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http://qhr.sagepub.com/content/21/11/1527The online version of this article can be found at:
2011 21: 1527 originally published online 1 July 2011Qual Health ResGabriela Novotn, Karen A. Urbanoski and Brian R. Rush
of Their Work EnvironmentClient-Centered Design of Residential Addiction and Mental Health Care Facilities: Staff Perceptions
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Client-centered approaches to health care are increasingly serving as guiding principles for service delivery and sys-tem design (Institute of Medicine, 2001; Mitchell, Closson, Coulis, Flint, & Gray, 2000), including treatment and support for people with mental and substance use disor-ders (Adams & Grieder, 2005). Rather than representing a single model of care, client-centeredness incorporates a broad array of operational and ideological approaches toward care planning and delivery. Examples include indi-vidualized service planning, multidisciplinary care teams, active client and family involvement in care planning and delivery, and broader efforts to facilitate personalization of services and access through administrative decentral-ization and localization nearer to clients (Adams & Grieder; Mitchell et al.; Reisdorfer, 1996). Ideologically, greater focus is placed on promoting independence, recovery, and well-being, and clients unique strengths, challenges, and goals are emphasized rather than their illnesses and symptoms.
There is clear evidence that physical and architectural design promotes positive outcomes and well-being among patients in health care facilities (Karlin & Zeiss, 2006; Ulrich et al., 2008). This evidence-based facility design includes a number of principles consistent with client-centeredness (Hendrich, Chow, & Goshert, 2009) by
413782QHR211110.1177/1049732311413782Novotn et al.Qualitative Health Research
1McMaster University, Hamilton, Ontario, Canada2Harvard University, Boston, Massachusetts, USA3University of Toronto, Toronto, Ontario, Canada
Corresponding Author:Gabriela Novotn, Department of Psychiatry & Behavioral Neurosciences, McMaster University, McMaster Childrens Hospital - Chedoke Site, 280 Holbrook Building, Box 2000, Hamilton, ON L8N 3Z5, CanadaEmail: email@example.com
Client-Centered Design of Residential Addiction and Mental Health Care Facilities: Staff Perceptions of Their Work Environment
Gabriela Novotn,1 Karen A. Urbanoski,2 and Brian R. Rush3
In this article we discuss the findings from a series of focus groups conducted as part of a 3-year, mixed-method evaluation of clinical programs in a large mental health and substance use treatment facility in Canada. We examined the perceptions of clinical personnel on the physical design of new treatment units and the impact on service delivery and the work environment. The new physical design appeared to support client recovery and reduce stigma; however, it brought certain challenges. Participants reported a compromised ability to monitor clients, a lack of designated therapeutic spaces, and insufficient workspace for staff. They also thought that physical design positively facilitated communication and therapeutic relationships among clinicians and clients, and increased team cohesion. We suggest that, from these findings, new avenues for research on achieving the important balance between client and staff needs in health facility design can be explored.
addiction / substance use; focus groups; health care professionals; mental health and illness; program evaluation
striving to support and enhance recovery and well-being through a physical setting that promotes client indepen-dence, environmental choice and control, and shared own-ership of therapeutic space. Examples might include private rooms where clients can personalize the space, noninsti-tutional furnishings and home-like amenities (e.g., kitchen equipment), and flexible and varied spaces for socializa-tion and quiet activities. Natural views and gardens, for example, have been cited as positive elements by clients themselves, in addition to being empirically linked to pos-itive outcomes (Karlin & Zeiss).
The specific mechanisms linking facility design to health outcomes have not been extensively studied and, as a result, are not well understood. Stress has been identified as a potential mediator of the impact of physical setting
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on health (Broyles et al., 2008; Shumaker & Pequegnat, 1989; Ulrich, 1991). Design elements that impede or chal-lenge the attainment of goals constitute a source of stress for users, which in turn erodes users attention, energy, and physical and psychological well-being. Identifying sources of stress stemming from issues of design, and linking them with downstream outcomes, are potentially important objectives for overall facility operations and evaluation.
In exploring the impact of redesigning and renovating health facilities on the quality of care, we must take into consideration the fact that clients represent only one of many user groups; there are also managers, clinical and allied staff, and visiting family and friends who use these facilities. Different user groups interact with designed spaces in fundamentally different ways, leading to poten-tially important differences in the impact of a given design modification on the types of users who occupy a particular space (Shumaker & Pequegnat, 1989). Likewise, a given space might serve a number of therapeutic or other func-tions, and efficiency achieved in one function as a result of a design modification might be offset by a decrease in the efficiency of another. Therefore, we must attend to com-peting interests and needs related to space and design in postoccupancy evaluations (POEs) of health care facilities.
Despite the known implications for care quality and client outcomes, the perspectives and behaviors of clinical staff have been underrepresented in evaluations of hospi-tal design and redesign (Shumaker & Pequegnat, 1989; Tyson, Lambert, & Beattie, 2002). As with client-centered care in general, design modifications focused on client-centeredness require that control over space and the thera-peutic environment is partially relinquished on the part of staff. Staff perceptions of this process and the implications for client care and the work environment are highly valu-able avenues for exploration and documentation. Changes to the workspace environment might require staff to alter established routines and workflow patterns. Design mod-ifications that enhance space for clients might come at the cost of space designated for clinicians and clinical work. In addition, merging spaces for joint use by clients and health professionals tends to force both groups of users to stay in proscribed roles at all times (Shumaker & Peguegnat). Each of these examples might constitute potential stressors for clinical staff and might negatively impact their work envi-ronment and well-being.
