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Staff and resident perceptions of mental and behavioural health environments

November 2021
The Center For Health Design
Why does this study matter?
There is broad support for using the built environment as a therapeutic tool for advancing health outcomes for mental and behavioral health staff and patients. Understanding how features within the environment contribute to outcomes, however, is less clear. The identification, characterization, importance, and efficacy of environmental features varies between location and populations. Environmental complexities are often excluded from consideration because of lack of expertise or awareness. There is a need to identify, prioritize, and evaluate the effectiveness of environmental features from the perspective of patients and staff to inform future mental and behavioral health development.

How was the study done?
Research took place within four mental and behavioral health facilities that accommodated between 14-26 in-patients, aged adolescent to adult; 1 site was in New York and the other 3 were in administered by a single healthcare provider in California.
Researchers used two complimentary survey tools each consisting of 28 items that use a 7-point Likert scale to rate the importance of environmental attributes for all mental and behavioral health settings, followed by a rating of the effectiveness of the same attributes in staff and patient’s current facility. One hundred and fifty-eight staff members from all four sites completed a previously developed Psychiatric Staff Environmental Design (PSED) survey tool. Twenty-four patients from two sites completed the newly developed Psychiatric Patient Environmental Design survey tool (PPED).
The environmental attributes are organized within 3 environmental categories: 1) Environmental qualities relate to overarching conceptual design goals (i.e. well-maintained, outdoor access, attractive, homelike, and orderly); 2) Environmental features are specific physical interventions (i.e. staff safety mechanisms, noise control, daylighting, comfortable furniture); and 3) Environmental characteristics are aspects of the environment that contribute to the effectiveness of the environmental qualities (i.e. unrestricted access to kitchen, spaces for therapy animals, board games). A significant calculated difference between ratings of importance and effectiveness is considered an inadequacy in the environment.

So what do we learn from the study?
Quantitative analysis was performed to evaluate a variety of hypothesis relating to the differences within and between stakeholder groups ratings for the importance and efficacy of environmental attributes both within and across care settings. The outcomes discussed are relegated to the two sites where surveys were administered to both staff and patients.

In general, the ratings were high and there was relatively high consensus between staff and patients for the degree of importance assigned to environmental attributes. Maximum agreement was achieved in relation to: social interaction, indoor therapy, staff-patient consulting, open nurse stations, comfortable furniture, good daylight, and staff safety and security.

There were, however, significant differences between staff and patients when it came to rating the effectiveness of the environmental attributes within their current setting. Residents mean ratings for effectiveness tended to be similar to (if not higher than) their mean ratings for importance, resulting in no significant environmental inadequacies. Staff’s mean effectiveness ratings, on the other hand, were much lower than their mean ratings for importance resulting in significant inadequacies for more than 78% of the environmental attributes.

Upon digging into the raw data provided within one of the publication tables, it’s worth highlighting that staff and patients shared agreement for three of their top five priorities (i.e., staff safety, suicide resistance, and staff respite). Coincidentally, staff and patients also shared agreement for three of their lowest five priorities (i.e., attractive furniture, open nurse station, and smoking). Interestingly, private bathrooms (and, to a lesser degree, private bedrooms) seem to be a polarizing proposition, as staff’s ratings placed this environmental attribute in their lowest 5 priorities, while patients rated it in their top 5.

Can we say the results are defininitive?
The authors indicated that measures had been taken to overcome perceived barriers related to survey language; they felt the term ‘importance’ was familiar and could be understood, but were less confident that ‘effective’ was equally clear. It’s possible that other environmental terms may also have been unclear to respondents. The small sample size, geographic and administrative concentration, as well as site-based differences for both staff and patient survey administration make it difficult to generalize outcomes. The ratings in this study are also somewhat inconsistent with the outcomes of other previous studies where patients had lower ratings than staff.

What's the takeaway?
The patient perspective is unique, cannot be replicated and is critical to understand when designing healthcare environments. Patients need advocates to elevate their voices within an industry where they are relegated to passive recipients of care. The approach that this research team took exemplifies the 15% rule: Everyone knows 15%, and everyone’s 15% is different.

Shepley, M. M., Peditto, K., Sachs, N. A., Pham, Y., Barankevich, R., Crouppen, G., Dresser, K. (2021) Staff and resident perceptions of mental and behavioural health environments. Building Research & Information, Pages in press

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