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The influence of evidence-based design on staff perceptions of a supportive environment for person-centered care in forensic psychiatry

November 2021
The Center For Health Design
Why does this study matter?
In Sweden, when individuals with mental disorders commit a crime and pose a danger to public safety, they are admitted to secure inpatient long-term forensic psychiatric care settings. In recent years, there has been a philosophical shift to prioritize a therapeutic social model for long-term forensic psychiatric care over a curative medical model. While previous studies have shown that person-centered care has a positive effect on caregiver’s engagement with their work and their job satisfaction, the person-centered approach dramatically changes  expectations for and demands placed upon the design of the healthcare environment. Research is needed to understand the relationship between the physical environment, the provision of care, and workforce outcomes.

How was the study done?
The researchers conducted a prospective longitudinal study between 2010 to 2014 that was designed to measure the impact of changes to the physical and psychosocial environment on staff.  The study focused on the delivery of an already implemented person-centered care approach before and after a relocation to new more supportive forensic psychiatric facilities in Sweden.

Two structured validated questionnaires were used for data collection. The Person-Centered Care Assessment Tool (P-CAT) consists of 13 items that use a 5-point Likert scale to evaluate staff’s perceptions of their ability to provide person-centered care and supportive environmental factors. The Person-Centered Climate Questionnaire–Staff Version (PCQ-S) consists of 14 items that use a 6-point Likert scale to evaluate staff’s perceptions of the environment’s ability to foster a feeling of safety, exhibit an everyday/commonplace character, and nurture social connections.

Questionnaires were returned by 239 of 254 staff before the relocation resulting in a 94% response rate. The response rate fell to 65% with 156 of the initial staff returning questionnaires 6 months after the relocation. A 50% response rate was achieved 18 months after the move.

So what do we learn from this study?
The responses to the questionnaires did not produce any statistically significant outcomes. An average rating of 3.5 out of 5 remained consistent between the pre-relocation baseline and post-relocation 6-month and 18-month follow-ups for staff’s perceived ability to be supported to provide person-centered care according to the Person-Centered Care Assessment Tool (P-CAT). The
staff version of the Person-Centered Climate Questionnaire (PCQ-S), on the other hand, revealed an initial increase at 6 months that was sustained at the same level at 18 months.

The biggest upward trend in the PCQ-S Questionnaire was owed to the “everydayness” domain where data revealed increasing agreement among staff that the character of the environment was commonplace. The domain of Safety saw a slight upward trend indicating that, while some staff felt safer after the relocation, this sentiment was probably not shared by all. Responses within the “community” domain went up and back down during questionnaire cycles.

Can we say the results are definitive?
While the staff outcomes were credited to changes in the designed environment, information about the type and extent of the changes was lacking in the publication. A supplemental article that was referenced in the publication provided information for 20 environmental factors that were implemented to support a person-centered approach. There are, however, omissions related to building configuration, unit-based subdivision, number of occupants, communication and security systems, and information about staffing ratios, daily routines and operations.

It is also unclear if the reduction in the questionnaire response rate is the result of staff turnover, which could have been used as a complimentary measure of staff satisfaction. Further, the questionnaires lacked open-ended questions; this and/or staff interviews or focus groups would have provided an opportunity to learn about features of the environment that are prioritized, do not contribute, or serve as barriers to the provision of person-centered care.

What’s the takeaway?
Person-centered care honors those receiving as well as providing rehabilitation and reintegration care and services. Staff satisfaction is an essential return on the investment being made to improve the provision and efficiency of care. Getting detailed staff feedback on the design of the built environment makes good heart and business sense.

Degl' Innocenti, A., Wijk, H., Kullgren, A., Alexiou, E. (2020) The influence of evidence-based design on staff perceptions of a supportive environment for person-centered care in forensic psychiatry. Journal of Forensic Nursing. Issue 3, Volume 16, Pages E23

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