Complex associations between hospital redesign and renovations and clinical staff perceptions of their work environments have been empirically demonstrated. For example, refurbished interiors at psychiatric inpatient units have been perceived positively by staff (Cleary, Hunt, & Walter, 2009; Devlin, 1992; Stahler, Frazer, & Rappaport, 1984) and, in some studies, improved staff morale has been documented after facility renovation (Christenfeld,
Wagner, Pastva, & Acrish, 1989; Stahler et al.). At the same time, however, disruptions and changes to the work envi-ronment associated with hospital redesign have been linked with reductions in job satisfaction and organizational commitment (Ingersoll et al., 2002). Following major renovations in a psychiatric hospital, involving a switch to largely single bedrooms and causing a reduction in the number of beds overall, and significant changes to building layout and usage policies for therapeutic and social spaces, Tyson et al. (2002) documented positive valuations of the new space by staff and increases in positive interactions between clients and staff. At the same time, however, they found increased levels of burnout and stress among staff. In discussing their findings, the authors suggested that the success of design-based modifications ultimately lies with organizational and managerial efforts to reduce environ-mental uncertainty and ensure that the needs of all relevant user groups are addressed (Tyson et al.).
Our aim is to contribute to the literature through a qual-itative examination of staff perceptions of their work envi-ronment in a new therapeutic setting designed to emphasize client-centered care. We conducted focus groups with clinical staff at redesigned units that were part of a 3-year mixed-method POE of new residential units at an existing mental health and substance use treatment facility in Canada. The evaluation was conducted to provide a pre/post comparison of clinical programs prior to and follow-ing the introduction of the new units. The units themselves (described in more detail below) were built in keeping with principles of client-centered care to provide an alter-native therapeutic setting to more traditional inpatient units. The introduction of the units represented a major change for the mental health and substance use programs involved, and afforded a unique opportunity to examine the impacts of cultural and architectural change on staff, clients, and service delivery. We used these focus groups to explore the experiences of clinical staff concerning the redesign process and the functionality of units in the new setting. Although cautious of potential stressors related to the renovation and relocation, clinical personnel expected that the new units would represent a positive change for clients and staff alike.
The evaluation took place from 2007 to 2009 in a mental health and substance use treatment facility located in a large urban center in Ontario, Canada. It involved a range of activities that provided client- and program-level data both pre- and postoccupancy. Using focus groups con-ducted both prior to and following the redesign of the units, we gathered qualitative data on staff expectations,
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perceptions, and experiences relating to service delivery, the work environment, and the physical setting. We also supplement this information with relevant findings of behavior mapping conducted at the new units concerning the use of designed spaces.
Two hospital-based residential programs participated in the evaluation. One of the programs offers residential care for individuals with mood and anxiety disorders, whereas the other focuses on substance use disorders. Both programs experienced unique changes related to the open-ing of the new units. The mood and anxiety residential pro-gram was a new care modality for the hospital. Prior to the redesign, there was a 16-bed inpatient unit serving indi-viduals with acute crises related to mood or anxiety disor-ders. The inpatient unit was traditional in design, with a typical length of stay of approximately 2 to 3 weeks (although this varied among clients). After the redesign, this tradi-tional unit remained open and was supplemented with a 24-bed alternative residential unit, where clients prepared more fully for transitioning to independent community living. In contrast, the substance use program was preex-isting but moved from an external site to the main hospital grounds as part of the redesign. Provided services included short-term, medically assisted withdrawal management and a 3-week, structured, group-based program focused on relapse prevention, stress management, and related skill development. In addition to the physical relocation and concomitant changes in building design and layout, the medical withdrawal service increased capacity from 12 to 24 beds. However, services and programming remained largely unchanged in the new units.
The newly designed units are now housed in three low-rise buildings located at one end of the main hospital cam-pus. Each unit has a capacity for 24 clients, with six clients on each of four floors. These were designed purposefully to provide a supportive therapeutic milieu in a more home-like setting, where clients reside and focus on the skills needed for successful transition to independent living in the community. The units resemble dormitories and include six private bedrooms, a shared kitchen/dining area, and a common living room on each floor. Each bedroom also has an ensuite bathroom equipped with a sink, toilet, and shower. There is at least one multipurpose room with a door on each floor, providing space for quieter social or solitary activity. Clients have electronic key cards for their rooms and for the main entrances to the units. They attend programming and other therapeutic services in adja-cent buildings, rather than in the units where they reside.
Workspace for clinical staff on the units is purposely limited, with two small staff centers that function as nurs-ing stations located on alternating floors. The purpose of such an arrangement is to facilitate staff interactions with clients outside of clinical spaces and, compared to more traditional models of care, to limit time spent in nursing
stations and staff centers. Allied health professionals, includ-ing social...