" and "staff empowerment." The intra-class correlation coefficients for the scale and checklist were .912 and .809, respectively. This study suggests that this instrument is a valid and reliable tool to assess safety in psychiatric wards.

Environmental Transformations Enhancing Dignity in an Acute Psychiatric Ward: Outcome of a User-Driven Service Design Project

OBJECTIVES

The goal of the current project was to enhance the feeling of dignity for patients in the seclusion unit in an acute psychiatric ward through environmental design changes and to evaluate the effect of the refurbishment.

BACKGROUND

Treating people with dignity is essential in all health-related work and important for our mental health. Hospital architecture and design signal values that can promote dignity. Patients who must spend time in seclusion are at their most vulnerable mental state and the often worn-down like environment can challenge the feeling of dignity. How environmental design can promote dignity in seclusion units have not been studied.

METHODS

To reach suggestions for design changes enhancing dignity, we used service design that included a broad user group. The effect of design changes was evaluated by a questionnaire answered by the nursing staff during a 4-week period pre- and post refurbishment and included a control group.

RESULTS

The design concepts agreed upon were a welcoming atmosphere, contact with nature, room for privacy, close contact with staff, and a designated smoking area inside the unit. The evaluation found that the environmental design changes significantly supported the patients in their situation and the staff in their work.

CONCLUSION

We conclude that dignity design concepts are highly applicable also in an acute psychiatric setting and improve the situation of secluded mental health patients, which is much needed. Findings align with other environmental changes in psychiatric wards that improve the patients' well-being and reduce aggression.

Exploring how to improve access to psychological therapies on acute mental health wards from the perspectives of patients, families and mental health staff: qualitative study

BACKGROUND

Psychological therapy is core component of mental healthcare. However, many people with severe mental illnesses do not receive therapy, particularly in acute mental health settings.

AIMS

This study identifies barriers to delivering and accessing psychological therapies in acute mental health settings, and is the first to recommend how services can increase access from the perspectives of different stakeholders (staff, patients and carers).

METHOD

Sixty participants with experiences of acute mental health wards (26 staff, 22 patients and 12 carers) were interviewed about barriers to accessing therapy in in-patient settings and how therapies should be delivered to maximise access.

RESULTS

Four themes were identified: (a) 'Models of care', including the function of in-patient wards, beliefs about the causes of mental health problems and the importance of strong leadership to support psychosocial interventions; (b) 'Integrated care', including the importance of psychologists being ward-based, as well as having strong links with community teams; (c) 'Acute levels of distress', including factors that aggravate or ameliorate the impact of this on engagement in therapy; and (d) 'Enhancing staff capability and motivation', which is influenced by contextual issues.

CONCLUSIONS

It is possible to improve access to therapy through strong leadership (that is supportive of talking treatments), flexible delivery of therapy (that considers short admissions) and a whole-systems approach that promotes ward staff understanding of the psychosocial causes of mental illness and staff well-being. It is essential to ensure continuity between in-patient and community therapy services, and for wards to have physical space to carry out therapy.

Take a picture! The role of visual methods in understanding psychiatric patient's everyday life

Background and aim:

Understanding the patient’s experience of mental illness can foster better support for this population and greater partnership with healthcare professionals. This study aims to explore the application of visual methods in the psychiatric field and, in particular, the experience of people suffering from psychotic disorders, because it is still an open question that has not been only partially empirically examined.

Methods:

This qualitative study was conducted using two visual methods (auto-photography and photo-elicitation) associated with the narrative that emerged from an unstructured interview, in a clinical setting of adult Mental Health in Italy, between October 2019 and February 2020. A total of 5 patients and 5 corresponding referring healthcare professionals were identified and enrolled. Patients were asked to produce photographs following 4 thematic areas: “Fun”, “Time”, “Something indispensable”, “Place where I feel good”.

Results:

A total of 85 photographs were produced. Visual methods have proved to be a useful technique in qualitative research in the area of adult psychiatry. From the interviews it emerged that visual methods have allowed psychotic patients to use a new language to be able to communicate their emotions.

Conclusions:

The healthcare professionals involved also confirm the potential of this tool which, when combined with the traditional interview, is able to deepen the patient’s knowledge by overcoming the verbal barriers that often make it difficult to reconstruct the individual experience of illness.

Comfort Equals Nurturing: Young People Talk About Mental Health Ward Design

AIM

The aim of this research was to obtain user perspectives of adolescent patients to inform the redesign of an adolescent mental health inpatient facility ward unit in regional Australia.

BACKGROUND

It is well established that the consumer will use and understand unit space differently than the health professional, because of their unique positioning and depth of experience. The participation of young people in the design of ward environments and programs is essential.

