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Promoting mental health recovery by design: Physical, procedural, and relational security in the context of the mental health built environment

November 2023
The Center For Health Design


Why does this study matter?
Mental health illness, disorder, and distress can require voluntary or involuntary hospitalization. In Australia, such hospitalizations are often longer than typical hospital admissions with an average length of stay of approximately 14 days. With such long admissions, it is important that facilities are designed to meet the physical, procedural and relational security needs of varied user groups including patients, family and staff. Patient perspectives are often neglected in mental health design, but are important to consider since patients may interpret and experience hospital facilities differently than health professionals or designers presume.


How was the study done?
In preparation for an inpatient mental health unit redesign, researchers in Australia conducted interviews and focus groups with various stakeholders from the existing mental health unit over a two day period.  4 patients, 5 carers (parents of inpatients), and 27 mental health professionals across different work shifts participated.

The following open-ended questions guided data collection: 1) Can you please describe what kind of environment you believe supports your wellbeing? 2) What would it look like? 3) Is there anything lacking on the ward that you believe it would benefit from? 4) In your opinion what space is available to you on the ward? 5) Is there anything else about your experience you would like to share with us? Interviews and focus groups each lasted 45-60 minutes and were recorded. Recordings were transcribed, coded and independently evaluated by two researchers.     


So what do we learn from the study?
Researchers framed recommendations using the Environmental Design Guide for Adult Medium Secure Services from the United Kingdom (2011). The domains of physical security, relational security, and procedural security served as overarching themes.

The first and highest priority theme was physical security which indicated the need for safe spaces for family activities; safe and private areas for the conduct of treatments; sensory rooms with various amenities; toileting in de-escalation rooms and bedrooms; integration of nature into patient areas; and appropriate nursing office space.

The second theme emphasized the importance of spaces and systems that promote relational security and therapeutic interactions. Key elements included the need to reduce patient or carer wait time for permission or access; separate cohorts or at a minimum provide options for like groups to congregate safely; invest resources in wayfinding including décor and staff guides; and {CLICK} ensure private staff space.

The third and final theme addressed procedural security and included the need for designers and administrators to value mental health as a unique specialty when {CLICK} allocating resources; to mitigate physical, social, and technological barriers between mental health units and other units within a facility; and the need for spaces to accommodate mental health patients with diverse needs.


Can we say the results are definitive?
The absence of non-health staff perspectives, the limited number of patients available to participate and human subjects restrictions preventing specific exploration of Aboriginal/First Nations patient were noted limitations. Other limitations included a lack of detail about data saturation and lack of distinction between data gathered via focus group vs interviews or how many of each stakeholder group participated in each activity. It should also be noted that this study was based in Australia and used UK standards to frame the overarching themes.


What’s the takeaway?
Design recommendations related to facility design that were identified from this study include: integrating mental health units into larger health facilities; incorporating nature into the therapeutic milieu; designing nursing stations with private areas and without a ‘fishbowl’ style; promoting meaningful navigation strategies; and devising spaces that accommodate a variety of activities with adequate privacy and observability. 

Summary of:
Wilson, R. L., Hutton, A., & Foureur, M. (2023). Promoting mental health recovery by design: Physical, procedural, and relational security in the context of the mental health built environment. International Journal of Mental Health Nursing, 32(1), 147–161 https://doi.org/10.1111/inm.13070




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