The authors allude to the challenge of managing risk to the security of patients and staff in psychiatric wards and how design of psychiatric hospitals contributes to it. The authors conducted an evaluation of a mental health inpatient facility. They found that although the intent was to achieve safety through the security of the physical environment, the judgment of the staff and patients was key to managing risks to security.
The objective of this paper is to present the findings from the evaluation of the design of inpatient units in a newly-built psychiatric hospital in England.
This research involved a qualitative evaluation of the facility – a new, purpose-built, 318-bed inpatient mental healthcare facility that was opened in 2010. Data was collected through group discussions and individual interviews of three groups of participants – staff (nursing staff, psychiatric consultants, matrons, ward managers, and occupational therapists), patients, and informal carers (family members and other patient representatives). Patients had been transferred from two other hospitals. Data was collected between April 2010 and November 2011 in three phases – just before the move, just after the move, and six to nine months after the move. In Phase 1, 19 staff and two family members participated in group discussions. A thematic analysis of the data, collected in the first two phases, was conducted. In Phase 2, one patient was interviewed and seven staff participated in group discussions. In Phase 3, three patients participated in a group discussion and two were interviewed, 18 staff participated in different group discussions and two were interviewed, and one patient representative was interviewed.
The following were the findings pertaining to the physical environment:
Violence and aggression towards staff and between patients:
- Staff in the forensic wards (patients who are required to be in the facility because of a court order) said that patients throw furniture at the staff (in addition to other forms of violence and aggression).
- A family member said that the new area had isolated areas where a patient could harm themselves or others.
- A patient requested the provision of an individual bedroom because it gave them a sense of control over their own security – they were able to lock it (staff had access).
Security:
- Staff noted that the new hospital was more secure than the old one.
- The internal courtyards in the hospital had a medium-security perimeter wall.
- Protruding features in the common areas were considered harmful, as they had the potential to become weapons for self-harm. These features were:
- Free-standing metal pole in a common area
- An artwork on the ground that had poetry written in raised metal lettering
- Sharp stones laid in the courtyard
- Ligature points were also potential risks.
- Staff reported that patients in seclusion rooms had stripped off the floor and that patients put their fists through chipboard walls.
- A kitchen designed for patient use as part of the therapeutic activity was not being used because of security concerns.
Surveillance:
The staff felt that the new hospital was good for observation because:
- It had good lines of sight throughout the building – enabling staff to see most places in the ward.
- Glass partitions afforded clear views of the courtyard.
- The shape of the building made observation convenient.
- The courtyard could be seen from every corridor in the ward.
- CCTV cameras allowed for discrete observation.
The staff were also critical that there were several blind spots in the new hospital, which heightened the fear that a patient who may potentially harm oneself would be unobserved. The following were identified by the staff as obstacles to observation:
- Walls and furniture – like a partition between an office and the dining area or a protruding television
- Doors that have to be closed to maintain energy-efficient heating
- Individual rooms
- Calm rooms – there is a recess in the calm room that cannot be seen.
The authors do not identify any limitations to their study. This study is an evaluation of a psychiatric facility, which housed patients with mental health issues varying from acute psychiatric illnesses to learning disabilities; the findings may not be generalizable to all types of mental health facilities.