METHODS

A combination of focus groups and interviews was undertaken with eight participants.

RESULTS

This study found that, in its current form, the unit revolves around routines, tasks, and patient safety, which in turn are driven by secure spaces and surveillance of the patients. Due to these routines and tasks, the aspects of individualized patient care and personal impetus and comfort are lost. Adolescent patients are able to identify solutions to enhance their hospital stay in the mental health context without being excessive and unrealistic in their suggestions.

CONCLUSIONS

When designing an adolescent unit, there needs to be some consideration as to how the group using the unit understands space. Through their role and depth of hospital experience, the adolescent patient will use and understand unit space differently from that of the health professional whose role is a worker. Therefore, it is necessary to gain the perspectives of adolescent patients for efficient and effective functioning of such an environment and to suit the needs of those it is "built for," the adolescent patient.

Evaluating health service outcomes of public involvement in health service design in high-income countries: a systematic review

BACKGROUND

Internationally, it is expected that health services will involve the public in health service design. Evaluation of public involvement has typically focused on the process and experiences for participants. Less is known about outcomes for health services. The aim of this systematic review was to a) identify and synthesise what is known about health service outcomes of public involvement and b) document how outcomes were evaluated.

METHODS

Searches were undertaken in MEDLINE, EMBASE, The Cochrane Library, PsycINFO, Web of Science, and CINAHL for studies that reported health service outcomes from public involvement in health service design. The review was limited to high-income countries and studies in English. Study quality was assessed using the Mixed Methods Appraisal Tool and critical appraisal guidelines for assessing the quality and impact of user involvement in health research. Content analysis was used to determine the outcomes of public involvement in health service design and how outcomes were evaluated.

RESULTS

A total of 93 articles were included. The majority were published in the last 5 years, were qualitative, and were located in the United Kingdom. A range of health service outcomes (discrete products, improvements to health services and system/policy level changes) were reported at various levels (service level, across services, and across organisations). However, evaluations of outcomes were reported in less than half of studies. In studies where outcomes were evaluated, a range of methods were used; most frequent were mixed methods. The quality of study design and reporting was inconsistent.

CONCLUSION

When reporting public involvement in health service design authors outline a range of outcomes for health services, but it is challenging to determine the extent of outcomes due to inadequate descriptions of study design and poor reporting. There is an urgent need for evaluations, including longitudinal study designs and cost-benefit analyses, to fully understand outcomes from public involvement in health service design.

Overcoming barriers to implementing ward-based psychosocial interventions in acute inpatient mental health settings: A meta-synthesis

BACKGROUND

The culture of acute mental health wards is often dominated by medical models of care despite some patient dissatisfaction with care in these settings and a demand for increased access to psychosocial interventions. Research has found that psychosocial interventions can improve a number of patient and staff outcomes, however, implementation within these settings is often challenging.

OBJECTIVES

The aim of this review was to provide a comprehensive synthesis of the barriers and facilitators to implementing psychosocial interventions on acute wards, in order to develop a list of recommendations for embedding psychosocial interventions within the ward culture in acute settings.

METHODS

Databases were systematically searched using search terms related to acute mental health wards and psychosocial intervention implementation from inception to December 2019. Thirty-nine studies (forty-three papers) that explored the implementation of psychosocial interventions on adult acute mental health wards using qualitative methods met inclusion criteria. Data relating to barriers and facilitators to implementing psychosocial interventions extracted from the results sections of the papers were synthesised using the COM-B model.

RESULTS AND CONCLUSIONS

We conclude that to address barriers to the implementation of psychosocial interventions, services should provide clear information to patients regarding the benefits of engagement, and additional training for staff. A shift in ward culture is required and can be achieved through the recruitment of empathic implementers, together with providing staff with protected time for delivery of psychosocial interventions with clear accountability for intervention delivery through the provision of clearly defined roles.

Consumers' understanding and expectations of a community-based recovery-oriented mental health rehabilitation unit: a pragmatic grounded theory analysis

AIMS

Incorporating consumer perspectives into mental health services design is important in working to deliver recovery-oriented care. One of the challenges faced in mental health rehabilitation services is limited consumer engagement with the available support. Listening to consumers' expectations of mental health services, and what they hope to achieve, provides an opportunity to examine the alignment between existing services and the priorities and preferences of the people who use them. We explored consumer understandings and expectations of three recovery-oriented community-based residential mental-health rehabilitation units using semi-structured interviews; two of these units were trialling a staffing model integrating peer support with clinical care.

METHODS

Twenty-four consumers completed semi-structured interviews with an independent interviewer during the first 6 weeks of their stay at the rehabilitation unit. Most participants had a primary diagnosis of schizophrenia or a related psychotic disorder (87%). A pragmatic approach to grounded theory guided the analysis, facilitating identification of content and themes, and the development of an overarching conceptual map.

RESULTS

The rehabilitation units were considered to provide a transformational space and a transitional place. The most common reason given for engagement was housing insecurity or homelessness rather than the opportunity for rehabilitation engagement. Differences in expectations did not emerge between consumers entering the clinical and integrated staffing model sites.

CONCLUSIONS

Consumers understand the function of the rehabilitation service they are entering. However, receiving rehabilitation support may not be the key driver of their attendance. This finding has implications for promoting consumer engagement with rehabilitation services. The absence of differences between the integrated and clinical staffing models may reflect the novelty of the rehabilitation context. The study highlights the need for staff to find better ways to increase consumer awareness of the potential relevance of evidence-based rehabilitation support to facilitating their recovery.

Layout Planning in Healthcare Facilities: A Systematic Review

This study presents a systematic review of the literature on layout planning in healthcare facilities. The review includes 81 articles from journals, conferences, books, and other documents. Articles were classified in two groups according to their main contents including (i) concepts and guidelines and (ii) techniques and tools to assist in layout planning in healthcare facilities. Results indicate that a great variety of concepts and tools have been used to solve layout problems in healthcare. However, healthcare environments such as hospitals can be complex, limiting the ability to obtain optimal layout solutions. Influential factors may include the flows of patients, staff, materials, and information; layout planning and implementation costs; staff and patients safety and well-being; and environmental contamination, among others. The articles reviewed discussed and often proposed solutions covering one or more factors. Results helped us to propose future research directions on the subject.

Satisfaction with care in a Brazilian psychiatric inpatient unit: differences in perceptions among patients according to type of health insurance

INTRODUCTION

User satisfaction assessment in mental health services is an important indicator of treatment quality. The objective of this study was to evaluate treatment satisfaction in a sample of inpatients with mental disorders and the associations between levels of satisfaction and clinical/sociodemographic variables.

METHODS

This exploratory study investigated 227 psychiatric inpatients who answered the Patient Satisfaction with Mental Health Services Scale (SATIS-BR) and the Perception of Change Scale (EMP). SATIS scores were analyzed according to associations with clinical and sociodemographic data. Pearson correlations were used to correlate SATIS scores with other variables.

RESULTS

We found a high degree of satisfaction with care at the psychiatric inpatient unit assessed. In general, patients rated maximum satisfaction for most items. The highest satisfaction scores were associated with patients receiving treatment through the Brazilian Unified Health System (SUS) and with less education. SATIS showed a moderate positive correlation with EMP. The worst evaluated dimension was physical facilities and comfort of the ward.

CONCLUSION

Patients treated via SUS may be more satisfied than patients with private health insurance when treated in the same facility. The evaluation of treatment satisfaction can be used to reorganize services at psychiatric inpatient units.

Showing the Unsayable: Participatory Visual Approaches and the Constitution of 'Patient Experience' in Healthcare Quality Improvement

This article considers the strengths and potential contributions of participatory visual methods for healthcare quality improvement research. It argues that such approaches may enable us to expand our understanding of 'patient experience' and of its potential for generating new knowledge for health systems. In particular, they may open up dimensions of people's engagement with services and treatments which exceed both the declarative nature of responses to questionnaires and the narrative sequencing of self reports gathered through qualitative interviewing. I will suggest that working with such methods may necessitate a more reflexive approach to the constitution of evidence in quality improvement work. To this end, the article will first consider the emerging rationale for the use of visual participatory methods in improvement before outlining the implications of two related approaches-photo-elicitation and PhotoVoice-for the constitution of 'experience'. It will then move to a participatory model for healthcare improvement work, Experience Based Co-Design (EBCD). It will argue that EBCD exemplifies both the strengths and the limitations of adequating visual participatory approaches to quality improvement ends. The article will conclude with a critical reflection on a small photographic study, in which the author participated, and which sought to harness service user perspectives for the design of psychiatric facilities, as a way of considering the potential contribution of visual participatory methods for quality improvement.

Service user involvement in the coproduction of a mental health nursing metric: The Therapeutic Engagement Questionnaire

Service users' involvement in mental health service research is increasingly acknowledged as important, yet, whilst involving users of mental health services as research participants is commonplace, seeking out their experience and indeed their "expertise" to facilitate the development of tools to be used within mental health services is in its infancy. This article describes the involvement and views of service users in the development of a nursing metric-the Therapeutic Engagement Questionnaire. It presents their role in the three stages of development: generation, statement reduction and authentication.